Abstract

Central venous catheterization is a commonly performed procedure in emergency and intensive care settings, a retained guide-wire is extremely rare and is almost never been discussed in literature.

Keywords: Central venous catheterization; Guidewire; Retained

Introduction

Central venous catheterization (CVC) is a common procedure in emergency, intensive care, and perioperative settings, widely used for hemodynamic monitoring, transfusion, drug administration, and fluid resuscitation. Despite its routine use, complications can occur, including malposition, vascular injury, thrombosis, infection, and, rarely, inadvertent retention of the guidewire used during the Seldinger technique [1-3].

A retained guidewire is considered a “never event,” since it is entirely avoidable but can have serious complications such as sepsis, thrombosis, embolism, vascular injury, or even death [4,5]. Its true frequency is likely under reported due to medico-legal concerns and the fact that some patients remain asymptomatic, with the diagnosis made only incidentally during imaging [6].

Radiological evaluation plays a pivotal role in these situations. Plain radiographs, ultrasound, and CT imaging are not only useful for identifying retained intravascular foreign bodies but also for accurately localizing them and guiding safe retrieval [7,8]. Importantly, a vigilant “radiological eye” is essential, as these findings are often incidental when imaging is performed for unrelated clinical indications. Detecting such hidden complications early can significantly reduce morbidity and prevent life-threatening outcomes.

Here, we present a case series of incidentally detected retained central venous pressure (CVP) guidewires, underscoring the importance of radiological vigilance in diagnosis and management.

Case Report

A 35-year-old male presented to the Emergency Department as a referred case for contrast-enhanced CT (CECT) abdomen with a clinical suspicion of acute biliary pancreatitis. He complained of severe epigastric pain radiating to the back, associated with nausea and vomiting. There was no history of fever, diarrhea, or constipation. Past medical history was significant for Cholelithiasis.

On examination, the patient appeared distressed but was vitally stable. Cardiovascular evaluation including ECG and cardiac enzymes was unremarkable. Laboratory investigations revealed markedly elevated serum amylase and lipase levels.

A CECT abdomen with pancreatic protocol was performed. The preliminary scannogram revealed an incidental finding of a linear radiodense foreign body extending along the right paraspinal region and terminating at the level of the L2 vertebral body, suggestive of a retained central venous pressure (CVP) guidewire. On CECT Abdomen images, the guidewire was visualized coursing from the suprahepatic inferior vena cava into its infrahepatic part, with the distal tip extending into the right renal vein. Multiple streak artifacts were noted along its course. Imaging findings of acute biliary pancreatitis were also present.

The surgical and interventional radiology teams were promptly notified. The retained CVP guidewire was successfully retrieved without complication. The patient remained hemodynamically stable and demonstrated uneventful recovery following the procedure.

Discussion

Central venous catheterization (CVC) is one of the most commonly performed invasive procedures in critical care, emergency departments, and perioperative settings. Its indications range from hemodynamic monitoring to administration of vasoactive drugs, long-term antibiotic therapy, chemotherapy, and hemodialysis [1]. Despite its life-saving utility, CVC is associated with a spectrum of complications, which may be immediate, such as arterial puncture, arrhythmias, pneumothorax, and hematoma formation, or delayed, including infection, thrombosis, and catheter malfunction [2,3].

Retention of a guidewire during central venous catheter placement is a rare but serious complication. Although considered a “never event,” it continues to be reported worldwide [4]. The incidence is difficult to quantify as it is often underreported due to medicolegal implications [5]. The first documented case was reported by Schummer et al. in 1983 [6], and despite advances in procedural training and the use of checklists, guidewire retention remains a persistent risk, particularly in high-pressure or emergency environments.

The underlying mechanism typically involves loss of control of the proximal end of the guidewire during insertion or inadvertent advancement into the venous circulation during dilation or catheter placement [7]. Factors contributing to such errors include operator inexperience, procedural haste, patient restlessness, poor lighting, and fatigue [8]. Additionally, lack of procedural supervision in training institutions and insufficient adherence to standardized insertion protocols further elevate the risk [9].

The clinical consequences of retained guidewires can range from asymptomatic presentations to life-threatening complications. Migration of the guidewire can result in vascular injury, cardiac arrhythmias, venous thrombosis, endocarditis, embolization, and even death [10]. In many cases, however, the guidewire is only detected incidentally during imaging performed for unrelated reasons. In our series, patients presented with fever or underwent imaging for abdominal pain, and the discovery of the retained guidewire was incidental. Such findings underscore the importance of maintaining a radiological eye for unexpected abnormalities, even when evaluating imaging studies for entirely different clinical indications.

Radiology plays a pivotal role in both diagnosis and management. Plain radiographs are often the first-line modality and can delineate the course of the radiopaque guidewire with high accuracy [11]. Chest radiographs and abdominal X-rays remain indispensable in such scenarios due to their accessibility, rapidity, and low cost. In our cases, careful interpretation of routine chest and abdominal radiographs revealed the presence of the foreign body, which might otherwise have been overlooked.

Ultrasound can complement radiography by confirming the intravascular position of the guidewire, especially in superficial venous segments such as the femoral or jugular veins [12]. CT imaging, though not always necessary, provides superior anatomical detail, allowing assessment of the wire’s exact position, relationship to adjacent structures, and evaluation for associated complications such as thrombosis, vascular injury, or abscess formation [13]. Hence, radiologists must remain vigilant in identifying incidental findings, as early recognition directly influences patient safety and outcome.

Once identified, prompt removal of the retained guidewire is imperative. Endovascular retrieval under fluoroscopic guidance is the preferred approach due to its minimally invasive nature and high success rate [14]. Surgical exploration is reserved for cases where endovascular techniques fail or where complications such as vascular perforation or infection necessitate open intervention [15]. In our series, collaboration between interventional radiology and surgical teams ensured safe removal without major morbidity [16,17].

Conclusion

Retained guidewires after central venous catheterization, though uncommon, represent a serious and entirely preventable iatrogenic complication. These cases emphasize the critical role of radiologists in identifying such foreign bodies, often incidentally, during routine imaging for unrelated clinical concerns. Maintaining a vigilant “radiological eye” for unexpected findings can prevent delayed diagnosis and reduce patient morbidity. Strengthening operator training, enforcing strict procedural checklists, and encouraging multidisciplinary communication are essential to minimize such events. Ultimately, timely recognition and retrieval of retained guidewires not only avert complications but also reinforce the indispensable role of radiology in patient safety.

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