An endless line on the chest radiograph.
A 40-year-old male patient had his right femoral vein catheterised following admission with altered conscious state from polypharmacy overdose. The procedure was documented as successful and uncomplicated. A postprocedural chest radiograph demonstrated a linear metallic opacity projecting over the superior vena cava and inferior vena cava (SVC and IVC, respectively), with superior and inferior ends not visualised. This did not alert the attending radiologist and intensivist who might have assumed such a metallic object to be external to the patient. Only the central line was removed prior to patient discharge 2 days later. The patient died 2 years later from unrelated streptococcal pneumonia complicated by septicaemia and multiorgan failure. The postmortem discovered a central venous guidewire in the IVC across the right atrium into SVC.
Department of Diagnostic Imaging, Monash Health, Clayton, Victoria, Australia.
Allan
A
Lee
Kenneth
K
Lau
Stephen
S
Stuckey
D000328:Adult; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D005547:Foreign Bodies / Q000000981:diagnostic imaging* / Q000209:etiology; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D013902:Radiography, Thoracic; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging*; D014683:Vena Cava, Superior / Q000000981:diagnostic imaging*