Coiling of guide wire in the internal jugular vein during central venous catheter insertion: A rare complication

Abstract

Sir, Central venous catheters (CVC) are traditionally used for access in the intensive care unit setting and in burn patients for monitoring central venous pressure,[1] for total parenteral nutrition (TPN),[2] and for rapid volume replacement during shock. Much has been written regarding the complications of CVC.[3 4] The rate of major and minor CVC complications is up to 10%. These complications include arterial puncture, haematoma, pneumothorax, haemothorax, chylothorax, brachial plexus injury, arrhythmias, air embolism, catheter malposition, and catheter knotting. Gladwin et al. have reported that the incidence of axillary vein or right atrial catheter malposition is 14% during internal jugular venous catheterisation[5] whereas the overall rate of non-infectious complications of subclavian CVC placement is 5%.[6 7] Guide wires have been reported to cause arrhythmias, cardiac perforation, and tamponade.[8] Here, we report a case in which we encountered an unusual complication. The complication is not malpositioning of the CVC itself, but coiling of the guide wire used during CVC placement. A 35-year-old female patient of average build was admitted in our hospital with 70% burn injury. CVC placement was judged necessary for administering TPN 4 days after the burn injury. Her vital parameters were within normal limits and her prothrombin time and international normalised ratio were also within normal limits. The left internal jugular vein (IJV) was the only option available for cannulation. Consent was obtained from the patient for placing a CVC. We attached electrocardiogram, non-invasive blood pressure, temperature and pulse oximetry monitors in the burn ward. A triple-lumen catheter was chosen (BD Careflow®). Due aseptic precautions were taken and we planned to do the procedure by Seldinger technique. After proper positioning, we located the left IJV with a 22 Gauge needle by free aspiration of dark red blood after applying local anaesthesia with 1% lignocaine. Then, we inserted the introducer needle and after free aspiration of blood, we started to thread the guide wire through it. During threading of the guide wire, we experienced mild resistance and hence proceeded with the act. However, after about half the length of the guide wire was introduced, resistance was felt which stopped us from threading it further. We attempted extracting the guide wire for reinsertion. Unfortunately, the initial extraction attempt failed and about 12 cm of the guide wire length remained inside. Two additional attempts were made by two other operators, but these failed too and further attempts were abandoned fearing vessel injury. An emergency bedside chest X-ray (anteroposterior view) was arranged, which revealed [Figure 1] that the guide wire was lying coiled about 3 cm distal to the puncture point. Clinical examination confirmed bilateral normal breath sounds, a normal respiratory rate and oxygen saturation of 98%. There was no subcutaneous emphysema and no evidence of haematoma, venous congestion, or limb ischaemia. Figure 1 Chest X-ray showing the coiled guide wire (arrow) We had no access to any interventional radiology procedure to extract the trapped guide wire and the decision was taken to arrange for emergency surgery for removal of the same [Figure 2]. Fortunately, a peripheral venous line was patent and all investigation reports, necessary for surgery, were already available. The emergency surgery was commenced within 30 min under general anaesthesia. A 4 cm long incision was made 3 cm distal to our insertion point and the coiled guide wire was extracted from the left IJV after clamping it for a very short period. A venesection of the right long saphenous vein was also performed for reliable, large-bore venous access since central venous access is difficult via the saphenous vein and no other site was available for attempting another central venous line. The operation lasted for about 30 min. The patient was reversed from anaesthesia uneventfully and was shifted back to the burn ward. Figure 2 Guide wire in situ (arrow) prior to extraction by surgery Complications during the insertion of CVC can take place due to kinking or looping of the wire itself. Applying force to thread a guide wire through the introducer needle despite significant resistance is likely to cause such a problem.[9] Kinking of the guide wire can also result in misdirection of the dilator and perhaps insertion of the guide wire outside the vessel.[10] These complications may result from inexperience, the number of needle passes made, use of a relatively larger gauge needle than usual, severe dehydration, morbid obesity and coagulopathy. In our patient, the guide wire was not kinked outside the vessel, but got coiled inside the IJV just 3 cm distal to its insertion site, which may be regarded as a rare complication. The possible explanation may be a forceful threading of the guide wire through the introducer needle, though in actuality; we did not use undue force during threading of the guide wire. We also did not encounter undue resistance early which would have alerted us before so much of the guide wire got coiled. There are possibilities of coiling and kinking of the guide wire inside the vessel during insertion by Seldinger technique, in addition to the possibility of kinking outside the vessel. Since the complication can be serious, we recommend that force should not be used when even little resistance is encountered during threading of the guide wire and bedside chest X-ray facility should be available to check for guide wire position if malpositioning is suspected.