Intraoperative Innominate Vein Perforation Due to Malpositioned Central Venous Catheters: A Dual Hazard with Fatal Outcome

This case report highlights a rare but catastrophic complication of central venous catheter (CVC) malposition during cardiac surgery. An 81-year-old woman with a thoracic aortic aneurysm and moderate aortic valve insufficiency developed an iatrogenic Type A aortic dissection following coronary angiography, resulting in hemorrhagic pericardial effusion and cardiogenic shock. Emergency surgery involved a Bentall procedure, partial aortic arch replacement, and coronary artery bypass grafting. Although cardiopulmonary bypass was successfully weaned, massive venous bleeding occurred during sternal closure due to a vascular defect between the left brachiocephalic vein and superior vena cava caused by malpositioned CVCs. Despite initial control with manual compression, the patient suffered refractory hemodynamic instability due to complete loss of venous access, leading to multiple episodes of ventricular fibrillation and intraoperative death. This case underscores the critical importance of vigilant CVC placement and monitoring during complex cardiac surgeries to prevent potentially fatal complications.