[Pulmonary artery injury caused by mal-manipulation of a pulmonary artery catheter].

A 71-year-old male was scheduled for aortic valve replacement. After tracheal intubation under high-dose fentanyl anesthesia, a pulmonary artery balloon catheter was inserted via the right internal jugular vein. However, after withdrawing the catheter with the balloon inflated, we found abrupt massive bleeding from the endotracheal tube. Fortunately, hemorrhage stopped with PEEP (20-25 cmH2O). Bronchofiberscopy could not detect the bleeding point. Chest X-ray showed the pulmonary artery balloon catheter in the right pulmonary artery and atelectasis of the middle and lower lobes. Five days later, he was extubated without rehemorrhage. Three weeks after hemorrhage, the patient successfully underwent an aortic valve replacement, and was discharged on the 25th post-operative day.