# Bedside management of a knotted Swan-Ganz catheter – A case report and literature review

## TL;DR

This case report describes the successful bedside removal of a knotted Swan-Ganz catheter and reviews management strategies for this rare but serious complication.

## Contribution

A novel bedside approach for managing a knotted pulmonary artery catheter is presented with a comprehensive review of existing techniques.

## Key findings

- A knotted catheter was successfully removed at the bedside by tightening the knot and extracting it through the insertion site.
- Bedside removal is feasible for simple, proximal knots but requires careful planning to avoid complications like venous injury.
- Endovascular and surgical approaches are preferred for more complex cases, with endovascular methods largely replacing surgery.

## Abstract

Pulmonary artery catheters use remain invaluable in continuous invasive hemodynamic monitoring for patients with severe cardiopulmonary dysfunction and those undergoing major cardiac surgeries. It detects cardiac dysfunction and guides treatment decisions. Its utilization has declined due to common complications associated with its insertion. This article highlights a rare, rather an important complication of pulmonary artery catheter knotting and reviews techniques for its management. Prompt recognition of this rare complication by the clinicians allow immediate intervention minimizing morbidity and optimizing the outcomes. This manuscript follows the SCARE guidelines.

A case of a 61-year-old man who was initially admitted to the cardiothoracic unit for mitral valve replacement for symptomatic severe mitral regurgitation secondary to a bi-leaflet prolapse. Intra-operatively, a pulmonary artery catheter was inserted for invasive continuous hemodynamic monitoring. It was noted on a routine postoperative chest X-ray coiling of the pulmonary artery catheter in the right atrium. The catheter was not repositioned. On postoperative day one, significant resistance was encountered while removing the catheter. A chest x-ray was done and showed a knotted catheter in the superior vena cava. After contingency planning, bedside removal was opted as the preferred management approach. The catheter was carefully pulled out to tighten the knot and decrease its diameter, allowing successful extraction through the insertion site at the neck.

Pulmonary artery catheter utilization remains essential; however its insertion is prone to complications, which includes pulmonary artery catheter knotting a rare but an important complication that warrants immediate recognition and management. Numerous approaches for the management of knotted catheter were described in the literature. Bedside removal of the knotted catheter may be considered if the knot is simple and more proximal. This approach carries the risk of venous injury and hematoma formation, thus thorough planning and preparation are needed to avoid complications. An endovascular approach is opted in more complex cases and has largely supplanted surgical methods. Innovative methods were described in the literature and include the introduction of guide wires or specialized catheters to untangle knots under fluoroscopic guidance. Retrieval baskets may also be used. Surgery is reserved for complex cases, when endovascular attempts fail.

While pulmonary artery catheter use provides significant benefits, its use demands meticulous planning and preparation to avoid complications. Catheter knotting requires immediate attention. If bedside maneuvers fail, endovascular or surgical approaches may be necessary.

•This case report presents the management of a rare complication, catheter knotting, during the use of a pulmonary artery catheter (PAC), highlighting its clinical implications and potential risks.•We successfully managed a knotted Swan-Ganz catheter at the bedside, emphasizing techniques to safely address simple and localized knots in stable patients while preparing for emergent intervention if needed.•The report reviews bedside, endovascular, and surgical options for knotted catheter removal, providing a comprehensive guide for clinicians to tailor management based on the knot's complexity and patient stability.

This case report presents the management of a rare complication, catheter knotting, during the use of a pulmonary artery catheter (PAC), highlighting its clinical implications and potential risks.

We successfully managed a knotted Swan-Ganz catheter at the bedside, emphasizing techniques to safely address simple and localized knots in stable patients while preparing for emergent intervention if needed.

The report reviews bedside, endovascular, and surgical options for knotted catheter removal, providing a comprehensive guide for clinicians to tailor management based on the knot's complexity and patient stability.