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Using a "dirty wire"

Posted By Marc Webb, 19 hours ago

"Using a dirty wire"

Long and short, working in a new hospital as a corporate employee after closing my practice,

getting used to a new environment, unfamiliar staff, different assortments of balloons, wires,

grafts, suture, drains - the whole man-from-the-moon routine. One of my first cases was a

patient I'd known since 2005 who managed to get her graft removed for infection during my 9

month transition period. With the left side healing and out for the short-term at least, I planned

a right arm fistula or graft depending on intraoperative ultrasound and venography.

Ultrasound demonstrated a played-out cephalic vein, but a reasonable median antecubital/

basilic system over 5mm. I put in a sheath, and found a nice basilic vein up to the axillary,

where it disappeared into a tangle. Not to be deterred, I worked a Kumpe catheter up by slow

degrees using a 40 cm destination long sheath, recanalizing the axillary, subclavian, and right

innominant clear to the SVC. This process took over an hour. Dilated with a 4mm low-profile

balloon (the only thing that would pass), then an 8mm balloon. The result was a very ratty

channel ruptured somewhere in the upper axillary vein without much progression of injected

dye flow. "Must place stent".

Now here is the problem - Viabahn stents available in this OR are only in a 0.018 wire

platform, and the only 0.018 wire is 260 cm long. We place the wire, then remove the exchange

catheter. In the process, the long 0.018 wire slumps off the upper side of the arm board and

OR table - not to the ground I thought, but below the drape "skirt" and it is "contaminated",

according to the vigilant C-arm operator. If I pull the wire, I am fairly sure I will never be able to

pass through the damaged territory again, especially with a ruptured axillary vein, and I will

either have to lose this opportunity to place a right arm access, wait a long time for the other

arm to heal, plan a femoral graft, or keep the patient on a permacath. Or I can wipe the wire.

I thought the risk of actual infection was very low - the patient had received Vanco, and I

wiped the wire with a saline 4 x 4, then a dilute betadiene solution, then saline again.

The moment I passed another catheter to the central end of my obstruction we pulled and

discarded the wire, but the damage was done - I had used a "dirty wire" in the mind of

whoever submitted the criticism.

So what would a "prudent operator" do in this unfortunate situation? I have already asked

for a shorter 0.018 wire.

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