European Journal of Radiology, 12 (1991) 4-10 Elsevier
4
EURRAD
00119
Percutaneous vascular foreign body retrieval: Experience of an l&year period R.F. Dondelinger,
B. Lepoutre
and J.C. Kurdziel
Department of Radiology, Centre Hospitalier,Luxembourg, Grand Duchy of Luxembourg (Accepted
Key words:
Interventional
radiology,
foreign body; Foreign
21 August 1990)
body, intervention; body
Vascular,
intervention;
Percutaneous
retrieval,
foreign
Abstract Over an 1 l-year period, percutaneous retrieval of intravascular foreign bodies was performed in 12 patients, using urological forceps and retrieval baskets. No clinically significant complication occurred, success rate was 100%. Review of 176 cases from the literature showed a success rate of 90%. -
Introduction Percutaneous retrieval of intravascular foreign bodies has emerged, since it was first described [ 11, as the standard method of treatment, avoiding major surgery. Hundreds of retrievals, previously published as case reports and short series have been analysed in review articles [ 2-61. A limited number of series with at least six patients and offering precise data are available [7-181. We report our experience with 12 cases recorded over an 1 l-year period in a 450-bed hospital and emphasize the ease and success of the procedure when prompt treatment is established. Patients and Methods From January 1979 to June 1990, a vascular foreign body was diagnosed in 12 patients, 8 male and 4 female, age ranging from 16 to 88 (mean 58) (Table 1). In 4 patients, a broken venous perfusion catheter was lost in the superior vena cava and in 2 patients it was a metal guide wire. The foreign body remained in the caval system in 4 patients, and in 2 patients the distal end migrated to the right atrium. Another patient had a Address for reprints: R.F. Dondelinger, M.D., Department of Radiology, Centre Hospitalier, 4 rue BarblC, L-1210, Luxembourg, Grand Duchy of Luxembourg. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
broken teflon catheter, which remained in the right radial vein, and in 1 polytraumatized patient a 7 cm venous catheter had migrated to a segmental branch of the left lower pulmonary artery (Fig. 1). In one patient, a Gianturco-Anderson-Wallace coil (diameter: 5 mm) was lost in the left renal vein during embolization of a varicocele (Fig. 2). One patient had two broken pace-maker electrodes, one remained in the left subclavian vein, another fell down in a segmental branch of the right renal vein (Fig. 3). One patient, referred from another hospital, presented a Gunther vena cava filter (diameter: 30 mm) that had been introduced in the wrong way by the femoral vein and had migrated to the right atrium. The filter was turned 180 o in the heart and was placed in the inferior vena cava. One patient had a sapphire laser tip detached during percutaneous recanalization of an obstructed superficial femoral artery. The probe was entrapped by the calcified atheromatous and thrombotic occlusive material (Fig. 4). Prior to extraction, plain radiographs of the suspected region were obtained for localization of the foreign body. Angiography was performed for localization in cases 2, 5, 11, 12. All foreign bodies were radio-opaque or had radio-opaque elements. In 11 cases, extraction was performed immediately after radiographic diagnosis, either during an interventional procedure (coil embolization, laser recanalization) or at
B.V. (Biomedical
Division)
TABLE
I
Percutaneous Patients
retrieval of foreign body in 12 patients Sex
Age
Foreign body
Location
Method of retrieval
1
M
58
CVP catheter
Dotter basket
2
M
66
3
F
58
4
M
52
Two pace maker electrodes Metal guide wire of CVP catheter CVP catheter
5 6
F F
19 86
Laser probe Gunther IVC filter
Prox: right internal jugular vein Dist: cave-atria1 junction Left subclavian vein and branch of right renal vein Prox: SVC Dist: right common iliac vein Prox: SVC Dist: left common iliac vein Right superficial femoral artery Right atrium
I
M
13
CVP catheter
8 9
M M
34 71
10 11 12
F M M
16 56 34
Embolization coil Metal guide wire of CVP catheter CVP catheter IV catheter line IV catheter line
maximum 2 days after the foreign body was abandoned. The patient with two lost pacemaker electrodes was treated 2 weeks after loss of the foreign bodies: he had a low-grade fever which vanished after extraction. The procedure was assessed as easy in 11 cases and difficult in 1 case: the short venous catheter lodged in a peripheral pulmonary artery broke in two fragments during manipulation and needed two attempts before it was successfully extracted.
Prox: right internal jugular vein Dist: right atrium Left renal vein Prox: SVC Dist: right internal iliac vein Right atrium Radial vein Segmental pulmonary artery of the left lower lobe
Dormia basket Dotter basket Dotter basket Urological forceps Urological forceps and Gunther filter retrieval set Dotter basket Dormia basket Dotter basket Dotter basket Urological forceps Dotter basket and biopsy forceps
In 9 cases, a Dormia stone removal basket or a Dotter type basket was used. The upper or lower end of the venous catheter or the guide wire was caught by the basket. In 2 cases, when a small object had to be extracted (sapphire probe, electrodes), flexible urological forceps were used. For extraction of the catheter wedged in a small pulmonary artery, a basket and long flexible percutaneous biopsy forceps were necessary. For venous extraction, percutaneous access was
Fig. 1. 34-year -old polytram natized male. (a) A small peripheral i.v. catheter migrated to the left lower pulmonary artery. (b) After percutaneous extraction with I a basket and an endoscopical biopsy forceps, angiography demonstrated segmental occlusion of the left lower pulmonary artery. Clinical follow-up was uneventful.
the wire basket or with the forceps, it was closed and pulled out either through or with the introducer sheath. No venous cutdown was necessary. No premeditation and no antibiotics were given. Results The percutaneous retrieval procedure was successful in all cases, without clinically significant complication. After extraction of the lost catheter from a branch of the left lower pulmonary artery, the angiogram showed thrombosis of a segmental pulmonary artery. Follow-up was uneventful in all patients. Discussion
Fig. 2. Embolization of the left spermatic vein for varicocele in a 34-year-old male. (a) A spring coil of 5 mm in diameter was lost in the left renal vein. (b) The coil was entrapped in a biliary stone removal basket, introduced through the coil delivery catheter, and removed.
obtained through the right femoral vein, using Seldinger’s technique. In one case, access was obtained through the left basilic vein to retrieve a broken pacemaker electrode located in the left subclavian vein. The catheter in the radial vein was extracted by a more cephalad venous puncture. For extraction and repositioning of the Gunther filter in the right atrium, a simultaneous right axillary access and a femoral access were required using flexible forceps and Gunther filter retrieval set. Once the foreign body was entrapped in
The incidence of lost catheters in the venous circulation was estimated at 0.1% [ 191 but the real rate is unknown. The growing application of intravascular tools in both diagnostic and therapeutic procedures and the more widespread use of percutaneously placed embolization and prosthetic material has increased the overall hazards, and in particular the risk for venous and arterial embolization of foreign material. It is interesting to notice that among 12 patients treated, 3 had a foreign body lost during an interventional radiological procedure. Migrated polyethylene central venous catheters cut in two by the needle introducer counted for about 80% of objects retrieved [2]. Others are SwanGanz catheters, hyperalimentary catheters, ventriculoatrial shunts, port-A-caths, cardiac stimulators, pace maker electrodes, preoperative vascular tubes, angiographic catheters or guide wire fragments, angioplasty equipment components, vascular stents, embolization
Fig. 3. Right renal phlebography confirmed a radio-opaque pace maker electrode (a) located in a branch of the right renal vein in a 66-year-old male. (b) The electrode was caught in a biliary stone removal basket and extracted.
Fig. 4. Percutaneous transluminal laser recanalization of the occluded right superficial femoral artery in a 79-year-old female. (a) The sapphire tip was detached from the catheter due to calcified atheromatous and thrombotic material. (b) The sapphire probe was caught by an urological forceps and extracted.
material, caval filters, broken puncture needles in drug addicts and foreign projectiles. The mechanism of embolization differs depending on the nature of the foreign body and the site of introduction. The distal end embolizes to the right heart or to the pulmonary arteries: if intracardiac, the tricuspid valve or the ventricular wall may stop the catheter. The trailing end stays either in the superior vena cava or curls in the right atrium. Venous foreign bodies tend to embolize distally immediately, secondary migration is uncommon [ 21. Venous catheters in the lower extremity are much less used and tend to migrate less. Passage from one caval system to another is rare. In the arterial system (left heart, aorta, collaterals), embolization is much less common due to greater care and better skills generally available for manipulations. Distal embolization is at particular risk, due to high blood flow, until the foreign body become firmely wedged in a coronary, cerebral, visceral or peripheral artery. Intravascular embolized foreign bodies must be retrieved as they can be associated with serious complications according to their location. A 2 1 y0 [ 61 to 7 1 y0 [ 41 long-term serious morbidity rate and a 23.7% [6] to 27% [ 191 death rate have been reported, directly related to the foreign body. Localization in the right heart means the largest likelihood for complications [6]. Common side effects are ventricular arrhythmia, myocardial infarct, myocarditis,
recurrent pericardial effusion and perforation of heart chambers with tamponade. Thrombus and thromboembolism occur with pulmonary or caval foreign bodies. Signs of infection are observed in variable degrees. Percutanous extraction of foreign bodies is still unsufficiently known and has not yet completely replaced surgery as a first attempt. Undoubtly, thoracotomy and open-heart surgery for cardiac foreign bodies are more invasive than percutaneous retrieval, and carry a mortality rate of lO”,b [ 201. Percutaneous extraction is performed with local anesthesia, using basic angiographic techniques. Relatively inexpensive material is necessary, rendering cost-effectiveness of the technique even more striking compared with surgery, some procedures being performed on an outpatient basis. Three principles are available to retrieve foreign bodies percutaneously: (a) The loop-snare technique, which consists of a guide wire folded in two and introduced through the catheter into the vessel, thus creating a loop of variable length. The technique has undergone many variations since description [21], and was generally used in 80% of retrieval attempts [2]. A free end to snare is mandatory. Poor torque control may be a disadvantage. (b) Helical baskets have been proposed [22] and various diameters are currently used. A liliform tip reduces the danger of perforation. Maximum diameter of
9
the devices has increased, thus enabling their use in the caval system and tributary veins. The three-dimensional configuration of the basket as well as its flexibility is an advantage. One end of the foreign body must be free in the vascular lumen to allow entrapment. (c) The forceps technique, since its first description [ 11, using a bronchoscopic device, can grasp foreign bodies at any point. Maneuverability is limited and the risk for perforation of the vascular wall is present. Other modified endoscopic, urological and myocardial biopsy forceps are used. Many other derived techniques to retrieve remnants have been described, which are placed too distally in the pulmonary circulation or without free end; hook catheters, hook guide wires, Fogarty catheters, Pigtail catheters, guide wire deflectors and platinum-cobalt magnets are such devices. In complex situations, a combination of all available methods increases success and shortens removal time. Review of 176 attempts of percutaneous retrievals from reports with at least six patients and precise patient data [7-181 including the present series shows a success rate of 90% (Table 2). Retrieval may fail when no free ends are available for snaring, when small catheter fragments are lodged too far in peripheral pulmonary artery branches [9-l 1,161 or coronary arteries [ 131, when objects such as pacemaker ‘catheters are anchored firmely, when small objects are entrapped in the pectinate muscles, or are incorporated in the vascular wall [ 11,12,14,18] or lodged in a thrombosed vessel [ 11,161 or outside the vessel [ 161, or finally when there is extreme friability of the fragment [9]. The foreign body may also be lost again after initial entrapment or break and migrate more distally in the pulmonary arteries [9]. Failure of percutaneous retrieval is obviated by early extraction. Large objects may need a limited venotomy at the entry site for extraction [24]. When spatial orientation is difficult, biplane fluoroscopy is helpful in the heart chambers and peripheral pulmonary arteries. In case of non-opaque foreign body, difficult to locate, ultrasound can be helpful [ 81. Relative contra-indications of percutaneous removal are large free floating thrombus and vascular perforation by the foreign body. Complications from percutaneous extraction are rare: three transient arrythmias were noticed in the analysed series [ 16,171. Conclusion In a series of 12 intravascular embolized foreign bodies, percutaneous retrieval was successful in all cases, without clinically significant complication. Avai-
labitiy of the technique should be known by the concerned physicians. Best prevention of retained vascular foreign bodies is adequate teaching of manual skills, exercise with new sophisticated techniques before clinical application and strong supervision of trainees.
References 1 Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Non-surgical retrieval of broken segment of steel spring guide from right atrium to superior vena cava. Circulation 1964; 30: 106-108. 2 Bloomfield DA. The non-surgical retrieval of intracardiac foreign bodies: an international survey. Cathet Cardiovasc Diagn 1978; 4: I-14. 3 Dotter CT, Rosch J, Bilbao MC. Transluminal extraction of catheter and guide fragments from the heart and great vessels: 29 collected cases. AJR 197 1; 11: 467-471. 4 Fisher RG, Ferreyro R. Evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies. AJR 1978; 130: 541-548. 5 Grand M, Harry G, Remy J, Doyon D. Extraction non-chirurgitale de corps &rangers iatrogenes intra-vasculaires. J Radio1 Electrol 1978; 59: 479-485. 6 Richardson JD. Grover FL, Trinkle JK. Intravenous catheter emboli: experience with twenty cases and collective review. Am J. Surg 1974; 128: 722-727. removal of catheter frag1 Aldridge HE, Lee J. Transvascular ments for the great vessels and heart. Can Med Assoc J 1977: 117: 1300-1302. 8 Block P. Transvenous retrieval of foreign bodies in the cardiac circulation. JAMA 1979; 224: 241-242. 9 Bloomfield DA. Techniques ofnonsurgical retrieval of iatrogenic foreign bodies from the heart. Am J Cardioi 1971; 27: 538-545. 10 Cho SR, Tisnado J, Beachley MC, Vines FS, Alford WL. Percutaneous unknotting of intravascular catheters and retrieval of catheter fragments. AJR 1983; 141: 397-402. Frendkorperentfernung 11 Erdmann E. Punkture transfemorale aus dem Herzen oder aus grossen Gefassen. Dtsch Med Wochenschr 1988; 113: 1594-1597. F, Bardach G, Dock W. Pinterits F. Percu12 Grabenwoerger taneous extraction of centrally embolized foreign bodies: a report of 16 cases. Br J Radio1 1988; 61: 1014-1018. 13 Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987; 60: 1260-1264. 14 Kappenberger L, Tartini R, Steinbrunn W. Transluminale Entfernung endovasaler Fremdkorper. Schweiz Med Wochenschr 1985: 115: 258-260. 15 Kuffer G, Gebauer A, Antes G, Rath M. Perkutane transluminale Entfernung embolisierter Katheterteile. Fortschr Rbntgenstr 1981; 135: 691-694. 16 Rossi P. Passariello R, Simonetti G. Intravascular iatrogenic foreign body retrieval. Ann Radio1 1980; 23: 286-290. 17 Uflacker R, Lima S, Melichar AC. Intravascular foreign bodies: percutaneous retrieval. Radiology 1986; 160: 731-735. 18 Weber J, Sartor K. Perkutane Entfernung intravasaler Fragmente von Infusions Angiographie und Liquor-Drainagekathetern mittels Fangschlingentechnik. Chirurgie 1980; 5 I : 7 1l-7 16. Schweiz 19 Burri C, Henkeneyer H, Passler H. Katheterembolien. Med Wschr 1971; 101: 1537-1541.
10 20 Schuler S, Hetzger R, Stegman T, Borst HG. Surgical therapy of intracardiac infected pacemaker electrodes and catheter remnants. Z Kardiol 1986; 75: 151-155. 21 Massumi RA, Ross AM. Atraumatic non-surgical retrieval technic for removal of broken catheters from cardiac chamber. N Engl J Med 1967; 277: 195-196. 22 Lassers BW, Pickering D. Removal of iatrogenic foreign body
from aorta by means of ureteric stone catheter. Am 73: 375-378. 23 Woo V, Gerber AM, Scheible W, Woo Seo K, Leopold G. Real-time ultrasound guidance for transluminal retrieval of non-opaque intravascular ment. AJR 1979; 133: 760-761.
Heart J 1967; Bookstein J, percutaneous catheter frag-
4
EURRAD
00119
Percutaneous vascular foreign body retrieval: Experience of an l&year period R.F. Dondelinger,
B. Lepoutre
and J.C. Kurdziel
Department of Radiology, Centre Hospitalier,Luxembourg, Grand Duchy of Luxembourg (Accepted
Key words:
Interventional
radiology,
foreign body; Foreign
21 August 1990)
body, intervention; body
Vascular,
intervention;
Percutaneous
retrieval,
foreign
Abstract Over an 1 l-year period, percutaneous retrieval of intravascular foreign bodies was performed in 12 patients, using urological forceps and retrieval baskets. No clinically significant complication occurred, success rate was 100%. Review of 176 cases from the literature showed a success rate of 90%. -
Introduction Percutaneous retrieval of intravascular foreign bodies has emerged, since it was first described [ 11, as the standard method of treatment, avoiding major surgery. Hundreds of retrievals, previously published as case reports and short series have been analysed in review articles [ 2-61. A limited number of series with at least six patients and offering precise data are available [7-181. We report our experience with 12 cases recorded over an 1 l-year period in a 450-bed hospital and emphasize the ease and success of the procedure when prompt treatment is established. Patients and Methods From January 1979 to June 1990, a vascular foreign body was diagnosed in 12 patients, 8 male and 4 female, age ranging from 16 to 88 (mean 58) (Table 1). In 4 patients, a broken venous perfusion catheter was lost in the superior vena cava and in 2 patients it was a metal guide wire. The foreign body remained in the caval system in 4 patients, and in 2 patients the distal end migrated to the right atrium. Another patient had a Address for reprints: R.F. Dondelinger, M.D., Department of Radiology, Centre Hospitalier, 4 rue BarblC, L-1210, Luxembourg, Grand Duchy of Luxembourg. 0720-048X/91/$03.50
0 1991 Elsevier Science Publishers
broken teflon catheter, which remained in the right radial vein, and in 1 polytraumatized patient a 7 cm venous catheter had migrated to a segmental branch of the left lower pulmonary artery (Fig. 1). In one patient, a Gianturco-Anderson-Wallace coil (diameter: 5 mm) was lost in the left renal vein during embolization of a varicocele (Fig. 2). One patient had two broken pace-maker electrodes, one remained in the left subclavian vein, another fell down in a segmental branch of the right renal vein (Fig. 3). One patient, referred from another hospital, presented a Gunther vena cava filter (diameter: 30 mm) that had been introduced in the wrong way by the femoral vein and had migrated to the right atrium. The filter was turned 180 o in the heart and was placed in the inferior vena cava. One patient had a sapphire laser tip detached during percutaneous recanalization of an obstructed superficial femoral artery. The probe was entrapped by the calcified atheromatous and thrombotic occlusive material (Fig. 4). Prior to extraction, plain radiographs of the suspected region were obtained for localization of the foreign body. Angiography was performed for localization in cases 2, 5, 11, 12. All foreign bodies were radio-opaque or had radio-opaque elements. In 11 cases, extraction was performed immediately after radiographic diagnosis, either during an interventional procedure (coil embolization, laser recanalization) or at
B.V. (Biomedical
Division)
TABLE
I
Percutaneous Patients
retrieval of foreign body in 12 patients Sex
Age
Foreign body
Location
Method of retrieval
1
M
58
CVP catheter
Dotter basket
2
M
66
3
F
58
4
M
52
Two pace maker electrodes Metal guide wire of CVP catheter CVP catheter
5 6
F F
19 86
Laser probe Gunther IVC filter
Prox: right internal jugular vein Dist: cave-atria1 junction Left subclavian vein and branch of right renal vein Prox: SVC Dist: right common iliac vein Prox: SVC Dist: left common iliac vein Right superficial femoral artery Right atrium
I
M
13
CVP catheter
8 9
M M
34 71
10 11 12
F M M
16 56 34
Embolization coil Metal guide wire of CVP catheter CVP catheter IV catheter line IV catheter line
maximum 2 days after the foreign body was abandoned. The patient with two lost pacemaker electrodes was treated 2 weeks after loss of the foreign bodies: he had a low-grade fever which vanished after extraction. The procedure was assessed as easy in 11 cases and difficult in 1 case: the short venous catheter lodged in a peripheral pulmonary artery broke in two fragments during manipulation and needed two attempts before it was successfully extracted.
Prox: right internal jugular vein Dist: right atrium Left renal vein Prox: SVC Dist: right internal iliac vein Right atrium Radial vein Segmental pulmonary artery of the left lower lobe
Dormia basket Dotter basket Dotter basket Urological forceps Urological forceps and Gunther filter retrieval set Dotter basket Dormia basket Dotter basket Dotter basket Urological forceps Dotter basket and biopsy forceps
In 9 cases, a Dormia stone removal basket or a Dotter type basket was used. The upper or lower end of the venous catheter or the guide wire was caught by the basket. In 2 cases, when a small object had to be extracted (sapphire probe, electrodes), flexible urological forceps were used. For extraction of the catheter wedged in a small pulmonary artery, a basket and long flexible percutaneous biopsy forceps were necessary. For venous extraction, percutaneous access was
Fig. 1. 34-year -old polytram natized male. (a) A small peripheral i.v. catheter migrated to the left lower pulmonary artery. (b) After percutaneous extraction with I a basket and an endoscopical biopsy forceps, angiography demonstrated segmental occlusion of the left lower pulmonary artery. Clinical follow-up was uneventful.
the wire basket or with the forceps, it was closed and pulled out either through or with the introducer sheath. No venous cutdown was necessary. No premeditation and no antibiotics were given. Results The percutaneous retrieval procedure was successful in all cases, without clinically significant complication. After extraction of the lost catheter from a branch of the left lower pulmonary artery, the angiogram showed thrombosis of a segmental pulmonary artery. Follow-up was uneventful in all patients. Discussion
Fig. 2. Embolization of the left spermatic vein for varicocele in a 34-year-old male. (a) A spring coil of 5 mm in diameter was lost in the left renal vein. (b) The coil was entrapped in a biliary stone removal basket, introduced through the coil delivery catheter, and removed.
obtained through the right femoral vein, using Seldinger’s technique. In one case, access was obtained through the left basilic vein to retrieve a broken pacemaker electrode located in the left subclavian vein. The catheter in the radial vein was extracted by a more cephalad venous puncture. For extraction and repositioning of the Gunther filter in the right atrium, a simultaneous right axillary access and a femoral access were required using flexible forceps and Gunther filter retrieval set. Once the foreign body was entrapped in
The incidence of lost catheters in the venous circulation was estimated at 0.1% [ 191 but the real rate is unknown. The growing application of intravascular tools in both diagnostic and therapeutic procedures and the more widespread use of percutaneously placed embolization and prosthetic material has increased the overall hazards, and in particular the risk for venous and arterial embolization of foreign material. It is interesting to notice that among 12 patients treated, 3 had a foreign body lost during an interventional radiological procedure. Migrated polyethylene central venous catheters cut in two by the needle introducer counted for about 80% of objects retrieved [2]. Others are SwanGanz catheters, hyperalimentary catheters, ventriculoatrial shunts, port-A-caths, cardiac stimulators, pace maker electrodes, preoperative vascular tubes, angiographic catheters or guide wire fragments, angioplasty equipment components, vascular stents, embolization
Fig. 3. Right renal phlebography confirmed a radio-opaque pace maker electrode (a) located in a branch of the right renal vein in a 66-year-old male. (b) The electrode was caught in a biliary stone removal basket and extracted.
Fig. 4. Percutaneous transluminal laser recanalization of the occluded right superficial femoral artery in a 79-year-old female. (a) The sapphire tip was detached from the catheter due to calcified atheromatous and thrombotic material. (b) The sapphire probe was caught by an urological forceps and extracted.
material, caval filters, broken puncture needles in drug addicts and foreign projectiles. The mechanism of embolization differs depending on the nature of the foreign body and the site of introduction. The distal end embolizes to the right heart or to the pulmonary arteries: if intracardiac, the tricuspid valve or the ventricular wall may stop the catheter. The trailing end stays either in the superior vena cava or curls in the right atrium. Venous foreign bodies tend to embolize distally immediately, secondary migration is uncommon [ 21. Venous catheters in the lower extremity are much less used and tend to migrate less. Passage from one caval system to another is rare. In the arterial system (left heart, aorta, collaterals), embolization is much less common due to greater care and better skills generally available for manipulations. Distal embolization is at particular risk, due to high blood flow, until the foreign body become firmely wedged in a coronary, cerebral, visceral or peripheral artery. Intravascular embolized foreign bodies must be retrieved as they can be associated with serious complications according to their location. A 2 1 y0 [ 61 to 7 1 y0 [ 41 long-term serious morbidity rate and a 23.7% [6] to 27% [ 191 death rate have been reported, directly related to the foreign body. Localization in the right heart means the largest likelihood for complications [6]. Common side effects are ventricular arrhythmia, myocardial infarct, myocarditis,
recurrent pericardial effusion and perforation of heart chambers with tamponade. Thrombus and thromboembolism occur with pulmonary or caval foreign bodies. Signs of infection are observed in variable degrees. Percutanous extraction of foreign bodies is still unsufficiently known and has not yet completely replaced surgery as a first attempt. Undoubtly, thoracotomy and open-heart surgery for cardiac foreign bodies are more invasive than percutaneous retrieval, and carry a mortality rate of lO”,b [ 201. Percutaneous extraction is performed with local anesthesia, using basic angiographic techniques. Relatively inexpensive material is necessary, rendering cost-effectiveness of the technique even more striking compared with surgery, some procedures being performed on an outpatient basis. Three principles are available to retrieve foreign bodies percutaneously: (a) The loop-snare technique, which consists of a guide wire folded in two and introduced through the catheter into the vessel, thus creating a loop of variable length. The technique has undergone many variations since description [21], and was generally used in 80% of retrieval attempts [2]. A free end to snare is mandatory. Poor torque control may be a disadvantage. (b) Helical baskets have been proposed [22] and various diameters are currently used. A liliform tip reduces the danger of perforation. Maximum diameter of
9
the devices has increased, thus enabling their use in the caval system and tributary veins. The three-dimensional configuration of the basket as well as its flexibility is an advantage. One end of the foreign body must be free in the vascular lumen to allow entrapment. (c) The forceps technique, since its first description [ 11, using a bronchoscopic device, can grasp foreign bodies at any point. Maneuverability is limited and the risk for perforation of the vascular wall is present. Other modified endoscopic, urological and myocardial biopsy forceps are used. Many other derived techniques to retrieve remnants have been described, which are placed too distally in the pulmonary circulation or without free end; hook catheters, hook guide wires, Fogarty catheters, Pigtail catheters, guide wire deflectors and platinum-cobalt magnets are such devices. In complex situations, a combination of all available methods increases success and shortens removal time. Review of 176 attempts of percutaneous retrievals from reports with at least six patients and precise patient data [7-181 including the present series shows a success rate of 90% (Table 2). Retrieval may fail when no free ends are available for snaring, when small catheter fragments are lodged too far in peripheral pulmonary artery branches [9-l 1,161 or coronary arteries [ 131, when objects such as pacemaker ‘catheters are anchored firmely, when small objects are entrapped in the pectinate muscles, or are incorporated in the vascular wall [ 11,12,14,18] or lodged in a thrombosed vessel [ 11,161 or outside the vessel [ 161, or finally when there is extreme friability of the fragment [9]. The foreign body may also be lost again after initial entrapment or break and migrate more distally in the pulmonary arteries [9]. Failure of percutaneous retrieval is obviated by early extraction. Large objects may need a limited venotomy at the entry site for extraction [24]. When spatial orientation is difficult, biplane fluoroscopy is helpful in the heart chambers and peripheral pulmonary arteries. In case of non-opaque foreign body, difficult to locate, ultrasound can be helpful [ 81. Relative contra-indications of percutaneous removal are large free floating thrombus and vascular perforation by the foreign body. Complications from percutaneous extraction are rare: three transient arrythmias were noticed in the analysed series [ 16,171. Conclusion In a series of 12 intravascular embolized foreign bodies, percutaneous retrieval was successful in all cases, without clinically significant complication. Avai-
labitiy of the technique should be known by the concerned physicians. Best prevention of retained vascular foreign bodies is adequate teaching of manual skills, exercise with new sophisticated techniques before clinical application and strong supervision of trainees.
References 1 Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Non-surgical retrieval of broken segment of steel spring guide from right atrium to superior vena cava. Circulation 1964; 30: 106-108. 2 Bloomfield DA. The non-surgical retrieval of intracardiac foreign bodies: an international survey. Cathet Cardiovasc Diagn 1978; 4: I-14. 3 Dotter CT, Rosch J, Bilbao MC. Transluminal extraction of catheter and guide fragments from the heart and great vessels: 29 collected cases. AJR 197 1; 11: 467-471. 4 Fisher RG, Ferreyro R. Evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies. AJR 1978; 130: 541-548. 5 Grand M, Harry G, Remy J, Doyon D. Extraction non-chirurgitale de corps &rangers iatrogenes intra-vasculaires. J Radio1 Electrol 1978; 59: 479-485. 6 Richardson JD. Grover FL, Trinkle JK. Intravenous catheter emboli: experience with twenty cases and collective review. Am J. Surg 1974; 128: 722-727. removal of catheter frag1 Aldridge HE, Lee J. Transvascular ments for the great vessels and heart. Can Med Assoc J 1977: 117: 1300-1302. 8 Block P. Transvenous retrieval of foreign bodies in the cardiac circulation. JAMA 1979; 224: 241-242. 9 Bloomfield DA. Techniques ofnonsurgical retrieval of iatrogenic foreign bodies from the heart. Am J Cardioi 1971; 27: 538-545. 10 Cho SR, Tisnado J, Beachley MC, Vines FS, Alford WL. Percutaneous unknotting of intravascular catheters and retrieval of catheter fragments. AJR 1983; 141: 397-402. Frendkorperentfernung 11 Erdmann E. Punkture transfemorale aus dem Herzen oder aus grossen Gefassen. Dtsch Med Wochenschr 1988; 113: 1594-1597. F, Bardach G, Dock W. Pinterits F. Percu12 Grabenwoerger taneous extraction of centrally embolized foreign bodies: a report of 16 cases. Br J Radio1 1988; 61: 1014-1018. 13 Hartzler GO, Rutherford BD, McConahay DR. Retained percutaneous transluminal coronary angioplasty equipment components and their management. Am J Cardiol 1987; 60: 1260-1264. 14 Kappenberger L, Tartini R, Steinbrunn W. Transluminale Entfernung endovasaler Fremdkorper. Schweiz Med Wochenschr 1985: 115: 258-260. 15 Kuffer G, Gebauer A, Antes G, Rath M. Perkutane transluminale Entfernung embolisierter Katheterteile. Fortschr Rbntgenstr 1981; 135: 691-694. 16 Rossi P. Passariello R, Simonetti G. Intravascular iatrogenic foreign body retrieval. Ann Radio1 1980; 23: 286-290. 17 Uflacker R, Lima S, Melichar AC. Intravascular foreign bodies: percutaneous retrieval. Radiology 1986; 160: 731-735. 18 Weber J, Sartor K. Perkutane Entfernung intravasaler Fragmente von Infusions Angiographie und Liquor-Drainagekathetern mittels Fangschlingentechnik. Chirurgie 1980; 5 I : 7 1l-7 16. Schweiz 19 Burri C, Henkeneyer H, Passler H. Katheterembolien. Med Wschr 1971; 101: 1537-1541.
10 20 Schuler S, Hetzger R, Stegman T, Borst HG. Surgical therapy of intracardiac infected pacemaker electrodes and catheter remnants. Z Kardiol 1986; 75: 151-155. 21 Massumi RA, Ross AM. Atraumatic non-surgical retrieval technic for removal of broken catheters from cardiac chamber. N Engl J Med 1967; 277: 195-196. 22 Lassers BW, Pickering D. Removal of iatrogenic foreign body
from aorta by means of ureteric stone catheter. Am 73: 375-378. 23 Woo V, Gerber AM, Scheible W, Woo Seo K, Leopold G. Real-time ultrasound guidance for transluminal retrieval of non-opaque intravascular ment. AJR 1979; 133: 760-761.
Heart J 1967; Bookstein J, percutaneous catheter frag-
