| Summary: | Knotting of a pulmonary artery catheter (PAC) is a rare, but well-known complication of pulmonary artery (PA) catheterization. We report a case of a double-knotted PAC with a large loop in a patient with hepatocellular carcinoma (HCC) undergoing liver transplantation, which has been rarely reported in the literature. A PAC was advanced under pressure wave form guidance. PAC insertion was repeatedly attempted and the PAC was inserted 80 cm deep even though PAC should be normally inserted 45 to 55 cm deep. However, since no wave change was observed, we began deflating and pulling the balloon. At the 30-cm mark, the PAC could no longer be pulled. Fluoroscopy confirmed knotting of the PAC after surgery (The loop-formed PAC was shown in right internal jugular vein); thus, it was removed. For safe PA catheterization, deep insertion or repeated attempts should be avoided when the catheter cannot be easily inserted into the pulmonary artery. If possible, the insertion of PACs can be performed more safely by monitoring the movement of the catheter under fluoroscopy or transesophageal echocardiography.
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