Case report of a guide wire loss and migration after central venous access

• Guide wire loss after catheter placement is an uncommon, preventable complication.
• Removal of a lost guide wire is mandatory.
• Adequate interpretation of imaging studies is necessary.

We report a case of guide wire loss and migration after central venous access for spinal deformity surgery. Guide wire migration was noticed on a follow-up full spine x-ray 69 days postoperatively. Percutaneous retrieval was successfully performed using endovascular techniques. With this case report, we want to highlight the fact that one could miss other pathologies visible on these full spine x-rays when concentrating only on the measurement of spinopelvic parameters.