Tubular Foreign Body or Stent: Safe Retrieval or Repositioning Using the Coaxial Snare Technique

Objective

To evaluate the utility and advantages of the coaxial snare technique in the retrieval of tubular foreign bodies.

Materials and Methods

Using the coaxial snare technique, we attempted to retrieve tubular foreign bodies present in seven patients. The bodies were either stents which were malpositioned or had migrated from their correct position in the vascular system (n=2), a fragmented venous introducer sheath (n=1), fragmented drainage catheters in the biliary tree (n=2), or fractured external drainage catheters in the urinary tract (n=2). After passing a guidewire and/or a dilator through the lumina of these foreign bodies, we introduced a loop snare over the guidewire or dilator, thus capturing and retrieving them.

Results

In all cases, it was possible to retrieve or reposition the various items, using a minimum-sized introducer sheath or a tract. No folding was involved. In no case were surgical procedures required, and no complications were encountered.

Conclusion

The coaxial snare technique, an application of the loop snare technique, is a useful and safe method for the retrieval of tubular foreign bodies, and one which involves minimal injury to the patient.     

Entrapment of J-Tip guidewires by venatech and stainless-steel greenfield vena cava filters during central venous catheter placement: Percutaneous management in four patients

We present four patients in whom beside placement of a central venous catheter was complicated by entrapment of a J-tip guidewire by a previously placed vena cava (VC) filter. Two Venatech filters were fragmented and displaced into the superior VC or brachiocephalic vein during attempted withdrawal of the entrapped wire. Two stainless-steel Greenfield filters remained in place and intact. Fluoroscopically guided extraction of both wires entrapped by Greenfield filters was successfully performed in the angiography suite.     

Retrieval of an embolization coil from the internal carotid artery using the Amplatz Microsnare Retrieval System

An unusual case of unintentional release of an embolization coil into the proximal internal carotid artery is reported. The coil migrated and lodged distally in the petrous portion of the internal carotid artery during initial removal attempts using a regular nitinol loop snare. The coil was retrieved with the Amplatz Nitinol Microsnare system.     

Retrieval of a guidewire introducer by catheter-capture from the proximal inferior vena cava: Technical note

We report a case of a retrieval of an iatrogenically placed guidewire introducer from the proximal stump of an obstructed inferior vena cava. The retrieval of the foreign body was achieved by a technique that we have named the “catheter-capture technique.”     

Percutaneous retrieval of a retained Jackson-Pratt drain fragment

A retained intraabdominal Jackson-Pratt drain fragment was percutaneously retrieved using an inflated angioplasty balloon that had been maneuvered inside of the drain lumen over a hydrophilic-coated steerable guidewire.     

Percutaneous fragmentation of pulmonary emboli in dogs with the impeller-basket catheter

A new catheter system for rapid percutaneous fragmentation of pulmonary emboli was tested in nine dogs. The system consisted of a high-speed rotating impeller, placed within the center of a self-expandable basket. Preformed radiopaque emboli were introduced via the right external jugular vein. In nine tests in five dogs, a single embolus was launched after the right pulmonary artery had been balloon occluded and the impeller-basket catheter had been positioned into the left pulmonary artery, Seven of nine emboli were completely fragmented, each within less than 10 s. In two tests, performed in two different dogs, the catheter was positioned after complete embolization of the left pulmonary artery. In both cases, the central pulmonary arteries could be fully, and the segmental arteries partly, recanalized. Mobility of the system within the pulmonary arteries was limited. There was no evidence of wall damage at the rotation site of the impeller. Free serum hemoglobin did not increase after treatment. We conclude that the device can be safely operated in the left pulmonary artery system of dogs. It causes no significant hemolysis, and is able to accomplish rapid recanalization of the central arteries. Due to limited steerability, occluded side branches cannot be treated consistently.     

Percutaneous transluminal angioplasty of the renal artery

Percutaneous transluminal renal angioplasty (PTRA) has been employed in 70 renal arteries, utilizing the balloon angioplasty technique described by Grüntzig for peripheral vessels. The procedure has been employed both in patients with normal renal function and in selected patients with decreased renal function. The complication rate has been low (5.7%), and no patient has required operative intervention as a result of a complication sustained during PTRA. The early results of PTRA compare favorably to those achieved through operative revascularization. An assessment of the duration of PTRA's effects must however, await the results of long-term follow-up.     

In situ formation of a loop snare for retrieval of a foreign body without a free end

A technique is described that allowed percutaneous retrieval of an endoscopically placed, obstructed biliary stent using loop snare capture of an angled hydrophilic wire which was wrapped around the stent initially.     

Percutaneous Retrieval of a Central Venous Catheter Sutured to the Wall of the Right Atrium

A transjugular central venous catheter was inadvertently sutured to the wall of the right atrium in a 63-year-old female during coronary bypass surgery. Using two nitinol Goose Neck snares via a transfemoral and a transjugular approach the catheter was severed into two pieces and retrieved percutaneously.     

Fixation Methods for Implantable Port Chamber: Comparative Study Using Glue, Self-stabilizing Leg and Suture Fixations in Rabbits

Objective

To evaluate the fixation strength and tissue reaction of the glue fixation and self-stabilizing leg fixation methods and to compare the results with those of the conventional tagging suture fixation method.

Materials and Methods

Twelve healthy rabbits were selected and three different methods of implanting the port chamber were employed on the back of each rabbit. A total of thirty six port chambers were implanted with these three different methods, viz. the glue fixation method using tissue adhesive, the self-stabilizing leg method using a self-expandable stabilizing leg, and the suture fixation method. The fixation strength and the gross and histopathologic changes of each fixation method were evaluated at three days, one week, two weeks and four weeks after port implantation.

Results

The glue fixation method showed a good fixation strength, which was similar to that of the tagging suture method (p = 0.3486). Five of the six ports (83%) implanted with the glue fixation method which were examined after two weeks showed cracks on the external surface, but this had no adverse effects on their function. A large amount of granulation tissue reaction was found at the bottom of the chamber (p = 0.0025). The fixation with the self-stabilizing leg showed relatively lower fixation strength (p = 0.0043), but no turning-over of the chamber occurred. The fixation strength improved with time after the first week, and minimal granulation tissue reaction was observed with this method.

Conclusion

The glue fixation method exhibited equal fixation strength compared to the suture fixation, but showed cracking and a large amount of granulation tissue, whereas the fixation with a self-stabilizing leg showed weaker fixation strength.     

Laboratory Investigations[cmFragmentation of Pulmonary Emboli: In Vivo Experimental Evaluation of Two High-Speed Rotating Catheters

Purpose: To test two over-the-wire systems for fragmentation of pulmonary emboli. Methods: In 11 dogs, 22 embolic occlusions of lobar or central pulmonary arteries were performed by injection of preformed emboli through a jugular vein sheath. A commercially available device (thrombolizer) and a modified version of the impeller catheter were introduced via the femoral vein and positioned at the embolus site. Results: Catheter placement at the site of the emboli was possible. In more than half of the cases a hydrophilic or an extra-stiff guidewire was necessary. The thrombolizer did not rotate properly with its original pneumatic drive and required a major modification. When sufficient rotation was provided, both fragmentation catheters were able to clear the occluded main arteries. Side branches were partly obstructed by the resulting fragments. Recanalization led to a reduction of the emboli-induced elevation of the pulmonary arterial pressure by two-thirds. Histology of the recanalized pulmonary artery segments revealed localized (impeller catheter) and widespread (thrombolizer) periarterial hemorrhage. Conclusion: Embolus fragmentation led to a hemodynamic improvement. The impeller catheter was less traumatic compared with the thrombolizer, which was technically insufficient.     

Percutaneous dilatation and recanalization of iliac and femoral arteries

Five-year follow-up studies in patients with superficial femoral arterial occlusions and iliac artery stenoses have demonstrated a high success rate with percutaneous transluminal angioplasty performed by the Dotter technique. The special balloon catheters developed by Grüntzig, a standardized accessory pharmaceutical regimen, and more exact indications have further increased the rate of long-term success; the patency rates now approach 70% after three years. Clinical follow-up studies by Doppler ultrasound are useful for assessing the hemodynamic effects of the procedure.     

Percutaneous retrieval of a central venous catheter sutured to the wall of the inferior vena cava

A central venous catheter was sutured to the wall of the inferior vena cava in a 20-year-old male undergoing retroperitoneal lymphadenectomy for malignant testicular germ cell tumor. We succeeded in retrieving the catheter percutaneously, using a combination of loopsnare wire and myocardial biopsy forceps.     

Preliminary Experience with Locoregional Intraarterial Chemotherapy of Uterine Cervical or Endometrial Cancer Using the Peripheral Implantable Port System (PIPS™): A Feasibility Study

The purpose of this study was to assess the suitability of a percutaneously implantable catheter port system (PIPS) for repeated intraarterial locoregional chemotherapy (ILC) for cervical and endometrial carcinoma. In 30 patients with advanced, recurrent, or high-risk cervical (n = 23) or endometrial (n = 7) carcinoma, PIPS for ILC was implanted via a femoral access, the catheter localized in the infrarenal abdominal aorta. Chemotherapy was performed adjuvantly after surgery (n = 14) or neo-adjuvantly to enable surgery, or for palliation (n = 16). Port implantation, catheter placement, and repeated port puncture was uneventful in all patients. Complications included catheter dislocation (n = 1), catheter thrombosis (n = 2), subcutaneous infection (n = 1), port-bed skin atrophy (n = 1), requiring port explantation in 3 patients. At 2 years follow-up, complete remission was observed in 7/14 patients with adjuvant chemotherapy, partial remission in 3/14. Successful down-staging could be achieved in 4/8 patients with neo-adjuvant chemotherapy. The PIPS is suitable for repeated ILC which may be a valuable method for pre- and post-surgical therapy of advanced or high-risk cervical and endometrial cancer, for adjuvant chemotherapy as well as neo-adjuvantly for down-staging, or for palliation.     

Percutaneous Venous Thrombectomy Using the Arrow-Trerotola Percutaneous Thrombolytic Device (PTD) with Temporary Caval Filtration: In Vitro Investigations

Purpose To evaluate the size and quantity of downstream emboli after thrombectomy using the Arrow-Trerotola Percutaneous Thrombolytic Device (PTD) with or without temporary filtration for extensive iliofemoral and iliocaval thrombi in an in vitro flow model.Methods Iliocaval thrombi were simulated by clotted bovine blood in a flow model (semilucent silicone tubings, diameter 12–16 mm). Five experimental set-ups were performed 10 times each; thrombus particles and distribution were measured in the effluent. First, after retrograde insertion, mechanical thrombectomy was performed using the PTD alone. Then a modified self-expanding tulip-shaped temporary vena cava stent filter was inserted additionally at the beginning of each declotting procedure and removed immediately after the intervention without any manipulation within or at the filter itself. In a third step, the filter was filled with thrombus only. Here, two experiments were performed: Careful closure within the flow circuit without any additional fragmentation procedure and running the PTD within the filter lumen, respectively. In the final set-up, mechanical thrombectomy was performed within the thrombus-filled tubing as well as in the filter lumen. The latter was closed at the end of the procedure and both devices were removed from the flow circuit.Results Running the PTD in the flow circuit without filter protection led to a fragmentation of 67.9% (±7.14%) of the clot into particles 500 m; restoration of flow was established in all cases. Additional placement of the filter safely allowed maceration of 82.9% (±5.59%) of the thrombus. Controlled closure of the thrombus-filled filter within the flow circuit without additional mechanical treatment broke up 75.2% (±10.49%), while additional mechanical thrombectomy by running the PTD within the occluded filter led to dissolution of 90.4% (±3.99%) of the initial clot. In the final set-up, an overall fragmentation rate of 99.6% (±0.44%) was achieved.Conclusions The combined use of the Arrow-Trerotola PTD and a temporary vena cava stent filter proved to be effective for even large clot removal in this experimental set-up.     

Subselective diagnostic and interventional arteriography using a simple coaxial catheter system

A simple, commercially available 6.5–3.0 French coaxial catheter system was used to obtain the subselective catheter position for diagnostic or interventional (drug infusions, embolizations) angiography. The system was employed 81 times in 75 patients without complication. We describe the catheter system, techniques for its use, and its clinical applications.     

Transthoracic 2D echocardiographic guidance for percutaneous removal of a nonopaque intracardiac catheter fragment

A radiolucent fragment of a fractured central venous catheter embolized to the right heart resulting in life-threatening dysrhythmias in a middle-aged male patient who had undergone orthotopic liver transplantation I day earlier. The fragment was removed via the right transjugular route using sonographic guidance to entrap the fragment with a brightly echogenic snare. The technique described protects the caval anastomoses in the liver transplant recipient and overcomes the limitation of fluoroscopy in removing radiolucent bodies     

Evaluation of venous injury caused by a percutaneous mechanical thrombolytic device

Purpose To study venous injury caused by a prototype percutaneous mechanical thrombolytic device.Methods Simulated thrombolysis was performed using the device, or the Fogarty balloon catheter (FBC) as control, in the infrarenal inferior vena cava (IVC) of 40 New Zealand white rabbits. Venous injury was evaluated by cavography, Evans blue dye staining, and histology at 0, 1, and 6 weeks postprocedure.Results Both devices resulted in near complete endothelial denudation acutely. No differences in reendothelialization were noted at any time in the proximal and mid-IVC, but there was significantly greater reendothelialization in the distal IVC in the rabbits treated 6 weeks earlier with the device (p 0.04). Additionally, the inner luminal diameter at necropsy for the 1-week rabbits treated with the FBC was significantly narrower in the distal and middle sections of the IVC when compared with the device (p 0.02 for both segments). There was no luminal diameter difference at 0 or 6 weeks.Conclusion Based on a rabbit model, venous injury from the device was found to be similar to, and in the distal IVC less than, the routinely used FBC.