Intraoperative removal of a knotted Swan-Ganz catheter during lung transplantation

We describe the case of a 52-year-old man with end-stage emphysema who underwent a right-sided lung transplantation. During preoperative monitoring an apparently non-functioning Swan-Ganz catheter could not be removed through the insertion site - right internal jugular vein. Another Swan-Ganz catheter was successfully installed through the left internal jugular vein, pulmonary artery pressures could be recorded and the transplant was performed uneventfully. Then, the first catheter was inspected and superior vena cava palpation surprisingly revealed a knot at approximately 25 cm. The catheter was pushed to the azygous vein, proximal and distal controls were obtained and a venotomy was performed. The knotted side was sectioned and removed, while the remaining catheter was removed through the insertion site. Despite being rare, knotted intravascular devices have been increasingly reported. Removal with interventional radiology techniques can be accomplished in most instances, nevertheless, complex knots or knots fixed into cardiac structures require open removal. Since in our case the knot was detected intraoperatively, it was readily removed through the azygous vein. To the best of our knowledge, this is the first report to describe such a route of removal.