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lost wire very interesting case

Category: Medicine • Surgery
Posted on: January 24, 2007 6:01 AM, by Orac

Via Kevin, MD, a picture of a complication I hope I never have:


A description of the complication:

A 40-year-old man with Crohn's disease underwent an uncomplicated operation involving lysis of adhesions that were causing intestinal obstruction. After surgery, a cardiologist inserted a central venous catheter through the left subclavian vein. No problems with catheterization were noted. Three weeks later, after discharge, mild pain and edema developed in the patient's right lower leg. He was treated with antibiotics for 1 week, and his symptoms diminished. Six months after the operation, the patient presented with posterior cervical pain. A guide wire, presumably lost during the insertion of the central venous catheter, was protruding from the back of his neck (Panel A, arrow). A computed tomographic scan showed the fractured guide wire in the central venous system (Panel B, arrows). The wire protruding from the back of the neck was removed easily; however, it was difficult to remove the part of the wire involving the saphenous vein, and an open procedure with general anesthesia was required. The involved leg vein was thrombosed and occluded. At 1 year of follow-up, the patient was free of symptoms and signs.

This is one of the stranger complications of a central line that I've ever seen. Basically, the way a central line is inserted is by the Seldinger technique. In brief, a needle is introduced into the vein; a guidewire is threaded through the needle; the needle is removed; and the catheter is threaded over the wire into the vein, after which the wire is removed. Losing the guidewire is a potential technical complication, and when that happens it's necessary to take the patient to angiography to find and retrieve the wire. However, I just don't see how anyone who knows what he is doing can possibly fail to realize that he has lost the wire. It is possible for the wire to break, but this usually only happens after a very difficult insertion with lots of mucking about, and after such an insertion it is incumbent upon the surgeon to examine the wire after removing it and make sure the entire wire was retrieved. If there is any suspicion that the wire may have broken off (and, believe me, given the gentle curve into a "J" shape at the end of the wire, which is designed to make it less likely that the wire can perforate the vein as it's threaded, it's not hard to tell if the wire has broken), the appropriate X-rays (chest, abdominal, etc.) must be obtained to look for it.

It just goes to show that even relatively simple procedures can have serious complications, or, as I've said before, there's no such thing as "minor" surgery. Central lines are no different.