Repair of a Perforated Pulmonary Artery Due to a Swan-Ganz Catheter Using Thrombin Injection
2009; Lippincott Williams & Wilkins; Volume: 119; Issue: 17 Linguagem: Inglês
10.1161/circulationaha.107.739482
ISSN1524-4539
AutoresDavid Dobies, Amanda L Cohoon, Ashley A. Bates,
Tópico(s)Central Venous Catheters and Hemodialysis
ResumoHomeCirculationVol. 119, No. 17Repair of a Perforated Pulmonary Artery Due to a Swan-Ganz Catheter Using Thrombin Injection Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBRepair of a Perforated Pulmonary Artery Due to a Swan-Ganz Catheter Using Thrombin Injection David R. Dobies, Amanda L. Cohoon and Ashley A. Bates David R. DobiesDavid R. Dobies From the Genesys Heart Institute, Genesys Regional Medical Center, Grand Blanc, Mich (D.R.B., A.L.C.), and Michigan State University, East Lansing (A.A.B.). , Amanda L. CohoonAmanda L. Cohoon From the Genesys Heart Institute, Genesys Regional Medical Center, Grand Blanc, Mich (D.R.B., A.L.C.), and Michigan State University, East Lansing (A.A.B.). and Ashley A. BatesAshley A. Bates From the Genesys Heart Institute, Genesys Regional Medical Center, Grand Blanc, Mich (D.R.B., A.L.C.), and Michigan State University, East Lansing (A.A.B.). Originally published5 May 2009https://doi.org/10.1161/CIRCULATIONAHA.107.739482Circulation. 2009;119:e521–e522Pulmonary artery perforation is a rare but often fatal complication of right heart catheterization that is due to Swan-Ganz catheter (Edward Lifesciences, Irvine, Calif) placement.1–3 Treatment of a catheter-induced pulmonary artery rupture includes emergent intubation, lung resection, surgical pulmonary artery repair, and catheter-based pulmonary artery embolization.4,5This case demonstrates a new therapeutic approach of injecting topical Thrombin-JMI (GenTrac Inc, Middleton, Wisc) through the distal port of the Swan-Ganz catheter to effectively treat a pulmonary artery rupture during a right heart catheterization.Case PresentationThe patient was a 72-year-old woman with a past medical history of severe mitral valve regurgitation. Left heart catheterization was performed first with no complications. The coronary angiogram demonstrated minimal luminal irregularities in all 3 major coronary arteries. The left ventriculogram demonstrated +3 mitral regurgitation with a 50% ejection fraction. Right heart catheterization was then performed using a 7.5Fr Swan-Ganz balloon-tipped catheter. The right atrial mean pressure was 8 mm Hg. Right ventricular pressure was 51/8 mm Hg. The pulmonary artery pressure was recorded at 51/20 mm Hg. The mean pulmonary capillary wedge pressure was 20 mm Hg.On inflation of the balloon, the pulmonary artery perforated. This was made evident by frank hemoptysis shortly after balloon inflation. Intubation was selective to the right bronchus then pulled back to a position just above the carina. With the Swan-Ganz catheter remaining in the pulmonary artery, a "pulmonary wedge" angiogram via the distal port of the Swan-Ganz was performed using Isovue 370 (Bracco Diagnostics, Princeton, NJ). The angiogram demonstrated formation of a pseudoaneurysm with extravasation of contrast (Figures 1 and 2). The tip of the catheter was retracted slightly, and the balloon was inflated to half its prior volume. Placement of the balloon at this location created a tamponade effect, stopping the hemoptysis. Download figureDownload PowerPointFigure 1. Extravasation of contrast with pseudoaneurysm formation.Download figureDownload PowerPointFigure 2. Enlarging pseudoaneurysm with a small amount of contrast extravasation.With each balloon deflation periodic pulmonary angiograms were performed through the distal port of the Swan-Ganz catheter. Mild hemoptysis was present with each deflation.The balloon was inflated for approximately an hour with periodic deflations and imaging to determine if the rupture would seal. The ruptured pulmonary artery failed to seal.A thrombin injection procedure was performed (topical US Pharmacopeia [bovine origin] Thrombin-JMI 20 000 IU/20 mL sterile saline). By angiography it was determined that 0.3 mL of contrast would fill the distal artery and the pseudoaneurysm. This measurement was obtained using a tuberculin syringe. Two injections of 0.2 mL each of thrombin were injected via the distal port of the Swan-Ganz catheter for a total dose of 400 IU thrombin delivered. Subsequent angiography demonstrated resolution and clotting of the affected pulmonary artery pseudoaneurysm. The adjacent pulmonary artery remained free from injury or clot (Figure 3). Download figureDownload PowerPointFigure 3. Seal of perforation without further obstruction of adjacent pulmonary arteries. Note resolution of the pulmonary artery pseudoaneurysm (dye staining).A follow-up high-resolution chest computed tomography scan performed 2 days later demonstrated minimal contrast in the right middle lung. No acute bleeding or pulmonary emboli were present. One month later, mitral valve repair was performed using a 28-mm annuloplasty. The patient was anticoagulated with warfarin without complications.DiscussionA thrombin injection procedure through the distal port of the indwelling Swan Ganz catheter was chosen. Advantages of this technique are (1) that the patient can be stabilized by tamponade of the pulmonary artery with the Swan-Ganz balloon tip, (2) that a precise volume of thrombin can be delivered on the basis of various contrast test injections, and (3) that the procedure can be performed on a very unstable patient, unlike the other therapeutic options. Direct injection of thrombin into a perforated pulmonary artery is a feasible and expedient technique for pulmonary artery rupture during right heart catheterization.DisclosuresNone.FootnotesCorrespondence to David Dobies, MD, FACC, FSCAI, Director of Genesys Heart Institute, c/o Kimberly R. Barber, PhD, Office of Research, Suite 2442, Genesys Regional Medical Center, One Genesys Pkwy, Grand Blanc, MI 48439. E-mail [email protected] References 1 Poplausky MR, Rozenblit G, Rundback JH, Crea G, Maddineni S, Leonardo R. Swan-Ganz catheter–induced pulmonary artery pseudoaneurysm formation: three case reports and a review of the literature. Chest. 2001; 120: 2105–2111.CrossrefMedlineGoogle Scholar2 Bhatia P, Saied NN, Comunale ME. Management of an unusual complication during placement of a pulmonary artery catheter. Anesth Analg. 2004; 99: 669–671.CrossrefMedlineGoogle Scholar3 Settergen G, Angdin M, Anderson RE, Liska J, Lundberg J, Tornberg DC, Weitzberg E. Wedging the pulmonary artery catheter: changes in left atrial and pulmonary artery pressures and risk for performation. J Cardiothorac Vasc Anesth. 2006; 20: 311–314.CrossrefMedlineGoogle Scholar4 Bossert T, Gummert JF, Bittner HB, Barten M, Walther T, Falk V, Mohr FW. Swan-Ganz catheter–induced severe complications in cardiac surgery: right ventricular perforation, knotting, and rupture of a pulmonary artery. J Card Surg. 2006; 21: 292–295.CrossrefMedlineGoogle Scholar5 Finfer S, Delaney A. Pulmonary artery catheters. BMJ. 2006; 333: 930–931.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Suri P and Kitley C (2022) Successful percutaneous embolization of an intraoperative swan ganz catheter-related pulmonary artery injury, Radiology Case Reports, 10.1016/j.radcr.2022.07.053, 17:10, (3851-3854), Online publication date: 1-Oct-2022. Leick J, Leinen S, Friedrich I, Werner N, Dastidar A, Ngo L and Ahmed N (2021) Iatrogenic perforation of a pulmonary artery side branch—a case report, European Heart Journal - Case Reports, 10.1093/ehjcr/ytab199, 5:6, Online publication date: 29-May-2021. Boukantar M, Gallet R, You K, Tacher V, Mouillet G, Kobeiter H, Teiger E, Hildebrandt H, Rassaf T, Kahlert P and Boudjemline Y (2017) How should I treat a pulmonary artery rupture occurring during a right heart catheterisation in the cathlab?, EuroIntervention, 10.4244/EIJ-D-16-00576, 12:18, (e2280-e2282) Zhang J and Jiang S (2015) Massive haemoptysis from a central pulmonary arterial pseudoaneurysm secondary to advanced lung cancer: successful treatment by Guglielmi detachable coil embolization, The Clinical Respiratory Journal, 10.1111/crj.12333, 11:2, (258-262), Online publication date: 1-Mar-2017. Melão F, Lopes R, Rodrigues R, Magalhães D, Vilares Morgado P, Silva J, Campelo M and Maciel M (2016) Massive hemoptysis as an unusual complication of right heart catheterization: Successful treatment with percutaneous stent, Revista Portuguesa de Cardiologia (English Edition), 10.1016/j.repce.2015.07.020, 35:4, (235.e1-235.e4), Online publication date: 1-Apr-2016. Melão F, Lopes R, Rodrigues R, Magalhães D, Vilares Morgado P, Silva J, Campelo M and Maciel M (2016) Massive hemoptysis as an unusual complication of right heart catheterization: Successful treatment with percutaneous stent, Revista Portuguesa de Cardiologia, 10.1016/j.repc.2015.07.014, 35:4, (235.e1-235.e4), Online publication date: 1-Apr-2016. Nellaiyappan M, Omar H, Justiz R, Sprenker C, Camporesi E and Mangar D (2014) Pulmonary artery pseudoaneurysm after Swan-Ganz catheterization: a case presentation and review of literature, European Heart Journal: Acute Cardiovascular Care, 10.1177/2048872613520252, 3:3, (281-288), Online publication date: 1-Sep-2014. Shin J, Shin J and Yoon H (2011) Endovascular Thrombin Injection for a Pulmonary Artery Pseudoaneurysm: Case Report, Journal of the Korean Society of Radiology, 10.3348/jksr.2011.65.6.573, 65:6, (573), . May 5, 2009Vol 119, Issue 17 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.107.739482PMID: 19414650 Originally publishedMay 5, 2009 PDF download Advertisement SubjectsCatheter-Based Coronary and Valvular InterventionsEchocardiographyImaging
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