An In Situ Technique to Retrieve an Entrapped J-Tip Guidewire from an Inferior Vena Cava Filter (2002)

The number of cases involving entrapment of a J-tip guidewire in vena cava filters (VCFs) during placement of central venous catheters (CVCs) has been increasing (1–5). Anesthesiologists should be cognizant of this potential complication and know how to manage it. We present a case in which attempted CVC placement resulted in entrapment of the J-tip guidewire within an inferior vena cava Greenfield filter (GF). The entrapped guidewire was successfully retrieved by using an in situ technique. Case Report A 77-yr-old male presented to the emergency room after an accidental fall. Magnetic resonance imaging of the spine revealed an unstable fracture of the T11 vertebra, which required surgical repair. Before surgery, a 12F stainless-steel GF was deployed in an infrarenal location because of lower-extremity popliteal venous thrombosis. On the day of surgery, placement of a CVC (7F, two lumen, 20 cm; Arrow International, Reading, PA) was attempted via the right internal jugular vein after uneventful induction of general anesthesia. The guidewire, 60 cm long, with a 3-J tip (the number before the J designates the radius of the curve of the guidewire tip in millimeters), was inserted smoothly but encountered resistance on withdrawal. Fluoroscopy revealed that the J tip was engaged within the apex of the GF (Fig. 1). Interventional radiology was consulted.Figure 1: Anterior-posterior radiograph of the abdomen demonstrating the J tip of the guidewire entrapped within the apex of a Greenfield filter located in the inferior vena cava.An initial attempt to free the guidewire by advancing it caudally and rotating the proximal end failed. Because it was clear that the J tip was entrapped in the apex of the GF, force directed in a cephalad fashion would be expected only to either make the entrapment worse or dislodge the GF. It would be optimal to create a situation in which the entrapped J tip could be freed from the GF by applying torque at its proximal end without any cephalad force. The torque force needed to be continuous until the J tip rotated 180° to dislodge from the GF struts. Therefore, the in situ technique (without accessing the femoral vein or using a vascular sheath, snare, or any other instrument) was implemented. The guidewire was held and stabilized with the nondominant hand at the skin insertion site. This nondominant hand stabilization served two purposes: it prevented the cephalad force and stabilized the guidewire constantly while torque was applied at the proximal end. Torque was applied with the proximal end of guidewire held between the thumb and middle-ring fingers. Each rotation transmitted the torque to the J tip while the nondominant hand prevented the unwinding. With continuous torque, the J tip was dislodged from the GF. The guidewire was then withdrawn to the right atrium, and CVC insertion was completed. The guidewire was inspected after removal and showed no damage. Postprocedure computed tomographic scan revealed no damage or malposition of the GF. Discussion VCFs have gained widespread acceptance in patients with contraindication to, complication of, or failure of anticoagulant therapy as a means of preventing pulmonary embolism. Complications of VCF, such as vena cava penetration, caval thrombosis, filter migration, and dislodgment of the filter have been described (6–8). Entrapment of a J-tip guidewire within the filter is a more recently described complication (2,9). The mechanism of entrapment appears to be hooking the guidewire J tip to the struts placed in a cone configuration, which converges toward the apex. As the guidewire is withdrawn, it becomes lodged at the point where the struts converge closely. Inappropriate techniques used in an attempt to free the guidewire, often with force, can wedge the guidewire and eventually dislodge the VCF (1,9–11). Severe complications related to the dislodgement of the VCF include acute myocardial infarction, pericardial tamponade, cardiac dysrhythmias, and death (12–14). This is the first case report to describe the in situ technique to free the entrapped guidewire. The in situ technique is simple to perform and does not require any other venous access or equipment. We suggest that this technique be attempted before any complex techniques (1,3–5,15–18) are applied. In a comprehensive evaluation of the guidewire and VCF, Kaufman et al. (19) showed that J-tip guidewires of 3 mm or less in radius are at increased risk of entrapment by the VCF. In contrast, the straight tip and 15-mm J-tip guidewires were never entrapped in this study. In our patient, the 60-cm 3-J guidewire was advanced to two-thirds of its total length. Overadvancement of the guidewire in this case might have been caused by the absence of marks on the guidewire, usage of a circular advancer, and concern to avoid contamination of the proximal end of the guidewire. To prevent potential disastrous complications associated with an entrapped J tip, we recommend detailed preoperative evaluation to identify patients with VCF, avoiding insertion of the guidewire beyond the length of the CVC, using either a straight-tip or 15-J guidewire, and considering fluoroscopic assistance during placement of a CVC in patients with VCF. It is important that force should never be used to withdraw a guidewire when unexpected resistance is encountered. We thank Jean Matchett, MD, for excellent technical support. We also thank Shailesh Shah, MD, and Frank Block, MD, for their participation in patient care.