Transjugular central venous catheter guidewire embolism to venoarterial extracorporeal membrane oxygenation cannula
Article information
A multimorbid 69-year-old gentleman presented with non-ST elevation myocardial infarction associated with bradyarrhythmias. Following pacemaker insertion, he developed an asystolic cardiac arrest requiring prolonged cardiopulmonary resuscitation before venoarterial extracorporeal membrane oxygenation (VA ECMO) support was established.
A right internal jugular central venous catheter (CVC) placed under ultrasound guidance in the intensive care unit was complicated by a lost guidewire during skin dilation. Pertinent VA ECMO settings included: pump speed of 3,600 rotations per minute, blood flow rate of 3.9 L/min, and venous circuit pressure of –71 mm Hg.
Immediate neck ultrasound, chest, abdominal, and pelvic X-ray (Figure 1A-C) failed to reveal the guidewire. It was found hours later in the VA ECMO access cannula tubing (Figure 1D) close to the pump (Figure 1E, Supplementary Video 1), confirming our suspicion of an entrained guidewire within the circuit. Nil changes in venous access cannulae parameters were noted. It was successfully removed later with a circuit change.
(A) The chest X-ray demonstrates a right internal jugular central venous catheter, along with an automated implantable cardioverter-defibrillator. (B, C) The right femoral venous access cannula is visible along the course of the inferior vena cava to the right femoral vein. The guide wire was not visible in any of these bedside X-ray imaging. (D) On closer inspection, the guidewire (arrow) was barely visible in the venous access cannula. (E) The guidewire (arrow) was subsequently found at the terminal end of the cannula following venous drainage upon preparation for cannula exchange.
Transient ECMO flow reduction with diligent guidewire control during CVC insertion in a VA ECMO patient [1] is vital due to the negative caval pressure. Maintaining continuous wire contact or clamping the guidewire [1,2] to the sterile drape offers a simple solution to prevent catastrophic complications [3,4].
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CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
FUNDING
None.
ACKNOWLEDGMENTS
Patient consent was waived for this clinical imaging report.
We thank Dr. Amy Sanguesa FCICM (Intensive Care Unit, Royal Adelaide Hospital) and Mr. Jason Quinn (Picture Archiving and Communication Systems Manager, Royal Adelaide Hospital) for procuring the clinical and radiological images, respectively.
AUTHOR CONTRIBUTIONS
Conceptualization: NAD, MF. Data curation: NAD, SD. Project administration: NAD. Writing–original draft: NAD. Writing–review & editing: all authors.
SUPPLEMENTARY MATERIALS
Supplementary materials can be found via https://doi.org/10.4266/acc.2023.01270.