| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
1 All authors: Department of Diagnostic Radiology, University Clinics of Ulm, Robert-Koch-Str., D-89081 Ulm, Germany.
Received September 7, 2000;
accepted after revision December 5, 2000.
Address correspondence to A. Gabelmann.
Abstract
 Top Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
MATERIALS AND METHODS. Over a period of 6 years, we attempted percutaneous treatment of intravascular foreign bodies in 45 patients. The 45 foreign objects consisted of 12 endovascular stents, 14 catheter fragments, 11 embolization coils, four guidewire fragments, three vena cava filters, and one cardiac valve fragment. Percutaneous extraction was performed using a combination of multipurpose catheters and nitinol snare loop or grasping forceps. Depending on their composition, misplaced or dislodged intravascular stents were either repositioned or percutaneously removed.
RESULTS. Percutaneous intervention was successful in 41 (91.1%) of 45 patients. Of 38 patients on whom we performed percutaneous removal, the procedure was successful in 34 patients (89.5%), including 13 of the 14 patients with catheter fragments, all four of the patients with guidewire fragments, 10 of the 11 patients with misplaced or dislodged embolization coils, four of the five patients with misplaced or dislodged endovascular stents, and all three of the patients with misplaced or dislodged vena cava filters. The procedure was not successful in the one patient with a cardiac valve fragment. All seven of the percutaneous repositioning procedures we performed resulted in the endovascular stent being successfully repositioned in a stable intravascular position. Most of the retrieval procedures (77.7%) were performed using the nitinol snare as the primary instrument. No late complications were registered during the follow-up period, which ranged from 9 to 68 months (mean, 42.4 months overall).
CONCLUSION. Percutaneous techniques for the extraction of intravascular foreign objects or for repositioning of dislocated endovascular stents are highly effective with a low rate of complications and should always be the primary method of choice.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
The rapid development and wide application of minimally invasive and interventional techniques are associated with an increased rate of specific method-related complications caused by intravascular foreign bodies or resulting from dislocation of vascular endoprostheses. Although earlier reports concentrated on objects such as broken catheters, guidewires, or vena cava filters [2,3,4], today, the spectrum of endoluminal foreign objects has broadened to include items such as embolization coils and endovascular stent components. Issues related to this broadened endovascular spectrum, particularly those issues related to misplaced stents, have been addressed in only a few articles that concentrate mainly on the problems associated with misplaced or dislocated stents that have embolized to peripheral vessels [5,6,7].
Since the first articles by Thomas et al. [1] and Dotter et al. [4], many devices have been reported to have been used as tools to retrieve various types of intravascular objects—snares, biopsy forceps, Dormia baskets, or tip-deflecting wires [2,3,4, 8]. In the meantime, technical innovations have altered the performance of intravascular recoveries. With the introduction of the nitinol gooseneck microsnare [9, 10], the disadvantage of a parallel-opening self-made wire snare was overcome. Consequently, retrieving foreign objects with only baskets or forceps [11] was no longer the method of choice. Both the materials and methods used have significantly simplified percutaneous retrieval and have increased the efficacy of retrieval.
Based on our experience with 45 patients, we report on the strategies, methods, success rate, and techniques of percutaneous retrieval of intravascular foreign bodies.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Indications for interventional retrieval included stent dislocations (n = 12), broken catheters between 6 and 25 cm long (n = 14), metal coils dislocated during embolization (n = 11), intravascular loss of guidewire fragments between 20 and 110 cm long (n = 4), dislocated vena cava filters (n = 3), and a fragment of an artificial heart valve (n = 1).
In each instance of diagnostic angiography of peripheral or coronary arteries and in each interventional procedure, such as embolization or placement of a stent or vena cava filter, the foreign body was immediately recognized as such and removed during the same session. In three of 14 patients undergoing placement or removal of a central venous catheter, up to 10 days passed before discovery of the catheter fragment. In these patients, interventional retrieval of the foreign bodies was performed within 24 hr of discovery.
Foreign bodies were primarily approached via the femoral access, except in three patients with a dislodged vena cava filter (transjugular venous approach). Standard vascular sheaths (5-14 French) were used for all procedures in both arterial and venous systems. In several patients, because of considerations of safety and practicability, we used the double-wire technique first described by Dawson et al. [12]. In six patients, a second, contralateral femoral or cervical access was required.
Despite all the structural and material differences characterizing the individual foreign bodies, the technique of percutaneous foreign body extraction was, in principle, comparable in all patients. Instruments of choice in most cases were nitinol gooseneck snares (Amplatz, Microvena, White Bear Lake, MN; Nitinol, Osypka-Sulzer, Berlin, Germany). The loop diameter of the snare was adapted to the vascular diameter, and the angulation of the snare was adapted to the intravascular position of the foreign body. If necessary, the direction of the snare was additionally manipulated using a 5-French guiding catheter with a cobra or vertebral curved configuration. In a few patients, we also used flexible grasping forceps (Cordis Endovascular, Haan, Germany) as well as stone baskets (Highflex; Bard-Angiomed, Karlsruhe, Germany).
To provide access for these devices we usually used a 9-French braided multipurpose catheter. The foreign body was then captured with one or more of the instruments at our disposal, fixed to the multipurpose catheter, and, if possible, pulled into the catheter. In cases in which it proved impossible to draw the foreign body into the catheter, a long sheath corresponding to the dimensions of the object was used to ensure an atraumatic vascular passage and to minimize potential injury to the internal vascular wall.
In some patients, an adjunctive technique was required to set up or to support the retrieval procedure. In one patient, the snare did not pass over the Wallstent (Boston Scientific-Schneider [Europe], Bülach, Switzerland). In this case, the loop of the snare was passed around the external end of the guidewire, using this as a leading edge to direct the snare toward the stent. In another patient with a Wallstent, a balloon catheter was inserted into the stent and partially inflated. Thus, the balloon was used as a guiding tool to direct the snare around the stent. In one patient with a partially dilated Palmaz stent (Cordis Endovascular, Haan, Germany) floating freely in the abdominal aorta, a gooseneck snare was positioned around the stent to hold the stent in place during insertion of a balloon catheter. In three patients, the retrieval procedure began with a forceps or a basket being used to move the catheter fragment. The catheter fragment was then pulled into a more favorable position, and the procedure completed with a snare.
The 12 dislocated stents included eight Palmaz stents in six arterial and two venous positions, two Wallstents in one arterial and one venous position, and one each of the Memotherm nitinol stent (Bard-Angiomed) and the Renal bridge stent (Arterial Vascular Engineering-Medtronics, Neuss, Germany), both in arterial application.
The exact technique used to retrieve a stent depended on criteria such as flexibility, remaining expansive capabilities, and options for alternate intravascular placement. With the Palmaz device, the stent's degree of expansion was the deciding factor for the subsequent procedure. If the stent was fully expanded but had slipped off of its guidewire, we inserted a 0.035-inch J-wire (Bard-Angiomed). A balloon catheter with a diameter 1-2 mm larger than the expansion diameter of the stent was then advanced over this guidewire. With the balloon partially inflated, it was possible to ensure a safe, atraumatic vascular passage without compromising the stent's remaining expansion reserves for reimplantation. Although in this stable stent—balloon combination, the stent was either returned to the site originally intended for implantation or to an alternate vascular segment.
In the case of stents that had only partially expanded, we inserted a 0.020-inch guidewire (Boston Scientific-Schneider [Europe]) over which a low-profile balloon catheter was introduced into the stent. Small unexpanded Palmaz stents were either captured with a snare or with the grasping forceps and then drawn into a multipurpose catheter and removed percutaneously through the access port.
In patients with dislocated Wallstents, percutaneous retrieval was always the first procedure attempted. Stents were captured with a nitinol snare, compressed, and drawn into the multipurpose catheter. The procedure used to correct the position of the Memotherm or Renal bridge stent was analogous to the previously described technique of snaring the stent with a gooseneck loop and then performing percutaneous extraction or repositioning.
All patients were treated with heparin for 24-48 hr after the procedure. Patency of the vascular segments in the vicinity of the retrieval maneuver and the final stent position were documented using duplex sonography or angiography after the intervention itself and at the follow-up examination.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Of 38 patients in whom percutaneous retrieval was considered the method of choice, the procedure was successful in 34 patients (89.5%). Of 18 patients with a fragment of catheter or guidewire, 13 of the 14 patients with catheter fragments (Fig. 1A,1B) and all four patients with guidewire fragments had successful retrieval procedures. All three malpositioned vena cava filters were captured and retrieved via jugular access without complications. Of 11 misplaced embolization coils, 10 coils were retrieved using a snare or forceps and four of five endovascular stents were removed successfully. Percutaneous removal failed in four patients (10.5%), including the patient with the cardiac valve fragment in whom the attempt at percutaneous retrieval was successful only in part.
|
|
The second method, performed in seven patients in this study, repositioned the endovascular stent.
Of the devices or techniques used in this study, the nitinol gooseneck snare in combination with a selective or multipurpose catheter was the most commonly used device. The snare was used as the primary technique in 35 patients (77.7%). The gooseneck snare proved to be effective in 13 of 14 catheter fragments retrieved from the subclavian vein, pulmonary arteries, right atrium or ventricle, or superior or inferior vena cava. With a gooseneck snare, all four guidewire fragments and two vena cava filters were successfully retrieved from the right atrium or ventricle, abdominal aorta, peripheral artery, or inferior vena cava.
With the snare technique, eight of 11 incorrectly positioned embolization coils (Fig. 2A,2B) were retrieved. Because of their flexibility and preformed intravasal configuration, it was possible to snare coils within small vessels, even in patients in whom the coils lay directly against the vascular wall. In larger arteries, we had better results with the grasping forceps (Fig. 3A,3B,3C) because in these patients the contralateral wall of the vessel could not support maneuvering of the nitinol snare.
|
|
|
|
|
The snare technique failed in five patients (14.2%). In three, removal could not be accomplished because the loop of the snare would not pass over the foreign body. In two of these patients—both of whom had a misplaced coil—percutaneous removal was successfully finished by changing to a grasping forceps. In one patient with gastrointestinal bleeding from a pancreatic tumor, an attempt at embolization resulted in a coil being lost in the common hepatic artery. During the retrieval attempt, however, the coil embolized into a segmental branch of the right hepatic artery, obviating further extraction. In one patient with Child class C cirrhosis, snaring of a fragment of a balloon catheter that had ruptured during creation of a transjugular intrahepatic portosystemic shunt and embolized into the inferior pulmonary artery proved impossible. After multiple procedures, the patient refused any further attempts. Finally, the snare technique failed in one patient with an endovascular stent.
On occasion, a grasping forceps was used as the primary instrument for removal. The device was used in only three patients. The decision to use a forceps instead of a snare was made because of the intravascular malposition of a vena cava filter in one patient and a Wallstent in another; in these patients, the forceps was used to move the foreign body to a more favorable position for snaring. Finally, only grasping was sufficient to remove the foreign bodies. In the third patient, a large fragment of a broken cardiac valve was grasped, brought down to the bifurcation, and removed by surgical cutdown.
In patients with dislodged endovascular stents, we performed either percutaneous retrieval or repositioning of the stent. Seven stents were successfully repositioned in a stable vascular position. Six partially or fully expanded stents were reimplanted using a balloon catheter at the site initially intended for stent deployment in the subclavian artery, and five were reimplanted in an iliac vein or artery. A slightly expanded Palmaz stent embolized into the proximal portion of internal iliac artery during the attempt to introduce a balloon catheter. The stent was secured in this position by implantation of a short Wallstent to hold the stent in place. Even if the stent was not actively moved, the final stent position was considered a stable intravascular position without any hemodynamic influence on blood flow.
Percutaneous retrieval by gooseneck snare or grasping forceps was performed in five patients, including two patients with an unexpanded Palmaz stent, two patients with a Wallstent, and one patient with a Memotherm stent. The procedure was successful in four patients. One Memotherm stent that had become dislocated after the device malfunctioned was captured primarily through the use of a snare. The stent, however, could not be sufficiently compressed. Percutaneous removal or replacement to the upper pelvic level was impossible because of the patient's extensive stenosing plaque formation. The stent was subsequently surgically removed.
No further complications, such as damage to the vascular wall, were noted. Two patients experienced groin hematoma, but they did not require surgical revision for this condition. Late complications occurring during the follow-up period were not recorded.
No difference was noted between the two techniques when we compared the vessel patency of patients whose stents had been percutaneously removed with that of patients whose stents had been repositioned. Mean follow-up time was 32.1 months (range, 18-56 months) for patients whose stents were percutaneously extracted versus a mean follow-up time of 38.6 months (range, 26-48 months) for those whose stents were not extracted.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
The rate of broken venous catheters has been estimated at 0.1% [13], but no data are available for other types of objects, such as broken guidewires or lost embolization coils. The rate of serious complications associated with foreign body embolism has been reported as high as 71% [14], with a mortality rate in the range of 24-60% [15, 16]. In particular, patients with cardiopulmonary localization of foreign bodies are at risk for severe complications, ranging from cardiac arrhythmias to perforation [17]. In stent implantations, the rate of incorrect stent positioning is reported to be 2.5% in peripheral vessels [7] and as high as 8.3% in the coronary arteries [18].
The indications for removal or positional correction of individual types of foreign body materials vary widely. The danger of imminent septic complications is of primary concern with intravascular catheter fragments. Bacterial contamination has been found in up to 52% of catheters in position for more than 48 hr [19]. With dislocated embolization coils, local thrombogenicity and distal ischemia represent the major concerns. Guidewires and vena cava filters may perforate the vascular wall. For these types of foreign objects, there is a clear and urgent indication for percutaneous removal. Besides the danger of thrombotic events, dislocated stents are associated with permanent traumatic injury to the vascular wall with subsequent threat of perforation [20].
The techniques for extraction of intravascular foreign objects have undergone significant changes over the years. Whereas in the early 1980s, retrieval of catheter fragments was still mostly attempted with a Dormia basket [11] or with a self-made wire snare [8], today the nitinol gooseneck snare loop introduced by Amplatz enjoys almost exclusive application [9, 10, 21]. In our study, the most frequently used device by far was a modular combination consisting of an angled snare and a multipurpose catheter with a hook configuration. The combination of these two individual components, because of the two-fold angles of the gooseneck and multipurpose catheter, made it possible to approach foreign objects even in difficult locations and, unlike the experience reported by Egglin et al. [3], to place the loop around objects immediately adjacent to the vascular wall. This latter capability is possible because the combination of the two devices permits the object to be lifted away from the vascular wall. Another advantage of this instrument is its predefined loop diameter and the shape-memory properties of nitinol, which facilitate planning of a three-dimensional procedure in nearly any vascular area. In addition, the nitinol snare is capable of developing a variable amount of force, and foreign bodies can be compressed.
Endovascular stents are designed to remain at sites within the vascular system. Because of their size and rigidity, they are often difficult to remove. For this reason, stents play a special role in the treatment of intravascular foreign bodies. When confronted with misplaced stents, the primary consideration of the radiologist is to reimplant the stent, whenever possible, at its intended position or to move it to a stable alternate site. First, however, one must determine whether correction of the stent's position is actually required. Furthermore, one must weigh the risks associated with the retrieval maneuver, such as permanent vascular wall trauma, against the benefit to the patient from the percutaneous procedure. The rescue technique used for the retrieval of incorrectly positioned stents depends in great degree on the type of stent involved. Stents are characterized by parameters such as flexibility, self-expandability, compressibility, and rigidity, together with the radial expansion force.
The flexibility and compressibility of the Wallstent make this stent type suitable for percutaneous extraction, especially because the stent reaches its nominal diameter when set free in the vascular lumen and does not expand further. The Wallstent is easily compressed with a nitinol loop and then drawn into a multipurpose catheter for subsequent percutaneous removal [10, 21]. The Palmaz stent, on the other hand, because of its inherent rigidity, would seem primarily unsuited for percutaneous extraction, although extraction is usually possible in a nonexpanded stent [22]. In our study, one nonexpanded stent was removed percutaneously without difficulty using a snare.
Partially or fully expanded Palmaz stents may be moved to alternate positions [23] once they have been attached by a balloon catheter [24, 25]. In our series, this technique was successful for the replacement of six stents (50%).
Another technique that is easy and quick to perform is the intravascular fixation of the dislocated stent to a second stent. For example, a slightly expanded Palmaz stent, which had embolized into the proximal internal iliac artery, was locally fixed to the vascular wall using another stent. In our opinion, this procedure was necessary because the stent moved within the vascular lumen synchronous to the patient's pulse, and likely would have resulted in significant injury to the vascular wall.
Long-term follow-up has shown no difference between patients in whom stents were removed to a stable alternate position and those whose stents were removed percutaneously. Based on these findings, we consider both options to be equally safe. The type of retrieval used depends primarily on the type and position of the endovascular stent.
Results from the percutaneous treatment of intravascular foreign bodies continue to prove the procedure's capabilities as a highly efficient, atraumatic method with success rates of 90% or above. Based on the high frequency with which this method is performed, its relevance cannot be underestimated. Creatively used and combined, the numerous available rescue devices can be adapted to the situation at hand and permit a safe retrieval of the intravascular foreign body, even in difficult cases.
|
TopAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  P. N. Nesargikar, M. Grannell, D. Hinwood, R. Orme, and A. Houghton Newton's Law to the Rescue: Therapeutic Effects of Gravity Aiding the Management of a Migratory Venous Foreign Body--A Case Report Vascular and Endovascular Surgery, August 1, 2009; 43(4): 406 - 409. [Abstract] [PDF]
|
|
|
|
 |
|
 Authors/Task Force Members, A. Torbicki, A. Perrier, S. Konstantinides, G. Agnelli, N. Galie, P. Pruszczyk, F. Bengel, A. J.B. Brady, D. Ferreira, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Eur. Heart J., September 2, 2008; 29(18): 2276 - 2315. [Full Text] [PDF]
|
|
|
|
 |
|
 A. Surov, M. Buerke, E. John, S. Kosling, R.-P. Spielmann, and C. Behrmann Intravenous Port Catheter Embolization: Mechanisms, Clinical Features, and Management Angiology, March 1, 2008; 59(1): 90 - 97. [Abstract] [PDF]
|
|
|
|
|
|
S. S. Poludasu, P. Vladutiu, and J. Lazar Migration of an Endovascular Stent From Superior Vena Cava to the Right Ventricular Outflow Tract in a Patient With Superior Vena Cava Syndrome Angiology, March 1, 2008; 59(1): 114 - 116. [Abstract] [PDF]
|
|
|
|
 |
|
 W. J. Chwals Vascular Access for Home Intravenous Therapy in Children JPEN J Parenter Enteral Nutr, January 1, 2006; 30(1_suppl): S65 - S69. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Murphy, A. E. Healey, J. Harper, S. Saltissi, and R. G. McWilliams Percutaneous removal of a right atrial catheter fragment: the value of the En Snare Nephrol. Dial. Transplant., October 1, 2004; 19(10): 2686 - 2687. [Full Text] [PDF]
|
|
|
|
 |
|
 D. J. Meier, K. P. Tamirisa, and D. T. Eitzman Ventricular tachycardia associated with transmyocardial migration of an epicardial pacing wire Ann. Thorac. Surg., March 1, 2004; 77(3): 1077 - 1079. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Bessoud, T. de Baere, V. Kuoch, E. Desruennes, M.-F. Cosset, N. Lassau, and A. Roche Experience at a Single Institution with Endovascular Treatment of Mechanical Complications Caused by Implanted Central Venous Access Devices in Pediatric and Adult Patients Am. J. Roentgenol., February 1, 2003; 180(2): 527 - 532. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
