What are the possible complications of pulmonary artery catheterization (PAC)?

Updated: Dec 22, 2017
  • Author: Bojan Paunovic, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

Complications associated with PAC use relate to the initial venous access, insertion of the PAC, and maintenance of the catheter in the PA. The incidence of complications varies on the basis of operator skill and patient status. Even with the use of ultrasonography-guided approaches, venous access complications may still occur, including arterial puncture, which may manifest immediately (eg, carotid artery hematoma if inserted via the internal jugular [IJ] route) or insidiously (eg, hemothorax via subclavian route). Also, the risk of pneumothorax relates to the selection of the access route, occurring more often in the subclavian than in the IJ site. However, it is important to note that low IJ approaches also carry this risk. Keep in mind that in ventilated patients, tension pneumothorax can develop rapidly.

Arrhythmias constitute the most common complication associated with PAC insertion. The majority of these are premature ventricular contractions (PVCs) or nonsustained ventricular tachycardia (VT) which resolve either with advancement of the catheter from the RV into the PA, or with prompt withdrawal of the catheter into the RA. Significant VT or ventricular fibrillation requiring treatment occurs in less than 1% of patients, usually those with concurrent cardiac ischemia or electrolyte distubances.

Right bundle-branch block (RBBB) can occur during PAC insertion and is usually transient after positioning the catheter into the PA. However, the presence of a preexisting left bundle-branch block (LBBB) puts the patient at risk for complete heart block should RBBB occur. In these patients, temporary pacing equipment should be kept nearby on standby. The incidence of knotting of the PAC on itself or on intracardiac structures is rare. This risk is potentially increased in patients with dilated cardiac chambers or in situations in which there is a persistent RV tracing despite further advancement (20 cm) of the PAC.

Of the complications associated with maintenance of the PAC, PA rupture is most catastrophic, with a mortality rate of 50%. Fortunately, it is a rare occurrence (< 1%). Patients at risk are those who have pulmonary hypertension, are older than 60 years, or are receiving anticoagulation therapy. The sudden onset of hemoptysis (especially after inflation of the PAC balloon) indicates this possibility. Immediate management includes lateral decubitus positioning (bleeding side down), intubation with a double-lumen endotracheal tube (ETT), and increasing PEEP. Embolization via bronchoscopy or angiography or lobectomy may be necessary if bleeding continues or is massive. A case report describes the use of a vascular plug to tamponade the culprit breach of the pulmonary artery. [31]

PAC-related infection is a fairly common complication. The incidence of positive catheter tip culture result is 45% in some series. Although sterile plastic sleeves have been used to decrease infection risk with PACs, a prospective observational study found positive cultures from the sleeve in some patients; these investigators warn that the sleeve should not be considered a sterile barrier. [32] Fortunately, the risk for clinical sepsis is less than 0.5% per day of catheter use.

The risk for significant catheter colonization increases after 4 days of catheterization. [33] The US Centers for Disease Control and Prevention (CDC) recommends against the routine replacement of PACs to prevent catheter-related infection. [33]

The incidence of pulmonary infarction is low. Unintentional distal migration of the PAC tip is the usual cause. Some evidence indicates that catheter-related thrombi also may be a significant cause. While postmortem studies have shown that rate of endocardial lesions (eg, thrombi, hemorrhage, vegetations) related to PAC use is significant, correlation with clinical events has not been established.


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