Introduction
Central venous catheterization (CVC) is a routine procedure performed in emergency departments, operation theaters, and intensive care units. Various indications for CVC include patients with difficult peripheral cannulation, trauma patients requiring fluid resuscitation, surgeries with major fluid shifts, critically ill patients, patients who require parenteral nutrition, and so on. The CVC-related complication rate is estimated to be approximately 12%–15%.[1,2] The guidewire-related complications are cardiac dysrhythmias, conduction abnormalities, perforation of chambers or vessels, kinking, loss, looping, breakage, and knot in the guidewire.[3,4] The loss of guidewire into circulation during the procedure is a rare and preventable complication. We report a case of accidental loss of guidewire during femoral CVC and its management.
Case Report
A 66-year-old female known case of mucinous adenocarcinoma was admitted to the surgery department for colostomy closure. Postoperatively, she was kept nil per oral, and intravenous fluids were continued. On the second postoperative day, femoral central venous line insertion was planned for long-term venous access. The patient was shifted to the emergency operation theater for CVC. The patient was evaluated prior to the procedure, and requisite blood investigations were within normal limits. Informed and written consent was obtained prior to right femoral CVC. A monitor was attached to record the baseline vital parameters, including heart rate, noninvasive blood pressure, and peripheral oxygen saturation.
Under all aseptic precautions, a supervised trainee anesthesiologist cannulated the right femoral vein with an introducer needle. After a successful puncture of the femoral vein followed by aspiration of venous blood, the guidewire was inserted smoothly, and the catheter was railroaded over the guidewire. While advancing the central venous catheter over the guidewire, the guidewire accidentally slipped along with the catheter but was still inside the tip of the catheter. While pulling back the catheter with the guidewire in it, only the catheter came out. The accidental loss of the guidewire might be due to not holding the guidewire at its proximal end during catheter insertion over it.
Local exploration was done after local anesthetic infiltration, but we could not find out the guidewire. X-ray abdomen and thorax were done in a supine position to locate the guidewire. The proximal end of the guidewire was at the level of the head of the femur, while the distal end was at the level of the third cervical (C3) vertebra [Figure 1]. The patient had no complaints and remained vitally stable.
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Figure 1:: X-ray chest and abdomen showing lost/migrated guidewire
The case was discussed with the cardiothoracic and vascular surgery department to manage this complication. The cardiothoracic and vascular surgeon planned for immediate exploration via the cervical approach to discover the guidewire’s J-tip in the internal jugular vein. The patient was evaluated and prepared for exploration and retrieval of guidewire under general anesthesia. All emergency drugs were kept ready along with two units of whole blood. A longitudinal incision was given at the C2–C3 level to explore the internal jugular vein [Figure 2], and the full length of the guidewire was removed carefully [Figure 3]. The intraoperative period was uneventful. The patient was extubated uneventfully with stable hemodynamics.
Figure 2:: Showing guidewire in internal jugular vein at cervical region
Figure 3:: The retrieved guidewire along with the J-shaped tip
Discussion
CVC is an important procedure indicated for various reasons. However, CVC has many serious complications such as failure to place the catheter, improper catheter position, misplacement, kinking, breakage, arrhythmias, arterial puncture, hematoma, thrombosis, embolism, pneumothorax, and infection which may arise in as many as 15% of these procedures.[5,6] The femoral approach is usually not a preferred approach due to more chances of infection, the possibility of the catheter getting “sucked in” along with the venous flow as well as the negative intrathoracic pressure and loss of concentration during any step can lead to complications as happened in our case. In our case, we had an accidental loss of guidewire during femoral CVC which was recognized timely and managed without any consequences. The previous case reports related to lost guidewire did not mention the extent of the length of lost guidewire but in our case, the guidewire had migrated up to the cervical level which is very rare or unique in terms of its possible passage via the inferior vena, superior vena cava, and then into the internal jugular vein. The guidewire usually coils if it migrates against the blood flow in cardiac chambers.
The predisposing factors for an intravascular loss of the guidewire include inattention (in almost all the cases), inexperienced operator (Seldinger’s technique), overtired staff, and inadequate supervision of trainees.[7] The signs of guidewire loss include missing guidewire (as seen in our case), lost guidewire visible on the radiograph, poor venous backflow from the distal lumen, and/or resistance to injection through the distal lumen. There are insufficient data on the complications related to lost guidewire due to medicolegal issues. Loss of a complete guidewire usually does not cause symptoms, but it may cause arrhythmia, thrombosis, embolism, and vascular damage in later stages with a fatality rate of up to 20%.[8] Interventional radiology is the method of choice to deal with lost catheters and this entire guidewire should be removed urgently to avoid further manifestations.[7] Surgical exploration is the next modality for extraction of lost guidewire which was planned in our case.
This complication can be avoided with due precautions. First, the procedure should be done by an experienced person. Second, if multiple manipulations are required for guidewire insertion, then the wire should be rechecked and replaced. Third, before advancing the catheter over the guidewire into the vein ensure that the wire is visible at the proximal end and during railroading the catheter over the guidewire, the wire should be held tightly. Lastly, the wire should always be inspected for complete removal at the end of the procedure.
Conclusion
CVC requires expertise and due attention during the procedure. Everyone should be aware of all possible problems which can be encountered during the procedure and complications thereafter. Holding the guidewire during CVC is an important step to be practiced so that complications associated with lost guidewires can be prevented. If this complication is timely identified, active management for its retrieval is very important to avoid further complications related to circulating guidewire.
Acknowledgement
Nil.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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