One of the major risks of right heart catheterization in the ICU is pulmonary artery rupture. While exceedingly rare (0.06% – 0.2%), it has a high mortality of approximately 50% usually within 30 minutes. When I was first learning about pulmonary artery catheters, I envisioned this primarily as a problem with the distal tip of the catheter migrating into the small vessel and capillary bed, which then is rupture during balloon inflation. I felt secure that this serious complication was eliminated by ensuring proper tip positioning. Unfortunately, like everything in medicine the reality is more complicated.

Mechanisms of rupture

  • Balloon over distension of small artery, arteriole or capillary.
  • Local trauma to the vessel wall by the pulmonary artery catheter tip.
  • Eccentric wedging of the balloon.

Risk Factors

  • Mechanical factors (rapid balloon inflation, distal catheter position, rigid catheters)
  • Poor compliance of pulmonary arteries (pulmonary hypertension, older patients)
  • Heparinization

During patient repositioning, transport or patient movement, the pulmonary artery catheter may migrate distally and become wedged. This spontaneous wedge happens without balloon inflation and may cause pulmonary infarction, but not necessarily pulmonary artery rupture. It can be detected by a change of the pulmonary artery waveform to a wedged waveform. This is the reason it is critical to monitor pulmonary artery pressure continuously.

In our patient, a brief episode of arrhythmia was noted as the catheter was floated through the right ventricle (see below). The pulmonary artery catheter should be moved through the right ventricle rather quickly. If the catheter requires re-positioned, the balloon should be deflated and the catheter withdrawn completely to the right atrium before attempting the repositioning to minimize time in the right ventricle.


We were able to correctly flow the pulmnonary artery catheter and obtain a normal appearing wedge waveform. Good practice is to inflate the balloon slo