Catheter Impaction After Pericardial Drainage Due to Inadvertent Entry Into the Transverse Pericardial Sinus

Figures

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  Visual Summary. Timeline and Mechanism of Catheter Impaction via the Transverse Pericardial Sinus (Left) Three-dimensional (3D) volume-rendered computed tomography showing the drainage catheter coursing through the transverse pericardial sinus between the ascending aorta and pulmonary trunk. (Middle) Fluoroscopy during drainage illustrating the anatomical corridor (dotted cylinder) through which the guidewire traversed the sinus. (Right) The 3-stage pathophysiology of this complication: 1) uneventful insertion through a distended sinus, 2) delayed impaction caused by collapse of the sinus around the angulated catheter after drainage, and 3) safe retrieval by saline-induced re-expansion of the pericardial cavity combined with gentle diastolic-phase traction. The take-home message emphasizes that smooth catheter insertion does not guarantee correct placement; if unexpected resistance occurs during removal, transverse sinus malposition should be suspected, forceful traction avoided, and saline re-expansion with diastole-synchronized gentle retrieval considered.

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  Figure 1. Transthoracic Echocardiography (A) Apical approach. (B) Subxiphoid approach showing a large inferior pericardial effusion.

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  Figure 2. Fluoroscopic Images During Pericardial Drainage (A) Fluoroscopy after guidewire insertion. The guidewire appeared to advance smoothly along the cardiac silhouette. The dotted cylinder indicates the projected location of the transverse pericardial sinus, which lies behind the ascending aorta and pulmonary trunk. The arrows indicate the direction of catheter advancement from the puncture site through the transverse pericardial sinus to the catheter tip. The labels “entry” and “lateral exit” indicate the points at which the guidewire entered and exited the sinus, respectively, as later confirmed by computed tomography. No resistance or abnormal trajectory was appreciable at this stage. (B) Fluoroscopic image after placement of a 6-F pigtail drainage catheter.

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  Figure 3. Computed Tomography Demonstrating Catheter Malposition Through the Transverse Pericardial Sinus (A) Volume-rendered CT image showing the pericardial drainage catheter (green) coursing posterior to the ascending aorta within the transverse pericardial sinus. The sinus is bounded anteriorly by the ascending aorta and pulmonary trunk and posteriorly by the roof of the left atrium. (B) Oblique axial CT image with color overlays highlighting the ascending aorta (red), pulmonary trunk (purple), and left atrium (blue), clearly demarcating the transverse pericardial sinus as the narrow space bounded anteriorly by the ascending aorta and pulmonary trunk and posteriorly by the left atrium. The catheter entered the sinus from the anterosuperior aspect of the ascending aorta, passed behind the aorta, and exited laterally into the main pericardial space, producing a sharply angulated course consistent with mechanical impaction. CT = computed tomography.