Removal of knotted dialysis guide wire under monitored anaesthesia care in radiological suite.

Sir,

Double lumen femoral catheterization (DLFC) is utilized for emergency dialysis.[1] Complications such as looping, knotting, vascular perforation, fragmentation and displacement of the guide wire are encountered frequently.[2] We describe a case wherein there was knotting of guide wire during insertion of DLFC, not amicable to removal and needed removal under anesthesia in the radiological suite.

A DLFC insertion was planned for dialysis of a 70-year-old man as the arterio-venous fistula was not working properly. Right-sided femoral vein was cannulated and guide wire inserted. The initial path of the guide wire was smooth but thereafter a resistance was felt. The guide wire was pushed in further with some force till no further insertion was possible. The operator then tried to pull the guide wire back by gentle traction but it was stuck. A swelling appeared at the site. He left the guide wire in position, applied pressure dressing. X-ray pelvis region showed that the guide wire had multiple loops and entanglement [Figure 1].

Figure 1

X-ray pelvis showing the entangled guide wire with formation of loop and knot

The patient was shifted to the catheterization laboratory for fluoroscopic-assisted guide wire removal. The knot of the guide wire tightened when gentle traction was applied for pulling it out. A 3-cm incision was made near the puncture site, followed by securing of the proximal vein with stay suture. A 7Fr femoral sheath dilator was inserted over the guide wire to dilate the subcutaneous tract of entry point. Over this 8Fr femoral sheath was inserted up to the point of the knot. Attempts to take the sheath distal to the knot failed. A 7Fr renal guiding catheter was inserted over the guide wire up to the point of the loop. The wire was pushed further proximal in the vein, distal to the knot, to get space for untying of the knot. A gentle traction was applied which led to the removal of the guide wire [Figure 2].

Figure 2

Disentangling of knot and loop of the guide wire

Catheter-related complications are well known, but there are few reports in which a guide wire has been involved. Common guide wire-related complications reported are entrapment of guide wire in the sternomastoid muscle[34] and in inferior vena cava filters.[5]

Dialysis catheter is often placed by personnel who are in training; closer supervision by a more senior person may help identify and prevent similar complications. The experience of an operator has direct bearing on the number of complications. Insertion of a catheter by a physician, who has performed 50 or more catheterizations, is half as likely to result in mechanical complications.[6] A direct relation is there between the number of attempts of insertions and mechanical complications.[7] After the occurrence of this complication, we made some changes in the dialysis catheter insertion protocol. In case of more than three attempts at insertion, the operator should seek help rather than continue the procedure. Force should not be applied during insertion/withdrawal of the guide wire. Any resistance felt should prompt removal of needle and guide wire en-bloc.