Retained haemodialysis—catheter guidewire in the head and neck: a multidisciplinary team approach

Abstract

Penetrating foreign body in the head and neck can be catastrophic from injury to the constellation of vascular and neural structures in the neck. Early recognition and prompt surgical intervention is imperative to save lives. Herein, we present an unusual case of iatrogenic foreign body—a coiled guidewire embedded in the deep neck space. The complications, radiological investigation and multidisciplinary surgical management are further discussed.

Background

Hippocrates once said ‘first, do no harm’. Though the medical profession is a noble profession, iatrogenic injury induced by medical procedures can occur. There are various reports of retained or missing guidewires during venous cannulation.^1–3 However, to the best of our knowledge, this is the first report of retained haemodialysis catheter guidewire in the prevertebral region successfully managed surgically by a multidisciplinary team approach. We report such a case and discuss our approach in managing it.

Case presentation

A 66-year-old man with underlying newly diagnosed end-stage renal failure was admitted to the nephrology department for catheter-related bloodstream infection. Infected haemodialysis (HD) catheter in the right internal jugular vein (IJV) was removed due to methicillin-resistant coagulase-negative staphylococci infection. The patient was subsequently positioned in supine posture with the head turned towards the right in an attempt to insert a new HD catheter on the left IJV. Cannulation was performed in a blind method by a junior nephrology resident after the surface anatomy of IJV was estimated with ultrasound prior. On cannulation, there was venous backflow, hence guidewire position was not confirmed with ultrasound post venous puncture. Minimal resistance was encountered after 10 cm of guidewire insertion. With the head repositioning, the guidewire was able to be advocated further smoothly and the HD catheter was inserted. However, post procedure the guidewire was unable to be retrieved. Immediate bedside ultrasound showed that the guidewire was not in the IJV.

Clinically, the patient presented with mild pain over the left side of the neck. There was neither shortness of breath nor noisy breathing. Vital signs were stable. Range of neck movement was normal. Neck examination showed vague left-sided neck swelling with a clamped guidewire protruding out (figure 1).

Figure 1.

Clinical photograph showing guidewire protruding out from the neck wound.

Investigations

The incident was reported to the senior clinician promptly. Immediate chest radiograph (CXR) showed coiling of the guidewire in the neck region (figure 2). Urgent computed tomography angiography (CTA) of the neck was done within 6 hours, which revealed the presence of the guidewire at the left-neck region traversing through sternocleidomastoid (SCM) muscle, located just anterior to the left IJV and the left common carotid artery (CCA). It coiled at the prevertebral region (C5–T1). No contrast extravasation was seen (figure 3). Haematoma measured 2.7×5.5× 7.1 cm was identified between the left SCM and the carotid sheath splaying the left CCA and IJV. Trachea was deviated to the right with minimal narrowing (figure 4).

Figure 2.

Chest radiograph showing coiled radiopaque foreign body in the neck region.

Figure 3.

CT angiography demonstrating no contrast leak from the internal jugular vein (red arrow) with the guidewire (black arrow) located anterior to it.

Figure 4.

CT angiography of the neck venous phase demonstrating guidewire pierced through sternocleidomastoid (SCM) and passed anterior to left internal jugular vein (IJV) (A) and left common carotid artery (CCA) (B) into the prevertebral region with the evidence of coiling. Haematoma (*) formed between SCM and carotid sheath, which splayed the left IJV and CCA and caused the airway narrowing. (C, D) Three-dimensional CT volume rendering view of the guidewire in relation to left CCA in the neck.

Treatment

The patient was immediately referred to the otolaryngology and vascular team for surgical intervention. A left-lateral cervical approach was adopted to allow optimal surgical access in anticipation of obtaining distal and proximal controls over the vascular neck structures such as IJV and CCA during retrieval of the guidewire. After developing superior and inferior subplatysmal flaps, we skeletonised and retracted the SCM. Carotid sheath was identified. Intraoperative findings showed the guidewire punctured through the left SCM, strap muscles and coiled posterior to the larynx and oesophagus deep in the prevertebral region as shown in the CT images. IJV wall was mildly injured; however, no active bleeding was seen from the IJV. Haematoma located in between the left SCM and the carotid sheath extending deep to the strap muscle was evacuated (figure 5A). Left-IJV wall weakened and was torn during the guidewire removal, hence ligated. In view of the coiling and the difficulty in removing the guidewire, it was cut into few pieces to facilitate the complete removal (figure 5B).

Figure 5.

(A) Intraoperative photo showing the coiled guidewire (arrow) with haematoma formation at the prevertebral region (*). (B) Coiled guide wire was cut into three pieces to facilitate removal intraoperatively.

Outcome and follow-up

The patient recovered well post operation and was dialysed via femoral catheter. One week later, he was discharged home with no complication seen and subsequent follow-up revealed complete healing of the neck wound.

Discussion

Neck is among one of the most complicated structures in the human body as it consists of a lot of vital structures. Penetration or migration of foreign body-like guidewire in the neck may cause life-threatening suppurative, intravascular or extravascular complications; hence, accurate location and removal is thereby essential. Vascular involvement can lead to CCA and IJV rupture; hence, torrential bleeding while haematoma and subcutaneous emphysema may compress the airway and lead to airway obstruction.⁴ A series of 192 patients presenting with traumatic penetrating neck injuries in Alzahra Hospital reported a mortality rate of 1.5%.⁵

Central venous catheterisation (CVC) in the neck region is a common but not innocuous procedure in medical practice. Adequate attention, supervision and experienced manipulation are important factors in avoiding unnecessary iatrogenic complication.^{1 6} It is imperative to not apply any force once the resistance is felt as this may cause kinking or looping of the guidewire which subsequently lead to intravascular or extravascular injury.⁷

CVC is commonly employed by a variety of medical teams, thus ensuring a safe practice by adhering strictly to the international or local guidelines is highly recommended. According to the guidelines by the Association of Anaesthetists of Great Britain and Ireland, ultrasound should be used routinely for IJV CVC particularly when the venous cannulation proves difficult.⁶ Confirmation with ultrasound is crucial not only on marking the surface anatomy of the IJV, but also during initial guidewire insertion and on any resistance felt during the procedure in order to confirm its exact location, thus avoiding disastrous complication as shown in our case. Clinicians need to have a heightened index of suspicion on CVC as sometimes resistance encountered during the cannulation may be one of the early signs of the severe complication that can be prevented if ultrasound imaging is used early, particularly by the junior inexperienced resident.

Vascular complications of CVC are not uncommon. Schummer et al reported four cases of unnoticed retained guidewires intravascularly, detected on performing CXR post cannulation and successfully removed under fluoroscopic guidance with Dormia basket.⁸ Srivastav et al described a rare case of intravascular loss of the guidewire during cannulation of the right IJV performed by a junior resident in which the guidewire flowed from the right IJV to the right external iliac vein, which eventually required exploration of the external iliac vein for proper removal.¹ Innami et al reported a case of right brachiocephalic vein perforation resulting in life-threatening haemothorax on IJV cannulation, which required immediate chest tube insertion and thoracostomy for the vein repair.⁹ To the best of our knowledge, most of the reported retained guidewire cases occurred intravascularly. Extravascular entrapment of the guidewire in the neck musculatures is exceedingly rare. Ansari et al reported a case of the guidewire embedded in between the IJV and the CCA, which was removed in the operation theatre with fluoroscopic guidance under local anaesthesia.¹⁰ Another report of extravascular entrapment of the guidewire beneath the subcutaneous tissue was removed successfully with gentle traction.¹¹ To date, there have not been any reported cases of retained guidewire embedded extensively in the prevertebral region and our case serves as the first one.

Notably, injury to the blood vessels could easily lead to haemodynamic instability. It was reported that brachiocephalic vein perforation with haemothorax secondary to IJV cannulation was detected only 3 hours after the incident.⁹ The delay in detection was mainly due to the fact that the patient was undergoing positive pressure ventilation in the operation theatre; however, with adequate vigilance and timely intervention, the patient survived. On the other hand, arterial injuries such as carotid artery puncture and subclavian artery injury post IJV cannulation may postulate immediate haemodynamic collapse with potentially high lethality instead.^{12 13} Our patient demonstrated a relatively stable haemodynamics wherein the guidewire was embedded in the extravascular structures of the neck. We postulate that the formation of the haematoma post trauma had acted as the tamponade to compress on the mildly injured IJV and SCM, hence temporarily stopped the bleeding. In most of the cases, the haematoma may expand with ongoing bleeding and compress on the trachea that may subsequently lead to disastrous outcome of airway compromise if no immediate intervention is given.

Radiological modalities are deemed invaluable in localising foreign body in the neck prior removal. Though CXR can usually display the presence of the radiopacity, which indicates the foreign body and the malposition of the guidewire, further imaging such as CTA is essential, particularly in our case as it helps in delineating the relation of the foreign body with the surrounding vessels in the neck such as IJV and CCA. Three-dimensional CT scan allows further precise evaluation and visualisation of the vessels and the vital structures adjacent to the foreign body.¹⁴ It is particularly helpful in planning the surgical approach in anticipation of difficulties during surgery especially in complicated cases.

Various reports of successful removal of intravascular retained guidewire under fluoroscopic guidance by interventional radiologist;^{3 8} however, it is not suitable in this case as the sharp guidewire was embedded in the deep neck space, posterior to the important vascular structures. Surgical removal is the best option. Immediate neck exploration, removal of the foreign body and evacuation of the haematoma was done in no delay as haematoma may expand and narrow the airway, potentially leading to airway obstruction.

Multidisciplinary team discussion is imperative to achieve a good surgical outcome. In our case, surgical retrieval of the guidewire was performed with the vascular team in anticipation of vascular injury that needed intraoperative repair or intervention. In view of the surgical difficulties with the complexity of the embedded coiled guidewire intraoperatively, mild injured IJV was torn, hence ligated. Removal of the guidewire was subsequently successful without massive bleeding. This case showed the importance of multidisciplinary co-management when it comes to complicated foreign body in the head and neck to ensure the greatest benefit to the patient.

Management of penetrating foreign body in the neck can be very challenging in view of the complexity of the neck anatomy. Urgent CTA imaging is mandatory for preoperative planning particularly in cases anticipating surgical difficulties. Having said that, early recognition, timely intervention and multidisciplinary management are important in order to prevent life-threatening complications.

Patient’s perspective.

I never expected this incident would happen to me. It was indeed frightening to have a wire-like object protruding out from my neck. Thank God my life was saved by the Ear Nose Throat and vascular team. I do hope this incident can be a good learning lesson to all other doctors worldwide whenever they perform any central venous catheterisation. Hopefully, this iatrogenic complication can be avoided in the future.

Learning points.

• Preoperative detailed discussion on the CT imaging is imperative in planning surgical approaches and on anticipating surgical difficulties.

• Multidisciplinary team discussion and management is essential in handling complicated foreign body cases.

• Complication sometimes is unavoidable in medical procedures, but knowing how to handle the complications incurred by the medical procedures with proper timely referral is essential.

• It is important for the healthcare workers to use diagnostic imaging when the need arises, and to know when to stop the procedure is imperative in order to prevent further disastrous iatrogenic injury.

• Junior residents must be well versed with all the possible complications and the risks of each step of central venous catheterisation prior performing it under supervision.