Cardiovasc Intervent Radiol (2009) 32:1308–1311 DOI 10.1007/s00270-009-9512-z
CASE REPORT
Occlusion Balloon Catheter-Assisted Removal of a Wedged Catheter Fragment Without a Free End from a Pulmonary Artery Jason Crandall Smith Æ Marlon Dean Black Æ Douglas Campbell Smith
Received: 14 October 2008 / Accepted: 8 January 2009 / Published online: 17 March 2009 Ó Springer Science+Business Media, LLC 2009
Abstract Inadvertent embolization of guide wires and catheter fragments are relatively common due to the widespread usage of central venous catheters. A variety of percutaneous techniques has been proposed to retrieve intravascular foreign bodies. The majority of described methods have been dependent on a free end or exposed portion of the foreign body to grasp, snare, or hook. We report the simple use of a balloon catheter to relocate a catheter fragment without a free end that was wedged into a small pulmonary branch to a larger branch. In the larger branch, the fragment was then easily engaged with a standard snare device. Keywords Foreign bodies Percutaneous retrieval Catheters and catheterization
Introduction With the increasing use of central venous catheters, catheter fragments (e.g., from subclavian ‘‘pinch-off’’ syndrome) and inadvertently left-behind guide wires are increasingly migrating to and lodging in peripheral vessels. A variety of minimally invasive percutaneous techniques has been developed to retrieve these and other intravascular foreign bodies. The majority of described methods are dependent on a free end or exposed portion of the foreign body to grasp, snare, or hook. We report a simple method for removing a wedged catheter fragment without a free
J. C. Smith (&) M. D. Black D. C. Smith Department of Radiology, Loma Linda University Medical Center, 2605 G Schuman Pavilion, Loma Linda, CA 92354, USA e-mail:
[email protected]
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end from a small branch of the middle pulmonary artery using an occlusion balloon catheter to relocate the fragment into a more accessible, larger basilar segmental pulmonary artery. This allowed the free end of the fragment to be easily snared and retrieved in standard fashion.
Case Report Our institutional review board does not require approval for single case reports. A 45-year-old male had a chest port placed using the left subclavian vein for intermittent chemotherapy. Approximately 1 year later, a chest x-ray demonstrated classic ‘‘pinch-off’’ syndrome, with embolization of a short catheter fragment into a branch of the right pulmonary artery. It was unknown when it had broken off and embolized. The patient was asymptomatic. The port and attached catheter were removed, and a new chest port was placed. He was subsequently referred to Interventional Radiology for endovascular foreign body retrieval. Scout image confirmed a 6-cm-long catheter fragment in the right chest (Fig. 1). A right common femoral vein 9-Fr vascular sheath was placed. The right pulmonary artery was then accessed using a 7-Fr pigtail catheter (Cook, Bloomington, IN) and Rosen wire (Cook). Multiple initial attempts to snare the proximal end were unsuccessful using both an EN Snare device (Angiotech, Gainesville, FL) and an Amplatz Goose Neck Snare (ev3, Plymouth, MN). A right pulmonary arteriogram was performed for clarification of the catheter and pulmonary artery relationship; this localized the catheter fragment to the middle pulmonary artery (Fig. 2). The distal end was wedged in a small peripheral lateral segmental branch, and a catheter could not be passed beyond its peripheral end. The proximal end extended at most only a few millimeters into the
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device (Fig. 4) and removed through the 9-Fr vascular sheath in the groin. Hemostasis was achieved with manual compression, and the patient was discharged home in stable condition after 4 h.
Discussion
Fig. 1 Scout image demonstrates a 6-cm-long catheter fragment (arrow) in the right mid lung. Note the indwelling left-sided port-acatheter
descending pulmonary artery. Working in various fluoroscopic projections, multiple further attempts to snare or displace the catheter fragment were unsuccessful. Finally, a 5.3-Fr flow-directed balloon catheter (Cook) was manipulated alongside the distal portion of the catheter fragment; it then was progressively inflated as it was retracted centrally (Fig. 3A, B). The friction between the occlusion balloon and the catheter fragment was effective in dragging the catheter fragment out of the middle pulmonary artery. The fragment immediately embolized into a generous-caliber basilar segmental artery. Subsequently, the catheter fragment was easily snared using the EN Snare
Fig. 2 Right anterior oblique projection right pulmonary arteriogram demonstrates the fragment (arrow) to be wedged into the middle pulmonary artery, with at most only a few mm apparently exposed in the descending pulmonary artery (Desc PA). Asc PA, ascending pulmonary artery
Intravascular foreign bodies may lead to serious complications, including erosion, thrombus/embolus, and infection. Percutaneous retrieval of these foreign objects is less invasive and morbid than surgical methods. Retrieval devices that may be used include snare loops, hooked catheters and guide wires, baskets, grasping devices, and balloon catheters [1]. Although such endovascular techniques are usually successful, when foreign bodies are in unfavorable positions, a variety of these devices may be used alone or in combination to pull them into more advantageous locations for ease in removal [2, 3]. In a recently reported series of 78 patients referred for removal of intravascular foreign bodies, a sidewinder catheter was necessary to facilitate loop snaring of the object in 8% of their cases [4]. When a free end is unavailable, the retrieval may be difficult or even impossible. This may occur when the ends of a foreign body are opposed to the walls of the cardiac chambers or if the object is wedged into a small, peripheral pulmonary artery. Several devices that may be useful to dislodge catheter fragments or wires into more favorable locations include sidewinder, pigtail, and hooked catheters, with or without tip-deflecting wires [5–7]. These generally require the foreign body to be located in a vessel capacious enough to allow these devices to form their respective shapes. The use of balloon catheters to assist in the removal of fragments has been previously reported, mostly single case reports in the cardiology literature. These techniques have involved variations of a theme, that of passing a balloon catheter either alongside or into the fractured catheter fragment, inflating the balloon catheter, and relying on the friction between the balloon and fragment to retract the fragment either into a guide catheter or femoral sheath or directly out of the vein. Two single case studies have reported the successful removal of coronary artery catheter fragments by the passage of a balloon catheter alongside the fragment, with subsequent inflation and retraction, similar to our case. In one report, the fractured distal fragment of a balloon catheter was orphaned in the right coronary artery (RCA). Through the previously positioned 8 French guiding catheter, a second 0.014-in guide wire and a 3 9 20-mm balloon catheter were positioned alongside the fragment; importantly, guide wire access had been maintained
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Fig. 3 A, B The balloon catheter (*) was advanced as far distally alongside the fragment as possible and progressively inflated as it was retracted along with the catheter fragment (arrows) into the descending pulmonary artery
Fig. 4 The catheter fragment was easily snared in the descending pulmonary artery
through the fragment [8]. Then with gentle inflation and retraction of the new balloon catheter, the fragment was withdrawn into the guiding catheter. Trehan and colleagues reported a similar case of the retrieval of a distal balloon catheter fragment orphaned in the RCA; it remained partially within the guiding catheter [9]. A new balloon catheter was passed alongside the fragment, and with subsequent inflation the assembly was removed from the patient as a unit. In another report, the authors were able to manipulate a 0.014-in guide wire through the lumen of several Judkins catheter fragments which had embolized to the distal aorta and superficial femoral artery [10]. They were able to pass a 1.5 9 10-mm balloon catheter into the fragments, inflate the balloon, and retrieve the fragments via femoral sheaths. Chen et al. reported a similar technique in the retrieval of a dehisced radiopaque ring of a guiding catheter orphaned in the right coronary artery [11]. In the radiology literature, a previous report described the retrieval of a catheter fragment from the subclavian vein via an antecubital vein [12]. They were able to pass a
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balloon catheter central to the fragment and, with subsequent balloon inflation and retraction of the catheter, retrieve the fragment out the antecubital vein. These cardiology case reports illustrate the principle of creating friction by inflating and retracting a balloon within or alongside a catheter fragment. We could have attempted to pass a guide wire through the lumen of the pulmonary artery catheter fragment and subsequently retrieved the catheter as did Harikrishnan et al. However, it is uncertain if canulation of this fragment would have been possible and, if so, how much time this would have required. We were unable to pass a balloon catheter distal to our fragment, as Mathur et al. did. But by using the friction created by the adjacent balloon we were able to reposition the fragment to a more favorable location for retrieval. The longer a foreign body has been embolized, the more likely it is to be endotheliazed, making it difficult or impossible to remove. Factors to consider in utilizing our method are the potential endothelial trauma or even rupture caused by the retraction of an inflated balloon in the pulmonary artery. However, with careful, progressive inflation of the balloon while retracting the balloon catheter into the larger-caliber central portion of the pulmonary artery, this risk may be minimized. Also, when using this technique, there is the risk that the catheter fragment may embolize to a new, equally challenging branch vessel. An alternative method to prevent this from occurring would be to have two venous accesses, with a snare device from the second venous access waiting in the parent pulmonary artery for a free end to appear as the fragment is partially retracted by the balloon catheter. Obviously, this would involve two venous accesses and two pulmonary artery catheterizations.
Conclusion We describe a simple method to assist in the removal of a catheter fragment wedged into a small peripheral pulmonary artery without a free end, using progressive
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inflation and retraction of a balloon catheter alongside the catheter fragment.
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1311 6. McSweeney WY, Schwartz DC (1971) Retrieval of a catheter foreign body from the right heart using a guidewire deflector system. Radiology 100:61–62 7. Koseoglu K, Parildar M, Oran I, Memis A (2004) Retrieval of intravascular foreign bodies with goose neck snare. Eur J Rad 49:281–285 8. Soylu A, Ozdemir K, Duzenli MA (2006) Removal of fractured balloon catheter using another balloon inflation in coronary artery: case report. Int J Cardiol 113:e81–e83 9. Trehan V, Mukhopadhyay S, Yusuf J, Ramgasetty UC, Mukherjee S, Arora R (2003) Intracoronary fracture and embolization of a coronary angioplasty balloon catheter. Catheter Cardiovasc Interv 59:473–477 10. Harikrishnan S, Rajeev E, Nair K, Tharakan J (2006) Retrieval of friable catheter fragments. Int J Cardiol 106:282–284 11. Chen Y, Fang CC, Yu CL, Jao YT, Want SP (2002) Intracoronary retrieval of the dehisced radiopaque ring of a guiding catheter: an unusual complication of coronary angioplasty. Catheter Cardiovasc Interv 55:262–264 12. Mathur AP, Pochaczevsky R, Levowitz BS, Feraru F (1971) Fogarty balloon catheter for removal of catheter fragment in subclavian vein [letter]. JAMA 217:481
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