Case report: Percutaneous removal of a knotted pulmonary artery catheter using a tracheostomy dilator

Pulmonary artery catheterization is a well established technique in the management of the critically ill. This technique is not entirely without complications, however. Serious complications occur in only 3-4.4% [1,2], and include pneumothorax, haemothorax, pulmonary artery rupture, valve damage, dysrhythmias and rarely knotting of the catheter. In case of a knotted catheter, its subsequent withdrawal may lead to damage of the tricuspid valve, or rupture of the papillary muscle or vessel wall [3]. In the present case, a subclavian Swan Ganz (pulmonary artery) catheter, after formation of a knot, became firmly stuck between the clavicle and the second rib, and its subsequent method of removal is described.A 69-year-old male with a history of silicosis was admitted to our hospital with a splenic abscess, for which computed tomography-guided percutaneous drainage was performed. Subsequently, he developed septic shock and respiratory failure, necessitating mechanical ventilation. A pulmonary artery catheter was uneventfully introduced via the right subclavian vein to manage fluid resuscitation and administration of inotropic agents. Initially, the patient recovered, and the Swan Ganz catheter was removed after 4 days. The abscess persisted, however, with ensuing haemodynamic instability. A splenectomy was performed, and postoperatively, in yet another uneventful procedure, a new pulmonary artery catheter (Criti Cath Thermodilution, 7F, SP 5107 H) was inserted through the left subclavian vein. Chest radiography showed a knot in the catheter at a distance of 16 cm from the tip, however (Fig 1).An attempt was made to remove the catheter. On gentle pulling the knot appeared to be firmly stuck between the left clavicle and the second rib, even after careful manipulation of shoulder and arm. Attempts to untie the knot using a guidewire or to tighten the knot using traction at the introducer sheath were unsuccesful. We felt reluctant to pull out the catheter with sheath withou