Indications, contraindications and complications of pulmonary artery catheter insertion

This came up in Question 2 from the second paper of 2002.

Anatomy of the pulmonary artery catheter  is discussed in greater detail elsewhere.


  • Cardiac output measurement especially in a patient with arrhythmia or aortic balloon pump, where PiCCO cant be used
  • Unequal right and left ventricular failure
  • Complex hemodynamic instability, some combination of obstructive, distributive, cardiogenic and hypovolemic shock
  • To differentiate cardiogenic pulmonary edema from non-cardiogenic
  • To guide use of vasopressors, inotropes, fluids and diuretics – when the patient has a hemodynamic problem combined with pulmonary oedema and ventricular dysfunction.
  • To titrate pulmonary antihypertensives in ARDS (like nitric oxide and prostacyclin)


Same as CVC:

  • Perforation of SVC
  • Hemothorax, pneumothorax
  • Atrial fibrillation

Unique to PA catheter

  • Ventricular Arrhythmia
  • Thromboembolic events (the catheter is a nidus for clot formation)
  • Mural thrombi in the right heart (up to 30%)
  • Air embolism from ruptured balloon
  • Pulmonary infarction
  • Endocarditis of the pulmonary valve ( 2%)

Right bundle branch block

  • If you already have LBBB, this causes complete heart block
  • If you are lucky, it is a transient phenomenon and you only need to pace them transcutaneously for a brief period. If you are unlucky, you have injured the AV node, and the patient needs prolonged transvenous pacing

Knotting on structures or on itself ( ~ 1%)

  • If it has gone into the right ventricle by 25-30cm and its still not in the pulmonary artery, you start to worry

Damage to the valves or the heart

  •  Never pull the catheter back with the balloon inflated! You could tear the valve leaflets
  • The RV can be perforated, particularly a dilated weak-walled RV
  • The RA can be perforated (perhaps even more easily)

Pulmonary artery rupture: 0.2% risk,  30% mortality

  • Risk factors: pulmonary hypertension, mitral valve disease, anticoagulants and age over 60


This a full-text version of the seminal paper from 1970:

Swan HJ, Ganz W, Forrester J, Marcus H, Diamond G, Chonette D (August 1970). "Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter"N. Engl. J. Med. 283 (9): 447–51.

A manufacturer (Edwards) offers some free information about the PA catheter on their product page.

The PA catheter section from The ICU Book by Paul L Marino (3rd edition, 2007) is a valuable read.

Armstrong, Ehrin J., James M. McCabe, and Melvin D. Cheitlin. "Pulmonary artery catheterization in the intensive care unit: just numbers floating by?."Archives of internal medicine 171.12 (2011): 1110-1111.

Additionally, UpToDate has an article on PA catheter complication