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Learning from errors
A delayed diagnosis of a retained guidewire during central venous catheterisation: a case report and review of the literature
  1. Yasemin Gunduz1,
  2. Mehmet Bulent Vatan2,
  3. Altug Osken2,
  4. Mehmet Akif Cakar2
  1. 1Department of Radiology, Sakarya University Medical Faculty, Sakarya, Turkey
  2. 2Department of Cardiology, Sakarya University Medical Faculty, Sakarya, Turkey
  1. Correspondence to Yasemin Gunduz, dryasemingunduz{at}


Central venous catheterisation allows delivery of medications, intravenous fluids, parenteral nutrition, haemodialysis and monitoring of haemodynamic variables. Various complications may occur during and after the procedure. However, the complete guidewire retention has rarely been reported. In this report, we have presented a complete guidewire retention as a result of inadvertent catheter insertion. After 17 months of the first operation performed upon the diagnosis of Fournier's gangrene, the patient was admitted to the cardiology polyclinic with a recurrent chest pain. Echocardiography showed a wire-shaped foreign body within the right part of the heart, and a fluoroscopic examination showed a guidewire reaching from the superior vena cava to the right external iliac vein. In retrospect, the wire was already visible on the postoperative chest x-rays and CT taken while the patient was still in intensive care unit, but its presence was overlooked at that time. The guidewire was retrieved completely during a surgery.

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