The forgotten guide wire: a rare complication of hemodialysis catheter insertion

Abstract

A rare complication of a hemodialysis catheter insertion is the loss of the complete guide wire into the circulation. A complete guide wire in the circulation may not necessarily produce symptoms, and it may remain unnoticed for a significant period of time. We present a rare case where a complete guide wire was lost into the circulation during insertion of a hemodialysis catheter into the right femoral vein in a 19-year-old female with systemic lupus erythromatosis. The patient remained asymptomatic through two plasmapheresis treatments over a period of 2 days. The guide wire was eventually retrieved without complications. The factors leading to the wire being forgotten will be reviewed, and the measures initiated to prevent any future occurrence will be addressed.

Keywords: Central venous catheter; hemodialysis; plasmapheresis.

Figure 1

A chest radiograph taken with the patient in the sitting position shows the presence of the intact guide wire in the right hemothorax.

Figure 2

An abdominal radiograph shows the tip of the guide wire originating from the hemodialysis catheter inserted in the right femoral vein.

Figure 3

The guide wire shown coiled measures 70 cm.