Cardiovasc Intervent Radiol DOI 10.1007/s00270-014-1010-2
TECHNICAL NOTE
Percutaneous Retrieval of Foreign Bodies Around Vital Vessels Aided with Vascular Intervention: A Technical Note Xiu-Jun Yang • Guang-Fu Xing
Received: 20 May 2014 / Accepted: 9 October 2014 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2014
Abstract Objective To describe a new interventional technique to remove foreign bodies (FBs) embedded in soft tissues around vital vessels. Methods Under fluoroscopic guidance and using local anesthesia, percutaneous removal of FBs was performed using forceps in nine patients. All patients suffered from a metallic soft tissue FB located in close proximity to important vessels and one also had a small traumatic pseudoaneurysm adjacent to the FB. Prior to removal of the FB, the position of the nearest vessel was identified using a guide wire or catheter placed into the vessel. Balloon catheter was also simultaneously used to temporarily stop the blood flow of the nearest artery during the FB removal in three of the nine patients. Results All of the nine FBs with 0–2 mm interval to the nearest vessel were successfully removed in the nine patients without any serious complications. The removed FBs measured 3–12 mm in length and 1–3 mm in width. The total fluoroscopic time of retrieval of each FB was 5–9 min (mean, 6.4 min). The volume of intraoperative bleeding ranged from 5 to 12 ml (mean, 7.5 ml). The length of hospital stay for each patient ranged from 4 to 8 days (mean, 5.5 days).
X.-J. Yang (&) Department of Radiology, Shanghai Eighth People’s Hospital, 8 Caobao Rd, Xuhui District, Shanghai 200235, China e-mail: [email protected] G.-F. Xing Department of General Surgery, Shanghai Eighth People’s Hospital, 8 Caobao Rd, Xuhui District, Shanghai 200235, China e-mail: [email protected]
Conclusion Vascular intervention-aided percutaneous FB removal is minimally invasive and an effective method for removal of FBs around vital vessels. Keywords Foreign bodies Soft tissue injuries Interventional radiology Endovascular procedures
Introduction Retained soft tissue foreign bodies (FBs) usually lead to acute or chronic injuries and complications, such as inflammation, infection, toxic and/or allergic reactions, granuloma, traumatic tumors, penetration of vessels and formation of hemangioma, or even migrate into joint or blood vessel [1–3]. Thus, FB removal in time is necessary once the diagnosis is made after weighing the injury and potential for further harm of the FB in its current location against the risks of removal of the FB. Traditionally, FB removal is performed surgically or surgically under X-ray fluoroscopy, but this method of treatment is widely invasive, costly, and a technical challenge with longer hospital stay, especially in some complicated cases [1]. Percutaneous FB extraction is an innovative method that has been used for years as an alternative to minimally invasive surgical or interventional removal of FB [1, 2, 4, 5]. In our hospital, there have been over 600 cases treated by the method of percutaneous FB removal every year [4, 5]. However, this technique is unsuitable for or even contraindicated to some complex cases in which the FB is located in a critical position between important vessels with or without associated complication of vascular injuries. These patients usually need to be hospitalized to receive open surgery to remove FB. The surgery requires thorough preparation, cooperation of multidisciplinary
123
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies Table 1 Baseline data of the nine patients suffered from a small radiopaque soft tissue foreign body among vital vessels Case
Sex
Age
Course (days)
FB location
FB long/short dimension (mm)
Distance from FB to nearest vessel(mm)
Fluoroscopy timea (min)
1b
Male
21
131
Left thigh, below the bifurcation of femoral vein and deep femoral vein
10/2
1
9
2
Male
49
3
Left forearm, between ulnar artery and interosseous artery
6/2
0
5
3
Male
37
6
Left forearm, among three abnormal radial arteries
3/1
1
5
4
Male
37
1
Right elbow, between brachial artery and cubital vein
4/1
2
5
5c
Male
40
8
Left thigh, among femoral artery and its branches
5/1
0
6
6
Male
34
6
Left groin, between femoral artery and femoral vein
5/2
1
5
7d
Male
55
1
Left thigh, among femoral artery and its branches
6/1
2
7
8d
Male
42
10
Left thigh, among femoral artery and its branches
11/3
2
8
9d
Male
40
1
Right thigh, among femoral artery and its branches
12/3
2
8
a
Including a total fluoroscopy time of during vascular and soft tissue interventions
b
Because of little granulation tissue formation, the FB surrounding tissue was loosened first by the forceps before retrieval
c
No special treatments for a FB-associated traumatic pseudoaneurysm (2 mm 9 3 mm 9 1 mm in size), which did not appear again on angiograms after FB removal maybe thanks to the parent artery spasm
d
Balloon catheter was used to temporarily block the flow of the femoral artery simultaneously during foreign body removal
specialties during and after surgery as well as long postoperative recovery time. In order to overcome these drawbacks mentioned above, we introduce a new, minimally invasive interventional method of percutaneous retrieval of FB from soft tissue around vital vessels aided with percutaneous transluminal vascular intervention.
Materials and Methods This study was reviewed and approved by the Institutional Review Board of Shanghai Eighth People’s Hospital, and all patients provided their written consent to participate in this study. All nine patients had been enrolled into this study. Their clinical presentation and description of FBs are shown in Table 1. Briefly, all patients were males, aging from 21 to 55 years with a clear history of skinpenetrating injury where FB stayed inside soft tissues for 1–131 days. All patients are industrial injuries at construction sites and all had a single radiopaque FB embedded into soft tissues. Conventional percutaneous X-rayguided FB retrieval was contraindicated to those cases because of its high risk of vascular damage and uncontrollable bleeding (Fig. 1).
123
After admission, all patients received the unenhanced and enhanced volume CT scan, and surface-shaded 3D reconstruction of local tissues form the skin to the bone with dynamic threshold values (virtual anatomy imaging,VAI) [4], in order to confirm the existence of FB and study its anatomical relation to surrounding structures. A route to reach and remove FB was designed according to its size, orientation, shape and depth, and interval distances to the adjacent vital organs in particular the large blood vessels and the FB-associated vascular injury complication (a serious complication of the FB injury before treatment). In the beginning of the operation, preventive measures were carried out as follows: (1) Povidone-iodine solution was used for skin disinfection, then 5–10 ml 2 % lidocaine solution was injected for local anesthesia, and a 3-mm longitudinal skin incision was made in the area of groin. (2) A 19 gage needle (Cook, USA) was used to access the femoral artery or vein using Seldinger technique and placement of a 5F sheath (Terumo, Japan) was secured in the appropriate vessel. Through the sheath, a 4F or 5F Cobra II angiographic catheter with or without a guidewire (Terumo, Japan) was then introduced into the target vessel closer to the FB. (3) Digital subtraction angiography (DSA) (Axiom Artis dTA, Siemens Medical Solutions,
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies
Fig. 1 A 21-year-old male (Case 1), whose FB locates near the branch of left femoral and deep femoral arteries and veins shown on the axial (A) and virtual anatomy imaging (VAI), (B) by volumn rendering based on enhanced CT images. The nearest vessel is the left femoral vein to the FB. The guide wire is positioned into the left femoral vein beyond the FB (C) after angiography through a 5F
Cobra catheter via the right femoral vein. The special FB forceps is then slowly moved in through a 5 mm skin incision in the medial skin of the left leg towards the FB until it is caught and pulled out carefully guided by the real-time enlarged view of X-ray fluoroscopy (D, E). No hematoma, nerve injury, infection and any other obvious complications are observed
Forchheim, Germany) was performed to illustrate the target vessel, possible FB-associated vascular damage, and to further define the anatomical relation between the FB and major surrounding vessels. (4) After angiography, the catheter was further advanced inside vessel beyond the
level of FB (Fig. 2). These procedures helped doctor to locate the vessels around FB when inserting a forceps under fluoroscopy. (5) In addition, blood flow in the major artery was temporarily blocked at the level above that of the FB in three of the nine patients by 4F balloon dilation
123
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies
Fig. 2 A 40-year-old male (Case 5) presented with a steel FB (A) in his left thigh and an irregular FB-associated traumatic pseudoaneurysm (shown only on angiography, 2 mm 9 3 mm 9 1 mm in size, (B) in a small branch femoral artery. After a 0.89-mm exchange guide wire is positioned into the pseudoaneurysm artery through a 5F angiographic catheter to locate this artery (C), percutaneous trans-soft
tissue no-trocar interventional removal of the sharp FB (D) is then carried out successfully under the X-ray fluoroscopic guidance without any serious complications. No special treatments for the pseudoaneurysm, which is not shown again on angiograms after FB removal maybe due to the parent artery spasm
catheter (Cook, USA) simultaneously during the procedure of FB retrieval, in order to prevent the damage of artery and to avoid blood loss. Next, percutaneous interventional FB removal was performed under fluoroscopy guidance (AXIOM Artis, Siemens Medical Solutions): (1) After skin disinfecting with povidone-iodine solution, 5–10 ml of 2 % lidocaine solution was injected under real-time fluoroscopic guidance into the soft tissues around FB for local anesthetic infiltration and regional nerve block. (2) A 3–5-mm skin incision was made along the long axis of the FB. (3)
Through the skin incision, a self-designed grasping FB forceps (Fig. 3) or ordinary hemostatic forceps was inserted slowly toward the FB under fluoroscopic guidance. For FB retained more than 2 weeks, pliers had to be used to bluntly rip the granulation tissue surrounding the FB by opening the pliers mouth repeatedly from different angles. (4) Under fluoroscopic monitoring, the forceps was used to catch one end of the FB and withdraw slowly along FB’s long axis (for the FB to pass through the small incision) to extract the FB out of the body. (5) After extraction, moderate manual pressure was applied to stop mild bleeding in
123
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies
was recommended to have follow-up examination of CT or MRI of lower extremity within 6 months.
Discussion Fig. 3 The open forceps is one kind of self-designed grasping FB forceps which is equipped with precise scales and magnetic mouth
the wound. (6) With confirmation of X-ray and angiography that no FB residue was left and no vascular damage was demonstrated, the skin incision was usually covered with a bandage. Post-operative treatments included (l) Tetanus prophylaxis was prescribed to all patients. (2) Antimicrobial prophylaxis with cephalosporins (2 g, IV, bid) was empirically prescribed for 1–2 days after the procedure. The procedural safety and effectiveness, in particular, the technical success rate and procedure-related complications, were noted during the subsequent one-week observation period.
Results Foreign Bodies were successfully removed in all nine patients by employing the vascular intervention-assisted percutaneous interventional FB removal. All these FBs were metallic and measured 3–12 mm in length and 1–3 mm in width, as shown in Table 1. The distance from FB to the closest vessel was 0–2 mm. The total fluoroscopic time for retrieval of each FB was 5–9 min (mean, 6.4 min). The volume of intraoperative bleeding ranged from 5 to 12 ml (mean, 7.5 ml, the bleeding volume calculation was counted approximately in 15 ml of one piece of swab soaked by blood). No signs of vascular damage, thrombus, or bleeding from the vessel were observed in the follow-up angiograms after FB removal. No serious complications, such as uncontrollable bleeding, hematoma, surgical site infection, nerve injuries, or muscular injury, were encountered during the interventional procedure, or during the one-week observation period. The length of hospital stay for each patient ranged from 4 to 8 days (mean, 5.5 days). Before FB interventional removal, one of the nine (11.1 %) patients treated by this dual intervention had a small asymptomatic pseudoaneurysm (2 mm 9 3 mm 9 1 mm in size) identified only by digital subtraction angiograms but not by pre-intervention CT. This pseudoaneurysm was untreated because of its small size and deep location, which disappeared on DSA images immediately after the FB removal, perhaps owing to the possible spasm of the parent artery. This patient
With the development of new imaging technology, especially with CT post-processing 3D vascular reconstruction [4, 6], it becomes safer, easier, and more effective for us to implement the interventional removal of small radiopaque FB with real-time fluoroscopic guidance, and many patients benefited from this minimally invasive treatment [2, 4, 6]. However, the neurovascular structures around the FB are invisible under fluoroscopy, and vascular damages due to the manipulation of the retrieval forceps could not be avoided. Therefore, it might be contraindicated to attempt to remove the small radiopaque FB adjacent to major vessels using the conventional interventional method. Percutaneous transluminal extraction has been described in vascular interventional radiology, particularly retrieval of experimental foreign objects [7] and of broken catheters, embolization coils, vascular guides, stents or inferior vena cava filters in clinic [8–10]. Here, we used percutaneous intravascular positioning method with guidewire or catheter to show indirectly the position of major vessel and its route under fluoroscopy. In addition, we also used percutaneous transluminal balloon to temporarily occlude blood flow in the vessel, providing less chance of injury during the foreign body retrieval. This new interventional method effectively avoided manipulation of FB retrieval forceps without knowledge of the location of adjacent vessels. This method also can replace the invasive and costly open surgical removal of FBs. Furthermore, for those complicated cases with associated vascular injuries (such as traumatic pseudoaneurysm, arteriovenous fistula, and vessel penetration), it will not only provide a novel treatment method of retrieving the FB itself but also help to treat associated vascular injuries with endovascular stent placement. It is worth mentioning here that for all kinds of FB retrieval, avoiding nerve injury is a major challenge. It is possible that the harmful manipulation of forceps on nerve(s) will cause uncomfortable symptoms, such as muscular cramps, pain, or burnings sensation, etc., which will alarm the interventionalist to adjust the manipulation of forceps to avoid the nerve damage. Prediction of the location of major nerves may be possible with the knowledge of location of major vessels. In conclusion, despite the small sample size of our pilot study, the initial results of this new method of removing FB percutaneously are encouraging, and it is worth promoting to treat the patient with FB(s) adjacent to major vessels as a safe and effective minimally invasive method.
123
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies Acknowledgments This study is supported by Scientific Research Fund from Shanghai Municipal Health Bureau (Program Code: 2008186) and Jiangsu University Medical Science Fund (Program Code: JLY2010059). All authors, Dr XJ Yang and Dr GF Xing, would like to submit our paper and the copyright transfer to this journal. Conflict of Interest conflict of interests.
All the authors and the institution had no
Statements of Ethical Approval and Informed Consent This study was reviewed and approved by the Institutional Review Board of our hospital and all patients provided their written consent to participate in this study.
References 1. Callegari L, Leonardi A, Bini A et al (2009) Ultrasound-guided removal of foreign bodies: personal experience. Eur Radiol 19(5):1273–1279 2. Amoretti N, Hauger O, Marcy PY et al (2010) Foreign body extraction from soft tissue by using CT and fluoroscopic guidance: a new technique. Eur Radiol 20(1):190–192
123
3. Ando A, Hatori M, Hagiwara Y et al (2009) Imaging features of foreign body granuloma in the lower extremities mimicking a soft tissue neoplasm. Ups J Med Sci 114(1):46–51 4. Yang XJ, Xing GF, Shi CW et al (2013) Value of 3D CT virtual anatomy imaging in complex foreign body retrieval from soft tissues. Korean J Radiol 14(2):269–277 5. Xing GF, Shi CW, Qian HX et al (2013) Novel methods of removing metallic foreign body from human soft tissue: a report of 7390 cases. J Surg Res 183(1):337–340 6. Tao K, Xu S, Liu XY et al (2012) Small metal soft tissue foreign body extraction by using 3D CT guidance: a reliable method. Eur J Radiol 81(11):3339–3343 7. Tsuchida M, Kawashiri MA, Uchiyama K et al (2010) An enhanced device for transluminal retrieval of vascular stents without surgical procedures: experimental studies. J Interv Cardiol 23(3):264–270 8. Wolf F, Schernthaner RE, Dirisamer A et al (2008) Endovascular management of lost or misplaced intravascular objects: experiences of 12 years. Cardiovasc Intervt Radiol 31(3):563–568 9. da Motta Leal Filho JM, Carnevale FC, Cerri GG et al (2010) Subclavian vein an unusual access for the removal of intravascular foreign bodies. Ann Vasc Surg 24(6):826.e1–4 10. McKenzie S, Gibbs H, Leggett D et al (2010) An Australian experience of retrievable inferior vena cava filters in patients with increased risk of thromboembolic disease. Int Angiol 29(1):53–57
TECHNICAL NOTE
Percutaneous Retrieval of Foreign Bodies Around Vital Vessels Aided with Vascular Intervention: A Technical Note Xiu-Jun Yang • Guang-Fu Xing
Received: 20 May 2014 / Accepted: 9 October 2014 Ó Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2014
Abstract Objective To describe a new interventional technique to remove foreign bodies (FBs) embedded in soft tissues around vital vessels. Methods Under fluoroscopic guidance and using local anesthesia, percutaneous removal of FBs was performed using forceps in nine patients. All patients suffered from a metallic soft tissue FB located in close proximity to important vessels and one also had a small traumatic pseudoaneurysm adjacent to the FB. Prior to removal of the FB, the position of the nearest vessel was identified using a guide wire or catheter placed into the vessel. Balloon catheter was also simultaneously used to temporarily stop the blood flow of the nearest artery during the FB removal in three of the nine patients. Results All of the nine FBs with 0–2 mm interval to the nearest vessel were successfully removed in the nine patients without any serious complications. The removed FBs measured 3–12 mm in length and 1–3 mm in width. The total fluoroscopic time of retrieval of each FB was 5–9 min (mean, 6.4 min). The volume of intraoperative bleeding ranged from 5 to 12 ml (mean, 7.5 ml). The length of hospital stay for each patient ranged from 4 to 8 days (mean, 5.5 days).
X.-J. Yang (&) Department of Radiology, Shanghai Eighth People’s Hospital, 8 Caobao Rd, Xuhui District, Shanghai 200235, China e-mail: [email protected] G.-F. Xing Department of General Surgery, Shanghai Eighth People’s Hospital, 8 Caobao Rd, Xuhui District, Shanghai 200235, China e-mail: [email protected]
Conclusion Vascular intervention-aided percutaneous FB removal is minimally invasive and an effective method for removal of FBs around vital vessels. Keywords Foreign bodies Soft tissue injuries Interventional radiology Endovascular procedures
Introduction Retained soft tissue foreign bodies (FBs) usually lead to acute or chronic injuries and complications, such as inflammation, infection, toxic and/or allergic reactions, granuloma, traumatic tumors, penetration of vessels and formation of hemangioma, or even migrate into joint or blood vessel [1–3]. Thus, FB removal in time is necessary once the diagnosis is made after weighing the injury and potential for further harm of the FB in its current location against the risks of removal of the FB. Traditionally, FB removal is performed surgically or surgically under X-ray fluoroscopy, but this method of treatment is widely invasive, costly, and a technical challenge with longer hospital stay, especially in some complicated cases [1]. Percutaneous FB extraction is an innovative method that has been used for years as an alternative to minimally invasive surgical or interventional removal of FB [1, 2, 4, 5]. In our hospital, there have been over 600 cases treated by the method of percutaneous FB removal every year [4, 5]. However, this technique is unsuitable for or even contraindicated to some complex cases in which the FB is located in a critical position between important vessels with or without associated complication of vascular injuries. These patients usually need to be hospitalized to receive open surgery to remove FB. The surgery requires thorough preparation, cooperation of multidisciplinary
123
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies Table 1 Baseline data of the nine patients suffered from a small radiopaque soft tissue foreign body among vital vessels Case
Sex
Age
Course (days)
FB location
FB long/short dimension (mm)
Distance from FB to nearest vessel(mm)
Fluoroscopy timea (min)
1b
Male
21
131
Left thigh, below the bifurcation of femoral vein and deep femoral vein
10/2
1
9
2
Male
49
3
Left forearm, between ulnar artery and interosseous artery
6/2
0
5
3
Male
37
6
Left forearm, among three abnormal radial arteries
3/1
1
5
4
Male
37
1
Right elbow, between brachial artery and cubital vein
4/1
2
5
5c
Male
40
8
Left thigh, among femoral artery and its branches
5/1
0
6
6
Male
34
6
Left groin, between femoral artery and femoral vein
5/2
1
5
7d
Male
55
1
Left thigh, among femoral artery and its branches
6/1
2
7
8d
Male
42
10
Left thigh, among femoral artery and its branches
11/3
2
8
9d
Male
40
1
Right thigh, among femoral artery and its branches
12/3
2
8
a
Including a total fluoroscopy time of during vascular and soft tissue interventions
b
Because of little granulation tissue formation, the FB surrounding tissue was loosened first by the forceps before retrieval
c
No special treatments for a FB-associated traumatic pseudoaneurysm (2 mm 9 3 mm 9 1 mm in size), which did not appear again on angiograms after FB removal maybe thanks to the parent artery spasm
d
Balloon catheter was used to temporarily block the flow of the femoral artery simultaneously during foreign body removal
specialties during and after surgery as well as long postoperative recovery time. In order to overcome these drawbacks mentioned above, we introduce a new, minimally invasive interventional method of percutaneous retrieval of FB from soft tissue around vital vessels aided with percutaneous transluminal vascular intervention.
Materials and Methods This study was reviewed and approved by the Institutional Review Board of Shanghai Eighth People’s Hospital, and all patients provided their written consent to participate in this study. All nine patients had been enrolled into this study. Their clinical presentation and description of FBs are shown in Table 1. Briefly, all patients were males, aging from 21 to 55 years with a clear history of skinpenetrating injury where FB stayed inside soft tissues for 1–131 days. All patients are industrial injuries at construction sites and all had a single radiopaque FB embedded into soft tissues. Conventional percutaneous X-rayguided FB retrieval was contraindicated to those cases because of its high risk of vascular damage and uncontrollable bleeding (Fig. 1).
123
After admission, all patients received the unenhanced and enhanced volume CT scan, and surface-shaded 3D reconstruction of local tissues form the skin to the bone with dynamic threshold values (virtual anatomy imaging,VAI) [4], in order to confirm the existence of FB and study its anatomical relation to surrounding structures. A route to reach and remove FB was designed according to its size, orientation, shape and depth, and interval distances to the adjacent vital organs in particular the large blood vessels and the FB-associated vascular injury complication (a serious complication of the FB injury before treatment). In the beginning of the operation, preventive measures were carried out as follows: (1) Povidone-iodine solution was used for skin disinfection, then 5–10 ml 2 % lidocaine solution was injected for local anesthesia, and a 3-mm longitudinal skin incision was made in the area of groin. (2) A 19 gage needle (Cook, USA) was used to access the femoral artery or vein using Seldinger technique and placement of a 5F sheath (Terumo, Japan) was secured in the appropriate vessel. Through the sheath, a 4F or 5F Cobra II angiographic catheter with or without a guidewire (Terumo, Japan) was then introduced into the target vessel closer to the FB. (3) Digital subtraction angiography (DSA) (Axiom Artis dTA, Siemens Medical Solutions,
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies
Fig. 1 A 21-year-old male (Case 1), whose FB locates near the branch of left femoral and deep femoral arteries and veins shown on the axial (A) and virtual anatomy imaging (VAI), (B) by volumn rendering based on enhanced CT images. The nearest vessel is the left femoral vein to the FB. The guide wire is positioned into the left femoral vein beyond the FB (C) after angiography through a 5F
Cobra catheter via the right femoral vein. The special FB forceps is then slowly moved in through a 5 mm skin incision in the medial skin of the left leg towards the FB until it is caught and pulled out carefully guided by the real-time enlarged view of X-ray fluoroscopy (D, E). No hematoma, nerve injury, infection and any other obvious complications are observed
Forchheim, Germany) was performed to illustrate the target vessel, possible FB-associated vascular damage, and to further define the anatomical relation between the FB and major surrounding vessels. (4) After angiography, the catheter was further advanced inside vessel beyond the
level of FB (Fig. 2). These procedures helped doctor to locate the vessels around FB when inserting a forceps under fluoroscopy. (5) In addition, blood flow in the major artery was temporarily blocked at the level above that of the FB in three of the nine patients by 4F balloon dilation
123
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies
Fig. 2 A 40-year-old male (Case 5) presented with a steel FB (A) in his left thigh and an irregular FB-associated traumatic pseudoaneurysm (shown only on angiography, 2 mm 9 3 mm 9 1 mm in size, (B) in a small branch femoral artery. After a 0.89-mm exchange guide wire is positioned into the pseudoaneurysm artery through a 5F angiographic catheter to locate this artery (C), percutaneous trans-soft
tissue no-trocar interventional removal of the sharp FB (D) is then carried out successfully under the X-ray fluoroscopic guidance without any serious complications. No special treatments for the pseudoaneurysm, which is not shown again on angiograms after FB removal maybe due to the parent artery spasm
catheter (Cook, USA) simultaneously during the procedure of FB retrieval, in order to prevent the damage of artery and to avoid blood loss. Next, percutaneous interventional FB removal was performed under fluoroscopy guidance (AXIOM Artis, Siemens Medical Solutions): (1) After skin disinfecting with povidone-iodine solution, 5–10 ml of 2 % lidocaine solution was injected under real-time fluoroscopic guidance into the soft tissues around FB for local anesthetic infiltration and regional nerve block. (2) A 3–5-mm skin incision was made along the long axis of the FB. (3)
Through the skin incision, a self-designed grasping FB forceps (Fig. 3) or ordinary hemostatic forceps was inserted slowly toward the FB under fluoroscopic guidance. For FB retained more than 2 weeks, pliers had to be used to bluntly rip the granulation tissue surrounding the FB by opening the pliers mouth repeatedly from different angles. (4) Under fluoroscopic monitoring, the forceps was used to catch one end of the FB and withdraw slowly along FB’s long axis (for the FB to pass through the small incision) to extract the FB out of the body. (5) After extraction, moderate manual pressure was applied to stop mild bleeding in
123
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies
was recommended to have follow-up examination of CT or MRI of lower extremity within 6 months.
Discussion Fig. 3 The open forceps is one kind of self-designed grasping FB forceps which is equipped with precise scales and magnetic mouth
the wound. (6) With confirmation of X-ray and angiography that no FB residue was left and no vascular damage was demonstrated, the skin incision was usually covered with a bandage. Post-operative treatments included (l) Tetanus prophylaxis was prescribed to all patients. (2) Antimicrobial prophylaxis with cephalosporins (2 g, IV, bid) was empirically prescribed for 1–2 days after the procedure. The procedural safety and effectiveness, in particular, the technical success rate and procedure-related complications, were noted during the subsequent one-week observation period.
Results Foreign Bodies were successfully removed in all nine patients by employing the vascular intervention-assisted percutaneous interventional FB removal. All these FBs were metallic and measured 3–12 mm in length and 1–3 mm in width, as shown in Table 1. The distance from FB to the closest vessel was 0–2 mm. The total fluoroscopic time for retrieval of each FB was 5–9 min (mean, 6.4 min). The volume of intraoperative bleeding ranged from 5 to 12 ml (mean, 7.5 ml, the bleeding volume calculation was counted approximately in 15 ml of one piece of swab soaked by blood). No signs of vascular damage, thrombus, or bleeding from the vessel were observed in the follow-up angiograms after FB removal. No serious complications, such as uncontrollable bleeding, hematoma, surgical site infection, nerve injuries, or muscular injury, were encountered during the interventional procedure, or during the one-week observation period. The length of hospital stay for each patient ranged from 4 to 8 days (mean, 5.5 days). Before FB interventional removal, one of the nine (11.1 %) patients treated by this dual intervention had a small asymptomatic pseudoaneurysm (2 mm 9 3 mm 9 1 mm in size) identified only by digital subtraction angiograms but not by pre-intervention CT. This pseudoaneurysm was untreated because of its small size and deep location, which disappeared on DSA images immediately after the FB removal, perhaps owing to the possible spasm of the parent artery. This patient
With the development of new imaging technology, especially with CT post-processing 3D vascular reconstruction [4, 6], it becomes safer, easier, and more effective for us to implement the interventional removal of small radiopaque FB with real-time fluoroscopic guidance, and many patients benefited from this minimally invasive treatment [2, 4, 6]. However, the neurovascular structures around the FB are invisible under fluoroscopy, and vascular damages due to the manipulation of the retrieval forceps could not be avoided. Therefore, it might be contraindicated to attempt to remove the small radiopaque FB adjacent to major vessels using the conventional interventional method. Percutaneous transluminal extraction has been described in vascular interventional radiology, particularly retrieval of experimental foreign objects [7] and of broken catheters, embolization coils, vascular guides, stents or inferior vena cava filters in clinic [8–10]. Here, we used percutaneous intravascular positioning method with guidewire or catheter to show indirectly the position of major vessel and its route under fluoroscopy. In addition, we also used percutaneous transluminal balloon to temporarily occlude blood flow in the vessel, providing less chance of injury during the foreign body retrieval. This new interventional method effectively avoided manipulation of FB retrieval forceps without knowledge of the location of adjacent vessels. This method also can replace the invasive and costly open surgical removal of FBs. Furthermore, for those complicated cases with associated vascular injuries (such as traumatic pseudoaneurysm, arteriovenous fistula, and vessel penetration), it will not only provide a novel treatment method of retrieving the FB itself but also help to treat associated vascular injuries with endovascular stent placement. It is worth mentioning here that for all kinds of FB retrieval, avoiding nerve injury is a major challenge. It is possible that the harmful manipulation of forceps on nerve(s) will cause uncomfortable symptoms, such as muscular cramps, pain, or burnings sensation, etc., which will alarm the interventionalist to adjust the manipulation of forceps to avoid the nerve damage. Prediction of the location of major nerves may be possible with the knowledge of location of major vessels. In conclusion, despite the small sample size of our pilot study, the initial results of this new method of removing FB percutaneously are encouraging, and it is worth promoting to treat the patient with FB(s) adjacent to major vessels as a safe and effective minimally invasive method.
123
X.-J. Yang, G.-F. Xing: Percutaneous Retrieval of Foreign Bodies Acknowledgments This study is supported by Scientific Research Fund from Shanghai Municipal Health Bureau (Program Code: 2008186) and Jiangsu University Medical Science Fund (Program Code: JLY2010059). All authors, Dr XJ Yang and Dr GF Xing, would like to submit our paper and the copyright transfer to this journal. Conflict of Interest conflict of interests.
All the authors and the institution had no
Statements of Ethical Approval and Informed Consent This study was reviewed and approved by the Institutional Review Board of our hospital and all patients provided their written consent to participate in this study.
References 1. Callegari L, Leonardi A, Bini A et al (2009) Ultrasound-guided removal of foreign bodies: personal experience. Eur Radiol 19(5):1273–1279 2. Amoretti N, Hauger O, Marcy PY et al (2010) Foreign body extraction from soft tissue by using CT and fluoroscopic guidance: a new technique. Eur Radiol 20(1):190–192
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