Inadvertent placement of pulmonary artery catheter into right carotid artery

Purpose: To report a case of misplacement of a pulmonary artery catheter (P AC) 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 a nd a PAC was inserted via the left internal jugular approach without compli cation. Two hours later, chest radiography showed the PAC in the right inte rnal 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 The PAC was withdrawn and a new PAC was inserted and its positio n was confirmed by chest radiography. Two years later echocardiography fail ed to demonstrate the second VSD or a residual leak through the patch altho ugh a PAC could be passed from the right ventricle to the left ventricle an d subsequently into the aorta and right carotid artery. Conclusion: Correct placement of a PAC should be confirmed by chest radiogr aphy or other techniques to prevent complication.