Loss of dialysis catheter guide-wire: How to prevent?

Sir,

The most common clinical procedure performed by nephrologists is placement of the dialysis catheter to obtain vascular access for immediate hemodialysis (HD). A lost guide-wire is a hazardous, yet completely preventable, and rare complication associated with catheter insertion.[1] There are some reports of forgotten guide-wire in the literature.[1-4] Lost guide-wire is the only complication that is completely avoidable, with a mortality rate as high as 20%.[4] Here, we report a case of a lost guide-wire in a 40-year-old female with end-stage renal disease who presented with inadequate flow through the femoral dialysis catheter. She was asymptomatic and had stable vital parameters. Diagnosis of lost guide-wire was confirmed by radiologic studies [Figures 1 and 2]. The patient was advised anticoagulation with heparin and surgical intervention to remove the guide-wire. The guide-wire was retrieved completely in a head-up position during aspiration of blood through the femoral canula without surgical operation (without basket-catheter or snare-catheter). After repeated suctioning of blood through the canula, the femoral canula was removed and just a tip of the guide-wire could be grasped at the insertion site.

Figure 1

An abdominal radiograph shows the tip of the guide-wire originating from the hemodialysis catheter inserted in the left femoral vein

Figure 2

An abdominal radiograph shows the course of the guide-wire in the vascular bed

We are not thinking of this complication because it is not familiar to us. Informing very soon makes it possible to retrieve the guide-wire that it is still near the catheter (not travelling completely into the vascular bed).[1] The usual attributes for a guide-wire loss are operator inexperience, inattention and inadequate supervision during catheterization and busy and overtired medical staff and hastiness.[2] A post-procedural chest radiograph is generally considered essential following cannulation of the internal jugular or subclavian veins, but is less frequently performed following cannulation of a femoral vein.

The signs of guide-wire loss include guide-wire is missing, resistance to injection via distal lumen, poor venous backflow from distal lumen and guide-wire visible on a radiograph.[2] Some tips to avoid complication when using this technique are recommended.[1] Inspect the guide-wire and catheter set for defects before insertion. Hold the proximal end of the guide-wire at all times until removal from the vessel. When resistance to insertion is met, remove and inspect the wire for damage and never push forward with force. Pass the catheter over the wire into the vein. Make sure that the guide-wire is visible at the proximal end before the catheter is advanced. Always inspect the guide-wire for complete removal at the end of the procedure.[5] Always after the procedure, obtain a control CXR and watch it yourself for all possible complications. Abuhasna et al.[3] suggested that prior to the procedure, the operator must turn his pager and/or mobile telephone to an individual not involved with the procedure in order to avoid any distractions. At the end of the procedure, a “time out” is instituted during which the operator calls out loudly and clearly that “the guide-wire is out of the patient,” and this is confirmed by the bedside nurse. These findings are then documented in the patient's medical (electronic) records. Taslimi et al, suggested that when you suspect a lost guide-wire, immediate consulting with an expert surgeon and an expert interventional radiologist is the most prudent approach.[1]

Retrieving a missed guide-wire or catheter fragments is now a routine angiographic intervention. Unless the patient is unstable or any concern exists about vascular damage, surgical intervention is the last choice. There are various angiographic techniques for percutaneous removal of intravascular foreign bodies; one of the most common is angiographic snaring. Other devices like Dormia baskets, balloon catheters and grasping devices are also used.[1]

In our case, the patient's normal vital parameters and hemoglobin convinced us not to choose the angiographic/surgical option, but to attempt a conservative approach.

Our case reminds physicians who place HD catheters that they should be aware of the existence, diagnosis and complications of lost guide-wire to prevent further morbidity and mortality, and it can be successfully retrieved completely without surgical intervention.