Loss of guidewire and its sequelae after central venous catheterization

Abstract

Rationale: Central venous catheterization is a common tool used to monitor central venous pressure and administer fluid medications in patients undergoing surgery. The loss of a broken guide wire into the circulation is a rare and preventable complication. Here, we report a peculiar case of a missed guidewire puncturing the aortic arch and cerebrum. Patient concerns: A 53-year-old man with complaints of an intermittent headache and right swollen ankle following central venous catheterization. Diagnoses: Using computed tomography; the patient was diagnosed with the loss of a guide wire in his body. The guide wire had migrated to the brain and punctured the vascular wall of the aortic arch. Interventions: Due to the risks of surgery, the patient was advised to have a follow-up visit once every 3 months. Outcomes: At present, the patient could live like a normal person, although he suffers from intermittent headaches. Lessons: The loss of a guide wire is a completely preventable complication, provided that a hold on the tip of the wire is maintained during placement, and the correct safety measurements and protocols are followed.

Delayed diagnosis of a retained guidewire after bedside femoral venous catheter insertion: A preventable complication

“…The CVC kit includes guidewires to facilitate the line placement. While the complication rate of inserting CVC catheters is approximately 15%, the intravascular loss of the guidewire during CVC placement is a rare but serious complication [ 5 ]. Since the guidewire does not completely occlude the catheter lumen, the blood can be aspirated from the CVC ports, which confirms the intravascular placement of the CVC.…”

“…Retained guidewires increase morbidity and mortality, particularly when used in the vascular system. Several complications are reported with retained guidewires related to CVC placement including arrhythmia, thrombosis, cardiac and aortic perforation, pneumothorax, and cardiac tamponade [ 5 – 7 ].…”

“…Further, the failure to adhere to good procedural practices likely resulted in this complication. We strongly feel that this complication is preventable by following standard procedural protocol and by documenting the removal of guide wire after CVC insertion [ 5 ].…”

“…In general, several predisposing factors are proposed for retained guidewires after CVC placement including inattention, inexperienced operator, inadequate supervision of trainees, lack of communication, and overtired staff [ 5 , 6 ].…”

Yet another lost guide wire

“…[ 2 ] Migration of a right femoral vein catheter guidewire into the circulation leading to damage of arch of aorta and cerebrum has also been reported. [ 3 ] The retained guidewires are also known to get fragmented inside the body. [ 1 ] Fortunately, there was no major complication in our patient in spite of the retention of a wire that did not have a flexible tip.…”