To the Editor:--Although many complications of central venous catheterization, including fragmentation of a guidewire with pulmonary artery embolism, have been published, [1,2]intravascular migration of an entire guidewire has not been reported.
A 69-yr-old woman underwent elective abdominoperineal surgery for advanced rectal carcinoma. After induction of anesthesia, an introducer needle attached to an Arrow Raulerson Syringe was inserted into the right jugular vein, followed by insertion of a J-tipped spring guidewire (0.89 mm in diameter, 60 cm in length) through the hole in the rear of the Raulerson Syringe plunger to a depth of 30 cm. After removal of a dilator, a 7-Fr double-lumen central venous catheter (CVC; Arrow International, CS-17702-E, Reading, PA) was inserted via the right jugular vein over the guidewire to a depth of approximately 12 cm. The CVC appeared to be inserted uneventfully, and both loss of the guidewire and abnormal findings on a chest radiograph taken 20 min after completion of the surgery went unnoticed (Figure 1).
Figure 1. Chest radiograph taken 20 min after completion of the surgery shows a looped metallic density extending from the lower part of the cardiac silhouette to the right subdiaphragmatic region (arrows).
Figure 1. Chest radiograph taken 20 min after completion of the surgery shows a looped metallic density extending from the lower part of the cardiac silhouette to the right subdiaphragmatic region (arrows).
The postoperative course was uneventful, and the patient remained asymptomatic. On a chest radiograph taken on the 56th postoperative day, a metallic density forming loops in the cardiac silhouette was noted (Figure 2). The computed tomograph revealed the intravascular wirelike foreign body with both free ends in the hepatic vein and loops in the right pulmonary artery through the right intracardiac chambers.
Figure 2. Chest radiograph taken on the 56th postoperative day shows a metallic density forming loops in a cardiac silhouette (arrows).
Figure 2. Chest radiograph taken on the 56th postoperative day shows a metallic density forming loops in a cardiac silhouette (arrows).
On the 64th postoperative day, with informed consent, a 6-Fr pigtail catheter was inserted via the right femoral vein to remove the foreign body under fluoroscopic nonsurgical technique. [2]The right pulmonary arterial and intracardiac portions of the foreign body were easily dislodged into the inferior vena cava (IVC) by caudad traction of a part of the foreign body. This technique failed to remove the foreign body from the IVC, because both free ends were fixed hard to the hepatic venous wall. A retrieval catheter with forceps at the tip was inserted, which enabled us to grasp a portion of the foreign body and remove it entirely from the IVC. The foreign body was confirmed to be identical in length to an entire guidewire. Cardiac dysrhythmias and signs and symptoms indicative of pulmonary embolism did not develop throughout the postoperative course.
In conclusion, guidewire retrieval is a crucial step in a catheterization technique wherein a catheter is inserted over a guidewire.
Satoshi Akazawa, M.D., Associate Professor, Department of Anesthesiology.
Yasushi Nakaigawa, M.D., Instructor, Department of Anesthesiology.
Kunihisa Hotta, M.D., Resident, Department of Anesthesiology.
Reiju Shimizu, M.D., Professor and Chairman, Department of Anesthesiology.
Hiroshi Kashiwagi, M.D., Research Fellow, Department of Surgery.
Khoji Takahashi, M.D., Instructor, Department of Radiology, Jichi Medical School, Minamikawachi-machi, Kawachi-gun, Tochigi-ken, 329–04, Japan.
