Endovenous laser ablation therapy is a safe and efficient treatment option for varicose veins with an optimal success rate (1-3). It is a minimally invasive procedure featuring less pain that can be easily performed under local anesthesia. Complications such as deep vein thrombosis, nerve injury, infection, recurrence, skin burns, superficial thrombosis, and hematoma have been reported; however, they are mostly transient and self-limited (3).

To ensure ablation success and safety, this procedure is usually performed under ultrasound guidance. After venous access is secured, a guidewire is placed intravenously prior to ablation catheter placement. The guidewire is usually removed before the start of the ablation. However, some case reports of retained guidewire after ablation therapy have been published (4-6). These retained guidewires may cause blood flow disturbances and thrombotic complications as well as specific symptoms according to their location.

Here we report a rare complication in which a post- ablation retained guidewire migrated to the facial vein, causing a severe headache.

This case report was approved by the Institutional Review Board of Korea University Anam Hospital (no. 2022AN0561).

A 29-year-old woman reported to the emergency depart-ment with a severe headache. The patient had no other past history, such as trauma or any other disease, but she reported recently undergoing endovenous laser ablation therapy for lower-extremity varicose veins 20 days prior at another hospital. The patient’s headache started immediately after the operation. She did not report any other neurological deficits; however, the continuous headache was refractory to medical treatment.

The patient’s vital signs were stable and laboratory results normal; however, simple radiography of the chest, neck, and skull showed a thin metallic wire spanning from the right femoral vein up to the right petrosal sinus area (Fig. 1).

Fig. 1. (A) Simple X ray of chest showing residual guidewire. (B) Simple X ray of abdomen showing residual guidewire. (C) AP view of simple X ray of skull showing residual guidewire extending up to right petrosal sinus area. (D) Lateral view of simple X ray of skull showing residual guidewire extending up to right petrosal sinus area.

After the intravenous existence of the guidewire was confirmed on ultrasound (Fig. 2), she consented to undergo emergent interventional removal of the guidewire.

Fig. 2. (A) Axial view of ultras-onography showing the intravascular residual guidewire. (B) Longitudinal view of ultrasonography showing the intravascular residual guidewire.

Under fluoroscopic guidance, the lower tip of the guidewire was grasped and removed through the popliteal vein without resistance (Fig. 3).

Fig. 3. (A) Fluoroscopic view of the guidewire removal procedure through intervention. (B) Fluoro-scopic view of the guidewire removal procedure through inter-vention. (C) Fluoroscopic view of the guidewire removal procedure through intervention.

The procedure was successful and uncomplicated, and complete removal of the guidewire was confirmed by chest radiography (Fig. 4).

Fig. 4. Post-procedural simple X ray of chest showing no residual guidewire.

After guidewire removal, her headache resolved completely. No other neurologic deficits were noted during the post-procedural close observation period. The patient was discharged without complications and is being followed up as an outpatient.

EVLT is a safe and effective ablation procedure for the treatment of lower-extremity varicose veins (1-3). It is widely used worldwide and continuously evolves with laser improvement (7,8).

Minor adverse effects have been reported, including deep vein thrombosis, nerve injury, infection, recurrence, skin burns, superficial thrombosis, and hematoma; however, these are mostly transient and self-limiting (3). To improve procedural quality and safety, additional techniques such as ultrasound examination, tumescent appliance, and use of higher-frequency lasers are being used. Considering the fact that a guidewire may be needed to ensure correct placement of the ablation catheter, combined ultrasound examination before, during, and after the procedure is crucial to avoid unnecessary complications such as that described herein.

Fortunately, our patient did not experience any neuro-logical deficits or thrombotic or vascular complications. However, the possibility of such additional complications due to a retained guidewire cannot be ignored. If it remains in place, problems with its removal could require additional surgery.

In conclusion, EVLT is a safe, simple, and effective varicose vein treatment. It is minimally invasive with minimal discomfort; thus, it may even be performed under local anesthesia. However, care must be taken during and after the procedure to avoid unnecessary major complica-tions. Moreover, the use of ultrasound is essential.

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