Case 1: A 30-year-old woman was scheduled for mitral valvuloplasty. A pulmonary artery (PA) catheter (Swan-Ganz CCOmbo model: 744HF75, Edwards(r), USA) was inserted via an introducer (8.5 Fr) placed in the right external jugular vein. The tip of the catheter could not be passed from the external jugular vein to the subclavian vein. When we attempted to advance the PA catheter again 30 minutes later, it could not be advanced or withdrawn. The PA catheter was removed with an introducer. The tip of the introducer had curled up into the intralummial space and the PA catheter had impacted in the narrowed lumen.

Case 2: A 48-year-old woman was scheduled for tricuspid annuloplasty. A PA catheter was inserted via an introducer placed in the right internal jugular vein without problem. After opening the right atrium and withdrawing the PA catheter, a vinyl strip was found to have torn away from the distal part of the PA catheter.