The technique described appears to be what was taught to me 20 years ago at the University of Wisconsin at Madison. I would be surprised if Dr. Dennis Maki didn't publish some information as to infection rates. If not, he may have unpublished data the author may be interested in. I do cringe at the picture of feeding the guidewire into the catheter without some grip on the catheter, with the cut end so close to the skin, even though the text states to hold the catheter. This is a good way to embolize the catheter, maybe not as easily with an internal jugular venous access, but a subclavian slides more easily.
Brian W. Heywood, MD
Author's response: As stated in the abstract, I am not aware of any published reports that mention the technique described in this article. However, I realize that other institutions may have used the same or similar techniques when guidewire exchange is necessary. I am well aware of Dr. Maki's numerous contributions to the literature regarding catheter-related bloodstream infections. As for the reader's concerns regardingFigure 4, which demonstrates a guidewire being fed into the catheter, the assistant's hand was removed only to allow the picture to be taken. The guidewire is never advanced into the catheter unless it is held securely. Although catheter embolization is theoretically possible with this technique, I have not experienced any catheter movement when advancing the wire.
James M. Cunningham, MD
Clinical Associate Professor of Surgery
Mercer University School of Medicine
I was jealous to find that Dr. Cunningham's technique of cutting the central line's ports is nearly the same as what I developed during my quest to find the cleanest way to exchange catheters. I wish to recommend one modification, which requires only one operator and, I feel, is cleaner. I recommend asking an assistant to hold the ports in the air as the operator preps the area and cuts the stitches. This way, you can place the sterile field over the ports, the assistant can let them go and thus exclude them completely from the field. The rest is just as Dr. Cunningham described.
I also strongly warn others of a potentially disastrous situation that can occur if this technique is used on the wrong catheter. In my enthusiasm for the technique, I once tried it during the exchange of a double-lumen 9F introducer (commonly referred to as a "Cordis") central venous catheter. After cutting it, I was about to insert my wire when I noticed something in the lumen, which I was fortunately able to clamp and retrieve. Cutting these catheters leaves the central lumen completely free-floating, and it could easily migrate into the patient's venous system, particularly if you push the guidewire. Do not try to cut a double lumen introducer or you risk embolizing the innermost tube!
(See: Galli S, et al. Accidental migration of ASH-split catheter during central venous catheter replacement: retrieval using an interventional radiology approach. J Vasc Access. 2001;2:64-67.)
Guillermo A. Escobar, MD
have been using Dr. Cunningham's technique for changing central lines since 1984. Dr. Stanley Dudrick taught it to me when I did a general surgery and nutrition fellowship with him that year. I always use a hemostat on the catheter to lessen the risk of air or catheter embolism. It is a nice technique and has worked well for my patients over the years.
Mark Rubin MD