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Table of Contents
LETTER TO EDITOR
Year : 2012  |  Volume : 28  |  Issue : 4  |  Page : 537-539

Removal of knotted dialysis guide wire under monitored anaesthesia care in radiological suite


1 Department of Anesthesia, Himalayan Institute of Medical Sciences, Dehradun, India
2 Department of Cardiology, Himalayan Institute of Medical Sciences, Dehradun, India

Date of Web Publication4-Oct-2012

Correspondence Address:
Rohit Goyal
Aggarwal House, Lane No. 8, Adarsh Nagar, Jolly Grants, Dehradun
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.101957

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How to cite this article:
Goyal R, Agrawal S, Kumar R. Removal of knotted dialysis guide wire under monitored anaesthesia care in radiological suite. J Anaesthesiol Clin Pharmacol 2012;28:537-9

How to cite this URL:
Goyal R, Agrawal S, Kumar R. Removal of knotted dialysis guide wire under monitored anaesthesia care in radiological suite. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2019 Jul 21];28:537-9. Available from: http://www.joacp.org/text.asp?2012/28/4/537/101957

Sir,

Double lumen femoral catheterization (DLFC) is utilized for emergency dialysis. [1] Complications such as looping, knotting, vascular perforation, fragmentation and displacement of the guide wire are encountered frequently. [2] We describe a case wherein there was knotting of guide wire during insertion of DLFC, not amicable to removal and needed removal under anesthesia in the radiological suite.

A DLFC insertion was planned for dialysis of a 70-year-old man as the arterio-venous fistula was not working properly. Right-sided femoral vein was cannulated and guide wire inserted. The initial path of the guide wire was smooth but thereafter a resistance was felt. The guide wire was pushed in further with some force till no further insertion was possible. The operator then tried to pull the guide wire back by gentle traction but it was stuck. A swelling appeared at the site. He left the guide wire in position, applied pressure dressing. X-ray pelvis region showed that the guide wire had multiple loops and entanglement [Figure 1].
Figure 1: X-ray pelvis showing the entangled guide wire with formation of loop and knot

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The patient was shifted to the catheterization laboratory for fluoroscopic-assisted guide wire removal. The knot of the guide wire tightened when gentle traction was applied for pulling it out. A 3-cm incision was made near the puncture site, followed by securing of the proximal vein with stay suture. A 7Fr femoral sheath dilator was inserted over the guide wire to dilate the subcutaneous tract of entry point. Over this 8Fr femoral sheath was inserted up to the point of the knot. Attempts to take the sheath distal to the knot failed. A 7Fr renal guiding catheter was inserted over the guide wire up to the point of the loop. The wire was pushed further proximal in the vein, distal to the knot, to get space for untying of the knot. A gentle traction was applied which led to the removal of the guide wire [Figure 2].
Figure 2: Disentangling of knot and loop of the guide wire

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Catheter-related complications are well known, but there are few reports in which a guide wire has been involved. Common guide wire-related complications reported are entrapment of guide wire in the sternomastoid muscle [3],[4] and in inferior vena cava filters. [5]

Dialysis catheter is often placed by personnel who are in training; closer supervision by a more senior person may help identify and prevent similar complications. The experience of an operator has direct bearing on the number of complications. Insertion of a catheter by a physician, who has performed 50 or more catheterizations, is half as likely to result in mechanical complications. [6] A direct relation is there between the number of attempts of insertions and mechanical complications. [7] After the occurrence of this complication, we made some changes in the dialysis catheter insertion protocol. In case of more than three attempts at insertion, the operator should seek help rather than continue the procedure. Force should not be applied during insertion/withdrawal of the guide wire. Any resistance felt should prompt removal of needle and guide wire en-bloc.

 
  References Top

1.Huang CC, Chen JH, Huang HH, Yen DH, Kao WF, Huang CI, et al. Emergency femoral hemodialysis catheter placement complicated by prevesical hematoma. J Emerg Med 2010;39:583-5.  Back to cited text no. 1
[PUBMED]    
2.Katiyar S, Jain RK. Entrapped central venous catheter guide wire. Indian J Anaesth 2010;54:354-5.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Mastan M, Clothier PR, Ousta B, Deulkar U. Internal jugular venous cannulation complicated by J-tip guide wire entrapment. Br J Anaesth2001;86:292-3.  Back to cited text no. 3
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4.Polos PG, Sahn SA. Complication of central venous catheter insertion: Fragmentation of a guidewire with pulmonary artery embolism. Crit Care Med 1991;19:438-40.  Back to cited text no. 4
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5.Andrews RT, Geschwind JF, Savadar SJ, Venbrux AC. Entrapment of J-tip guidewires by venetech and stainless-steel Greenfield vena cava filters during central venous catheter placement. Percutaneous management in four patients. CardiovascInterventRadiol 1998;21:424-8.  Back to cited text no. 5
    
6.Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization: failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259-61.  Back to cited text no. 6
[PUBMED]    
7.Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735-8.  Back to cited text no. 7
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