An unexpected image on a chest radiograph

Introduction Central venous catheterisation is an essential component of patient care in hospital. A forgotten complete guide-wire is a rare complication, although the reported incidence has increased rapidly over the last decade. Case report We report a 72-year-old man with a complete guide-wire inadvertently overlooked during catheter insertion. A central venous catheter had been inserted for total parental nutrition during treatment for pancreatitis. Five years later, the patient was readmitted with a painful lesion on his neck and the sensation of a sharp object under his skin. He was discharged without complication following removal of the free part of the guide-wire that had not become attached to the endothelial layer. Conclusion Inattention, inexperience and lack of supervision by a more experienced clinician are considered the most important contributing factors to this complication. Ultrasonography assistance during the procedure, senior supervision, a set count and a chest X-ray after the procedure are recommended in order to prevent forgotten guide-wires.