Loss of guide-wire during central venous cannulation - Life long learning!

Dear Editor,

Central venous catheterization (CVC) is a routine procedure done in operation room and ICU. Only few complications related to guidewire have been reported due to medico-legal issues and iatrogenic origins.[1]

A 50-year-old male got admitted in the ICU as a postoperative case of right temporoparietal subdural hematoma. Central venous cannulation was planned for prolonged intravenous access. Under aseptic conditions, right IJV was cannulated with an introducer needle by an experienced resident doctor. Following this, the guide-wire was introduced without any resistance. Then the catheter was railroaded over the guide-wire but while checking for backflow through the catheter, the doctor noticed that the proximal end of the guide-wire was not visible through the catheter. Immediately, a bedside chest X-ray was obtained which showed the proximal end of the guide-wire out of the distal end of the catheter and it was traversing through superior vena cava (SVC), right atrium and inferior vena cava (IVC) [Figure 1]. Although the patient’s vitals remained stable during this period, the patient was immediately shifted to the Cath lab for removal of the guide-wire. During fluoroscopy, the guide-wire was found to be traveled further down there into lower IVC with distal end in right iliac vein above the femoral head [Figure 2]. Then the guide-wire was retrieved with a goose neck snare by placing 8 French catheters in venous sheath of right femoral vein without any complications.

Figure 1

Showing proximal end of guide wire (black arrow) was out of the distal end of the catheter (white arrow) and was traversing through SVC, right atrium and IVC

Figure 2

Showing J shaped distal tip of the guide wire in right iliac vein above the femoral head

The loss of guide-wire is a preventable and a rare complication of CVC insertion. Predisposing factors for this complication can be tired, inexperienced, unsupervised operator with incomplete preprocedural knowledge.[2] Sudden patient movement and excessive insertion of the guide-wire (due to fear of losing vascular access)) are additional risk factors.[3] A complete guide-wire loss can be asymptomatic but it may cause arrhythmia, thrombosis, embolism and vascular damage in later stages with a fatality rate up to 20%.[4] So the guide-wire should be removed as quickly and completely as possible if lost. Use of Dormia basket and biopsy forceps has been described with some limitation. Extraction by surgical exploration has also been reported if percutaneous methods fail.[5] To prevent intravascular loss of guide-wire, following precautions must be considered- a) hold the proximal tip of the guide-wire at all times b) avoid excessive insertion of the guide-wire (maximum 18 cm from puncture sites) c) using the Seldinger technique, the wire must be visible at the proximal end before railroading the catheter d) after catheter insertion, the immediate step should be removal of the guide-wire e) after catheterization, always inspect the procedural tray for complete wire removal and get the chest X ray.

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Conflicts of interest

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