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Unusual Complication of Pulmonary Artery Catheter Placement; Entanglement with ICD Leads
Description
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A3461 - Unusual Complication of Pulmonary Artery Catheter Placement; Entanglement with ICD Leads
Author Block: N. Biru1, A. M. Zaaqoq2; 1Pulmonary and Critical Care, Medstar Washingtom Hospital Center, Washington, DC, United States, 2Department Surgical Critical Care, Medstar Washington Hospital Center, Washington, DC, United States.
Introduction
Over the past 40 years the pulmonary artery catheter (PAC) has become a widely used hemodynamic monitoring device in the management of critically ill patients, though doubts exist about its safety.
Case presentation
62 yo M from El Salvador who has a history of cardiomyopathy due to combination of Chagas and Ischemic heart disease s/p AICD requiring IABP and LVAD placement 3 months ago as bridge to transplant with course complicated by acute acalculous cholecystitis requiring percutaneous cholecystostomy tube with drains growing Bacillus and Enterococcus faecium. He improved and was discharged with the T tube in place, but was readmitted 2 weeks ago with left sided chest pain and found to have heart failure requiring diuresis. While he is being treated for heart failure, surgery team was called regarding planned cholecystectomy and he underwent elective laparoscopic cholecystectomy a month ago. Pt after that developed hypotension and shock concerning for sepsis, although without fevers with course. It was decided to place a PA catheter to help hemodynamics. Reportedly, this catheter encountered resistance when being pulled back and follow-up chest imaging reveals dislodgment of atrial and ventricular leads.
Fluoroscopy in the electrophysiology lab confirmed Swan-Ganz entanglement in at least the right atrial and right ventricular leads. Initial attempts to remove Swan-Ganz catheter consisted of passing a Glidewire into the Swan-Ganz catheter. The guidewire would not pass beyond the knot. Therefore a 6 French steerable catheter and a long sheath was successfully passed through the knot of the Swan-Ganz catheter via femoral access. Gentle traction was applied, but the knot would not untie. A snare technique was also used divide additional traction on the tip of the 6 French catheter, but despite extensive manipulation the knot could not be undone. Then he had a successful of extraction of the ICD leads which led easy removal of the PA catheter.
Discussion
Mechanical complications related to the Swan-Ganz catheter occur in 10% of all cases, with the most frequent being haematoma at the insertion site (4%), arterial puncture (3%), arrhythmias (3%), pneumothorax (0.5%), retrieval of lost insertion guidewire (0.5%) and haemothorax (0.2%).
Reference:
Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, PACMan study collaboration et al (2005) Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomized controlled trial. Lancet 366:435-436
Author Block: N. Biru1, A. M. Zaaqoq2; 1Pulmonary and Critical Care, Medstar Washingtom Hospital Center, Washington, DC, United States, 2Department Surgical Critical Care, Medstar Washington Hospital Center, Washington, DC, United States.
Introduction
Over the past 40 years the pulmonary artery catheter (PAC) has become a widely used hemodynamic monitoring device in the management of critically ill patients, though doubts exist about its safety.
Case presentation
62 yo M from El Salvador who has a history of cardiomyopathy due to combination of Chagas and Ischemic heart disease s/p AICD requiring IABP and LVAD placement 3 months ago as bridge to transplant with course complicated by acute acalculous cholecystitis requiring percutaneous cholecystostomy tube with drains growing Bacillus and Enterococcus faecium. He improved and was discharged with the T tube in place, but was readmitted 2 weeks ago with left sided chest pain and found to have heart failure requiring diuresis. While he is being treated for heart failure, surgery team was called regarding planned cholecystectomy and he underwent elective laparoscopic cholecystectomy a month ago. Pt after that developed hypotension and shock concerning for sepsis, although without fevers with course. It was decided to place a PA catheter to help hemodynamics. Reportedly, this catheter encountered resistance when being pulled back and follow-up chest imaging reveals dislodgment of atrial and ventricular leads.
Fluoroscopy in the electrophysiology lab confirmed Swan-Ganz entanglement in at least the right atrial and right ventricular leads. Initial attempts to remove Swan-Ganz catheter consisted of passing a Glidewire into the Swan-Ganz catheter. The guidewire would not pass beyond the knot. Therefore a 6 French steerable catheter and a long sheath was successfully passed through the knot of the Swan-Ganz catheter via femoral access. Gentle traction was applied, but the knot would not untie. A snare technique was also used divide additional traction on the tip of the 6 French catheter, but despite extensive manipulation the knot could not be undone. Then he had a successful of extraction of the ICD leads which led easy removal of the PA catheter.
Discussion
Mechanical complications related to the Swan-Ganz catheter occur in 10% of all cases, with the most frequent being haematoma at the insertion site (4%), arterial puncture (3%), arrhythmias (3%), pneumothorax (0.5%), retrieval of lost insertion guidewire (0.5%) and haemothorax (0.2%).
Reference:
Harvey S, Harrison DA, Singer M, Ashcroft J, Jones CM, Elbourne D, PACMan study collaboration et al (2005) Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomized controlled trial. Lancet 366:435-436
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