Central venous catheterization is a commonly performed procedure in the intensive care unit that is technically challenging, and associated with several risks and complications. Guide wires are routinely used in the Seldinger technique during central venous catheter placement.1 Catheter looping and knotting are known complications of central venous catheterization; however, there are few reports of guide wire-related complications. The most common known complication of a guide wire is cardiac arrhythmias. Other complications also include looping and knotting, vascular perforation, fragmentation and embolization, and intravascular entrapment of the wire. Although intravascular entrapment of a guide wire is rare, this complication needs to be emphasized as it increases morbidity and mortality. We present a case in which a guide wire was retained and incidentally found in a patient.
A fifty-eight year old African-American male nursing home resident presented with a past medical history of congestive heart failure secondary to dilated cardiomyopathy, Charcoat’s foot secondary to diabetes mellitus, gout and pulmonary hypertension. He also had end-stage renal disease previously on dialysis for a short period of time, for which he had femoral vein access two years prior to this admission. Three days prior to this admission, he was started on treatment for bacterial sinusitis and mastoiditis. On this admission, he was admitted to the hospital for altered mental status and hypoglycemia; the most concerning diagnosis was septic shock, although he had multiple other co-morbidities. During this hospital course, a chest x-ray was done that incidentally revealed a guide wire extending from his right internal jugular vein down to the right iliac vein. According to the patient, the guide wire had been in his body for more than a year. Despite the team’s efforts, more information on where and who placed the guide wire was unable to be obtained.*
Not only did the patient have a concurrent infection on this admission, he had a high risk of underlying occult infections like osteomyelitis and bacteremia. Because he had multiple sources of infection and presented with some signs of septic shock, it was determined in the best interest of the patient’s morbidity to remove the incidental foreign body.
The percutaneous transvenous approach was used to remove the guide wire. Prior to obtaining access via the right femoral vein, fluoroscopy was used to visualize the guide wire, which extended from the internal jugular vein to the superior vena cava to the right atrium to the inferior vena cava to the right iliac and to the common femoral vein. Several attempts were made to retrieve the guide wire using an eV3 GooseNeck snare and multiple other snares. The attempts were unsuccessful, likely because the guide wire had endothelialized and had a fibrin sheath that had allowed it to become part of the intracardiac and intravenous structures.
The patient was then scheduled for sternotomy with cardiopulmonary bypass and removal of the retained wire. After the procedure, the patient was then transferred to the ICU in critical but stable condition.
One week after the procedure, the patient developed sternal wound dehiscence with evidence of mediastinitis. He also had evidence of septic and cardiogenic shock. He was taken to the operating room for sternal debridement. He was again transferred to the ICU with an open sternal wound in critical but stable condition. The patient remained in the hospital for 2 months and was then transferred to the nursing home for rehabilitation.
The guide wire was an incidental finding in this case and patients may remain asymptomatic for years. However, serious complications, including arrhythmias, myocardial perforation, infection and thrombosis, can occur. Once symptomatic, removal of the object becomes necessary.2,3 The newer advanced techniques of percutaneous intervention have made the retrieval of retained foreign bodies feasible and effective.3,4 However, in this case, all attempts to remove the guide wire by using percutaneous tools failed and the patient required a surgical procedure for the retrieval that resulted in substantial morbidity in the patient.
A guide wire could potentially be retained in any of the following situations: inadequate supervision, inexperienced operator, distraction, critically ill patient undergoing multiple other procedures and overworked staff.5 Line placement is generally considered a single-person task with no standardized process. Placement does not involve visual, verbal or documented confirmation that the guide wire has been removed.6-8 Guide wire removal is solely reliant on the memory of the person who placed the wire. Because there is no check method, there is an increased risk of retention, particularly when there are distractions and competing priorities.9 Immediate removal requires good communication among providers and the consistent application of reliable and standardized processes of care. The person doing the procedure should account for all the items as part of the kit. A checklist can also be included in the kit. Another method to prevent long-term morbidity in patients is to do a confirmatory chest x-ray to ensure absence of the guide wire and correct placement of the catheter.
Our case report emphasizes the importance of awareness of the potential entrapment and embedding of a guide wire during cardiovascular catheterization. Guide wire complications, especially intravascular embedding, can be reduced or avoided if the operating physician has an assistant who carefully watches for any retained object during the procedure. It can also be reduced by using radio-opaque guide wires, and using x-ray and other technology during the procedure to ensure that there is no retained object in the operative field.10 A final method that may have poor sensitivity is to flush the catheter to check for resistance to venous back flow.
To ensure removal of a guide wire after insertion, the following recommendations should be strictly followed:
- The physician should be aware of the risk factors involved in the procedure.
- The trainee, supervisor or assistant must hold the wire at all times.
- The physician should be reminded of guide wire removal.
- Besides an insertion checklist and documentation, there must be an observer who verifies removal of the guide wire.
- The physician should complete theoretical and practical training in inserting and removing central lines.11
The true incidence of retained foreign bodies is unknown; however, it is estimated at 0.1% to 1.5%.12 Mortality rates resulting from unintended retention of foreign objects in surgical patients are as high as 35%, and objects are left in 1,500 people each year in the United States. In a 2003 case control study of 54 patients involving a retained foreign object, 69% of the objects were sponges and 31% were instruments. More than half (54%) of the foreign bodies were left in the abdomen or pelvis, 29% in the vagina, 7% in the thorax and 10% elsewhere.13
The basic retrievers for removing intravascular foreign bodies are loop snare catheters, hook tip guide wires or catheters, basket retrievers, and grasping forceps or catheters.14 Importantly, force should never be used to withdraw a guide wire when unexpected resistance is encountered, as this may result in fracture of the wire and damage to internal structures. In our patient, the common transfemoral approach was used to remove the guide wire. But all efforts were fruitless because of the endothelization of the guide wire, and the only option remaining was median sternotomy.9 The patient had to undergo cardiopulmonary bypass for the retrieval, a procedure that has its own risks and complications.
This case is a reminder that the team should pay attention to guide wire removal and alert the physician if the guide wire has not been removed. If such an instance occurs, the team should address it by reviewing and adapting procedures and processes, and the physician should discuss it with the patient. One should also address long-term complications with a retained guide wire and if a patient is willing, the guide wire should be removed before it becomes symptomatic. Only appropriately trained physicians should perform central line procedures; trainees should be appropriately supervised. This case emphasizes not only the responsibility of the physician, but the team, in maintaining and improving patient care and safety.
Acknowledgements. We would like to thank Ahmad Pasha, MD, and Daniyah Khurram, MD, for their contributions to this case report.
This article received double-blind peer review from members of the Cath Lab Digest editorial board.
The authors can be contacted via Dr. Muhammad Usman Baig at email@example.com.
*Note: This patient presented to our facility in October 2008. Despite investigation into the patient’s medical records, we were unable to discover where and how the guide wire mishap occurred, nor who had done the original procedure in order to be able to speak with the team. Our inability to find any additional records leads us to believe that the guide wire was placed at another facility.
- Song Y, Messerlian AK, Matevosian R. A potentially hazardous complication during central venous catheterization: lost guidewire retained in the patient. J Clin Anesth. 2012 May; 24(3): 221-6. doi: 10.1016/j.jclinane.2011.07.003.
- Actis Dato GM, Arslanian A, Di Marzio P, Filosso PL, Ruffini E. Posttraumatic and iatrogenic foreign bodies in the heart: report of fourteen cases and review of the literature. J Thorac Cardiovasc Surg. 2003 Aug; 126(2): 408-414.
- Tucciarone M, Othman H, Frederick M, Boguszewski A, Rama K. A novel approach to the removal of a retained guidewire. Journal of Medical Cases 2011 Aug; 2(4): 159-161. doi:10.4021/jmc233w
- Bessoud B, de Baere T, Kuoch V, et al. Experience at a single institution with endovascular treatment of mechanical complications caused by implanted central venous access devices in pediatric and adult patients. AJR Am J Roentgenol. 2003 Feb; 180(2): 527-532.
- Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: mishap or blunder? Br J Anaesth. 2002 Jan; 88(1): 144-146.
- Duncan JR, Henderson K, Street M, Richmond A, Klingensmith M, Beta E, Vannucci A, Murray D. Creating and evaluating a data-driven curriculum for central venous catheter placement. J Grad Med Educ. 2010 Sep; 2(3): 389-397. doi: 10.4300/JGME-D-10-00007.1.
- Evans LV, Dodge KL, Shah TD, Kaplan LJ, Siegel MD, Moore CL, Hamann CJ, Lin Z, D’Onofrio G. Simulation training in central venous catheter insertion: improved performance in clinical practice. Acad Med. 2010 Sep; 85(9): 1462-1469. doi: 10.1097/ACM.0b013e3181eac9a3.
- CLAB ICU Project: Preventing Central Line Infections. Training framework for clinicians new to inserting central lines in NSW. September 2008. Available online at http://www.cec.health.nsw.gov.au/. Accessed February 14, 2013.
- National Health Service. Patient Safety Services. Signal: risk of harm from retained guidewires following central venous access. September 29, 2011. Available online at http://www.nrls.npsa.nhs.uk/resources/?EntryId45=132829. Accessed February 14, 2013.
- Commonwealth of Massachusetts: Health and Human Services. January 2011. Retained Guidewire Advisory. Available online at http://www.mass.gov/eohhs/provider/licensing/occupational/physicans/quality-patient-safety/reports-advisories-and-guidelines.html. Accessed February 14, 2013.
- New South Wales - National Trust of Australia. NSW Government. Health. Safety Alert 002/09 - Guidewire Alert (2009). June 16, 2009. Available online at http://www0.health.nsw.gov.au/resources/quality/sabs/sa20090616_pdf.asp. Accessed February 14, 2013.
- Massachusetts Department of Public Health. Patient Safety Update. Retained Foreign Objects. August 2010. Available online at http://www.mass.gov/eohhs/docs/dph/patient-safety/retained-foreign-objects-advisory.pdf. Accessed February 14, 2013.
- Kruse MJ, Khoynezhad A. Thoracic endovascular aortic repair (TEVAR). The Cardiothoracic Surgery Network. July 27, 2007. Available online at http://www.ctsnet.org/portals/endovascular/procedures101/exp_tech1.html. Accessed February 14, 2013.
- Phy MP, Neilson Jr. RW. Guide wire complication with central line placement. Hospital Physician. 2004 June; 41-43. Available online at http://www.turner-white.com/hp/hp01.php. Accessed February 14, 2013.