Non-invasive removal of a misplaced and knotted guidewire during ultrasound-guided central venous catheter insertion in a hybrid operating room: a case report

CVC placement into the IJV is an invasive procedure that can result in mechanical complications, including arterial puncture, hematoma, and pneumothorax, occurring in 6.3–11.8% of cases [4]. Complications related to the guidewire placement are rare but also potentially serious [5]. Looping, kinking, or knotting of the guidewire may occur during CVC placement. Guidewire knotting during CVC placement was reported by Majek in 1975[6]. More recently, knotting of the guidewire during CVC placement in the subclavian vein was reported by Yong in 2013 [7] and Sekiguchi in 2022 [8]. Knotting of the guidewire has also been reported in other procedures, including cardiac catheterization [9], peripherally inserted central catheter placement [10], and biliary drainage [11]. Although the misplaced and knotted guidewire can be removed surgically, these techniques require invasive approaches [8, 12, 13]. Previous reports have shown that a 5-French sheath can be useful for removal of the knots in the guidewire [7, 14]. We report a novel approach using sheath placement under fluoroscopy. In this case, the guidewire knot was successfully removed under fluoroscopy using a push–pull technique in a hybrid operating room thereby avoiding a more invasive surgical procedure.

In our case, resistance to removal of the guidewire prompted the immediate performance of ultrasound, standard radiographic imaging, and CT imaging. These techniques led to a rapid diagnosis of the problem and precluded further attempts at simple manual removal of the knotted wire which may have resulted in vessel trauma or shearing of the wire within the patient. The diagnosis of the problem enabled consultation with other departments at an early stage and safe removal of the guidewire with minimal invasiveness in the hybrid operating room. The use of fluoroscopy provided invaluable in obtaining a comprehensive view of the wire and the complication that had occurred.

This complication may be avoided by using the over-the-needle catheter technique, which may be preferred over puncturing the vessel with a thin-wall needle. Lee et al. reported that the over-the-needle catheter technique had a higher first attempt success rate of needle and guidewire insertion (87.3% vs 77.3%, p = 0.037) and fewer puncture attempts (1.14 ± 0.4 vs 1.3 ± 0.6, p = 0.026) than puncture with a thin-wall during internal jugular vein catheterization; however, there was no difference in complications between the two groups [15]. Similar findings have been reported in neonates [16]. However, Kim et al. have shown that the over-the-needle technique increased the incidence of catheterization-related complications and decreased the first-time success rates when compared to the thin-wall needle technique[17]. In our case, the guidewire knot was believed to have formed as a result of the needle penetrating the posterior wall of the IJV during the insertion of the guidewire. It is possible that this complication would be less likely to occur with an over-the-needle catheter technique. In addition, it has been reported that the incidence of mechanical complications is reduced by 50% when the catheter is inserted by a clinically experienced physician [4]. Thus, in cases where catheter insertion is expected to be difficult, a clinically experienced physician should perform the insertion.

In conclusion, we present a very rare complication of a guidewire penetrating the posterior wall of the vessel and forming a knot. The case illustrates that it is imperative to adhere the fundamental principle of not extracting the guidewire by force when encountering resistance. The use of US, CT, and fluoroscopy was helpful for diagnosis, while the hybrid operating room proved invaluable for the removal procedure. Prospective trials are needed to further define whether needle placement technique (over-the-needle catheter vs. direct needle puncture) is beneficial in avoiding this complication. This anecdotal experience may be useful as the current clinical guidelines do not address the diagnosis and management of CVC-associated trauma or injury, with the exception of cases involving carotid arterial injury [3].

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