Experience and Technique for the Endovascular Management of Iatrogenic Subclavian Artery Injury N.S. Cayne, T.L. Berland, C.B. Rockman, T.S. Maldonado, M.A. Adelman, G.R. Jacobowitz, P.J. Lamparello, F. Mussa, S. Bauer, S.S. Saltzberg, and F.J. Veith, New York, New York Background: Inadvertent subclavian artery catheterization during attempted central venous access is a well-known complication. Historically, these patients are managed with an open oper- ative approach and repair under direct vision via an infraclavicular and/or supraclavicular inci- sion. We describe our experience and technique for endovascular management of these injuries. Methods: Twenty patients were identified with inadvertent iatrogenic subclavian artery cannula- tion. All cases were managed via an endovascular technique under local anesthesia. After correcting any coagulopathy, a 4-French glide catheter was percutaneously inserted into the ipsi- lateral brachial artery and placed in the proximal subclavian artery. Following an arteriogram and localization of the subclavian arterial insertion site, the subclavian catheter was removed and bimanual compression was performed on both sides of the clavicle around the puncture site for 20 min. A second angiogram was performed, and if there was any extravasation, pressure was held for an additional 20 min. If hemostasis was still not obtained, a stent graft was placed via the brachial access site to repair the arterial defect and control the bleeding. Results: Two of the 20 patients required a stent graft for continued bleeding after compression. Both patients were well excluded after endovascular graft placement. Hemostasis was success- fully obtained with bimanual compression over the puncture site in the remaining 18 patients. There were no resultant complications at either the subclavian or the brachial puncture site. Conclusion: This minimally invasive endovascular approach to iatrogenic subclavian artery injury is a safe alternative to blind removal with manual compression or direct open repair. INTRODUCTION The insertion of central vein catheters into the subclavian vein was first described by Aubaniac in 1952. 1 Since that time, millions of central venous catheters have been placed every year by medical and surgical specialists into the femoral, internal jugular, and subclavian veins. These centrally placed catheters are often of large bore and can be paramount in the management of many patients who may require rapid volume resuscitation, hemo- dialysis, parenteral nutrition, or multiple drug therapy. Inadvertent arterial puncture with a small needle is usually benign and occurs about 5% of the time. 2 The consequences can be much more severe if a large-caliber catheter is placed into the artery, and this is estimated to occur 0.1-0.8% of the time. 3 Accidental intra-arterial cannulation has traditionally been treated with open surgery, utilizing a supraclavicular and/or infraclavicular approach. Herein, we describe our experience with the endovascular management of patients sustaining iatrogenic subclavian artery cannulation. MATERIALS AND METHODS We retrospectively reviewed our experience at New York University Medical Center. From 2001 until 2008, the vascular surgery department was Presented at the 19th Annual Winter Meeting of the Peripheral Vascular Surgery Society, Steamboat Springs, CO, January 30 - February 1, 2009. Division of Vascular Surgery, New York University Medical Center, New York, NY. Correspondence to: Neal S. Cayne, MD, Director of Endovascular Surgery, NYU Medical Center, 530 1st Avenue, Suite 6F, New York, NY 10016, USA, E-mail: neal.cayne@nyumc.org Ann Vasc Surg 2010; 24: 44-47 DOI: 10.1016/j.avsg.2009.06.017 Ó Annals of Vascular Surgery Inc. Published online: September 7, 2009 44