Inadvertent placement of pulmonary artery catheter into right carotid artery

PURPOSE: To report a case of misplacement of a pulmonary artery catheter (PAC) into the carotid artery after open heart surgery. CLINICAL FEATURES: A 20-mo-old boy underwent open heart surgery (VSD repair). On the first day postoperatively, he had severe pulmonary hypertension and a PAC was inserted via the left internal jugular approach without complication. Two hours later, chest radiography showed the PAC in the right internal carotid artery which it had reached via the right and left ventricles and aorta. The PAC was withdrawn and a new PAC was inserted and its position was confirmed by chest radiography. Two years later echocardiography failed to demonstrate the second VSD or a residual leak through the patch although a PAC could be passed from the right ventricle to the left ventricle and subsequently into the aorta and right carotid artery. CONCLUSION: Correct placement of a PAC should be confirmed by chest radiography or other techniques to prevent complication.