• Shenyu Zhao, Zhe Wang, and Yu Zhao.
• Department of Vascular Surgery, First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
• Medicine (Baltimore). 2019 Jul 1; 98 (29): e16513.

RationaleCentral venous catheterization is a common tool used to monitor central venous pressure and administer fluid medications in patients undergoing surgery. The loss of a broken guide wire into the circulation is a rare and preventable complication. Here, we report a peculiar case of a missed guidewire puncturing the aortic arch and cerebrum.Patient ConcernsA 53-year-old man with complaints of an intermittent headache and right swollen ankle following central venous catheterization.DiagnosesUsing computed tomography; the patient was diagnosed with the loss of a guide wire in his body. The guide wire had migrated to the brain and punctured the vascular wall of the aortic arch.InterventionsDue to the risks of surgery, the patient was advised to have a follow-up visit once every 3 months.OutcomesAt present, the patient could live like a normal person, although he suffers from intermittent headaches.LessonsThe loss of a guide wire is a completely preventable complication, provided that a hold on the tip of the wire is maintained during placement, and the correct safety measurements and protocols are followed.

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