A Needle's Misdirection: Unravelling Vascular Injuries in Malpositioned Central Venous Catheters and Safe Removal Approaches

Central venous catheters (CVC) are commonly inserted to obtain vascular access. Complications such as vascular injuries arising from malpositioned CVC may occur, and safe surgical removal is required to prevent further complications. We retrospectively reviewed all patients treated in the cardiothoracic surgery department at our institution in the past 10 years for intrathoracic vascular injuries in malpositioned CVC without the need for concurrent cardiac or thoracic surgical procedures. Among the 21 patients in our series, 2 patients (10%) had a single arterial injury, 16 patients (76%) had venous injuries only, and 3 patients (14%) had both arterial and venous injuries. 16 patients (76%) underwent surgery to remove the malpositioned CVC; majority of them underwent sternotomy (n=12, 57%) and 7 of them had repair of blood vessels, and 4 patients (19%) underwent video assisted thoracoscopic surgery (VATS). 2 out of the 5 patients who had their CVC directly removed followed by external compression required emergency sternotomy due to pericardial effusion. In patients with artery or mediastinal vessel injuries, a sternotomy approach was preferred, whereas VATS was chosen when subclavian vessels or brachiocephalic vein injuries were noted. Endovascular procedures are alternatives for high surgical risk patients, but these advanced procedures are currency limited due to high expertise and facilities requirements.