Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 165-167

Guidewire complications during central vein cannulation: A peril underestimated


Department of Cardiothoracic and Vascular Surgery, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission10-May-2021
Date of Decision02-Jun-2021
Date of Acceptance04-Jun-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
Raja Lahiri
Department of Cardiothoracic and Vascular Surgery, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_48_21

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  Abstract 


Medical intervention procedures are never complication-free. Even after years of refinement in techniques and laying out protocols and checklists, errors do occur. Most of them are preventable, but not all of them. In such cases, efficient and timely diagnosis and management of complications is a key to a successful outcome. In this case series, we describe three situations of complications due to guidewire used in central venous cannulations and different approaches toward their successful management.

Keywords: Central venous catheters, vascular access ports, vascular surgical procedure


How to cite this article:
Darbari A, Lahiri R. Guidewire complications during central vein cannulation: A peril underestimated. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:165-7

How to cite this URL:
Darbari A, Lahiri R. Guidewire complications during central vein cannulation: A peril underestimated. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jul 4];8, Suppl S2:165-7. Available from: https://www.indjvascsurg.org/text.asp?2021/8/6/165/336022




  Introduction Top


In 1953, Dr. Sven Ivan Seldinger revolutionized the medical practice with his described “Seldinger technique” to access blood vessels. This technique has led to the success of angiographies, central venous catheters, and the myriad of percutaneous interventions. Almost every medical and paramedical personnel use this technique to perform cannulations and catheterizations in the various fields of medical practice. However, even after nearly 60 years of the advent of this technique, it is still not complication-free. We report three cases of guidewire-related complications in different settings and how they were managed.


  Case Reportss Top


Case report 1

A 43-year-old age male patient suffering from chronic kidney disease Stage 5 was planned for hemodialysis. He was admitted in the nephrology unit and was advised insertion of a right femoral venous access line for hemodialysis by the consultant. The resident doctor on duty, while inserting the line, failed to secure the guidewire at the end, and it accidentally went inside completely. Immediate bedside X-ray of this region was done [Figure 1], which showed the guidewire inside the iliofemoral venous system. The patient was wheeled into the radiology laboratory, and the wire removal was attempted by the radiologist using a snare with a new femoral venous puncture in the vicinity of the previous one. However, the wire could not be delivered out as it was possibly stuck. The vascular surgical team was consulted, and the patient was taken to the emergency operating room. Under local anesthesia and after proper groin region exposure, the guidewire was successfully removed from the right femoral vein, which was stuck in the venous wall near the entry point [Figure 2]. The venous repair was required and done by 6-0 Prolene simple suture. After proper approximation and closure, the dressing of the site was done. Groin wound was again examined after 24 h, and there was no hematoma or active bleeding found.
Figure 1: X-ray pelvis showing the retained guidewire in the iliofemoral venous system. The straight course indicates the possibility of the guidewire being completely inside the vascular system

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Figure 2: Operative photograph showing the exposure of the femoral vein and delivery of the guidewire tip (blue arrow)

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Case report 2

A 28-year-old aged female patient suffering from chronic kidney disease Stage-5 was planned for hemodialysis. She was admitted in the nephrology unit and was scheduled for insertion of a right internal jugular venous access line for hemodialysis. The procedure went smooth, but the physician was unable to retrieve the guidewire in entirety after inserting the main venous line. Due to repeated failed attempts, an immediate bedside X-ray of the region was done. X-ray showed the guidewire inside the jugular venous system with a knot [Figure 3]. The specialist vascular surgical team was called to deal further. Skin opening was slightly dilated and exposed under local anesthesia. After removing the venous line, the sheath was again carefully loaded on guidewire till the venous insertion point. By gentle pull on the guidewire, it was released and smoothly taken out. The venous opening was compressed with head-end elevation for hemostasis. After 5 min, venous opening and site were seen and confirmed about proper hemostasis. No venous repair was required. Gentle dressing of this site was done with head-end elevation. The wound was again examined after 24 h, and no hematoma or bleeding was found.
Figure 3: X-ray showing self-knotting of the guidewire just below the puncture site

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Case report 3

A 48-year-old aged male patient diagnosed with chronic pancreatitis was planned for insertion of a right internal jugular venous access line for parental nutrition purposes and long-standing venous access requirement. While inserting the line, suddenly, patient became agitated, and due to failure to secure the guidewire at the end, it accidentally went inside completely. Immediate bedside X-ray of this region was done, which showed the guidewire completely inside the venous system up to the right-sided atrial chamber. The patient was taken into the radiology laboratory, and the wire removal was attempted by the vascular interventionist using a snare with a new venous puncture in the vicinity of the previous one under general anesthesia. The guidewire was successfully removed from the right jugular venous side by making a loop around it and snaring method. Dye study to confirm any leakage from the venous system also done at completion. A confirmatory two-dimensional Echo to rule out any cardiac structure damage was also done after the retrieval procedure. The neck region was again examined after 24 h, and there was no hematoma or bleeding found.


  Discussion Top


Guidewire-related complications during the various types of vascular access procedures are not unheard of. Although not very commonly seen, most of them are avoidable. In most situations, these complications arise either due to unsupervised insertion by inexperienced persons or in an emergency situation due to an expeditious attempt to secure a line.[1] In many situations, soft-tissue interposition due to double puncture through the vessels wall[2] and self-knotting[3] (as described in our second case) can be a cause of the inability to remove the guidewire. The use of improper sized or nonstandard guidewires can also lead to these complications. Other complications described include perforation of deeper or inaccessible structures including the right atrium, entanglement with previously placed devices, namely pacemaker leads, fracture, and embolization of a part of the wire and injury to conduction system.[4]

The management of these situations largely depends on the nature of complications. The preliminary investigation in these situations is an X-ray that approximates the location and the extent of travel of the guidewire.[5],[6] It is essential in cases of guidewires completely lost into the vascular system. It is also helpful in detecting complications such as knotting and kinking. If intervention radiology laboratory facilities are available in the premises, it is preferable to take the patient to an angiography suite. Diagnostic angiography is often supplanted by a successful percutaneous intervention of removal of the guidewire. A percutaneous approach is a first and most preferred method in cases of “lost guidewires” due to complete insertion into the vascular system.[7] Most of the guidewires which are entirely inside the vascular system can be successfully removed using a percutaneous approach. An endovascular forceps or a snare is usually used to catch the free end of the wire, and it is delivered through the sheath insertion site (can be separate from the previous site of puncture). Guidewires partially embedded in the vessel wall or the one which are traversing through soft tissue are not favorable for endovascular removal.[8] Guidewires that undergo looping or knotting can be unlooped by pushing them to a larger vessel and using two separate access sites for manipulation inside the vessel. In case of failure to do so, the knot can be brought to the most accessible and peripheral location and can be surgically delivered out of the wound by increasing the size of the puncture under proper vascular control. The defect can be closed if required.

A computed tomography (CT) or a CT angiography may be required in cases where radiology laboratory facilities are not available or in cases where vital structures are involved.[9] Surgical exploration is usually reserved for patients where endovascular extraction had failed or is not available. Proper vascular control is essential before the attempt of removal. Care should be taken to prevent further migration of the guidewire during surgical exploration. Occasionally, embolised fragments or iatrogenic injury during endovascular removal may require major exploration.[10]


  Conclusion Top


An apparently simple and routine procedure such as central venous cannulation can lead to potential complications. Awareness regarding the possible complications and its management is crucial. The role of proper techniques and checklists in preventing iatrogenic injuries and complications cannot be reinforced further. Certain techniques, namely cannulation under duplex imaging control and retention of the sheath till postprocedural X-ray confirm the position massively helps in managing iatrogenic complications, if any.

Take home message

  • Cannulation complications during central venous line insertion are not uncommon but can be easily prevented and better managed if proper protocols are adhered to
  • Preferably, all cannulations should be performed under duplex ultrasound imaging, whenever possible instead of blind technique
  • In case of complication or anticipated problem, sheath should be retained until postprocedure imaging (regional X-ray in both views) confirms the proper position of the cannula and guidewire status. The presence of sheath helps in efficient management of iatrogenic complications
  • Never hesitate to call vascular specialists for help. Right intervention on the right time by the right team helps in the right outcome.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Okyere I, Adu-Takyi C, Adabie JA, Okyere P, Boateng NA. Accidental guidewire migration following emergency femoral central venous catheterization. Pan Afr Med J 2019;33:259.  Back to cited text no. 1
    
2.
Kumar N, Burman S, Yadav A, Tomar GS. Stuck guidewire due to soft tissue imposition: A rare complication of central line catheter placement. BMJ Case Rep 2018;2018:bcr2018224219. Published 2018 May 23. doi:10.1136/bcr-2018-224219.  Back to cited text no. 2
    
3.
Saito H, Suda T, Nishida Y. Guidewire knot formation with peripherally inserted central catheter. Clin Case Rep 2021;9:1035-6.  Back to cited text no. 3
    
4.
Khasawneh FA, Smalligan RD. Guidewire-related complications during central venous catheter placement: A case report and review of the literature. Case Rep Crit Care 2011;2011:287261.  Back to cited text no. 4
    
5.
Srivastav R, Yadav V, Sharma D, Yadav V. Loss of guide wire: A lesson learnt review of literature. J Surg Tech Case Rep 2013;5:78-81.  Back to cited text no. 5
    
6.
Zhao S, Wang Z, Zhao Y. Loss of guidewire and its sequelae after central venous catheterization: A case report. Medicine (Baltimore) 2019;98:e16513.  Back to cited text no. 6
    
7.
Ghatak T, Azim A, Baronia AK, Ghatak NK. Accidental guide-wire loss during central venous catheterization: A report of two life-threatening cases. Indian J Crit Care Med 2013;17:53-4.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Goyal SS, Panditrao MM, Garg A. The accidental loss of guidewire during emergency femoral central venous cannulation: A case report. Adesh Univ J Med Sci Res 2020;2:61-3.  Back to cited text no. 8
    
9.
Abuhasna S, Abdallah D, Ur Rahman M. The forgotten guide wire: A rare complication of hemodialysis catheter insertion. J Clin Imaging Sci 2011;1:40.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Xiao Hong C, Abd Wahab S, Azman M. Retained haemodialysis-catheter guidewire in the head and neck: A multidisciplinary team approach. BMJ Case Rep 2020;13:e236484.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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