Accidental placement of an infusaport into the pulmonary artery: Case report and review of the literature

BACKGROUND: Misplacement of central venous catheters (CVC) may have devastating consequences. PATIENTS AND METHODS: Placement of a CVC into the pulmonary artery (PA) and management of the complication is described. Literature search for accidental direct placement of CVCs into the PA was performed. RESULTS: A 46 year old morbidly obese female required an infusaport for chemotherapy. She was anaesthetized and placed in Trendelenburg. Three attempts to access the left subclavian vein (LSCV) using landmarks failed. In steeper Trendelenburg, a blood vessels was accessed. Non pulsatile dark blood was aspirated, a guidewire was easily advanced. Fluoroscopy projected the guidewire tip over the right atrium; infusaport placement was without difficulties. Postoperative chest x-ray showed the tube initially pointing caudally, then traversing the midline with the tip projecting over the right atrium. Emergent angiogram showed placement of the tube into the mainstem of the PA. The tube was removed; CT-angiogram showed no extravasation but a 3cm left mediastinal hematoma. Transfer to an ICU in a facility offering emergent cardiothoracic surgery was done. She remained stable, repeat CT-scan showed decreased hematoma size and she was retransferred. The infusaport was placed under ultrasound guidance into the left jugular vein. Six additional cases of direct puncture of the PA were reported; in all except one the LSCV had been targeted. No patient died directly from the complication, all catheters were removed, four patients required surgery or interventional procedures. CONCLUSIONS: Accidental placement of CVC s into the PA is a rare complication. The catheter should be removed. Patients should be urgently transferred to a center with access to interventional radiology and cardiothoracic surgery.