Man With Acute Gastrointestinal Bleed
Article Outline
[Ann Emerg Med. 2008;52:764.]
A 60-year-old man with a history of deep venous thrombosis status post–inferior vena cava filter placement presented with acute gastrointestinal bleeding requiring insertion of a central subclavian catheter with a standard-length guidewire and insertion kit. During placement, the guidewire became stuck. Attempts were made to retract the guidewire, but it was only able to be partially withdrawn. A chest radiograph was ordered (Figure 1).
Figure 1.
Chest x-ray.
Diagnosis
Guidewire ensnarement
Guidewire entrapment in inferior vena cava filter is a known complication, usually occurring during blind central venous access. Secondary complications include inferior vena cava filter breakage or dislodgment, guidewire fracture, and inability to remove the wire from the filter.
The 2 commonly used guidewires are straight and J-tip guidewires. Studies show that J-tip guidewires engaged all major filter types, whereas certain filters are more susceptible to entrapment. Straight guidewires did not engage any of the filters.1 The mechanism is likely hooking of the filter with the curved wires.2
The advancement of interventional radiology has permitted the development of several techniques for removing entrapped guidewires.3 Our patient's guidewire was retrieved under fluoroscopy through the right common femoral artery (Figure 2). During the original, blind attempts at withdrawing the guidewire, our patient's inferior vena cava filter migrated into the superior vena cava. Because the inferior vena cava filter was firmly fixed in its new location, it was left in place (Figure 1).
Figure 2.
Fluoroscopic image. Used with permission of Moshe Weizberg, Department of Emergency Medicine, Staten Island University Hospital, Staten Island, NY.
Some preventive measures include awareness of an inferior vena cava filter before insertion of a central venous catheter, use of a straight guidewire when the patient has an inferior vena cava filter, and introduction of the guidewire only up to 20 cm (depth of the superior vena cava). This distance can be estimated by placing the guidewire over the chest from the insertion site to the angle of the manubrium.3, 4
References
- . In vitro study of guidewire entrapment in currently available inferior vena cava filters. J Vasc Interv Radiol. 2003;14:905–910
- . Greenfield inferior vena cava filter dislodged during central venous catheter placement. Chest. 1994;106:957–959
- . J-tip spring guidewire entrapment by an inferior vena cava filter. J Am Osteopath Assoc. 2004;104:87–89
- . Guidewire incidents with inferior vena cava filters. J Am Osteopath Assoc. 2004;101:231–233
For the diagnosis and teaching points, see page 771.
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PII: S0196-0644(08)00792-0
doi:10.1016/j.annemergmed.2008.04.029
© 2008 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
