Identical wave forms of vena cava and pulmonary artery during pulmonary artery catheter insertion due to kinking: a case report of a rare complication.
BACKGROUND
We experienced a rare malposition of a pulmonary artery catheter due to kinking in a 63-year-old male who was scheduled for an off-pump coronary artery by-pass graft.


RESULTS
Given the difficulty to obtain stable pulmonary artery waveform, we discovered that the two waveforms of the distal and proximal ports of the pulmonary artery catheter were completely identical. Subsequent fluoroscopy revealed that because the catheter had formed a kink around the apex of the right ventricle, the distal port faced the proximal port of the catheter.


CONCLUSIONS
We recommend that both ports of the pulmonary artery catheter need to be monitored simultaneously in case neither portable fluoroscopy nor transesophageal echo is available.
Department of Anesthesia, Kobari General Hospital, 29-1 Yokouchi, Noda, Chiba 278-0004 Japan.
Masayuki
0000-0003-4438-132X
M
Oshima
Department of Anesthesia, Metropolitan Bokutoh Hospital, Tokyo, Japan.
Tatsuki
T
Onishi
Department of Anesthesia, Kobari General Hospital, 29-1 Yokouchi, Noda, Chiba 278-0004 Japan.
Hitomi
H
Iwata
Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, Canada.
Kazuyoshi
K
Aoyama
Fluoroscopic guidance; Kinking; Knotting; Pulmonary artery catheter