|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 4 | Page : 581-582
Kinking, unwinding and retrieval of the Seldinger guide wire
Prakash K Dubey
Department of Anaesthesiology and Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, India
|Date of Web Publication||14-Oct-2014|
Prakash K Dubey
E ¾, IGIMS Campus, Patna - 800 014
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dubey PK. Kinking, unwinding and retrieval of the Seldinger guide wire
. J Anaesthesiol Clin Pharmacol 2014;30:581-2
This is with reference to the case report by Jalwal et al., "Percutaneous retrieval of malpositioned, kinked and unraveled guide wire under fluoroscopic guidance during central venous cannulation" in the April-June 2014 issue of Journal of Anaesthesiology Clinical Pharmacology.  We commend the authors for managing an unusual and potentially fatal problem extremely well.
However, we would like to make certain observations.
We agree with the authors' observation that such guide wire-related complications can happen either due to manufacture defect or because of a faulty technique. Malposition of subclavian guide wire into the ipsilateral internal jugular vein during insertion attempts is not uncommon. We believe that the insertion of tissue dilator in an attempt to dilate the tract was the triggering event in this case. It appears from the description that the tissue dilator was inserted deep inside the vein rather than being used to dilate the tissue along the tract outside the vein. Considerable force may have been inadvertently applied during this step which led to the kinking and initiation of the unraveling of the guide wire. Subsequent attempts at withdrawal increased the unwinding of the guide wire.
It is only the skin, subcutaneous tissue, and the entry point in the vessel wall that need to be dilated and any insertion of the dilator beyond the vessel wall only increases the chance of injury.  When the dilator is advanced over the guide wire, it should move over a firmly held guide wire. The moment the dilator "hangs up" and moves the wire forwards along with, one should get suspicious as at this point kinking may occur. 
Various other suggestions have been made for safer use of dilators. Avoidance of using excessive force, inserting smallest bore that will allow the wire and inserting the smallest length to reach the vein are some of them. 
We also agree that the withdrawal of a kinked guide wire by means of interventional radiology is the procedure of choice. We, however, do not agree that blind attempts at removing a kinked guide wire should not be made. Facilities like fluoroscopy and interventional radiology suit may not be available at all centers where central venous catheterization is being practiced. However, unwinding or unraveling of the guide wire is more serious.
Attempts should be made to retrieve a suspected kinked guide wire gently. The force applied should not be more than what is required during removal of a normal guide wire after catheterization. Gentle manipulations like pushing the guide wire inside for a few centimeters or gently twisting the wire should be attempted. In the event where the catheter has already been passed, attempts can be made to manipulate the catheter over the guide wire to negotiate the kink or both the catheter and the guide wire should be removed together. In this case, the guide wire was inserted up to 15 cm mark and the catheter was inserted up to 13 cm mark over the guide wire. In all probability, the catheter had negotiated the kinked part and an attempt should have been made to remove both the catheter and the guide wire together.
We do not feel it was prudent to insert the tissue dilator inside the vein even during the subsequent successful attempt at removal and positioning of the catheter. The right subclavian vein is at the greatest risk for such a dilator-related kinking or vessel perforation because of sharpness of the angle as it turns into the superior vena cava. 
| References|| |
Jalwal GK, Rajagopalan V, Bindra A, Rath GP, Goyal K, Kumar A, et al
. Percutaneous retrieval of malpositioned, kinked and unraveled guide wire under fluoroscopic guidance during central venous cannulation. J Anaesthesiol Clin Pharmacol 2014;30:267-9.
Oropello JM, Leibowitz AB, Manasia A, Del Guidice R, Benjamin E. Dilator associated complications of central vein catheter insertion: Possible mechanisms of injury and suggestions for prevention. J Cardiothorac Vasc Anesth 1996;10:634-7.
Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD 2 nd
. Perforation of the great vessels during central venous line placement. Arch Intern Med 1995;155:1225-8.