Image intensification - A solution for difficult guidewire insertion for central venous access: A case report

Presentation of case: A 56-year old male presented for an elective redo-sternotomy, aortic valve replacement, tricuspid valve annuloplasty, and coronary artery bypass grafting. During central vascular access using a standard Seldinger technique, resistance to two spring-wire guide wires was encountered when the wires were advanced through the patient's internal jugular vein. Ultrasound provided limited views of the anatomical path of the guidewires and was unable to provide visualisation of the level or cause of obstruction. We describe the application of continuous image intensification to successfully identify the anatomical location and safe circumnavigation of guidewire obstruction during the insertion of a central venous and pulmonary artery catheter for cardiac surgery. Discussion: The use of x-ray image intensification enabled the immediate identification of the cause of obstruction, minimising further attempts at guidewire insertion and subsequent complications. The direct real-time visualisation allowed for manoeuvres such as wire manipulation, rotation and advancement to be safely performed. Conclusion: Image intensification may decrease malposition rates and mechanical complications associated with difficult central venous catheterisation. Further research comparing the safety and efficiency of ultrasound-guided and fluoroscopy-guided CVC insertion should be contemplated.