Unusual path taken by peripherally inserted central catheter guidewire

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259
Saudi Journal of Anesthesia / Volume 13 / Issue 3 / July‑September 2019
Letters to Editor
Sir,
A 26‑year‑old male diagnosed with acute T‑cell lymphoblastic
leukemia was planned for chemotherapy, for which long‑term
venous access was required. He was referred to the
Department of Anaesthesia for placement of peripherally
inserted central catheter (PICC) line. The patient was
explained about the procedure and informed consent was
taken. A complete blood picture was advised which revealed
a platelet count of 113 × 109/ml.
The procedure was planned in the operation theatre under
ultrasound (US) guidance and fluoroscopy. Under aseptic
precautions, Sonosite US machine (M‑turbo) with linear array
probe (13–6 MHz) was used to screen for the veins in the
right arm. After identifying the basilic vein and measuring the
dimensions of the vein with US, Cook’s 5‑Fr PICC was selected.
After infiltrating lidocaine 2% 1 ml as local anesthetic, the vein was
punctured with an out of plane technique. After confirming free
aspiration of blood, guidewire was inserted without resistance.
Guidewire in the basilic vein was identified by ultrasound, and
screening with fluoroscopy was done. However, guidewire
was not visible in the central thoracic area. We screened the
right shoulder and found the guidewire to the lateral wall of
right side of the chest [Figure 1a and b]. On reviewing the
fluoroscopic image in detail, we realized that the wire was in
the right thoracoepigastric vein [Figure 1b and c]. We pulled the
guidewire out under US guidance till it reached the axilla. Once
the guidewire tip reached the axillary vein, it was redirected and
checked again with fluoroscopy. Thereafter, the PICC was placed.
The binal position of PICC was confirmed with fluoroscopy.
During the entire procedure the patient was comfortable.
PICC line insertion is commonly performed for long‑term
intravenous access in a patient requiring chemotherapy. PICC
lines should be performed under US guidance as it reduces
complications, reduces cost, and provides greater comfort
to patients.[1] Complications during PICC line insertion
procedure are hematoma, bleeding, and guidewire entering
ipsilateral internal jugular vein or opposite side subclavian
vein.[2] Some rare complications such as missing guidewire after
placement of PICC line have been reported.[3] Complications
after placement of PICC line include hematoma, infection,
thrombosis of vein, occlusion of the catheter, migration of
the tip. We did a literature search but found no reports of
Unusual path taken by peripherally inserted central catheter
guidewire
Figure 1: (a) Fluoroscopic image showing unusual entry of the guidewire in the venous system of lateral thoracic wall. (b) Fluoroscopic image showing
reference of guidewire with shoulder joint. (c) Venous system in the thoracic wall. Thoracoepigastric vein is underlined with red. Permission obtained for
using the image from Springer Nature ‑ License number: 4465161441512. (Citaon: Saxena A.K., Alalayet Y.F. (2017) Surgical Anatomy of the Chest Wall.
In: Saxena A. (eds) Chest Wall Deformies. Springer, Berlin, Heidelberg)
c
b
a
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260 Saudi Journal of Anesthesia / Volume 13 / Issue 3 / July‑September 2019
Letters to Editor
PICC guidewire entering the thoracoepigastric vein. This is
possibly the first case describing such an unusual entry of PICC
guidewire in the thoracoepigastric vein. Consent for taken from
the patient for obtaining images for publication in a medical
journal without disclosing the name for academic purpose.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conicts of interest
There are no conflicts of interest.


Department of Anaesthesiology, Basavatarakam Indo‑American
Cancer Hospital and Research Institute, Hyderabad,
Telangana, India

Dr. Abhijit S. Nair,
Department of Anaesthesiology, Basavatarakam Indo‑American
Cancer Hospital and Research Institute, Hyderabad ‑ 500 034,
Telangana, India.
E‑mail: abhijitnair95@gmail.com
References
1. Li J, Fan YY, Xin MZ, Yan J, Hu W, Huang WH, et al. A randomised,
controlled trial comparing the long‑term effects of peripherally inserted
central catheter placement in chemotherapy patients using B‑mode
ultrasoundwithmodied Seldinger technique versus blindpuncture.
Eur J Oncol Nurs 2014;18:94‑103.
2. Song L, Li H. Malposition of peripherally inserted central catheter:
Experience from 3,012 patients with cancer. Exp Ther Med
2013;6:891‑3.
3. Kashif M, Hashmi H, Jadhav P, Khaja M.A Missing Guide Wire After
Placement of Peripherally Inserted Central Venous Catheter. Am J Case
Rep 2016;17:925‑8.
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How to cite this article: Mantha SS, Kaushik S, Nair AS, Rayani BK.
Unusual path taken by peripherally inserted central catheter guidewire.
Saudi J Anaesth 2019;13:259‑60.
© 2019 Saudi Journal of Anesthesia | Published by Wolters Kluwer ‑ Medknow
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DOI:
10.4103/sja.SJA_778_18
Novel technique of using laryngoscope in HIV, hepatitis B, and
hepatitis C infected patients
Sir,
The laryngoscope is an important instrument in an
anesthetists’ armamentarium. However, it may be a potential
source of cross infection due to contact with mucous
membrane, saliva, and at times blood if not sterilized
properly.[1] We used a novel technique to use laryngoscope
in an HIV infected patient.
Laryngoscope and tegaderm were taken [Figure 1]. Tegaderm
was wrapped around the laryngoscope, as shown in
Figures 2 and 3. We were worried about the illumination of
laryngoscope due to tegaderm. However, when the handle
was connected to the blade, there was good illumination
[Figure 4]. We wish to highlight that laryngoscope covered
by tegaderm is useful in infected patients without obscuring
illumination.
Financial support and sponsorship
Nil.
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