Importance of Dermatotomy Incision without Residual Skin Bridge during Central Venous Catheterization.

Dear Editor:

We read with great interest Dr. Tayebi’s description of the endovascular removal of an entrapped central venous catheter guidewire in the March issue of Vascular Specialist International [1]. We commend Dr. Tayebi for both the ingenious approach to this problem and the review of guidewire-related complications during central venous catheter placement.

Guidewire kinking, knotting, and fracture can and do occur during multiple-step central venous catheter placement using the Seldinger technique [2,3]. In addition to the author’s recommendation to avoid advancing the guidewire against resistance, attempts to advance dilators or catheters through the skin with force or in a direction not parallel to the in situ guidewire can result in guidewire kinking, looping, and fracture. In our practice, we emphasize making a small dermatotomy incision at the wire entry site prior to any attempts to advance catheters or dilators over the wire and into the vessel. It is imperative that this incision be made contiguous with the wire entry site, as residual skin bridges (Fig. 1) often necessitate the use of excessive force for device passage and increase the risk of wire-related complications.

Fig. 1

Guidewire in the right internal jugular vein after an attempted incision with a standard #11 scalpel (left of image is cephalad, right of image is caudad). Notice the residual skin bridge between the wire insertion site and the dermatotomy incision. Non-contiguous dermatotomy incisions such as this one can make dilator and catheter passage difficult and predispose to wire related complications.