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Case Reports: Case Report

Perioperative Surface Ultrasound for Placement and Confirmation of Central Venous Access: A Case Report

Bortman, Jeffrey BS*; Knio, Ziyad BS; Amir, Rabia MD*; Hamid, Khadija BS*; Mahmood, Feroze MD*; Matyal, Robina MD*

Author Information
doi: 10.1213/XAA.0000000000000463
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Abstract

Although use of ultrasound (US) is considered safer than the landmark technique for central venous catheter (CVC) insertion, there is no standardized protocol for its use. It is used for real-time guidance during venipuncture by localizing the internal jugular (IJ) vein and then ensuring the presence of the guidewire in the IJ vein.1 When available, the identification of the inserted guidewire tip at the superior vena cava to right atrial junction (SVC–RA) with transthoracic or transesophageal echocardiography (TTE, TEE) adds another level of safety to the procedure.2,3

After obtaining written informed consent from the patient, a case is reported in which US was used for real-time guidance during venipuncture and for confirmation of the position of the guidewire in the short-axis view of the right IJ vein. However, the tip of the guidewire could not be visualized at the SVC–RA junction. This prompted a reinterrogation of the venipuncture site with US in the short-axis and long-axis views. The guidewire was coiled in the IJ vein distal to the point of venipuncture. This case serves to highlight the use of the entire scope of perioperative US to enhance patient safety during CVC insertion.

CASE DESCRIPTION

US-guided CVC insertion was attempted in a patient at the authors’ institution after induction of general anesthesia during a routine cardiac surgical procedure using a high-frequency (9–12 MHz) surface echo probe (Philips Medical Systems, Andover, MA). The right IJ vein was identified in the short-axis view and cannulated under real-time guidance. The guidewire was then advanced to 20 cm without any resistance through a thin-walled needle into the IJ vein. A short-axis view of the IJ vein confirmed the presence of wire in the lumen (Figure 1). As per protocol at this institution, the position of the guidewire tip is routinely confirmed at the SVC–RA junction with a 3- to 5-MHz TTE probe (Philips Medical Systems, Andover, MA) by a second examiner before dilation and CVC insertion. In this case, the tip of the guidewire could not be visualized at the SVC–RA junction. The wire was then advanced several centimeters, but it could still not be seen crossing the SVC–RA junction.

Figure 1.
Figure 1.:
Short-axis view of RIJ vein and CCA in the neck visualizing guidewire during central venous catheter cannulation. RIJ indicates right internal jugular; CCA, common carotid artery.
Figure 2.
Figure 2.:
Long-axis view of the RIJ vein in the neck showing the guidewire looping in the cephalad direction onto itself. RIJ indicates right internal jugular.
Figure 3.
Figure 3.:
A, Modified subcostal 4-chamber view showing the guidewire entering the RA from the SVC. B, Positive right atrial swirl sign confirming accurate central venous catheter placement in the RA–SVC junction. RA indicates right atrium; SVC, superior vena cava.

Attention was diverted to the venipuncture site again, and visualization of the vein was attempted with the high-frequency surface echo probe. In the long-axis view of the IJ vein, the guide was found to be looped distal to the insertion site and was directed in the cephalad direction (Figure 2). The guidewire was removed, and the procedure was repeated under real-time US guidance. The intraluminal position of the guidewire was confirmed both in the short-axis and long-axis views of the IJ vein. The presence of guidewire tip at the SVC–RA junction was confirmed with TTE (Figure 3A), and the correct position of catheter tip was confirmed with TTE by means of a positive right atrial swirl sign (Figure 3B). The rest of the case proceeded uneventfully.

DISCUSSION

Our case highlights the importance of the knowledge of the entire scope of perioperative US for the safe insertion of CVCs. Intraluminal visualization of the guidewire with US in the IJ vein is a crucial step for the accurate placement of the CVC. Centrally placed catheters are known to coil, kink in the lumen of the vein, and be directed to the subclavian vein.4–6 The risk of complications during US-guided CVC placement is greater when the guidewire is not visually localized during its insertion and advancement.3,7,8

Whereas the lack of visualization of the tip of the guidewire at the SVC–RA junction prompted re-evaluation of the puncture site, it could have been possibly detected with the long axis of the IJ vein. Our lack of visualization of the guidewire loop in the short-axis view of the vein can be explained by the position of the loop distal to the puncture site. Initial advancement of the guidewire could have also possibly pushed the guidewire more in the cephalad direction. Use of TEE and TTE has been reported for confirmation of the position of the CVC at the SVC–RA junction.3,9 Visualization of the guidewire tip at the SVC–RA junction confirms the cannulation of a venous structure and excludes malposition of the guidewire. In some patients, defibrillator wires or existing pacemakers may be mistaken for the guidewire. In these patients, the guidewire tip can be distinguished by moving it slightly to distinguish it from other wires at the SVC–RA junction.

The use of TEE in visualizing the guidewire tip during CVC insertion is ideal when possible, but this is limited only to specific procedures in which perioperative TEE is being employed regardless. In such cases, TTE has been shown to be a useful modality for perioperative guidewire localization despite it being limited in patients with a very high body mass index or unique body habitus.8–10 Specifically, the modified subcostal 4-chamber window provides imaging of the superior vena cava and right atrium and allows real-time localization of the guidewire tip as it is advanced toward the right atrium. Lack of confirmation of the presence of the tip of guidewire at the SVC–RA junction demands a reinterrogation of the puncture site and can only enhance safety. In cases with poor US windows, other means such as pressure monitoring and blood gas analysis can possibly be used to confirm correct placement.

DISCLOSURES

Name: Jeffrey Bortman, BS.

Contribution: This author helped draft and revise the manuscript.

Name: Ziyad Knio, BS.

Contribution: This author helped draft and revise the manuscript.

Name: Rabia Amir, MD.

Contribution: This author helped draft and revise the manuscript.

Name: Khadija Hamid, BS.

Contribution: This author helped draft and revise the manuscript.

Name: Feroze Mahmood, MD.

Contribution: This author helped conceive the case report, acquire the ultrasound images, and review the manuscript.

Name: Robina Matyal, MD.

Contribution: This author helped conceive the case report, acquire the ultrasound images, and review the manuscript.

This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.

REFERENCES

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