A 75-year-old white woman with a history of ischemic cardiomyopathy and congestive heart failure (New York Heart Association class II) was hospitalized because of a traumatic hip fracture. The preoperative evaluation revealed physical signs and symptoms of moderate congestive heart failure. For this reason, operative correction was delayed and therapy including diuretics and afterload reducers was instituted after a Swan-Ganz catheter was placed through a right internal jugular approach. Initially some difficulty was encountered in obtaining an accurate pulmonary capillary wedge pressure. A chest x-ray film demonstrated the catheter tip to be located in the middle third of the pulmonary artery. Pressures at this time were 49/21 mm Hg (pulmonary artery systolic/diastolic) with a wedge pressure of 19 mm Hg.
With intensive medical treatment, the patient improved over the following four days, and the Swan-Ganz catheter was temporarily removed. Intraoperative and postoperative volume management was considered essential because of the patient’s precarious cardiac condition; prior to surgery, a second Swan-Ganz catheter was inserted through a right internal jugular approach. Difficulty again was encountered in obtaining the capillary wedge pressure. The catheter was carefully advanced to what was felt to be a maximally safe distance; however, a satisfactory wedge tracing could not be obtained. The balloon was then deflated and reinflated without difficulty or documented increased resistance to inflation. vardenafil 20 mg
Pulmonary arterial diastolic pressures were followed because of the difficulty encountered in obtaining a wedge pressure. Scant hemoptysis was documented one hour postoperatively. A chest x-ray film revealed a wedge-shaped infiltrate (Fig 1) and a small effusion in the right lung field distal to the Swan-Ganz catheter tip. The catheter was prompdy removed while the patient was under close medical observation. An uneventful recovery led to discharge nine days postoperatively.
FIGURE 1. Chest x-ray film demonstrating the Swan-Ganz catheter in a retracted position and a wedge-shaped defect in the right lower lobe.
Three weeks postoperatively, the patient was evaluated in the emergency room for a recurrence of hemoptysis. Chest x-ray film at this time showed two nodular densities in the right lower lobe (Fig 2). A ventilation-perfusion scan demonstrated a perfusion defect in the right lower lung field that was consistent with the mass seen on chest x-ray film. The patient was followed up as an outpatient and did well until ten weeks later, when she returned to the emergency room complaining of generalized weakness and temperature of 38.5°C for one day. Chest x-ray film at the time revealed an increase in size and in density of these two nodules.
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FIGURE 2. Chest x-ray film three weeks later, with two nodular densities in the right lower lobe in the area previously subjected to trauma from the Swan-Ganz catheter.
They now measured 7 cm and 3 cm, respectively. A CT scan confirmed the presence of two well-circumscribed nodular soft- tissue densities and suggested the possibility of metastatic nodules. A fine-needle aspiration was attempted under fluoroscopic guidance. When the larger of the two lesions was entered, brisk blood return was noted. A small amount of contrast material injected through the biopsy needle filled the lesion and revealed distal runoff, suggesting the presence of a pulmonary artery aneurysm. At the time of pulmonary arteriograph, the pulmonary artery pressures had increased to 60/29 mm Hg with a mean of 40 mm Hg. With manual injection, contrast completely filled and passed through the lesion with flow to the distal pulmonary arterial tree, confirming that the lesions were aneurysms. Later that day, the patient developed a leak in the large aneurysm and a right hemothorax, requiring chest tube drainage and exploratory surgery leading to a right lower lobe lobectomy. Two pseudoaneurysms of the pulmonary artery were documented surgically and confirmed by pathologic analysis. No thrombus was found, and the routine, fungal, and acid-fast cultures were negative.