Kusum Lata, MD, FSCAI; Gauhar Khan, MD; Faisal Latif MD, FSCAI

Introduction

Central venous catheter (CVC) placement is a common bedside procedure.¹ Venous access can be facilitated with the use of ultrasound guidance.² An important potential complication during the placement of a CVC is a guidewire lost into the venous circulation. The retrieval of a lost guidewire using an endovascular procedure can avoid the potential need for surgery.^3–5 In this Tip of the Month, we discuss some tips on how to facilitate the retrieval of a lost J-shaped guidewire, based on an actual case.

Case-Based Tips

During an emergency room (ER) visit, a patient received a chest X-ray, which determined the patient had retained a J-shape guidewire. History revealed that the patient had a CVC placed at an outside facility a few weeks prior, and it was presumed that this guidewire was lost during that bedside procedure. The decision was made to pursue the endovascular retrieval of this guidewire. Initial fluoroscopy showed that the J-shaped end of the guidewire was at the level of the right internal jugular vein (see Image 1, Video 1).

1. Choice of venous access
   • The selection of access based on fluoroscopic appearance of the two ends of the J-shaped guidewire is important. The straight end would be difficult to coil around the snare; plus there would be a risk of the J-shaped end getting entangled with the vessel wall/sheath during retrieval. Therefore, it is preferred to capture the J-shaped end of the guidewire.
   • In this case, femoral venous access was felt to be the most appropriate because the J-shaped end of the guidewire was in the right internal jugular vein; therefore, there would not be enough room to capture if internal jugular access was utilized.
2. Sheath size
   • An “adequate-sized” sheath that has enough room to accommodate two ends of a guidewire folded upon itself is important. For this case, a 7-French sheath was used, but a 7- or 8-French sheath would generally be appropriate.
3. Ensuring the ends of the guidewire are not endothelialized
   • If a guidewire has been left behind for a few weeks, there is the potential that one or both ends could be endothelialized. A pigtail catheter can be used to manipulate the two ends of the guidewire to ensure that it is free in the bloodstream. Additionally, in this case, the pigtail catheter was used to pull the J-shaped portion up to the superior vena cava for more room to manipulate the snare to capture the J-shaped end of the guidewire (see Video 2).
4. Type of snare
   • Different types of snares can be used to capture the end of the guidewire. For retrieval of a guidewire-like foreign material, either a single-loop (6–15mm) or multiloop snare can be used (Ensnare Endovascular Snare System, Merit Medical). The Multiloop Ensnare is generally more useful in capturing the tip of the guidewire since we visualize two-dimensional images of a three-dimensional object.
   • For this case, a 7-French Ensnare (Endovascular Snare System, Merit Medical) was advanced and looped around the J-shaped tip of the guidewire and pulled under with fluoroscopic guidance.
5. An acceptable “V-shaped bend” of the snared guidewire:
   • Fluoroscopy showed that the snare did not capture the very tip of the guidewire, but rather a few mm inside of the very tip, which created a tiny V-shaped bend at the end of the guidewire. However, the sheath worked well since it was a very small V-shaped bend of the tip; the bend occurred in a soft portion of the guidewire; the guidewire could still be easily removed with a slight tug; and taking the guidewire out altogether with the sheath rather than pulling through inside the sheath worked out well. Otherwise, the 7-French sheath might not accommodate the V-shaped bent tip of the J-shaped guidewire and could cause shearing of the sheath (see Video 3).

Conclusion

Guidewire-related complications are rare but potentially serious. Utilizing the aforementioned tips can help retrieve an abandoned guidewire, which can potentially save the patient from a surgical retrieval. Such errors can be avoided by following procedural checklists and equipment counts at the end of bedside invasive procedures.

References

1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003 Mar 20;348(12):1123–33.
2. Franco-Sadud R, Schnobrich D, Mathews BK, et al. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. J Hosp Med. 2019 Sep 6;14:E1–E22.
3. Song Y, Messerlian AK, Matevosian R. A potentially hazardous complication during central venous catheterization: lost guidewire retained in the patient. J Clin Anesth. 2012 May;24(3):221–6.
4. Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: mishap or blunder? Br J Anaesth. 2002 Jan;88(1):144–6.
5. Alves DR, Carvalho C. [Lost guide wire – lessons learned]. Braz J Anesthesiol. Mar–Apr 2018;68(2):183–185.

Image 1

Image 2

Video 1

Video 2

Video 3