Keywords
central venous catheters - guidewires
Introduction
Central venous catheters (CVC) are placed commonly for long-term access in critically
ill patients for injecting medicines, including chemotherapy in oncology patients,
and for total parenteral nutrition. Guidewires used in these procedures can accidentally
get misplaced inside the body. Location of misplaced wires can be confirmed using
X-rays. These are removed percutaneously using Gooseneck snares, endobronchial forceps,
Dormia basket, or manually prepared snare using guidewires. We herein describe innovative
method of snaring two misplaced guidewires using balloons and guidewires.
Case 1
A 25-year-old male presented to Interventional Radiology (IR) clinic, with a request
for the removal of misplaced guidewire. CVC placement was attempted by a Gastroenterology
Resident under supervision, but during the procedure he lost access to the guidewire.
On fluoroscopy, the guidewire was seen extending from superior vena cava (SVC) through
right atrium into the inferior vena cava (IVC). Financial constrains limited the use
of snare in this patient and a different approach was required. We first secured a
10-F vascular sheath in the right internal jugular vein and, thereafter, two hydrophilic
J-tip Terumo guidewires (0.035ʺ) and a 10 × 40 mm percutaneous transluminal angioplasty
(PTA) balloon into the IVC. The J-tip Terumo guidewires and the PTA balloon were rotated
to engage the misplaced guidewire. The whole assembly was gradually drawn into the
sheath and then PTA balloon was partially inflated. The vascular sheath, along with
the misplaced guidewire, PTA balloon, and two Terumo guidewires, was finally removed
as a single assembly ([Fig. 1]). Compression was applied at the puncture site for 5 minutes after removal of the
sheath.
Fig. 1 Case 1 of a 25-year-old man who presented with trauma with misplaced guidewire in
superior vena cava (SVC). (A) Misplaced guidewire in SVC. (B) Assembly of guidewire, balloon, and misplaced wire that was gradually retrieved.
Case 2
Left common femoral vein cannulation was attempted in a 32-year-old male, with known
case of chronic kidney disease with thrombosed arteriovenous fistula, by a Nephrology
Resident. A call was made to the IR department to retrieve the wire. On fluoroscopy,
the misplaced guidewire was seen extending from the IVC through right atrium into
the SVC. Unavailability of snare forced us to find a different approach for its retrieval.
We accessed the right internal jugular vein and secured a 10-F vascular sheath. Snaring
of the misplaced guidewire was attempted with the help of two J-tip Terumo guidewires
and 10 × 40 mm PTA balloon, but was unsuccessful. The PTA balloon was removed, followed
by the introduction of Amplatz Super Stiff wire (Boston Scientific) (0.035ʺ), which
was rotated along with the two J-tip Terumo guidewires (0.035ʺ); however, this was
again with no success. Finally, a snare was prepared using Hi-Torque BMW (Abott) microwire
(0.014) and the misplaced guidewire was gradually removed under fluoroscopic guidance,
along with the sheath as well as the stiff and Terumo guidewires as a complete assembly
([Fig. 2]). Compression was applied at the puncture site for 5 minutes after removal of the
sheath.
Fig. 2 Case 2 of a 32-year-old female in whom guidewire was accidentally misplaced while
obtaining central venous access through left common femoral vein. (A, B) Misplaced wire in the pelvis within the venous system reaching up to the superior
vena cava through inferior vena cava and right atrium. (C) Engaged misplaced wire via Hi-Torque BMW microwire placed through a 10-F vascular
sheath into right internal jugular vein. (D) En masse retrieval of entire assembly. (E) Retrieved misplaced guidewire along with other hardware used.
Discussion
Misplaced guidewire is a scenario faced by the clinicians and interventional radiologists
in the following two situations: (a) when the CVC is placed by the residents in training,
or (b) when the CVC is placed by the clinicians who are tired, lethargic, and not
attentive.[1] Guidewire misplacement is detected immediately, or in some cases after few hours.
Holding to end of wire is a good practice, as it drastically reduces the chance of
misplacing guidewire. Removal of the misplaced guidewire within 24 hours is of utmost
priority for the interventional radiologist, to prevent complications.[2]
[3] Till 1963, surgery was the only option left with the clinicians to remove the misplaced
guidewire and other foreign bodies. Seldinger technique was first described in 1953
and in 1964, Dotter and Judkins first described a technique for percutaneous vascular
access using Seldinger technique.[4]
[5] This drastically reduced associated morbidity, with the advantage that large-sized
catheters could be placed percutaneously through a small-size hole in the skin using
Seldinger technique.
Thomas et al reported nonsurgical retrieval of a broken segment of a steel spring
guide from the right atrium and IVC in 1964.[6] Watson described snare loop technique for the removal of a broken steerable wire
in 1987.[7] Snares are commonly used to retrieve misplaced guidewires. But the disadvantage
of using snares is that these snares are costly and not afforded by many patients
in India, as most patients are not covered by insurance. Moreover, it is difficult
to maintain stock of differently sized snares, due to low usage rate. In our first
case, snare could not be used due to prohibitive cost and in the second case, snare
was not available in stock at that time. In the first case, we could successfully
retrieve the misplaced guidewire in the first attempt using two guidewires and one
PTA balloon. In the second case, we could retrieve the misplaced guidewire after multiple
attempts, after manually making a snare using Hi-Torque BMW microwire. The hardware
we used in both our cases was available in our digital subtraction angiography laboratory.
Moreover, the hardware we used was cheaper than currently available snares in the
market. Some interventional radiologists have advocated the usage of heparin as an
anticoagulant, both before and during the procedure. However, we do not believe that
our technique needed any additional anticoagulant.
Our both cases highlight the point that interventional radiologists have to use innovative
techniques when faced with complex clinical situation, especially when the desired
hardware is not available in their stock. Keeping cool and thinking about possible
solutions can help the interventional radiologist tide over difficult situations.
Conclusion
We hereby conclude that innovative methods like combination of guidewires and PTA
balloon can be used successfully to retrieve misplaced guidewires, when snare is not
available in our stock. Teaching our residents and fellows to successfully carry out
IR procedures is our moral duty. But this should not be at the expense of affecting
patient care services. Trainees should first be encouraged to learn the basics of
IR from their seniors and guides. After these trainees have shown proficiency while
assisting, they should be allowed to carry out IR procedures under guidance. Second,
these trainees should be taught to call their seniors and mentors for help, in case
of emergency. Most importantly, they should be taught never to hide their mistakes
and to discuss important cases and complications with their seniors. Only then we
can label our trainees as safe radiologists.
