Accidental arterial puncture is a rare complication that may occur during central venous catheter insertion. Arterial injury may be a potentially lethal problem of serious bleeding or large hematoma. The author described the incidence, predilection site, clinical presentation, prevention and management guideline based on the patient’s clinical data. Central venous cannulation under the guidance may be an effective preventive technique for accidental arterial injury. © Springer-Verlag Italia 2012.