Self knotting of a J tip guidewire during femoral hemodialysis catheterization in a resource limited setting

Guidewire knotting is an exceptionally rare yet clinically significant complication encountered during central venous catheter placement using the Seldinger technique. Although this technique has undergone substantial refinement since its introduction in the mid-twentieth century, guidewire-related mechanical events—including knotting, looping, and intravascular entrapment—continue to be reported, particularly in situations where real-time imaging is unavailable. We describe an unusual case of self-knotting of a J-tip guidewire during femoral venous catheterization performed for urgent initiation of hemodialysis in an elderly patient with severe metabolic derangements. The procedure was undertaken using anatomical landmarks because bedside ultrasound was temporarily unavailable, reflecting a common challenge in many resource-limited clinical environments. Resistance encountered during guidewire advancement was followed by failed attempts at withdrawal, ultimately necessitating surgical exploration. A tightly knotted guidewire was retrieved intact through a controlled venotomy, and the patient subsequently recovered without vascular or procedural complications. This case highlights the importance of early recognition of abnormal guidewire behavior, avoidance of forceful manipulation, and timely escalation to surgical or interventional support when required. It also underscores the ongoing need for improved access to ultrasound equipment, regular maintenance of existing devices, structured competency-based training, and adherence to standardized vascular access protocols. Strengthening these systems is essential to reduce preventable complications and improve patient safety, especially in settings where clinicians must frequently rely on landmark-guided techniques.