• C Ortmann, R Diallo, A Du Chesne, and B Brinkmann.
• Institut für Rechtsmedizin der Universität Münster.
• Anaesthesist. 1996 Aug 1; 45 (8): 755-9.

UnlabelledThree cases are presented dealing with rare lethal complications during the insertion of pulmonary artery catheters (PAC). Complications resulting from catheter insertion have been reported on numerous occasions; we report further examples of inadequate insertion techniques.Case ReportsDeviating from the recommended guidelines was presumably a significant factor in the development of fatal pulmonary bleeding. In the first case PAC-related perforation of the right ventricle resulting in cardiac tamponade was found at autopsy. Clinically, this perforation had not been noticed. A guidewire was allegedly employed during insertion. The diameter of the perforation (3 mm) suggests that either the balloon was deflated or the guidewire was used incautiously. In the second case during insertion the balloon was described as being inflated "after" reaching a wedge position. Considering this fact, catheter migration with perforation of a distal small artery was evident. Distal migration is more frequently associated with rupture of the pulmonary artery. In the third case we found a sequence of intimal lesions in the right main pulmonary artery and a segmental artery of the right lung. This high number of PAC-induced lesions is unusual and suggests inappropriate inflation technique.ConclusionsBased on our observations, we believe the low complication rate associated with PAC insertion has led to deviations from the normal guidelines by some physicians. Despite adequate precautions and insertion technique, iatrogenic lesions cannot be avoided in all cases because of pre-existing risk factors. For the evaluation of catheter-induced complications and the development of a risk profile, more autopsies as well as more detailed clinical documentation would be necessary.

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