Minimally Invasive Management of Subclavian Artery Catheter Misplacement: The New Standard?

Abstract

Background: The accidental puncture of the supra-aortal arteries during central venous catheterization is a rare but potentially life-threatening complication. Traditional management often requires open surgical repair, which is associated with significant morbidity. This study evaluates an endovascular approach for managing such cases using an Angio-Seal™ vascular closure device (Terumo Medical Corporation, Somerset, NJ, USA). Methods: Between January 2010 and December 2024, 47 patients with misplaced catheters in supra-aortal arteries were treated at our institution. Of these, 37 cases involving subclavian artery catheter misplacements were managed using a standardized algorithm and form the focus of this study. Additional interventions, such as stent graft placement or balloon inflation, were performed as needed. Results: Primary technical success was achieved in 86.5% of cases. Four patients required stentgrafts and one balloon inflation for persistent extravasations. One patient developed a small subclavian pseudoaneurysm, which resolved spontaneously. Primary assisted technical success and clinical success rates were both 100%. Conclusions: This study demonstrates the efficacy and safety of our minimally invasive endovascular approach for managing subclavian artery catheter misplacements. With a high success rate, low complication rate, and the avoidance of open surgery, this algorithm offers a promising alternative for treating this rare but serious complication of central venous catheterization.

Keywords: Angio-Seal; catheter misplacement; percutaneous closure device; standardized algorithm; subclavian artery.

Figure 1

(a) Non-subtracted angiography of a 66-year-old male shows a misplaced 12F 3-lumen central venous catheter (CVC) in the right peripheral subclavian artery (thick arrows), extending to the ascending aorta; correctly positioned gastrointestinal and tracheostomy tubes, and correctly placed left-sided CVCs; 0.035-inch “lock wire” (arrowheads) through a 5F MAP1 catheter in the brachiocephalic trunk. (b) Stiff Amplatz guide wire (thin arrows) inserted via a misplaced CVC in the right subclavian artery, used for CVC removal. (c) Post-procedure DSA after CVC removal and Angio-Seal™ deployment shows complete closure without complications.

Figure 2

Images from a 20-year-old male patient: (a) non-subtracted angiography shows the misplaced catheter in the right subclavian artery (thick arrow). (b) Subtracted selective angiography after catheter removal shows contrast extravasation (arrowhead). (c) Balloon inflation (thin arrow) at the arterial puncture site. (d) Subtracted angiography confirms the successful and complete closure of the puncture site.