National University Hospital
Correspondence to: Joyce C. Choy, MB,BS, MMED, Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; e-mail: email@example.com
To the Editor:
Complications when using the balloon-tipped, flow-directed
pulmonary artery catheter (PAC) abound. We wish to report an unusual
episode of acute angulation of the PAC in the right internal jugular
A 68-year-old man with poor left ventricular function (ejection
fraction, 30%) was scheduled for elective coronary artery bypass
grafting. Preinduction, both the central venous pressure
catheter and PAC (7.5F thermodilution catheter, model 1755HD,
21–000007-93C; Biosensors International Pte Ltd; Singapore) were
inserted into the right IJV via a double-puncture technique. We were
unable to float the PAC into the pulmonary artery. On the third
attempt, it was noted that the PAC had been advanced to the 50-cm mark.
Subsequent withdrawal of the catheter was met with a definite
resistance at the 20-cm mark. No waveform was obtained, and the
aspiration of blood was unsuccessful. The chest radiograph (Fig 1
) revealed an acute angulation of the PAC at the end of its introducer
in the right IJV. After discussion with the surgeon, a decision was
made to unfurl the PAC by opening the right atrium intraoperatively.
The kink in the PAC is shown in Figure 2
. Surgery proceeded uneventfully.
This case highlights the possibility of acute angulation of the PAC
loop in the IJV itself. Acute angulation has been described when a PAC
was inserted into the external jugular vein (EJV).1
This is attributed to the variations in the EJV-subclavian vein (SCV)
course. Theoretically, this angulation also could occur using the right
Boyd et al2 reported an incidence of 0.1% for the
inability to wedge the PAC and an incidence of 0.2% for catheter
looping. As is widely reported, multiple attempts at floating
the PAC and floating too long a section of the PAC should be
avoided. In our case, we postulate that the PAC had looped in
the right ventricle and retraced its path back into the right IJV.
During withdrawal, the loop tightened, causing the acute angulation
that resulted in complete occlusion of the PAC.
We considered using a guidewire to push the PAC into the right atrium
then straightening it, but chose to induce the patient and solve the
problem by opening the right atrium intraoperatively.
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