Guidewire localization by transthoracic echocardiography during central venous catheter insertion: a periprocedural method to evaluate catheter placement

To evaluate the feasibility of guidewire detection in right cardiac cavities by transthoracic echocardiography (TTE) in order to detect catheter misplacement and to optimize central venous catheter (CVC) positioning. Ultrasonic control for catheter tip positioning was compared to that by chest X-ray (CXR). We conducted a monocentric prospective observational study (January-November 2010). All consecutive patients undergoing CVC insertion were included. The puncture was performed using the landmark method or ultrasound guidance. TTE was performed during the procedure to follow the arrival of the guidewire in the right cardiac cavities. Catheter misplacement was defined as an aberrant position on the postprocedural CXR (catheter positioning in ipsilateral or contralateral veins). The primary endpoint was the prediction of catheter misplacement by guidewire detection in the cardiac cavities. The secondary endpoint was the optimization of the catheter tip placement in the superior vena cava. A total of 98 patients received 101 CVC. The guidewire was visualized in 92 cases. In five cases, the guidewire was not seen in the right cardiac cavities and CXR showed catheter misplacement. In four cases, poor echogenicity led to the ultrasound examination being abandoned. Catheter misplacement was detected by TTE with a sensitivity of 96 % (CI 90-98 %), a specificity of 83 % (CI 44-97 %), a positive predictive value of 98 %, and a negative predictive value of 55 %. Likelihood ratios were LR+ 5.7 (CI 0.96-34.4) and LR- 0.05 (CI 0.02-0.14). Guidewire removal under TTE avoided an excessively distal position of the catheter tip in all cases. TTE is a reliable tool to detect catheter misplacement and to optimize catheter tip positioning during the procedure of CVC insertion.