Tehran University of Medical Sciences The Research in Heart Yield and Translational Medicine (RHYTHM) 3115-7270 10 1 2015 10 13 368 368 EN Manouchehr Hekmat Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Hamid Ghaderi Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Seyedeh Adeleh Mirjafari Brain and Spinal Injury Research Center (BASIR), Tehran University of Medical Sciences, Tehran, Iran. 2015 10 13 2015 10 13 At the final stages of a coronary artery bypass graft operation on a 64-year-old man, an experienced physician attempted to insert an intra-aortic balloon pump into the femoral artery via the Seldinger technique. However, while the balloon pump was being passed over the guide wire, the latter was completely lost. The guide wire should be held at the tip at all times to prevent passage into the vessel. Strict adherence to this rule will prevent guide-wire loss, which is, albeit rare and completely avoidable, a potentially life-threatening complication of central vein or artery catheterization, with reported fatality rates of up to 20% when the whole wire is lost. The literature contains several reports on guide-wire loss during central venous, arterial, and hemodialysis catheterization, but we report for the first time the loss of a guide wire as a rare complication of intra-aortic balloon pump insertion. https://rhythm.tums.ac.ir/index.php/jthc/article/view/368 https://rhythm.tums.ac.ir/index.php/jthc/article/download/368/361