Retained guidewire

[Cowboy95]

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Hello all,
I am a medical student and was observing a mediastinal hematoma evacuation on a pt who had recently had a LVAD placed. While inserting a right IJ central line, the anesthesia resident accidentally inserted the guidewire along with the catheter, and proceeded to suture the line and aspirate/flush all ports before realizing what had happened.
After informing the surgeon and confirming via chest x-ray that the wire was still partially in the catheter, the surgeon came up with a plan for removing the wire. This is where my memory gets foggy as I wasn't allowed to get a good view of this portion. From what I understand, the surgeon ordered a C-arm to be brought in and under fluoroscopic guidance made an incision in the rt neck, performed a cut-down of the SVC, placed a clamp on the catheter/wire, and had it all removed at once by the anesthesiologist.
Does this sound correct/plausible?
How would you control bleeding when performing a cut-down of a large vein like this?
What type of clamp could be used for this? I'm assuming it would have to be rather small, correct?
What is used for hemostasis after a cut-down? Is just pressure applied?
Since he was reopening the sternal incision to perform the hematoma evacuation, why would he need to make a neck incision? Couldn't he access the vein through the sternotomy?
What other options are available to remove a retained guidewire? Interventional radiology through the groin?

Thanks for all your help. I'd really like to understand the details of what happened but I don't have much context to go by and cannot get in touch with the surgeon to ask questions.

 

[mimelim]

Most likely they did not cut down on the SVC. Making a 'neck' incision to access the SVC is asking for trouble. They likely cut down on the IJ or maybe the brachiocephalic vein. Accessing the SVC surgically to remove a guidewire that is still in either the IJ or BC is unnecessary and potentially more harmful to the patient. It would be much easier to remove the wire from it's most distal point than from mid-way along the wire and would limit proximal manipulation which can harm the vessel.

I'm not sure what you mean by "placed a clamp on the catheter/wire and had it removed at once" Do you mean that they clipped it externally and then pulled through the sub-q with the clip on the outside? Personally, I would use my c-arm to locate where the wire was, clamp the wire in the catheter, cut the catheter distal to my clamp and extract the wire/catheter.

You control venous bleeding in a variety of ways. Manual pressure with your hand, sponge stick, peanut, lap, etc is typically the first maneuver. Even in torrential Liver/IVC/iliac bleeding, simply packing with lap pads will stop bleeding. If you avulse a small branch, a right angle for control + silk tie will work. Alternatively medium clips are a good bet. For inadvertent entry/injury prolene suture is generally the preferred method of closure.

I would use a medium/large clamp to make sure I don't lose the wire. I might even use two. But, typically a hemostat or tonsil will work just fine. Most catheters are pretty easy to compress with either.

 

[deleted547339]

Most likely they did not cut down on the SVC. Making a 'neck' incision to access the SVC is asking for trouble. They likely cut down on the IJ or maybe the brachiocephalic vein. Accessing the SVC surgically to remove a guidewire that is still in either the IJ or BC is unnecessary and potentially more harmful to the patient. It would be much easier to remove the wire from it's most distal point than from mid-way along the wire and would limit proximal manipulation which can harm the vessel.

I'm not sure what you mean by "placed a clamp on the catheter/wire and had it removed at once" Do you mean that they clipped it externally and then pulled through the sub-q with the clip on the outside? Personally, I would use my c-arm to locate where the wire was, clamp the wire in the catheter, cut the catheter distal to my clamp and extract the wire/catheter.

You control venous bleeding in a variety of ways. Manual pressure with your hand, sponge stick, peanut, lap, etc is typically the first maneuver. Even in torrential Liver/IVC/iliac bleeding, simply packing with lap pads will stop bleeding. If you avulse a small branch, a right angle for control + silk tie will work. Alternatively medium clips are a good bet. For inadvertent entry/injury prolene suture is generally the preferred method of closure.

I would use a medium/large clamp to make sure I don't lose the wire. I might even use two. But, typically a hemostat or tonsil will work just fine. Most catheters are pretty easy to compress with either.

What sort of suture would you use for a bleeding dialysis access?

 

[mimelim]

What sort of suture would you use for a bleeding dialysis access?

Assuming we are talking about the typical, extended bleeding after dialysis or rupture of thinning area overlying aneurysmal degeneration of access... The correct answer is whatever you have lying around in the 3-0 to 5-0 range. Personally I prefer monofilaments with a reverse cutting needle. I always have 4-0 prolene in my white coat for this specific purpose. I think the take home point with bleeding accesses however is that a hemostasis stitch for bleeding is a temporary fix. Every single one of those patients should have their access evaluated. If there is thinning of the skin, even if the bleeding is controlled with a suture, they should not be discharged and should be evaluated expeditiously by a surgeon. We lose on average one patient a year from exsanguination secondary to AVF or AVG rupture.

But to answer your question specifically, most people will use nylon or prolene.

 

[deleted547339]

Assuming we are talking about the typical, extended bleeding after dialysis or rupture of thinning area overlying aneurysmal degeneration of access... The correct answer is whatever you have lying around in the 3-0 to 5-0 range. Personally I prefer monofilaments with a reverse cutting needle. I always have 4-0 prolene in my white coat for this specific purpose. I think the take home point with bleeding accesses however is that a hemostasis stitch for bleeding is a temporary fix. Every single one of those patients should have their access evaluated. If there is thinning of the skin, even if the bleeding is controlled with a suture, they should not be discharged and should be evaluated expeditiously by a surgeon. We lose on average one patient a year from exsanguination secondary to AVF or AVG rupture.

But to answer your question specifically, most people will use nylon or prolene.

Thanks. I'm EM and work somewhere with vascular readily available, but moonlight in a little ED where I'm pretty sure there's not a vascular surgeon within an hour. This came up the other day. Thankfully, it stopped bleeding with a little focal pressure, but it made me realize that I'm not sure what type of stitch would be ideal if I had to place on. Definitely would ship this if I had to place a suture.

Thanks again.

 

[mimelim]

Thanks. I'm EM and work somewhere with vascular readily available, but moonlight in a little ED where I'm pretty sure there's not a vascular surgeon within an hour. This came up the other day. Thankfully, it stopped bleeding with a little focal pressure, but it made me realize that I'm not sure what type of stitch would be ideal if I had to place on. Definitely would ship this if I had to place a suture.

Thanks again.

Also, I typically do a figure of 8 or u stitch. Just be sure to get healthy tissue because if it is infected and the stitch pulls through, you may have a liter of blood/min hitting you.

 

[Apollyon]

you may have a liter of blood/min hitting you.

So it will stop in 5 or so minutes, then? Score!

 

[ACSurgeon]

Thanks. I'm EM and work somewhere with vascular readily available, but moonlight in a little ED where I'm pretty sure there's not a vascular surgeon within an hour. This came up the other day. Thankfully, it stopped bleeding with a little focal pressure, but it made me realize that I'm not sure what type of stitch would be ideal if I had to place on. Definitely would ship this if I had to place a suture.

Thanks again.

Also, it's helpful to know where the arterial and venous sides of the AVF are; this is more complicated with leg transposition access. Putting pressure on the arterial and venous sides will occlude inflow and outflow thereby stopping the hemorrhage so that you can see the hole and put your stitch(es).

 

[mimelim]

So it will stop in 5 or so minutes, then? Score!

I was reading vascular lab studies last night (while at a conference, don't get me started...) and had an AVF at 5.3L/min. I do a lot of dialysis access research and that is new high (previous was 4.9L/min). So... Maybe even 1 minute 😉. My division chief is very fond of saying, "all bleeding eventually stops."

Also, it's helpful to know where the arterial and venous sides of the AVF are; this is more complicated with leg transposition access. Putting pressure on the arterial and venous sides will occlude inflow and outflow thereby stopping the hemorrhage so that you can see the hole and put your stitch(es).

+1000

Most bleeding can be controlled with one finger in the right place. Rarely is that finger over the hole where the blood is coming from. Knowing where the inflow and outflow are is critical. And if there is any question, use the freakin sonosite. It isn't that complicated.

 

[VisionaryTics]

Also helpful for bleeding from free-flaps. Knowing where they plugged in the anastomoses helps direct the pressure...

I think our free flap surgeons would murder a resident who held pressure on the anastomosis. Better to let the patient bleed out than let the flap go unperfused.

 

[badasshairday]

What other options are available to remove a retained guidewire? Interventional radiology through the groin?

Thanks for all your help. I'd really like to understand the details of what happened but I don't have much context to go by and cannot get in touch with the surgeon to ask questions.

Not sure about the details of what happen. But if the guide wire were lost, ie. if the anesthesiologist placed in the catheter and could not retrieve the wire you may be able to clamp down on the external portion of the catheter and wire with a kelly and try to remove both the wire and catheter as a unit. If the guide wire was inserted into the catheter and lost in the central veins it could migrate to the right heart and a pulmonary artery. If that did happen, IR could retrieve by accessing the IJ or femoral vein to insert a catheter with a loop/lasso to retrieve it from the central veins, heart, or pulmonary artery branch.

 

[Fab5Hill33]

+1. The incision/cut down seeems unnecessarily aggressive... but I don't know all the nuances of the situation. IR is the go to for foreign body retrievals at my hospital.

Not sure about the details of what happen. But if the guide wire were lost, ie. if the anesthesiologist placed in the catheter and could not retrieve the wire you may be able to clamp down on the external portion of the catheter and wire with a kelly and try to remove both the wire and catheter as a unit. If the guide wire was inserted into the catheter and lost in the central veins it could migrate to the right heart and a pulmonary artery. If that did happen, IR could retrieve by accessing the IJ or femoral vein to insert a catheter with a loop/lasso to retrieve it from the central veins, heart, or pulmonary artery branch.

 

[deleted547339]

Not sure about the details of what happen. But if the guide wire were lost, ie. if the anesthesiologist placed in the catheter and could not retrieve the wire you may be able to clamp down on the external portion of the catheter and wire with a kelly and try to remove both the wire and catheter as a unit. If the guide wire was inserted into the catheter and lost in the central veins it could migrate to the right heart and a pulmonary artery. If that did happen, IR could retrieve by accessing the IJ or femoral vein to insert a catheter with a loop/lasso to retrieve it from the central veins, heart, or pulmonary artery branch.

As an intern, I did this. I started to advance the catheter and lost hold of guide wire (was holding it between the catheter and skin). The back of the guidewire wasn't out of the back port. I took the needle drivers, clamped the catheter at the skin and withdrew it all as a unit. Thankfully, no lost guide wire.