What would you do if you inadvertently cannulated the carotid artery (CA) during central venous catheter (central line) placement?

From the Guidelines

If I accidentally cannulated the carotid artery during central line placement, I would immediately stop the procedure and leave the catheter in place, as removing it without proper precautions could lead to severe complications, including stroke, hematoma, and even death. This approach is supported by the Association of Anaesthetists of Great Britain and Ireland's guidelines on safe vascular access, which emphasize the importance of careful management in cases of accidental arterial cannulation 1.

Key Considerations

• The incidence of accidental arterial cannulation is estimated to be between 0.1-1% 1, highlighting the need for vigilance during central line placement.
• Larger catheters (6Fr or greater) should not be removed without consulting interventional radiologists or vascular surgeons due to the high risk of morbidity and mortality associated with carotid artery cannulation 1.
• For smaller catheters (5Fr or less), removal may be considered based on the insertion site, presence of arterial disease, and coagulation status, but this should be done with caution and ideally under the guidance of specialists 1.

Management Approach

• Apply direct pressure to the insertion site while arranging for urgent consultation with surgical or interventional radiology teams.
• Monitor the patient closely for signs of neurological changes, hemodynamic instability, and other complications.
• Arrange for immediate imaging, such as CT angiography, to assess the extent of arterial injury.
• Consider management options including surgical repair, endovascular stenting, or percutaneous closure devices, depending on the clinical situation and available resources.

Patient Communication and Care

• Maintain clear and transparent communication with the patient and their family about the complication, the steps being taken, and the importance of immediate intervention to prevent further complications.
• Ensure the patient is closely monitored and receives appropriate care to minimize the risk of adverse outcomes, as carotid artery puncture is a serious complication with significant potential for morbidity and mortality 1.

From the Research

Inadvertent Carotid Artery Cannulation During Central Venous Catheter Placement

• Inadvertent carotid artery cannulation during central venous catheter placement is a serious complication that can lead to significant morbidity, including bleeding, arteriovenous fistula, and stroke 2, 3, 4.
• If inadvertent carotid artery cannulation occurs, prompt management is crucial to prevent long-term sequelae 2, 5, 6.
• Management options include removal of the catheter and manual compression, off-label use of percutaneous closure devices and/or stent grafts, and open surgical removal 5.
• Endovascular therapy, including the use of stent grafts and percutaneous closure devices, can be an effective treatment option for inadvertent carotid artery cannulation 5, 6.
• Open surgical repair may be necessary in more complex cases, such as those with associated pseudoaneurysms and/or arteriovenous fistulas 5.

Diagnostic Strategies

• Computed tomography (CT) or magnetic resonance imaging (MRI) can be used to facilitate diagnosis and guide therapy 5.
• CT angiogram of the head and neck can help identify the misplaced catheter and any associated complications 2.

Therapeutic Strategies

• Catheter removal and carotid artery sheath placement, followed by dual antiplatelet therapy, may be necessary to manage inadvertent carotid artery cannulation 2.
• Percutaneous closure using a suture-mediated closure device can be a safe and effective treatment option 6.
• Open surgical repair may be necessary in some cases, and can be performed with a high degree of technical success and low risk of complications 6.