Nitinol gooseneck snare for removal of foreign bodies: experimental study and clinical evaluation

Port-a-Cath fracture and migration in paediatric cancer patients: incidence and management at a tertiary care centre - a 15-year experience

INTRODUCTION

Port-a-Cath or chemoport provides prolonged central venous access for cancer patients requiring prolonged chemotherapy. Prolonged use of chemoport is associated with many complications. Dislodgement and migration of chemoport catheter is a rare and reportable complication with potentially serious consequences.

METHODS

The medical charts of 1222 paediatric cancer patients admitted to the Children's Cancer Center in Lebanon who had chemoports inserted for long-term chemotherapy were retrospectively reviewed. Descriptive analysis of data was conducted.

RESULTS

Chemoport fracture and migration were found in seven cases with an incidence of 0.57%. The duration of chemoport use before the event of dislodgement varied from 2 months to 102 months. Non-functioning chemoport was the most common presentation. Totally, six cases were managed successfully by loop snaring, three cases by paediatric cardiology team, and three cases by interventional radiology team. One case was managed surgically during chemoport removal.

CONCLUSION

Fracture and migration of chemoport catheter is a rare complication of uncertain aetiology and with potentially serious consequences. Percutaneous retrieval, done by experienced cardiologist or interventional radiologist, is the first choice for management of this complication as it is considered as a safe and effective approach.

The claw: A novel intraocular foreign body removal forceps

Removal of intraocular foreign body (IOFB) from the posterior segment of the eye is challenging. In addition to surgical skill, it requires specific instrumentation to grasp and remove the IOFB. Small metallic IOFB can be removed using intraocular rare earth magnets but metallic IOFB larger than 3 mm and nonmetallic IOFBs like shot gun pellets, stones, or large glass fragments require specialized IOFB grasping forceps for removal. We describe the design and case-based clinical applications of a novel IOFB removal forceps, "the claw" that consists of a titanium handle and a 27-mm, 19-G metallic shaft that houses four retractable prongs made of nitinol wire. When completely extended, the prongs measure 14 mm in length and open up to 8-8.5 mm in the widest extent. The four prongs offer a very secure grip without crushing or splintering the IOFB leading to minimal chances of IOFB slippage and inadvertent retinal trauma.

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.

Port-A-Cath Catheter Embolization to Distal Pulmonary Artery Branches: Two Tailored Percutaneous Retrieval Approaches

Several types of intravascular devices and catheters are frequently used for long-term drug therapy, especially for oncological patients. As a result, complications are becoming increasingly common, namely catheter embolization. Retrieving these devices is important, as embolized fragments may lead to serious consequences, such as arrhythmias, myocardial injury, thrombosis, infection, and even perforation and death. We describe 2 cases of long-term drug catheter (Port-A-Cath) fracture, incidentally documented in a routine chest radiograph. In both cases, percutaneous extraction was attempted, yet the procedure was complicated by embolization of smaller fragments into the arterial pulmonary vasculature. We describe unusual approaches in successfully retrieving the remaining fragments. The ideal approaches for removal of foreign bodies from the cardiovascular system differ from case to case, but percutaneous extraction should be preferred in most of the cases. Less common techniques may be helpful in challenging cases.

Spontaneous fracture of the outlet catheter of a totally implanted catheter system (Port-A-Cath)

A case of spontaneous fracture of the outlet catheter of a totally implanted catheter system (Port-A-Cath) is presented. The outlet catheter was fractured at the entrance into the left subclavian vein twenty-one weeks after insertion and the distal part was embolized in the right ventricle. The embolized catheter fragment was retrieved by a ‘goose-neck’ snare via the right femoral vein. The awareness of a possible spontaneous fracture of the outlet catheter of a totally implanted catheter system (Port-A-Cath) is important to prevent accidental spillage of potent cytotoxic substances.

Totally implantable catheter migration and its percutaneous retrieval: case report and review of the literature

Totally subcutaneous intravascular portals have been increasingly used to administer long-term chemotherapy and parental nutrition. The reported complications are rare. Accidental endovascular rupture of a fragment of catheter is one of the most formidable complications of the central vein catheterization. The Authors report a case of deployment of a Port-a-Cath catheter and its percutaneous retrieval. The catheter accidentally detached and migrated from the reservoir of the port-a-cath placed in the left subclavian vein to the right heart cavities through the blood stream. A review of the Literature is also given, focusing on the possible factors responsible for this unusual complication.

Application of an enhanced device to transluminal retrieval of malappositioned coronary stents: An experimental study

OBJECTIVES

This study investigated the application of a novel enhanced device to retrieval of deployed stents in a porcine coronary model.

BACKGROUND

Recurrence of in-stent restenosis and stent thrombosis still remains to be resolved. Under these conditions, it is sometimes necessary to retrieve malfunctional stents responsible for thrombosis. However, few data exist regarding the feasibility and safety of retrieval device use in previously deployed coronary stents.

METHODS

We have developed an enhanced device consisting of an asymmetric forceps, conducting shaft (1.6 mm diameter, 150 cm length), and control handle. Bare-metal stents (3 mm diameter) were implanted in four pigs to create a malapposition model. Coronary artery injury was evaluated by intravascular ultrasound (IVUS) and histological imaging on the first and 14th days.

RESULTS

The device was delivered to the coronary artery using the existing catheter (7 Fr). After opening the forceps, the blade was forced into the space between the vessel wall and the stent, and the stent struts were then grasped with the forceps. This was then pulled back into the catheter, still grasping the stent struts with the forceps. All stents were successfully retrieved by this method (n = 4). On the first day, no apparent vessel wall injury was detectable by IVUS, although histological findings revealed damage to endothelial monolayer on retrieval of deployed stent. On the 14th day, mild intimal thickening was observed by IVUS and histology.

CONCLUSIONS

These results demonstrate that the present device can be applied to transluminal retrieval of acquired malappositioned coronary stents.

Republished: Endovascular retrieval of dental needle retained in the internal carotid artery

Intravascular foreign bodies are a known complication of medical and dental procedures. Dental anesthetic needles may be broken off and retained in the oropharynx. These needles have occasionally been reported to migrate through the oral mucosa in to deeper structures. Here we present the case of a 57-year-old man who had a retained dental needle that had migrated into his internal carotid artery. The needle was removed using endovascular techniques. To our knowledge, this is the first report of a retained dental needle being retrieved using this method. We review the literature on intravascular foreign bodies, retained dental needles, and endovascular techniques for retrieval of such foreign bodies.

Endovascular retrieval of dental needle retained in the internal carotid artery

Intravascular foreign bodies are a known complication of medical and dental procedures. Dental anesthetic needles may be broken off and retained in the oropharynx. These needles have occasionally been reported to migrate through the oral mucosa in to deeper structures. Here we present the case of a 57-year-old man who had a retained dental needle that had migrated into his internal carotid artery. The needle was removed using endovascular techniques. To our knowledge, this is the first report of a retained dental needle being retrieved using this method. We review the literature on intravascular foreign bodies, retained dental needles, and endovascular techniques for retrieval of such foreign bodies.

Nerve Damage Secondary to Removal of Fractured PICC Fragment

Purpose

To increase awareness of peripherally inserted central catheter (PICC) fracture and necessary nursing assessment to identify development of nerve injury after removal of the PICC fracture.

Methods

This is a case review of a cancer patient with fractured PICC and the postoperative symptoms leading to nerve injury.

Results

The reason for PICC fracture is the fragility of silicon. Secondary surgical intervention of a PICC fragment resulted in nerve damage from a hematoma placing pressure on the median nerve in the arm.

Conclusions

It is necessary to use power injectable polyurethane PICCs. It is vital to have a clear understanding of signs and symptoms of nerve impingement in the arm when monitoring a post-operative patient. Assessment of neurological status, circulation, swelling and patient complaints of pain are all necessary functions of the nurse in caring for this type of patient.

Application of a snare technique in retrograde chronic total occlusion percutaneous coronary intervention - a step by step practical approach and an observational study

Percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has recently become popular among interventional cardiologists. CTO originating from the ostium has been one of the most difficult CTO lesions to treat with PCI for a number of reasons. Our aim was to illustrate a specific technique during retrograde CTO PCI referred to as the "snare technique."We retrospectively examined the use of "snare technique" among 371 consecutive retrograde CTO PCIs performed at our institution between 2006 and 2015."Snare technique" was used in 10 patients among the 371 retrograde CTO PCIs. The baseline clinical and angiographic characteristics of patients with or without "snare technique" were similar. The "snare technique" group had significantly fewer side branches at occlusion (30.0% vs 71.2%, P = 0.01) and a higher incidence of externalization (90% vs 25.5%, P < 0.001). The contrast volume was significantly lower in the "snare technique" group (285.0 ± 68.5 vs 379.2 ± 144.0, P = 0.04). The incidence of major complications, retrograde success, or final success did not differ between the groups.The "snare technique" is safe and feasible in retrograde CTO PCI, especially in cases of difficult coronary engagement in cases such as ostial occlusion, challenging coronary anatomy, or retrograde guidewire cannot get in antegrade guiding catheter.

Successful Retrieval of a Dismembered Central Venous Catheter Stuck to the Right Pulmonary Artery Using a Stepwise Approach

Recent advances in anticancer chemotherapy have resulted in an increase in the number of patients requiring a central venous port catheter, and the incidence of catheter pinch-off syndrome has been increasing. Catheter pinch-off syndrome is a rare and unusual complication. It is difficult to retrieve dislodged catheters from the pulmonary artery, especially if the catheter is stuck to the peripheral pulmonary artery. We herein describe the successful removal of a catheter stuck in the pulmonary artery with a stepwise approach. First, a pigtail catheter was used to tug the dislodged catheter in order to free the unilateral end. Then, a gooseneck snare was used to catch and pull the catheter out of the patient. The key to success is to free the end of the catheter.

Technique for Retrieval of a Guidewire Lodged in a Vena Cava Filter

A case in which the guidewire used to place a percutaneous jugular central line became entangled in the limbs of a Trapease inferior vena cava filter is presented. A 7F sheath introducer was fashioned into a monorail system to uncurl the wire's J tip and remove the wire without disturbing the filter's position. This report highlights an increasingly frequent clinical scenario and an inexpensive effective method for resolution.

Approach to Fragmented Central Venous Catheters

Prolonged venous access devices are needed in cancer patients for central venous access. Catheter fragmentation leading to catheter malfunction represents a rare problem. Herein we present our experience in the management of fragmented catheters.

Between 2001 and 2003, 183 catheters were placed via the subclavian vein, and five cases of fragmented catheters were observed. Fragments were removed by an Amplatz gooseneck snare (Microvena, St. Paul, MN) with angiographic intervention.

The diagnosis of the breakage was made by chest radiography. The incidence of catheter rupture was 2.7%. All fragments were removed by the snare, without any complications. Catheter narrowing and breakage owing to its medial positioning in the subclavian vein were the main causes of catheter malfunction.

In any case of catheter malfunction, radiologic evaluation of the catheter must be done to rule out its rupture. Removal of the fragments using the Amplatz snare is a safe and easily applied procedure.

Transvenous Lead Extraction via the Inferior Approach Using a Gooseneck Snare versus Simple Manual Traction

Background and Objectives

The number of patients with cardiac implantable electronic devices needing lead extraction is increasing for various reasons, including infections, vascular obstruction, and lead failure. We report our experience with transvenous extraction of pacemaker and defibrillator leads via the inferior approach of using a gooseneck snare as a first-line therapy and compare extraction using a gooseneck snare with extraction using simple manual traction.

Subjects and Methods

The study included 23 consecutive patients (43 leads) who underwent transvenous lead extraction using a gooseneck snare (group A) and 10 consecutive patients (17 leads) who underwent lead extraction using simple manual traction (group B). Patient characteristics, indications, and outcomes were analyzed and compared between the groups.

Results

The dwelling time of the leads was longer in group A (median, 121) than in group B (median, 56; p=0.000). No differences were noted in the overall procedural success rate (69.6% vs. 70%), clinical procedural success rate (82.6% vs. 90%), and lead clinical success rate (86% vs. 94.1%) between the groups. The procedural success rates according to lead type were 89.2% and 100% for pacing leads and 66.7% and 83.3% for defibrillator leads in groups A and B, respectively. Major complications were noted in 3 (mortality in 1) patients in group A and 2 patients in group B.

Conclusion

Transvenous extraction of pacemaker leads via an inferior approach using a gooseneck snare was both safe and effective. However, stand-alone transvenous extraction of defibrillator leads using the inferior approach was suboptimal.

Retained Fractured Fragment of A Central Venous Catheter: A Minimally Invasive Approach to Safe Retrieval

BACKGROUND

Complication following fracture of a central venous catheter can be catastrophic to both the patient and the attending doctor. Catheter fracture has been attributed to several factors namely prolong mechanical force acting on the catheter, and forceful removal or insertion of the catheter.

CASE DETAILS

In the present case, the fracture was suspected during the process of removal. The tip of the catheter was notably missing, and an emergency chest radiograph confirmed our diagnosis of a retained fracture of central venous catheter. The retained portion was removed by the interventional radiologist using an endovascular loop snare and delivered through a femoral vein venotomy performed by the surgeon.

CONCLUSION

Endovascular approach to retrieval of retained fractured catheters has helped tremendously to reduce associated morbidity and the need for major surgery. The role of surgery has become limited to instances of failed endovascular retrieval and in remote geographical locations devoid of such specialty.

Ventricular Tachycardia from a Central Line Fracture Fragment Embolus: A Rare Complication of a Commonly Used Procedure-A Case Report and Review of the Relevant Literature

A 22-year-old male admitted with multiple gunshot wounds (GSW) had central line placed initially for hemodynamic monitoring and later for long term antibiotics and total parenteral nutrition (TPN). On postoperative day 4 he presented with bouts of nonsustained ventricular tachycardia; the cause was unknown initially and later attributed to a catheter fragment accidentally severed and lodged in the right heart. Percutaneous retrieval technique was used to successfully extract the catheter fragment and complete recovery was achieved.

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.

Novel kissing catheter technique for foreign body retrieval

We report a novel technique ‘the kissing catheter technique’ for retrieval of a broken catheter fragment in a patient undergoing closure of a patent ductus arteriosus.

Percutaneous retrieval of an intrathecal foreign body: technical note

A 58-year-old man had an intrathecal baclofen pump implanted. A guidewire used during removal of a previously placed lumbar drain catheter fractured, and a fragment was left within the thecal sac. Using fluoroscopic guidance, a loop snare device was used to retrieve the intrathecal foreign body successfully and without complication. The pump was placed without any difficulty, and the patient's hospital course was uneventful.

A novel homemade snare, safe, economical and size-adjustable

AIMS

Snaring has recently been reported as being effective in catching the retrograde guidewire (GW) in retrograde percutaneous coronary intervention (PCI) for chronic total occlusion. However, commercially available snares and previously reported homemade snares have a number of drawbacks, such as additional cost, limited size adjustability, risk of vessel injury and difficult handling. We report here a novel method to create easily an inexpensive, safe and size-adjustable snare.

METHODS AND RESULTS

Our newly developed homemade snare consists of a conventional 0.014" GW, a PCI balloon, and a guiding catheter (GC). In most cases, no extra cost is needed. As the snare is created by the soft wire tip, vascular injury is negligible. To adjust the size of the snare loop, the snare wire is simply pulled backwards and pushed forwards. Using this snare technique, we succeeded in the total revascularisation of a CTO in the left main trunk with a retrograde approach.

CONCLUSIONS

We report a novel method to create easily an inexpensive, safe and size-adjustable snare, and demonstrate its use in a retrograde CTO intervention. In some cases where a conventional snare is indicated, such as removal of intravascular iatrogenic foreign bodies, this novel homemade snare would be preferable because of its advantages.

A simplified pull-through angioplasty technique without a snare device. A technical note

The pull-through angioplasty technique allows stable wire tension and stabilization of the device during the procedure. In this technique, a guide wire is passed from one sheath to another, usually with the aid of a snare device. We describe the treatment of occlusive subclavian artery disease and lesion at the origin of the vertebral artery employing a brachiofemoral pull-through technique without using a snare device. In this technique, the guide wire is advanced from the femoral artery to the brachial artery. The guide wire is directly inserted into the sheath placed at the brachial artery. The brachial artery is compressed proximal to the point of sheath insertion to prevent bleeding. The sheath is extracted temporally and the guide wire is caught outside of the body. The sheath is then introduced again through the guide wire. We used the pull-through technique without a snare device in seven cases, and we were able to build the pull-through system in six of these cases without a snare device. This pull-through technique without a snare device is not difficult to use, and may reduce the time and cost of angioplasty procedures.

Paediatricians' referral preference of patients with embolised intravascular foreign bodies: a survey-based study

BACKGROUND

Central line insertion is a routine procedure in medical practice. Dislodgement of lines into the vascular system is a rare complication. We noticed that paediatric health care providers (PHCP) contact the cardiac or general paediatric surgeon for extraction of dislodged lines more frequently than using the less invasive percutaneous approach.

AIM

To study the referral preference of PHCP for patient with embolised intravascular foreign bodies.

METHODS

A questionnaire with three questions was distributed to PHCP of all paediatric subspecialties, including surgery, in two tertiary care centres. The questions were about the total number of patients seen with central line, experience with complications, and preferred specialty for removal of dislodged central lines.

RESULTS

The questionnaire was distributed to 128 professionals. The response rate was 79% (n=101). Incomplete answers (n=14) were excluded. The grades of responders were senior consultants 18%, junior consultants 38%, and residents 43%. Thirty nine percent of care providers experienced dislodgement or fragmentation of central lines. The majority (82%) prefer to refer the patients for surgical removal.

CONCLUSIONS

Most PHCP in the selected hospitals prefer to refer patients with embolised foreign bodies in the vascular system for surgical removal. The local health policy should be updated for the use of the alternative percutaneous approach.

Successful removal of an entrapped and kinked catheter during right transradial cardiac catheterization by snaring and unwinding the catheter via femoral access

Since its introduction by Campeau in 1989, the transradial approach for coronary angiography has gained significant popularity among interventional cardiologists due to its lower access site complication rates, cost-effectiveness, and shorter hospital course. Although the transradial approach is much safer than the transfemoral approach, it has its own inherent rare complications including radial artery occlusion, thrombosis, nonocclusive radial artery injury, vasospasm, and compartment syndrome. Herein, we present an unusual case of entrapment and kinking of a catheter in the radial artery, which was successfully removed by using a gooseneck snare via the transfemoral route. The distal and proximal tips were then simultaneously rotated in opposite directions, allowing for the unkinking and removal of the catheter. To our knowledge, this is the first report of this rare complication.

A close cut: a technical report of endovascular removal of a penetrating intravascular foreign body after a lawn mowing injury

We present a case of endovascular retrieval of a penetrating foreign body that was originally lodged in the mediastinum and then migrated to the hepatic vein. The steel nail entered the thorax and traversed the left lung causing a pneumothorax. The patient underwent a thoracotomy, but the foreign body had migrated from its original mediastinal position. A postsurgical CT showed that the object was below the right hemidiaphragm. Diagnostic venogram demonstrated that the object was in the main hepatic vein. Using a double-snare technique, the object was safely and successfully removed from the hepatic vein via the right common femoral vein.

Repositioning of surgically placed peritoneovenous shunt catheter by forming "in situ" loop snare: case report and review of literature

We describe a technique that allows repositioning of malfunctioning peritoneovenous shunt (PVS) catheters. We report a 67-year-old female with refractory ascites, who presented with malfunctioning PVS. The catheter tip was outside the superior vena cava (SVC), possibly in a small mediastinal vein, which makes its tip inaccessible to regular snares and retrieval devices. We used "in situ" loop snare technique to reposition the tip of the catheter into the inferior vena cava (IVC). In situ loop snare technique can be used to reposition malfunctioning PVS catheters caused by a kink or by malposition of its tip. The technique avoids surgical or interventional replacement of these catheters. This technique can be also used for retrieval of foreign body fragments that have no free ends and, therefore, cannot be captured by a snare or other retrieval devices.

Real-time MR-guided retrieval of inferior vena cava filters: an in vitro and animal model study

PURPOSE

To develop interventional magnetic resonance (MR) guidance techniques for inferior vena cava (IVC) filter retrieval in vitro and demonstrate feasibility in vivo.

MATERIALS AND METHODS

Three optional IVC filters and their retrieval systems were investigated. Experiments were performed on a 1.5-T MR system. Real-time MR imaging was optimized by using a custom-built IVC phantom. A three-dimensional (3D) contrast-enhanced MR venography sequence was optimized in vitro for improved detection of thrombus trapped within the filters. Filters were then retrieved in vitro and in vivo in a swine model under MR guidance. In-vivo retrieval procedure time was measured.

RESULTS

The combination of one of the nitinol filters and a loop snare was suitable for real-time MR procedures. With a 90° flip angle, 3D MR venography allowed detection of simulated thrombus within the filter. A radial true fast imaging sequence with steady-state precession allowed visualization of the loop snare and IVC filter hook and successful retrieval of the filter in vivo and in vitro. In-vivo MR fluoroscopy time for retrieval was 97 seconds ± 51 (mean ± SD).

CONCLUSIONS

MR-guided retrieval of a nitinol-based IVC filter by using a loop snare is feasible with the use of optimized sequences and passive device tracking.

Missing the guidewire: an avoidable complication

Central venous catheterization is an imperative tool in the critically ill patient to administer fluids, medications and for monitoring the central venous pressure. This procedure is associated with a variety of complications, some of which can be life threatening. In this brief report, we are addressing one of the rare complications of central venous catheterization which is missing the guidewire. We also described several precautions to avoid this complication as well as modifications in the guidewire to prevent its escape.

Guiding catheter tip avulsion--an unusual complication of renal artery stenting

A 68-year-old hypertensive male underwent stenting for critical stenosis of the right renal artery through right femoral approach. The stent missed the ostium and repeated attempts at stenting the ostium did not succeed. Brachial approach was resorted to and ostium could be stented successfully. While deploying the stent the balloon was slightly inside the guiding catheter and the catheter tip got partially detached. The whole assembly was withdrawn to the brachial artery and the detached fragment was snared and removed.

Minimally invasive catheter procedures to assist complicated pacemaker lead extraction and implantation in the operating room

We report on percutaneous catheter procedures in the operating room (OR) to assist complicated manual extraction or insertion of pacemaker (PM) and implantable cardioverter defibrillator leads. We retrospectively reviewed complicated PM revisions and implantations performed between 2004 and 2009 that required percutaneous catheter procedures performed in the OR. The type of interventional procedure, catheter and retrieval system used, venous access, success rates, and procedural complications were analyzed. In 41 (12 female and 29 male [mean age 62 ± 17 years]) of 3021 (1.4%) patients, standard manual retrieval of old leads or insertion of new leads was not achievable and thus required percutaneous catheter intervention for retrieval of misplaced leads and/or recanalisation of occluded central veins. Thirteen of 18 (72.2%) catheter-guided retrieval procedures for misplaced (right atrium [RA] or ventricle [RV; n = 3], superior vena cava [n = 2], brachiocephalic vein [n = 5], and subclavian vein [n = 3]) lead fragments in 16 patients were successful. Percutaneous catheter retrieval failed in five patients because there were extremely fixed or adhered lead fragments. Percutaneous transluminal angiography (PTA) of central veins for occlusion or high-grade stenosis was performed in 25 patients. In 22 of 25 patients (88%), recanalization of central veins was successful, thus enabling subsequent lead replacement. Major periprocedural complications were not observed. In the case of complicated manual PM lead implantation or revision, percutaneous catheter-guided extraction of misplaced lead fragments or recanalisation of central veins can be performed safely in the OR, thus enabling subsequent implantation or revision of PM systems in the majority of patients.

Intravascular foreign bodies: danger of unretrieved fragmented medical devices

A warning on the danger of unretrieved device fragments and recommendations to mitigate the danger were issued by the Food and Drug Administration in January 2008. The causes of intravascular foreign bodies are classified into three main categories: improper manipulation and usage, device defects, and others, such as patient and anatomical factors. Device failure after long-term use is rarely predicted at the time of approval, since device abnormality is rarely experienced in animal studies and clinical trials conducted during development of the device. Stent fracture due to metal fatigue is one example. Complex complications could occur from simultaneous use of two or more devices with diverse characteristics. The success rate of percutaneous retrieval of intravascular foreign bodies has improved with the advances in commercially available devices. However, the procedure is not always successful and sometimes surgical removal becomes necessary. Appropriate device selection and acquisition of experience in using the device are important. When an intravascular foreign body cannot be retrieved, the risk of complication could be high. Magnetic resonance imaging examination sometimes causes adverse events, including burns due to the heat generated by metal movement. Such information should be correctly recorded. Furthermore, it is necessary to provide patients with adequate information about the characteristics of implanted devices and unretrieved fragments. We reviewed the literature on unretrieved medical device fragments and include articles that describe the Japanese experience.

Internal jugular vein thrombosis presenting as a painful neck mass due to a spontaneous dislocated subclavian port catheter as long-term complication: a case report

Central venous access devices are extensively used for long-term chemotherapy and parenteral nutrition. However, there are some possible immediate, early, and late complications related to the implantation technique, care, and maintenance. We present the uncommon occurrence of a thrombosis of the internal jugular vein due to a spontaneous migration of a Port-A-Cath catheter into the ipsilateral internal jugular vein as a delayed complication of a central venous access catheter implanted for chemotherapy delivery. A review of the literature is given, and the factors responsible for this unusual complication will be discussed.

Extraction of Dental Crowns from the Airway: A Multidisciplinary Approach

We describe two cases of airway foreign bodies (FB) consisting of a dental crown. The shape and composition of dental crowns complicate their extraction from the tracheobronchial tree, sometimes necessitating thoracotomy. We describe the use of a multidisciplinary approach involving rigid and flexible bronchoscopy in concert with the use of wire snares under fluoroscopic guidance for extraction of these challenging FB. These cases illustrate that this multidisciplinary approach can allow successful extraction of the difficult FB from much of the tracheobronchial tree and the avoidance of thoracotomy.

Dislodgment of port-a-cath catheters in children

BACKGROUND

Port-a-cath catheters are frequently used in children with malignancies. Their dislodgment is rare, but carries potentially serious risks. This study analyzed our 11-year experience of this important issue.

METHODS

Between June 1997 and January 2008, 290 ports of different brands were implanted in children by pediatric surgeons. Among the patients, 12 children with catheter dislodgement were retrospectively studied. Their ages ranged from 2-16 years, with a median of 6.4 years. Their body weights ranged from 12-39 kg, with a median of 20 kg. Ten patients presented with a port-a-cath dysfunction, while the other two patients were identified incidentally during surgery for removal of their ports.

RESULTS

The downstream ends of dislodged catheters were located in the right ventricle (five patients), right atrium (four), main pulmonary artery (one), left pulmonary artery (one) and right pulmonary artery (one). Eleven catheters were broken, and one catheter was disconnected from the port. Most (10/11) catheters were broken at the site of anastomosis to the port. All dislodged catheters were successfully retrieved without complications by transcatheter retrieval using a gooseneck snare.

CONCLUSION

The dislodgment rate of port-a-cath catheters in children in our series was 4.1%. Most (83%) catheters were broken at the site of anastomosis to the port. All dislodged catheters could be successfully retrieved by transcatheter retrieval using a gooseneck snare.

Endovascular snare kit in the combined antegrade and retrograde management of ureteral avulsion: report of two cases

We report the feasible and safe use of the Amplatz Goose Neck Snare kit for avulsed ureter retrieval during ureteroscopy. A 49-year-old lady and a 61-year-old man complaining of urolithiasis underwent ureteroscopy; following stone fragmentation, and basketing avulsion of the ureter occurred. Using the Amplatz Goose Neck Snare kit it was possible to place an indwelling ureteral catheter in both cases aiming at restoring the urinary upper tract continuity. The snare-assisted endovascular technique may be an interesting tool even in endourology for the management of ureteral avulsion. This endoscopic mini-invasive procedure makes it possible to avoid an immediate invasive surgical approach often resulting in nephrectomy, having time for planning a possible durable conservative treatment.

[Practical aspects in the percutaneous extraction of foreign bodies using a Goose-Neck Snare]

OBJECTIVE

To present our clinical experience in the extraction of different foreign bodies (from vascular or other sites) using a goose-neck snare in 13 patients, with emphasis on practical and technical aspects used during the procedures.

MATERIAL AND METHODS

A total of 13 foreign bodies, including 9 intravascular objects and 4 in other locations, were included. The intravascular foreign bodies were stents (n = 2), coils (n = 2), fragments of broken central venous catheters (n = 3), and fragments of broken balloon catheters (n = 2). The nonvascular foreign bodies were fragments of broken double-J catheters (n = 2), one double-J catheter located entirely within the calyces of the kidney, and a fragment of a broken metallic guide wire in an intrahepatic bile duct. Goose-Neck Snares of different diameters (depending on the location) were used to extract the foreign bodies. Forceps were used as an auxiliary device in one patient with a fragment of double-J catheter, and in another case with a catheter fragment in a pulmonary vein, a pigtail catheter was also used to move the fragment and facilitate its extraction with the Goose-Neck Snare.

RESULTS

All of the foreign bodies were successfully extracted except a transjugular intrahepatic portosystemic shunt that migrated to the right heart cavities and was correctly repositioned in the right brachiocephalic venous trunk. No complications of any kind were seen during the procedures.

CONCLUSIONS

The Goose-Neck Snare is very useful, safe, and versatile for the extraction of different types of foreign bodies in different territories. Especially in vascular territories, it is necessary to have ample knowledge about and experience in the different techniques used for catheterization.

Stretched platinum coil during cerebral aneurysm embolization after direct carotid puncture: two case reports

We describe two cases of coil unraveling that occurred during cerebral aneurysm embolization after direct carotid puncture. The unraveled coil was stretched and buried in the subcutaneous part of the neck. No immediate or long-term complication was observed.