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Catheter knotting and / or entrapment.
Catheter knotting 1, 2 occurs as a result of looping of the catheter within the right ventricle. Such knots have been untied by radiologists using guide wires operated under fluoroscopic control. Untying of a knot by the use of a guide wire in combination with an angioplasty catheter has also been reported 3. An alternative approach has been to tighten the knot and to withdraw the catheter percutaneously together with the introducer sheath. - This latter approach is obviously contraindicated if the knot involves the papillary muscles. Under these circumstances surgical removal is necessary.
The likelihood of catheter knotting can be reduced if care is taken to avoid intraventricular loops. Looping should be suspected if the catheter is passed an excessive distance into the ventricle without encountering a pulmonary arterial waveform, or if the patient begins to suffer multiple ventricular ectopics or runs of ventricular tachycardia. Suspected looping must be treated by withdrawal of the catheter to the 20cm mark before further attempts at flotation are made.
Catheter looping within the pulmonary artery itself has also been reported 23, but is an uncommon event in our experience.
Balloon separation.
Separation of the balloon from the body of the catheter has been described 4, but appears to be an exceptionally rare event.
Balloon rupture.
Rupture of the terminal balloon should be suspected whenever inflation of the balloon is not accompanied by a feeling of slight resistance. The diagnosis can be confirmed by applying the inflation syringe firmly to the port, injecting about 1.5ml of gas and immediately attempting to aspirate the same volume. If the inflating gas is not returned, the diagnosis of balloon rupture should be assumed.
If the PAC is already in the pulmonary artery and PAOP measurements are not necessary for the further management of the case, (for example if PAEDP measurements can be used as a measure of PAOP), the catheter need not be removed, but the balloon inflation port should be closed and clearly labelled as being 'Not for further use'.
The incidence of balloon rupture is unreported. It is our impression that it is a relatively rare event in catheters which remain in use for less than 72 hours.
It has been suggested that during nitrous oxide anaesthesia overinflation of the balloon may occur as a result of passage of N2O into the balloon 5. This concern appears to be of no practical significance 6.
Valvular damage.
Damage to both the tricuspid 7 and pulmonary 8 valves has been reported as resulting from the withdrawal of the catheter through the valve with the balloon still inflated. These complications are extremely rare, nevertheless, when the catheter is being manipulated, excessive force must never be used and the balloon must be always be deflated if the catheter is being withdrawn.
Thrombocytopenia.
Mild thrombocytopenia (which may be a reflection of a consumptive coagulopathy) has been reported in patients with indwelling pulmonary artery catheters 9. Heparin-coated catheters may also trigger overt Heparin Induced Thrombocytopenia 10 and such catheters should not be used in patients with heparin-associated antiplatelet antibodies.
Venous Line Obstruction.
Obstruction of the venous line (from patient to cardiotomy reservoir) has been reported on various occasions during cardiopulmonary bypass 11, 12 (Figure 1). If PAC is withdrawn from the pulmonary artery during bypass, the tip should be positioned in the superior vena cava, not the atrium. The catheter should not be refloated until the venous line has been removed and the atrial purse string has been tied.
Bradycardia.
Transient bradycardia has been observed during cardiac output measurement when the cold indicator is injected into the right atrium. In a prospective study, one investigator observed that with the use of iced injectate a decrease in heart rate of more than 10% occurred in about 20% of the determinations 13. The chances of bradycardia can be reduced if room temperature injectate is used, but this may degrade the accuracy of the output measurement.
Extravascular lumen placement.
This may occur if either the catheter or the introducer sheath is partially withdrawn after correct placement. If it occurs, it can result in the effective non-administration of any drug or fluid which is being given through the extravascular lumen. It is a particularly insidious form of technical failure.
Pericardial placement of a PAC occurring as a result of insertion through a previously inserted introducer sheath has also recently been described 14.
Pericardial effusion / tamponade.
Pericardial effusion and / or tamponade is a largely theoretical complication of pulmonary arterial catheterisation. It is more commonly associated with the use of central venous catheters 15, 16 although the use of catheter-introducer systems have recently been implicated as a cause of ventricular perforation 17.
Microshock.
Microshock is a potential hazard whenever a direct electrical connection to the heart exists. Saline filled catheters can provide a conducting pathway for a microshock current. Current flows of as little as 100 microamps can result in ventricular fibrillation. In practice, microshock incidents are extremely rare in the modern intensive care or operating theatre environment.
Thrombus formation.
The PAC is an intravascular foreign body that may act as a nidus for thrombus formation. Heparin coating of PAC's during manufacture is now commonly practised and this may reduce the thrombogenicity of the devices 18. Such catheters should not be used in patients with heparin induced thrombocytopenia syndromes.
Coronary sinus cannulation.
The coronary sinus (CS) can occasionally be inadvertently cannulated with a pulmonary artery catheter 19. CS cannulation should be suspected if there is a gradual, rather than sudden, development of a 'right ventricular' trace during advancement of the catheter, or if there is paradoxical behaviour of the catheter such that balloon inflation produces a more pulsatile and deflation a less pulsatile trace (Figure 2).
Catheter migration.
Catheter migration through a patent ductus arteriosus into the aorta has been described 20.
Cannulation of a persistent left-sided superior vena cava.
Persistent left superior vena cava occurs in about 0.3% of the normal population. If the left internal jugular or left subclavian vein is chosen for cannulation, the catheter may take this route to the heart. Under these circumstances, the catheter enters the right atrium via the coronary sinus 21 (Figure 3).
Puncture of the cuff of an endotracheal tube.
Puncture of the cuff of an endotracheal tube has been reported complicating attempted cannulation of the internal jugular vein 22.
Induction of valvular incompetence.
Induction or exacerbation of tricuspid incompetence after passage of a PAC has been demonstrated recently 24. However, it seems likely that induced regurgitation is rarely of clinical significance and these authors commented that "The increase in regurgitation in most patients was small, but 17% of patients had an increase in TR jet area 1 cm2, and 30% had an increase in TR severity by at least one clinical grade."
Induction or exacerbation of pulmonary valvular incompetence was also demonstrated in the same study, but appears to be an even less significant clinical problem.
References:1. Schwartz KV, Garcia FG Entanglement of Swan-Ganz catheter around an intracardiac structure. JAMA 237:113, 1987.
2. Mehta N; Lochab SS; Tempe DK; Trehan V; Nigam M Successful nonsurgical removal of a knotted and entrapped pulmonary artery catheter. Cathet Cardiovasc Diagn, 43:87-9, 1998 Jan
3. Tan C, Bristow P. J. , Segal P et al A Technique to Remove Knotted Pulmonary Artery Catheters Anaesth Intens Care 1997; 25:160-162
4. Helena W, McKay RSF. An unusual complication of pulmonary artery catherization. Anesthesia and Analgesia. 1992; 74:154-155
5. Kaplan R, Abramowitz MD, Epstein BS Nitrous oxide and air-filled balloon-tipped catheters. Anesthesiology 1981 Jul;55(1):71-3
6. du Boulay PM, Nahrwold ML In vivo response of air-filled balloon-tipped catheters to nitrous oxide. Anesthesiology 1982 Dec;57(6):530
7. Boscoe MJ, de Lange S: Damage to the tricuspid valve with a Swan-Ganz catheter. Br Med J 283:346, 1981.
8. O'Toole JD, Wurtzbacher JJ, Wearner NE, and Jain AC: Pulmonary-valve injury and insufficiency during pulmonary-artery catheterization. N Eng J Med 301:1167-1168, 1979.
9. Kim YL, Richman KA, Marshall BE Thrombocytopenia associated with Swan-Ganz catheterization in patients. Anesthesiology 53:261, 1980
10. Laster J, Silver D Heparin-coated catheters and heparin-induced thrombocytopenia. J Vasc Surg 1988 May;7(5):667-72
11. Oyarzun JR; Donahoo JS; McCormick JR; Herman S Venous cannula obstruction by Swan-Ganz catheter during cardiopulmonary bypass. Ann Thorac Surg, 62(1):266-7 1996 Jul
12. Gilbert TB Scherlis ML Fiocco M Lowinger TA Pulmonary artery catheter migration causing venous cannula obstruction during cardiopulmonary bypass. Anesthesiology 1995 Feb, 82 [2]: 596- 7.
13. Harris AP, Miller CF, Beattie C et al The slowing of sinus rhythm during thermodilution cardiac output determination and the effect of altering injectate temperature. Anesthesiology 63:540, 1985
14. Cardwell ME, Winter B Pericardial placement of a pulmonary artery catheter. Anaesthesia 1998 Mar;53(3):290-2
15. Collier PE, Ryan JJ, Diamond DL Cardiac tamponade from central venous catheters. Report of a case and review of the English literature. Angiology 1984; 35: 595-600
16. Greenall MJ, Blewett RW, McMahon MJ Cardiac tamponade and central venous catheters BMJ 1975; 2:595-597
17. Porter JM, Page R, Wood AE et al Ventricular perforation associated with central venous introducer-dilator systems. Can J Anaesth 1997; 44: 317-320
18. Mangano DT Heparin bonding and long-term protection against thrombogenesis. N Engl J Med 307:894, 1982
19. Baciewicz FA, Nirdlinger MA, Davis JT An unusual position of a Swan-Ganz catheter. Intensive Care Med 1987;13(3):211-212
20. Moore RA, McNicholas K, Gallagher JD, Niguidula F. Migration of pediatric pulmonary artery catheters. Anesthesiology 1982; 52: 102-104.
21. Lai YC, Goh JCY, Lim SH et al Difficult Pulmonary Artery Catheterization in a Patient with Persistent Left Superior Vena Cava. Anaesth Intensive Care 1998; 26: 671-673
22. Blitt CD; Wright WA An unusual complication of percutaneous internal jugular vein cannulation, puncture of an endotracheal tube cuff. Anesthesiology, 40:306-7, 1974 Mar
23. Wilson SW, Moorthy SS, Mahomed Y, Vix VA. Catheter doubling in left main pulmonary artery. Anesthesiology. 1984 Mar;60(3):266-7.
24. Sherman SV, Wall MH, Kennedy DJ, Brooker RF, Butterworth J. Do pulmonary artery catheters cause or increase tricuspid or pulmonic valvular regurgitation? Anesth Analg 2001 May;92(5):1117-22
Last edited on: 25/08/2001
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