Workflow for treating inadvertent arterial placement of the central venous catheter

We read the article"How to manage the malposition of deep vein catheterization into the artery"[1] with keen interest.However,we have several concerns with the proposed algorithm.First,the site of catheter misplacement is asstumed to be the subclavian artery,the most frequent site of misplacement during internal jugular vein catheterization.[2] However,catheter misplacement can occur in the common carotid and vertebral arteries during internal jugular vein catheterization.[2,3] If a catheter is misplaced in one of these arteries,preventing cerebral ischemia is a priority.[2,4,5] For example,if a thrombus forms around the catheter,a method is chosen to resolve it while preventing dispersion and closing the perforation.[2,6] Therefore,open surgical closure must be selected.Second,the algorithm may not handle instances of realistic catheter misplacement in the arteries.We assume a case where an internal jugular venous catheter （5Fr double-lumen catheter） is inserted but accidentally penetrates the subclavian artery and is placed in the thoracic cavity.Suppose that the injured site is about 5 mm from the confluence of the right common carotid or vertebral arteries.