Here, we report a peculiar case of a missed guidewire puncturing the aortic arch and cerebrum” Zhao et al (2019).
Abstract:
RATIONALE: Central venous catheterization is a common tool used to monitor central venous pressure and administer fluid medications in patients undergoing surgery. The loss of a broken guide wire into the circulation is a rare and preventable complication. Here, we report a peculiar case of a missed guidewire puncturing the aortic arch and cerebrum.
PATIENT CONCERNS: A 53-year-old man with complaints of an intermittent headache and right swollen ankle following central venous catheterization.
DIAGNOSES: Using computed tomography; the patient was diagnosed with the loss of a guide wire in his body. The guide wire had migrated to the brain and punctured the vascular wall of the aortic arch.
INTERVENTIONS: Due to the risks of surgery, the patient was advised to have a follow-up visit once every 3 months.
OUTCOMES: At present, the patient could live like a normal person, although he suffers from intermittent headaches.
LESSONS: The loss of a guide wire is a completely preventable complication, provided that a hold on the tip of the wire is maintained during placement, and the correct safety measurements and protocols are followed.
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Reference:
Zhao, S., Wang, Z. AND Zhao, Y. (2019) Loss of guidewire and its sequelae after central venous catheterization: A case report. Medicine. 98(29), P.e16513. doi: 10.1097/MD.0000000000016513.