A Repositioning Method for a Malpositioned Guidewire in the Internal Jugular Vein for Central Venous Catheterization Via the Subclavian Vein in Infants

To the Editor: A 0.018-inch J tip guidewire (GW) migrated into the ipsilateral internal jugular vein (IJV) after percutaneous insertion through the right subclavian vein in two 2-mo-old infants and could not be redirected by reinsertions. The tip of the GW was withdrawn to the lower end of the IJV under visualization using radiographic imaging. The right neck was compressed gently with the nondominant hand of the operator, at which time the GW was advanced. The GW looped at the junction between the IJV and subclavian vein and was subsequently, advanced toward the innominate vein. The loop extended spontaneously toward the superior vena cava in one patient. In the other patient, the introducer cannula was inserted fully up to the hub over the extended segment of the GW; thus, the tip of the cannula faced to the innominate vein. The looped GW was then withdrawn and reinserted toward the superior vena cava. Venous vessels of infants are very small in size and are fragile; hence, repositioning of the malpositioned GW is difficult in some patients and risks unintentionally removing it from the vein. Our method provides easy and quick repositioning. However, gentle manipulation is necessary to avoid injury to the structures. Figure 1Figure 1: A 0.018-inch J guidewire was inserted via the right subclavian vein, but it migrated into the ipsilateral internal jugular vein in a 2-mo-old boy. The right neck was gently compressed with the operator's nondominant hand, and the guidewire was advanced, thereby looping the guidewire and directing it toward the innominate vein.