Carotid Artery Perforated During Central Venous Catheter Placement

This case involves a 71-year-old woman with end stage renal disease who died as a result of complications following placement of a central venous catheter to enable hemodialysis. During the procedure, her left carotid artery was perforated, causing massive internal bleeding.

Question(s) For Expert Witness

1. What are your initial thoughts on this situation?

2. Do you regularly place central venous catheters to enable hemodialysis for end-stage renal failure?

Expert Witness Response E-003939

Because the complication rate decreases with training, a standardized method of CVC insertion must be followed to promote prevention and decrease the incidence of adverse events. Most arterial large-bore perforations can be attributed to the unsafe manipulation of the dilators, which should only be used to widen the skin and SC tissues but frequently are inserted unnecessarily far, sometimes even causing ventricular perforation. This case seems as if an untrained individual or someone who has very little experience in placing CVCs was aggressive in the manipulation of the dilator or guidewire. Complications do arise but the way in which a complication is handled speaks to the level of care given. Whatever management choices are made to treat these arterial complications, it is prudent to leave the offending catheter in place until the next step is taken. Individual patient circumstances might dictate the selection of surgical procedure, thrombin injection, percutaneous suture devices, or stent graft placement as the best way to handle these emergencies. I regularly place central venous catheters for hemodialysis and have probably placed at least 2500 central venous catheters over the last 25 years.