Correspondence

14-Year Follow-up of Central Embolization by a Guide Wire

N Engl J Med 1993; 329:970-971September 23, 1993

Article

To the Editor:

After a 53-year-old man was admitted to the hospital in October 1990 with mild exertional dyspnea, a chest film showed a foreign body about 40 cm long. The foreign body was obviously a guide wire. One end was coiled in the left and right pulmonary arteries; the other extended into the right ventricular outflow tract (Figure 1Figure 1A 40-cm Guide Wire (Arrowheads) in the Right Ventricular Outflow Tract, Pulmonary Trunk, and Left and Right Pulmonary Arteries.). The man had been hospitalized 14 years earlier for the treatment of a fractured left femur. A central venous line had been placed from the right cubital vein. We presumed that central embolization by the guide wire occurred then. The patient had no pulmonary symptoms for 12 years. In the two years before his hospitalization in 1990, seasonal cough and sputum developed. Pulmonary-function tests showed moderate peripheral obstruction, partially reversible with beta-2 sympathomimetic drugs. A perfusion lung scan detected no segmental defects suggesting pulmonary embolism. Right-sided cardiac catheterization showed that the pulmonary-artery pressure was slightly elevated (47/17 mm Hg; mean, 27). A pulmonary angiogram was normal. The diagnosis was chronic obstructive lung disease with mild pulmonary hypertension. This was attributed to the patient's abuse of nicotine for more than 35 years. As of May 1993, he was alive and continuing to have dyspnea on moderate exertion.

Embolization by a polyethylene catheter passed from the cubital vein to the right atrium was reported in 19541. In a series of 220 documented cases of catheter embolism, the morbidity was 71 percent and the mortality was 38 percent if the catheter fragment causing central embolization was not removed2. The causes of death included pericardial tamponade due to myocardial perforation, sepsis, endocarditis, thrombosis with subsequent pulmonary embolism, myocardial infarction, and arrhythmias. Mortality was highest when the catheter was located in the right side of the heart, lower when it was in the vena cava, and lowest when it was in the pulmonary artery. For extraction of iatrogenic foreign bodies causing central embolization, percutaneous removal is preferable. Loop snares, Dormia baskets, bronchoscopy forceps, and hooked guide wires and catheters may be used3. Thoracotomy is indicated if nonsurgical removal fails.

Embolization due to catheters and guide wires rarely remains asymptomatic. In one case the interval between central embolization by a catheter fragment and the patient's death in an unrelated traffic accident was 6 1/2 years4; postmortem examination showed that the catheter fragment was partly incorporated into the vessel wall. In our patient, the guide wire showed no flotation on fluoroscopy and appeared to adhere to the vascular wall. Therefore, extraction was not attempted.

Klaus Reynen, M.D.
University of Erlangen-Nurnberg, D-8520 Erlangen, Germany

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Citing Articles (8)

Citing Articles

1. 1

   Minori Tateishi, Yasuko Tomizawa. (2009) Intravascular foreign bodies: danger of unretrieved fragmented medical devices. Journal of Artificial Organs 12:2, 80-89
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2. 2

   Stephen R. Tokarz, Mehmet K. Aktas, Daniel Kroening, Thomas J. Sawyer, James P. Daubert, David T. Huang, Karl Q. Schwarz. (2009) Identification of a Retained Intravascular Wire by Three-Dimensional Transesophageal Echocardiography. Echocardiography 26:4, 463-464
   CrossRef

3. 3

   Mike Kipling, Aza Mohammed, Robert N Medding. (2009) Guidewires in clinical practice: applications and troubleshooting. Expert Review of Medical Devices 6:2, 187-195
   CrossRef

4. 4

   Roberto E. Kusminsky. (2007) Complications of Central Venous Catheterization. Journal of the American College of Surgeons 204:4, 681-696
   CrossRef

5. 5

   Jason N. MacTaggart, Iraklis I. Pipinos, Jason M. Johanning, Thomas G. Lynch. (2006) Acrylic cement pulmonary embolus masquerading as an embolized central venous catheter fragment. Journal of Vascular Surgery 43:1, 180-183
   CrossRef

6. 6

   Vishal Sagar, Eleanor Lederer. (2004) Pulmonary embolism due to catheter fracture from a tunneled dialysis catheter. American Journal of Kidney Diseases 43:2, e13-e14
   CrossRef

7. 7

   LILY M. VAN DEN AKKER-BERMAN, SERGEY PINZUR, ALP AYDINALP, MARC BREZINS, MARC GELLERMAN, AMIR ELAMI, NATHAN ROGUIN. (2002) Uneventful 25-Year Course of an Intracardiac Intravenous Catheter Fragment in the Right Heart. Journal of Interventional Cardiology 15:5, 421-423
   CrossRef

8. 8

   Mark A. Chaney. (1995) Transesophageal Echocardiography and Normal Variants. Anesthesia & Analgesia 81:5, 1112-1113
   CrossRef