Air Embolism after Central Venous Catheter Removal: Fibrin Sheath as the Portal of Persistent Air Entry

Central venous catheterization is of common practice in intensive care units; despite representing an essential device in various clinical circumstances, it represents a source of complications, sometimes even fatal, related to its management. We report the removal of a central venous catheter (CVC) that had been wrongly positioned through left internal jugular vein. The vein presented complete thrombosis at vascular ultrasonography. An echocardiogram performed 24 hours after CVC removal showed the presence, apparently unjustified, of microbubbles in right chambers of the heart. A neck-thorax CT scan showed the presence of air bubbles within the left internal jugular vein, left innominate vein, and left subclavian vein. A vascular ultrasonography, focused on venous catheter insertion site, disclosed the presence of a vein-to-dermis fistula, as portal of air entry. Only after air occlusive dressing, we documented echographic disappearance of air bubbles within the right cardiac cavity. This report emphasizes possible air entry even many hours after CVC removal, making it mandatory to perform 24–72-hour air occlusive dressing or, when inadequate, to perform a purse string. 1. Introduction Venous air embolism is a well-known complication of venous catheterization in critically ill patients: it is generally related to insertion and removal procedures and daily management. Late air embolism after CVC removal is less known. We describe the case of a nonlethal air embolism 24 hours after removal of a malpositioned CVC, placed through left internal jugular vein, which was completely occluded by a thrombus. 2. Case Presentation A 75-year-old woman was admitted to our intensive care unit for clinical monitoring after right parotid gland removal; she was diagnosed with a colliquative tumoral parotid gland mass in a peripheric hospital and then moved to the local otolaryngological surgical department to undergo surgery. Her past history included hypertensive cardiomiopathy, with episodes of heart failure, and atrial fibrillation. On admission to our unit she underwent a chest radiograph that showed a wrong positioning of the CVC (arrow 7？Fr, 3 lumen, and 16？cm length): as shown in Figure 1 the tip projected over the left side of the descending aorta, at the level of carina, creating an angle with the spine greater than 40° [1]. Moreover, we noticed saline leak from the insertion site and suspected a catheter rupture. In addition we performed a vascular ultrasonography that showed a complete thrombotic occlusion of the left internal jugular vein. Figure 1: Chest