Unusual position of J-guide wire during ultrasound-guided subclavian vein catheterization

Abstract

Editor—We conducted a retrospective analysis of all the ultrasound-guided catheterizations in which unusual J-guide wire atypical positions had been identified. The protocol included ultrasound, long-axis viewing of the J-guide wire,1Fragou M Gravvanis A Dimitriou V et al.Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study.Crit Care Med. 2011; 39: 1607-1612Crossref PubMed Scopus (264) Google Scholar 2Karakitsos D Labropoulos N De Groot E et al.Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients.Crit Care. 2006; 10: R162Crossref PubMed Scopus (493) Google Scholar always before dilatation of the axillary/subclavian vein. The catheterization of the subclavian veins was performed according to the technique of Fragou and colleagues.1Fragou M Gravvanis A Dimitriou V et al.Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study.Crit Care Med. 2011; 39: 1607-1612Crossref PubMed Scopus (264) Google Scholar All ultrasound-guided venous catheterizations were performed by a competent consultant anaesthetist with great experience in this technique. Manual ultrasound examinations were conducted using a high-frequency, linear transducer on a portable ultrasound unit (CX 50, Phillips Healthcare, The Netherlands; or Vivid I, GE Healthcare, Waukesha, WI, USA). The central venous catheterizations took place on patients in the postoperative acute care unit, operating theatres, and the cardiothoracic care unit. Owing to the retrospective design of the study, formal research ethics committee approval and patients’ written informed consent for publication of this manuscript and accompanying images were deemed unnecessary. According to our results, throughout a 70 month period, 220 subclavian ultrasound-guided catheterizations were conducted, and all the potential complications were recorded in our archives. The J-guide wire was clearly seen in 220 out of 220 (100%) patients. In 13 out of 220 (5.9%) subclavian vein catheterizations, unusual J-wire positions in the lumen of the subclavian vein were acknowledged. Unusual positions of the J-wire included the following: seven (3.1%) instances of the J-wire looping within the lumen of the subclavian vein (Fig. 1a), two (0.9%) instances of double penetration of the subclavian vein wall, with the J-wire passing below the posterior wall, fortunately without inducing pneumonothorax, and one (0.45%) occasion when the J-wire coiled within and exited out of the subclavian vein lumen, by piercing the anterior wall of the vein (Fig. 1b). In all these instances, the J-wire was gently rotated, slightly advanced or moved out until it precisely repositioned and straightened within the vessel lumen. It is known that the Seldinger technique for central venous catheterization is always performed by using a J-tip guide wire. Kinking, looping, fracture, cardiac arrhythmias, or even cardiac arrest constitute severe complications of this technique.3Khan ZH Graham D Ermenyi A Pillay W. Case report: managing a knotted Seldinger wire in the subclavian vein during central venous cannulation.Can J Anaesth. 2007; 5: 375-379Crossref Scopus (29) Google Scholar 4Kusminsky RE. Complications of central venous catheterization.J Am Coll Surg. 2007; 204: 681-696Abstract Full Text Full Text PDF PubMed Scopus (247) Google Scholar Additionally, ultrasound imaging can enable reliable viewing of the guide wire during central venous catheter insertion, always offering essential safety during ultrasound-guided central venous catheter placement. Indeed, ultrasound viewing of the guide wire predicts central venous catheter placement with 100% sensitivity and 100% specificity.5Stone MB Nagdev A Murphy MC Sisson CA. Ultrasound detection of guide wire position during central venous catheterization.Am J Emerg Med. 2010; 28: 82-84Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Our case series showed that J-guide wire can be seen easily with ultrasound imaging and that unusual positions are rare but recognizable, with J-guide wire looping within the lumen of the subclavian vein being the most frequent. In conclusion, although retrospectively designed, our study underscores the decisive role of ultrasound imaging as a simple and feasible technique in the identification of J-guide wire atypical positions; thus, it can be used reliably as an additional safety measure during catheterization of the subclavian vein in clinical practice. None declared.