Guidewire loss: mishap or blunder?
A 40 year old man underwent an uncomplicated operation for adhesive intestinal obstruction caused by Crohn’s disease six months previously. After surgery, a cardiologist in his second year of training inserted a central venous catheter via the left subclavian vein. No problems with the catheterisation procedure were recorded. The trainee cardiologist was not familiar with central venous catheterisation or the Seldinger technique and was unsupervised. The catheter tray was not checked for guide wires after the procedure. A check chest x ray was reported to show no problems, and postoperative recovery was uneventful. Three weeks after discharge the patient felt mild pain and oedema on the right lower extremity, but nobody took it seriously and, after taking antibiotics for one week, the patient felt better. Six months after the initial abdominal surgery, the patient presented with posterior cervical pain and a guidewire, lost during post-surgical insertion of the central venous catheter, was shown protruding from the back of neck, like an antenna (left panel). The spiral computed tomography and three dimensional reconstruction confirmed suspicions (middle panel). A guidewire was seen extending from the saphenous vein, vena cava, right atrium, right ventricle, pulmonary artery, and lung and to the back of neck. The inner steel wire is separated from outer spring ring in the heart, and breakage of the outer spring ring is clearly visible. The inner steel wire on the back of neck was removed easily (right panel, B), but it was more difficult to remove the two parts of the outer spring ring (right panel, C1 and C2).