Perforation of the Great Vessels During Central Venous Line Placement

BACKGROUND: Placement of central venous lines for the administration of a variety of therapies has become common practice. The most severe complication of this procedure is perforation of a large vessel, with bleeding, infusion of fluids into an extravascular site, and death. It is not clear from currently available data how often this occurs, what risk factors are associated, and how this complication can be avoided. METHODS: We reviewed the records of all patients who were identified as having perforation of a major vessel during central venous line placement occurring between 1986 and 1993 at the University Hospital, the major teaching facility of the University of Colorado Health Sciences Center, Denver. Data collected included the age and sex of the patient, diagnosis, type of catheter and site of placement, operator means and time to the diagnosis of perforation, and outcome. RESULTS: Eleven such complications were identified and 10 of them are reviewed in detail. The overall incidence was less than 1%. Most complications occurred when the right subclavian vein approach was attempted, and they were thought to result from guidewire kinking during advancement of a vessel dilator. All medical specialties and levels of training were involved. Four of 10 patients died of immediate or subsequent complications of the perforation. CONCLUSIONS: Perforation of a great vessel is an uncommon, but often fatal, complication of central venous line placement. It occurs most often, when using the right subclavian vein approach, from guidewire kinking. Physicians performing this procedure should have formal training in central venous catheterization and be aware of this complication, its presumed cause, diagnosis, and treatment.