Lymphatic Leak Complicating Central Venous Catheter Insertion Alex M. Barnacle, Tricia M. Kleidon Department of Radiology, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK Abstract Many of the risks associated with central venous access are well recognized. We report a case of inadvertent lymphatic disruption during the insertion of a tunneled central venous catheter in a patient with raised left and right atrial pressures and severe pul- monary hypertension, which led to significant hemodynamic instability. To our knowledge, this rare complication is previously unreported. Key words: Central venous access—Lymphatic disruption— Pulmonary hypertension Central venous access for the insertion of indwelling catheters has well-recognized risks and complications, most of which have been extensively documented in the modern literature. We report a case ofinadvertentlymphaticdisruptionduringtheroutineplacementof a central venous catheter, causing significant hemodynamic com- promise. To our knowledge, this complication is previously unre- ported. Case Report A 15-year-old female with a history of restrictive cardiomyopathy and secondary pulmonary hypertension was referred to our interventional radiology service requiring central venous access for continuous epopros- tenol therapy to control her pulmonary hypertension while awaiting heart- lung transplantation (pulmonary arterial pressure = 42 mmHg). We ac- cepted the patient for insertion of a tunneled dual-lumen catheter under general anesthesia, as is standard practice in our institution. It is well rec- ognized that procedures under general anesthesia are a significant under- taking in patients with severe pulmonary hypertension, given the anesthesia-related risks of right ventricular failure, pulmonary hypertensive crisis, and cardiac arrest. Allowing for this, however, there were no par- ticular concerns regarding placement of the central venous catheter itself. The procedure was performed under anesthetic in the interventional radiology department and a standard insertion technique was used [1, 2]. A 7 Fr dual-lumen catheter (Bard Access Systems, Salt Lake City, UT, USA) wastunneledthroughthesofttissuesoftheanterolateralaspectofthechest wall, to the level of a stab incision above the clavicle. There had been no previous attempts at central venous access in this patient and the neck vesselswereclearlyvisualizedonultrasound.Theinternaljugularveinwas widely patent with no collateral veins or other vessels visualized. A single ultrasound-guided puncture of the right internal jugular vein was per- formed, using a 21G one-part needle (William Cook Europe, Bjaeverskov, Denmark). The catheter was inserted via a 7 Fr Peel-away introducer (William Cook Europe, Bjaeverskov, Denmark) over a standard 0.018 inch guidewire;thetipofthecatheterwasplacedattheleveloftherightatrium. Following catheter insertion, a steady stream of serous fluid was ob- served from the site of the neck incision. The rate of fluid leak increased during recovery of the patient. The fluid was assumed to represent chyle following inadvertent lymphatic disruption during placement of the cathe- ter. Following consultation with the referring cardiology team and the on- call surgical registrar, the neck incision was not sutured, to avoid a local- ized subcutaneous serous collection. The incision was closed with adhesive strips (3M Health Care, Neuss, Germany) and a pressure dressing was applied. Prophylactic antibiotic cover was administered and the patient returned to the acute cardiology ward for observation. Four hours later, the patient was noted to be pale and breathless, with oxygensaturationsof86% inair(normaloxygensaturation98%)andafall in blood pressure from 110/70 mmHg to 90/60 mmHg, with a heart rate of 150beats/min.Examinationrevealedacapillaryrefilltimeofgreaterthan5 sec. A large volume of serous fluid was noted saturating the dressing and the bedclothes. A 15 ml/kg intravenous fluid bolus was required and a dopamine infusion commenced. The neck incision was then closed with several nondissolvable sutures. No further serous leak was documented. A portable chest radiograph and echocardiogram were unremarkable. The patient made a good clinical recovery over the next 90 min. No further serous leak was documented and the remainder of the hospital admission was unremarkable. Discussion The risks of complications arising from the placement of a central venous catheter have decreased significantly with the advent of image guidance and modern interventional techniques. In general, risks include bleeding, air embolism and patient discomfort [3]. The incidence of pneumothorax has reduced significantly with the routine use of image-guided venous punctures [1, 2]. Although the presence of lymphatic channels adjacent to the great vessels is recognized, lymphatic disruption is not usually of concern during centralvenousaccess.Inadvertentpunctureofthethoracicducthas previously been documented, without sequelae [4]. As far as we are aware, there is no evidence to confirm that intrathoracic lymphatic system pressures are raised in patients with pulmonary hypertension. Such a situation appears feasible, how- ever, given markedly increased venous pressures within the right atrium and superior vena cava, into which the thoracic duct drains. In our subject, the presence of a restrictive cardiomyopathy meant that left atrial and ventricular pressures were also raised, further restricting drainage of intrapulmonary lymphatics. Raised venous pressures may have been a significant contributing factor to the volume and duration of lymphatic leak in this patient. Visualiza- tion of lymphatic channels during ultrasound-guided puncture is veryunlikelyandinadvertentpuncturemaythereforebedifficultto avoid. Disruption of the lymphatic system is also possible, and Correspondence to: Alex M. Barnacle, BM, MRCP, FRCR email: alexbar- nacle@yahoo.co.uk ª Springer Science+Business Media, Inc. 2005 Published Online: 20 April 2005 CardioVascular and Interventional Radiology Cardiovasc Intervent Radiol (2005) 28:839–840 DOI: 10.1007/s00270-004-0283-2