Anesth Analg 2004;99:669-671
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000133244.59867.6F
CARDIOVASCULAR ANESTHESIA
Management of an Unusual Complication During Placement of a Pulmonary Artery Catheter
Parneeta Bhatia, MD,
Nahel N. Saied, MB BCh, and
Mark E. Comunale, MD
Department of Anesthesiology, School of Medicine, St. Louis University, St. Louis, Missouri
Address correspondence and reprint requests to Nahel N. Saied, MB, BCh, St. Louis University Hospital, Department of Anesthesiology, 3635 Vista Ave. at Grand Blvd., St. Louis, MO 63110. Address e-mail to saiedn{at}mac.com
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Abstract
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We describe an unusual complication during flotation of a pulmonary artery catheter through a preexisting percutaneous introducer sheath. A malfunctioning pulmonary artery catheter, which was placed through an introducer sheath in the right internal jugular vein, was removed. Attempts at repositioning a second pulmonary artery catheter met with resistance, and we were unable to either advance or withdraw it. Chest radiograph showed a bent introducer sheath going from the right internal jugular vein into the right subclavian vein and a pulmonary artery catheter loop. Under continuous fluoroscopy, the introducer sheath and the pulmonary artery catheter were withdrawn as one unit, which resulted in relaxation of the acute angulation in the introducer sheath and allowed the pulmonary artery catheter to unfold, thus facilitating their complete extraction. We conclude that complications may occur during placement of a pulmonary artery catheter through a well positioned introducer sheath and that fluoroscopy is a valuable tool for safe management of such a complication.
IMPLICATIONS: Pulmonary artery catheters are widely used to manage critically ill patients but can be associated with various complications. This case report describes the occurrence and management of a highly unusual complication associated with the placement of a pulmonary artery catheter through a previously well positioned introducer sheath.
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Introduction
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Since its introduction in 1970, the pulmonary artery catheter (PAC) has been widely used in perioperative and intensive care patient management (1,2). According to current estimates, more than 1.2 million PACs are placed annually in the United States, with an associated cost of more than $2 billion (3). Complications associated with PACs are either inherent to central venous catheter insertion or specific to the PAC itself. Recently, we encountered an unusual complication during the flotation of a PAC that was placed through a preexisting percutaneous introducer sheath in the right internal jugular vein (RIJV).
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Case Report
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A 61-yr-old man with cirrhosis and liver cancer underwent liver resection with alcohol injection and radiofrequency ablation under general anesthesia. On the fourth postoperative day, the patient developed respiratory failure; the trachea was intubated, and mechanical ventilation was initiated. The patient had an indwelling right subclavian triple-lumen catheter (TLC) (7F; Arrow Inc., Reading, PA). A PAC (746HF8; 8F; Swan-Ganz CCO/SVO2/VIP; Edwards Life Sciences, Irvine, CA) was placed through a 9F percutaneous introducer sheath (NL-09903-S; Arrow Inc.) in the RIJV without complications.
Forty-eight hours later, we decided to remove the existing PAC because the pulmonary artery tracing was dampened and attempts to flush and reposition the catheter were unsuccessful. A new PAC was threaded through the existing introducer sheath in the RIJV without difficulty. Because we were unable to obtain a pulmonary artery tracing after advancing the PAC to 55 cm, the balloon was deflated, and the PAC was withdrawn to 20 cm. The second attempt to advance the PAC encountered resistance at an insertion distance of 28–30 cm. The PAC could neither be advanced nor withdrawn. A portable chest radiograph showed a bent introducer sheath coursing into the right subclavian vein (RSCV) and a PAC loop (Fig. 1). A decision was made to withdraw the subclavian TLC that was thought to be entwined with the PAC loop. Because there was no resistance to withdrawal of the subclavian TLC, fluoroscopic guidance was not used. However, after the subclavian TLC was removed, advancement or withdrawal of the PAC was still impeded. Subsequently, it was decided to remove the introducer sheath along with the PAC under fluoroscopic guidance. By visualizing the introducer sheath and PAC under continuous fluoroscopy, both were gently twisted sideways and withdrawn slowly as one unit. Multiple attempts were needed to avoid undue deformation along the anatomical alignment of the RSCV and RIJV. By withdrawing the introducer sheath tip back into the RIJV/RSCV junction, we relaxed the acute angulation in the introducer sheath and allowed more space for the PAC loop to unfold, thus facilitating its complete withdrawal (Fig. 2). The extracted introducer sheath was bent at 90° (Fig. 3). The patient tolerated the procedure well, with no further consequences.
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Figure 1. Chest radiograph showing the subclavian triple-lumen catheter, bent introducer sheath, and pulmonary artery catheter loop.
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Figure 2. Mechanism of pulmonary artery catheter (PAC) extraction under fluoroscopy. a, The PAC loop as seen in the chest radiograph. The PAC could neither be advanced nor withdrawn. b, Withdrawal of the PAC and introducer sheath as one unit, which straightened the bend in the introducer sheath and allowed more space for the PAC to unfold. c, Further withdrawal of the introducer sheath results in unfolding of the PAC. d, The PAC loop is fully unfolded, thus allowing its complete extraction.
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Discussion
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This case highlights the possibility of acute angulation of a percutaneous introducer sheath going from the RIJV to RSCV during placement of a PAC. Acute angulation of the PAC, but not the introducer sheath, has been described when a PAC was inserted through the external jugular vein (4) or internal jugular vein (5). The risk of malpositioning a well placed introducer sheath while replacing a PAC should be negligible and has not been previously reported.
We hypothesize the following mechanism by which this complication could have occurred. First, after removal of the malfunctioning PAC, the new PAC looped in the right heart during the first attempt at flotation. Second, during withdrawal, the loop tightened, abutting against the tip of the introducer sheath, and further traction on the PAC caused the introducer sheath to bend into the RSCV (Fig. 4). Subsequently, during the second attempt at refloating the PAC, its advancement was impeded because of the angulation of the introducer sheath and the PAC loop seen on the chest radiograph (Fig. 1). The introducer sheath angulation could have resulted from withdrawing the PAC while the balloon was inflated beyond the introducer sheath tip. This did not occur in our patient because the catheter was withdrawn only to 20 cm.
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Figure 4. Proposed mechanism of pulmonary artery catheter (PAC) loop formation and introducer sheath angulation. a, First attempt at PAC replacement, showing a loop in the right heart. b, Tightening of the PAC loop during withdrawal. c, Further withdrawal of the PAC, forcing the introducer sheath to angulate into the right subclavian vein and form the PAC loop. d, The second attempt at PAC advancement was met with resistance.
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Boyd et al. (6) reported an incidence of 0.1% for the inability to wedge the PAC and an incidence of 0.2% for catheter looping. Other reported complications of PACs include catheter knotting, cardiac perforation, damage to heart valves, entrapment in chordae tendineae, pseudoaneurysm of the pulmonary artery, endocarditis, and pulmonary embolism (7). Mechanical complications resulting from central venous catheterization are likely to be underreported in the literature (8). For all devices like the PAC, the harm associated with catheter insertion and management may vary among physicians, thus underscoring how operator-dependent complications are not generalizable to other settings (9). Most such complications are inconsequential and are not life-threatening (6). The risk of mechanical complications during PAC insertion is determined, to a large extent, by patient factors (morbidity, underlying disease, and local anatomy) and by the experience of the physician performing the procedure (10). As widely reported, multiple attempts at floating a PAC and/or floating an excessive length of PAC should be avoided (5). When a PAC is kinked, knotted, or entrapped in cardiac structures, it can be retrieved in various ways. Retrieval is fairly straightforward for patients undergoing open-heart surgery (5). Fluoroscopic guidance has also been used to aid the removal of a knotted catheter with a guidewire, sometimes with fatal consequences (causing rupture of the tricuspid valve and death) (11).
In intensive care settings, fluoroscopy is usually readily available and is useful in the management of intravascular catheter complications. In this case, the PAC was looped, but not knotted, which made the need for specialized radiological intervention unnecessary and allowed us to manage this complication under simple fluoroscopic guidance in the intensive care unit.
We conclude that it is important to recognize that complications of PAC placement can occur during placement of a PAC through a previously well positioned introducer sheath. Although fluoroscopy use is not recommended for routine PAC placement, any deviation from the ordinary, e.g., resistance during insertion, should warrant radiological studies to prevent morbidity or mortality. The presence of multiple central venous catheters in the same vascular structure may be another indication for fluoroscopy use to avoid potential complications.
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References
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- Sandham JD, Hull RD, Brant RF, et al. Randomised, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348: 5–14.[Abstract/Free Full Text]
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- Bowdle TA. Complications of invasive monitoring. Anesthesiol Clin North Am 2002; 20: 333–50.
- Ruesch S, Walder B, Tremèr M. Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med 2002; 30: 454–60.[ISI][Medline]
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Accepted for publication March 19, 2004.
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Abstract
Introduction
