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Using a "dirty wire"

Posted By Marc Webb, Friday, October 31, 2025

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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Comments on this post...

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Alejandro C. Alvarez says...
Posted 21 hours ago
Use a wire cutter and remove the contaminated segment. I always have sterile wire cutters available in the center. Taught to me in my early days by a very experienced Rad Tech.
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Timothy O'Connor says...
Posted 18 hours ago
Tough situation, particularly if you are new to the team and you/they haven't had enough early cases together to mesh yet. We should all allow anyone in the procedure room to call out concerns or contaminations.. And then stop procedure to discuss. Without getting too "prudent" (it's a legal word, in case readers didn't pick up on that), you did just what a surgeon would do if a critical contamination occurred that jeopardizes completion of a procedure - like a saphenous vein for fem-pop getting suctioned to the container, or a kidney transplant being dropped. Never happened to me, of course, but thinking about it gives me a Halloween fright. I have heard and read of such things being wiped and treated with dilute betadine with successful outcomes.

Another suggestion is try to track a new 018 wire along the original. Sometimes works, no harm in trying, not going to make a low pressure rupture worse.
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Max J. Glaser says...
Posted 18 hours ago
Ideally, if the external length of the clean portion of wire is equal to or greater than the length from your insertion site to the area past the rupture, you can cut the wire (I use Mayo scissors and just gnaw at it!) then swap out a new wire over any diagnostic catheter.
Otherwise is there a catheter that uses a rail system (like IVUS) but also has a port that will accommodate a new wire to pass through it? That would solve the problem.
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Max J. Glaser says...
Posted 17 hours ago
If the catheter I asked about doesn’t exist, or you don’t have one, perhaps you could McGuyver one at the bedside. Id think about getting a conquest or dorado balloon, pole two holes in the balloon and use that as your rail over the bad wire then run a new wire throught the end once you crossed the rupture
Just a thought. Never done it!
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