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Mediastinal Hematoma With SVC Syndrome From A Central Venous Catheter Insertion: A Case Report

Henry Ford Hospital, Detroit, MI

INTRODUCTION: Superior vena cava syndrome (SVCS), mostly secondary to malignant disease, is a rare complication of intraluminal catheters, caused by thrombosis and obstruction to flow in the SVC. We describe what may be the first reported case of SVC syndrome caused by a compressing mediastinal hematoma from an attempted central line insertion.

CASE PRESENTATION: 49-year-old male presented to the ED with progressive dyspnea and syncope during hemodialysis. Pertinent physical exam findings included tachypnea, tachycardia, facial and upper extremities edema. CXR revealed right mediastinal opacity. CT thorax showed a homogeneous mass extending from apex to subcarinal level occluding the RUL bronchus, right brachiocephalic and jugular veins, and compressing the distal trachea and SVC.

12 days earlier, he was admitted to another hospital with anasarca, and started on hemodialysis for ESRD. Records from that hospitalization indicate multiple unsuccessful attempts at right subclavian and internal jugular line placement and a negative post-procedure CXR. We diagnosed him with a compressing mediastinal hematoma. With his symptoms improving, he required conservative management with outpatient follow-up. CT thorax 2 months later revealed slow resolution of the hematoma.

DISCUSSION: Subclavian line insertion carries more risk of hemothorax and pneumothorax than internal jugular insertion. This latter has higher risk of arterial puncture. The overall risk for mechanical complications for both insertion sites is similar. This risk increases significantly in less experienced hands and with repeated attempts. Our patient’s sizable hematoma probably resulted from an inadvertent arterial puncture/injury or venous laceration, and aggravated by the bleeding diathesis from uremia. This compressing hematoma led to the SVCS in our case, thus distinguishing it from previous case reports of vascular access-induced SVCS where the cause is intraluminal thrombosis.

CONCLUSION: To the best of our knowledge, there has not been a reported case of hemomediastinum with SVCS from a central venous catheter insertion. We report this case aiming to draw the attention to this rare occurrence.

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