Lost guide wire – lessons learned

Central venous catheter placement is a relatively common procedure in current practice, but it is not devoid of risks. Utmost care must be taken to follow a correct technique, and only appropriately trained and/or supervised medical professionals should perform this invasive act. One of the possible complications, completely avoidable by appropriate care, is the intravascular loss of the guide wire during insertion, which is a potentially serious complication. We describe one such case.