Repair of a Perforated Pulmonary Artery Due to a Swan-Ganz Catheter Using Thrombin Injection
Pulmonary artery perforation is a rare but often fatal complication of right heart catheterization that is due to Swan-Ganz catheter (Edward Lifesciences, Irvine, Calif) placement.1–3 Treatment of a catheter-induced pulmonary artery rupture includes emergent intubation, lung resection, surgical pulmonary artery repair, and catheter-based pulmonary artery embolization.4,5
This case demonstrates a new therapeutic approach of injecting topical Thrombin-JMI (GenTrac Inc, Middleton, Wisc) through the distal port of the Swan-Ganz catheter to effectively treat a pulmonary artery rupture during a right heart catheterization.
The patient was a 72-year-old woman with a past medical history of severe mitral valve regurgitation. Left heart catheterization was performed first with no complications. The coronary angiogram demonstrated minimal luminal irregularities in all 3 major coronary arteries. The left ventriculogram demonstrated +3 mitral regurgitation with a 50% ejection fraction. Right heart catheterization was then performed using a 7.5Fr Swan-Ganz balloon-tipped catheter. The right atrial mean pressure was 8 mm Hg. Right ventricular pressure was 51/8 mm Hg. The pulmonary artery pressure was recorded at 51/20 mm Hg. The mean pulmonary capillary wedge pressure was 20 mm Hg.
On inflation of the balloon, the pulmonary artery perforated. This was made evident by frank hemoptysis shortly after balloon inflation. Intubation was selective to the right bronchus then pulled back to a position just above the carina. With the Swan-Ganz catheter remaining in the pulmonary artery, a “pulmonary wedge” angiogram via the distal port of the Swan-Ganz was performed using Isovue 370 (Bracco Diagnostics, Princeton, NJ). The angiogram demonstrated formation of a pseudoaneurysm with extravasation of contrast (Figures 1 and 2⇓). The tip of the catheter was retracted slightly, and the balloon was inflated to half its prior volume. Placement of the balloon at this location created a tamponade effect, stopping the hemoptysis.
With each balloon deflation periodic pulmonary angiograms were performed through the distal port of the Swan-Ganz catheter. Mild hemoptysis was present with each deflation.
The balloon was inflated for approximately an hour with periodic deflations and imaging to determine if the rupture would seal. The ruptured pulmonary artery failed to seal.
A thrombin injection procedure was performed (topical US Pharmacopeia [bovine origin] Thrombin-JMI 20 000 IU/20 mL sterile saline). By angiography it was determined that 0.3 mL of contrast would fill the distal artery and the pseudoaneurysm. This measurement was obtained using a tuberculin syringe. Two injections of 0.2 mL each of thrombin were injected via the distal port of the Swan-Ganz catheter for a total dose of 400 IU thrombin delivered. Subsequent angiography demonstrated resolution and clotting of the affected pulmonary artery pseudoaneurysm. The adjacent pulmonary artery remained free from injury or clot (Figure 3).
A follow-up high-resolution chest computed tomography scan performed 2 days later demonstrated minimal contrast in the right middle lung. No acute bleeding or pulmonary emboli were present. One month later, mitral valve repair was performed using a 28-mm annuloplasty. The patient was anticoagulated with warfarin without complications.
A thrombin injection procedure through the distal port of the indwelling Swan Ganz catheter was chosen. Advantages of this technique are (1) that the patient can be stabilized by tamponade of the pulmonary artery with the Swan-Ganz balloon tip, (2) that a precise volume of thrombin can be delivered on the basis of various contrast test injections, and (3) that the procedure can be performed on a very unstable patient, unlike the other therapeutic options. Direct injection of thrombin into a perforated pulmonary artery is a feasible and expedient technique for pulmonary artery rupture during right heart catheterization.