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Table of Contents
LETTER TO EDITOR  
Year : 2012  |  Volume : 15  |  Issue : 3  |  Page : 254-255
Resistance to withdraw a Swan-Ganz catheter: A word of caution


Department of Cardiac Anesthesia, Dharam Vira Heart Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India

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Date of Web Publication4-Jul-2012
 

How to cite this article:
Raut MS, Maheshwari A, Garg V. Resistance to withdraw a Swan-Ganz catheter: A word of caution. Ann Card Anaesth 2012;15:254-5

How to cite this URL:
Raut MS, Maheshwari A, Garg V. Resistance to withdraw a Swan-Ganz catheter: A word of caution. Ann Card Anaesth [serial online] 2012 [cited 2019 Nov 15];15:254-5. Available from: http://www.annals.in/text.asp?2012/15/3/254/97989


The Editor,

A 58-year-old, 65 kg, male patient was scheduled for off-pump coronary artery bypass grafting (OPCABG). In the operating room, standard monitors were applied, and peripheral intravenous cannula and arterial line were inserted under local anesthesia. Anesthesia induction was uneventful. The right internal jugular vein was accessed without difficulty for Swan-Ganz sheath introduction. A pulmonary artery (PA) catheter was introduced through the sheath and balloon inflated at 20 cm mark with 1.5 cc of air. The catheter was wedged at 50 cm mark. Before surgical incision, 650 mg of tranexamic acid was administered through the side port of the introducer catheter over 20 min, followed by a continuous infusion of 65 mg/ hr for 5 hours. Anesthesia was maintained with isoflurane (1-3%) and increments of vecuronium and fentanyl. OPCABG was performed uneventfully. Patient remained hemodynamically stable during surgery with support of inotropes and vasopressors. At the end of surgery, the patient was shifted to cardiac intensive care unit (CICU). In the CICU, the patient was mechanically ventilated, and laboratory investigation and chest X-ray (CXR) were done. The CXR revealed normal course of the PA catheter without any knotting. Transthoracic echocardiography was unremarkable. After 72 h when withdrawal of the  Swan-Ganz catheter More Details was attempted, great resistance was encountered. As there was no knotting of the PA catheter on the CXR, the PA catheter was pulled out along with the sheath. A thrombus was found attached to the PA catheter [Figure 1]. The patient remained stable after the removal of the PA catheter. Transthoracic echocardiography did not reveal any vegetation. The remaining course of the patient in the hospital was uneventful.
Figure 1: Thrombus attached to the Swan-Ganz catheter

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Several studies have reported PA catheter thrombosis as a post-mortem finding. [1],[2],[3] PA catheter thrombosis is an uncommon complication which can be fatal. Dentz et al, described two cases of early thrombus formation on heparin-bonded PA catheters in patients receiving epsilon aminocaproic acid during cardiac surgery. [4]

We believe that the PA catheter thrombosis observed in this patient was related to high concentrations of tranexamic acid achieved around the PA catheter during its administration over 5 hours through the side port of the introducer catheter. Despite encountering resistance during its attempted withdrawal, we decided to remove the PA catheter along with the sheath, as catheter knotting was absent on the CXR. Forceful removal of the PA catheter through the introducer sheath would have dislodged the thrombus and the patient could have suffered PA thromboembolism and its consequences. Thrombosis around the PA catheter should be suspected when difficulty is encountered during its withdrawal; its forceful withdrawal can dislodge thrombus and might result in PA thromboembolism. The removal of the PA catheter with its introducer sheath might help its removal.

 
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1.Pace NL, Horton W. Indwelling pulmonary artery catheters. Their relationship to aspetic thrombotic endocardial vegetations. JAMA 1975;233:893-4.  Back to cited text no. 1
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2.Lange HW, Galliani CA, Edwards JE. Local complications associated with indwelling Swan-Ganz catheters: Autopsy study of 36 cases. Am J Cardiol 1983;52:1108-11.  Back to cited text no. 2
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3.Connors AF Jr, Castele RJ, Farhat NZ, Tomashefski JF Jr. Complications of right heart catheterization. A prospective autopsy study. Chest 1985;88:567-72.  Back to cited text no. 3
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4.Dentz ME, Slaughter TF, Mark JB. Early thrombus formation on heparin-bonded pulmonary artery catheters in patients receiving epsilon aminocaproic acid. Anesthesiology 1995;82:583-6.  Back to cited text no. 4
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Correspondence Address:
Monish S Raut
Department of Cardiac Anesthesia, Dharam Vira Heart Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi-110 060
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.97989

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