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 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 58-60

Thoracoscopy and fluoroscopy assisted broviac central line insertion utilizing bedside echocardiogram to prevent cardiac tamponade

1 Department of Pediatric Critical Care, King Fahad Medical City, Riyadh, Saudi Arabia
2 Department of Pediatric Surgery, King Fahad Medical City, Riyadh, Saudi Arabia

Date of Submission13-Mar-2021
Date of Decision19-Dec-2021
Date of Acceptance04-Jan-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Muhammed Nishil Aboo
Department of Pediatric Critical Care, King Fahad Medical City, P O BOX: 59046, Riyadh 11525
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sccj.sccj_8_21

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Prolonged and multiple requirements of central venous catheters in some patients gradually make access to the central vein problematic due to possible formation of obstructive thrombi. Here, we describe a case of chronic intestinal failure and difficult access of central vein, where cardiac tamponade (CT) developed even after thoracoscopy and fluoroscopy-guided insertion of a Broviac catheter. This report points out the importance of a postprocedural echocardiogram after central venous line placement in difficult cases to detect fatal complications such as CT.

Keywords: Cardiac tamponade, central venous catheter, echocardiogram, fluoroscopy, thoracoscopy

How to cite this article:
Aboo MN, Al-Hasani M, Zahraa J, Al-Jubab A. Thoracoscopy and fluoroscopy assisted broviac central line insertion utilizing bedside echocardiogram to prevent cardiac tamponade. Saudi Crit Care J 2022;6:58-60

How to cite this URL:
Aboo MN, Al-Hasani M, Zahraa J, Al-Jubab A. Thoracoscopy and fluoroscopy assisted broviac central line insertion utilizing bedside echocardiogram to prevent cardiac tamponade. Saudi Crit Care J [serial online] 2022 [cited 2023 Jun 4];6:58-60. Available from: https://www.sccj-sa.org/text.asp?2022/6/2/58/357646

  Introduction Top

Children who are chronically dependent on parenteral nutrition (PN) essentially require central venous catheter (CVC). They are prone to develop thrombosis of central veins due to recurrent infections and frequent replacement of the catheter, which later result in accessing central veins extremely difficult.[1] In such cases, certain innovative methods of CVC insertion have been described in the literature including thoracoscopic-assisted percutaneous cannulation of the intrathoracic vessels.[2],[3],[4] Out of numerous complications related to CVC, cardiac tamponade (CT) is a rare but well-documented complication that is often fatal.[5] We present a pediatric case of chronic intestinal failure with difficult central venous access who developed CT postthoracoscopy and fluoroscopy-guided CVC insertion, which was detected by bedside echocardiogram.

  Case Report Top

A 7-year-old child with chronic intestinal failure related to microvillus inclusion disease and on PN was admitted in the pediatric intensive care unit (PICU) for observation following right-sided thoracoscopy and fluoroscopy assisted Broviac CVC insertion.

He was dependent on PN since infancy. As a result of frequent securements of CVC, he had multiple centralized venous thrombi, including the upper part of superior vena cava (SVC), detected by computed tomography with contrast. The expertise of pediatric surgeons was called upon. Under general anesthesia, through right-sided thoracoscopy, the upper part of the mediastinum and right atrium (RA) was visualized. The needle was inserted from the right supraclavicular area through the mediastinum traversing the thrombus into the lower part of SVC by direct thoracoscopic visualization; free backflow of blood aspirated confirmed that the needle crossed the thrombi. The guidewire was inserted under fluoroscopic guidance [Figure 1] until it reaches the RA. After dilation, the CVC was placed and the position of the tip was reconfirmed with the aid of fluoroscopy. After securing the CVC and checking the blood flow, the patient was shifted to PICU for close observation. Blood gas assessment from CVC was concordant with venous blood. Chest x-ray (CXR) findings were consistent with the position of CVC on the right side of the mediastinum [Figure 2]. He was closely monitored in the PICU; the rhythm was normal on the electrocardiogram (ECG) monitor and he was hemodynamically stable, became fully conscious, alert, and oriented. Good inflow and backflow were noted from the CVC. He was started on maintenance IV fluid through the CVC.
Figure 1: Fluoroscopic image shows the position of the guidewire

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Figure 2: Central Venous Catheter Position on Chest X-ray

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After a few hours of the onset of IV fluid, he expressed uneasiness and became irritable. He soon became tachycardic and blood pressure started dropping. Considering his hemodynamic disturbance, he was given fluid bolus through the CVC suspecting hypovolemia. However, this worsened the situation and he became more tachycardic, tachypneic, hypotensive, and drowsy. On auscultation, heart sounds were distant. Pulsus paradoxus wave on pulse oximeter plethysmograph and low-voltage tracings on ECG monitor became evident. Meanwhile, the blood sample taken from the CVC was so diluted that hemoglobin was low, which was not accordant with the blood sample taken from the peripheral line. CT due to malposition of the CVC was suspected; his fluid bolus through CVC was immediately stopped, a peripheral IV cannula was secured, and fluid bolus was started. An urgent bedside echocardiogram was done, which revealed the CVC in the pericardial sac [Figure 3]. A saline flush test was also done, but there was no turbulence in the RA which corroborated the position of CVC tip in the pericardial cavity. The pericardial fluid was aspirated immediately through the same line; his clinical condition improved, hemodynamic parameters normalized and later, he was transferred to the ward.
Figure 3: Echocardiogram shows the misplaced Central Venous Catheter in the Pericardial Sac

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  Discussion Top

PN is essential for children with chronic intestinal failure to meet their caloric needs. Long-term PN demands an adequate central venous access, but maintaining this is an arduous task for the care providers. This is usually due to recurrent episodes of line sepsis and multiple replacements of CVCs, which eventually leads to venous thrombosis.[1] In patients that do develop significant thrombosis of the vessels, insertion of CVC proved to be extremely difficult. Certain innovative methods of obtaining central venous access have been described in such cases.[2]

Thoracoscopic-assisted percutaneous cannulation of the intra-thoracic vessels has been reported before and proved to be successful.[3] A similar technique implemented in our patient; the percutaneous insertion of the catheter from the neck into the RA traversing a thrombosed SCV using video-assisted thoracoscopic surgery has also been reported.[4] A recent study suggested that the use of transesophageal echocardiography in totally implantable venous access port implantation could ensure accurate placement of the catheter in the SVC or RA and correct localization of the catheter tip.[6]

Interventional radiologists have been using combined ultrasound and fluoroscopy for CVC placement and claim that peri-procedural complications, i.e., complications occurring during or within the first 24 h after the implantation, are virtually negligible under image guidance.[7] Surgeons involved in our case also adopted fluoroscopy guidance, which enabled them to visualize the intravenous guide wire and location of the catheter tip, as well as immediate evaluation of the line function. CXR after CVC placement under fluoroscopy guidance to confirm the position and tip of the catheter is not normally recommended in asymptomatic patients and is considered as a superfluous procedure.[8] However, in this particular case of difficult access, we followed it up with a CXR.

CT related to CVC is a well-known complication. Nevertheless, its incidence in the literature is variable and remains low because it was not recognized or not disclosed.[9] Analysis of closed malpractice claims for CVC injuries shows CT leading to a higher proportion of death (81%) than claims for other CVC injuries combined. One-third of those claims involved pediatric patients ranging in age from 2 months to 6 years.[10] Multiple CVC-related CTs have been reported before; in our case, CT was found in a patient after thoracoscopy and fluoroscopy-guided placement of CVC. These procedures in fact misled into wrongly positioning the guidewire and CVC in the pericardial sac. Pericardial hemorrhage associated with the procedure led to an outflow of blood during aspiration through the CVC and revealed a venous type on blood gas analysis. This further obscured the real position of CVC in the pericardial sac.

Close monitoring and keeping a high index of suspicion for complications are essentially required in all cases of difficult CVC insertion. We concluded to the importance of postprocedural bedside ultrasonogram in CVC insertion, especially in difficult cases such as thrombosed central veins. The absence of bubbles under sonographic visualization of a saline flush in the RA after CVC placement could serve as an indicator of extravascular or extracardiac placement of the catheter,[11],[12] as was the case of our patient. It also necessitates the intensivists to be proficient in bedside ultrasonogram to prevent fatal complications such as CT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ross P Jr., Ehrenkranz R, Kleinman CS, Seashore JH. Thrombus associated with central venous catheters in infants and children. J Pediatr Surg 1989;24:253-6.  Back to cited text no. 1
Rodrigues AF, van Mourik ID, Sharif K, Barron DJ, de Giovanni JV, Bennett J, et al. Management of end-stage central venous access in children referred for possible small bowel transplantation. J Pediatr Gastroenterol Nutr 2006;42:427-33.  Back to cited text no. 2
Bax NM, van der Zee DC. Thoracoscopic guided percutaneous cannulation of the azygos vein in children. Surg Endosc 1996;10:863-4.  Back to cited text no. 3
Alqahtani AR. Thoracoscopic-assisted central line placement for a thrombosed superior vena cava. J Pediatr Surg 2008;43:1405-7.  Back to cited text no. 4
Adar R, Mozes M. Fatal complications of central venous catheters. Br Med J 1971;3:746.  Back to cited text no. 5
Yang S, Kong X, Liu L, Xu Y, Zhang J. Application of transesophageal echocardiography for localization in totally implantable venous access port implantation through subclavian approach in children. Clin Cardiol 2021;44:129-35.  Back to cited text no. 6
Gebauer B, El-Sheik M, Vogt M, Wagner HJ. Combined ultrasound and fluoroscopy guided port catheter implantation – High success and low complication rate. Eur J Radiol 2009;69:517-22.  Back to cited text no. 7
Dalton BG, Gonzalez KW, Keirsy MC, Rivard DC, St. Peter SD. Chest radiograph after fluoroscopic guided line placement: No longer necessary. J Pediatr Surg 2016;51:1490-1.  Back to cited text no. 8
Booth SA, Norton B, Mulvey DA. Central venous catheterization and fatal cardiac tamponade. Br J Anaesth 2001;87:298-302.  Back to cited text no. 9
Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA, Cheney FW. Injuries and liability related to central vascular catheters: A closed claims analysis. Anesthesiology 2004;100:1411-8.  Back to cited text no. 10
Blans MJ, Endeman H, Bosch FH. The use of ultrasound during and after central venous catheter insertion versus conventional chest X-ray after insertion of a central venous catheter. Neth J Med 2016;74:353-7.  Back to cited text no. 11
Iacobone E, Elisei D, Gattari D, Carbone L, Capozzoli G. Transthoracic echocardiography as bedside technique to verify tip location of central venous catheters in patients with atrial arrhythmia. J Vasc Access 2020;21:861-7.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]


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