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CARDIOVASCULAR ANESTHESIOLOGY

Inadvertent Aortic Cannulation with a Pulmonary Artery Catheter Detected by Transesophageal Echocardiography

Claas Siegmueller, MD, FRCA^*, Alexander Bell, MBChB, Tarun Mittal, MD, FRCR, and Shane George, FRCA, FRCP^*

From the Departments of *Anesthesia and Intensive Care, Pathology, and Radiology, Harefield Hospital, Uxbridge, UK.

Address correspondence and reprint requests to Dr. Claas Siegmueller, Department of Anesthesia and Intensive Care, Harefield Hospital, Hill End Road, Uxbridge UB9 6JH, UK. Address e-mail to claassiegmueller{at}yahoo.com.

Abstract

Attempted pulmonary artery catheterization via the left internal jugular vein resulted in a misdiagnosis of pulmonary hypertension before transesophageal echocardiography revealed the catheter positioned in the ascending aorta. Inadvertent aortic cannulation through an unusual type of partial anomalous pulmonary venous connection was confirmed with transcatheter fluoroscopy and later at autopsy. Partial anomalous pulmonary venous connection describes one or more of the pulmonary veins draining into the right atrium or its tributaries instead of the left atrium.

A partial anomalous pulmonary venous connection (PAPVC) together with a persistent left superior vena cava is one of the most common congenital abnormalities of the intrathoracic veins, with an incidence at autopsy of 0.4% to 0.7%. This occurs most commonly in the right lung and the upper lobes.1,2

The abnormality can appear when tributaries to the caval venous system are catheterized. We present a case in which the diagnosis of a PAPVC was aided by transesophageal echocardiography (TEE) after inadvertent aortic cannulation with a pulmonary artery (PA) catheter via the left internal jugular vein (LIJV) route.

CASE REPORT

A 59-yr-old man presented for explantation of a left ventricular assist device. He had initially been admitted with myocardial infarction, treated with emergency coronary angioplasty. However, repeated angioplasty for further chest pain with ST-segment changes did not halt his clinical deterioration, and on Day 12 after admission, left ventricular assist device implantation and coronary artery bypass grafting were performed. Postoperative complications included a chest infection, atrial fibrillation, and cerebral infarction. Nevertheless, by Day 24, the left ventricular assist device had been weaned.

The patient presented for surgery that was conducted without respiratory or inotropic support. After induction of anesthesia, a central venous catheter and 7.5F introducer sheath were inserted into the LIJV, replacing a right subclavian vein catheter. A PA catheter was advanced through the sheath, showing appropriate atrial, ventricular and subsequently arterial pressure waveforms. Right ventricular and PA pressures at systemic levels with an inability to "wedge" the catheter were noted. Given the history of poor left ventricular function, these readings were not unexpected and immediately suggested that device explantation might not be possible. However, blood gas sampling from the catheter tip (for mixed venous O₂ saturation) showed an arterial partial pressure of O₂, and aortic or arterial cannulation was suspected. TEE then visualized the catheter in the left atrium, left ventricle, and aorta (Fig. 1), but not the right heart. There was no evidence of a patent foramen ovale, atrial septal defect (ASD), or ventricular septal defect as a route for inadvertent aortic cannulation from a central vein; however, dynamic/bubble testing was not performed. After withdrawal to the left atrium, simultaneous blood gas analysis from the catheter tip, peripheral arterial line, and introducer sheath confirmed a central venous position of the sheath and atrial position of the catheter tip, suggesting an anastomosis between the LIJV and the left atrium. This was verified postoperatively by fluoroscopy (Fig. 2).

View larger version (32K): [in this window] [in a new window]   Figure 1. Transesophageal echocardiogram (left: aortic long axis view; right: left atrium); 1 = left atrium; 2 = pulmonary artery catheter; 3 = left ventricle; the catheter can be seen entering the left atrium from the left, suggesting its origin from the left upper pulmonary vein, and then on its course through the mitral valve into the left ventricle and through the aortic valve into the ascending aorta.

View larger version (46K): [in this window] [in a new window]   Figure 2. Fluoroscopy; contrast was injected through the introducer sheath in the left internal jugular vein; 1 = left internal jugular vein; 2 = partial anomalous pulmonary venous connection (PAPVC); 3 = left upper pulmonary vein; 4 = left brachiocephalic vein. Contrast distribution to left brachiocephalic vein as well as PAPVC and left pulmonary vein is visible.

The patient’s condition subsequently deteriorated, with sepsis and multiorgan failure, and he died on Day 37. Postmortem examination showed the aberrant connection between the left upper pulmonary vein and the left brachiocephalic vein (Fig. 3) but no other pulmonary or cardiac abnormalities such as ASD or unroofed coronary sinus.

View larger version (30K): [in this window] [in a new window]   Figure 3. Postmortem examination (left: anterior view of heart and great vessels; right: diagram); 1 = left internal jugular vein; 2 = partial anomalous pulmonary venous connection (PAPVC); 3 = left upper pulmonary vein; 4 = left brachiocephalic vein; Ao = aorta; PA = pulmonary artery; the dotted line in the diagram represents the course of the PA catheter towards the left atrium.

DISCUSSION

We report a case of a PAPVC between the left brachiocephalic and left upper pulmonary vein leading to inadvertent PA catheter cannulation of the left ventricle and aorta and its diagnosis by TEE intraoperatively. This type of PAPVC is unusual, as pulmonary venous drainage to the left atrium is also present, allowing the observed PA catheter passage (Fig. 3). To our knowledge, six cases have been reported in which the diagnosis of PAPVC was made incidentally after central venous, but not attempted PA catheterization.3–8 These were diagnosed only on subsequent radiography. Interestingly, in all of these cases, the LIJV was used for cannulation. A PAPVC from the right upper lobe usually drains into the superior vena cava. It connects at an angle and is therefore unlikely to be entered by a central venous catheter inserted into the right internal jugular vein. In contrast, a PAPVC from the left upper lobe usually drains into a persistent left superior vena cava, if present, or the left brachiocephalic vein. This type of PAPVC lies on a similar anatomical axis as the LIJV (Figs. 2 and 3). Therefore, a left-sided internal jugular central venous catheter might be more likely to enter and reveal the anomalous channel, despite a left-sided PAPVC being less common.

Early in embryogenesis the lungs are drained by splanchnic plexus channels to the cardinal and umbilicovitelline veins. Then an outpouching from the left atrium forms the common pulmonary vein, which links to the splanchnic plexus and establishes lung drainage to the left atrium. The cardinal and umbilicovitelline vein communications subsequently atrophy. PAPVCs to the umbilicovitelline (portal venous) or cardinal (superior vena cava) system occur if either the common pulmonary vein fails to establish communications to the splanchnic plexus, or pulmonary-systemic venous channels persist.2 Unusually in the presented case, the persistence of the primitive connection of pulmonary veins to the systemic circulation, as well as a normally completed connection to the left atrium, appear to be the underlying mechanism, since the PAPVC connects to the left brachiocephalic vein from an otherwise normally developed left upper pulmonary vein. A persistent left superior vena cava with unroofing of the coronary sinus could present in the same way, but was excluded at postmortem.

TEE demonstrated the course of the long PA catheter through the left heart, suggesting an underlying PAPVC, and correcting our initial misdiagnosis of pulmonary hypertension. If a shorter central venous catheter is introduced, an unusual catheter projection onto the left heart border on the chest radiograph and aspiration of arterialized blood from the catheter tip would hint at a left-sided PAPVC.

An incidental diagnosis of a PAPVC is relevant to patient management. The direct communication with the systemic circulation requires meticulous care to avoid introducing air into a central venous catheter. The frequent association with secundum type ASDs warrants further investigation of these patients. The significance of the left-to-right shunt needs to be established, and depends on the size and number of PAPVCs and presence of an intact atrial septum.

The left side is not the preferred site for internal jugular venous cannulation, although occasionally chosen for patients requiring venous catheter changes due to blockage, infection, etc. Although the incidence of PAPVCs is generally quite high, the presented variant is rare. However, PA catheterization is a common procedure, and it therefore appears important to be aware of the condition, as it could present for the first time this way, especially with left-sided cannulation, falsely suggesting pulmonary hypertension.

Footnotes

Accepted for publication September 11, 2007.

REFERENCES

1. Brody H. Drainage of the pulmonary veins into the right side of the heart. Arch Pathol 1942;33:221–40[Web of Science]
2. Krabill KA, Lucas RV. Abnormal pulmonary venous connections. In: Emmanouilides GC, Riemenschneider TA, Allen HD, Gutgesell HP, eds. Moss and Adams’ heart disease in infants, children, and adolescents. 5th ed. Baltimore: Williams and Wilkins, 1994:838
3. Sobrinho G, Salcher J. Partial anomalous pulmonary vein drainage of the left lower lobe: incidental diagnostic after central venous cannulation. Crit Care Med 2003;31:1271–2[Web of Science][Medline]
4. Townley SA. Central venous catheter malposition in an anomalous pulmonary vein. Eur J Anaesthesiol 2003;20:985–6[Web of Science][Medline]
5. Orme R, Harper L, Olliff JFC. In what’s my line? Br J Radiol 1998;71:457–8[Web of Science][Medline]
6. Cheng CJ, Lim BL, Tan BS. Inadvertent catheterisation of a partial anomalous pulmonary venous channel during central venous cannulation. Anaesthesia 2002;57:198–200[Web of Science][Medline]
7. Wylam ME, Schmidt GA. Seredipitous discovery during jugular catheterization. Chest 1990;98:493–5[Web of Science][Medline]
8. Wu E-T, Huang S-C, Wu M-H, Wang J-K, Chang C-I. An unusual position of central venous catheter. Paediatr Anaesth 2006;16:216–25[Medline]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Siegmueller, C. Articles by George, S. Search for Related Content PubMed PubMed Citation Articles by Siegmueller, C. Articles by George, S. Related Collections Cardiovascular Complications Monitoring (Cardiac)