i 83

Technical Note

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Simple Technique for Redirecting Malpositioned Central

Venous Catheters
Michael P. Recht,1’2 Dana R. Burke,1 Steven G. Meranze,1 and Constantin Cope1

Central venous catheterization by using the infraclavicular The catheter is removed over a 0.038-in. (0.97 mm) guidewire. A
subclavian vein approach is a standard method of monitoring 5.5-French Simmons 1 catheter (Cook, Bloomington, IN) is then
central venous pressure, administering hyperalimentation, inserted and reshaped within the jugular vein by using the technique
maintaining venous access when there is a lack of peripheral described by Cope (Fig. 2) [5]. In this technique (Fig. 3), the free end
of a standard 75-cm length of tough braided surgical plastic suture
veins, and administering irritating solutions such as antibiotics
(4.0 Tevdek, Deknatel, Queens Village, NY) is threaded through the
or chemotherapeutic agents. Unfortunately, the infraclavicular tip of the Simmons catheter for approximately 3 cm. The catheter
approach has a significant rate of complication. A frequent with the preloaded suture is then threaded over the guidewire into
problem is malpositioning of the catheter tip, which occurs in the vein. Under fluoroscopic guidance, the guidewire is then retracted
1 i -i 9% of cases [i 2]. Several techniques
, for redirecting until only the floppy tip protrudes from the catheter. The trailing end
the catheter tip into the superior vena cava have been de- of the suture is then gently pulled, causing the sidewinder shape to
scribed [3, 4]. However, in certain circumstances, such as an be re-formed. The guidewire is then removed from the catheter,
inadvertent direct internal jugular puncture or a very central freeing the suture and allowing it to be extracted from the vein. Once
subclavian vein puncture, these maneuvers are often unsuc- re-formed, the Simmons catheter is pulled down into the superior
vena cava and exchanged over a guidewire for a central venous
cessful, necessitating repuncture of the subclavian vein. In 2i
catheter (Fig. 4).
recent cases of direct internal jugular punctures, we have
In all 21 cases, the central venous catheter tip was repositioned
successfully used a Simmons catheter, reshaped with the successfully in the superior vena cava by using this method. There
suture technique [5], to reposition the central line into the were no failures, and no morbidity was associated with the procedure.
superior vena cava, obviating repuncture of the subclavian
vein.
Discussion
Materials and Methods The shepherd’s crook curve of the Simmons catheter is
well suited to redirecting catheters from the internal jugular
Between April 1 987 and December 1 988, 21 patients presented
vein to the superior vena cava. However, the potential diffi-
to the angiography/interventional radiology section with central ye-
nous catheters directly inserted into the internal jugular vein. Eleven culty of re-forming the Simmons shape in the internal jugular
catheters were in the right internal jugular vein, and 1 0 were in the vein prevented its use for this function. The Simmons catheter
left internal jugular vein (Fig. 1). All 21 catheters were repositioned can easily, quickly, and safely be reshaped in the internal
by using the following technique. jugular vein by using the suture technique.

Received January 31 , 1989; accepted after revision May 22, 1989.

, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4034.
2 Present address: Department of Radiology, University Hospitals of Cleveland, 2074 Abington Rd., Cleveland, OH 44106. Address reprint requests to M. P.
Recht.
AJR 154:183-184, January 1990 0361-803X/90/1541-0183 © American Roentgen Ray Society
 Fig. 1.-Injection of central venous catheter
reveals direct internal jugular vein puncture.

Fig. 2.-Simmons catheter being reshaped in

internal jugular vein by gentie traction on suture
(arrow Indicates tip of catheter).

I 2

Fig. 4.-Simmons catheter being used to redirect the guidewire Into left
innominate vein.

of access as well as procedure failure is not infrequent,

Fig. 3.-A, Simmons catheter preloaded with Tevdek suture advanced particularly in cases of direct jugular puncture. Also, torque-
over guidewire into jugular vein. able wires and deflecting wires are relatively rigid, with more
B, Guidewire withdrawn so that only its floppy tip protrudes from cath-
potential for vascular damage than floppy-tipped wires.
eter.
C and D, Tension applied to suture, causing sidewinder shape to be re- Once we became convinced of the efficacy of the suture
formed. technique, we used it primarily in cases of direct internal
jugular or central subclavian punctures, resulting in significant
decreases in time and equipment expenditure.

Damage to the vein wall by the suture while reshaping the

catheter is unlikely because very little tension needs to be REFERENCES

developed. Another potential problem occurs-when the suture 1 . van Berge Henegouwen DP, Marinkovic D, Lam D, Brummelkamp WH.
slips and fails to reshape the catheter; this can be remedied Roentgenological monitoring of the position of subclavian catheters intro-
by making a small knot on the end of the suture to improve duced by the infraclavicular approach. Diagn Imag Clin Med 1980;49:
320-325
the friction fit.
2. Deitel M, McIntyre JA. Radiographic confirmation of site of central venous
In our earlier cases, several techniques, such as buckling pressure catheters. Can J Surg 1971;14:42-51
soft-tip guidewires, use of torqueable guidewires or cobra 3. Hawkins IF Jr, Paige AM. Redirection of malpositioned central venous
catheters, or turning the end of the catheter with a tip- catheters. AJR 1983;140:393-394
deflecting wire, were tried unsuccessfully before we used the 4. Carrasco CH, Richli WR, Chamsangavej C, Wallace S. Technical note:
repositioning misplaced central venous catheters. Cardiovasc Intervent
suture technique with the Simmons catheter. Because the Radiol 1987; 10:234-236
other techniques require that the catheter be withdrawn al- 5. Cope C. Suture technique to reshape the “sidewinder” catheter curve.
most to the puncture site before redirection is attempted, loss J Intervent Radiol 1986;1 :63-64