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The use of Swan-Ganz catheters has increased tremendously since they were first introduced in 1970. Their ability to give vital hemodynamic measurements in critically ill patients makes their use invaluable when providing quality medical care. The formation of pulmonary artery (PA) pseudoaneurysm from a Swan-Ganz catheter-induced perforation of the PA is a rare but potentially fatal complication of Swan-Ganz catheter use. Three case presentations and a review of the literature are presented.

Digital subtraction angiography is an indispensable complement to cut film studies for the detection of pulmonary artery injury. Immediate transcatheter embolization of catheter-induced pulmonary artery pseudoaneurysm is a safe, minimally invasive, fast, and cost-effective alternative to surgical treatment.

A case is presented in which the insertion of a pulmonary artery catheter was complicated by the formation of a knot around the chordae tendineae of the tricuspid valve. The catheter was pulled out under fluoroscopic guidance using a guidewire inserted through the femoral vein.

In 43 percent of 30 consecutive open heart surgery patients, Swan-Ganz catheter tips lodged within 1 cm of or above the left atrium. When in this position the wedge pressure measured by the catheter was not an accurate estimate of left atrial pressure when positive end-expiratory pressure (PEEP) was used, especially when left atrial pressure was low. Catheters located below the left atrium were accurate at all levels of PEEP tested. The position of Swan-Ganz catheters should be confirmed by a lateral chest roentgenogram when PEEP is used, and catheter tips not below the left atrium should be repositioned.

The accuracy with which pulmonary pressures reflect sudden changes in left ventricular (LV) pressures was studied in 15 patients without mitral disease. Mean pulmonary artery (PA), pulmonary artery end-diastolic (PAd), mean pulmonary capillary (PC), and pulmonary capillary V wave (PCa) pressures were compared with simultaneous LV diastolic pressures measured before (LV pre V) and after atrial systole (LVEDP). Recordings were made at rest and after angiography. There were significant correlations (r > 0.75, P

Mesure de la pression d'occlusion de l'artere pulmonaire. Relations entre les pressions endodiastoliques ventriculaire gauche et le volume ventriculaire gauche

Fifty-seven patients requiring catheterization with a thermodilution Swan-Ganz catheter in the surgical intensive care unit were prospectively studied to determine the incidence and significance of positive pulmonary arterial blood cultures. Nonseptic (group 1) and septic (group 2) patients were identified, with subdivision of the groups into A and B classes contingent upon a negative or positive pulmonary arterial blood culture respectively. In the nonseptic group, there were no positive blood cultures, provided there was only one catheterization (Swan-Ganz), less than three repositionings of the catheter, and discontinuation of the catheterization within 72 hours after insertion. Although the septic group followed this pattern, 25 percent incidence of positive pulmonary arterial blood cultures was present within the 72-hour period. We believe that the thermodilution Swan-Ganz catheter is presently a valuable clinical tool and does not predispose the patient to an excessive infectious disease risk.

Nonejection systolic and diastolic clicks appeared when a Swan-Ganz catheter was positioned in the proximal portion of the right pulmonary artery. The clicks disappeared on inflation of the catheter's balloon. Initial impressions included secondary prolapse of the mitral leaflets, an accentuated third heart sound, and the exposure of an occult opening snap. These high-frequency sounds are thought to be generated by the forward and backward movement of the catheter against either the proximal portion of the pulmonary artery or the right ventricular outflow tract or by a whipping action of the catheter itself.

The use of the Swan-Ganz flow-directed catheter in establishing the diagnosis of the superior vena cava syndrome in two patients (one with Hodgkin's disease and the other with carcinoma of the lung) is described. A pressure tracing showing elevated pressures above the obstruction without respiratory or cardiac fluctuations is characteristic of obstruction of the superior vena cava.

A balloon-tipped catheter was used in the preoperative assessment of a patient with a solitary pulmonary arteriovenous fistula and coexistent chronic obstructive pulmonary disease and ischemic heart disease. Studies before and two months following surgical excision of the fistula showed that the increase in arterial oxygenation (49 mm Hg vs 77 mm Hg) and the reduction in the fraction of the shunted cardiac output (37 percent vs 6 percent) closely approximated the predicted preoperative estimates.

In 68 patients, subxiphoidal, percordial, and suprasternal echocardiography was used to trace the Swan-Ganz catheter during its passage to the pulmonary artery and to localize its position. The localization of the catheter could be exactly identified in 62 out of 68 patients in whom we managed to obtain a suprasternal echocardiogram. In one patient, the catheter was found (by chest x-ray film) in the left pulmonary artery (LPA) and was regarded to be in the right pulmonary artery according to suprasternal echocardiography. In two patients, the catheter could not be localized by suprasternal echocardiography although it was positioned in the LPA. In three patients, the catheters could not be advanced to the pulmonary circulation and were visualized within the right ventricular cavity by precordial and subxihpoid echocardiogarphy. Thus, echocardiography, particularly the suprasternal approach, has proven a safe, reliable, and easy way for position control of Swan-Ganz catheters.

A single view, wedge, pulmonary angiogram was performed at bedside in nine patients using a Swan-Ganz catheter which had been inserted previously for other indications. Criteria for consideration of a bedside study were as follows: (1) a clinical suspicion of significant, acute pulmonary embolism; (2) the inability or inadvisability of transferring the patient for definitive studies; and (3) a Swan-Ganz catheter in situ.Seven of the nine patients subsequently died. Of five patients who underwent necropsy, three positive studies and one negative, were confirmed. No post-mortem evidence for embolism could be demonstrated in one patient with a positive study. Of the two patients who survived, one negative study was confirmed with a negative radionuclide perfusion lung scan. There was no morbidity or mortality associated with the procedure. These data suggest that this technique is safe and has a role in the early diagnosis of significant pulmonary embolism in selected critically ill patients.

A patient with severe respiratory failure due to overwhelming pneumonia was monitored with a Swan-Ganz catheter. Postmortem examination revealed massive antemortem thrombosis surrounding the Swan-Ganz catheter tip. The presence of the thrombus about the catheter tip was not suspected before death, but retrospective analysis of a variety of parameters suggested massive pulmonary vascular obstruction.

Two cases of histologically documented tricuspid valve ulcers caused by use of Swan-Ganz catheters are described. The implication of these clinically silent erosions is discussed.

Complete heart block was caused by passage of a Swan-Ganz catheter into the pulmonary artery of a patient with acute myocardial infarction and complete left bundle branch block. This complication could be easily treated with the prophylactic insertion of a temporary pacing catheter.