central vein catheterization has commonly been used for volume resuscitation , emergency venous access , chemotherapy , parenteral nutrition , hemodialysis , and central venous pressure monitoring . the percutaneous approach includes access via the internal jugular vein , femoral vein , or subclavian vein . during a case of right subclavian venous catheterization using the landmark method , we experienced extravasation , breakage , and entrapment of a guidewire within the thorax that was subsequently removed using video - assisted thoracoscopic surgery ( vats ) . we report this case for educational purposes because this procedure is common but must be performed carefully . a 79-year - old female patient diagnosed with ascending colon cancer was admitted to the division of colon and rectal surgery of our institution for a scheduled operation on july 23 , 2012 . at admission , the patient 's calculated acute physiology and chronic health evaluation ii score was 10 with a predicted death rate of 11.3% . central venous catheterization was performed for preoperative , intraoperative , and postoperative volume resuscitation and nutritional therapy . a senior surgical resident used the landmark method to perform catheterization of the right subclavian vein . the spectrum central venous catheter set ( length , 20 cm ; size , 7.0 f ; william a. cook australia pty . ltd . , brisbane , australia ) the right subclavian vein was successfully punctured using the seldinger technique , and the guidewire was then inserted . slight resistance was detected during the guidewire insertion process , but the resident proceeded with it . when guidewire advancement was not possible , its removal was attempted . however , by this point , it could be neither advanced nor removed because of resistance . chest radiography was immediately performed to determine the position of the guidewire , and the results indicated guidewire looping and entrapment within the upper right clavicle ( fig . chest computed tomography scans revealed that the broken guidewire was outside the vein and had not induced hemothorax , pneumothorax , or hematoma of the soft tissues ( fig . after we had explained this to the patient , under local anesthesia , we tried to remove the broken guidewire through infraclavicular skin incision but we could not find the guidewire . the patient was transferred to the operating room for the scheduled operation and underwent vats of the right thorax . the surgical manifestation was metallic foreign body impaction in the upper chest wall that was successfully removed ( fig . volume resuscitation was conducted through the internal jugular vein during the operation , while nutritional support was delivered via peripheral venous access . the use of subclavian venous access has decreased in recent years because of its associated potentially life - threatening complications such as hemothorax , pneumothorax , and mediastinal hematoma . however , it has the advantages of increased patient comfort and convenience in the postoperative care period . especially considering its convenience of consistent landmarks despite being a blind procedure in emergent settings , it is frequently performed when rapid venous access is required , such as during cardiopulmonary resuscitation . a recent study reported that the use of bedside real - time ultrasound for subclavian vein catheterization was effective . however , more studies have demonstrated that the ultrasound technique is better than the landmark method in the internal jugular vein , and its effectiveness in the subclavian vein is both controversial and known to be technically difficult [ 3 - 5 ] . when ultrasound is not possible or a patient is in a surgically emergent setting , rapid venous access via the subclavian fig . wang and sweeney   reported a case of guidewire entrapment during left subclavian venous catheterization in which they were able to remove the entrapped catheter using gentle traction . that report argued that a guidewire should not be inserted further if resistance is detected during insertion or removal , and that j - tip guidewires should be used to reduce the risk of vascular perforation . despite these lessons of wang and sweeney , complications involving guidewire knotting and entrapment onan et al .   recently reported a case of a knotted and entrapped guidewire that was removed using an infraclavicular incision under local anesthesia . in our case , because the patient was already scheduled for an operation that required general anesthesia , the entrapped guidewire can be removed using vats . there has been a recent decrease in the use of the subclavian venous catheterization method . however , use of this procedure is inevitable sometimes in emergency conditions requiring rapid venous access or when other insertion sites are unavailable because of previous insertions or catheter - related infections . therefore , surgeons and physicians must be well familiarized with and educated on the standard landmark method . as our experience demonstrates , resistance encountered during guidewire insertion indicates possible knotting , looping , or entrapment ; in such cases , the guidewire should not be forcibly inserted or removed . in addition , when experts are not available , the use of ultrasound - guided internal jugular vein access rather than the subclavian vein approach can help reduce the risk of complications . in conclusion , mastery of the basic principles of this technique is important , and such procedures should be gently performed using accurate landmark assessment with the patient in trendelenburg position long enough to allow for sufficient venous retention .
subclavian venous catheterization was once widely used for volume resuscitation , emergency venous access , chemotherapy , parenteral nutrition , and hemodialysis . 
 however , its use has drastically reduced recently because of life - threatening complications such as hemothorax , pneumothorax . in this case , a patient admitted for a scheduled operation underwent right subclavian venous catheterization for preoperative , intraoperative , and postoperative volume resuscitation and parenteral nutrition . 
 the procedure was performed by an experienced senior resident . despite detecting slight resistance during the guidewire insertion , the resident continued the procedure to the point of being unable to advance or remove it , then attempted to forcefully remove the guidewire , but it broke and became entrapped within the thorax . 
 we tried to remove the guidewire through infraclavicular skin incision but failed . 
 so video - assisted thoracoscopic surgery was used to remove the broken guidewire . 
 this incident demonstrates the risks of subclavian venous catheterization and the importance of using a proper and gentle technique .