Percutaneous Retrieval of a Lost Guidewire That Caused Cardiac Tamponade
Central venous access techniques are commonly used for diagnosis and treatment, especially in critical care units. Complications may arise in as many as 15% of these procedures, although loss of the complete guide wire as a result of deficient insertion with the Seldinger technique has rarely been reported.1 A 48-year-old man was admitted to the burn unit in critical condition after an explosion in a fireworks factory. He needed mechanical ventilation and multiple central venous catheters. During insertion of a central venous catheter through the right femoral vein with the Seldinger technique, inadvertent loss of a 60-cm guide wire occurred. The guide wire was visible in chest x-rays taken while the patient was still in the burn unit (Figure 1), but its presence was overlooked at that time. During the next year the patient underwent several surgical interventions for palliation of sequelae; the guide wire was discovered in preoperative studies, but because the patient was asymptomatic and the guide wire appeared to be immobilized, it was decided to leave it in place. Three years after the initial injury, the patient was admitted to the emergency room with syncope and chest pain consistent with acute pericarditis. An echocardiogram showed severe pericardial effusion with diastolic collapse of the right atrium and ventricle, which suggested cardiac tamponade. Subxiphoid pericardiocentesis drained 800 cc of hemorrhagic fluid with no complications and brought about clinical and echocardiographic improvement. The chest film (Figure 2) showed that the guide wire was fractured in the right atrium, with sharp ends on both fragments caused by the protrusion of the core wire (Figure 3). The fractured guide wire was considered to have perforated the right atrium and caused subsequent tamponade. A few days later, a fluoroscopic examination was performed (online Data Supplement Movie), which clearly showed the fracture of the guide wire and further migration of the lower fragment when compared to the chest films taken on admission. The patient was accordingly scheduled for percutaneous removal of the guide wire fragments after resolution of pericarditis.
To remove the guide wire fragments we used a double vascular access: the right femoral vein to retrieve the upper fragment and the right subclavian vein to remove the lower fragment. A 10-mm snare (Amplatz Goose Neck Microsnare, Microvena Corp, White Bear Lake, Minn) was used through an 8F multipurpose catheter,2 and the guide wire fragment, the snare, the catheter, and the sheath were removed together.
Percutaneous removal should be the first choice in the management of intravascular foreign bodies and should be performed as soon as the diagnosis is made, although retrieval should still be attempted several months or years after the event, because late complications may appear.
The online-only Data Supplement, which consists of a movie, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/24/e629/DC1.