Yesterday I attempted to place a PICC line in a patient with very bad CAD.  I was able to access the brachial  and basilic veins several times but could not thread the guidewire.  I was using the nitinol wire and even got a second one out to see if it would help. Any suggestions for this problem? Amy Graham Nutritional Support Memorial Hospital
Once you have access the vein with the 21ga needle are you laying the needle flat with the skin so that the path into the vein is easier for the wire to follow?
I agree with the previous comments about being in the vein and not being able to get the wire to thread. It takes some time and experience to recognize what to try next. I do find that with training people they have a tendency to stop with blood return and not rely on the image that they see. I think they see the blood return and do not have all of the bevel in the vein, therefore cannot thread easily.
On the really difficult ones, I might intentionally go through the vein and try to position the needle in the middle of the vein as I pull back. I always watch the vein's reaction to the movement of the needle on the ultrasound screen. Many times I feel the difference with the withdrawal of the needle, as well as the image of the needle in the vein.
Like Tim said, I will gently lay the needle flat to avoid hitting the wall of the vein and allow the wire to enter the vein.
Gwen Irwin
Austin, Texas
You also might be stuck in the bottom-vein wall, if you attempted double wall puncture or pushed the needle too far.You could also not be in far enough and be stuck in the top vein wall. Some of the needles have really long bevels, so you get excellent blood return but your wire hits the wall or goes outside of the blood vessel. I find that lightly tugging (not to confuse with pulling back the needle) will help, sometimes you can actually fell the vein wall pop off the needle. Also "rolling" the needle between your finger sometimes helps (moves the bevel around).
Michael Drafz RN, CRNI, VA-BC
Clinical Lead Vascular Access Service
Sharp Metropolitan Medical Campus
San Diego, CA