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 The forceps and guiding catheter were withdrawn through the sheath as a unit.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

endo1986;

31:1100-1104. 1 1.

Smith

PU.

tra-artenial ogy 1982;

An

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

Experience with new retrieval forceps for foreign body removal in the vascular, urinary, and biliary systems.

A new type of foreign body retrieval forceps recently has become available. It consists of single- or multiple-tooth forceps mounted on a flexible sta...
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