Complications of guiderwire during catheter insertion

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. Guidewire – induced asystole
A case report
Dr. Ramadan Arafa; MD, FRCPI
Physician and Nephrologist
Fujairah hospital

3. Vascular accesses for Hemodialysis are:
AV fistula, an AV graft, and a venous catheter

4. Recommendations
Renal Association 2011 guidelines
• Preferred type of vascular access
We recommend that any individual who
commences haemodialysis should do so with an
AVF as first choice, an AV graft as second choice, a
tunneled venous catheter as third choice and a non
tunneled catheter as an option of necessity. (1B)

5. Types of hemodialysis catheter

6. Catheter Kit

7. Tunneled Catheter Kit

8. Venous approach

10. Femoral vein catheter

11. • What to do if the patient has IJV,
Subclavian and femoral vein
thrombosis ???

12. Transhepatic vein cannulation

13. • 23 patients required a single transhepatic access
procedure.
• Technical success was achieved in 22 procedures.
• Functionality success was achieved in 20 patients.
Functionality failure occurred in 3 patients.
• The trans-hepatic catheters stayed in place
between 90 and 300 days. Complications occurred
in 14 patients (3 major + 11 minor).

14. Prosthetic axillary- axillary AVG
• Prosthetic axillary-axillary arm loop AVG for
hemodialysis (Hossam El Wakeel et al; 2013):
– The primary patency rate at 1 year was 63.4% and at 2
years was 21.8%. The secondary patency rate at 1 year
was 75.6% and at 2 years was 43.5%.
• AVG with outflow in the proximal axillary vein
(Teruya et al 2009):
– Patency rates were 78%, with mean follow-up of 16
months.

15. Translumbar inferior vena cava catheter
• Initially used for post bone marrow
transplantation
• Later was used as a vascular access in ESRD
patients for hemodialysis with difficult access
• A complication specific to placement of IVC
hemodialysis catheters is migration of the
catheter into the subcutaneous soft tissues,
retroperitoneum, or iliac veins
Alain Guy Assounga et al; SAMJ 2008
Goupta et al; J Am Soc Nephrol. 1995
Rajan et al; Radiographics 1998

16. Transthoracic SVC catheterization
• Transthoracic permanent catheter placement
is an appropriate alternative for patients in
whom traditional venous access sites are no
longer available.
Wellons et al; Journal of Vascular Surgery 2005

17. Saphenofemoral AVF
• SFAVF is an adequate alternative for patients
without the possibility for other access in the
upper limbs, allowing efficient dialysis with
good long-term patency with a low
complication rate.
Correa et al, BMC Surgery201010:28

18. Cumulative patency curve in 59 months (±5.49%; N = 51).
Correa et al, BMC Surgery201010:28

19. Cumulative patency curve in 59 months excluding primary failures
(±6.36%; N = 42).
Correa et al, BMC Surgery201010:28

20. General rules

21. • If the patient has a coagulopathy, the femoral
or external jugular veins are the preferred
first site, and the internal jugulars are the 2nd
choice.
• Relative contraindications for subclavian
insertion include bilateral pulmonary
pathology, high-pressure mechanical
ventilation, and altered local anatomy.

22. • If one attempt at subclavian insertion has been
unsuccessful, an attempt on the opposite
subclavian is relatively contraindicated because
of the risk of bilateral pneumothorax
• If a unilateral pulmonary disease is present, SC
and IJ insertion should be done on the same
side as the affected lung.

23. •Avoid putting lines close to contaminated areas (eg
burns, infected tracheostomy site)
• Inexperienced operators are only allowed 2 passes
for the vein at a particular site before requesting
help
•Only insert lines with the number of lumens that
are required e.g patients requiring long-term
venous access for antibiotics only require a single
lumen

24. • K/DOQI Guidelines state that subclavian
vein (SCV) catheterization should be
avoided in patients with ESRD because of
the risk for central venous stenosis, with
subsequent loss of the entire ipsilateral arm
for vascular access.

25. • Both the National Institute of Clinical
Excellence in the UK and the USA KDOQI
recommend ultrasound guidance as the
preferred method for insertion of central
venous catheters into the internal jugular
vein

26. Documentation
The following must be legibly documented in
patient notes:
• Date, time
• Operator(s) and his / her assistants.
• Form of anasthesia or use of analgesia
• Line type and indication for use
• Insertion site
• Complications recognized during insertion,
including arterial puncture
• CXR result

27. Risks and Precautions

28. EJV approach for perm. Cath insertion
Ali Akbar et al; Adv Biomedical
Research J 2014

30. Complications decreased over the time
from 18% to 6% after 6 months

31. Guidewire – induced asystole
A case report

32. • Mr. K A is a 72 year old gentleman, has HTN, DM II,
PVD and ESRD.
• He was admitted with poor oral intake, persistent
vomiting and shortness of breath with raised
serum creatinine and urea. His serum potassium
was 5.4 mmol/L and bicarbonate was 23 mmol/L.
He was planned for long-term regular hemodialysis
through a right internal jugular venous access till
creation of arteriovenous fistula.

33. • He had repeated episodes of acute pulmonary
edema associated with gradual progressive
worsening of renal function which required
hemodialysis.
• ECG showed LBBB with QRS duration of 140 ms.
• Echocardiography: severe LV dysfunction (LV EF
28%) with global hypokinesia and evidence of
dysynchrony.

34. Baseline ECG - LBBB

35. • After threading the guidewire in the needle and
advancing it in for about 35-40 cm, the patient
suddenly collapsed and the monitor showed
asystole. The guidewire was pulled immediately
out, the procedure was terminated and
cardiopulmonary resuscitation was initiated. He
was managed with chest compression, IV
adrenaline, atropine, sodium bicarbonate, calcium
gluconate and bag breathing

36. • He had alternating episodes of asystole followed
by wide complex bradycardia with RBBB pattern
with left axis deviation (LAHB) at a rate of 36 – 48
beats/minute. Appropriate resuscitation was done
and continued for approximately 2 hours.
• Transcutaneous pacing was not effective in
capturing. Hence, a temporary trans-venous
pacemaker was inserted and he was revived.

37. Post CPR ECG - LAFB

38. • He regained his consciousness fully without
neurologic deficit.
• Three days later, the temporary pacemaker
was changed to a Dual chamber CRT
Defibrillator Device with permanent pacing.
Follow up ECG later showed paced rhythm.

39. Post pacing ECG

40. CXR post PPM insertion

41. Guidewire – induced arrhythmia
• Guidewire – related cardiac complications are
rare. The commonest arrhythmias noticed are
premature atrial and ventricular contractions, and
supraventricular tachyarrhythmia.
• The commonest cardiac conduction abnormalities
are RBBB, LAHB and very rarely asystole.
• Complete heart block (CHB) is a well-documented
complication known to occur during
catheterization of one side of the heart when
contralateral bundle branch block pre-exists
Jain et al; International journal of Case Reports and Images, vol. 2, No. 4, April 2011.
Eissa NT, Kvetan V. Anesthesiology 1990; 73: 772-4

42. • Unnikrishnan documented CHB in a patient with
pre-existing LBBB during central venous cannula
insertion. RBBB may occur in 5% of cases while
CHB may occur in 23% of cases with pre-existing
LBBB.
• In published cases of guide wire – induced CHB, it
was transient and most of patients recover
without the need for permanent pacing.
Unnikrishnan et al. British Journal of Anaesthesia, 2003, Vol. 91, No. 5 747-749
D. Morris et al; Archives of Internal Medicine ,vol.147,no.11,pp.2005–2010,1987

43. • In our case the patient has asystole which
alternates with severe bradyarrhythmia and left
anterior fascicular block pattern. He did not
respond to immediate measures of atropine,
adrenaline or transcutaneous pacing. He was
revived only with transvenous pacing.

44. • The pathophysiology of CHB in patients with pre-
existing LBBB is not clear but it may be due to
direct impingement of the catheter up on right
bundle branch. Fascicular block may be due to
longitudinal dissociation of fibres in the bundle of
His but the exact proven mechanism is still
unknown.
• Careful insertion of guidewire to less than 22 cm
decreases the incidence of complications by 70%.
So, it is better to consider the safe limit up to 18
cm
Jain et al; International journal of Case Reports and Images, vol. 2, No. 4, April 2011.
Eissa NT, Kvetan V. Anesthesiology 1990; 73: 772-4
Wani et al; Case Reports in Critical Care, Volume 2016, Article ID 9531210,

45. • The risk factors for guidewire – induced
arrhythmia are: height less than 170 cm, female
gender, the use of rigid guide wire and advancing
the guidewire more than 20 cm. The risk of
asystole is higher if the patient has preexisting left
bundle branch block.
• Some authors suggest using a prophylactic
temporary trans-venous pacemaker in high risk
patients because of the risk of CHB, while others
argue against it because of low incidence of this
complication and need for care during GW
insertion in patient with preexisting blocks.
Lee et al; J Clin Anesth. 1996 Aug;8(5):348-51.

46. Guidewire complications
Geeta et al; Indian J Crit Care Med. 2014
Dec; 18(12): 831–833.

47. Srivastav et al; J Surg Tech Case Rep. 2013
Jul-Dec; 5(2): 78–81.

48. Intracardiac guidewire for 14 years
Klaus Reynen N Engl J Med 1993;
329:970-971

49. Other catheter – related
complications

50. 1. Bleeding:
Check the clotting screen on the day of insertion.
CVC insertion should be postponed (or done by
experienced clinicians) if the platelet count is <
50,000 or the INR is > 1.5.
2. Arterial puncture
Stop procedure and compress the site for 10
minutes by the clock (better to use US-guided
insertion)
3. Air embolism
Patient should be lying head down -15 to -20°
during SC or IJ insertion. Keep the needle hub and
catheter lumens as close to patient skin as possible.

51. Risks and …. continue
4. Break in sterile technique
• Re-gown if required. Replace any contaminated
equipment before continuing with the procedure
5. Pneumothorax
• If patient is at high risk of pneumothorax
because of lung hyper-expansion, the IJ site is
preferable. Check CXR post-insertion (SC or IJ)

52. Risks and …. continue
7. Malposition
• Check CXR post-insertion (SC and IJ only).
• Catheter tip should lie in the lower SVC
8. Thoracic duct damage
• Avoid the LIJ or LSC site if possible
9. Catheter-induced thrombosis
• Limit insertion attempts to 2 for inexperienced
clinicians
• Tip of SC or IJ CVC should lie in the lower SVC
• Any femoral CVC must be removed after 6 days
regardless of the clinical situation.

53. Risks and …. continue
10. Laryngeal injury

54. Risks and …. continue
12. Catheter dysfunction:
• Kinked Catheter
• Catheter Tip in Azygos Vein
• Fibrin Sheath Formation
• Intraluminal Thrombus
• Exposed Cuff
• Catheter – related infection

55. 12- Catheter – related infection

56. What are the interventions for CRI ?
1. Surveillance and data feed back
2. Chlorhexidine for skin antisepsis: during catheter
insertion and during dressing changes
3. Hand hygiene audits
4. Catheter care and access care observations
5. Scrub the hub
6. Patient education and engagement
7. Staff education and competency
8. Catheter reduction
9. Antimicrobial ointment or chlorhexidine sponge at
catheter exit site

57. Treatment of infection
• 7.4.1 Catheter exit-site infections, in the absence
of a tunnel infection, should be treated with
topical and/or oral antibiotics, ensuring proper
local exit-site care. In general, it should not be
necessary to remove the catheter.
• 7.4.2 If a patient with bacteremia is afebrile
within 48 hours and is clinically stable, catheter
salvage might be considered by using an
interdialytic antibiotic lock solution and 3 weeks
of parenteral antibiotics in appropriate situations.
A follow-up blood culture 1 week after
completion of the course of antibiotics should be
performed.

58. Treatment of infection … cont’d
• 7.4.3 Antibiotic lock with antibiotic to which the
organism is sensitive is indicated when follow-up
cultures indicate reinfection with the same
organism in a patient with limited catheter sites.
• 7.4.4 Short-term catheters should be removed
when infected. There is no conclusive evidence to
support a rationale for scheduled replacement
except for those in the femoral area.
KDIGO guidelines 2006

59. Points for discussion
1. Prophylactic vancomycin injection?
2. If yes; before or after the procedure?
3. If No; is it absolutely contraindicated?
4. Thrombolytic therapy for possible infected
catheter?
5. Thrombolytic therapy for AVG thrombosis: what
is your experience?
6. HIV cases: what is the preferred approach?

63. Thank you

64. Pneumothorax

65. Malposition

66. Kinked Catheter

67. Catheter Tip in Azygos Vein
Catheter tip
Catheter tip

68. Fibrin Sheath Formation

69. Intraluminal Thrombus

70. Exposed Cuff

71. Tunnel Infection
Exit Site Infection
Catheter – related infection