Entrapment of a pulmonary artery catheter by invagination of a percutaneous introducer sheath.
Article Type: Case study
Subject: Cardiac catheterization (Complications and side effects)
Cardiac catheterization (Case studies)
Authors: Kim, S.-H.
Kim, H.-Y.
Yoon, T.-G.
Kim, T.-Y.
Pub Date: 03/01/2010
Publication: Name: Anaesthesia and Intensive Care Publisher: Australian Society of Anaesthetists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Australian Society of Anaesthetists ISSN: 0310-057X
Issue: Date: March, 2010 Source Volume: 38 Source Issue: 2
Accession Number: 225792565
Full Text: The pulmonary artery catheter (PAC) has been widely used and can provide important clinical information for perioperative management (1). Although many complications regarding PAC are recognised, immobilisation of the PAC by invagination of the percutaneous introducer sheath has not been reported previously.

A 62-year-old woman arrived at the operating room for a cardiac transplantation. After anaesthesia was induced, a PAC (Swan-Ganz CCOmbo CCO/Sv[O.sub.2][R], Edwards Lifesciences LLC, USA) was placed through a 9 F percutaneous introducer sheath (Advanced Venous Access High-Flow Device, Edwards Lifesciences LLC, USA) into the left internal jugular vein uneventfully. A pulmonary capillary wedge pressure was obtained at 48 cm, and the PAC was fixed at 45 cm. Before starting cardiopulmonary bypass (CPB), the PAC was withdrawn to 30 cm. Cardiac transplantation, using the bicaval technique, was completed. An attempt to reposition the PAC met resistance during CPB and the PAC could not be moved. After weaning the patient from CPB, the PAC still could not be moved. Several attempts to advance or retrieve the PAC were tried but failed. The operator could not palpate the PAC in the superior vena cava. After a discussion with the surgeon, it was decided that we should explore the left brachiocephalic vein. The PAC tip could be seen upon incision of the left brachiocephalic vein. The PAC tip was pulled by the surgeon, but it would not move. After removal of the percutaneous introducer sheath with the PAC, it was seen that the percutaneous introducer sheath had invaginated itself and gripped the PAC (Figure 1).


We suspected two possibilities when we first tried to reposition the PAC. First, that the superior vena cava cannula for CPB, which is thick and hard, could have restricted the movement of the PAC. Therefore, we waited until CPB weaning and removal of the superior vena cava cannula. Second, that surgical sutures could have inadevertently restricted PAC movement. Although transoesophageal echocardiography is a useful tool for diagnosing PAC entrapment (2), it was not helpful in this instance because the PAC was not in the heart. Fluoroscopy was not used due to the infection risk.

We speculate that in the present case, the cause of the complication was as described below. The design of the percutaneous introducer sheath integrates the hub and sheath (Figure 1). A triangular shaped hub, constructed of plastic, is hard and cannot be deformed whereas the sheath, including the multi-lumen, is constructed of polyurethane, making it flexible and resistant to kinking. If damage or deformation occurs at the sheath, the PAC cannot be inserted into the indwelling percutaneous introducer sheath. Therefore, PAC entrapment could occur at the transition from the hard hub to the soft sheath. Because the hub is heavier than the sheath, if the sheath is not fully advanced into the skin and the hub is not tightly fixed at the skin, angulation at the transition site can occur by gravity. Repetitively advancing and retrieving the PAC without tightly fixing the hub at the skin may result in more angulation or folding of the sheath at the transition zone. The soft and flexible sheath might have become invaginated into the hard hub at the angulated transition site when the PAC was retrieved before starting CPB.

Invagination of a percutaneous introducer sheath may be rare, but we should be aware that it can cause PAC entrapment. Fully advancing the percutaneous introducer sheath into the skin with tight fixation may prevent this complication.


(1.) Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D. Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter. N Engl J Med 1970: 283:447-451.

(2.) Rupert E, Paul A, Mukherji J. Transoesophageal echocardiography: a useful tool to diagnose entrapment of pulmonary artery catheter. Anaesthesia 2006; 61:702-704.

S.-H. Kim

H.-Y. Kim

T.-G. Yoon

T.-Y. Kim

Seoul, Korea
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