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A patient was scheduled for open infrarenal abdominal aortic aneurysm repair and the procedure was performed without complication. The pulmonary artery catheter (PAC) was unintentionally placed in the coronary sinus via an undiagnosed persistent left superior vena cava anomaly. Interpreting the waveform produced by the PAC in standard and abnormal locations such as the coronary sinus is equally as important as measuring and monitoring hemodynamic status.

Entrapment of a pulmonary artery catheter (Swan-Ganz catheter) in the heart, vena cava, or pulmonary artery is a very rare and serious complication that may lead to life-threatening complications such as cardiac rupture, pulmonary artery rupture, cardiac tamponade, among others, if not recognized and treated early. We report entrapment of a Swan-Ganz catheter in the purse-string suture at the inferior vena cava cannulation site for a patient undergoing aortic valve replacement. This situation required a repeat sternotomy to release the pulmonary artery catheter.

Arterial misplacement of the Swan-Ganz catheter occurs occasionally and usually can be easily detected. However, in some special clinical settings, the problem may become more complicated. We report a case of chronic obstructive pulmonary disease in which, because of severe hypoxemia, systemic hypotension, and pulmonary hypertension, conventional methods failed to recognize the misplacement, until confirmed with blood gas analysis.