Entrapment of the introducing sheath of a pulmonary artery catheter.
A 74-year-old woman was admitted to our institution complaining of chest pain and dyspnoea on exertion. An echocardiogram revealed a dilated left ventricle with moderate to severe mitral regurgitation and mild to moderate aortic regurgitation. Left ventricular function was also significantly impaired. A coronary angiogram showed severe worsening triple-vessel disease. After stabilisation of her cardiac function, she was taken for coronary artery bypass and valve surgery.
As a part of the cardiac anaesthetic, venous access was established under ultrasound guidance with the double cannulation of the right internal jugular vein for the insertion of a triple lumen central venous catheter and a pulmonary artery catheter (PAC) sheath introducer. A PAC was then floated uneventfully into the pulmonary artery for invasive haemodynamic monitoring. Venous drainage for cardiopulmonary bypass was achieved in a standard fashion via cannulation of the superior and inferior vena cavae. She underwent coronary artery bypass grafting (two arterial grafts) and an aortic valve replacement with a mitral valve repair. Following the release of the aortic cross clamp, the patient was weaned successfully from bypass with decannulation and purse-string suture repair of the individual cavae.
The patient was transferred to the cardiothoracic intensive care unit and successfully extubated 24 hours following the surgery. Prior to planned discharge to the ward, the PAC was removed uneventfully. However it was noted that there was some resistance to removal of the PAC introducing sheath. The central venous catheter above the sheath was removed without any resistance. The chest X-ray demonstrated that the tip of the pulmonary artery sheath was in the distal superior vena cava. Bedside transthoracic echocardiogram was inconclusive on the entrapment. Fluoroscopy was not attempted. The patient underwent a 'redo' sternotomy for sheath removal the following day and it was found that the purse-string suture had gone through the PAC sheath and attached it to the superior vena cava. The suture was cut, the pulmonary artery sheath released and a new purse-string suture was placed. Following closure of the sternotomy wound the patient was transferred to the intensive care unit, successfully extubated and then transferred to the ward.
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Despite the controversy surrounding the use of the PAC in clinical practice, it remains an important method of measuring cardiac output, particularly in patients undergoing high-risk cardiac surgery (1,2). If appropriately used, these catheters are safe and facilitate the management of patients intra--and postoperatively. Complications encountered during their use have been well described, including cardiac conduction disturbances, vascular injuries, vessel thrombosis, valvular injuries, catheter knotting, entrapment and pulmonary artery haemorrhage and pulmonary infarction (3-5).
Entrapment of the PAC and difficulties in the removal of entrapped PACs, leading to serious morbidity and mortality, have been reported previously (3,5). Sites of PAC entrapment include the superior and inferior vena cavae and the left and right pulmonary arteries. Any resistance felt during the attempt to withdraw a PAC is highly suspicious of PAC entrapment. The cause of the problem is usually knotting of the catheter related to the insertion of an excessive length of the catheter, advanced in the absence of the expected pressure changes (3,5). knotting of the catheter is usually seen on a chest X-ray but fluoroscopy and echocardiography have been used to confirm entrapment (3).
Entrapped PACs can be removed by surgical and non-surgical methods, judged on a case-by-case basis (3,6). Non-surgical methods of removal require the assistance of an expert interventional radiologist and the availability of various endovascular instruments (3). Surgical removal of the catheter involves a sternotomy, with or without the requirement for cardiopulmonary bypass (6). Surgical Figure 2: Hole in the pulmonary artery sheath. removal is advocated in situations where the catheter has perforated or become firmly attached to the cardiovascular structures (3). Problems with surgical removal relate primarily to the sternotomy, which is not only invasive but also associated with an increased risk of infection, sternal dehiscence, mediastinitis and prolonged hospitalisation (3,6). However, any attempted manipulation of such an entrapped catheter by non-surgical means might lead to a tear in the involved cardiovascular structure leading to catastrophic bleeding, cardiac tamponade and death (3).
It has been suggested that, for patients undergoing cardiac surgery, the mobility of the PAC should be routinely checked before closing the sternotomy so as to exclude catheter entrapment (3,6). This manoeuvre however would not have helped in our patient, as it was the PAC sheath that was caught in the caval purse-string suture. As far as we are aware, this complication has not been reported before. Another potential explanation for entrapment of the sheath might have been knotting with the central venous catheter placed in the same jugular vein. However, this was excluded in our case by the easy removal of the central venous catheter.
The presence of an entrapped PAC or its introducing sheath should be recognised if resistance is noted during attempts to remove either. No undue force should be used in removing the sheath, even if the PAC is able to be removed easily. Physicians and nurses should abandon attempts to remove the PAC or the introducing sheath after cardiac surgery if resistance is noted. Minimal force might result in serious morbidity or death.
Accepted for publication on May 8, 2009.
(1.) Practice guidelines for pulmonary artery catheterization: an updated report by the American Society of Anesthesiologists Task Force on Pulmonary Artery Catheterization. Anesthesiology 2003; 99:988-1014.
(2.) Oransky I. H. Jeremy C. Swan. Lancet 2005; 365:1132.
(3.) Jacobsohn E, Fessler D, Rosemeier F, Tymkew H, Avidan M. Morbidity and mortality associated with accidentally entrapped pulmonary artery catheters during cardiac surgery: a case series. J Cardiothorac Vasc Anesth 2006; 20:371-375.
(4.) Bhatia P, Saied NN, Comunale ME. Management of an unusual complication during placement of a pulmonary artery catheter. Anesth Analg 2004; 99:669-671.
(5.) Vucins EJ, Rusch JR, Grum CM. Vent stitch entrapment of Swan-Ganz catheters during cardiac surgery. Anesth Analg 1984; 63:772-774.
(6.) Kaplan M, Demirtas M, Cimen S, Kut MS, Ozay B, Kanca A et al. Swan-Ganz catheter entrapment in open heart surgery. J Card Surg 2000; 15:313-315.
H. RAMASWAMYKANIVE *, D. J. BIHARI [[dagger]]
Cardiothoracic Intensive Care Unit, Prince of Wales Hospital, Sydney, New South Wales, Australia
* M.B., B.S., Dip.N.B. (Medicine) (India), E.D.I.C. (Lond.), Fellow, Intensive Care Unit.
[[dagger]] M.A. (Cambridge), M.B., B.S. (Lond.), F.R.C.P. (Lond.), F.R.A.C.P., F.J.F.I.C.M., Associate Professor, University of New South Wales and Intensive Care Physician.
Address for correspondence: Dr H. Ramaswamykanive, Cardiothoracic Intensive Care Unit, Prince of Wales Hospital, Barker Street, Sydney, NSW 2031.
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|Author:||Ramaswamykanive, H.; Bihari, D.J.|
|Publication:||Anaesthesia and Intensive Care|
|Article Type:||Case study|
|Date:||Nov 1, 2009|
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