Guidewire Misplacement into the Hepatic Vein During Inferior Vena Cava Cannulation via the Femoral Vein: The Role of Transesophageal Echocardiography

To the Editor, Venous cannulation is a critical step in establishing cardiopulmonary bypass and extracorporeal membrane oxygenation. Misplacing a venous cannula can result in inadequate venous drainage or traumatic vascular injury. Although misplacement during inferior vena cava (IVC) cannulation via the femoral vein has been reported,[1,2] the role of intraoperative transesophageal echocardiography (TEE) in this approach is unknown. This letter describes a case of guidewire tip misplacement into the hepatic vein during IVC cannulation via the femoral vein. A 24-year-old man with Loeys–Dietz syndrome was scheduled for descending aortic replacement due to an aortic aneurysm. Preoperative computed tomography imaging revealed an absence of structural abnormalities. Cardiopulmonary bypass by cannulating the left femoral artery and vein was planned. During the procedure, the guidewire was advanced from the femoral vein to the right atrium (RA). However, despite sufficient advancement, the guidewire could not be detected in the RA using TEE. Instead, the guidewire tip had entered the hepatic vein [Figure 1]. Under TEE guidance, the guidewire orientation was modified, and the cannula was successfully positioned within the IVC.Figure 1: Two-dimensional transesophageal echocardiography from transgastric view (92°) showing (a) the junction of the hepatic vein and inferior vena cava and (b) guidewire misplacement into the hepatic vein during cannulation via the femoral vein. IVC = Inferior vena cava, HV = Hepatic veinGuidewire tip misplacement into the hepatic vein can be identified using TEE, which helps to avoid difficulty in introducing and positioning the venous cannula. TEE should ideally be used to confirm the position of the guidewire tip in the RA before attempting to cannulate the femoral vein. However, failure to visualize the guidewire within the RA should raise suspicion of misplacement, leading to further investigation within the IVC region and changing its direction into the RA as necessary. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his 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 The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.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.