Staged guidewire externalization for complex right brachiocephalic vein occlusion complicated by angiographically occult iatrogenic internal jugular vein injury: a case report

Complex thoracic central venous occlusions may require advanced endovascular techniques when conventional recanalization fails. We report a case of successful recanalization of right brachiocephalic vein (RBCV) occlusion using staged guidewire externalization, which was complicated by an iatrogenic internal jugular vein injury that was initially angiographically occult. A 48-year-old woman receiving maintenance hemodialysis presented with progressive right upper extremity and facial swelling caused by complete RBCV occlusion. After conventional antegrade and retrograde approaches failed, staged guidewire externalization was established using the right internal jugular vein as an intermediate guidewire exchange route, allowing successful balloon angioplasty and covered stent placement. The procedure was subsequently complicated by an iatrogenic internal jugular vein injury, which was not initially detected on angiography and resulted in massive hemothorax and hemorrhagic shock. Repeat selective angiography localized the bleeding to the proximal internal jugular vein, and a second covered stent was immediately deployed, achieving complete hemostasis. Following aggressive multidisciplinary resuscitation, the patient recovered without neurological or vascular sequelae. Repeated guidewire exchange and snare manipulation within a localized venous segment may increase the risk of iatrogenic venous injury and should be performed with caution. Angiographically occult iatrogenic venous injury should be considered when unexplained hemodynamic deterioration occurs despite apparently satisfactory angiographic findings during complex central venous interventions.