Endovascular Management of Lost or Misplaced Intravascular Objects: Experiences of 12 Years

Percutaneous Transcatheter Retrieval of Central Venous Port Fragments in Pediatric Patients; A Single-center Experience From the Pediatric Cardiology Department

BACKGROUND

Split/fracture and embolization of central venous/shunt catheters are rare but serious complications in children. Percutaneous retrieval of intravascular foreign bodies is an important minimal invasive treatment. This study is aimed to represent our largest pediatric sample experience till now of 17 years from a single institution. Another aim is to compare the results regarding the removal or leaving in place of embolized or ruptured intravascular or cardiac venous catheter parts in children.

PATIENTS AND METHODS

A total of 26 cases were included in this study. Any pediatric patient with normal coagulation parameters and a fractured catheter fragment was included in this study. Other intravascular foreign bodies related to interventional devices and/or pacemaker/implantable cardiac defibrillator leads were excluded from this study.

RESULTS

Twenty-six patients, of whom 25 had oncologic diseases and 1 had a ventriculoatrial shunt, were included. The median age was 83.5 months (between 20 mo and 18 y) at treatment.Superior vena cava (9 cases), followed by the right atrium (5 cases), were the most two common sites of embolization for cardiovascular foreign bodies. The success rate of percutaneous retrieval was 92.3% in all patients. There were neither complications nor deaths. The retrieval technique revealed a predisposition for extraction through the femoral vein (96.1%) and using snare techniques (100%). Additional catheters like pigtail, National Institutes of Health, or ablation catheters were used for stabilization in selective cases in which the permanent central venous fragments stuck to the vessels. A tractional maneuver and capturing the ruptured material in the middle were other trick points for successful retrieval. Patients were asymptomatic in 76.9% of cases (20/26).

CONCLUSION

Percutaneous retrieval of cardiovascular foreign bodies is a reasonable, safe, and effective way in children when the catheter fragments are free and mobile. It should be considered the preferred treatment option instead of surgery. In patients where catheter fragments are stuck and are adherent to vessels, it could be left, and followed up by anticoagulation. Novel techniques accompanied by an experienced team could be helpful in difficult cases.

Case report: Amplatzer septal occluder device migration into the descending thoracic aortic isthmus: percutaneous retrieval and redeployment

Percutaneous closure has emerged as the standard treatment for secundum-type atrial septal defects (ASDs). However, there is a rare but serious complication of occluder device migration and embolization to the heart chambers or distal vasculature during or shortly after implantation. Although this occurrence is extremely rare, it can have disastrous consequences. Fortunately, advancements in equipment and technology have facilitated the transition from surgical procedures to percutaneous techniques for removing embolized occluder devices. In this report, we present a case in which an Amplatzer septal occluder (ASO) device embolized to the descending thoracic aortic isthmus two days after implantation. The device was successfully retrieved using a percutaneous technique, and another ASO device was subsequently redeployed to the ASD. Regrettably, the patient experienced an intraoperative cardiac arrest. Despite prompt rescue efforts and recovery of vital signs, the patient still suffered postoperative sequelae. The main reason for occluder device migration in this case may have been the undersizing of the ASO device due to the operator's lack of caution.

Endovascular Removal of Foreign Bodies: Single Center Experience

Catheter rupture or displacement is a serious and rare complication of central venous catheterization, with an incidence of approximately 1%. Once the intravascular foreign body is found, it should be removed as soon as possible. This study investigated the safety and efficacy of endovascular techniques for the removal of intravascular foreign bodies. This was a retrospective analysis of 23 patients with intravascular foreign bodies admitted to our hospital from January 2009 to June 2019 summarizing the types and locations of foreign bodies and the removal techniques. Overall Twenty-three cases of intravascular foreign bodies were successfully treated with endovascular techniques, for a technical success rate of 100%. The types of foreign bodies included 14 infusion port catheters (60.9%), 6 peripherally inserted central catheters (26.1%), 2 temporary deep vein catheters (8.7%), and 1 intravenous stent (4.3%). The most common orientation of foreign body displacement was one end of the foreign body in the inferior vena cava and the other end in the right atrium (14/23, 60.9%). In terms of technique, all patients underwent removal procedures with only one venous access point. The operative time ranged from 6 to 153 min, with an average of 28.7 min. This study preliminarily demonstrates the safety and efficacy of percutaneous interventional intravascular foreign body removal. Endovascular techniques are minimally invasive and reliable and can be used to safely and effectively remove intravascular foreign bodies.

Endovascular removal of intravascular foreign bodies: A single-center experience and literature review

OBJECTIVE

To describe causes, clinical signs, experience and endovascular techniques for extraction of intravenous foreign bodies (IFB) and literature review.

METHODS

This retrospective study was based on data collected from the medical records of 51 consecutive patients (26 women and 25 men) treated from July 2007 to May 2020 at a single quaternary center in Brazil and case series with data, published in the literature since 2000 on IFB removal, of at least five patients. The average patient age was 43.54 years (range, 2 months to 84 years). The different retrieval method using the following was used in the procedure: gooseneck snare, guidewire, balloon, and custom snares.

RESULTS

The retrieval process rate was 100%. Thirty-one port-a-caths, six guidewires, four double lumens, three permcaths, three Shiley® catheters, one intra cath, two peripherally inserted central catheters, and one stent were extracted. The locations where the IFBs were most frequently trapped were the right atrium (39.2%), the pulmonary artery (17.64%), the superior vena cava (13.72%), and the right ventricle (16.12%). Single venous access was used in 67.07% of the patients. Femoral access, which was the most commonly used approach, was used in 85.71% of the patients. The loop was used in 64.70% of the patients. A fractured catheter was the main IFB in 60.76% of the cases (31 patients). Only one complication related to the extraction of an IFB was noted in a single patient who suffered from atrial fibrillation (1.96%). The 30-day mortality rate was zero.

CONCLUSION

Percutaneous IFB removal should be considered as an alternative for the treatment and retrieval of IFBs because it is a minimally invasive procedure that is relatively simple, safe, and has low complication rates.

A Simple Rescue Maneuver to Retrieve Intravascular Foreign Body: The Triple Wire Twisting Technique

INTRODUCTION

Device fracture causing intravascular foreign body (IFB) is a rare event during endovascular procedures, with potential catastrophic outcome if not promptly removed. We present two cases of retrieval of fractured devices during peripheral lower limb procedures using three guidewires tangled around the IFB.

TECHNIQUES

Case 1 was a patient with critical limb ischemia. During balloon angioplasty of a high calcified peroneal artery, the balloon catheter Amphirion Deep 2.5/150 mm (Medtronic) fractured in two pieces, leaving a 20 cm distal part into the artery. Three 0.014" guides were advanced distally the IFB and twisted all together using a single torque-device. It was possible to pull back the long balloon fragment into the popliteal and to reline it inside a 5 French sheath. Case 2 was a patient with acute limb ischemia. During the mechanical thrombo-aspiration using the Indigo System (Penumbra inc.), the distal wire of the olive-shaped separator cracked in the posterior tibial artery. By crossing the IFB with three 0.014" wires and twisting them around it, this 15mm fragment was successfully recaptured.

CONCLUSIONS

We named this procedure Triple Wire Twisting Technique and, in our experience, this technique is safe and effective to recapture IFB during complex peripheral procedures. This poorly known rescue technique is not complex and requires materials that are available in all cath-lab. We truly believe that physicians can take advantage of knowing it when facing with IFB in any vessel.

Distal retrieval of dislodged and migrated guidewires after retrograde puncture of the deep femoral and dorsal pedal artery. A case series

We report on retrograde retrieval of the soft end of dislodged guidewires during complex interventions. Interventionalists may consider this as an option for the endovascular management of this complication if an antegrade retrieval is not possible or fails.

Diagnostic error in detection of fractured and migrated totally implantable venous access device fragments and experience with percutaneous retrieval: A report of 27 cases

PURPOSE

To assess diagnostic efficacy/error to identify broken or dislocated totally implantable venous access device (TIVAD) fragments on radiological studies and to analyze interventional outcome of percutaneous retrieval.

MATERIALS AND METHODS

Retrospective, single-center analysis of 27 patients, referred for percutaneous retrieval of embolized TIVAD fragments between 2000 and 2018. Demographic data, underlying disease, diagnostic studies, diagnostic error, interval between implantation and diagnosis of TIVAD-dysfunction, interval between diagnosis and retrieval, anatomical location of the embolized fragments, and technical aspects of retrieval procedure were identified from the patients' electronic medical records.

RESULTS

Overall, diagnostic error was found in six patients (22%) with an average delay of 53 days. Ten fractures were caused during surgical removal, eleven fractures by pinching between first rib and clavicle and six cases by spontaneous disconnection between reservoir and catheter. Success rate of retrieval was 96% and the complication rate 0%.

CONCLUSION

Fractured or retained TIVAD fragments were initially overlooked on radiological studies in more than 20% of patients. Percutaneous retrieval of broken and dislocated TIVAD fragments is very safe and highly successful.

Embolia por proyectil por arma de fuego: a propósito de un caso

Introducción. La embolia pulmonar por herida con arma de fuego es potencialmente fatal y una complicación rara que puede presentarse en los servicios de urgencias. En los últimos años, se ha presentado una mayor incidencia por la violencia social civil (85 %) que por las guerras (15 %). Los principales síntomas de los pacientes son dolor torácico, disnea y hemoptisis por la erosión vascular y el infarto pulmonar asociado. Caso clínico. Se presenta el caso de un paciente de 18 años de edad que ingresó por múltiples heridas por proyectiles de arma de fuego, una de ellas con un proyectil alojado en la arteria pulmonar del lóbulo inferior derecho y embolia pulmonar aguda en las ramas arteriales distales al proyectil. Se optó por un tratamiento conservador y la evolución fue adecuada. Discusión. La sintomatología de esta condición depende de la localización, la trombosis asociada, los fenómenos de isquemia y las complicaciones hemorrágicas. Entre las complicaciones de un proyectil de fuego alojado en una arteria pulmonar, están la isquemia, la trombosis, los pseudoaneurismas, la hemorragia, el derrame pleural, la insuficiencia vascular y la endocarditis. La mayoría de los pacientes deben someterse a una intervención quirúrgica cuando el proyectil se aloja en las arterias pulmonares principales o lobares y las compromete; cuando se localiza en las arterias segmentarias y subsegmentarias, tienden a presentar fístulas con el bronquio y vasoespasmo compensatorio, lo que permitiría el manejo conservador.

Guidewire Entrapped in the Right Ventricle: A Rare Complication of Hemodialysis Catheter Insertion

How to cite this article: Verma A, Chitransh V, Jaiswal S, Vishen A, Sheikh WR, Haldar M, et al. Guidewire Entrapped in the Right Ventricle: A Rare Complication of Hemodialysis Catheter Insertion. Indian J Crit Care Med 2020;24(1):80–81.

Delayed Penetration of the Thoracic Aorta by Pedicle Screws: A Case Report of Screws Left As-Is

STUDY DESIGN

A case report.

OBJECTIVE

Presentation of a patient diagnosed with perforation of the aorta by pedicle screws at levels T6 and T9 2 years after spinal fusion, who was advised no intervention. Review of other reported cases that did not undergo excision of the penetrating screws.

SUMMARY OF BACKGROUND DATA

More than 30 cases of aortic penetration by pedicle screws were described. Gradual penetration of the screws into the aorta rarely causes symptoms other than backache. However, only two cases were treated conservatively.

METHODS

A 65-year-old female patient underwent spinal decompression and T5-T10 posterior fusion following a spinal abscess. Two years and 8 months postoperatively, she underwent a computed tomography scan for suspicion of spinal hardware infection, which showed T6 and T10 screws penetrating the thoracic aorta.

RESULTS

Due to high morbidity, the patient was not offered an operation for screw excision.

CONCLUSION

This case report adds to the only two previous reports of patients who did not undergo revision of pedicle screws penetrating thoracic aorta.

LEVEL OF EVIDENCE

5.

Loss of guidewire and its sequelae after central venous catheterization: A case report

RATIONALE

Central venous catheterization is a common tool used to monitor central venous pressure and administer fluid medications in patients undergoing surgery. The loss of a broken guide wire into the circulation is a rare and preventable complication. Here, we report a peculiar case of a missed guidewire puncturing the aortic arch and cerebrum.

PATIENT CONCERNS

A 53-year-old man with complaints of an intermittent headache and right swollen ankle following central venous catheterization.

DIAGNOSES

Using computed tomography; the patient was diagnosed with the loss of a guide wire in his body. The guide wire had migrated to the brain and punctured the vascular wall of the aortic arch.

INTERVENTIONS

Due to the risks of surgery, the patient was advised to have a follow-up visit once every 3 months.

OUTCOMES

At present, the patient could live like a normal person, although he suffers from intermittent headaches.

LESSONS

The loss of a guide wire is a completely preventable complication, provided that a hold on the tip of the wire is maintained during placement, and the correct safety measurements and protocols are followed.

Beyond Pulmonary Embolism; Nonthrombotic Pulmonary Embolism as Diagnostic Challenges

Nonthrombotic pulmonary embolism (NTPE) is less well understood and is encountered less frequently than pulmonary embolism from venous thrombosis. NTPE results from embolization of nonthrombotic material to the pulmonary vasculature originating from many different cell types as well as nonbiologic or foreign materials. For many radiologists NTPE is a challenging diagnosis, presenting nonspecific or unusual imaging findings in the setting of few or unusual clinical signs. The aim of this paper is to review the pathophysiology of diverse causes of NTPE, which should aid radiologists to better understand and, more importantly, diagnose these infrequent events.

Materials and techniques for percutaneous retrieval of intravascular foreign bodies

The presence of an intravascular foreign body represents a well-known risk of serious complications. While in the past surgical removal of intravascular foreign body was the most common intervention, nowadays a percutaneous approach in the retrieval of an intravascular foreign body is widely accepted as the first-line technique. In the literature, many case reports describe different techniques and materials. This article summarizes and illustrates the main materials and techniques currently applied for percutaneous retrieval of intravascular foreign body, providing a simplified tool with different interventional possibilities, adaptable to different clinical situations.

[Nonthrombotic pulmonary embolisms]

The term nonthrombotic pulmonary embolism (NTPE) is defined as embolization of pulmonary arteries caused by foreign bodies (e. g. detached catheter fragments), biological substances (e. g. septic thrombus) or exogenous substances (e. g. gas). The frequency of NTPE is underestimated. Symptoms can cover the spectrum from undetectable to sudden death. In addition to mechanical obstruction of the pulmonary arteries, some NTPEs trigger an inflammatory cascade that causes deterioration of vascular, pulmonary and cardiac function. Radiological imaging in combination with the medical history of patients is sufficient to identify most NTPEs with certainty. The aim of this article is to make readers aware of the symptoms, frequency, relevance, classification, pathophysiology, laboratory findings and radiological findings of the most frequent forms of NTPE. The spectrum of forms presented here includes pulmonary embolisms due to foreign bodies (intravascular, intracorporeal and extracorporeal), amniotic fluid, endogenous tissue, fat, tumors, septic thrombi, hydatids, cement, metallic mercury, gas, silicone and particles.

Cross-Over Endovascular Retrieval of a Lost Guide Wire from the Subclavian Vein

Background

The lost guidewire in central venous catheterization is a commonly described complication. The percutaneous endovascular retrieval method is safe and has a very low complication rate.

Objectives

Guidewires extending to the inferior cava vein are usually retrieved via the femoral vein. Under special circumstances, femoral venous access may be impossible and alternative vascular approaches are required.

Case report

We report a case in which we used an alternative vascular approach, from the subclavian site contralateral to the insertion, in a patient with extensive inguinal burn injuries.

Conclusions

Cross-over subclavian retrieval can be an alternative approach for retrieval of a lost guidewire, but it involves an increased risk of puncture-related complications such as pneumothorax.

Unintentionally retained vascular devices: improving recognition and removal

The increased demand for minimally invasive placement of intravascular medical devices has led to increased procedure-related complications, including retention of all or part of the implanted device. A number of risk factors can predispose to unintentionally retained vascular devices (uRVD); most are technical in etiology. Despite best efforts to insert and remove vascular devices properly, uRVD still occur. Prevention or early identification of uRVD is ideal; however, procedural complications are not always recognized at the time of device insertion or removal. In these cases, early radiologic diagnosis is important to enable expeditious removal and reduction of morbidity, mortality, and medicolegal consequences. The diagnostic radiologist's role is to identify suspected uRVD and ensure proper communication of the findings to the referring clinician. The diagnostic radiologist can implement various strategies to increase detection of uRVD and advise the referring clinician regarding the use of minimally invasive percutaneous techniques for safe removal of uRVD.

Needle Migration to the Heart: An Unusual Association of Hemodialysis and Cardiovascular Morbidity

In this report, we present a unique complication of hemodialysis: the hemodialysis access needle was lost into an arteriovenous fistula. The event went unnoticed for several months. The needle eventually migrated into the right ventricle, requiring an operative retrieval. Loss of the needle was likely unrecognized because of the use of a retracting safety cannula that conceals the needle within a sheath after removal. This case highlights a rare and potentially serious complication of hemodialysis access, demonstrates a possible hazard of retracting safety needles, and reviews the management of foreign bodies that have migrated into the heart.

Intravascular foreign bodies: what the radiologist needs to know

The intravascular foreign bodies (IFBs) can originate from many sources both iatrogenic and noniatrogenic; as the frequency of endovascular therapies increases, the incidence of lost or embolized iatrogenic foreign bodies is also increasing. As IFB can cause significant complications such as thrombosis, pulmonary and peripheral embolism, etc. It is therefore necessary to remove them, and this may be accomplished through surgery or by means of percutaneous radiologic techniques. Percutaneous approach is widely perceived as the best way to retrieve IFB. We provide an overview of recent literature, clarifying what devices are being lost, what symptoms occur as a result, and how retrieval is being performed.

Percutaneous Retrieval of Foreign Bodies Around Vital Vessels Aided with Vascular Intervention: A Technical Note

OBJECTIVE

To describe a new interventional technique to remove foreign bodies (FBs) embedded in soft tissues around vital vessels.

METHODS

Under fluoroscopic guidance and using local anesthesia, percutaneous removal of FBs was performed using forceps in nine patients. All patients suffered from a metallic soft tissue FB located in close proximity to important vessels and one also had a small traumatic pseudoaneurysm adjacent to the FB. Prior to removal of the FB, the position of the nearest vessel was identified using a guide wire or catheter placed into the vessel. Balloon catheter was also simultaneously used to temporarily stop the blood flow of the nearest artery during the FB removal in three of the nine patients.

RESULTS

All of the nine FBs with 0-2 mm interval to the nearest vessel were successfully removed in the nine patients without any serious complications. The removed FBs measured 3-12 mm in length and 1-3 mm in width. The total fluoroscopic time of retrieval of each FB was 5-9 min (mean, 6.4 min). The volume of intraoperative bleeding ranged from 5 to 12 ml (mean, 7.5 ml). The length of hospital stay for each patient ranged from 4 to 8 days (mean, 5.5 days).

CONCLUSION

Vascular intervention-aided percutaneous FB removal is minimally invasive and an effective method for removal of FBs around vital vessels.

Loss of guide wire: a lesson learnt review of literature

Catheterization of central veins is a routine technique which is widely used in emergency department and medical intensive care units. Seldinger's technique is widely used to place central venous and arterial catheters and is generally considered safe. The technique does have multiple potential risks. Guide wire-related complications are rare but potentially serious. We describe a case of a lost guide wire during central venous catheter (CVC) insertion followed by a review of the literature of this topic. Measures which can be taken to prevent such complications are explained in detail as well as recommended steps to remedy errors should they occur.

Migration of an AMPLATZER atrial septal occluder to the abdominal aorta

Percutaneous closure of an atrial septal defect has been increasingly used, and complications have been rare. We report the case of a 63-year-old man who had undergone endovascular closure of a secundum atrial septal defect months earlier. The occluder was later found in the abdominal aorta.

Successful retrieval of intravascular stent remnants with a combination of rotational atherectomy and a gooseneck snare

Stent migration from the delivery balloon catheter is a rare but serious complication during percutaneous coronary intervention, particularly when a part of the stent stretches into the aorta. We report an unusual case of stent migration treated with a combination of a gooseneck snare and rotablation. A part of the stent was overstretched and unrolled into the aorta and the rest of the stent remained implanted in the coronary artery. The stent was captured with a gooseneck snare but could not be retrieved because it was connected to a stent remnant implanted in the coronary artery. The stent strut was cut with rotablation, and the stent was successfully removed through the femoral sheath.