Central venous catheter arterial puncture — FFICM MCQ

Correct answer: A — Leave the dilator in place and obtain urgent vascular surgical or interventional advice

The correct answer is A, leave the dilator in place and obtain urgent vascular surgical or interventional advice. A large-bore dilator inadvertently placed in the carotid or subclavian artery creates a controlled tamponade of the puncture tract; removing it blindly, especially in an anticoagulated patient, risks catastrophic haemorrhage, airway compromise from an expanding haematoma, or embolic stroke. Current UK guidance on safe vascular access specifically addresses this scenario, stating that inadvertent arterial lines or dilators of 6 Fr or larger should be left in situ and definitive removal planned with interventional radiology or vascular surgery, often under fluoroscopic or surgical control with the option of closure device or surgical repair. Because the patient is ventilated and haemodynamically stable, there is time to arrange this safely rather than acting impulsively. This approach converts an emergency into a controlled, monitored procedure with the resources needed to manage major vessel injury. Why the other options are wrong: C. Remove the dilator and apply brief pressure: this is appropriate for a small-bore needle or cannula puncture but not for a large dilator, where digital pressure cannot reliably tamponade a defect in the carotid or subclavian artery, particularly with coagulopathy, risking rapid expanding haematoma and airway obstruction. B. Flush the line and use it as arterial access: this leaves a large mismatched device in a vessel it was never intended for, risking thrombosis, dissection, distal embolisation and vessel injury, and does not address the underlying puncture. E. Dilate further to complete the central line: intentionally advancing a central venous catheter through the arterial wall converts a dilator puncture into a large catheter traversing the artery, massively increasing bleeding, thrombotic and embolic risk. D. Give thrombolysis to prevent thrombosis: thrombolytics in a freshly punctured artery in an anticoagulated patient would provoke uncontrollable haemorrhage and are not indicated for this problem. Key point: any dilator or catheter 6 Fr or larger inadvertently placed in an artery must be left in situ with urgent vascular or interventional radiology input rather than removed at the bedside.

Reference: Association of Anaesthetists guidelines: safe vascular access 2025, Johnston et al., Anaesthesia 2025 (https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.16727)