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Misplacement of a Pulmonary Artery Catheter

Varelmann, Dirk J. MD, DESA, EDIC; Hilberath, Jan N. MD

doi: 10.1213/XAA.0000000000000079
Case Reports: Case Report

Placing a flow-directed pulmonary artery catheter (PAC) can be difficult and lead to serious complications. We present the case of an attempted PAC insertion in a patient undergoing implantation of a left ventricular assist device. Although physiologic pressure waveforms were established, plausible measurements of cardiac output and pulmonary capillary wedge pressure were not initially obtainable. Chest radiography showed that the catheter was looped in the pulmonary artery. This malposition could not be visualized intraoperatively by transesophageal echocardiography. The PAC was replaced in the operating room after the left ventricular assist device was implanted.

From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.

Accepted for publication March 18, 2014.

Funding: Support was provided solely from departmental sources at the Brigham and Women’s Hospital, Boston, MA.

The authors declare no conflicts of interest.

Address correspondence to Dirk J. Varelmann, MD, DESA, EDIC, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115. Address e-mail to

Pulmonary artery catheters (PACs) are frequently used to monitor cardiac pressures and hemodynamic variables in high-risk patients during surgical procedures and postoperative care. Placing PACs can be very challenging, and not all complications become obvious at the time of insertion. This report describes a rare complication of PAC insertion and exemplifies the debatable decision making that can occur in a complex operating room (OR) environment.

The case report does not contain identifiable information. The patient and family were not contacted, and our center’s IRB determined that approval was not required.

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A 59-year-old man was scheduled for implantation of a left ventricular assist device for end-stage dilated cardiomyopathy. His surgical history was significant for the placement of an automatic implantable cardioverter defibrillator (AICD) for ventricular tachycardia. After general anesthesia was induced, a PAC was placed through a 9F introducer sheath from the right internal jugular vein. While the PAC was advanced, the central venous pressure (CVP) sensor, rather than the pulmonary artery (PA) transducer, showed a right ventricular pressure trace at an insertion depth of 55 cm and subsequently a PA pressure waveform at 65 cm. The PA transducer depicted a normal CVP waveform throughout the entire placement. Given the physiologic appearance of both waveforms, it was assumed that the respective transducers had been erroneously connected during OR setup. As a result, connections were switched and relabeled. The PAC was further advanced in an unsuccessful attempt to measure pulmonary capillary wedge pressure, which was complicated by the occurrence of multiple premature ventricular contractions. In light of the significant potential for arrhythmias, no more adjustments of the PAC were made at that time, and the operation proceeded as planned. Intraoperative attempts to clearly visualize the PAC with transesophageal echocardiography remained unsuccessful, despite a comprehensive examination according to current guidelines, because the AICD leads were causing reverberation and scatter artifacts (Fig. 1).1

Figure 1

Figure 1

After the procedure was completed, a chest radiogram was obtained in the OR to verify the catheter’s position: The distal tip of the PAC projected over the AICD coil in the superior vena cava (Fig. 2, arrow A), and the central venous orifice projected into the right PA while the catheter described a loop (Fig. 2, arrow B). The PAC was withdrawn without resistance and re-floated after the transducers were reconnected and labeled appropriately (CVP transducer to CVP port, PA transducer to PA port). Wedge position was now reached at 55 cm, and chest radiography confirmed that the PAC tip was in the right PA. The patient was transferred to the cardiac surgery intensive care unit for postoperative management and eventually discharged to rehabilitation.

Figure 2

Figure 2

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For patients undergoing complex cardiac surgical procedures such as the insertion of a ventricular assist device, PACs are often placed perioperatively to monitor cardiac filling pressures, mixed venous oxygen saturation, and cardiac output. In the OR, PACs are most commonly inserted without fluoroscopic guidance. Placing PACs can be challenging in patients with low cardiac output states.2 Our patient presented with low cardiac output, as well as a severely enlarged right ventricle from dilated cardiomyopathy, and required continuous inotropic support before the operation. What complicated this case further were the patient’s in situ AICD leads: the inflated balloon at the catheter tip got caught on the proximal AICD coil at the superior vena caval–right atrial junction. Therefore, as the PAC was advanced, the right ventricular and PA tracings were transduced through the CVP port, while the distal PA port showed a normal CVP waveform throughout.

An instinctive response of clinicians who are troubleshooting problems is the attempt to eliminate common errors first, such as faulty pressure transducer connections during OR setup. Hence, cables were switched and relabeled, and the problem seemed solved. Being unable to wedge the PAC despite significant catheter depth was accepted to proceed with surgery, given the patient’s medical history and because of arrhythmias during catheter placement. The AICD leads in this patient’s vasculature and right heart made echocardiographic visualization of the PAC challenging because hardware frequently causes echogenic artifacts.3 After the operation, a chest radiogram was taken in the OR to confirm the PAC’s position, and an unlikely loop was found, in which the PAC tip had been caught on the AICD coil and the CVP port was looped in the PA.

This example of a misplaced PAC highlights the potential pitfalls of treating patients with intravascular hardware in place. Placements of central venous lines or PACs have intrinsic risks that can lead to complications. Most safety initiatives addressing placement of central venous catheters focus on the prevention of central line–associated bloodstream infections.4 However, most litigious claims of central vascular catheter injuries are related to mechanical complications, such as emboli (from catheter or guidewire), cardiac tamponade, carotid artery puncture/cannulation, hemo/pneumothorax, PA rupture, and air embolism.5 Complex environments are a common factor in placement errors, and many system factors may contribute to these incidents (e.g., patient factors, task factors, provider factors, team factors, training and education, OR/intensive care unit environment, and institutional environment).6 In this case, multiple factors contributed to the misplacement of the PAC:

  • –Patient factors: complexity of underlying disease (low cardiac output, AICD, dilated cardiomyopathy)
  • –OR environment: complicated setup with multiple pressure transducers
  • –Team factors: the omission of team members to voice concerns when unusual events occurred
  • –Institutional environment: time pressure to start the case

The case should also serve as a reminder to be vigilant even during routine placement of catheters and to profoundly question data that do not seem right.7 In the fast-paced, noisy OR environment, we too frequently dismiss monitoring alarms or inexplicable results because they “just can’t be.” It is important for all involved multidisciplinary team members to pause whenever unusual findings occur to prevent potentially detrimental effects on patient safety and outcome.8

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