Placing central line, difficulty passing wire fully

[Sufenta]

I've been practicing a while, do cardiac regularly, usually lines no trouble. Today, to start off pt has BMI 50+. Not much neck but nice size right IJ, easy to needle and pass wire to 10-15 cm past tip, but at that point clearly catching/ resisting.

I typically double stick for a 15cm cvp and cordis w/ swan. I usually thread the wire to 20cm. With ultrasound, it appears at the limiting point pt has floppy valve. I twist / rotate... Nothing works. Wires come out with deformed j tips.

What would you do?
Just dilate and hope the catheter/ swan will pass even tho the wires won't? What are the chances they would tear the vein? Use the non-j tip end of the wire? I'm worried about perforation.

I went to the left side which was much smaller, and struggled some more. Hoping you guys can share advice for what to do if the wire won't go as far as I'd like, but is clearly in the vein.

Thanks

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[urge]

I've been practicing a while, do cardiac regularly, usually lines no trouble. Today, to start off pt has BMI 50+. Not much neck but nice size right IJ, easy to needle and pass wire to 10-15 cm past tip, but at that point clearly catching/ resisting.

I typically double stick for a 15cm cvp and cordis w/ swan. I usually thread the wire to 20cm. With ultrasound, it appears at the limiting point pt has floppy valve. I twist / rotate... Nothing works. Wires come out with deformed j tips.

What would you do?
Just dilate and hope the catheter/ swan will pass even tho the wires won't? What are the chances they would tear the vein? Use the non-j tip end of the wire? I'm worried about perforation.

I went to the left side which was much smaller, and struggled some more. Hoping you guys can share advice for what to do if the wire won't go as far as I'd like, but is clearly in the vein.

Thanks

I wouldn't place the line if the wire doesn't advance without too much struggling. Go to other side, subclavian, or femoral.

If you ever do lines with fluoro you would see the wire tends to do rogue things and loop upon it self even when the veins are pretty normal.

If feasible calling for portable fluoro would be the best choice.

 

[Mman]

With ultrasound, it appears at the limiting point pt has floppy valve. I twist / rotate... Nothing works. Wires come out with deformed j tips.

What do you mean a "floppy valve" on ultrasound? If you got the wire to go 10-15 cm past the skin insertion point, it's way past what you can see with the U/S probe. Or are you watching the SVC with the TEE probe while doing this?

My usual approach at that point is to just try starting over and resticking the vein. I think your wire is possibly heading up an IJ (either a U turn to go back up the same side or heading up the contralateral or maybe down the subclavian. Either that or there is something abnormal in the venous anatomy you are getting hung up on.

 

[T-burglar]

Did the wire loop back and go retrograde in the IJ? if so I guarantee it’s because the IJ was tapering to a small caliber low in the neck. The only thing you can do there is stick the IJ in long axis (And low in the neck ) with the needle directed past the narrowed length. Otherwise stick a subclavian or opposite neck .

 

[2Fast2Des]

Agree, doing lines under fluoro helps really appreciate that even with a good ultrasound image all the wonky ways the wire goes, especially coiling or wrapping around somewhere. When I did lines in IR the radiologists would use the fine micropuncture wire instead of the regular one we use for CVLs, they really help in traversing past difficult points

 

[cchoukal]

Whether the wire hangs at 10cm or 15cm is critical, as the needle ( at least ours) is 10 cm. If it’s hanging at 10 cm, then you just aren’t in the vein, if it’s hanging at 15 cm, then there is something in the van, either stenosis, or a jugular venoud valve, which do exist.

 

[leaverus]

I had a pt once similar to this tried right IJ, left IJ, left SC and then finally smooth insertion right SC. these vasculopaths often have all kinds of bizarre things going on in their veins. of course you have to be certain you haven't cause bilateral PTX....

 

[vector2]

My practice has changed dramatically with these distal stenosis since the introduction of 4-5 fr micro puncture kits. If I cant get the wire to go past 10-15cm, I stick with a MP needle, thread the small soft tip wire (if small wire wont go then abandon that vessel entirely), place the 5fr cathether, and then thread the bigger central line wire through that. Usually the MP cathether/sheath is long enough to get your J tip past the obstruction and into the distal svc.

 

[Sufenta]

Thank you all for your thoughtful responses.

When I had difficulty, I exchanged the needle for the catheter over the wire and could then fiddle more. Follow the path down the IJ and (as I do routinely) angle the probe under the clavicle, looking toward the chest. I figure I'm seeing several cm in the neck and a few more under clavicle. You are right, would be less than 15. Usually I see the wire diving. Instead I saw a complex looking valve, like perhaps more than one leaflet, although my angle is not perpendicular looking under the clavicle. I could either see the wire coiling there or it was the J of the wire.

On the left side, the struggle was different. The wires passed after hitting the small vessel. The cordis was a problem I think because I had taken too steep an angle with the needle and the vein was deep. But I understood the problems... On the right I didn't know what to do about the valve, and I was so tempted by the medium wire depth and seeing the wire in the vessel. Next time I will ask for a softer wire... Instead I had been thinking I needed a stiffer one to poke thru the valve, but was worried that would tear it too.

 

[T-burglar]

Never try to dilate and advance over a wire that doesn’t go in like butter. The list of injuries you can cause includes a couple that are life threatening and you will wish you hadn’t

 

[Drwine]

My normal practice is to put TEE probe seconds after ETT on same laryngoscopy. I have abandoned transducing Angiocath or using tubing to visually see CVP before the wire. My "platinum standard" is to watch wire enter SVC. If the wire can't get that far, fluoro is a great backup.

 

[Ronin786]

I can't think of any time that I've tried dilating/advancing a central line over a wire that didn't go smoothly and had success. Never do it anymore as a result.

 

[dabears505]

I always thought central veins had no valves. What valve were you seeing?

 

[caligas]

Faced these struggles too. My algorithm:

-pull back wire and rotate 90 degrees
-have someone pull on right arm
-pull back a bit on the needle, change the angle of the needle, reconfirm return of blood
-re stick higher or lower in neck or change sides

(Avoid steep angles. Try to hit the middle of the vein using ultrasound)

 

[DM27]

I always thought central veins had no valves. What valve were you seeing?

The internal jugular vein has a well established valve, you can seen it in some patients on neck ultrasound when you scan lower. Below that you can deal with the eustachian valve at the SVC/RA junction. The former is the one that tends to cause issues, that and some vestigial remnant/redundant smaller valves.

 

[Twiggidy]

My practice has changed dramatically with these distal stenosis since the introduction of 4-5 fr micro puncture kits. If I cant get the wire to go past 10-15cm, I stick with a MP needle, thread the small soft tip wire (if small wire wont go then abandon that vessel entirely), place the 5fr cathether, and then thread the bigger central line wire through that. Usually the MP cathether/sheath is long enough to get your J tip past the obstruction and into the distal svc.

The micropuncture can be a lifesaver, especially in stenotic veins. I'm not a huge fan of the micropuncture wire but there is a reason why many a vascular surgeon swears by them.

 

[vector2]

The internal jugular vein has a well established valve, you can seen it in some patients on neck ultrasound when you scan lower. Below that you can deal with the eustachian valve at the SVC/RA junction. The former is the one that tends to cause issues, that and some vestigial remnant/redundant smaller valves.

Remnant eustachians are at the IVC/RA junction

 

[T-burglar]

Yeah there’s no valve at the SVC RA junction. Cancers and masses and other things can create obstruction there, but the eustachian remnant isn’t there

 

[DM27]

Remnant eustachians are at the IVC/RA junction

Sorry about that, the eustachian valve was a brain fart on my end. The main valve I am talking about is the IJ valve.

Internal Jugular Valve and Central Catheter Placement | Anesthesiology | ASA Publications

 

[caligas]

bit of a necro bump but I just used the micro puncture kit for a difficult R IJ and it was fantastic.

Stuck neck with regular introducer needle and US. Small IJ but got good venous return. Wire hung up at 15 cm. Tried all the tricks, wire would not go…Placed micro wire easily through same needle. Then micro puncture carh 2.9 F. Then removed micro dilator, CVL wire went easy down this cath. Check wire with US. Good to go. MAC cath then swan normal waves.

 

[sevoflurane]

bit of a necro bump but I just used the micro puncture kit for a difficult R IJ and it was fantastic.

Stuck neck with regular introducer needle and US. Small IJ but got good venous return. Wire hung up at 15 cm. Tried all the tricks, wire would not go…Placed micro wire easily through same needle. Then micro puncture carh 2.9 F. Then removed micro dilator, CVL wire went easy down this cath. Check wire with US. Good to go. MAC cath then swan normal waves.

I use it to place IJ pacers. A little limpy, but can’t recall if i’ve ever had an issue. I don’t think so.

For access/heart cases I usually just go on the other side, but will keep this in mind next time. 👍🏽

 

[sevoflurane]

In general, I think micropunture for alines/peripheral and central access are underutilized in our field. Definitely a good trick to have up your sleeve.

 

[NicholasPavona]

If it doesn't go, force it. Works every time.

 

[Twiggidy]

bit of a necro bump but I just used the micro puncture kit for a difficult R IJ and it was fantastic.

Stuck neck with regular introducer needle and US. Small IJ but got good venous return. Wire hung up at 15 cm. Tried all the tricks, wire would not go…Placed micro wire easily through same needle. Then micro puncture carh 2.9 F. Then removed micro dilator, CVL wire went easy down this cath. Check wire with US. Good to go. MAC cath then swan normal waves.

I think the micro wire can pass through stenotic areas of the vein that may not be seen on U/S that the J-wire would otherwise have difficulty passing, especially if on visualization the IJ is already small to begin with. I don't always use it but when I'm running into problems I'll say to the nurses "Start motioning towards a micropuncture kit". Honestly, if it's good enough for vascular surgeons and the population of arteries and veins they have to access I can't turn my nose up at it.

 

[DesiredMemberName?]

bit of a necro bump but I just used the micro puncture kit for a difficult R IJ and it was fantastic.

Stuck neck with regular introducer needle and US. Small IJ but got good venous return. Wire hung up at 15 cm. Tried all the tricks, wire would not go…Placed micro wire easily through same needle. Then micro puncture carh 2.9 F. Then removed micro dilator, CVL wire went easy down this cath. Check wire with US. Good to go. MAC cath then swan normal waves.

This is my go-to when the wire won’t pass, assuming the vein otherwise looks pretty normal on US. I don’t think it’s ever failed me.

 

[Drwine]

I am a fan of the "double barrel intubation" in hearts for this reason. During induction I intubate the trachea first and then place the TEE probe seconds later on the same laryngoscopy. The micropuncture kit is a good idea but I have also used the glide wire in situations like this. Fluoro can help but much easier to see the wire on the bicaval view with the TEE. If placing a Swan, I then can watch it go into the PA or see how to manipulate it.

 

[castafari]

My normal practice is to put TEE probe seconds after ETT on same laryngoscopy. I have abandoned transducing Angiocath or using tubing to visually see CVP before the wire. My "platinum standard" is to watch wire enter SVC. If the wire can't get that far, fluoro is a

It’s a small world doc. Pretty sure you trained me in hearts 10+ years ago. Still remember you teaching me about gold (transducing), silver (ultrasound) and platinum (TEE).
It’s funny the things you remember from residency.

 

[PpfSuxTube]

Internal Jugular Valve and Central Catheter Placement | Anesthesiology | ASA Publications

It sound to me that this is the problem the 2019 op was having...

Now you need to be really careful here and know exactly what you're doing/seeing/treating.

You can always see an ijv valve on USs. If you can't it may be something else and as others have alluded to. Never ever ever dilate an ijv unless you're sure you're in. You can kill someone with an ijv laceration

Int jugular valve is common enough, around 10% of ppl have one iirc and can cause some trouble getting the wire down...

Often just using the straight end of the wire gets thru this obstruction. The nurses have a 'slippy wire' some times that works. Idk what it's called honestly, I stopped using it cause it's too cumbersome and long

Puncturing lower in the neck with the IV type catheter over needle, that comes in the kit can get thru the valve.
Very rarely you just can't get thru it at all, that happens me maybe 1 every 6 months, so then I just go to alternate sites.

About once or twice a year I'll have to use left ijv or subclavian

You must keep very high levels of suspicion if the wires not going down. These are very high stakes, I've seen ppl die from this type of situation where the wire isn't in the vein at all, thru and thru or knuckled up

 

[dchz]

I had the same issue as OP. It turns on it that the pts neck was too flexed.

I went through the whole thing with ultrasound and fluro, realizing, next time, just extend the head more, as the vein was patent on ultrasound.

My standard practice is also seeing wire in the RA with TEE. Just such a good test.

 

[urge]

Often just using the straight end of the wire gets thru this obstruction.

I would never do that. Easy to poke a hole in the vein that way. There is a reason there is a j at the front of the wire.

Indefensible if there is an issue.

 

[2buckchuck]

I would never do that. Easy to poke a hole in the vein that way. There is a reason there is a j at the front of the wire.

Indefensible if there is an issue.

There’s a specific arrow art line that comes in a big pre-package that can require you to use the straight pokey end if the vessel is too small to accommodate the J. I remember doing this one time as an ICU fellow and the rotating PGY-5 IR resident was horrified. Gave me a new respect for the J.

 

[DesiredMemberName?]

I would never do that. Easy to poke a hole in the vein that way. There is a reason there is a j at the front of the wire.

Indefensible if there is an issue.

I agree. I have done this before, and it was OK, but I wouldnt recommend it. We have micro puncture kits with the soft, flimsy wire tip that can accomplish the same thing with much less risk.

 

[Beeftenderloin]

I would never do that. Easy to poke a hole in the vein that way. There is a reason there is a j at the front of the wire.

Indefensible if there is an issue.

This is a silly take. There are different wires in different kits. Some wires have a “back end” that is straight and rigid, I wouldn’t do it with one like that. Others kits have a back end that is straight, but springy and flexible. It’s a completely reasonable approach to lead with this type/end as a rescue maneuver.

 

[DesiredMemberName?]

This is a silly take. There are different wires in different kits. Some wires have a “back end” that is straight and rigid, I wouldn’t do it with one like that. Others kits have a back end that is straight, but springy and flexible. It’s a completely reasonable approach to lead with this type/end as a rescue maneuver.

I dont think the take is silly. My assumption is that they were talking about the standard rigid wire that I’ve seen in every kit I’ve used at a dozen different hospitals.

Of course if there is a special wire with a soft, flexible tip opposite the j tip that is designed to be inserted safely, that’s fine. I’ve never seen that wire, so I assumed they were referring to the standard wire. Maybe that’s a silly assumption.

 

[Beeftenderloin]

I dont think the take is silly. My assumption is that they were talking about the standard rigid wire that I’ve seen in every kit I’ve used at a dozen different hospitals.

Of course if there is a special wire with a soft, flexible tip opposite the j tip that is designed to be inserted safely, that’s fine. I’ve never seen that wire, so I assumed they were referring to the standard wire. Maybe that’s a silly assumption.

There is no ‘standard wire’. I have seen kits with wires that have the rigid, pointy back ends. My current shops MAC introducer kits come standard with the wire with the straight, but soft and springy back end. Different kits have different wire diameters and lengths that may or may not be compatible with catheters from other kits. This is why it remains a silly statement to make globally for every CVC insertion. It’s kit dependent.

 

[DesiredMemberName?]

There is no ‘standard wire’. I have seen kits with wires that have the rigid, pointy back ends. My current shops MAC introducer kits come standard with the wire with the straight, but soft and springy back end. Different kits have different wire diameters and lengths that may or may not be compatible with catheters from other kits. This is why it remains a silly statement to make globally for every CVC insertion. It’s kit dependent.

Like I said, at a dozen different hospitals, I haven’t seen that, and the poster didn’t specify that.

Obviously if there are kits with a wire that was specifically designed to be safely used in that way, then it’s kit dependent. I don’t think anyone is trying to make a global statement to the contrary.

It’s still reasonable to warn against doing that if the wire doesn’t have a soft tip at the other end.

 

[Twiggidy]

I don’t think I’ve read a bad take. I would just say that the wires they put in the kit is the given wire for a reason. I’ve never really been a fan of them using the back end of the J wire because I just don’t want to perforate anything but that’s not to say you can’t do it.

I tend to follow the the vascular surgeons and I’ve never personally seen any of them use the flip end of the wire, so that’s why I personally don’t do it

 

[Shimmy8]

Micropuncture is a lifesaver for any type of access.

Every once in awhile a surgeon will ask for help with a port from IR due to the issues described above, and they ALWAYS come over with a glide.

 

[sanityonleave]

I'll second and third (and forth) the micropuncture kit for difficult access. I also use it for all my subclavian/fem access, and any IJ where I anticipate trouble (super high BMI, etc).

However, the MP kit may not help you if your problem is deeper - let's say you're coming from the left in a patient with an ICD etc. Sometimes the MP sheath will get around the bend from the LIJ to the innominate but sometimes it's too prox (esp in a big patient) and you're left with the same issue.

If your wire is hanging up deep (i.e., the problem is not that you're not in the vein or the wire won't get into the vein), I highly recommend using some sort of hydrophilic guidewire - ideally with fluoroscopy. We stock a "short" (approx 50cm) hydrophilic J tip 0.035" wire made by a company named Argon which is nice because it's not the full 150cm that the glide / most of the surgical working wires are -- but those work well too, you just have to be careful you don't contaminate your wire.

Also fluoroscopy is key. Anyone with likely very difficult access (heart txp who needs left sided access, RSCV swan, VV cannulation) I tend to call for fluoro right away. There's no substitute for being able to see your wire (or your PAC, if that's what you're trying to get in).

One thing I see from anesthesiologists a lot is people tend to re-stick when they are having trouble - which sometimes works, but if the problem is not your access re-accessing the patient may not help and increases your risk of complications.

 

[caligas]

I'll second and third (and forth) the micropuncture kit for difficult access. I also use it for all my subclavian/fem access, and any IJ where I anticipate trouble (super high BMI, etc).

However, the MP kit may not help you if your problem is deeper - let's say you're coming from the left in a patient with an ICD etc. Sometimes the MP sheath will get around the bend from the LIJ to the innominate but sometimes it's too prox (esp in a big patient) and you're left with the same issue.

If your wire is hanging up deep (i.e., the problem is not that you're not in the vein or the wire won't get into the vein), I highly recommend using some sort of hydrophilic guidewire - ideally with fluoroscopy. We stock a "short" (approx 50cm) hydrophilic J tip 0.035" wire made by a company named Argon which is nice because it's not the full 150cm that the glide / most of the surgical working wires are -- but those work well too, you just have to be careful you don't contaminate your wire.

Also fluoroscopy is key. Anyone with likely very difficult access (heart txp who needs left sided access, RSCV swan, VV cannulation) I tend to call for fluoro right away. There's no substitute for being able to see your wire (or your PAC, if that's what you're trying to get in).

One thing I see from anesthesiologists a lot is people tend to re-stick when they are having trouble - which sometimes works, but if the problem is not your access re-accessing the patient may not help and increases your risk of complications.

I’ve done a zillion lines safely, mostly using US, some TEE, never floro. So what would I look for on floro to rule out the wire being somewhere bad?

 

[Twiggidy]

I’ve done a zillion lines safely, mostly using US, some TEE, never floro. So what would I look for on floro to rule out the wire being somewhere bad?

I agree with you and the other post. If you’re in Cath lab or a hybrid room I see no problem in firing up the flouro, if you’re in a regular OR that could be a huge hassle. If I’m in a CV case in the OR the TEE will be my fail safe or quite frankly it may be time for groin lines. If it’s a non-CV case and it’s a struggle then it becomes a risk vs benefit discussion and if central access is absolutely needed then again probably a groin line if im struggling with the “cleaner” lines.

The further away from working with a cv surgeon-type the more conservative I get with central lines because a cv surgeon can bail me out if I put a needle/catheter in the wrong place more than a gyn or podiatrist

 

[Radetzky]

If you put longtitudinal tension on the wire the J tip unfurls and then returns to its usual configuration once you let the tension go.

 

[urge]

There is no ‘standard wire’. I have seen kits with wires that have the rigid, pointy back ends. My current shops MAC introducer kits come standard with the wire with the straight, but soft and springy back end. Different kits have different wire diameters and lengths that may or may not be compatible with catheters from other kits. This is why it remains a silly statement to make globally for every CVC insertion. It’s kit dependent.

Have never seen it but if that’s the case, it’s reasonable.

 

[sanityonleave]

I’ve done a zillion lines safely, mostly using US, some TEE, never floro. So what would I look for on floro to rule out the wire being somewhere bad?

There are a number of things but the basic gist is that fluoro allows you to see exactly where the wire is so when you're having trouble passing it you can see where things are hanging up and adjust accordingly.

A couple recent examples:

- LIJ PAC placement for a patient with a thrombosed RIJ and a bunch of ICD leads. Wire wouldn't go past 10cm without significant resistance. We brought in fluoro and the wire was curling in the IJ/innom junction and/or trying to go down the left arm. We switched to a glidewire and were able to get the wire down to the RA
- PAC placement in a patient with an RVAD. Significant resistance trying to advance the PAC (from the LSCV since the RVAD was in the RIJ). We shot fluoro and the PAC was in the right position but couldn't pass the RVAD down the SVC with the balloon inflated. Dropped the balloon and the PAC advanced into the SVC, then inflated the balloon to get it across the tricuspid valve. We ran into the same problem in the PA - with the balloon up the catheter wouldn't advance past the RVAD - so dropped the balloon to get past the RVOT and then reinflated to navigate the PA bifurcation.

I think for the vast majority of CVLs, it's not necessary - but if you're doing complex patients and cases, it's a great adjunct to be facile with.

 

[Iso4ane]

I’ve had wires hang up at or near the clavicle, which is consistent with the resistance at 10-15cm. A little inward/downward pressure at the clavicle can help the wire pass in these situations. Of course, having flouro or TEE available is useful to make sure you didn’t pass down the arm or anything.

 

[caligas]

I’ve had wires hang up at or near the clavicle, which is consistent with the resistance at 10-15cm. A little inward/downward pressure at the clavicle can help the wire pass in these situations. Of course, having flouro or TEE available is useful to make sure you didn’t pass down the arm or anything.

I don’t find the clavicle moves much when I press on it

 

[deleted545787]

I've been practicing a while, do cardiac regularly, usually lines no trouble. Today, to start off pt has BMI 50+. Not much neck but nice size right IJ, easy to needle and pass wire to 10-15 cm past tip, but at that point clearly catching/ resisting.

I typically double stick for a 15cm cvp and cordis w/ swan. I usually thread the wire to 20cm. With ultrasound, it appears at the limiting point pt has floppy valve. I twist / rotate... Nothing works. Wires come out with deformed j tips.

What would you do?
Just dilate and hope the catheter/ swan will pass even tho the wires won't? What are the chances they would tear the vein? Use the non-j tip end of the wire? I'm worried about perforation.

I went to the left side which was much smaller, and struggled some more. Hoping you guys can share advice for what to do if the wire won't go as far as I'd like, but is clearly in the vein.

Thanks

I usually attempt to contact with the IJ as distal as I can behind the clavicle and if I encounter a valve I pierce/bypass it with the needle and pass the wire.

 

[nimbus]

I usually attempt to contact with the IJ as distal as I can behind the clavicle and if I encounter a valve I pierce/bypass it with the needle and pass the wire.

No problems visualizing the wire distally when you do that? Can you see the valve when you pierce it with the needle?

 

[DrOwnage]

I know everyone is writing these tips and tricks but honestly I don’t encounter these problems that often. I don’t do a ton of CVCs but I’ve probably put in 150 over the last 4 years. The main thing I do different is I spend extra time walking my needle into the IJ slowly at a 30-45 degree angle, making sure the wire gets inserted with the needle flush in the middle of the lumen, not near the top or bottom. I find none of my colleagues do this, they just use the u/s to find the needle trajectory/tenting and once they get blood they start inserting. Or when it doesn’t thread they move the needle to restablish flow rather than restabbing. Not saying my **** don’t stink but I really think this makes the biggest difference in preventing the wire from sneaking around corners you don’t want.

 

[Hoya11]

I know everyone is writing these tips and tricks but honestly I don’t encounter these problems that often. I don’t do a ton of CVCs but I’ve probably put in 150 over the last 4 years. The main thing I do different is I spend extra time walking my needle into the IJ slowly at a 30-45 degree angle, making sure the wire gets inserted with the needle flush in the middle of the lumen, not near the top or bottom. I find none of my colleagues do this, they just use the u/s to find the needle trajectory/tenting and once they get blood they start inserting. Or when it doesn’t thread they move the needle to restablish flow rather than restabbing. Not saying my **** don’t stink but I really think this makes the biggest difference in preventing the wire from sneaking around corners you don’t want.

I use the catheter always to thread the wire.
I also find these tips and tricks interesting, and I have heard most before from colleagues, but once i put the catheter in and the wire doesnt go easily, forget about it I try another site. I want the whole process to go smoothly. I'm not going to sit there and get fancy with backwards wires, Im just trying another site until there is no doubt in my mind its going in correctly.