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CARDIOVASCULAR ANESTHESIA

Direction of the J-Tip of the Guidewire, in Seldinger Technique, Is a Significant Factor in Misplacement of Subclavian Vein Catheter: A Randomized, Controlled Study

Mukesh Tripathi, MD, MNAMS^*, Prakash K. Dubey, MD, and Sushil P. Ambesh, MD^*

*Department of Anesthesiology; Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India; Department of Anesthesiology; Indira Gandhi Institute of Medical Sciences, Patna, India.

Address correspondence and reprint requests to Mukesh Tripathi, MD, MNAMS, Type IV-21, Campus, SGPGIMS, Lucknow-226 014, India. Address e-mail to mukesh_tripathi{at}yahoo.com

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during right subclavian catheterization. In this randomized, double-blind clinical study, we observed the placement of catheters via the right subclavian vein while keeping the J-tip directed either caudad in Group 1 (n = 147) or cephalad in Group 2 (n = 148) patients. The majority of catheters (97% and 57%) in Groups 1 and 2 respectively entered the superior vena cava/right atrium (P < 0.05). The incidence of catheter misplacement into the ipsilateral internal jugular vein was 2% and 40% in Groups 1 and 2, respectively (P = < 0.01). Subsequent experimental study confirmed that the direction of the J-tip was retained inside a model of vascular tubes and its tip led the guidewire into the tubing on the same side even at the acute angulation formed between tubings representing the subclavian, internal jugular, and superior vena cava junction complex. The authors conclude that the simple measure of keeping the guidewire J-tip directed caudad increased correct placement of central venous catheters towards the right atrium during right subclavian catheterization.

IMPLICATIONS: The direction of the guidewire J-tip plays a significant role in the malpositioning of catheters introduced via the right subclavian vein.

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