Complications of Central Venous Catheterization
Roberto E Kusminsky, MD, MPH, FACS
It is estimated that millions of central venous catheters
(CVCs) are inserted yearly in US hospitals.1 The pro-
found impact of the complications associated with CVC
use is so important that efforts to minimize and prevent
their occurrence should be a routine element of quality
improvement programs. This review aims at centralizing
the evidence currently available and presenting it as a
ready reference that could assist in estimating the mag-
nitude of the problem and formulating prevention ini-
tiatives. Additionally, emphasis is placed on the grow-
ing body of information that supports the use of
ultrasonography-assisted insertion (UAI) as a superior
technique to decrease adverse events from CVC inser-
tion. From a clinical and practical point of view, which
better correlates with usage issues, CVC complications
are best classified as secondary to insertion, indwelling,
and extraction practices.
RISK FACTORS
The incidence of mechanical complications is modified
by a variety of factors:
1. Inexperience, variably defined but with a consistent
relationship between less experience and the rate of
complications.2,3
2. Number of needle passes, with the incidence of com-
plications rising with two venopunctures2-5 to a six-
fold increase with three or more.6
3. Body mass index ⬎ 30 or ⬍ 20,4,7 previous catheter-
izations, and severe dehydration or hypovolemia are
factors that increase risk.
4. Coagulopathies do not appear to increase the risk of
percutaneous insertion8-11 if appropriate precautions
are taken,12 such as transfusing thrombocytopenic
patients with platelets until a count of 50,000 or
Competing Interests Declared: None.
Received October 24, 2006; Revised January 16, 2007; Accepted January 17,
2007.
From the Department of Surgery, West Virginia University, Robert C Byrd
Health Sciences Center, Charleston Division and Charleston Area Medical
Center, Charleston, WV.
Correspondence address: Roberto E Kusminsky, MD, MPH, FACS, West
Virginia University, 3110 MacCorkle Ave, Charleston, WV 25304.
© 2007 by the American College of Surgeons
Published by Elsevier Inc.
higher is reached, and fresh-frozen plasma in patients
with elevated prothrombin and partial thromboplas-
tin times. Administration of antihemophilic globulin
before subclavian vein (SCV) catheterization has led
to reports with similar conclusions in patients with
hemophilia.13 Even heparinization does not appear to
increase the risk of bleeding or hematoma during
internal jugular vein (IJV) insertion.14 Although co-
agulopathies are not a clear contraindication,15 the
IJV or femoral vein (FV) appears to be the compress-
ible access site chosen by many authors for patients
with coagulation disorders.16,17
5. Large catheter size, such as those used for dialysis,
appears to influence the risk of vascular complica-
tions of insertion.18
6. Failure to catheterize is influenced by factors such as
experience,2,3,19 previous catheterizations, previous
catheterization attempts, and previous operation or
radiotherapy in the anatomic region of interest.4,6
7. Unsuccessful insertion attempts are the strongest pre-
dictor of insertion complications.6 Overall rates of
unsuccessful insertion attempts for IJV access have
been reported at 12%20 and 12% to 20% for SCV
and IJV in adults19 and infants weighing ⬍ 10 kg.21
Among patients who fail attempts at catheterization,
complications develop in 28%.6
Overall incidence
Complications associated with CVC insertion fluctuate
according to their definition and the correlation with the
multiple factors that influence their occurrence, ranging
between 5% and 19%.19,22 Femoral catheterization has a
higher incidence of mechanical complications than SCV
or IJV access,22 and can be associated with severe injury
if an inadvertent femoral artery puncture is too high and
is followed by anticoagulation.23 IJV and SCV catheter-
ization carry similar risks of mechanical complications,1
although IJV insertion has been reported to have a
higher incidence of mechanical complications than SCV
in elective24 and emergency situations.25 A prospective,
comparative study suggests that during cardiac arrest the
catheterization success rate can be higher for SCV than
for FV access.26
ISSN 1072-7515/07/$32.00
681 doi:10.1016/j.jamcollsurg.2007.01.039
682 Kusminsky Complications of Central Venous Catheterization
Abbreviations and Acronyms
CVC ⫽ central venous catheter
FV ⫽ femoral vein
IJV ⫽ internal jugular vein
SCV ⫽ subclavian vein
UAI ⫽ ultrasonography-assisted insertion
Because the complication rate decreases with train-
ing,27,28 designing a standardized method of CVC inser-
tion29 is a logical process to promote prevention and
decrease the incidence of adverse events.1,30,31 Standard-
ization can also establish management guidelines for
some complications that commonly follow CVC inser-
tion, such as pneumothorax.32 Standardization can es-
tablish a best-practice approach based on evidence, and
it can provide an answer to the questions sometimes
raised about the competence of house officers.
The advantages of UAI of CVCs have been reported
as far back as 1978,33 and the body of literature support-
ing its adoption continues to expand. There is now
abundant evidence to establish UAI as the safest method
to prevent or decrease overall and specific complications
of insertion. Reports of the advantages of ultrasonogra-
phy over the anatomic landmark method support the
findings of risk reduction20,34 and improved cannulation
success20,34-36 for all access sites—FV37, SCV, IJV36—in
adults and children36,38 and in different settings.39 In
addition, the gap between experienced and inexperi-
enced operators has been reported to disappear when
UAI is used.40 Conversely, UAI can be of help to a skillful
operator who is otherwise unable to cannulate.41 There
are reports disputing these results,42 although some of
the discrepancies have been reported in studies in which
ultrasonography was not used in real-time mode.6
Insertion complications
Pneumothorax is one of the most common complica-
tions of CVC insertion, reportedly representing up to
30% of all mechanical adverse events.43,44 Its incidence
varies between 0%7,24 and 6.6%,45,46 with higher inci-
dences when the number of needle passes increases,4 in
emergency situations,47-49 and when the catheters in-
serted are large, such as those used for dialysis.45 A 1% to
1.5% incidence is more consistently reported.6,32,50 Most
of the evidence points toward a higher incidence of
pneumothorax when the SCV is cannulated, as com-
pared with the IJV.5,24 SCV catheterization has occasion-
J Am Coll Surg
ally been linked to a lower incidence of pneumothorax
than IJV access.51
Delayed pneumothorax has been reported to occur in
0.5%44,52 to 4% of the insertions,45 but the incidence is
quite a bit lower in some studies.53 Symptoms com-
monly appear within 6 hours but not in all patients,53
which calls for the need to exercise caution and increased
awareness in those cases where the insertion was diffi-
cult,54 despite the ostensible early lack of complications.
A standardized treatment algorithm of CVC-induced
pneumothorax can lead to good results with safety, im-
provements in patients’ comfort, and decreases in length
of stay in adults32,55-57 and children.58 Such an algorithm
should include elements of awareness and treatment of
reexpansion pulmonary edema,59,60 particularly if pa-
tients are treated on outpatient basis.57 Re-expansion
pulmonary edema is estimated to occur in 1% to 14% of
patients with pneumothorax.59,61
Clinician-performed bedside ultrasonography allows
the diagnosis of pneumothorax to be made immediately,
with a high degree of sensitivity and with better accuracy
than supine chest films and equal to that of CT scan.62-64
This approach has not yet gained widespread accep-
tance, is operator-dependent, and patient selection and
equipment can influence the results.65
Malpositioning of a CVC has been associated for
years with problems of local toxicity, perforation, and
venous thrombosis and its sequelae. In the past, a con-
siderable percentage of catheters were left within the
right atrium,66 but today the consensus in the literature
opposes this practice67 because of the increased risk of
perforation. The debate about the validity of this recom-
mendation continues to surface68,69 and many believe
that the purported advantages of a CVC tip in the
atrium are associated with minimal risks.69-71 These dis-
agreements produce difficulties with the interpretation
of the true incidence of malposition, particularly if the
analysis includes information derived from older series,
when the definition of malposition, catheter length, and
angle of incidence was not a common element of discus-
sion, and when repositioning was not a major concern.72
Today, malposition includes the recognition that an an-
gle of incidence of the CVC tip against the wall of the
vessel ⬎ 40 degrees carries an increased risk of perfora-
tion.73 To avoid the tip from abutting against the wall of
the vein at an inappropriate angle, it is best to approach
left-sided insertions with a 20-cm catheter and the right-
sided ones with a 16-cm catheter74,75 in adult patients.
Vol. 204, No. 4, April 2007 Kusminsky
Just as catheter length bears a direct relationship to tip
position,76 such might be the case as well with catheter
diameter and tip malposition in children ⬍ 10 kg.77
When a CVC is inserted without image-guided assis-
tance, as it regularly happens, the initial estimate of in-
sertion depth must be made in the clinical setting fol-
lowing unreliable anatomic landmarks. One such
approximation is made by premeasuring to a central des-
tination point located just above one-third of the dis-
tance between the manubrium and the xyphoid, where
the caval-atrial junction can be expected to be. It is com-
mon practice, then, to assess the final position of the
catheter’s tip radiologically, accepting that the pericar-
dial reflection is below the carina.74 A more precise mea-
surement emerges from the study by Aslamy and col-
leagues,78 which establishes convincingly that the right
tracheobronchial angle is the most reliable landmark to
assure that a catheter’s tip is at least 2.9 cm above the
pericardial reflection, even if it appears to lie within the
cardiac silhouette. Similarly, 20% of catheter tips con-
firmed to be in the atrial-caval junction by transesopha-
geal echocardiography are still visualized in the midpor-
tion of the right atrium on supine chest films.79 From a
practical point of view, it is prudent to judge the final
position of the catheter in light of the fact that the tip
practically always migrates, peripherally, as demon-
strated by changes between supine and upright postpro-
cedure imaging.71,80
In general, there appears to be less opportunity for
malposition with jugular than with subclavian access.50
Subclavian entry is followed by misplacement of the
CVC into the ipsilateral jugular vein in up to 15% of the
catheterizations.81 This can be avoided in a major frac-
tion of patients by simply assuring that the J tip of the
guidewire is pointing caudad during insertion.82 Addi-
tionally, turning the head toward the insertion side nar-
rows the os of the IJV,83 and manual compression of the
jugular can avoid misdirection as well while the guide-
wire is threaded.84 UAI has been reported to be effective
in detecting anatomic variants85 and in steering the suc-
cessful placement of the tip to avoid catheter misplace-
ment in adults86 and children.87
Postprocedure films are useful to check for complica-
tions and misplacement.81 Congenital anatomic varia-
tions can confound the radiologic interpretation of the
tip’s location. Of these, the most common clinically sig-
nificant anomaly of the great systemic veins is the per-
sistence of a left superior vena cava, which is seen in
Complications of Central Venous Catheterization 683
0.3% of patients; the incidence is higher when cardiac
congenital abnormalities are present.88 In children cath-
eterized through a FV, unusual but serious complica-
tions secondary to misplacement might be preventable
by postprocedure films and contrast injections.89 Pediat-
ric peripherally-inserted central catheters inserted with-
out image guidance require repositioning of the tip in as
many as 85% of the patients.90
Vascular injuries during CVC insertion encompass a
wide spectrum of complications, with arterial puncture
the most common. It occurs more frequently with IJV
and FV22,91 access than with SCV,50 and even though this
complication is usually self-limiting, it should not be
dismissed as inconsequential because it can lead to sub-
stantial morbidity92 or death,93,94 even if the puncturing
needle is of a relatively small gauge95 or the catheter is
correctly placed in its intended venous location.96
Puncture of the carotid artery during IJV catheteriza-
tions attempts averages 6% in prospective studies,97 al-
though higher rates have been reported with the land-
mark method20,91 and as high as 18% to 25% in
infants.21,91 Of greater clinical significance is the fact that
up to 40% of carotid punctures are associated with a
hematoma; 10 of 25 in one study.20 This, in conjunction
with manual pressure, has been interpreted as the mech-
anism responsible for the appearance of cerebrovascular
neurologic deficits97-99 and death.100 Puncture of the sub-
clavian artery during SCV catheterization attempts oc-
curs in 0.5% to 4% of the patients.6,22,50 Hemothorax
after CVC insertion is mostly an expression of an inad-
vertent arterial injury, which has been reported to occur
approximately in 1% of central catheterizations,50 some-
times leading to uncommonly severe consequences, such
as quadriplegia.101
It stands to reason that the best way to care for arterial
perforations during CVC insertion is to avoid them, and
the first preventive step to be taken is to recognize that
the needle entering the vessel is actually in a vein. More
often than not, the operator can rapidly determine that
the vessel is an artery because of pulsatile back flow, but
that is not always the case. A variety of methods, and
their pros and cons, have been described to facilitate
recognition of an inadvertent arterial puncture,102,103 but
none is foolproof. UAI remains the best prevention prac-
tice currently available,1,20,35,40 although these advantages
are not universally reproduced.104
Large-bore arterial perforation or cannulation of the
carotid or subclavian occurs in approximately 0.1% to
684 Kusminsky Complications of Central Venous Catheterization
1% of cases.18,91,105-108 Uncommon as it is, this compli-
cation is associated with potentially devastating conse-
quences: approximately 30% of these patients can be
expected to become symptomatic—bleeding,109 neuro-
logic findings or other sequelae106,108—and if so, the
mortality rate reaches 20% to 40%.18,105,107 Stroke or
neurologic deficits associated with large-bore arterial in-
jury can be estimated to occur in 27% of the patients106
and is reported often,97,100,110,111 particularly in associa-
tion with infusions through the cannulated artery.112,113
Most arterial large-bore perforations can be attributed
to the unsafe manipulation of the dilators,105,114-117
which should only be used to widen the skin and SC
tissues but frequently are inserted unnecessarily far,
sometimes even causing ventricular perforation.118
Other possible mechanisms of injury include kinking of
the guidewire resulting in misdirection of the dilator and
perhaps insertion of the wire outside the vessel.119,120
Arterial puncture and perforation during CVC inser-
tion appears to be mostly a right sided phenome-
non,91,121,122 which coincides with the anatomic differ-
ences of the vascular system at either side of the midline.
On the right, the subclavian-jugular venous junction
overlies the subclavian artery, making this vessel more
prone to injury than it is on the left. The right SCV
enters the innominate at a sharper angle than its coun-
terpart on the left, which would make it then more vul-
nerable to perforation if a firm dilator is inserted too
deeply.105,121
Whatever management choices are made to treat
these arterial complications, it is prudent to leave the
offending catheter in place until the next step is
taken.103,106,116,123 Individual patient circumstances
might dictate the selection of surgical procedure,106
thrombin injection,124 percutaneous suture devices,125
stent graft placement,126 or balloon tamponade123 as the
best way to handle these emergencies.
Perforation of the aorta during CVC insertion ap-
pears in the literature more often than would have been
expected,127-130 suggesting some degree of underreport-
ing. It sometimes presents with a simultaneous perfora-
tion of the superior vena cava.130 If the perforation oc-
curs within the pericardial reflection there will be an
associated cardiac tamponade, in which case the mortal-
ity rate reaches 90%.131,132 Aortic injuries, as with arterial
perforations in general, are also attributable to the im-
proper use of the dilator, although they can also occur
with a needle133 or a large catheter.134 Most reports of
J Am Coll Surg
aortic perforation describe multiple insertion attempts
and have been right-sided,133,135 although a left-sided en-
try does cause this injury as well. The diagnosis of an
aortic injury and the estimation of its extent requires
careful assessment, as is the case with any arterial injury
after attempted venous catheterization; it is not uncom-
mon for a chest x-ray to be misleading,106,136 and often
the artery is entered after the vein is perforated.106,109,121
Ultrasonography and CT scanning have been used with
success, but the more central the injury the best way to
study the damage is a contrast study, if there is time.
Both percutaneous closure137 and balloon tamponade138
have been described as a treatment approach to aortic
injuries.
Injuries to the pulmonary artery result more com-
monly from the use of pulmonary artery catheters,139-141
although occasionally the vessel is punctured directly
during CVC insertion attempts.142 The estimated inci-
dence of pulmonary artery catheter-associated injury—
hemorrhage and infarct—is 0.1% to 0.2%, with a mor-
tality rate of 42%.139,141
Pseudoaneurysms143, AV fistulas144 and vertebral ar-
tery injuries145 are rare complications of inadvertent ar-
terial perforation or cannulation. AV fistulas can develop
shortly or years after catheterization attempts.144 They
have been estimated to occur in 0.2% of IJV146 and 0.6%
of SCV catheterization attempts.147 Vertebral artery in-
juries are sometimes associated with acute neurologic
injury, but more frequently they have a delayed presen-
tation as a fistula after SCV or IJV attempts, or as a
pseudoaneurysm.148
The treatment of most pseudoaneurysms of central
arteries has evolved into progressively less invasive and
effective approaches.148,149 Ultrasonography-guided per-
cutaneous thrombin injection has been used in the ca-
rotid artery,150 but this technique is viewed with unease
because of its potential for embolization into the cerebral
circulation.149 Similarly, the use of stents to treat
pseudoaneurysms and AV fistulas is a reasonable ap-
proach if the grafts do not obstruct the takeoff of the
vertebral or carotid arteries,148 although stenting the ca-
rotids directly to treat these problems has been
successful.151
Dysrhythmias accompany CVC insertion fairly often
and more so when pulmonary artery catheters are used.
Even palpation and pressure on the carotid artery during
insertion of a pulmonary artery catheter has resulted in
ventricular fibrillation and cardiac arrest.152
Vol. 204, No. 4, April 2007 Kusminsky
The incidence of cardiac ectopy during catheteriza-
tion is clearly related to the guidewire insertion depth,
reaching 75% as the wire is advanced between 25 cm
and 32 cm from an IJV entry site, the usual finding
being the occurrence of premature atrial contractions.153
Ventricular ectopy can be triggered in up to 25% of
patients, suggesting the possibility that a malignant ar-
rhythmia could arise.154 Only a small percentage of all
arrhythmias are symptomatic155 and almost invariably
these difficulties cease after the guidewire is withdrawn.
Occasionally, serious problems arise during guidewire
insertion in patients at risk, such as a complete heart
block,156 and even sudden death.157
Indwelling catheters have been reported to cause ar-
rhythmias in 0.9% of patients, with some necessitating
therapeutic intervention in addition to removal.158
Rarely, inserting a guidewire in a patient with an im-
planted cardioverter device can lead to the most unusual
situation of inducing an arrhythmia while delivering a
shock to the operator.159
The rarity of serious sequelae and the usually transient
nature of the arrhythmias induced by CVC insertion
commonly permeate institutional cultures with feelings
that these consequences are negligible. In the past, the
medical literature reported seeking out ectopy during
guidewire insertion as a marker of correct positioning.160
Considering the possibility of inducing ventricular ec-
topy,154 efforts to avoid overinsertion of the guidewire
would be a prudent strategy.
In contrast with CVCs, pulmonary artery catheters
induce dysrhythmias in 72% of the patients,141 with ven-
tricular ectopy in 65% to 68% of them.141,152 Three per-
cent of all pulmonary artery catheters have persistent
PVCs requiring therapy141 and ventricular tachycardia
develops in 1.5%, with one-fourth of these patients re-
quiring cardioversion.140
The neurologic complications of CVC insertion
more commonly reported—excluding cerebrovascular
accidents—include brachial plexus injury and Horner
syndrome. Brachial plexopathies can follow IJV161 or
SCV162 catheterization, and are mostly transient, partic-
ularly if the local anesthetic is the cause of the symp-
toms.161 Multiple punctures or hematoma163 can lead to
progressively worsening symptoms resulting sometimes
in permanent damage.99,164,165 Typically, IJV insertions
are associated with injury to the upper trunk161 and SCV
access with the lower trunk163 of the brachial plexus. The
Complications of Central Venous Catheterization 685
incidence of brachial plexus punctures is approximately
1.7% and can be decreased substantially by UAI.20
Horner syndrome has been reported to occur in 2%
of IJV cannulations,111 but this appears to be somewhat
high an incidence, inconsistent with the realities of cur-
rent clinical practice. Other reports describe the syn-
drome in 2 of 1,000 patients undergoing pulmonary
artery catheterization152 and CVC insertions,16 which
appears to be a more reliable estimate. This complication
is occasionally permanent152 and perhaps likelier to oc-
cur with larger-sized catheters,166 and is sometimes cou-
pled with other neurologic manifestations, such as vocal
cord paralysis.167
Incidence of lymphatic injuries during CVC insertion
is difficult to assess, because most of the available litera-
ture is limited to isolated reports, although it is estimated
that 25% of overall cases of chylothorax are a result of
surgical injury.168 Chylothorax and chylopericardium
can occur as a complication of venous thrombosis in-
duced by a CVC169-171 or by direct damage to the lym-
phatic ducts.168,172,173 Traditional thinking suggests that
lymphatic injuries are associated with left IJV or SCV
insertions and represent thoracic duct damage.168,174,175
Interestingly, a right-sided approach can lead to lym-
phatic duct harm in adults176 and children.172 Right su-
praclavicular access has been associated with a 0.5%
incidence of lymphocutaneous fistula.177 The supracla-
vicular approach appears to be associated with a higher
than expected rate of lymphatic injury, in the range of
1%.178,179 Notably, UAI does not appear to prevent this
complication.174,177,180
Over the past several years, innovative and well–
thought-out methods of treating these complications
have emerged. Proposed and successfully tried therapies
include the use of nitric oxide,181 thoracoscopic fibrin
glue application,182 and percutaneous embolization with
platinum microcoils.183-185
Guidewire loss during insertion of a CVC is a rare
event, occurring approximately twice in several thou-
sand catheterizations.186 Guidewires can loop and be-
come entrapped,187 stick inside the inserted catheter,188
knot and fracture,189 and embolize producing acute ar-
terial insufficiency190 or paradoxically through a patent
foramen ovale.191 Straight-tipped guidewires can cause
cardiac perforation.192 Occasionally, a lost wire presents
in a most bizarre manner: protruding through the
skin.193 Entrapment of a guidewire within a vena cava
filter is a serious complication of vascular access that can
686 Kusminsky Complications of Central Venous Catheterization
lead to displacement or fracture of the intravascular de-
vice, but clinician awareness and careful technique could
make this a largely preventable problem.194
The cornerstone of safe guidewire insertion is to avoid
kinking105,188 and potentially lethal injury,117-120 simulta-
neously assuring that resistance during insertion or re-
moval is met with cautious response.187 Under these cir-
cumstances, the needle-guidewire ensemble must be
removed and the procedure reinitiated. To do otherwise
substantially increases the risks of wire fracture and its
serious sequelae.190,191
Despite admonitions that guidewire loss is a totally
preventable situation if the operator makes sure to hold
onto the wire during insertion and to inspect it after
removal,189,195 these and other precautions are not
enough to avoid the problem entirely. An easily inserted
guidewire, normally shaped after removal, can still be
associated with fracture and embolism196 and multiple
films might not demonstrate the complication,197 so the
diagnosis of a retained foreign body is commonly de-
layed.198 Attempts to design a safer guidewire have been
reported, with good results.199
Indwelling complications
Infection is the main complication of indwelling cathe-
ters, with an incidence of approximately 5.3 per 1,000
catheter days and an attributed mortality of 18% (0% to
35%).200 Most infections arise from the skin insertion
site or the catheter hub, depending on the indwelling
time, and are then perpetuated by biofilm, a bacterial-
derived community embedded in a matrix of extracellu-
lar polymeric substances that they produce.201 This de-
terminant factor could explain the favorable results seen
with the injection of hydrochloric acid to treat CVC
infections.202
FV catheters have a higher risk of infection than SCV
or IJV catheters,1 as do noncuffed catheters compared
with cuffed ones.200 Because the risk of infection is
heightened by thrombosis,203,204 efforts to render the
catheters less thrombogenic have included heparin-
coating, but the risk of activating heparin induced
thrombocytopenia makes their use imprudent.205
Catheter-related bloodstream infections can be pre-
vented: in an elegantly designed study, Berenholtz and
colleagues206 instituted sequential measures in an ICU
population, bringing the incidence of infection down to
virtually zero. Currently, this “bundle” of standard ac-
tions includes educating caregivers in hand hygiene, clo-
J Am Coll Surg
rhexidine preparation, use of full sterile garb precau-
tions, and CVC removal as soon as possible. This
educational module includes a checklist to ensure adher-
ence to evidence-based guidelines.206,207 Other preven-
tive measures found to be effective additions to the pre-
viously mentioned bundle include voiding routine
catheter exchanges and the use of antibiotic ointments
on the entry site, plus the use of clorhexidine impreg-
nated sponges to dress the insertion area.200 Some studies
suggest that adhering to these measures eliminates the
difference in infection rates seen in all three insertion
sites.208 Gram-positive infections and those involving
implanted reservoirs practically always require removal
of the catheter.209
The use of antimicrobial impregnated catheters is still
debated by some authors,210 and the Center for Disease
Control and Prevention guidelines recommends the use
of antimicrobial-impregnated CVCs in selected clinical
situations,200 but a strong body of evidence justifies their
use.207 In a persuasively written viewpoint, Crnich and
Maki207 provide an excellent summary of the numerous
sound studies demonstrating that a substantial number
of blood stream infections can be prevented—40%
at least—with the use of short-term antimicrobial-
impregnated CVCs.
Thrombosis induced by CVCs is a frequent occur-
rence, ranging between 33%1 and 59% of indwelling
catheters, although clinical symptoms develop in just a
small percentage of patients.211 The pathogenesis is mul-
tifactorial, but endothelial injury, turbulence of the ve-
nous flow and catheter thrombogenicity211 play a role, as
does the composition of the infusate212 and the charac-
teristics of the disease process. A fibrin sheath develops
within 24 hours of catheter insertion, and although this
sheath contributes to catheter occlusion, it does not pre-
dict subsequent deep vein thrombosis of the vessel,203
but all CVCs are subjected to malfunction as a result of
this fibrin casing.213
The rate of CVC-induced thrombosis is lower for
SCV than for IJV and FV access.1 The rate of thrombosis
is reported at 1.9% for SCV access22 and 22% to 29%
after 4 to 14 days of indwelling time214 for a femoral
CVC.22,204 Location of the CVC tip within an inlet vein
increases the likelihood of catheter-associated thrombo-
sis 16 times,215 but malfunction is lessened when the
catheter lies in a high-flow central vein.216 Superior vena
cava obstruction can be a substantial problem, estimated
to occur in 1/1,000 indwelling devices.217
Vol. 204, No. 4, April 2007 Kusminsky
Varying degrees of occlusion induced by CVCs are
associated with varying degrees of stenoses,218 although
as many as 30% of the patients without previous cath-
eterizations might have clinically significant venous an-
atomic abnormalities—greater than 50% stenoses and
angulations—that could increase the risks of catheteriza-
tion.219 Twice as many patients—60%—will have de-
fects if they have been catheterized previously,219 partic-
ularly through a subclavian approach.204 Longer catheter
dwell times increase development of central vein abnor-
malities,220 as expected. Stenoses induced by large-bore
catheters are reported in the range of 40% to 50%, and
higher if the CVC has been infected.221 Narrowing de-
velops mostly behind the clavicle, an area difficult to
visualize with ultrasonography.222
In cancer patients, CVCs cause vessel thrombosis in
41% of the patients, with postphlebitic syndrome devel-
oping in 15% to 30% of them and pulmonary embolism
developing in 11%.203 Morbidity and mortality of jugu-
lar and subclavian thrombosis appears to be similar.223
Although treatable, longterm relief for central venous
occlusive disease is rarely achieved.224 Despite this, the
consensus in the medical literature indicates that routine
antithrombotic therapy for oncologic patients with
CVCs is not warranted,225 a conclusion that is likely
applicable to patients without cancer.
Fibrin sheath stripping and urokinase infusion work
equally well to salvage catheter patency,226 and appropri-
ate differentiation between a fibrin sheath and thrombo-
sis is necessary before the initiation of therapeutic ma-
neuvers.213 There is increasing interest in endoluminal
brushing as a method to regain patency of occluded
catheters.227
Vascular erosion and perforation of an indwelling
CVC can be associated with cardiac tamponade, de-
pending on whether the perforation occurs below or
outside the pericardial reflection. Perforation without
tamponade occurs in 0.4% to 1% of catheterizations,
with a resulting mortality rate of 12%.228,229 Erosion fol-
lowed by tamponade is estimated to take place in 0.2%
of patients,230 with an associated mortality under these
circumstances of nearly 90%.131,132 Use of peripherally
placed catheters in neonates carries an overall reported
mortality rate of 0.7%,231 because of the disproportion-
ate higher risk of cardiac tamponade with these type of
lines.232 Although perforation without tamponade can
present as a hemothorax,233 it manifests most commonly
Complications of Central Venous Catheterization 687
as a hydrothorax,228,229,234 which is bilateral in up to one-
third of patients.235
A useful predictor of impending perforation is the
radiographic confirmation of a curled-up catheter tip,
which occurs in approximately 4% of placements,236 and
sometimes requires a lateral chest film for visualiza-
tion.237 Myriad reports discuss the likelihood of perfora-
tion by indwelling catheters as a function of the entry
side, because most of the cases reported have been asso-
ciated with left-sided CVC insertions,228 which results in
a more horizontal position of the catheter shaft and
abutting of its tip against the vein wall when the catheter
is of insufficient length. The pathogenesis of this com-
plication must be attributed to the steady pressure and
friction exerted on the vessel wall by the catheter tip
eventually leading to erosion, the same way a decubitus
ulcer forms. So, abutting the vein wall or curling of a
catheter tip that does not normally have a curvature, is
basically a signal that the CVC tip is compressing the
vein and should be repositioned to lie parallel to the
vessel wall by whatever maneuvers are required. Unfor-
tunately, this cannot always be accomplished by staying
above the pericardial reflection.
This information then leads to the simple question of
why is it that pigtailed venous catheters are not being
used more often? In an intelligently conceived study,
Gravenstein and Blackshear238 demonstrated that a pig-
tail catheter is 100 times less likely to perforate than
straight-tipped catheters. There is also additional com-
pelling evidence to support the use of pigtail catheters:
studies in a porcine model have shown that central access
with looped catheters can eliminate the vein wall injury
process for substantial periods as compared with straight
catheters.239 This also suggests that a thrombus at the tip
of the catheter—a common cause of dysfunction—
might be less likely to develop if the tip does not lie in
direct contact with the vein wall. So far, clinical experi-
ence with catheters contoured in this manner is limited
but favorable.240,241
Catheter fracture and embolization is reported to oc-
cur in 0.5%186 to 3% of patients203 with indwelling
CVCs. Embolization can lead to arrhythmia242 with car-
diac arrest,243 pulmonary embolism with hemoptysis,244
perforation, thrombosis, and infection, for an overall
morbidity rate of 71%245 and a mortality of 30% to
38%.245,246 Compression of the central catheter between
the clavicle and the first rib causes the pinch-off syn-
drome,247 clinically manifest by a functional occlusion
688 Kusminsky Complications of Central Venous Catheterization
linked to postural changes. The mechanical shearing
forces on the catheter can, over time, lead to fracture and
embolization. This syndrome is estimated to occur in
1% of patients,248 and it is important to differentiate it
from other causes of catheter obstruction, which can be
done by detecting telling radiographic findings. Because
raising the arms or shrugging opens the costo-clavicular
angle, the films should be taken with the patient upright
and with arms by the side.248,249 Catheter fracture can
also occur by shearing from the insertion needle or dur-
ing extraction.250 This information suggests that a safer
way to remove a SCV catheter should include elevation
of the patient’s arm as traction is applied.
Extraction complications
Although air embolism can occur during insertion of a
CVC,251 it is perhaps more commonly seen as a compli-
cation of catheter extraction.252 It is reported to occur in
0.13%251 to 0.5%3,253 of CVC insertions, with tunneled
catheters inserted through a peel-away sheath a likelier
source of this complication.251 The associated mortality
is substantial, ranging between 23%252 and 50%,254 of-
ten if not always connected to neurologic deficits of
varying degree.255
One-hundred milliliters of air can pass through a 14-
gauge needle in 1 second,255 so it is imperative to be
aware of this possibility during cannulation of any vessel
and during catheter exchanges and removal.256 Air em-
bolism has occurred during accidental hub disconnec-
tion,257 through a residual catheter track,258 as a worri-
some factor during home infusion therapy,259 and has
been reported to lodge in the coronary circulation.260 It
is occasionally a result of inadvertent arterial cannula-
tion, in which case, neurologic sequelae are frequent.
During venous catheterization, the path leading the air
embolus to produce a cerebrovascular accident appears
to be mostly by pulmonary shunting or through a patent
foramen ovale.252,261 When air embolism is recognized, if
the usual therapeutic maneuvers—left lateral Trendelen-
burg, air aspiration, 100% oxygen—are not effective,
hyperbaric oxygen treatment could be of help.262 Im-
proved designs of protective insertion sheaths appear
capable of decreasing the incidence of this grave compli-
cation.263 Technique standardization should include ed-
ucation about prevention of air embolism during CVC
insertion30 and removal.255,264
Other extraction complications include breakage,265
separation from the hub,246 and knotting of the cathe-
J Am Coll Surg
ter266,267 or guidewire.268 Breakage is frequently a result of
excessive traction force,246 although the catheter material
can sometimes be faulty and ruptures or dilates.269 Acci-
dental CVC removal is a serious problem because of the
associated risks of hemorrhage and air embolism, and it
occurs between ⬍ 1% and 7.5% in ICU popula-
tions270,271 and in children.269 Rarely, extraction of a
CVC placed in the ipsilateral side of a patient with an AV
fistula for dialysis can lead to hemothorax.272 Central
catheters attached to the vein are more commonly a
consequence of dwell time273 and the constellation of
histologic changes associated with fibrin formation.274
Occasionally, a stuck catheter might be a result of frac-
tures in the material.275 This complication has been re-
ported in adults,276 children,277 and with peripherally
inserted lines.278
Technical considerations and discussion
Over the years, a plethora of reports and adjunct com-
mentary have highlighted the myriad complications that
can befall patients receiving a CVC, in an effort to em-
phasize effective prevention opportunities. In this con-
text, UAI can help the operator decide the relationship
between artery and vein,41,279 how often the venous anat-
omy is abnormal,280 which vessel is best to use,281 how
much the head should be turned,282 and the effect of
patient position on the diameter of the vein.283
UAI is not infallible, and certain complications and
precautions require constant operator alertness. Arterial
puncture, for example, can still occur with UAI,20 and
the methods described to ascertain if a catheter is inside
an artery are not foolproof, but they are reasonable and
effective. Routinely measuring blood gases or attaching
the catheter to a transducer is not always practical, nor
can physicians realistically be expected to use these tech-
niques on every patient. A simple method to detect ar-
terial placement might be to return to the standard of
running saline solution through the line before using a
volumetric pump,112 a practice that perhaps can be re-
suscitated as part of a standardized method of insertion.
Final position of the CVC tip is particularly impor-
tant in relationship to the complications seen with an
atrial location, or when the tip is curled on itself 236,237
and exerts pressure against the vessel’s wall. Regardless of
how rational some arguments in favor of an atrial loca-
tion might be, the sine qua non of any procedure is
patient’s safety, and the mortality of an atrial perforation
and tamponade makes any such debate a rather gratu-
Vol. 204, No. 4, April 2007 Kusminsky
itous point. Instead, the scientific world needs the con-
tribution of a method that avoids this lethal complica- 6.
tion, and such could be the possibility that emerges with
the use of venous pigtailed catheters.239
7.
The site of insertion remains an issue of discussion
and varied preferences, but in terms of infection preven-
tion the consensus points toward the SCV as the better 8.
route of access.1 The agreement is not as clear in terms of
prevention of mechanical complications, particularly in 9.
the areas of malposition and pneumothorax.50
Side of insertion also remains a contested theme.
10.
Many believe that left-sided insertions are burdened
with a higher probability of superior vena cava perfora-
tion68 than access through the right side, although the 11.
important element of catheter length and its relationship
to this problem is not always emphasized. Others 12.
present good evidence that right-sided SCV and IJV
insertions are likelier to induce arterial injury,114,122 al- 13.
though the left side offers a smoother and more obtuse
angle of subclavian approach.284 A left-sided approach is
14.
reported to be associated with less technical difficulty285
and complications122,236 in a statistically significant num-
ber of patients.286 15.
Ultimately, physicians should be cognizant of the
many complications associated with CVCs, recognizing 16.
that the sheer volume of lines used is substantial enough
to convert a rare problem into one they will be likely to 17.
experience. With this in mind, prevention of even the
most unusual complication becomes a worthwhile ini-
18.
tiative. The weight of evidence in favor of UAI to de-
crease the incidence of mechanical complications sug-
gests that this kind of image-guided approach to CVC 19.
insertion should be made available routinely.
20.
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