Intravascular Retained Surgical Items: A Multi-Center Study of Risk Factors

Abstract

Introduction: Retained surgical items (RSI) have been previously studied in patients undergoing major surgical procedures. However, little information is available regarding RSI associated with vascular procedures. This is the first case-control study that specifically examines potential risk factors for intravascular RSI. Methods: Multi-center retrospective review of 83 RSI events was performed. Among these, 13 cases involved intravascular RSI (ivRSI). Cases were compared to procedure-matched controls to determine potential risk factors for ivRSI including procedural factors (urgency, complicating factors); patient factors (BMI); equipment failure and safety variances. Fisher's exact testing were performed. Results: Thirteen ivRSI cases and 14 controls were examined. There were no differences between the two groups with regards to age, gender, or BMI. ivRSI items included guidewires (8/13), catheter/catheter fragments (4/13) and a coil (1/13). The incidence of unexpected procedural factors was significantly higher among ivRSI cases (10/13) than among controls (3/14, p<0.007). Equipment failure occurred in 5 ivRSI cases, with no such incidences among controls (p><0.016). There were no differences between the two groups with regards to proportion of urgent procedures, bleeding >500 mL, procedure between 5pm-7am, or trainee involvement. Both groups had a very high proportion of safety variances (8 in ivRSI and 11 in control group, p=ns). In addition, 7/13 ivRSI were missed on confirmatory post-procedural imaging. Conclusions: Unexpected procedural factors and equipment failure are significantly associated with ivRSI. of concern, over half of all ivRSI were missed on confirmatory post-procedural imaging. Strict adherence to established safety protocols and incorporation of more stringent radiographic review for intravascular procedures.