External Guidewire Direction as an Adjunctive Clue for Accurate Central Venous Catheter Placement: A Case Report

Central venous catheterization (CVC) under ultrasound guidance is a widely adopted and current standard practice that enhances safety and accuracy, particularly in high-risk patients. As the procedure provides a visual aid, we usually expect fewer complications. We report a case of right internal jugular vein (IJV) central catheter placement where the CVC guidewire was misplaced after IJV puncture under ultrasound guidance. A 65-year-old male with advanced liver failure and coagulopathy underwent CVC placement. The direction of the external guidewire segment suggested some abnormalities. Repeat ultrasonographic confirmation, following up on the guidewire, identified an internal misplacement; the guidewire had pierced the medial wall of the IJV and crossed the midline. Real-time ultrasound was then used to guide the repositioning of the guidewire and the subsequent correct placement of the CVC. Real-time ultrasound guidance for repositioning prevented repeat puncture, which increases the risk of bleeding, especially in high-risk patients. This case highlights the value of following up guidewire placement beyond the puncture point entry as a routine procedure, emphasizing the critical role of visualizing the guidewire entry into the brachiocephalic vein as confirmatory. Further, it highlights that external guidewire segment orientation is a valuable adjunct to ultrasound guidance during CVC placement, especially in patients with complex anatomy.