(Chest. 2001;120:2105-2111.)
© 2001
American College of Chest Physicians
Swan-Ganz Catheter-Induced Pulmonary Artery Pseudoaneurysm Formation*
Three Case Reports and a Review of the Literature
Maurice R. Poplausky, MD;
Grigory Rozenblit, MD;
John H. Rundback, MD;
Gastone Crea, MD;
Shekher Maddineni, MD and
Robert Leonardo, MD
*
From the Departments of Radiology and Surgery (Drs. Poplausky, Rozenblit, Rundback, Crea, and Maddineni) and Radiology (Dr. Leonardo), New York Medical College, Westchester Medical Center, Valhalla, NY.
Correspondence to: Maurice R. Poplausky, MD, Department of Radiology, Westchester Medical Center, Grasslands Reservation, Valhalla, NY 10595; e-mail: Poplauskym{at}wcmc.com
 |
Abstract
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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.
Key Words: complications • hemoptysis • pseudoaneurysm • pulmonary artery • pulmonary artery rupture • Swan-Ganz catheter • treatment
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Introduction
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In
1970, Swan and colleagues1
were the first to describe the
use of a flow-directed, balloon-tipped catheter for cardiac
catheterization and cannulation of the pulmonary artery (PA). Since
that time, the use of Swan-Ganz catheters has become widely accepted
and has proven to be extremely helpful in the management of critically
ill patients.2
3
The use of the catheter, however, is not
without risk as a wide range of complications has been reported. The
complications can be categorized as those of the initial venous
cannulation (ie, subclavian or carotid artery laceration,
pneumothorax, thoracic duct laceration, phrenic nerve injury, air
embolism, and endotracheal tube cuff rupture) and those due to the
catheter itself (ie, arrhythmias, infection, valvular
damage, thrombosis, pulmonary infarction, and PA
perforation).4
5
6
7
8
9
10
11
12
Of these, PA rupture is the most
serious complication, with a reported mortality rate as high as
50%.13
14
15
We present three cases of PA rupture with
pseudoaneurysm formation, all of which were successfully treated
percutaneously with coil embolization, that occurred over a 6-month
period. A review of the literature also is presented.
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Case Reports
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Case 1
An 83-year-old woman with a history of hypertension, congestive
heart failure, myocardial infarction, end-stage renal disease,
abdominal aortic aneurysm rupture and repair, and osteomyelitis
presented with congestive heart failure and acute cholangitis, the
latter being secondary to choledocholithiasis. A Swan-Ganz catheter was
placed to assist in monitoring the patient’s hemodynamic status. Two
days after placement, the patient developed hemoptysis immediately
following Swan-Ganz catheter manipulation and recording measurements
(PA pressure, 45/22 mm Hg; wedge pressure, 25 mm Hg). An emergent
portable chest radiograph (Fig 1
) then was obtained, and the patient was brought to the angiography
suite where a right pulmonary angiogram was performed in the left
anterior oblique projection via a right common femoral vein approach,
utilizing an 80-cm, 8.2F catheter (Monte 1; Cook; Bloomington, IN). The
Swan-Ganz catheter was left in place to help localize the area of
injury. Images revealed a faint extravascular collection of contrast
arising off the right lower lobe PA adjacent to the Swan-Ganz catheter
(Fig 2 , top). The catheter then was exchanged for a 4F, 100-cm
catheter (Headhunter; Angiodynamics; Queensbury, NY), which then was
advanced into the neck of the pseudoaneurysm. The catheter tip position
was verified with contrast injection (Fig 2
, bottom), and
the pseudoaneurysm then was embolized with multiple 8-mm, 10-mm, and
12-mm coils (Cook). A repeat angiogram revealed complete occlusion of
the pseudoaneurysm (Fig 3
). The Swan-Ganz catheter then was removed, and the cordis sheath was
left in place for venous access. A follow-up chest radiograph (Fig 4
top) and CT of the chest (Fig 4
, middle and
bottom) performed 1 day after embolization revealed partial
right lower lobe atelectasis and an effusion. No further hemoptysis was
experienced by the patient, who was discharged from the hospital 2
weeks later to a rehabilitation center. A chest radiograph performed 2
months after embolization showed complete resolution of the atelectasis
and the effusion (Fig 5
).
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Figure 2.. Image from a right PA angiogram
(top) showing a faint extravascular collection (arrows)
adjacent to the right lower lobe PA. The pseudoaneurysm is visualized
much better after a selective catheterization arteriogram of the
pseudoaneurysm (bottom).
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Figure 3.. Postembolization digital subtraction angiography
demonstrates complete occlusion of the pseudoaneurysm with sparing of
the feeding vessel. The subtracted images of the coils within the
pseudoaneurysm are easily seen (arrow).
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Figure 4.. Chest radiograph (top) and CT scan
of the chest (middle and bottom)
performed after embolization demonstrate an effusion (open arrow) and
atelectasis (arrow heads) of the right lower lobe. The coils in the
pseudoaneurysm are easily identified (curved arrows).
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Case 2
An 81-year-old woman with a history of hypertension was a front
seat passenger in a head-on motor vehicle accident. She sustained
multiple serious injuries including bowel perforations requiring small
bowel resection and sigmoid colostomy, pelvic fractures with hemorrhage
requiring emergent percutaneous embolization of branches of the
internal iliac arteries, and multiple long-bone fractures. The patient
had a prolonged hospital course with multiple complicating factors
including a myocardial infarction, ARDS, and sepsis. Multiple Swan-Ganz
catheters had been placed during the patient’s prolonged hospital stay
to help monitor the hemodynamic status. The existing catheter had been
present for 10 days when, immediately following the retrieval of
hemodynamic parameters (PA pressure, 40/18 mm Hg; wedge pressure, 20 mm
Hg), bright red blood was noted in the tracheostomy tube and ventilator
tubing. The Swan-Ganz catheter was quickly pulled back several
centimeters by the house staff. An emergent portable chest radiograph
revealed a new, focal round infiltrate in the right upper lobe (Fig 6
). The patient was sent for an emergent pulmonary arteriogram, which was
performed through a right common femoral vein approach using an 8.2F,
80-cm Monte 1 catheter. It revealed a pseudoaneurysm arising off the
right upper lobe PA (Fig 7
, top) and a new right pleural effusion (Fig 7
,
bottom). The feeding artery of the pseudoaneurysm then was
selected using a 4F, 100-cm Berenstein catheter (Angiodynamics) [Fig 8
], and the pseudoaneurysm was embolized using multiple 8-mm coils
(Cook) with the catheter positioned at the neck of the aneurysm. A
repeat angiogram showed complete occlusion of the pseudoaneurysm and
the small feeding artery (Fig 9
). As the patient still required close hemodynamic monitoring, the
Swan-Ganz catheter then was directed into the opposite PA. A chest
radiograph performed 1 day after embolization showed the coils to be
present within the infiltrate (Fig 10
). The patient did not experience any further episodes of bleeding but
succumbed to complications of her injuries 4 weeks later.
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Figure 6.. An anterior-posterior portable chest radiograph
demonstrating a new, right upper lobe, circumscribed infiltrate (large
arrows) in a patient with a Swan-Ganz catheter (small arrows).
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Figure 7.. Early (top) and late
(bottom) subtracted images of a right PA angiogram
demonstrating an upper lobe PA pseudoaneurysm (arrow). The visceral
pleural edge (open arrows) has been displaced from the chest wall
(small arrows) by a large effusion.
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Case 3
A 78-year-old woman with a history of moderate aortic stenosis
was transferred to our institution after an anterior-wall myocardial
infarction and cardiac arrest. The patient was resuscitated
successfully and underwent a cardiac catheterization and Swan-Ganz
catheter placement. Forty-eight hours after the Swan-Ganz catheter
placement and immediately following balloon deflation to determine the
pulmonary wedge pressure (25 mm Hg), bright red blood was noticed
coming from the endotracheal tube. The Swan-Ganz catheter then was
removed by the house staff, and the patient was sent for an emergent
pulmonary angiogram. Via a right common femoral vein approach, an 8.2F,
80-cm Monte 1 catheter was manipulated into the right PA, and an
angiogram was performed, revealing a pseudoaneurysm arising off the
medial-segment branch of the right middle-lobe PA (Fig 11
, top). The flush catheter was exchanged for a 100-cm, 4F
Headhunter catheter, which then was advanced into the PA pseudoaneurysm
where 10-mm and a 3-mm coils (Cook) were deployed. A repeat pulmonary
arteriogram revealed persistent filling of a portion of the
pseudoaneurysm with sluggish flow (Fig 11
, bottom). Multiple
attempts to recatheterize the pseudoaneurysm were unsuccessful, and the
procedure then was terminated. It was believed that the remainder of
the pseudoaneurysm would spontaneously thrombose off, so the feeding
artery was not embolized. The patient underwent aortic valve
replacement and three-vessel coronary artery bypass grafting and was
discharged to a rehabilitation center 15 days later without any further
episodes of hemoptysis.
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Figure 11.. A right PA arteriogram (top)
demonstrating a pseudoaneurysm (arrows) arising from the right middle
lobe PA. A postembolization image (bottom) shows a
partial occlusion of the pseudoaneurysm.
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Discussion
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Major complications associated with Swan-Ganz catheter insertion
have been reported to occur in up to 17% of cases.16
17
The most serious complication that can occur is PA rupture with
hemorrhage and/or pseudoaneurysm formation. In a prospective study
involving 528 consecutive Swan-Ganz catheter placements, Boyd et
al4
found the rate of PA rupture with hemorrhage to be
0.2%. Other retrospective studies5
15
16
17
18
involving
thousands of Swan-Ganz catheter placements have shown rates ranging
from 0.001 to 0.47%. The mortality rate associated with pulmonary
rupture is as high as 50%, secondary to aspiration and asphyxia
following intrapulmonary hemorrhage.11
15
A number of risk factors, some of which have been brought into
question, have been attributed to the development of PA rupture and
pseudoaneurysm formation. These include pulmonary hypertension,
systemic anticoagulation, long-term steroid use, surgically induced
hypothermia, age > 60 years, female gender (69% preponderance),
cardiac decompression, and cardiac manipulation during
surgery.5
In the presence of pulmonary hypertension, it was postulated that the
catheter and balloon could be propelled into the smaller, more fragile
arterioles, thereby increasing the likelihood of rupture. This
postulate was found to be erroneous by Hardy et al,9
whose
experimental studies performed on human cadaveric lungs failed to
verify this, suggesting that pulmonary hypertension poses no additional
risk of pulmonary rupture and may be merely a coincidental finding.
Furthermore, small PA branches were found to withstand higher pressures
without rupture than the larger PA branches. These same cadaveric
studies of PA pressures have demonstrated that the pulmonary arteries
in patients who are > 60 years of age were more likely to rupture at
a given pressure than similar arteries in younger
patients.9
Chronic steroid use is believed to increase the fragility of the
vascular system by its negative effect on collagen formation and
connective tissue strength and healing, making vascular rupture more
likely.19
While not increasing the risk of vascular injury
directly, anticoagulation inhibits the body’s ability to seal any
vascular injury caused by a Swan-Ganz catheter, leading to
pseudoaneurysm formation.
In a retrospective study involving 32,442 Swan-Ganz catheter
placements, Kearney and Shabot5
have shown that in 7 of 10
patients who sustained ruptures of the PA, difficulty was experienced
either as the balloon was inflated or as the catheter was advanced or
withdrawn. Fletcher and colleagues8
proposed five
potential mechanisms for the etiology of PA rupture secondary to
Swan-Ganz catheter manipulation. They concluded that the most plausible
etiology was that the pressure in the expanded Swan-Ganz balloon
exceeded the tensile strength of the vessel wall with subsequent
rupture. Hardy et al9
further expanded on this
when they demonstrated on cadaveric models that the distal PA ruptured
at 1,875 mm Hg and the mid-PA ruptured at 975 mm Hg. When the pressure
in the balloon exceeded these pressures, rupture occurred in an
all-or-none phenomenon.
"Spearing" or penetration of the PA by the Swan-Ganz catheter tip
is another proposed mechanism of PA injury. Shin and
colleagues10
demonstrated that eccentric balloon
inflation, particularly in smaller vessels, could leave the catheter
tip exposed, allowing it to act as a spear and to penetrate the wall of
the PA. In another study, Johnson and colleagues11
showed
that during balloon deflation, the catheter tip migrates distally,
which could also spear the vessel wall, causing injury. Lastly, cardiac
motion transmitted to the arterial wall through the catheter tip also
can induce trauma to the PA by spearing. Other causes of injury that
have been reported include retraction of a wedged balloon and the
flushing of a wedged catheter.5
The probability of Swan-Ganz catheter-induced injury to the PA may be
diminished by proper catheter placement and management. First, balloon
inflation should be performed in a large, proximal PA. The catheter
then is advanced or "floated" to its wedged position to obtain the
necessary hemodynamic parameters. Second, the time spent with the
catheter in a wedged position should be minimized. Third, the balloon
should be deflated while traction is applied on the catheter and
then should be withdrawn when completely deflated to avoid the
spearing.
Some patients with PA rupture secondary to Swan-Ganz catheter
manipulation remain asymptomatic and present with a new nodule or
infiltrate on chest radiographs, while others present with the classic
symptom of hemoptysis. In patients who survive the initial hemoptysis
from a PA rupture, the formation of a pseudoaneurysm has been reported
to occur anywhere between minutes to 7 months later.16
Thrombus formation and compressed lung parenchyma usually contain the
pseudoaneurysm, preventing extravasation. The rate of recurrent
hemorrhage associated with the identification of a pseudoaneurysm is
approximately 30 to 40%, with an attendant mortality rate of 40 to
70%.2
A review article described 92 cases of PA rupture
induced by pulmonary catheterization that led to the formation of 28
false aneurysms.3
All patients who were treated prior to
rupture of the pseudoaneurysm (12 of 28 patients) survived, whereas a
100% mortality rate was found in those patients whose false aneurysm
ruptured prior to treatment. The 100% mortality rate reported in this
study is somewhat misleading as not all untreated pulmonary
pseudoaneurysms rupture. In a case report by You and
Whatley,16
a 2.2-cm pseudoaneurysm was described that
resolved spontaneously over a 4-month period. Despite this single
reference, most authors emphasize the importance of prompt treatment of
the pseudoaneurysm once the diagnosis is established. In fact, Yellin
and colleagues13
recommend that all survivors of an
initial episode of hemoptysis associated with PA catheter manipulation
undergo emergent contrast-enhanced spiral CT scanning or angiography of
the chest for diagnosis and possible treatment.
The radiographic diagnosis of PA pseudoaneurysm usually begins with a
chest radiograph. Findings vary according to the pathophysiology and
chronicity of the lesion. Occasionally, the chest radiograph may appear
normal. This nonvisualization can be due to several factors, including
the small size of the lesion, its location within the lung, its
proximity to the mediastinum, or the radiographic technique used to
expose the radiograph. When changes are noted on a radiograph, they
follow a fairly characteristic pattern. Early films may show a dense
pulmonary infiltrate with hazy margins.6
However, within 1
to 3 weeks, a round, well-circumscribed, persistent nodule or mass with
a diameter of 2 to 8 cm often can be visualized. The right PA is
involved in 93% of cases,3
usually affecting the right
lower or middle-lobe branches. This is consistent with the usual
location of Swan-Ganz catheter tips as seen on chest radiographs.
Contrast-enhanced spiral CT scanning has been advocated by many as the
noninvasive procedure of choice to diagnose a PA pseudoaneurysm. The
pseudoaneurysm appears as an enhancing mass with an adjacent vessel.
Occasionally, a partially thrombosed lumen can be seen. Guttentag and
colleagues20
have described two cases in which CT scans
demonstrated a sharply circumscribed nodule surrounded by a halo of
faint density. While contrast-enhanced CT scanning is an excellent
diagnostic modality for detecting PA pseudoaneurysms, angiography
remains the "gold standard." Angiographically, it appears as
an extravascular collection of contrast in continuity with a vessel.
Angiography is not only diagnostic, but it can also be used as a
treatment option (ie, transcatheter embolization).
Several different therapeutic options are available to treat PA
pseudoaneurysms. Transcatheter embolization has become the treatment of
choice for most Swan-Ganz catheter-induced PA
pseudoaneurysms.21
22
23
It is a relatively simple procedure
that can be performed at the same time as the diagnostic angiogram and
carries a lower rate of morbidity and mortality than surgical
resection. In all three of the cases presented, the time from
hemoptysis to embolization was within 3 h. Steel coils are usually
used, which are preferentially placed in the pseudoaneurysm sac itself,
thrombosing the pseudoaneurysm and preserving pulmonary blood flow.
Alternatively, the feeding vessel of the pseudoaneurysm can be
embolized to occlusion. Surgical options include lobectomy,
pneumonectomy, hilar clamping with direct arterial repair, and PA
ligation.23
24
25
26
27
Parenchymal resection remains the
treatment of choice by some28
29
when an acute rupture of
the PA occurs during cardiac surgery, because the procedure is
relatively quick and easy as the patient’s thorax is already exposed.
Swan-Ganz catheters have become an indispensable part of intraoperative
and critical-care patient management. PA rupture with subsequent
pseudoaneurysm formation is a rare but potentially fatal complication.
Confirmation of the diagnosis can be made using dynamic CT scanning
with IV contrast or with pulmonary arteriography. Because of the
potential risk of rupture, early diagnosis and treatment is essential.
Transcatheter embolization has become the treatment of choice for PA
pseudoaneurysms as it is relatively safe, easy, and provides good
long-term results.
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Acknowledgements
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The authors thank Diane E. Forman for her help in
the preparation of this manuscript.
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Footnotes
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Abbreviation:
PA = pulmonary artery
Received for publication January 17, 2001.
Accepted for publication May 2, 2001.
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References
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TOP
Abstract
Introduction
