The IJ Guide-wire Is “Stuck”

To the Editor:-We encountered an instance of a guide-wire that could not be withdrawn after cannulation of the internal jugular vein. The eventual explanation involved sufficient patient hazard to prompt us to describe it for the benefit of others.

A 75-yr-old man with chronic renal failure (creatinine 13.1, BUN 96) was brought to the operating room for placement of a left forearm A-V fistula and a temporary internal jugular hemodialysis access catheter. An axillary block was performed. The surgical team, using local anesthesia, then undertook the placement of a Hemo-Cath (Medcomp, Harleysville, PA) double lumen catheter in the right internal jugular vein. The vein was entered quickly and uneventfully with an 18-gauge “thinwall” needle. The J-tipped, 70-cm guide-wire was introduced and the vascular access catheter was passed over it. However, the guide-wire could not be withdrawn. The catheter was removed. The guide-wire still could not be withdrawn. The suspicion was that there was a knot in the wire. The possibility that the knot involved other structures or objects was entertained, but was dismissed because no other intravascular foreign bodies (catheters, pacemakers) were present within the great vessels of the head or neck. The possibility of the chordae tendineae of the tricuspid valve being included in the knot was considered.

An image intensifier was obtained. The wire was followed from the neck through the heart and into the abdomen, where an inferior vena caval filter of the Greenfield type (Medi-Tech, Watertown, MA) was identified. The J-tip of the guide-wire appeared to be wedged between two of the struts of the filter (Figure 1). Consultation by the Interventional Radiology Service was sought. The radiologist passed, using the original internal jugular access site and guide-wire, a rigid catheter to and beyond the Greenfield filter. This had the effect of pulling the J-tip caudally out of its wedged location. The tip of the wire was withdrawn to the thorax. The rigid catheter was removed and the dialysis access catheter was passed. The guide-wire was withdrawn uneventfully. The A-V fistula was then completed in the left forearm.

Entrapment of guide-wires or dislodgement of caval filters have been reported six times, beginning with a report in 1993. [1–6]In addition, an in vitro evaluation of the phenomenon was reported very recently. [6]Kaufman et al. observed entrapment only with J-tipped and not straight guide-wires. That investigation revealed that certain types of filters, in particular Vena-Tech filters (B. Braun Vena-Tech, Evanston, IL), are more likely to entrap wires than others. Their report notes that all of the six reported clinical events involved a Vena-Tech filter (including the one whose title identifies the filter as a “Greenfield”[4]). However, our experience indicates that Greenfield-type caval filters are not exempt from this potential complication.

The particular concern in this instance was that over-vigorous attempts to withdraw the wire, with the unsuspected filter attached, could have resulted in a disruption of the inferior vena cava, with a potential for retroperitoneal exsanguination. When a caval filter is known to be present, care to avoid unnecessarily deep passage of a guide-wire appears appropriate. In addition, anesthesiologists should add unrecognized caval filters to the list of foreign bodies and anatomic structures that can cause entrapment of guide-wires.

John C. Drummond, M.D., F.R.C.P.C.

Professor of Anesthesiology

University of California, San Diego

Anesthetist-in-Chief

VA Medical Center, San Diego, California

James P. Spaeth, M.D.

Resident in Anesthesiology

University of California, San Diego, California

Murali Dharan, M.D.

Resident in Surgery

University of California, San Diego, California

(Accepted for publication December 9, 1996.)