Procedural Complications of Central Venous Catheter Placement in Pediatric Oncology Practice (a Clinical Case Series)

The availability of central venous access is the cornerstone of contemporary pediatric oncology and hematology. As a result, the percentage of pediatric patients receiving infusion chemotherapy who require a central line remains high. Central venous catheter insertion can be associated with procedural complications, including life-threatening ones.

Aim — to investigate the potential factors leading to complications during central venous catheterization in order to develop preventive strategies.

Materials and methods. The study included 1,512 original cases of patients aged 1 month to 20 years treated at the D. Rogachev National Research Medical Center between 2019 and 2022. The following 10 complications were examined: failed first venipuncture attempt, guidewire/catheter malpositioning, guidewire knotting, lifethreatening arrhythmias, guidewire entrapment in the trabecular network of the right ventricle, arterial puncture, pneumothorax, hemothorax, puncture of lung parenchyma, Horner's syndrome. In addition, four rare complications were noted, including phrenic nerve injury, cardiac tamponade, alveolar hemorrhage, and arterial pseudoaneurysm.

Results. The primary cause of all complications was direct mechanical injury to anatomical structures by a needle or guidewire/catheter. When inadvertent vascular injury and bleeding occur, the resulting hematoma may lead to further damage by compressing soft tissues. Excessively deep insertion of the guidewire may cause its knotting or cardiac arrhythmias. Adequate physician training and strict adherence to procedural protocols are essential to avoid these complications.

Conclusion. Central venous catheterization remains a procedure with potential complications. Although ultrasound guidance does not eliminate all risks, it increases the likelihood of successful venipuncture at the first attempt, thereby reducing complication rates. Recognizing the potential causes of procedural complications during central venous access placement, including uncommon ones, facilitates early diagnosis and appropriate medical intervention. 

1. Askegard-Giesmann J. R., Caniano D. A., Kenney B. D. Rare but serious complications of central line insertion. Semin Pediatr Surg. 2009; 18 (2): 73–83.

2. Vartanova I. V., Vartanov V. Ya., Rodina N. A. Applied anatomical and clinical aspects of central vein catheterization. St. Petersburg: S. M. Kirov Military Medical Academy; 2024: 46–51. (in Russ.).

3. Pittiruti M., Boxtel T. V., Scoppettuolo G., Carr P., Konstantinou E., Miluy G. O., Lamperti M., et al. European recommendations on the proper indication and use of peripheral venous access devices (the ERPIUP consensus): A WoCoVA project. J Vasc Access. 2021: 24 (1): 165–182. DOI: 10.1177/11297298211023274. PMID: 34088239.

4. Seldinger S. I. Catheter replacement of the needle in percutaneous arteriography; a new technique. Acta radiol. 1953; 39 (5): 368–376. DOI: 10.3109/00016925309136722. PMID: 13057644.

5. Kaleda V. I. Sven Ivar Seldinger (1921–1998) and his method of catheterization of arteries. Diagnostic and Interventional Radiology = Diagnosticheskaya i Iinterventsionnaya Radiologiya. 2016; 10 (1): 64–67. (in Russ.).

6. Barone G., Pittiruti M., Biasucci D. G., Elisei D., Iacobone E., La Greca A., Marinosci G. Z., et al. Neo-ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in neonates. J Vasc Access. 2022; 23 (5): 679–688. DOI: 10.1177/11297298211007703. PMID: 33818191.

7. La Greca A., Iacobone E., Elisei D., Biasucci D. G., D’Andrea V., Barone G., Marinosci G. Z., et al. ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in adult patients. J Vasc Access. 2023; 24 (4): 535–544. DOI: 10.1177/11297298211044325. PMID: 34494474.

8. Marinosci G. Z., Biasucci D. G., Barone G., D’Andrea V., Elisei D., Iacobone E., La Greca A., et al. ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients. J Vasc Access. 2023; 24 (1): 5–13. DOI: 10.1177/11297298211031391. PMID: 34256613.

9. Verma A., Chitransh V., Jaiswal S., Vishen A., Sheikh W. R., Haldar M., Ahuja R., et al. Guidewire entrapped in the right ventricle: a rare complication of hemodialysis catheter insertion. Indian J Crit Care Med. 2020; 24 (1): 80–81. DOI: 10.5005/jp-journals-10071-23334. PMID: 32148357.

10. Unnikrishnan K. P., Sinha P. K., Nalgirkar R. S. An alternative and simple technique of guidewire retrieval in a failed Seldinger technique. Anesth Analg. 2005; 100 (3): 898–899. DOI: 10.1213/01.ANE.0000146654.99367.DD. PMID: 15728092.

11. Park S. K., Yi I.-K., Lee J.-H., Kim D.-H., Lee S.-Y. Fracture of J-tipped guidewire during central venous catheterization and its successful removal under fluoroscopic guidance — a case report. Korean J Anesthesiol. 2012; 63 (5): 457–460. DOI: 10.4097/kjae.2012.63.5.457. PMID: 23198042.

12. McGee D. C., Gould M. K. Preventing complications of central venous catheterization. N Engl J Med. 2003; 348 (12): 1123–1133. DOI: 10.1056/NEJMra011883. PMID: 12646670.

13. Romanenko N. A., Shilova E. R., Alborov A. E., Voloshin S. V., Chebotkevich V. N. Thrombotic, hemorrhagic and other complications detected during and after catheterization of the central vein in patients with hematological profile. Bulletin of Hematology = Vestnik Gematologii. 2020; 16 (4): 54–55. (in Russ.)

14. Bykov M. V. Ultrasound examinations in providing infusion therapy in intensive care units. Tver: LLC «Publishing House «Triada»; 2011: 36.

15. Soleimanpour H. Inadvertent arterial puncture during central venous catheter insertion. Ann Clin Anal Med. 2016; 7 (161). DOI: 10.4328/JCAM.1699

16. Wierstra B., Au S. S., Cantle P. M., Romens K. Arterial placement of central venous catheters: beyond prevention to management. Can J Gen Intern Med. 2020; 159 (3): 45–48.

17. Saugel B., Scheeren T. W. L., Teboul J.-L. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017; 21 (1): 225. DOI: 10.1186/s13054-017-1814-y. PMID: 28844205.

18. Wang L., Liu Z.-S., Wang C.-A. Malposition of central venous catheter: Presentation and management. Chin Med J (Engl). 2016: 129 (2): 227–234. DOI: 10.4103/0366-6999.173525. PMID: 26830995.

19. Chen W.-M., Chiang M.-S., Wang P. C., Wei K.-L., Tung S.-Y., Chang T. S., Hung C.-H. Esophageal perforation caused by a central venous catheter: A case report and literature review. Adv Dig Med. 2020; 7 (2): 93–96. DOI: 10.1002/aid2.13160.

20. Kayashima K. Evaluation of mechanical complications during pediatric central venous catheter placement from 1994 to 2013. Int J Anesthesiol Res. 2013; 1 (1): 34–36. DOI: 10.14205/2310-9394.2013.01.01.5

21. Karapinar B., Cura A. Complications of central venous catheterization in critically ill children. Pediatr Int. 2007; 49 (5): 593–599. DOI: 10.1111/j.1442-200X.2007.02407.x.PMID: 17875082.

22. Yelgeç N. S., Osken A., Turkkan C., Alper A. T. Subclavian vein puncture-induced massive pulmonary hemorrhage and hemoptysis during pacemaker implantation. North Clin Istanb. 2018; 5 (3): 254–255. DOI: 10.14744/nci.2017.86619.PMID: 30688923.

23. Bagchi A., Agarwal R. K., Talwar K. K. Hemoptysis after subclavian vein puncture for pacemaker implantation: a case report. J Cardiol Cardiovasc Med. 2019; 4 (3): 192–194. DOI: 10.29328/journal.jccm.1001065.

24. Bawa A. S., Jain V., Gutierrez G. Local pulmonary hemorrhage as a complication of subclavian vein catheterization. Chest. 2007; 132 (4): 695A. DOI: 10.1378/chest.132.4_MeetingAbstracts.695a

25. Goldberg A., Rosenfeld I., Marmor A. Hemoptysis — a rare complication of pacemaker implantation. Indian Pacing Electrophysiol J. 2008; 8 (1): 75–76. PMID: 18270606.

26. Kossaify A., Nicolas N., Edde P. Hemoptysis after subclavian vein puncture for pacemaker implantation: importance of wire-guided venous puncture. Clin Med Insights Case Rep. 2012; 5: 119–122. DOI: 10.4137/CCRep.S10006. PMID: 22859867.

27. Truong A. T., Brown D. L. Catastrophic hemothorax from lobar pulmonary artery puncture during attempted subclavian vein catheterization: the fallibility of venous blood aspiration. J Clin Anesth. 2009; 21 (5); 377–378. DOI: 10.1016/j.jclinane.2008.10.005. PMID: 19700295.

28. Horner F. On a form of ptosis. Arch Neurol. 1968; 19 (5): 541–542. 10.1001/archneur.1968.00480050111013.

29. Khan T. A., Zameer S., Ijaz U., Zahid M. A., Zameer N. U. A. Iatrogenic Horner’s syndrome after insertion of a central venous catheter: recommendations for clinical practice. Egypt J Intern Med. 2022; 34 (1): 55. DOI: 10.1186/s43162-022-00144-6

30. Zou Z. Y., Yao Y. T. Horner syndrome caused by internal jugular vein catheterization. J Cardiothorac Vasc Anesth. 2020; 34 (6): 1636–1640. DOI: 10.1053/j.jvca.2019.06.031. PMID: 31350153.

31. Narouze S., Vydyanathan A., Patel N. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain Physician. 2007; 10 (6): 747–752. PMID: 17987096.

32. Paraskevas G. K., Raikos A., Chouliaras K., Papaziogas B. Variable anatomical relationship of phrenic nerve and subclavian vein: clinical implication for subclavian vein catheterization. Br J Anaesth. 2011; 106 (3): 348–351. DOI: 10.1093/bja/aeq373. PMID: 21233111.

33. Takasaki Y., Arai T. Transient right phrenic nerve palsy associated with central venous catheterization. Br J Anaesth. 2001; 87 (3): 510–511. DOI: 10.1093/bja/87.3.510. PMID: 11517143.

34. Bykov M. V., Lazarev V. V., Madorsky K. S., Bagaev V. G., Bykova L. V. Injure to the vagus nerve in the puncture and catheterization of the internal jugular vein: Russ J Pediatr Surg Anesth Intensive Care = Rossiyskiy Vestnik Detskoy Khirurgii Anesteziologii i Reanimatologii. 2017; 7 (3): 54–62. (in Russ.&Eng.). DOI: 10.17816/psaic334.

35. Leone V., Misuri D., Console N. Radial artery pseudoaneurysm after a single arterial puncture for blood-gas analysis: a case report. Cases J. 2009; 2: 6890. DOI: 10.4076/1757-1626-2-6890. PMID: 19829877.

36. Levis J. T., Garmel G. M. Radial artery pseudoaneurysm formation after cat bite to the wrist. Ann Emerg Med. 2008; 51 (5): 668–670. DOI: 10.1016/j.annemergmed.2007.11.031. PMID: 18325629.

37. Eisenberg L., Paulson E. K., Kliewer M. A., Hudson M. P., DeLong D. M., Carroll B. A. Sonographically guided compression repair of pseudoaneurysms: further experience from a single institution. AJR Am J Roentgenol. 1999; 173 (6): 1567–1573. DOI: 10.2214/ajr.173.6.10584803.PMID: 10584803

38. Lenartova M., Tak T. Iatrogenic pseudoaneurysm of femoral artery: case report and literature review. Clin Med Res. 2003; 1 (3): 243–247. DOI: 10.3121/cmr.1.3.243. PMID: 15931315.

39. Mol T. N., Gupta A., Narain U. Brachial plexus compression due to subclavian artery pseudoaneurysm from internal jugular vein catheterization. Indian J Nephrol. 2017; 27 (2): 148–150. DOI: 10.4103/0971-4065.179334. PMID: 28356671.

40. Al-Thani H., Hussein A., Sadek A., Barah A., El-Menyar A. Balloonassisted percutaneous thrombin injection for treatment of iatrogenic left subclavian artery pseudoaneurysm in a critically ill COVID-19 patient. Case Rep Vasc Med. 2021; 2021: 4245484. DOI: 10.1155/2021/4245484. PMID: 34659861.

41. Weger N., Klaassen Z., Slurt C., Hertz S. Endovascular treatment of a pseudoaneurysm after an iatrogenic axillary artery injury. Ann Vasc Surg. 2010; 24 (6): 826. e9–12. DOI: 10.1016/j.avsg.2009.12.019. PMID: 20471203.

42. Balethbail S., Singha S. K., Gayatri P. Vertebral artery pseudoaneurysm a complication after attempted internal jugular vein catheterization in a neurosurgical patient. J Neurosurg. Anesthesiol. 2011; 23 (1): 53. DOI: 10.1097/ANA.0b013e3181f20616. PMID: 21252709.

43. Scholten H. J. Pourtaherian A., Mihajlovic N., Korsten H. H. M., Bouwman R. A. Improving needle tip identification during ultrasound-guided procedures in anaesthetic practice. Anaesthesia. 2017; 72 (7): 889–904. DOI: 10.1111/anae.13921. PMID: 28542716.

44. Lakhin R. E., Antipin E. E., Bautin A. E., Koryachkin V. A., Uvarov D. N., Teplykh B. A., Ulrikh G. E., et al. Clinical guidelines for catheterization of blood vessels under ultrasound control. All-Russian public organization «Federation of Anesthesiologists and Intensive Care Specialists». 2015. (in Russ.). eLIBRARY ID: 26002350.