Knot formation of a pulmonary artery catheter associated with right internal jugular vein thrombosis: a case report

Abstract

Introduction:

Pulmonary artery catheters (PACs) are an important hemodynamic monitoring tool; however, they are associated with various complications. We report a rare case of PAC entanglement with a central venous catheter (CVC) occurring in the internal jugular vein, due to right internal jugular vein thrombosis.

Presentation of case:

An 81-year-old woman underwent reoperation mitral valve replacement and left ventriculoplasty. During PAC insertion via the right internal jugular vein, resistance was encountered and the PAC was entangled with the CVC. The catheters were ultimately removed safely after CVC withdrawal.

Discussion:

It is presumed that the thrombus within the internal jugular vein was the cause of resistance and nodule formation. Careful ultrasound assessment and fluoroscopic guidance are essential when resistance occurs.

Conclusion:

PAC knotting in the internal jugular vein is extremely rare. Evaluation of venous thrombosis before reinsertion and cautious manipulation may prevent such complications.

Introduction

Pulmonary artery catheters (PACs) are an important hemodynamic monitoring tool; however, they are associated with various complications. We report a rare case of PAC entanglement with a central venous catheter (CVC) occurring in the internal jugular vein, due to right internal jugular vein thrombosis. This case report has been reported in line with the SCARE checklist^[1^].

Case report

An 81-year-old woman (height 144 cm, weight 42 kg) underwent aortic and mitral valve replacement and coronary artery bypass surgery for aortic valve stenosis and regurgitation, mitral valve stenosis and regurgitation, and coronary artery stenosis. Follow-up computed tomography (CT), performed as per departmental practice, revealed a left ventricular rupture near the suture line of the mitral valve prosthesis, as well as a left ventricular pseudoaneurysm. An urgent mitral valve replacement and left ventriculoplasty were scheduled for postoperative day 13. Although the preoperative left ventricular ejection fraction was preserved at 67%, placement of a PAC was planned in anticipation of potential myocardial injury associated with left ventricular reconstruction, as well as the possible need for mechanical cardiac support.

HIGHLIGHTS

• A rare case of PAC entanglement with a central venous catheter.

• Effects of thrombus formed by central venous catheters inserted in initial surgery.

• Formation of a knot due to retrograde flow caused by obstruction of the pulmonary artery catheter by a thrombus.

• In patients with a history of central venous catheterization, the possibility of thrombus formation should be considered.

• In situations where the PAC is entangled with the CVC, removal of the CVC may facilitate subsequent management.

Following induction of general anesthesia, maintenance with remifentanil and sevoflurane was initiated, and the right internal jugular vein was punctured under ultrasound guidance for a CVC (Argyle™ Fukuroi SMAC™ Plus, Cardinal Health) and a 9 Fr sheath introducer (Arrow-Flex^® Sheath, Teleflex) placement. During the insertion of both the CVC and the sheath introducer, slight resistance was encountered at a depth of approximately 10 cm during the first attempt to advance the guidewire in each procedure. However, in both procedures, the guidewire was eventually advanced without resistance after several attempts, and both devices were successfully placed without difficulty. Transient hypotension (mean arterial pressure 30–50 mm Hg) developed after induction of anesthesia and promptly resolved following a single dose of ephedrine. Throughout catheter manipulation, no malignant arrhythmias or significant hemodynamic instability suggestive of extravascular catheter placement were noted. When the PAC (Swan-Ganz catheter, Edwards Lifesciences) was advanced through the sheath introducer after balloon inflation, slight resistance was noted, and the pressure waveform disappeared. After balloon deflation, an attempt to withdraw the PAC was impeded by significant resistance. A chest radiograph performed at that time revealed that the PAC had formed a knot and was entangled with the CVC in the right internal jugular vein (Fig. 1). Despite repeated pushing and pulling manipulations under X-ray fluoroscopy, the PAC remained largely immobile and could not be untied. Since retrieval of the PAC from the insertion site was deemed impossible, surgery was initiated with a plan to retract it from the surgical field and reposition it into the pulmonary artery. Under total systemic circulatory bypass, the surgeons attempted to capture the PAC through a longitudinal incision in the superior vena cava. However, surgeons were unable to reach the PAC in the right internal jugular vein despite using various surgical instruments. The surgery was continued as planned, with plans to consult the radiology department regarding the PAC issue postoperatively. In addition to the planned mitral valve reimplantation, a coronary artery bypass grafting to the circumflex branch was performed along with left ventricular reconstruction. Furthermore, the aortic valve prosthesis, which had been temporarily removed to secure the surgical field, required reimplantation. After releasing the aortic clamp for 418 minutes, cardiac contractility gradually improved with intra-aortic balloon pumping and continuous infusion of noradrenaline and dobutamine, allowing for gradual weaning from cardiopulmonary bypass. Trans-esophageal echocardiography was used to closely monitor cardiac function and left ventricular loading, and it was determined that additional mechanical cardiac support was not necessary. As a trial, the CVC was removed instead of the PAC after the surgery; and unexpectedly, it was withdrawn without any resistance. Remarkably, the PAC was subsequently extracted smoothly along with the sheath introducer in a loosened configuration. Another CVC was reinserted in the left internal jugular vein, and the patient was admitted to the intensive care unit. Although her intraaortic balloon pump was discontinued on postoperative day 7, continuous administration of inotropes and diuretics was required for 19 days due to persistent fluid retention. She was weaned from mechanical ventilation on postoperative day 27, but remained unable to ambulate and later developed renal failure, ultimately resulting in death on postoperative day 100. The patient did not express particular concern regarding the treatment process.

Figure 1.

(A) Chest X-ray showing the PAC tangled with the CVC in the right internal jugular vein (red box). (B) Enlarged image of the red box in (A). (C) A photo that recreates the relative positions of the PAC and CVC from (B). CVC, central venous catheter; PAC, pulmonary artery catheter.

In order to investigate the causes of the resistance during guide wire insertion and PAC knotting, the preoperative CT was rechecked, which revealed a thrombus at the internal jugular vein (Fig. 2B and C) that had not been observed before the initial surgery (Fig. 2A). The thrombus extended from the upper edge of the thyroid gland to near the confluence with the right subclavian vein (Fig. 2C).

Figure 2.

(A) Horizontal section of contrast-enhanced CT at the supraclavicular level before the previous surgery. No thrombus is observed. (B) Preoperative CT of this surgery at almost the same level as (A). The red arrow indicates the right internal jugular vein thrombosis. (C) Coronal section of (B). Red arrow indicates the right internal jugular vein thrombosis. The right internal jugular vein thrombosis is observed from the laryngeal level to the junction with the subclavian vein (red arrow). CT, computed tomography.

Discussion

In recent years, PAC applications have been subject to strict scrutiny due to the high incidence and severity of complications. PAC-related complications are reported to occur in 10% of cases^[2^]. Although PAC knotting is rare, it often requires invasive solutions, such as sternotomy, leading to an increased risk of complications, costs, and delays in recovery^[3^]. Repeated advancement and excessively long insertion lengths of the PAC have been reported to be associated with coiling and subsequent knotting^[4,5^]. Right ventricular dilation has been suggested as a contributing factor to excessively long catheter insertion lengths^[6^]. However, the insertion length in the present case was only about 15 cm, which indicates that the PAC knot was formed in the right internal jugular vein near the insertion site. PAC knotting is known to occur between the superior vena cava and the pulmonary artery^[7^]. To the best of our knowledge, there are no previous reports of PAC knots occurring in the internal jugular vein, and patient risk factors in such cases are largely unknown. When inserting the guide wire into the right jugular vein, we experienced slight resistance at a depth of around 10 cm. Since the PAC also encountered resistance at a similar insertion length, we hypothesize that the thrombus in the internal jugular vein caused the resistance and knot formation. Figure 3 describes the assumed sequence of the formation of the PAC knotting. When the passage of the catheter was blocked by the thrombus, the tip was hooked on the venous wall and bent in a hairpin shape. Advancing further resulted in a loop shape; and finally, pulling caused the catheter to become knotted.

Figure 3.

The assumed sequence of the formation of the PAC knotting is shown in the illustrations (A)–(D). Red arrows indicate the direction of the PAC’s movement. (A) When the passage of the catheter was blocked by the thrombus, (B) the tip got hooked on the venous wall and bent in a hairpin shape. (C) Advancing further resulted in a loop shape. (D) Finally, pulling caused it to become knotted. PAC, pulmonary artery catheter.

Various methods have been reported for the retrieval of knotted PACs. The most common strategy involves removal of the knotted PAC from the insertion site, with prior cases reported both with^[8,9^] and without^[3,5^] venotomy. In the present case, the configuration in which the PAC was entangled with the CVC led us to consider retrieval from the insertion site unfeasible, at least in the preoperative setting. Retrieval was further complicated by thrombosis of the right internal jugular vein. Although some reports have described the use of a basket catheter^[10^] or a snare catheter^[11^] to retrieve a PAC via the femoral vein, these methods may be hindered by the presence of thrombus. Furthermore, if the PAC can be advanced into the cardiac chamber, it may be untangled through interventional procedures performed by a radiologist^[12^] or surgically removed via sternotomy^[13^]. However, such approaches require advancement of the PAC into the superior vena cava or the intracardiac cavity. Accordingly, obstruction of PAC advancement due to thrombosis in the right internal jugular vein renders most reported retrieval techniques impractical.

A previous study reported a case in which a PAC was entangled with a CVC and was successfully untangled by first removing the CVC^[14^]. Similarly, in our case, the decision to remove the CVC first was considered a key step in the safe retrieval of the PAC. When the CVC is inserted first and the PAC is subsequently advanced, the latter may form a knot that entangles the CVC without altering its structure. In such cases, as observed in our case, the CVC can be withdrawn smoothly, which may have led to the spontaneous release of the entanglement involving the PAC.

The presence of a thrombus in the right internal jugular vein in this case may be associated with the CVC inserted during the previous surgery. Catheter-related thrombosis is a known complication after CVC insertion, with an incidence in the internal jugular vein ranging from 1.9 to 78%^[15,16^]. Advanced age, prolonged immobility, impaired cardiac function following the initial surgery, and malignancy – the patient had undergone chemoradiotherapy for esophageal cancer – are recognized patient-related risk factors for catheter-related thrombosis, and were present in this case^[17^]. Due to the emergency nature of the procedure, the cervical region on preoperative CT may not have been adequately assessed. As described above, internal jugular vein thrombosis can contribute to PAC knotting and complicate retrieval. When reinserting a catheter at a previous site, thrombosis should be carefully evaluated. While contrast-enhanced CT remains the gold standard, a more thorough ultrasound examination during puncture might have detected the thrombus near the clavicle. Furthermore, resistance during guidewire or catheter advancement may indicate thrombosis and can result in serious complications such as vascular injury or hemothorax^[18^]; fluoroscopic guidance should be considered in such situations. Taken together, these considerations highlight several preventive strategies, including careful assessment of prior catheterization sites, preferential use of ultrasound/Doppler to confirm venous patency, avoidance of reinsertion through previously cannulated veins when feasible, and the use of fluoroscopic guidance if abnormal resistance is encountered.

In conclusion, we described a case of PAC knotting in the internal jugular vein. In situations where the PAC is entangled with the CVC, removal of the CVC may facilitate subsequent management. Thrombosis along the path of the PAC may contribute to knot formation and difficulty in retrieval. In patients with a history of central venous catheterization, the possibility of thrombus formation should be considered. Although fluoroscopy was not employed in this case, its use may help avoid complications when resistance is encountered.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Our institution does not require ethical approval for reporting individual cases or case series.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

The authors declared no sources of funding of interest with respect to the research, authorship, and publication of this article.

Author contributions

M.K.: writing – review & editing, original draft, data curation, investigation, conceptualization; M.H.: writing – review & editing, original draft, visualization, investigation, conceptualization, supervision; D.F.: writing – review & editing, conceptualization; M.Y.: writing – review & editing, conceptualization; T.H.: writing – review & editing, conceptualization, supervision.

Conflicts of interest disclosure

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Masayo Kawakami.

Provenance and peer review

Not commissioned; externally peer reviewed.

Data availability statement

Not applicable.