Misplaced Central Venous Catheters and Retained Guidewires: A “Never Event” Pictorial Review and Case Series Analysis

Abstract The central venous catheter (CVC) plays an important role in the management of patients. Often, the deployment is in emergency situations, and despite the availability of sonological guidance, there are remote chances of a guidewire being retained in the vasculature or the catheter tip being malpositioned outside the vasculature. This “never event” can further increase the morbidity and mortality. Timely management of these complications can lead to enhanced patient recovery. In this case series analysis, consenting patients with retained guidewires and malpositioned catheter tips, presenting for management by vascular surgeons at a tertiary care hospital were included. This analysis was also a pictorial review of the cases that were managed. Four cases of misplaced guidewires and four cases of malpositioned catheter tips were included in the analysis. All patients underwent either hybrid or endovascular management for the retrieval of a retained guidewire and malpositioned catheter tip. This case series exemplifies the intricate challenges associated with the “never events” of central venous catheterization, namely a retained guidewire and misplaced CVC. It highlights the role of operator awareness and use of assisted technology in mitigating the debilitating effects of such conditions and improving patient outcomes. All efforts should be made to avoid this “never event” by change in-training protocols and increased vigilance. Hybrid procedures encompassing open and endovascular techniques should be employed to minimize the morbidity associated with the condition.