Successful Bleeding Control by a Combined Conventional Surgical Approach and Video-Assisted Surgery: A Case Report

Maurizio Cheli, MD,1 Daniele Alberti, MD,1 Tartufari Adriana, MD,2 Elvira Zaranko, MD,1 Mara Colusso, MD,1 Rossella Arnoldi, MD,1 Daniela Codazzi, MD,2 and Giuseppe Locatelli, MD1

The use of central venous catheters (CVCs) nowadays is a routine practice in the treatment of severely acute-diseased children. However, the procedure still carries a risk of morbidity, and severe complications are reported. When respiratory and/or hemodynamic instability develop after the procedure, prompt patient evaluation to exclude iatrogenic damage is mandatory, regardless of the primary patient condition. If a vascular injury related to CVC placement procedure is detected, the availability of an interventional radiologist and/or any surgical facilities plays an important role in the management of this life-threatening complication. We report the case of a 12-year-old boy hospitalized in the Pediatric Intensive Care Unit of our hospital for a severe motorveicle accident, who, about 30 minutes from the percutaneous CVC placement, developed tachycardia, hipoxemia, and hypotension. A chest X-ray confirmed the right positioning of the catheter, the presence also of a large left hemothorax. Interventional radiology took place, but it failed to stop the bleeding. Urgent anterolateral thoracotomy was performed while the patient was kept in a supine position because of a cervical spine luxation. During surgery, bleeding was found coming from the thoracic dome and because of a tear next to the left subclavian artery. Access to that area was technically difficult; after blood and clots were removed, multiple attempts to obtain the hemostasis failed, and definitive control of the hemorrhage was achieved only by video-assisted thoracic surgery (VATS). The postoperative period was uneventful. In this study, the authors discuss the management of this kind of complication and the value of a combined surgical approach (conventional, with a minimal access surgery procedure such as VATS) in the treatment of thoracic vascular injuries related to the insertion of a percutaneous CVC. To the best of our experience, this is the first time in which this combination of procedures has been reported in the literature. (Ann Thorac Cardiovasc Surg 2009; 15: 253-256)

Key words: central venous catheter, percutaneous cannulation, vascular injury, hemothorax, video-assisted thoracic surgery

1Department of Pediatric Surgery and 2Pediatric Intensive Care Unit, Azienda Ospedaliera, Ospedali Riuniti di Bergamo, Bergamo, Italy

Received March 27, 2008; accepted for publication July 11, 2008
Address reprint requests to Maurizio Cheli, MD: Department of Pediatric Surgery, Azienda Ospedaliera, Ospedali Riuniti di Bergamo, L.go Barozzi, 1 24128 Bergamo, Italy.