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Communications to the Editor |

A Kinky Catheter FREE TO VIEW

Joyce C. Choy, MB, BS; ; Thean Seng; , MB, BS
Author and Funding Information

National University Hospital Singapore

Correspondence to: Joyce C. Choy, MB,BS, MMED, Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Rd, Singapore 119074, Singapore; e-mail: joycechoy@hotmail.com



Chest. 2000;117(1):292. doi:10.1378/chest.117.1.292
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Published online

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 vein (IJV).

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 SCV.

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.

Figure Jump LinkFigure 1. Chest radiograph showing the acute angulation of the PAC in the right IJV at the end of the sheath.Grahic Jump Location

References

Bromley, JJ, Moorthy, SS (1983) Acute angulation of a pulmonary artery catheter [letter].Anesthesiology59,367-368. [PubMed] [CrossRef]
 
Boyd, KD, Thomas, SJ, Gold, J, et al A prospective study of complications of pulmonary artery catheterizations in 500 consecutive patients.Chest1983;84,245-249. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Chest radiograph showing the acute angulation of the PAC in the right IJV at the end of the sheath.Grahic Jump Location

Tables

References

Bromley, JJ, Moorthy, SS (1983) Acute angulation of a pulmonary artery catheter [letter].Anesthesiology59,367-368. [PubMed] [CrossRef]
 
Boyd, KD, Thomas, SJ, Gold, J, et al A prospective study of complications of pulmonary artery catheterizations in 500 consecutive patients.Chest1983;84,245-249. [PubMed]
 
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