complications of guidewire insertion in central line placement

Proper management of the guidewire during placement of a central line via the Seldinger technique can be an afterthought compared with emphasis on successful venipuncture, but guidewire mismanagement can lead to serious complications. The first step is inserting the guidewire through the venipuncture needle to an appropriate depth to safely guide the central line into proper position. Of the choices, a depth of 15 cm (at the skin, not the hub of the needle) facilitates reliable placement of the central line into proper position in the superior vena cava without risking complications associated with deep insertion (choice B is correct). The guidewire in most central line kits is 60 cm long with marks every 10 cm.

Shallow guidewire insertion of only 5 cm increases the potential for inadvertent retraction of the guidewire out of the vein during manipulation, such as removal of the venipuncture needle. With the guidewire tip now in the soft tissue of the neck, central venous catheter (CVC) insertion will be unsuccessful. The guidewire should be visualized via ultrasonography as being within the vessel to proceed to subsequent steps. A rigid vein dilator is briefly inserted over the guidewire to widen the tract in the soft tissue and vein wall to facilitate CVC insertion. However, insertion of the rigid vein dilator past the tip of the guidewire, as in the case with a 5 cm insertion depth, raises the potential for dilator-induced damage to the vessel wall (choice A is incorrect).

Insertion of excessive length of guidewire can induce atrial or ventricular arrhythmias. In a double-blind, randomized, controlled trial of guidewire insertion depths during right internal jugular vein central line placement, arrhythmias were significantly more common with a 20-cm depth vs 15-cm depth (OR, 5.31 [CI, 1.4-18.8]). One can assume that arrhythmias would be even more frequent with a depth of 25 or 35 cm (choices C and D are incorrect). Arrhythmias generally resolve with retraction of the guidewire.

Inserting the guidewire to 35 cm and beyond introduces additional risks (choice D is incorrect). Entanglement of the guidewire with an inferior vena cava (IVC) filter is a well-described serious complication because the deeply inserted guidewire passes through the right atrium into the IVC. The coil-and-core construction of the wire and the J-shaped tip contribute to entanglement with the IVC filter, and the wire often cannot be retracted, requiring interventional radiology or surgical intervention to disentangle. In a case series, the entanglement was not recognized in nearly one-half of cases, resulting in iatrogenic migration of the filter to the right atrium or central veins as the stuck guidewire was forcefully retracted. During iatrogenic migration, the filter was often damaged, including strut fracture and distal embolization. Retrieval of the damaged filter was infrequently successful. In contrast, endovascular wire disengagement was successful in nearly all cases when IVC filter entanglement was recognized before migration.

Finally, retained guidewire is an additional complication more common with deep guidewire placement. With insertion of more than 25 cm of a typical 60-cm long guidewire, there is insufficient guidewire length outside the patient to permit the operator to simultaneously grasp the wire both at the skin and the proximal end as the wire emerges from the hub of the distal port while the CVC is advanced over the wire before actual insertion. As the CVC is advanced into the patient, the guidewire within the lumen may be retained within the CVC unseen, and it may be embolized following injection of fluid through the distal port. Insertion of 15 cm of guidewire leaves plenty of guidewire outside the patient to allow the operator to control the wire and prevent retention. Some central line checklists require the operator to state “guidewire out” to their assistant to help avoid this complication.123456

Footnotes

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  3. Lee JM, Lee J, Hwang JY, et al. Randomized comparison of three guidewire insertion depths on incidence of arrhythmia during central venous catheterization. Am J Emerg Med. 2017;35(5):743-748. PubMed ↩

  4. Pokharel K, Biswas BK, Tripathi M, Subedi A. Missed central venous guide wires: a systematic analysis of published case reports. Crit Care Med. 2015;43(8):1745-1756. PubMed ↩

  5. Song Y, Messerlian AK, Matevosian R. A potentially hazardous complication during central venous catheterization: lost guidewire retained in the patient. J Clin Anesth. 2012;24(3):221-226. PubMed ↩

  6. Wu A, Helo N, Moon E, Tam M, Kapoor B, Wang W. Strategies for prevention of iatrogenic inferior vena cava filter entrapment and dislodgement during central venous catheter placement. J Vasc Surg. 2014;59(1):255-259. PubMed ↩