Arterial Cannulation Near-Miss During Jugular Venous Catheterization With Carotid Artery Aneurysm: A Case Report

Abstract

Central venous catheterization is a common procedure that may lead to inadvertent arterial cannulation, potentially causing bleeding, hematoma, stroke or rarely, death. In this near-miss case presentation, an aneurysmal carotid artery was misidentified with ultrasound by a junior resident, nearly leading to placement of a sheath into the artery. This case highlights arterial punctures that still occur even with ultrasound guidance. Further, training inadequacies as well as anatomic, cultural, and production pressure factors led to this potentially highly morbid near-miss. Physician teachers should critically evaluate teaching methods to confirm that trainees are learning skills as intended. (A&A Practice. 2023;17:e01661.)