The two-headed swan

Pulmonary artery catheterization is a frequent procedure for hemodynamic monitoring in critically ill patients or high-risk surgical patients. Mechanical and infectious complications are recognized, though catheter dysfunction and malposition are more frequent and often require clinical intervention. We present the case of a Swan-Ganz catheter with the appearance of a mechanical fracture at the distal end, which required clinical and radiographic investigation to determine the nature of the aberrancy. The evaluation of a malfunctioning pulmonary artery catheter (PAC) is a frequent occurrence in the intensive care unit and requires careful clinical consideration and radiographic examination.