J. Bayne
Selby,
MD
J. Tegtmeyer,
#{149} Charles
MD
#{149} Gloria
M. Bittner,
MD
Experience with New Retrieval Forceps for Foreign Body Removal In the Vascular, Urinary, and Billary Systems’ A new type of foreign body retrieval forceps recently has become available. It consists of singleor multiple-tooth forceps mounted on a flexible stainless steel 0.038-inch shaft. The authors have successfully used this device in the vascular systern (three cases), in the urinary tract (seven cases), and in the biliary system (two cases) without complications. Foreign bodies removed indude a catheter fragment, angiographic guide wire, detachable balloon, stone retrieval basket, and various stents. All the procedures were performed quickly and without difficulty. For the authors, these forceps have become the first choice in many retrieval situations. Index
terms:
Catheters
complications, 76.46, 81.46,
9*442
82.46
Radiology
1990;
and
eign bodies placed objects
of intemventional tnieved from dude catheter bullet there items
misplaced
teral stents that cannot from below (6,7). Less bodies are encountered
I
From
the
1990;
April
16.
of Virginia
of Radiology, Health
revision
received
March
Address
reprint
requests
2 9* indicates volvement. C
RSNA,
1990
Likewise, to extract system,
doubbe-J
most
dicates
that
in the
bibiary
technique
on a cable
that
while
Box
Sciences
generalized
vein
26;
accepted
to J.B.S.
and
artery
in-
AND
were
then
advanced
RESULTS
foreign
superior in all cases. We use of a new simple meeffective to use.
forceps
be removed
often
no particular
forceps
The
through the guiding catheter and the object was securely grasped. The forceps and guiding catheter were withdrawn through the sheath as a unit. One procedure was performed in the operating room with C-arm fbuonoscopic guidance. All other retrievals were penformed with standard angiographic guidance.
ume-
baskets, and various types of grasping forceps. The barge number of meports on a variety of instruments in-
been highly ing simple
Center, Charlottesville, VA 22908. From the 1989 RSNA scientific assembly. Received December 1 1, 1989; revision requested February 22,
me-
system incoils, and
has remain-
176:535-538
Department
University
Items
difficult.
tree (8-10). Devices used for retrieval of these objects include wire snares,
MATERIALS
170,
radiology. the vascular fragments,
fragments (1-5). is often the need from the urinary
commonly
trieval
bodies, 9*442, procedures
retrieval of foror iatrogenicably has become a mainstay
NTRAVASCULAR
has proved report the
catheterization,
Foreign #{149} Interventional #{149}
I
Removal successful
other tempted. tooth though
foreign
body
in all 12 cases methods of retrieval
of the
(Table). were
The singleforceps were no record
act frequency were no cases
and
was No at-
multiple-
both used, alwas kept of the
ex-
of use for each. There in which the forceps
grasped the object and then inadventently released it. No complications were observed any of the cases. The average total time for retrieval was less than 30 minutes per case.
in
METHODS
From February 1988 through July 1989, 12 foreign body removals were penformed with use of retrieval forceps at the University of Virginia Hospital. The foreign body was located in the vascular tree (three cases), urinary tract (seven cases), or biliany system (two cases). All procedunes were performed with use of a new type of retrieval forceps (Cook Umobogical, Spencer, md) (Fig 1). These are mounted on a flexible 3-F (0.038-inch) stainless steel shaft and are available in 65- or 115-cm lengths. The forceps are commercially available. All retrievals were performed through a sheath. A diagnostic study was penformed initially to determine the exact bocation of the foreign object. Standard catheter techniques were then employed to place a catheter in immediate proximity to the object. If a larger-bone catheter was needed to accommodate the retrieval forceps, an exchange was made oven a wine. This was often the case when the retrieval path followed a tortuous course and increased friction made passing the forceps through the catheter exceedingly
Illustrative
Cases 1.-A 3-year-old granubomatous
Case chronic
denwent
central
boy
with
disease
venous
un-
catheter
placement via a night subclavian approach in the operating room. During the procedure, a 4-cm fragment of the catheter was cut off and lost into
the
right
atrium
(Fig
2a).
We
were consulted immediately, but by the time we reached the operating room, the catheter fragment had migrated
through
the
heart
and
night lower lobe pulmonary (Fig 2b). We manipulated ten through the heart and night
lower
lobe
into
a
artery a 5-F catheinto the
pulmonary
artery
through an 8-F sheath in the right subclavian vein. Although the forceps would fit through this catheter in the
straight
negotiate ing
through
exchanged
position,
the turns the it for
it could
required
heart. an
8-F
Therefore, guiding
not
in passwe cath535
eter and placed the pulmonary catheter
it in the segment artery containing
fragment.
vanced easily The fragment
forceps
forceps
through this was grasped
and
through sheath
The
withdrawn
catheter
carefully
interventionab
dune.
During
tion,
uneventfully.
a detachable
vertently
balloon
released
aorta.
It lodged
mon diate
of the placed
with tefor an neunoradiobogy proceattempted emboliza-
2.-A
iliac loss
placed threaded
a sheath. through balloon
set of forceps
was
easily.
then
the sheath the balloon.
Case
3.-A
During
an
and
wine
attempt
placed
straight
a sheath. catheter
a.
During the procedure tuned in half, and the
the basket fracportion me-
maining
could
grasped
in the ureter
not be
the
536
a
system.
The
proximal
end
and the aorta. We groin situated
b.
#{149} Radiology
(Fig
4b).
The
forceps
and
rurrr
b.
Retrieval forceps. (a) The flexible 0.038-inch stainless steel shaft very tortuous courses. (b) The grasping portion is available in a “rat tooth” gator” type (lower) forcep. 1.
can negotiate (upper) or “alli-
was
A nontapered, was
a. Figure
at
this, easi-
Body
Foreign
Retrieval
Patient No.
Foreign
Body
Location
1 2 3
Catheter fragment Angiographic guide Detachable balloon
4
Double-J
stent
Ureter
and renal
5
Double-J
stent
Ureter
and
renal
pelvis
6
stent stent
Ureter Ureter
and renal
pelvis
7
Double-J Double-J
8
Double-J
stent
9 10 11 12
Ureteral stone Catheter hub Biliany stent Stone retrieval
Right lower Abdominal Left common
wire
lobe pulmonary aorta and right iliac artery
artery common
branch iliac artery
pelvis
Ureter
retrieval basket
basket
Ureterovesical junction Sheath in renal pelvis Left hepatic bile duct Common bile duct
c.
Removal of a catheter fragment from right lower lobe pulmonary artery of a 3-year-old of a subclavian catheter, the catheter tip (arrows) sheared off and temporarily lodged in the right right lower lobe pulmonary artery. (c) Catheter following removal with alligator forceps. 2.
was
to
for
the aortic bifurcation. Through we advanced the forceps, which
Figure
sheath
v#{149}
antemiography.
vascular
with
6-F
A 10-F
&
was used The balloon
in the common iliac artery distal end in the thoracic punctured the contmalateral
and
dilated.
A second
to exchange
the
remained
was
were and
woman
thoracic
into
tract
placed to the level of the middle of the ureter. The forceps were passed through this, and the basket was
and
selective catheter, a guide wire (Tenumo, Piscataway, NJ) was inadvertently pushed through the arteniotomy
43-year-old man underextraction of a distal ureby means of umeteroscopy.
advanced
and
77-year-old
for
without
left corn-
and both forceps were withdrawn simultaneously through the sheath (Fig 3b). Complete blood flow was mestored to the beg, and a strong palpable fernomal pulse was present. admitted
removed (Fig 4a). He was referred to us for percutaneous removal of the stone retrieval basket. A pencutaneous nephrostomy was performed into a posterior middle cabyx, and the
mad-
groin
The forceps the sheath
the
through puncture
the sheath
of the with-
(Fig 3a) with immefernoral pulse. We
the ipsibatemal
grasped
through
portion was then
descending
in the distal
artery of the
punctured
was
in the
the middle guide wire
incident. Case 4.-A went basket tenal stone
14-year-old boy of Falbot was admitted
Case
tralogy
by grasped wine. The
drawn
ad-
catheter. with the
the heart and out (Fig 2c). The surgeons
another
of the
boy. (a) During intmaoperative atrium. (b) Fragment (arrows)
placement migrated to
August
1990
basket (Fig
were
then
withdrawn
as a unit
4c).
Case 5.-A 74-year-old man with painless jaundice presented 1 year aften a Whipple procedure for cholangiocarcinoma of the common bile duct. A percutaneous transhepatic cholangiogram demonstrated complete obstruction of the common hepatic duct by recurrent tumor. A straight stent that had been placed in the pancreatic duct at the time of surgery was now noted to reside within the left hepatic duct (Fig 5a). The obstruction
was
crossed,
and
satisfac-
Figure
3. Removal of detachable balloon left common iliac artery. (a) Detachable balloon was accidentally released in the aorta and lodged in the distal common iliac artery. (Barium is present in colon.) (b) One forcep was used to grasp balloon, and the other was used to puncture it.
from
a.
b.
a.
c.
b.
Figure
4.
the stone
Retained
(arrow)
stone
resides
retrieval
in right
basket
ureter
in distal just above
ureter
following
the ureterovesical
attempted
junction.
cystoscopic
stone
(b) Basket is grasped
removal. with
(a) Half of basket forceps. (c) Basket
still containing fragment follow-
ing removal.
a.
D.
Figure
5.
Pancreatic duct
Removal
stent
has
c.
of migrated stent from left hepatic duct. (a) Patient returned 1 year after Whipple procedure migrated into left hepatic duct. (b) Satisfactory biliary drainage is established with internal
with biliary obstruction. stent. (c) Stent in left hepatic
is removed.
Volume
176
#{149} Number
2
Radiology
#{149} 537
tory 5b).
tube
drainage
was
obtained
(Fig
On the patient’s follow-up visit, stent removal was elected. The stent now served no purpose but represented a foreign body. The bibiary drainage catheter was exchanged for an
8-F
sheath.
A safety
wire
was
left
across the obstruction. A 6-F catheter was manipulated into the left hepatic duct, but because of the sharp turns, the retrieval forceps would not advance through it. An 8-F catheter was then placed in the left hepatic duct. The forceps were passed through this and the stent was removed (Fig 5c).
ble is strong and very flexible. The forceps will advance through any catheter that will accept a 0.038-inch guide wire if the catheter is held in a relatively straight-line position. Larger catheters are used as progressive bends are added in the course of the retrieval; however, we have not needed to use a catheter larger than 8 F in
even
(case
1). The
simple
and
Wire
snares
are
by used
device
in retrieval
the
most
commoncases
today
They combine a high degree of success with very little risk of doing harm. They do have limitations. They require practice and dexterity on the part of the operator to ensure a quick retrieval. The technique can only be (2).
successful
when
there
is a free
float-
ing end to the foreign body. Advocates of this technique have descnibed different preliminary manipubations to orient the object in a manner suitable for snaring, a step that increases success but also lengthens the procedure. There is also the possibility that the object may migrate during manipulation making it more difficult to remove. Blood loss through the guiding catheter is a potential problem in prolonged procedures, although modifications to handle this problem have been descnibed (11). Stone retrieval baskets have also proved useful in foreign body memoval (4). They are safe but, again, are limited to removal of foreign bodies with a free end. The basket cannot be guided, so it is most useful in small
vessels
where
it is certain
to
come in contact with the object. Many types of grasping forceps have been tried (12-15). In theory, forceps seem the most practical metrieval device, but they have been limited by their large size and rigidity. Early forceps required a “straight shot” to the retrieval location. Subsequently, flexible forceps were developed, but the potential for damage to the lumen wall remained. These all required use of guiding catheters that were 8 F or banger. The new retrieval forceps overcome these problems nicely. The ca-
538
#{149} Radiology
most
jaw
tortuous
course
mechanism
responsive.
is very
In
our
graspers
on
catheter
fragments
This
eliminates
repositioning tiab
stage
of the to the
procedure.
the capability to grab place along its length sidered in the retrieval The optimum “point should
the
object
need
for
as an
mi-
an object any should be conplanning. of attack”
be determined
in the
vascular
and
the
for-
tree.
To
in very
barge
1.
spaces
where
methods.
U
R#{246}schJ, Bilbao
Dotter
CT,
minal wire
extraction fragments
2.
Bloomfield
cases.
DA.
The
al of intracardiac national survey. 3.
AJR
1971; retriev-
bodies: Cardiovasc
S, Melichar
4.
vascular foreign trieval. Radiology Aldridge HE, Uee moval of catheter great vessels and
5.
Mikolich
JR.
retrieval
of intracoronary
an interDiagn
AC.
Intra-
bodies: percutaneous me1986; 160:731-735. J. Transvascular mefragments from the heart. Can Med Assoc
117:1300-1304.
plasty
6.
Translu-
nonsurgical
foreign Cathet
1978; 4:1-14. Uflacker R, Uima
1977;
MC.
of catheter and guidefrom the heart and great
vessels: 29 collected 111:467-472.
Hanson
guidewire
MW.
Transcatheter
detached
segment.
angio-
Cathet
Cardio-
vasc Diagn 1988; 15:44-46. Coleman CC, Kimura Y, Castaneda-Zuniga
WR, et al.
Interventional
the
Semin
ureter.
techniques
Intervent
in
Radiol
1984;
1:24-37.
7.
Fritzsche P. Antegrade pyelogmaphy: therapeutic applications. Radiol Clin North Am 1986; 24:573-586.
8.
Carcia
9.
Corps #{233}trangers des voies Chin 1982; 36:437-444. Zanbilowicz J. Migration
JC,
biliary
Uemarchand
tree.
Can
F, Samama
Assoc
C.
biliaries.
Ann
of T-tubes
into
J 1984;
Radiol
35:383-387. 10.
Bedogni
C,
Foreign
bodies
scopic
mini-
mize the chance of vascular injury, we place the catheter tip immediately adjacent to the foreign body. The forceps are advanced to the end of the catheter, and then the catheter is pulled back to expose the forceps. The jaws are opened, and the object is grasped by using a combination of rotation of the forceps and slight forward and back movements. If resistance is encountered on withdrawal, the possibility that the wall has been grasped must be considered. The object should be released and then reapproached for removal. The major limitation would seem to be
as alternate
of
with other Snare and are used
types
In fact,
ceps directed there first. An interesting use of these forceps is demonstrated in case 2 in which one set was used to grasp a detachable balloon while a second set punctured it. This allowed the deflated balloon to be pulled out through the sheath. Our major concern has been darnage to the endotheliurn. The teeth of the forceps are set back slightly from the end so that a blunt surface is presented to the wall. The forceps are very opaque, which allows excellent visualization during maneuvering. Caution is still recommended, particularly
to those unfamiliar of retrieval forceps. basket retrieval techniques
in ease
References
while reserving the alligator type (multiple-tooth) for irregularly shaped objects. A major advantage of forceps over snares or baskets is the ability to seize a foreign body at its middle portion.
by try this type of forceps first most retrieval situations. The use should make them attractive
even
series
we did not have a problem with the forceps letting go of an object. Both grasper configurations work well. We prefer to use the rat tooth (singletooth)
DISCUSSION
the
eters from the renal pelvis, so this may be less of a problem than it seems. The use of larger guiding catheters with preformed shapes (eg, cobra) would seem beneficial in this situation. Our technical success and back of complications have led us to routine-
Meinero
M,
of the
management.
Barbieri
biliary Dig
Dis
I, et al.
tract: Sci
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Smith
PU.
tra-artenial ogy 1982;
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improved
foreign 145:539.
body
method
for
retrieval.
in-
Radiol-
12.
Millan VC. Retrieval of intravascular foreign bodies using a modified bronchoscopic forceps. Radiology 1978; 129:587-
13.
Shaw
589. ters
Heart 14.
Tanaka nique
15.
TRD. Removal of embolised catheusing flexible endoscopy forceps. Br
J 1982; 48:497-500. M, lyomasa for
removal
Y.
Nonsurgical
of catheter
tech-
fragments
from the pulmonary artery. Cathet Cardiovasc Diagn 1983; 9:109-112. Vujic I, Moore U, McWey RE. Retrieval of coil after unintentional embolization of ileocolic artery. Radiology 1986; 160:563564.
it
may be difficult to bring the forceps close enough to the object. We were able to grasp a free guide wine in the aorta (case 3) and have removed cathAugust
1990