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Loss of the guide wire: a case report
Hangyuan Guo1, Fang Peng, Takanori Ueda
1Department of Cardiology, Shaoxing People's Hospital, The First Affiliated Hospital of Shaoxing University, Shaoxing, Zhejiang 312000, China. ghangyuan@hotmail.com
Summary
A lost guide wire migrated from the vena cava to the neck after central venous catheterization. This case highlights the critical need for operator vigilance and supervision during central venous catheter placement to prevent serious complications.
Area of Science:
- Vascular Surgery
- Interventional Radiology
Background:
- Central venous catheterization is a common procedure.
- Complications can arise from guide wire manipulation.
Observation:
- A guide wire was completely inserted into the left subclavian vein during central venous catheterization in a post-operative patient.
- The misplaced guide wire was identified 6 months later, having migrated extensively through the venous system to the neck.
Findings:
- The guide wire traversed the saphenous vein, vena cava, right atrium, right ventricle, pulmonary artery, and lung tissue.
- This extensive migration demonstrates a rare but severe complication of guide wire loss.
Implications:
- Emphasizes the necessity for meticulous technique and constant monitoring of guide wires during central venous catheterization.
- Highlights the importance of adequate training and supervision for medical trainees to prevent adverse events.
- Underscores the potential for serious patient harm due to procedural errors and lack of attention to detail.