NDT Advance Access originally published online on December 6, 2005
Nephrology Dialysis Transplantation 2006 21(5):1447-1448; doi:10.1093/ndt/gfi271
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Iatrogenic pseudo-aneurysm of the subclavian artery and dissection of the aorta, secondary to central venous line insertion: a treatment dilemma!
Email: drrajarajan{at}yahoo.comSir,
Pseudo-aneurysm formation of the left subclavian artery is rare in patients undergoing central venepuncture [1]. We report a case of iatrogenic pseudo-aneurysm of the subclavian artery with an associated dissection of the thoraco-abdominal aorta, secondary to previous central venous line placement.
Case. A 41-year-old lady with IgA nephropathy started haemodialysis in 1990 and received a renal transplant in 1991. She had multiple insertions of central venous catheters in both sides of her neck for haemodialysis and postoperative CVP monitoring. Her hypertension control ranged from 120/70 to 190/120. In 2001, she had a routine abdominal ultrasound scan for her hepatitis B. An incidental dissecting aneurysm of the lower thoracic and abdominal aorta was identified. A subsequent CT scan of her thorax demonstrated a left subclavian artery pseudo-aneurysm (Figure 1) and a dissection of the thoracic and abdominal aorta originating at the left subclavian artery origin.
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Comment. A rare, but potentially serious, complication of dialysis line insertion is the development of pseudo-aneurysm of the subclavian artery [2]. In our patient, the subclavian pseudo-aneurysm was identified incidentally. We suggest that the dissection of the thoracic aorta and left subclavian artery pseudo-aneurysm were a complication of the insertion of a previous left neckline. Following literature review, to our knowledge, this combination of complications has not been reported before. Our hypothesis is that, due to the close proximity of the left innominate vein and subclavian vein to the left subclavian artery and the aortic arch, it is likely that in our patient, the introducer needle, guide wire or dilator used in the insertion of a dialysis neckline injured the subclavian artery creating the pseudo-aneurysm and also injured the intima of the aortic arch at the origin of the left subclavian artery leading to dissection. This, fuelled by the severe hypertension, could have propagated the dissection of the aorta to the level of the common iliac artery.
In our case, due to the close proximity of the pseudo-aneurysm to the vertebral artery origin (Figure 2), attempts at stenting the subclavian artery [3] could potentially occlude the left vertebral artery or lead to vertebral embolization. There is also a recent report of a successful treatment of iatrogenic subclavian artery pseudo-aneurysm with percutaneous thrombin injection [1]. Previous studies have shown that attempts at treating pseudo-aneurysms with necks greater than 8 mm by thrombin injection have a high chance of failure [4].
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In conclusion, this is the first reported case of subclavian artery pseudo-aneurysm plus dissection of the thoraco-abdominal aorta as a complication of central venous cannulation. There is a high morbidity associated with both these complications and their management is not well defined in the literature.
Conflict of interest statement. None declared.
1 Department of Transplant Surgery2 Department of Nephrology3 Department of Radiology Royal Liverpool University Hospital Liverpool, UK
References
- Jeganathan R, Harkin DW, Lowry P, Lee B. Iatrogenic subclavian artery pseudo-aneurysm causing airway compromise: treatment with percutaneous thrombin injection. J Vasc Surg 2004; 40: 371–374[Medline]
- Akgun S, Civelek A, Baltacioglu F, Ekici G. Related articles, links successful endovascular repair of a subclavian artery pseudoaneurysm. Nephrol Dial Transplant 1999; 14: 2219–2221
[Free Full Text] - Moffatt SD, Mitchell RS. Endovascular stent management of thoracic aneurysms and dissections. In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. McGraw-Hill, New York, 2003: 1191–1204
- Sheiman RG, Mastromatteo M. Iatrogenic femoral pseudoaneurysms that are unresponsive to percutaneous thrombin injection: potential causes. Am J Roentgen 2003; 181: 1301–1304
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