Swan Ganz catheter misplacement with pulmonary artery rupture

Case contributed by Francisco Samson Cajal

Presentation

Patient with a history of congestive heart failure, hypertension, and cardiovascular bypass. Consults to the emergency department presenting acute dyspnea. Further evaluation reveals a requirement for a Swan Ganz catheter and a diagnosis of pulmonary hypertension is made. A routine chest X-ray is requested.

Patient Data

Age: 80 years
Gender: Female

Distal end of the Swan Ganz catheter in the middle lobe.

Diffuse alveolar pattern in the right basal and middle lobes. Blunting of the left costophrenic angle, pacemaker, and sternal strapping.

Patient presents 250 mL of hemoptysis 20 minutes after the diagnosis is made, and an urgent CT angiography is requested.

Distal end of the Swan Ganz catheter in the middle lobe, medial segment, with intraparenchematous trajectory, perforating the middle lobe artery. Acute contrast extravasation visible in the right basal and middle lobes, compatible with active hemorrhage 1,2.

Bilateral pleural effusion. Peacemaker in situ and sternal post-surgery changes

3D heart reconstruction shows the catheter in white, perforating the middle lobe artery, with the distal end next to the right atrium.

Case Discussion

On the contrast-enhanced CT, the distal end of the catheter can be visualized in the middle lobe, medial segment, perforating the lobar artery. There is active contrast extravasation, compatible with hemorrhage. The patient died of refractory hypotension during surgery, due to massive bleeding.

The catheter misplacement was not initially reported as an acute urgent finding until the hemoptysis presented. A note to remember when examining post Swan-Ganz colocation x-rays.

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