Guidewire for central venous catheter: Ideal or needs improvement?

Sir, In the intensive care unit (ICU), central venous cannulation is frequently performed with the Seldinger technique. The incidence of mechanical issues related to this technique is estimated at 5%–19%. In addition to well-known complications, literature documents rare occurrences involving the guidewire, such as intravascular and extravascular looping and knotting leading to breakage.[1] We present a rare occurrence where the withdrawal of the J-tip of the guidewire resulted in vessel wall shearing. A 20-year-old male was admitted to the ICU following exploratory laparotomy. The patient appeared to be hypovolemic; despite fluid resuscitation, the patient’s mean arterial pressure remained below 65 mm Hg, requiring the use of vasopressors for support. The initial ultrasound (USG) showed that the internal jugular vein (IJV) appeared to be collapsed with no unusual anatomy detected. Using the Seldinger technique and USG guidance, a 7 Fr 16 cm triple-lumen central venous catheter was inserted into the right IJV via an out-of-plane approach. During the removal of the guidewire, resistance was encountered. A USG was performed to recheck the placement and revealed the presence of the guidewire within the vessel lumen. Again, upon withdrawing the guidewire, resistance persisted. Despite using gentle force during the guidewire extraction, it caused a shearing of the vessel wall by its J-tip, as shown in Figure 1. A bedside two-dimensional echo was performed promptly to exclude pericardial effusion and confirm the vessel’s integrity. The catheter was then secured in place.Figure 1: Withdrawn J tip of guidewire showing the sheared vesselThe removal of an intact J-tipped guidewire resulted in the shearing of the vessel wall, likely due to the preexisting collapsed vein. Although this case went uneventfully without any complications for the patient, it still needs to be addressed to avoid serious complications. While it is recommended not to remove the guidewire against resistance, in this case, it was taken out with gentle force as the team ruled out the possibility of the “razor effect” causing the resistance. Guidewire withdrawal could have caused a fracture of the guidewire or embolization of the fragment. However, we did not encounter such complications in our case, though they have been mentioned in literature along with other complications such as knotting and loss of guidewire.[2] Apart from the nonadherence to protocols, inherited flaws in the design of a guidewire can lead to complications. The structure of a guidewire consists of a single filament core surrounded by a coiled wire cover. The coiled wire provides support for the inner wire and flexibility, while the J-tip, made of a flattened round core 2.5 cm from the tip, may have a structural weakness at the junction of the rounded and flattened segments and may lead to potential breakage.[3] Gravenstein and Blackshear[4] demonstrated that using a pigtail tip decreases the risk of catheter-related perforations. We believe that an atraumatic rounded tip design for guidewires could help reduce vessel wall shearing and other complications associated with J-tipped guidewires. This idea needs further validation through clinical studies. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.