Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2012  |  Volume : 23  |  Issue : 5  |  Page : 1059--1060

Unrecognized migration of an entire guide wire during hemodialysis catheter placement


Bahaa Hadj Sadek, Hakim Hanin, Fatima Zahra Batta, Mohammed Arrayhani, Tarik Sqalli Hussaini 
 Department of Nephrology-Dialysis, Hassan II University Hospital, Fes, Morocco

Correspondence Address:
Bahaa Hadj Sadek
Department of Nephrology-Dialysis, Hassan II University Hospital, Fes
Morocco




How to cite this article:
Sadek BH, Hanin H, Batta FZ, Arrayhani M, Hussaini TS. Unrecognized migration of an entire guide wire during hemodialysis catheter placement.Saudi J Kidney Dis Transpl 2012;23:1059-1060


How to cite this URL:
Sadek BH, Hanin H, Batta FZ, Arrayhani M, Hussaini TS. Unrecognized migration of an entire guide wire during hemodialysis catheter placement. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Jul 14 ];23:1059-1060
Available from: http://www.sjkdt.org/text.asp?2012/23/5/1059/100952


Full Text

To the Editor,

Central venous catheterization is routinely used in critically ill patients. It is also a routine technique for emergent hemodialysis. Many complications have been published for this approach. [1] We report a case of a retained intra­venous guide wire that had inadvertently slipped into a patient who underwent jugular catheterization for hemodialysis. This missed guide wire was subsequently diagnosed six months later at routine chest radiograph and confirmed at computed tomography. To our knowledge, this is the longest reported interval for guide wire extraction. A 49-year-old man on hemodialysis for four years received a central venous catheter via the right internal jugular vein by a nephrologist six months prior to presentation to establish venous access for the hemodialysis. No chest radiograph was performed subsequently. The chest radiograph taken six months later to evaluate the patient's dry weight displayed a linear foreign body with metallic density projecting from the neck to the cardiac silhouette [Figure 1]. It was confirmed to be identical in length to an entire guide wire. The computed cervical, thoracic, abdominal and pelvic tomography confirmed the diagnosis [Figure 2]. Cardiac dysrhythmias and signs and symptoms indicative of pul­monary embolism did not develop throughout the course. The guide wire was removed easily by exploration of the right internal jugular vein under general anesthesia and careful traction [Figure 3]. The course was uneventful and the patient remained asymptomatic. To our knowledge, only three cases have been published in which a previously unre­cognized misplaced guide wire was diagnosed incidentally on imaging. [1],[2],[3] This is a very rare complication that is a human error and is to­tally preventable by doing the procedure by a skilled physician. If the rules of catheter in­sertion procedure are followed, the guide wire cannot get lost. Guide wire retrieval is a cru­cial step in the catheterization technique, wherein a catheter is inserted over a guide wire.{Figure 1}{Figure 2}{Figure 3}

The signs of guide wire loss include missing of the guide, resistance to injection via the distal lumen and poor venous backflow. After the procedure, the chest X-ray allows evaluation of the position of the catheter and its possible complications. [4]

The intravascular loss of a guide wire must be immediately recognized at the time of the procedure and should be removed as quickly and completely as possible, because of all the potential complications: endocarditis, heart dysrhythmias or myocardial perforation. [5] Interventional radiology is the method of choice. [2],[6] But, sometimes, surgical exploration can be attempted with careful extraction, as done with our patient. Uncomplicated removal was achieved in the present case after six months, which is, to our knowledge, the longest reported interval for guide wire extraction. Awareness of this rare scenario may facilitate prompt diagnosis and treatment, and prevent the associated complications.

References

1Akazawa S, Nakaigawa Y, Hotta K, Shimizu R, Kashiwagi H, Takahashi K. Unrecognized migration of an entire guidewire on insertion of a central venous catheter into the cardio­vascular system. Anesthesiology 1996;84:241-2.
2Cassie CD, Ginsberg MS, Panicek DM. Panicek. Unsuspected retained 60-cm intravenous guidewire. Clin Imaging 2006;30:287-90.
3Reynen K. 14-year follow-up of central embolization by a guide wire. N Engl J Med 1993; 329: 970-1.
4Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: Mishap or blunder? Br J Anaesth 2002;88:144-6.
5Chabanier A, Dany F, Brutus P, Vergnoux H. Iatrogenic cardiac tamponade after central venous catheter. Clin Cardiol 1988;11:91-9.
6Gabelmann A, Kramer S, Gorich J. Percu­taneous retrieval of lost or misplaced intravascular objects. Am J Roentgenol 2001;176: 1509-13.