Central venous catheters (CVC) are often inserted perioperatively to administer drugs or monitor patients’ hemodynamics. Central venous catheterization is usually achieved via the right internal jugular vein (IJV) because this approach allows the catheter to be inserted linearly and is associated with fewer complications than access via the subclavian veins. However, central venous catheterization through the IJV is reportedly associated with a mechanical complication rate of 6.3% to 11%.1 The Seldinger technique,2 in which a needle trocar is used to puncture the target IJV during guidewire insertion, is commonly used for CVC cannulation.
Having obtained patient consent to publish this report, we describe an extremely rare case in which a significant complication occurred during double guidewire insertion into the right IJV by the Seldinger technique.
A 61-year-old man (weight: 83 kg; height: 163 cm) was scheduled to undergo emergency aortic arch replacement for a ruptured thoracic aorta. Before general anesthesia was induced, an arterial line was placed in his left radial artery under local anesthesia. General anesthesia was induced with propofol and remifentanil, and tracheal intubation was performed after muscular relaxation was induced with rocuronium. We planned to insert a triple-lumen CVC (Safe Guide™ Microneedle Seldinger Kit; Nippon Covidien Ltd., Tokyo, Japan) and a 9-Fr sheath introducer (Arrow™ polyurethane introducer set; Teleflex Medical Japan Ltd., Tokyo, Japan) into the right IJV to administer cardiovascular drugs and install a pulmonary artery catheter, respectively.
In a sterile environment, the patient was placed in the head-down tilt position. First, under ultrasonographic guidance, a 22-G venous indwelling trocar (BD Angiocath™; Nippon Becton, Dickinson and Company Ltd., Tokyo, Japan) was placed in the right IJV, through which a CVC kit guidewire of approximately 20 cm in length (GW1; an angle-type guidewire with an outer diameter of 0.46 mm) was inserted. Only 1 puncture was made, and long-axis view ultrasonography images confirmed that GW1 was pointing toward the heart. No abnormalities such as resistance were detected when GW1 was moved a few centimeters back and forth. In addition, no guidewire-induced atrial premature contractions or ventricular premature contractions were observed during GW1 insertion.
Second, with the GW1 puncture site used as a reference, a 20-G venous indwelling trocar (BD Angiocath) was placed in the right IJV approximately 1 cm cranial to the GW1 puncture site by the landmark-based method. Although mild resistance was encountered during the puncture procedure, backflow of venous blood through the trocar was confirmed. Then, a guidewire of approximately 20 cm in length from a sheath introducer kit (GW2; a J-tip-type guidewire with an outer diameter of 0.81 mm) was inserted through the trocar without any complications. Two transient atrial premature contractions were observed during GW2 insertion.
A dilator attached to a CVC was used to dilate the GW1 puncture site, and a CVC of approximately 12 cm in length was uneventfully inserted into the right IJV over GW1. However, during attempts to remove GW1, we unexpectedly encountered strong resistance. We removed the CVC and rechecked the mobility of GW1; however, we again met with strong resistance when it was withdrawn to approximately 5 cm from the skin. In addition, we found that we were unable to remove GW2. Fluoroscopy showed that GW1 and GW2 intersected and appeared to have become firmly entangled with each other (Fig. 1).
To prevent the guidewires from breaking, we attempted to extract them via the GW2 puncture site. With the sheath introducer and dilator included in the abovementioned kit, the GW2 puncture site was dilated to approximately 4 mm in diameter, which allowed us to extract the entangled portions of GW1 and GW2 (Fig. 2A). We extracted GW1 from the dilated GW2 puncture site, and we cut GW2 directly below the entangled region. Both guidewires were eventually removed without any breakages. Examining the extracted guidewires revealed that GW2 had penetrated GW1 approximately 5 cm from its tip between the steel core and outer wire (Fig. 2B). Although the outer wire of GW1 was bent, neither of the guidewires had snapped. Fluoroscopy did not detect any foreign objects in the patient’s veins. Finally, a triple-lumen CVC and sheath introducer were successfully placed in the right IJV, and the operation proceeded as planned. No abnormal hemorrhaging or hematoma occurred in the cervical region during the procedure.
The Seldinger method of guidewire-assisted CVC insertion is widely used and is relatively safe. However, several reports describe guidewire-related complications, including arrhythmia,3 transmission disorders,3,4 the formation of twisting loops or knots,5 puncture of blood vessels or the heart,6,7 wire-tip damage causing embolus formation, and intravascular wire loss.8
In our case, 2 guidewires inserted into the right IJV became entangled, making their removal difficult. However, it should be noted that this is an extremely rare complication. Fluoroscopy indicated that the tip of GW1 had strayed in a cranial direction somewhere within the IJV for reasons unknown (Fig. 1); however, ultrasonographic images captured after GW1 insertion showed it pointing toward the heart. Consequently, the venous indwelling needle used to insert GW2 penetrated GW1. Most commercially available guidewires comprise an extra-fine, chemically adhesive outer wire wound around a stainless steel core, and this outer wire is only attached to the steel core at its ends. Therefore, when the needle punctured GW1, it may have loosened its outer wire, allowing GW2 to penetrate it. To confirm this, we attempted to pierce a guidewire identical to GW1 with a venous indwelling needle identical to GW2. Only slight resistance was experienced, depending on the direction of the bevel, and the needle easily penetrated the guidewire (Fig. 3). In addition, a previous study9 described outer wires being damaged or snapped, suggesting that some parts of guidewires are structurally prone to breaking, even though they appear strong. If we had discontinued the procedure when slight resistance was encountered during the puncturing procedure before GW2 insertion and evaluated its cause by ultrasonography, this complication could have been avoided.
Guidewires can arch after coming into contact with vascular walls or venous valves. Several reports describe guidewires arching at the subclavian vein confluence or straying toward the internal thoracic veins.10–12 In addition, because of the difficulty of accurately monitoring guidewire advancement toward the heart with body-surface ultrasonography,13 it is important to adequately assess the guidewire’s freedom of movement after insertion.
Under fluoroscopic observation, we were able to remove both guidewires by dilating the puncture site with a sheath introducer and a dilator. However, dilating the puncture site without confirming how the guidewires were entangled could have put pressure on the attachment site and caused the wires to snap. If it is confirmed that a guidewire has snapped, surgical removal of the guidewires must be considered.
In surgical procedures that necessitate hemodynamic monitoring (e.g., cardiac and great vessel surgery), we often insert a CVC and sheath introducers. Our routine procedure involves making a second puncture cranial to the first puncture site to avoid guidewire damage. However, Lowe and Pagel14 report that complications can still arise, even when the second puncture site is cranial to the first. Because of the complications that occurred in the present case, we recommend that during double cannulation, the second puncture procedure should only be performed after the correct passage of the first guidewire is confirmed. An alternative is avoidance of the practice of “double” sticking a single vein for central venous access.
The authors would like to thank Enago (www.enago.jp) for the English language review.
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