Intravascular foreign bodies: danger of unretrieved fragmented medical devices

Successful Removal of a Fractured Desilets-Hoffman Sheath in a Patient With a Loop Arteriovenous Graft: Balloon-Supported Retrieval Technique

INTRODUCTION

While a Desilets-Hoffman sheath rarely fractures, when it does, the presence of an intravenous foreign body can cause various complications.

CASE PRESENTATION

A 74-year-old woman receiving hemodialysis for end-stage renal disease via a left forearm arteriovenous graft (AVG) was referred to the interventional radiology department following thrombotic occlusion of the AVG. A corrective procedure was initiated, and the 7F Desilets-Hoffman sheath fractured after the purse-string suture. A .035-inch guidewire was passed through the fractured sheath, and a 3.0-mm x 60-mm balloon catheter was inflated, allowing for the successful removal of the sheath fragment without complications.

CONCLUSION

The fractured Desilets-Hoffman sheath was successfully removed in a patient with a loop arteriovenous graft using balloon-supported retrieval technique.

Pulmonary embolism and hemorrhage after displacement of angiographic catheter tip to pulmonary artery: A case report and literature review

Pulmonary embolism and massive hemoptysis caused by intravascular foreign bodies have rarely been reported. We report a case of an end-stage renal disease patient in which the tip of the angiographic catheter fell off into the pulmonary artery during endovascular interventional opening when the patient underwent vascular access occlusion for dialysis. During the operation, the foreign body was displaced repeatedly and finally anchored to the posterior basal segment branch of the right lower pulmonary artery. A pulmonary embolism occurred during the operation, and massive hemoptysis and hemorrhagic shock occurred after anticoagulation and thrombolytic therapy. After receiving anti-shock and symptomatic treatment, the patient gradually recovered. After six months of follow-up, no pulmonary embolism or pulmonary infarction occurred. Our case report presents an alternative approach to extracting a foreign object from the pulmonary artery by locating the foreign object within the vascular terminations, without resorting to forceful removal. This method mitigates the potential risks of pulmonary embolism and bleeding associated with forceful extraction.

Endovascular Retrieval of a Fractured Tunneled Hemodialysis Central Venous Catheter Using the Loop Snare Technique

The tunneled cuffed hemodialysis catheter is a valuable vascular access option for patients with end-stage renal disease (ESRD). Healthcare providers have become more familiar with the insertion of medical devices, including central venous catheters, in their daily practice. The occurrence of foreign body fragmentation is rare with these catheters. This article presents a case in which a fracture of the distal portion of the hemodialysis catheter was inadvertently identified during a coronary angiography. Percutaneous removal of the fractured venous catheter was performed successfully using a loop snare catheter, which prevented the patient from experiencing further complications.

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.

CT-guided retrieval of a fractured intravenous cannula in a toddler: A case report

Introduction

Fractured cannula is a complication of peripheral intravenous cannula (PIVC) insertion. It is a rare but potentially fatal complication. We present a case of iatrogenic fracture of a PIVC in a toddler.

Case report

An acutely ill 30-month-old boy presented at the emergency room and a PIVC insertion was attempted several times using the same cannula which fractured in the process. While the main part of the device was recovered, about 7 mm of the cannula was retained in the tissues and was not palpable. Computed tomography was used to locate the foreign body which was surgically removed under general anesthesia.

Discussion

A fractured and retained PIVC, especially when it is not palpable clinically, is an emergency due to possible embolization and the consequent potentially fatal outcome. This case underscores strict adherence to standard guidelines in prevention and the importance of computed tomography in the management of this condition.

Successful percutaneous transvenous retrieval of intravascular fractured port catheter: a single center experience

BACKGROUND

Fractured catheter as a foreign body in situ is a rare complication after port catheter placement. We report a single center's experience on percutaneous transvenous retrieval of intravascular fractured port catheter and treatment techniques.

METHODS

Patients undergoing percutaneous transvenous retrieval of intravascular fractured port catheter from Jan 2010 to Dec 2018 were retrospectively collected. A total of 10 patients (8 females and 2 males) were enrolled in this study. Procedures were performed within 1 day after diagnosis. Two methods of retrieval were considered, direct retrieval by gooseneck snare and guide wire as media to retrieve were used in the procedure.

RESULTS

All the fractured catheters in 10 patients were successfully retrieval by 2 methods, direct retrieval by gooseneck snare(n = 6) and guide wire as media of retrieval(n = 4). The time interval between port catheter implantation and discovery of catheter fracture was 36.50 ± 42.99(ranged 1 to 146) days. The operation time was 24.10 ± 8.32(ranged 10 to 36) minutes. No immediate procedure related or 1 month follow-up complications occurred in all the 10 patients.

CONCLUSION

Percutaneous transvenous retrieval of intravascular fractured port catheter is a simple and safe procedure, which maybe recommended as the first choice for patients with fractured port catheter in situ.

Successful treatment of unexpected complication during aortic stent-grafting: retrieval of broken stent-graft tip by coaxial technique

Thoracic aortic endovascular repair (TEVAR) is increasingly preferred as a treatment of choice in thoracic aortic diseases. Intravascular foreign body is one of the TEVAR-related complications similar to the other endovascular operations. Here, to the our best knowledge for the first time in the English literature, this report presents an extremely rare complication of a broken and stuck tip part of aortic stent-graft in the intravascular space and successful removal by using the coaxial technique. Thoracic aortic endovascular repair (TEVAR) has been increasingly preferred as the treatment of choice in thoracic aortic diseases (1). Endovascular treatment has been gaining popularity compared with open surgery due to its less invasive approach and rapid application, and allows the patient to easily return to daily life (2). However, TEVAR is associated with several specific complications including paraplegia, stroke, vascular injuries and local complications. These complications depend on vascular or nonvascular comorbidities, vascular anatomy, equipment, and experience of the provider (3-6). Intravascular foreign body could be among TEVAR-related complications similar to other endovascular operations (7). Several types of equipment, including guidewire, vascular sheath, or suboptimally uncoiled stents may get stuck in the intravascular space, causing complications (8). Herein, to the best of our knowledge, we present the first report in the English literature of broken and stuck tip part of an aortic stent-graft in the intravascular space and its successful removal using the coaxial technique.

In Vitro and In Vivo Models for Assessing the Host Response to Biomaterials

The foreign body response (FBR) occurs ubiquitously to essentially all non-biological materials that are implanted into higher organisms. The FBR is characterized by inflammation followed by fibrosis and is mediated largely by macrophages. While many current medical devices tolerate the FBR, the FBR is responsible for many asceptic device failures and is hindering advancements of new devices that rely on device-host communication to function. To this end, in vitro and in vivo models are critical to studying how a biomaterial, via its chemistry and properties, affect the FBR. This short review highlights the main in vitro and in vivo models that are used to study the FBR. In vitro models that capture macrophage interrogation of a biomaterial and evaluation of macrophage attachment, polarization and fusion are described. In vivo models using rodents, which provide a relatively simple model of the complex FBR process, and human-relevant nonhuman primate models are described. Collectively, the combination of in vitro and in vivo models will help advance our fundmental understanding of the FBR and enable new biomaterials to be developed that can effectively modulate the FBR to achieve a desire device-host outcome.

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.

Endovascular retrieval of a migrating pedicle screw within the inferior vena cava after instrumented spinal surgery: case report

During L3-5 instrumented spinal surgery for degenerative spondylolisthesis in a 75-year-old woman, the right L-3 pedicle screw was accidentally pushed into the retroperitoneum and then migrated to the inferior vena cava (IVC). The patient was transferred to the surgical intensive care unit, and after careful discussion with cardiology specialists, a minimally invasive endovascular technique was used to remove the migrating pedicle screw within the IVC and thus salvage this critical case. Pedicle screw instrumentation is an effective procedure, but not risk free. Every detail should be scrutinized during surgery, even instrument construction. A minimally invasive endovascular technique should be considered in this patient population.

A Novel Two-Step Technique for Retrieving Fractured Peripherally Inserted Central Catheter Segments Migrating into the Heart or the Pulmonary Artery

Objective. To report the experience of a percutaneous technique for retrieving fractured peripherally inserted central catheter (PICC) segments migrating into the heart or the pulmonary artery. Method. From April 2013 to July 2015, we performed percutaneous retrieval of fractured PICC segments migrating into the heart or the pulmonary artery in five cancer patients who had undergone chemotherapy via PICC. The fractures were diagnosed with chest plain radiography. The patients included three cases of breast cancer, one case of rectal cancer, and one case of lower limb Ewing's tumor. The fractures were retained in the vessels of the patients for 1 to 3 days. All the fractures were retrieved by using a novel two-step technique in the digital subtraction angiography (DSA) suite. This two-step technique involves inserting a pigtail catheter to the heart or the pulmonary artery to grasp the fractured catheter fragment and bring it to the lower segment of the inferior vena cava, followed by grasping and removing the catheter fragment with a retrieval loop system of the vena cava filter retrieval set. Result. The fractured PICC segments were removed successfully in all five patients via unilateral (four patients) or bilateral (one patient) femoral vein access. No complications occurred during the interventional procedure. Conclusion. Percutaneous retrieval can be a safe, convenient, and minimally invasive method for the removal of fractured PICC segments. The technique reported in this paper will be applicable for the retrieval of fractured PICC segments and other catheter fragments migrating into the heart or the pulmonary artery.

Complications in musculoskeletal intervention: important considerations

Musculoskeletal (MSK) intervention has proliferated in recent years among various subspecialties in medicine. Despite advancements in image guidance and percutaneous technique, the risk of complication has not been fully eliminated. Overall, complications in MSK interventions are rare, with bleeding and infection the most common encountered. Other complications are even rarer. This article reviews various complications unique to musculoskeletal interventions, assists the reader in understanding where pitfalls lie, and highlights ways to avoid them.

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.

Superiority of proximal embolization of the gastroduodenal artery with the Amplatzer vascular plug 4 before yttrium-90 radioembolization: a retrospective comparison with coils in 134 patients

PURPOSE

To evaluate the effectiveness of proximal embolization of the gastroduodenal artery (GDA) using the Amplatzer Vascular Plug 4 (AVP 4) compared with pushable coils to avoid hepaticoenteric collaterals of the GDA stump, which may serve as pathways for nontarget embolization.

MATERIALS AND METHODS

One hundred thirty-four patients scheduled for 90-yttrium radioembolization (Y-90 RE) using either plugs (n = 67) or standard coils (n = 67) for GDA occlusion were retrospectively analyzed. Parameters recorded were length of the perfused GDA stump, distance device to the GDA origin, perfused proximal side branches after embolization, and durability of vessel occlusion at Y-90 RE.

RESULTS

Length of the residually perfused GDA stump was 3.89 ± 2.86 mm for the AVP 4, which was significantly shorter compared with 5.78 ± 3.85 mm for coils (p = 0.005). Distance of the plug to the GDA origin was 1.41 ± 2.60 mm, which was also significantly shorter than 4.73 ± 3.44 mm for coils (p < 0.001). This resulted in significantly fewer patients with residually perfused side branches in the AVP 4 group (n = 2; 3.0%) compared with the coil group (n = 18; 26.9%; p < 0.001). At Y-90 RE, no GDA reperfusion was found after plug embolization compared with 2 cases after coil embolization (3.0%; p = 0.156). Only one patient had a radiation-induced duodenal ulcer after coil embolization, whereas no Y-90-related toxicity was identified after plug embolization.

CONCLUSION

Use of the AVP 4 for embolization of the GDA allowed an optimal proximal and more effective target vessel occlusion compared with coil embolization, which can avoid complications caused by extrahepatic gastrointestinal deposition of Y-90 microspheres by way of residually perfused proximal side branches.

Atrial septum defect closure device in a beating heart, from the perspective of a researcher in artificial organs

Transcatheter closure of atrial septum defect (ASD) with a closure device is increasing, but the history of clinical use of this procedure is still short, and the efficacy and long-term safety remain unproved. The total number of closure devices implanted throughout the world has not been counted accurately. Therefore, the probability of complications occurring after implantation is uncertain. Device-related complications that occur suddenly late after implantation are life-threatening, and quite often necessitate emergency surgical intervention. In Japanese medical journals, authors reporting closure devices have mentioned no complications and problems in their facilities. Detailed studies of device-related complications and device removal have not been reported in Japan. In fact, this literature search found an unexpectedly large number of reports of various adverse events from many overseas countries. When follow-up duration is short and the number of patients is small, the incidence of complications cannot be determined. Rare complications may emerge in a large series with a long observation period. Consequently, the actual number of incidents related to ASD closure devices is possibly several times higher than the number reported. Guidelines for long-term patient management for patients with an implanted closure device are necessary and post-marketing surveillance is appropriate. Development of a national database, a worldwide registration system, and continuous information disclosure will improve the quality of treatment. The devices currently available are not ideal in view of reports of late complications requiring urgent surgery and the need for life-long follow-up. An ideal device should be free from complications during life, and reliability is indispensable.

Emergent coronary artery bypass grafting after a broken Rotablator drive-shaft

A 75-year-old man, who presented with acute myocardial infarction and cardiogenic shock underwent emergency cardiac catheterization, assisted by catecholamine administration, respiratory support with intubation and intra-aortic balloon pumping (IABP). The coronary arteriogram showed a high-grade obstruction of two main branches of the left coronary artery. The occlusion of the left anterior descending coronary artery required immediate treatment. As it was heavily calcified, the cardiologists were forced to use Rotablator®, but the device became stuck and the drive-shaft broke. An emergency coronary artery bypass grafting (CABG) with left internal thoracic artery and saphenous vein graft and mitral valve annuloplasty was performed successfully. The patient was weaned off IABP on the fourth postoperative day, and a defibrillator was implanted on the 81st postoperative day because of heart failure. After these procedures, his general state improved gradually and he was able to leave the hospital, walking alone on the 101st postoperative day. Various reports have appeared describing residual foreign bodies in coronary arteries, and almost 90% of these cases can be dealt with by intravascular procedures, but some need removal by open-chest surgery. An early decision by the cardiologists to go to surgery is recommended to save lives. There has been no previous report of emergent CABG after a stuck Rotablator® tip due to a 'broken drive-shaft'. However, because damage is possible even with reliable devices, there should be no hesitation converting to open-heart surgery in such cases.