Intravascular foreign body (IFB) embolization is a potential complication of any vascular operation [1]. Placement of a central venous catheter (CVC) is a common procedure that has been increasing over time, especially during surgery, hemodialysis, or in critically ill patients [2]. The complete loss of the introducing guidewire into the circulation is a rare, but recognized complication [3]. The majority of cases are identified immediately or shortly after the procedure [4-6]. In those rare cases that the guidewire has been retained long after the procedure, the diagnosis is usually incidental, during X-ray or other imaging modality [7]. IFB retrieval can be achieved using percutaneous techniques, open surgery, or hybrid techniques [1].

We report an unusual case of an 82-year-old male with an unrecognized, retained CVC guidewire, extending from the right common femoral vein (CFV) to the superior vena cava (SVC), that was identified incidentally 2 years after right internal jugular vein (IJV) cannulation during colorectal surgery. The guidewire was successfully extracted surgically under local anesthesia through a venotomy of the right CFV. The study protocol received approval from Institutional Review Board at “G. Gennimatas” General Hospital of Thessaloniki (No. 311/2023) and adhered to the principles outlined in the Helsinki Declaration (2013 amendment). The patient provided written informed consent for the operation and the publication of his medical information and images.

An 82-year-old male underwent open surgery for colorectal cancer in September 2021. The tumor was diagnosed at an early stage and completely resected, obviating the need for adjuvant therapy. Two years later, in October 2023, he had a follow-up abdominal computed tomography (CT) scan, in which an IFB, specifically a misplaced guidewire, was identified. The guidewire extended from the right CFV to the SVC, with its J-tip end located at the junction of the right femoral vein and the right profunda femoris vein, and its straight end passing through the right ventricle and right atrium to the SVC (Fig. 1, 2). There was no evidence of current or previous iliocaval venous thrombosis.

Figure 1. Retained intravascular foreign body (guidewire): X-ray imaging (left) and surgical specimen after open retrieval (right).

Figure 2. Computed tomography image of the retained intravascular guidewire, extending from the right common femoral vein to the superior vena cava.

The patient’s previous medical records revealed that he had undergone intraoperative right IJV catheterization with CVC placement (7 Fr; 3 Lumen; 20 cm; BIP Central Venous Catheter, Bactiguard^®) during the colorectal surgery. The catheter remained in place during his stay and was removed prior to discharge. The IJV CVC placement was performed by the attending anesthesiologist without ultrasound or fluoroscopic guidance, and no chest X-ray was performed postoperatively. No additional clinical or technical information was documented regarding the procedure of CVC placement. It is noteworthy that the patient was not admitted to the intensive care unit during his hospitalization, and no follow-up imaging was performed until October 2023.

The patient was asymptomatic at the time and clinical examination was normal. He had a medical history of arterial hypertension, dyslipidemia, and tobacco smoking. His laboratory results were within normal range. A 12-lead electrocardiogram (ECG) and a transthoracic echocardiogram (TTE) were performed, both demonstrating normal findings without evidence of arrhythmia or structural heart abnormalities. Bilateral lower extremity screening with color duplex ultrasound (cDUS) revealed no signs of deep vein thrombosis (DVT) or post-thrombotic syndrome. Conservative treatment with follow-up was rejected due to the serious risks of a retained, indwelling IFB. After a comprehensive discussion, the patient provided written informed consent to proceed with open surgical removal of the guidewire.

Open surgical extraction of the guidewire was performed under local anesthesia and fluoroscopic guidance. After a femoral cut-down, a transverse venotomy of the right CFV was performed. Using a curved Mosquito clamp, the guidewire was gently pulled out, beginning with its distal J-tip end, followed by the proximal straight end (Fig. 3). Intraoperative fluoroscopy of the chest, abdomen, and pelvis did not identify any remaining guidewire fragments, and completion venography showed no signs of venous bleeding. The venotomy was closed with interrupted 5-0 monofilament polypropylene sutures. The total length of the retrieved guidewire was 60 cm, which corresponded exactly to the designated length of the CVC introducing guidewire (Fig. 1).

Figure 3. Intra-operative step-by-step open removal of the guidewire through venotomy of the right common femoral vein.

The patient was transferred to the general ward and was mobilized on the same day as the surgery with thigh-high graduated compression stockings. His postoperative hospitalization was uneventful, and he was discharged on postoperative day 1 in good general condition under low molecular weight heparin at therapeutic dosage (tinzaparin 14,000 IU o.d.) for 2 weeks. Follow-up cDUS at 1 and 6 months revealed the patency of the right CFV without any signs of DVT. At present, the patient remains asymptomatic.

Central venous catheter placement is nowadays considered a routine procedure, especially during surgery or in critically ill patients [1]. It has been steadily increasing over time, due to the need for hemodynamic invasive monitoring, fluid and drug administration, parenteral nutrition, and hemodialysis [2]. Accordingly, the incidence of complications associated with CVC insertion has also risen, possibly due to the increased workload or the enhanced reporting of clinical adverse events [1,3]. Intravascular complete loss of the introducing guidewire is an extremely rare complication, likely under-reported due to fear of litigation, as it is completely preventable by precisely following the procedural protocol [8]. Moreover, it can lead to costly investigations and procedures for its retrieval, imposing an economic burden on the healthcare system and potentially harming the patient, thereby raising medicolegal issues [3].

The majority of such cases are identified immediately or shortly after the procedure [3]. Detection usually occurs when the operator notices the missing guidewire while inspecting the catheter tray, or when its tip is missing during extraction [4,7]. However, a lost guidewire may remain unnoticed and be discovered incidentally after a long period, as in our case, where it was randomly discovered 2 years after the CVC insertion [4]. In one reported case, a lost guidewire was detected during post-mortem examination [3]. The longest reported time gap is 20 years [3].

Potential consequences and complications include cardiac arrhythmias, vascular damage, thromboembolic complications, infection, cardiac perforation, and/or tamponade [9,10]. Moreover, the guidewire can undergo kinking, looping, knotting, or entanglement [11]. Guidewire fragmentation may also lead to subsequent embolism [12,13]. In our case, the guidewire was intact, extending from the right CFV to the SVC, passing through the heart chambers, without causing any symptoms or complications, whatsoever, despite its long-term intravascular indwelling.

Various imaging modalities such as radiography, CT scan, ultrasonography, echocardiography, and angiography have been used for detecting retained guidewires [3]. Moreover, advanced imaging techniques, such as 3D CT reconstruction, can provide detailed visualization, aiding in the planning of the extraction procedure. In our case, the misplaced guidewire was discovered during a follow-up CT scan after colorectal cancer surgery. Importantly, despite the patient’s history of cancer and major abdominal surgery, no postoperative imaging was performed for two years, which contravenes published international guidelines for cancer follow-up and raises potential liability questions.

Various risk factors have been identified so far that can increase the risk of guidewire retention, including the operator’s level of experience, lack of proper supervision, distraction during the procedure, and high workload [2-4]. Lack of adequate supervision has been identified as the most common risk factor, with most cases attributed to trainee doctors [3]. Numerous strategies have been suggested to avoid this procedural error, including awareness of this possibility of retained guidewire, training on a manikin, effective supervision, strong vigilance during insertion, and provision of an adequate workforce, especially outside routine hours, as well as avoiding insertion at night, unless absolutely essential [7,11,12,14]. Moreover, measures to train personnel under the supervision of skilled practitioners may minimize these complications, including confirming that the guidewire has been retracted and verifying the correct placement with a chest X-ray [7,11,12,14]. In our case, the attending anesthesiologist inserted the CVC without ultrasound or fluoroscopic guidance, and no chest X-ray was performed postoperatively. Furthermore, no other clinical or technical information was documented regarding the procedure, which underscores the importance of proper documentation, especially in cases where medicolegal issues may arise.

Retrieval of a lost guidewire can be achieved using percutaneous techniques, open surgery, or hybrid techniques [1]. Clinical and technical factors, such as the exact location, position and orientation of the guidewire, the presence of any kinking or looping, and the patient’s vascular anatomy can greatly influence the ease of guidewire removal. Percutaneous endovascular removal is considered a minimally invasive and usually first-choice technique due to its high success rate and low morbidity [1]. Numerous endovascular IFB removal techniques have been described, such as loop snare, proximal/distal grab, coaxial snare, lateral grasp, stone retrieval basket, small balloon catheter, guidewire as snare, hairpin trap, and two-wire technique [15]. In our case, open surgical removal was deemed a better and more suitable choice due to the location of the distal end of the guidewire in the CFV, which facilitated its expeditious exposure and retrieval through a limited cut-down and local anesthesia, while maintaining vascular control and vascular access. The short operating time, minimal cardiopulmonary burden, and rapid postoperative mobilization led to an uneventful hospitalization, with no morbidity and mortality. The 1-month and 6-month follow-up cDUS revealed the patency of the CFV, without any signs of DVT, and the patient remains asymptomatic to date.

In summary, we presented a case of an unrecognized, retained CVC guidewire, that remained intravascular for 2 years, was discovered incidentally during imaging, and was successfully removed by open surgery. Guidewire retention continues to occur despite following procedure protocols, as it partly relies on the human factor [14]. To minimize the risk of guidewire retention, proper education and advanced awareness are advised, and a more rigorous procedural protocol may need to be developed.

None.

The author has nothing to disclose.

Concept and design: DAC, GAP. Analysis and interpretation: DAC, AGP, Apostolos G. Pitoulias. Data collection: DAC, GVT, TNZ. Writing the article: DAC, VEPS, IIK. Critical revision of the article: all authors. Final approval of the article: all authors. Statistical analysis: none. Obtained funding: none. Overall responsibility: GAP.