Abstract
Interventional procedures involving the use of intravascular or endoluminal objects have rapidly increased over the years with advancements in minimally invasive techniques. These foreign objects such as endovascular coils, guidewires, and endoluminal catheters, if lost or malpositioned, are a potential threat, which can result in complications such as embolization, perforation, infections, and arrhythmias. Therefore, timely removal of these foreign bodies is essential. In this technical report, we have described our experience with different scenarios in which percutaneous interventional techniques for retrieval of such foreign bodies were performed at our institute

Barakzai, Muhammad Danish

Khandwala, Kumail

Ul Haq, Tanveer

English

eCommons@AKU

Masthead Logo eCommons@AKUDepartment of Radiology Medical College, PakistanJanuary 2019Non-surgical retrieval of dislodged or misplacedintravascular/ ndoluminal foreign objects.Muhammad Danish BarakzaiAga Khan UniversityTanveer Ul HaqAga Khan University, tanveer.haq@aku.eduKumail KhandwalaAga Khan University, kumail.khandwala@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolRecommended CitationBarakzai, M. D., Ul Haq, T., Khandwala, K. (2019). Non-surgical retrieval of dislodged or misplaced intravascular/ ndoluminal foreignobjects.. Cureus, 11(1), 1-21.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/336Received 01/08/2019 Review began 01/10/2019 Review ended 01/16/2019 Published 01/21/2019© Copyright 2019Barakzai et al. This is an open accessarticle distributed under the terms ofthe Creative Commons AttributionLicense CC-BY 3.0., which permitsunrestricted use, distribution, andreproduction in any medium, providedthe original author and source arecredited.Non-surgical Retrieval of Dislodged orMisplaced Intravascular/EndoluminalForeign ObjectsMuhammad Danish Barakzai  , Tanveer U. Haq  , Kumail Khandwala 1. Radiology Department, Aga Khan University Hospital, Karachi, PAK 2. Department of Radiology, AgaKhan University Hospital, Karachi, PAK 3. Radiology, Aga Khan University Hospital, Karachi, PAK Corresponding author: Kumail Khandwala, kumail.khandwala@gmail.com Disclosures can be found in Additional Information at the end of the articleAbstractInterventional procedures involving the use of intravascular or endoluminal objects haverapidly increased over the years with advancements in minimally invasive techniques. Theseforeign objects such as endovascular coils, guidewires, and endoluminal catheters, if lost ormalpositioned, are a potential threat, which can result in complications such as embolization,perforation, infections, and arrhythmias. Therefore, timely removal of these foreign bodies isessential. In this technical report, we have described our experience with different scenarios inwhich percutaneous interventional techniques for retrieval of such foreign bodies wereperformed at our institute.Categories: RadiologyKeywords: retrieval, vascular, malposition, foreign body, interventional radiology, misplacedIntroductionMinimally invasive and interventional techniques involving the implantation and use ofintravascular objects have rapidly increased over the years [1], and simultaneously, there is anincrease in the number of such objects that become malpositioned or misplaced. These foreignobjects are a potential threat that can result in embolization, perforation, infections, andarrhythmias [2]. Therefore, timely and effective removal of these foreign bodies is essential.The spectrum of iatrogenic endoluminal foreign objects has broadened to include items such asembolization coils and endoluminal catheters, and most of the studies and case reports focuson intravascular wire retrieval [3]. Appropriate tools, expertise, and prompt actions are requiredwhile retrieving a lost object using minimally invasive techniques.Technical ReportWe report four different scenarios wherein percutaneous interventional techniques for retrievalof foreign bodies were performed at our institute. Formal ethical review was taken from theEthics Review Committee at the Aga Khan University Hospital, Karachi prior to conducting thestudy. Informed consent was taken from each patient before performing the procedures.Patient 1A 35-year-old male patient presented to the emergency room (ER) with multiple episodes ofhematemesis and melena. Upper gastrointestinal (GI) endoscopy showed a large duodenal ulcerwith a clear base and a visible oozing vessel. Argon plasma coagulation (APC) was performed;1 2 3 Open Access TechnicalReport  DOI: 10.7759/cureus.3931How to cite this articleBarakzai M, Haq T U, Khandwala K (January 21, 2019) Non-surgical Retrieval of Dislodged or MisplacedIntravascular/Endoluminal Foreign Objects. Cureus 11(1): e3931. DOI 10.7759/cureus.3931however, bleeding persisted. Injection of adrenalin in aliquots at the bleeding site was given;however, bleeding could not be controlled. Multiple small healed ulcers were also seen at theantrum. The patient was subsequently intubated and managed along the lines of hemorrhagicshock and disseminated intravascular coagulation (DIC). Resuscitation was done along withmassive transfusion protocol. Omeprazole infusion was continued and norepinephrine started. The patient was shifted to the interventional radiology (IR) suite immediately. A 4 French (Fr)vascular access femoral sheath was placed followed by the insertion of a 4 Fr C1 catheter.Angiogram of the celiac and superior mesenteric artery showed significant spasm. Activeextravasation of contrast was noted from the gastroduodenal and inferior pancreaticoduodenalarteries.A Progreat microcatheter (2.7 Fr, catheter 130-cm long, with a 0.021-inch wire) was used toselectively cannulate these arteries. The inferior pancreaticoduodenal artery was successfullyembolized first with a coil (Figure 1).FIGURE 1: Angiogram of celiac artery showing activeextravasation of contrast from gastroduodenal artery (whitearrow); coils in the inferior pancreaticoduodenal artery (whitearrowhead); the right and left hepatic arteries are also seen(black arrows).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 2 of 21While placing the FIB2x25 pushable coil to embolize the gastroduodenal artery, the coil gotdislodged into the right hepatic artery (Figure 2).FIGURE 2: While embolizing the gastroduodenal artery, a partof the coil got dislodged into the right hepatic artery (arrow)resulting in its occlusion.A microsnare (175-cm long, 4-mm loop, 0.18 inch) was used to catch the lost coil and it wasretrieved percutaneously through the right femoral sheath (Figures 3-5). Subsequently, thegastroduodenal artery was embolized using multiple coils and histoacryl glue.2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 3 of 21FIGURE 3: Dislodged coil ensnared with gooseneck microsnare(arrow); active extravasation from the gastroduodenal artery(arrowhead).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 4 of 21FIGURE 4: Trapped coil in the aorta (arrow); coil in the inferiorpancreaticoduodenal artery (arrowhead).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 5 of 21FIGURE 5: Fluoroscopic spot image showing coil beingwithdrawn from the right femoral sheath approach.Patient 2A 40-year-old male presented in the ER with a history of multiple gunshots to the head, neck,thorax, abdomen, and the right lower limb. Computed tomography (CT) scan was done whichshowed active extravasation from the left thyrocervical trunk, inferior thyroid artery, and theleft facial artery which was confirmed on angiography (Figure 6).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 6 of 21FIGURE 6: Angiogram showing active extravasation of contrastfrom left thyrocervical trunk (arrowhead). The left vertebralartery (arrow) appears normal.The patient was planned for angioembolization. During the procedure, while embolization ofleft thyrocervical trunk, the coil got dislodged into the right posterior cerebral artery andoccluded its distal flow (Figures 7-8).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 7 of 21FIGURE 7: A 4 French H1 catheter in the left subclavian artery(arrow); coil within the extravasating thyrocervical trunk(arrowhead).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 8 of 21FIGURE 8: Left vertebral angiogram showing coil dislodgedinto the right posterior cerebral artery (arrow). The coil isoccluding the distal flow in this vessel.A microsnare (175 cm length, 4-mm loop, 0.18 inch ) was used to catch the lost coil and it wassuccessfully retrieved off the right femoral sheath (Figures 9-10).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 9 of 21FIGURE 9: Gooseneck microsnare holding the coil(arrowhead). A bullet (arrow) is visualized above the clivus onthe right side.2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 10 of 21FIGURE 10: Trapped coil and microsnare in the abdominalaortaPost-retrieval angiogram of the vertebral artery showed normal flow in the right posteriorcerebral artery (Figure 11).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 11 of 21FIGURE 11: Left vertebral angiogram post-coil removalshowing normal flow in the right posterior cerebral artery(arrow)Patient 3A 65-year-old male, whose status was post-Whipple procedure, developed jaundice after fivemonths of the surgery. Liver function tests (LFTs) showed total bilirubin level of 5.3 mg/dL,direct bilirubin level of 4.1 mg/dL, and an indirect bilirubin level of 1.2 mg/dL, gamma-glutamyltransferase (GGT) level of 1012 U/L, and alkaline phosphatase (AP) level of 460U/L. Cholangiogram was performed which showed mild dilatation of intrahepatic bile ducts anda stricture at the hepaticojejunostomy anastomotic site. Multiple filling defects were seenwithin the intrahepatic ducts especially in the left main hepatic duct representingstones. Following balloon cholangioplasty, an 8 Fr locking pigtail catheter was placed acrossthe stricture into the bowel as an internal-external biliary drain (Figure 12).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 12 of 21FIGURE 12: Fluoroscopic spot image showing internal/external biliary drain in place (arrow).Initially, the patient had improvement in liver function but again came with deranged LFTs inincreasing trend. He was planned for re-cholangioplasty and placement of 12 Fr pigtailcatheter. During removal of the previously placed pigtail catheter, it slipped into theintrahepatic ducts. A glidewire was placed to cannulate the misplaced pigtail and over the wire,a 7 Fr sheath was placed into the tract. A 3 mm x 2 cm over the wire balloon was used to extractthe catheter (Figures 13-15).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 13 of 21FIGURE 13: Fluoroscopic spot image showing glidewirecannulating the dislodged catheter (arrow)2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 14 of 21FIGURE 14: Fluoroscopic spot image showing 7 French sheath(arrow) and balloon deployed in the catheter (arrowheads).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 15 of 21FIGURE 15: Fluoroscopic spot image showing retrieval ofpigtail catheterSubsequently, a new 12 Fr pigtail catheter was successfully deployed after cholangiopasty.Patient 4A 45-year-male came to the ER with fever for six days, vomiting for two days, and threeepisodes of per oral bleeding. The patient had a history of exposure to cattle and ticks.Laboratory workup showed a positive polymerase chain reaction (PCR) for Congo virus andderanged LFTs. Shortly after, the patient developed respiratory distress because of which hewas intubated and shifted to the intensive care unit (ICU) for observation. Meanwhile, a multi-lumen central line (arrow, 7 Fr, 16 cm length with 0.32-inch guidewire) was placed in the ICUvia the right femoral approach.After the procedure, while collecting instruments, the guidewire was missing. An X-rayconfirmed that the guidewire was lodged within the IVC, crossing the heart with its tip reachingthe right internal jugular vein (Figure 16).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 16 of 21FIGURE 16: Post-procedural portable chest radiographshowing trapped guidewire (arrow); nasogastric tube andendotracheal tube also seen in placeThe IR team was taken on board to remove the wire. The patient was shifted to the IR suitewith all the precautions. Initial fluoroscopic spot confirmed the exact position of the wire. Subsequently, a 7 Fr sheath was placed in the right jugular vein, and a microsnare (175-cmlong, 4-mm loop, 0.18 inch) was used. Multiple attempts were made to get hold of the J-tip butwere unsuccessful. The distal straight end of the wire was targeted to snare. Once in position,gradually the snare was retracted under fluoroscopy to reach the proximal J-tip. The J-tip wassnared and the wire was removed from the sheath (Figures 17-18).2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 17 of 21FIGURE 17: Fluoroscopic spot image shows snared J-tip ofguidewire (arrow) at the level of the right internal jugular vein.2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 18 of 21FIGURE 18: The tip of the trapped 0.18-inch wire is within thesheath (arrow).DiscussionNew endovascular materials and devices require constant education and updated expertise forthe intervention. Similarly the technical proficiency required to deal with dislodged ormisplaced endoluminal material also needs enhancement [3]. Foreign bodies should beremoved as soon as possible because of above mentioned complications. Major complicationsafter embolization of these particles are reported as high as 71% [4].Dotter et al. in the first review of the percutaneous retrieval of intravascular foreign bodiesrefer exclusively to catheters and wire fragments, but now the spectrum of intravasculardevices and objects has broadened significantly to include items such as vena cava filters,embolization coils, and endovascular stents [5]. For most of the cases, percutaneous treatmentof intravascular foreign bodies continues to be safely and effectively applied in numerouspatients [3]. Retrieval tools have transformed and evolved in recent decades. Dormia basket was used inthe early 1980s, while gooseneck snare or grasping forceps is mostly used nowadays [3]. TheAmplatz gooseneck snare is, by far, the most often used device for the retrieval of intravascular2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 19 of 21foreign objects. The loops and shaft feature the shape memory and superelastic properties ofnitinol, and so they retain their shape and are extremely kink-resistant [1,6]. It is also the mosteffective method with high success and fewer complication rates [1]. Additionally, the snare iscapable of developing a variable amount of force, and foreign bodies can be easily compressed.In a study by Gabelmann et al, the most frequently used device was a combination of an angledsnare and a multipurpose catheter with a hook configuration. This made it possible to retrieveforeign objects even in difficult locations because of the two-fold angles of the gooseneck and amultipurpose catheter. They reported a success rate of 91.1% [7]. Another study shows atechnical success rate in 19 out of 24 cases (79.2%) [8]. Therefore, the goose snare is a highlyefficient atraumatic instrument. The relevance of these methods cannot beunderestimated. Numerous available rescue devices to retrieve lost objects and the creativeusage of wires and catheters in different situations make difficult cases safer and easier toperform. In our experience, percutaneous treatment of intravascular foreign bodies was successful in allfour patients. The microsnare was also the most valuable tool for the retrieval of endovascularand endoluminal foreign body devices. Because of its inherent flexibility and preformedintravascular configuration, it has been possible to snare coils within small-sized vessels. Nopost-retrieval complications, such as damage to the vessel wall, were noted in our patients.However, previous studies have shown minor complications such as groinhematoma cardiac arrhythmias, ventricular or vessel perforation, artery spasm, thrombosis,and injury to the vessel at the puncture site [7,9-10]. The most important limitation was theneed of fluoroscopy, which has an inherent risk of radiation exposure to the patient. Thebiggest drawback we felt is the cost of the snare, for which it has to be re-sterilized andautoclaved, and so that it could be reused in our setting.ConclusionsIn conclusion, endovascular retrieval of lost or misplaced foreign devices, particularly with theAmplatz goose neck snare, is highly effective. On the basis of this single-center technical reportof four cases, this method has proven to be safe and should be considered the tool of choice forthe removal of intravascular/endoluminal foreign objects.Additional InformationDisclosuresHuman subjects: Consent was obtained by all participants in this study. Ethics ReviewCommittee, Aga Khan University issued approval 2018-0695-798. Animal subjects: All authorshave confirmed that this study did not involve animal subjects or tissue. Conflicts of interest:In compliance with the ICMJE uniform disclosure form, all authors declare the following:Payment/services info: All authors have declared that no financial support was received fromany organization for the submitted work. Financial relationships: All authors have declaredthat they have no financial relationships at present or within the previous three years with anyorganizations that might have an interest in the submitted work. Other relationships: Allauthors have declared that there are no other relationships or activities that could appear tohave influenced the submitted work.References1. Wolf F, Schernthaner RE, Dirisamer A, et al.: Endovascular management of lost or misplacedintravascular objects: experiences of 12 years. Cardiovasc Intervent Radiol. 2008, 31:563-8.10.1007/s00270-007-9201-82. Grabenwoeger F, Bardach G, Dock W, Pinterits F: Percutaneous extraction of centrally2019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 20 of 21embolized foreign bodies: a report of 16 cases. Br J Radiol. 1998, 61:1014-8. 10.1259/0007-1285-61-731-10143. Gabelmann A, Kramer S, Gorich J: Percutaneous retrieval of lost or misplaced intravascularobjects. AJR Am J Roentgenol. 2001, 176:1509-13. 10.2214/ajr.176.6.17615094. Fisher RG, Ferreyro R: Evaluation of current techniques for nonsurgical removal ofintravascular iatrogenic foreign bodies. AJR Am J Roentgenol. 1978, 130:541-548.10.2214/ajr.130.3.5415. Dotter CT, Rosch J, Bilbao MK: Transluminal extraction of catheter and guide fragments fromthe heart and great vessels: 29 collected cases. AJR Am J Roentgenol. 1971, 111:467-472.10.2214/ajr.111.3.4676. Liu JC, Tseng HS, Chen CY: Percutaneous retrieval of 20 centrally dislodged Port-A catheterfragments. Clin Imaging. 2004, 28:223-229. 10.1016/S0899-7071(03)00119-07. Gabelmann A, Kramer S, Gorich J: Percutaneous retrieval of lost or misplaced intravascularobjects. AJR Am J Roentgenol. 2001, 176:1509-1513. 10.2214/ajr.176.6.17615098. Carroll MI, Ahanchi SS, Kim JH, Panneton JM: Endovascular foreign body retrieval. J VascSurg. 2013, 57:459-463. 10.1016/j.jvs.2012.01.0929. Koseoglu K, Parildar M, Oran I, Memis A: Retrieval of intravascular foreign bodies with gooseneck snare. Eur J Radiol. 2004, 49:281-285. 10.1016/S0720-048X(03)00078-010. Schechter MA, O’Brien PJ, Cox MW: Retrieval of iatrogenic intravascular foreign bodies . J VascSurg. 2013, 57:276 - 281. 10.1016/j.jvs.2012.09.0022019 Barakzai et al. Cureus 11(1): e3931. DOI 10.7759/cureus.3931 21 of 21

Non-surgical retrieval of dislodged or misplaced intravascular/ ndoluminal foreign objects.

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Non-surgical retrieval of dislodged or misplaced intravascular/ ndoluminal foreign objects.

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