We read with interest the recent case by Goubran et al1 describing removal of a knotted Swan-Ganz catheter through sheath-assisted traction, highlighting the practical challenges and multiple strategies for addressing this uncommon complication. We would like to share a complementary case that underscores an alternative bedside technique.
An 83-year-old man undergoing pulmonary artery (PA) catheter placement encountered resistance at 34 cm. Chest radiography demonstrated the introducer with the PA catheter kinked within the superior vena cava and its tip directed laterally into the innominate vein (Figure 1). Notably, the catheter was kinked rather than knotted, differing from the case previously described. Despite repositioning, the kink persisted, looping back within the distal superior vena cava. Vascular surgery and interventional radiology were consulted; given the absence of hemodynamic instability, no emergent invasive retrieval was recommended.
Figure 1.
Kinked Pulmonary Artery Catheter on Chest Radiography
Chest radiograph demonstrating kinked pulmonary artery catheter within the superior vena cava (arrow) with the tip taking a left lateral course, likely within the innominate vein (left). Follow-up radiograph after catheter removal following cold saline administration shows resolution without complication (right).
Because catheter malpositioning can predispose to vascular injury during attempted removal, we adopted an approach described by Pugin et al:2 injection of cold saline to transiently stiffen the catheter. A total of 40 mL of cold saline was instilled through the PA catheter lumen, after which the catheter was successfully withdrawn without resistance or complication.
This case underscores several important considerations. As outlined by Goubran et al1, traction against the sheath, balloon-assisted unknotting, and snare retrieval have been reported as potential strategies, but cold saline instillation offers a simple and effective bedside option. Moreover, greater awareness of this maneuver may reduce reliance on invasive approaches, while avoiding additional radiation, contrast exposure, and procedural risk.
In summary, cold saline injection represents a practical, low-risk adjunct to the armamentarium of strategies for managing Swan-Ganz catheters. We commend the authors for drawing renewed attention to this rare but challenging complication and hope our case adds to the spectrum of available solutions.
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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