A 62-year-old man (body weight, 80 kg; height, 185 cm) with traumatic descending aorta dissection was transferred to our hospital. He was in a state of shock (blood pressure, 75/61 mmHg; heart rate, 142 beats/min) and emergency thoracic endovascular aortic repair was planned. After entering the operating room, arterial cannulation was performed in the radial artery. Anesthesia was induced with intravenous fentanyl, propofol, and rocuronium, and his trachea was intubated. Anesthesia was maintained with air, oxygen, desflurane, and remifentanil. After the induction of anesthesia, he remained in a state of shock with systolic blood pressure of 60–70 mmHg, and common carotid artery palpation was weak. Using short-axis ultrasound imaging, a 12-gage central venous catheter (CV RegaForce EX®, Terumo, Tokyo) was inserted in the right internal jugular vein by the Seldinger technique. After catheter placement, the pressure waveform from the central venous catheter showed the arterial blood pressure waveform, indicating arterial cannulation. Since administration of heparin was planned during surgery, we decided not to remove the catheter that had been inserted into the artery. The endovascular surgery was completed in 1 h and 59 min. A postoperative chest radiograph showed the catheter in his right chest. He was transferred to the intensive care unit (ICU) without extubation.
After entering the ICU, the shock state persisted despite continuous administration of noradrenaline and dopamine. Contrast-enhanced CT showed intra-abdominal bleeding from liver injury and intestinal necrosis. It also showed that the tip of the catheter was located in the right brachiocephalic artery. A laboratory examination revealed coagulopathy: low fibrinogen level (70.0 mg/dL), prolonged PT-international normalized ratio (INR) (2.60), and prolonged aPTT (≥ 200.0 s). The catheter was therefore not removed. Two hours after entering the ICU, hepatic artery embolization, small intestine resection, and right hemicolectomy were performed.
On the 6th day after entering the ICU, he remained to be intubated and received noradrenaline and dopamine to maintain his blood pressure. His blood coagulability was improved: fibrinogen level, 415.0 mg/dL; PT-INR, 1.22; and aPTT, 31.2 s. We therefore planned to remove the catheter. We considered that surgical repair would be highly invasive for the patient and decided to place a percutaneous intravascular stent after removal of the catheter. Angiography showed that the catheter was inserted into the artery near the bifurcation of the right vertebral artery and subclavian artery (Fig. 1a). A stent (GORE® VIABAHN® Stent graft, Japan Gore, Tokyo) was percutaneously inserted through the right axillary artery. The position of stent deployment was adjusted so that the stent covered the catheter insertion site and did not occlude the opening of the right vertebral artery (Fig. 1b). After the catheter was removed, the stent was immediately expanded. Post-procedural angiography revealed that there was no leak from the catheter insertion site and no occlusion of the right subclavian artery and right vertebral artery (Fig. 1c). There were no obvious hematoma or thrombotic complications.
Although the catheter was successfully removed, the patient’s general condition gradually deteriorated. Thirteen days after entering the ICU, he died of multiple organ failure.
