{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,17]],"date-time":"2026-07-17T17:04:31Z","timestamp":1784307871667,"version":"3.55.0"},"reference-count":24,"publisher":"Wiley","issue":"6","license":[{"start":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T00:00:00Z","timestamp":1781654400000},"content-version":"vor","delay-in-days":16,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,6,1]],"date-time":"2026-06-01T00:00:00Z","timestamp":1780272000000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Clinical Case Reports"],"published-print":{"date-parts":[[2026,6]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:p>Central venous catheters (CVCs) are essential in transplantation but can rarely fracture and embolize, with donor\u2010to\u2010recipient transmission of catheter fragments scarcely described. A 62\u2010year\u2010old woman with hepatitis C\u2013related cirrhosis and hepatocellular carcinoma underwent orthotopic liver transplantation from a brain\u2010dead donor with a left subclavian multi\u2010lumen CVC in\u00a0situ at procurement. Postoperative chest radiography identified a new curvilinear opacity at the left hilum, and contrast\u2010enhanced computed tomography showed a 5\u2009cm radiopaque structure in a segmental branch of the left lower lobe pulmonary artery, consistent with an embolized CVC tip. All recipient vascular access devices were removed intact, strongly suggesting a donor\u2010origin catheter fragment transplanted with the liver graft. Alternative explanations, including unrecognized recipient catheter fracture and pre\u2010existing foreign body, were considered but deemed less likely given the temporal relationship, imaging findings, and systematic device inspection. Percutaneous endovascular retrieval via femoral venous access was attempted but failed because of the fragment's distal location and probable endothelialization. Therapeutic anticoagulation was considered but not commenced because there was no radiological evidence of thrombus formation or pulmonary embolism, and substantial competing postoperative bleeding risk. The patient remained asymptomatic, and conservative management with clinical and imaging surveillance was adopted; at 6\u2009months, she had excellent graft function and no cardiopulmonary sequelae. However, an uneventful short\u2010term follow\u2010up does not establish long\u2010term safety, and early retrieval remains the preferred strategy whenever technically feasible and clinically safe. This case represents, to our knowledge, a previously unreported mechanism of donor\u2010to\u2010recipient CVC fragment transmission in liver transplantation, with the most plausible explanation being unrecognized transection of the donor catheter during heart procurement with subsequent lodgment in hepatic venous outflow, although definitive proof is not possible in the absence of direct intraoperative recognition. It highlights an important systems\u2010level vulnerability at the interface between donor procurement, graft preparation, and recipient implantation. Modern multiorgan retrieval frequently involves multiple independent procedural teams, overlapping operative fields, and rapid transitions, creating fragmented responsibility for confirming removal and integrity of vascular access devices. This case underscores the importance of standardized vascular access reconciliation, careful inspection of donor venous structures, and early postoperative imaging. Structured vascular access reconciliation and verification protocols, analogous to surgical instrument counts and implant verification systems, may represent an important patient\u2010safety intervention in transplantation.<\/jats:p>","DOI":"10.1002\/ccr3.72962","type":"journal-article","created":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T09:06:57Z","timestamp":1781687217000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["From Donor Liver to Recipient Pulmonary Artery: Embolization of a Transected Central Venous Catheter During Liver Transplantation, A Rare Complication of Organ Procurement"],"prefix":"10.1002","volume":"14","author":[{"given":"Fawaz Ahmed Prem","family":"Navaz","sequence":"first","affiliation":[{"name":"Department of Anaesthesia Austin Health  Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7403-7680","authenticated-orcid":false,"given":"Laurence","family":"Weinberg","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia Austin Health  Melbourne Victoria Australia"},{"name":"Department of Critical Care The University of Melbourne  Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nattaya","family":"Raykateeraroj","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Faculty of Medicine Siriraj Hospital Mahidol University  Bangkok Thailand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Moncrieff","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia Austin Health  Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernice","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Anaesthesia Austin Health  Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marie","family":"Sinclair","sequence":"additional","affiliation":[{"name":"Department of Gastroenterology and Hepatology Austin Health  Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helen","family":"Opdam","sequence":"additional","affiliation":[{"name":"Department of Intensive Care Austin Health  Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manfred","family":"Spanger","sequence":"additional","affiliation":[{"name":"Department of Radiology Eastern Health  Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hin\u2010Boon","family":"Lew","sequence":"additional","affiliation":[{"name":"Department of Radiology Austin Health  Melbourne Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Fink","sequence":"additional","affiliation":[{"name":"Department of Surgery The University of Melbourne, Austin Health  Heidelberg Victoria Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,6,17]]},"reference":[{"key":"e_1_2_14_2_1","doi-asserted-by":"publisher","DOI":"10.1001\/jamainternmed.2023.8232"},{"key":"e_1_2_14_3_1","doi-asserted-by":"publisher","DOI":"10.7759\/cureus.43044"},{"key":"e_1_2_14_4_1","doi-asserted-by":"publisher","DOI":"10.1177\/0148607109335121"},{"key":"e_1_2_14_5_1","doi-asserted-by":"publisher","DOI":"10.1136\/bcr\u20102012\u2010007249"},{"key":"e_1_2_14_6_1","doi-asserted-by":"publisher","DOI":"10.1155\/2018\/5406098"},{"key":"e_1_2_14_7_1","doi-asserted-by":"publisher","DOI":"10.1155\/2019\/4359197"},{"key":"e_1_2_14_8_1","unstructured":"\u201cStatutory Duty of Candour and Protections for SAPSE Reviews \u201d 2025 https:\/\/www.safercare.vic.gov.au\/report\u2010manage\u2010issues\/adverse\u2010events\/duty\u2010of\u2010candour."},{"key":"e_1_2_14_9_1","unstructured":"\u201cStatutory Duty of Candour and Protections for SAPSE Reviews \u201d 2025 https:\/\/www.health.vic.gov.au\/quality\u2010safety\u2010service\/open\u2010disclosure\u2010following\u2010adverse\u2010events\u2010in\u2010health\u2010services."},{"key":"e_1_2_14_10_1","doi-asserted-by":"publisher","DOI":"10.1186\/1757\u20101626\u20101\u2010394"},{"key":"e_1_2_14_11_1","doi-asserted-by":"publisher","DOI":"10.1308\/003588412X13171221499515"},{"key":"e_1_2_14_12_1","doi-asserted-by":"publisher","DOI":"10.5090\/kjtcs.2018.51.5.333"},{"key":"e_1_2_14_13_1","doi-asserted-by":"publisher","DOI":"10.2214\/ajr.130.3.541"},{"key":"e_1_2_14_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/0002\u20109610(84)90340\u20104"},{"key":"e_1_2_14_15_1","doi-asserted-by":"publisher","DOI":"10.1378\/chest.117.4.1209"},{"key":"e_1_2_14_16_1","doi-asserted-by":"crossref","unstructured":"T. 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