A multimorbid 69-year-old gentleman presented with non-ST elevation myocardial infarction associated with bradyarrhythmias. Following pacemaker insertion, he developed an asystolic cardiac arrest requiring prolonged cardiopulmonary resuscitation before venoarterial extracorporeal membrane oxygenation (VA ECMO) support was established.

A right internal jugular central venous catheter (CVC) placed under ultrasound guidance in the intensive care unit was complicated by a lost guidewire during skin dilation. Pertinent VA ECMO settings included: pump speed of 3,600 rotations per minute, blood flow rate of 3.9 L/min, and venous circuit pressure of –71 mm Hg.

Immediate neck ultrasound, chest, abdominal, and pelvic X-ray (Figure 1A-C) failed to reveal the guidewire. It was found hours later in the VA ECMO access cannula tubing (Figure 1D) close to the pump (Figure 1E, Supplementary Video 1), confirming our suspicion of an entrained guidewire within the circuit. Nil changes in venous access cannulae parameters were noted. It was successfully removed later with a circuit change.

Transient ECMO flow reduction with diligent guidewire control during CVC insertion in a VA ECMO patient [1] is vital due to the negative caval pressure. Maintaining continuous wire contact or clamping the guidewire [1,2] to the sterile drape offers a simple solution to prevent catastrophic complications [3,4].