Treating the Trifecta: Central Venous Catheter Injury, Entrapped Lung, and Pneumothorax Ex Vacuo

Introduction: Mediastinal hematoma and hemothorax, which can be fatal, are rare complications of internal jugular vein (IJV) cannulation. Pneumothorax ex vacuo (PEV) is uncommon with an entrapped lung. We report a case of subclavian artery (SCA) injury during IJV cannulation that progressed to a pseudoaneurysm and complicated hemothorax.


Description: A 30-year-old female required hemodialysis for severe metabolic acidosis and hyperkalemia due to an acute lupus nephritis flare. Bright red pulsatile blood during right IJV cannulation prompted pressure application and chest X-rays (CXR) which revealed interval development of a 7 cm mediastinal hematoma and a large right pleural effusion with near complete atelectasis of the right lung. Computed tomography angiography (CTA) confirmed active extravasation from the right SCA immediately distal to the right common carotid artery bifurcation. The hemothorax was drained using a 14 Fr Wayne catheter. Therapeutic embolization was deferred given the high-risk location.  Despite a 3-liter sanguineous drain, CXR showed PEV and persistent residual fluid in the posterior pleural space without tube displacement, necessitating another 28 Fr chest tube. Intrapleural alteplase was administered for the decreased chest tube output. At last, lung re-expansion was achieved with video-assisted-thoracoscopic surgery (VATS) converted to mini thoracotomy for total clot extraction. Hb dropped despite daily blood transfusions. Repeat CTA revealed a 1.1 cm pseudoaneurysm with short neck. Direct catheterization for it was not possible due to a tortuous aortic arch. Stent placement was deferred due to a possible risk of stroke from right vertebral artery occlusion. Decision was made to monitor for spontaneous thrombosis of the pseudoaneurysm. Ultimately, with a stable Hb and stable small pneumothorax over 1 week after chest tube removal, the patient was discharged.


Discussion: We should be vigilant of IJV cannulation complications like arterial injury, and even rarer, hemothorax and mediastinal hematoma. PEV does not require thoracostomy. Entrapped lung if left untreated might lead to symptoms, PEV, fluid re-accumulation, trapped lung and fibrothorax. In our case, early VATS was done for clotted hemothorax after incomplete evacuation with chest tubes and intrapleural fibrinolytics.