Pulmonary artery catheter complications: report on a case of a knot accident and literature review

Bedside management of a knotted Swan-Ganz catheter - A case report and literature review

INTRODUCTION AND IMPORTANCE

Pulmonary artery catheters use remain invaluable in continuous invasive hemodynamic monitoring for patients with severe cardiopulmonary dysfunction and those undergoing major cardiac surgeries. It detects cardiac dysfunction and guides treatment decisions. Its utilization has declined due to common complications associated with its insertion. This article highlights a rare, rather an important complication of pulmonary artery catheter knotting and reviews techniques for its management. Prompt recognition of this rare complication by the clinicians allow immediate intervention minimizing morbidity and optimizing the outcomes. This manuscript follows the SCARE guidelines.

CASE PRESENTATION

A case of a 61-year-old man who was initially admitted to the cardiothoracic unit for mitral valve replacement for symptomatic severe mitral regurgitation secondary to a bi-leaflet prolapse. Intra-operatively, a pulmonary artery catheter was inserted for invasive continuous hemodynamic monitoring. It was noted on a routine postoperative chest X-ray coiling of the pulmonary artery catheter in the right atrium. The catheter was not repositioned. On postoperative day one, significant resistance was encountered while removing the catheter. A chest x-ray was done and showed a knotted catheter in the superior vena cava. After contingency planning, bedside removal was opted as the preferred management approach. The catheter was carefully pulled out to tighten the knot and decrease its diameter, allowing successful extraction through the insertion site at the neck.

CLINICAL DISCUSSION

Pulmonary artery catheter utilization remains essential; however its insertion is prone to complications, which includes pulmonary artery catheter knotting a rare but an important complication that warrants immediate recognition and management. Numerous approaches for the management of knotted catheter were described in the literature. Bedside removal of the knotted catheter may be considered if the knot is simple and more proximal. This approach carries the risk of venous injury and hematoma formation, thus thorough planning and preparation are needed to avoid complications. An endovascular approach is opted in more complex cases and has largely supplanted surgical methods. Innovative methods were described in the literature and include the introduction of guide wires or specialized catheters to untangle knots under fluoroscopic guidance. Retrieval baskets may also be used. Surgery is reserved for complex cases, when endovascular attempts fail.

CONCLUSION

While pulmonary artery catheter use provides significant benefits, its use demands meticulous planning and preparation to avoid complications. Catheter knotting requires immediate attention. If bedside maneuvers fail, endovascular or surgical approaches may be necessary.

A rare complication of intracardiac double knotting of temporary pacemaker lead during bedside insertion: a case report

Background

Temporary pacemaker lead implantation is a common low-risk procedure, but can occasionally get complicated by infections, arrhythmias, thromboembolic events, and perforation of the vessel or the heart. However, intracardiac knotting of the temporary pacemaker lead has been rarely reported. This could lead to vascular or valvular injury, pneumothorax, symptomatic loss of pacing or haemodynamic compromise, and difficult lead removal.

Case summary

We are reporting a case of twice twice-knotted temporary pacemaker lead, which to our knowledge has not been reported before. The two knots in the transjugularly inserted temporary pacemaker lead, via a 6F venous sheath made it difficult to retrieve it.

Discussion

We decided to snare the knotted TPI into the inferior vena cava, and then retrieve it via a large-size femoral sheath, thus avoiding the need for a venotomy or any surgical intervention.

Untying the Knot: A Rare Case of Formation of a Life-Threatening Intracardiac Knot Following the Placement of a Temporary Transvenous Pacemaker

The implantation of a temporary pacemaker lead is a very common procedure performed in most hospitals and is known to be relatively safe, but there can be serious complications in rare circumstances. Reported complications including arrhythmias, infection, thromboembolic phenomena, and perforation of the vessel or the heart are all extensively described. However, an unusual and life-threatening complication that is not frequently discussed is the formation of intracardiac knots. We present a case of a rare complication of a temporary pacemaker placement with the formation of a knot in the distal lead requiring expert technique for removal.

Cephalad misplacement of a pulmonary artery catheter in a patient with a preexisting Hickman catheter

Background

Pulmonary artery catheter insertion is a routine practice in high-risk patients undergoing cardiac surgery. However, pulmonary artery catheter insertion is associated with numerous complications that can be devastating to the patient. Incorrect placement is an overlooked complication with few case reports to date.

Case presentation

An 18-year-old male patient underwent elective mitral valve replacement due to severe mitral valve regurgitation. The patient had a history of synovial sarcoma, and Hickman catheter had been inserted in the right internal jugular vein for systemic chemotherapy. We made multiple attempts to position the pulmonary artery catheter in the correct position but failed. A chest radiography revealed that the pulmonary artery catheter was bent and pointed in the cephalad direction. Removal of the pulmonary artery catheter was successful, and the patient was discharged 10 days after the surgery without complications.

Conclusions

To prevent misplacement of the PAC, clinicians should be aware of multiple risk factors in difficult PAC placement, and be prepared to utilize adjunctive methods, such as TEE and fluoroscopy.

Transvenous Retrieval of a Pulmonary Artery Catheter Knot Around Pacing Leads: A Case Report

BACKGROUND

Pulmonary Artery Catheter (PAC) knotting is a rare complication of PAC insertion. In patients with dilated right heart chambers, blind insertion of PAC significantly increases the risk of catheter knotting. We demonstrate a safe and successful approach to resolving a PAC knot around pacing leads of a cardiac resynchronization device.

CASE PRESENTATION

A 63-year-old African American male with dilated cardiomyopathy and a cardiac resynchronization therapy (CRT) device for severe left ventricular systolic dysfunction required PAC insertion for hemodynamic management of acute heart failure. PAC insertion was complicated by catheter knotting around the pacing leads. The PAC was successfully retrieved using a transvenous technique.

CONCLUSION

Fluoroscopy-guided insertion of PAC is advisable and preferred over blind insertion in patients with high risk of PAC entanglement.

LEARNING OBJECTIVE

To highlight a potential complication of blind pulmonary artery catheter insertion and provide a safe technique to resolve catheter knots.

Pulmonary Artery Catheter Knotted in the Tricuspid Valve Apparatus Requiring Surgery With Cardiopulmonary Bypass: A Case Report

Placement of a pulmonary artery catheter (PAC) is associated with complications such as entrapment or knotting. PAC entrapment in the heart, vena cava, or pulmonary artery is serious, potentially life-threatening, particularly if they are unrecognized. We present a patient with a PAC knot after aortic valve replacement. Interventional radiology (IR) determined that the catheter may have lodged in the tricuspid valve. Surgical exploration requiring cardiopulmonary bypass revealed that the PAC had passed through the tricuspid valve orifice and knotted itself around the anterior leaflet chordal structure. The catheter was unknotted, with the patient subsequently recovering without long-term sequelae.

Successful percutaneous retrieval of unusually knotted temporary pacemaker lead

Implantation of temporary pacemaker lead is commonly performed procedure and is usually safe, but can sometimes develop rare and serious complication like intracardiac lead knotting which may require challenging retrieval techniques. We report a case of successful percutaneous retrieval of unusually knotted right internal jugular venous temporary pacing lead via left femoral transvenous approach using snare over a long sheath after cutting the electrode proximally and thus avoiding any surgical intervention.

Diagnosis and Rescue of a Kinked Pulmonary Artery Catheter

Invasive hemodynamic monitoring with a pulmonary catheter has been relatively routine in cardiovascular and complex surgical operations as well as in the management of critical illnesses. However, due to multiple potential complications and its invasive nature, its use has decreased over the years and less invasive methods such as transesophageal echocardiography and hemodynamic sensors have gained widespread favor. Unlike these less invasive forms of hemodynamic monitoring, pulmonary artery catheters require an advanced understanding of cardiopulmonary physiology, anatomy, and the potential for complications in order to properly place, manage, and interpret the device. We describe a case wherein significant resistance was encountered during multiple unsuccessful attempts at removing a patient's catheter secondary to kinking and twisting of the catheter tip. These attempts to remove the catheter serve to demonstrate potential rescue options for such a situation. Ultimately, successful removal of the catheter was accomplished by simultaneous catheter retraction and sheath advancement while gently pulling both objects from the cannulation site. In addition to being skilled in catheter placement, it is imperative that providers comprehend the risks and complications of this invasive monitoring tool.

Effects of a dexmedetomidine constant rate infusion and atropine on changes in global perfusion variables induced by hemorrhage followed by volume replacement in isoflurane-anesthetized dogs

OBJECTIVE

To evaluate the effects of a dexmedetomidine constant rate infusion (CRI) and atropine on changes in global perfusion variables induced by hemorrhage and volume replacement (VR) in isoflurane-anesthetized dogs.

ANIMALS

8 adult dogs.

PROCEDURES

Each dog was anesthetized twice, with a 2-week interval between anesthetic sessions. Anesthesia was maintained with 1.3 times the minimum alveolar concentration of isoflurane with and without dexmedetomidine (1.6 μg/kg, IV bolus, followed by 2 μg/kg/h, CRI). Dogs were mechanically ventilated and received an atracurium neuromuscular blockade during both sessions. During anesthesia with isoflurane and dexmedetomidine, atropine was administered 30 minutes before baseline measurements were obtained. After baseline data were recorded, 30% of the total blood volume was progressively withdrawn and VR was achieved with an equal proportion of autologous blood.

RESULTS

Following hemorrhage, cardiac index, oxygen delivery index, and mixed-venous oxygen saturation were significantly decreased and the oxygen extraction ratio was significantly increased from baseline. The anaerobic threshold was not achieved during either anesthetic session. When dogs were anesthetized with isoflurane and dexmedetomidine, they had a significantly lower heart rate, cardiac index, and mixed-venous oxygen saturation during VR than they did when anesthetized with isoflurane alone. Plasma lactate concentration, mixed venous-to-arterial carbon dioxide difference, base excess, and anion gap were unaltered by hemorrhage and VR and did not differ between anesthetic sessions.

CONCLUSIONS AND CLINICAL RELEVANCE

Results indicated that the use of a dexmedetomidine CRI combined with atropine in isoflurane-anesthetized dogs that underwent volume-controlled hemorrhage followed by VR did not compromise global perfusion sufficiently to result in anaerobic metabolism.

[Acute respiratory distress syndrome: a review of the Berlin definition]

Acute Respiratory Distress Syndrome (ARDS) is due to many causes. The absence of a universal definition up until now has led to a series of practical problems for a definitive diagnosis. The incidences of ARDS and Acute Lung Injury (ALI) vary widely in the current literature. The American-European Consensus Conference definition has been applied since its publication in 1994 and has helped to improve knowledge about ARDS. However, 18 years later, in 2011, the European Intensive Medicine Society, requested a team of international experts to meet in Berlin to review the ARDS definition. The purpose of the Berlin definition is not to use it as a prognostic tool, but to improve coherence between research and clinical practice.

Successful retrieval of a knotted pulmonary artery catheter trapped in the tricuspid valve apparatus

We report the case of a 64-year-old patient in whom a pulmonary artery catheter formed a knot fixed within the right ventricle in the region of the tricuspid valve apparatus. Knot formation is a recognized complication associated with pulmonary artery catheters (PAC) insertion. This problem is usually dealt with by simply withdrawing the PAC until the knot impacts onto the introducer and after enlarging the puncture site by a small skin incision removing the introducer-PAC as one unit. However, we recently encountered a situation where the PAC was knotted around the tricuspid valve apparatus and could not be withdrawn. An interventional radiologist was able to unknot the catheter and release it from the tricuspid valve. We reviewed the literature related to this topic. We believe our experience could be of use to others.

[Intracardiac node of Swan-Ganz catheter: report of a case]

Le monitorage hémodynamique par cathéter de Swan-Ganz est utile surtout en cas de fonction cardiaque altérée. La mise en place de ce cathéter peut être accompagnée par des complications sévères dans 3 à 4,4% des cas tel que la rupture de l'artère pulmonaire, l'atteinte valvulaire, les troubles de la conduction, le pneumothorax, l'hémothorax et rarement la formation d'un nœud intracardiaque. Nous rapportons un cas de cathéter de Swan-Ganz compliqué d'un nœud formé à son extrémité et nous discutons les éventuels moyens diagnostiques et thérapeutiques de cette complication.