Four-Stage Rocket technique: A novel strategy for lead extractions using laser sheaths from the femoral vein.

INTRODUCTION: Transvenous lead extractions (TLEs) for cardiac implantable electronic device complications often encounter difficulties with strong adhesions to the myocardium or vessels. In this report, we introduce a novel "Four-Stage Rocket" technique for effective TLE in cases where conventional methods fail. METHODS AND RESULTS: Two challenging cases where conventional TLE methods failed were treated using a combination of four devices: Needle's Eye Snare, Agilis NxT Steerable Introducer, GlideLight Laser sheath, and GORE® DrySeal Flex Introducer sheath, employed via the inferior vena cava. The "Four-Stage Rocket" technique successfully detached firmly adhered leads near the tricuspid valve annulus, where the traditional superior vena cava approach was inadequate. CONCLUSION: The "Four-Stage Rocket" technique offers a potential alternative in complex TLE cases, aligning the laser direction with the adhesion detachment and reducing the tissue damage risk.

Practical techniques for safely removing long-term implanted ventricular catheters to minimize bleeding.

INTRODUCTION: Removing ventricular catheters, particularly those implanted for extended periods, poses significant challenges for neurosurgeons due to potential complications such as bleeding from adhesions to the ependyma or choroid plexus. OBJECTIVE: This study aimed to review various techniques for safely removing ventricular catheters, emphasizing methods that minimize the risk of hemorrhagic complications. METHODS: A comprehensive narrative review focused on techniques developed and documented in the literature for safely detaching ventricular catheters adhered to brain structures. RESULTS: Various techniques have been identified that enhance the safety of catheter removal. Notably, the use of monopolar diathermy to coagulate and release adhesions has proven effective. Innovations such as insulated suction devices and the strategic use of flexible endoscopes have also contributed to safer removal procedures, minimizing the risk of damaging surrounding cerebral tissue and preventing catastrophic hemorrhage. CONCLUSION: The removal of ventricular catheters, especially those with long-term implantation, requires precise and cautious techniques to avoid severe complications. The study underscores the importance of adopting advanced surgical techniques and the continuous evolution of safer practices in neurosurgery. These methods not only ensure patient safety but also facilitate the handling of potentially complex and life-threatening situations during catheter removal.

Removal of central venous catheter using Evolution® Rotating Dilator.

We experienced the first case of a difficult-to-extract central venous catheter removed with a pacemaker lead removal system: a 14-year-old boy with Hirschsprung's disease who had repeated catheter infections that could not be removed by traction. Because the catheter lumen was occluded, a suture was tied around the end of the catheter and the catheter was removed with a rotating dilator.

Current Controversies in Inferior Vena Cava Filter Placement: AJR Expert Panel Narrative Review.

Despite inferior vena cava (IVC) filter practice spanning over 50 years, interventionalists face many controversies in proper utilization and management. This article reviews recent literature and offers opinions on filter practices. IVC filtration is most likely to benefit patients at high risk of iatrogenic pulmonary embolus during endovenous intervention. Filters should be used selectively in patients with acute trauma or who are undergoing bariatric surgery. Retrieval should be attempted for perforating filter and fractured filter fragments when imaging suggests feasibility and favorable risk-to-benefit ratio. Antibiotic prophylaxis should be considered when removing filters with confirmed gastrointestinal penetration. Anticoagulation solely because of filter presence is not recommended except in patients with active malignancy. Anticoagulation while filters remain in place may decrease long-term filter complications in these patients. Patients with a filter and symptomatic IVC occlusion should be offered filter removal and IVC reconstruction. Physicians implanting filters may maximize retrieval by maintaining physician-patient relationships and scheduling follow-up at time of placement. Annual follow-up allows continued evaluation for removal or replacement as appropriate. Advanced retrieval techniques increase retrieval rates but require caution. Certain cases may require referral to experienced centers with additional retrieval resources. The views expressed should help guide clinical practice, future innovation, and research.

Comparison between TightRail rotating dilator sheath and GlideLight laser sheath for transvenous lead extraction.

BACKGROUND: There are limited data on the comparative analyses of TightRail rotating dilator sheath (Philips) and laser sheath for lead extraction. OBJECTIVE: To evaluate the effectiveness and safety of the TightRail sheath as a primary or secondary tool for transvenous lead extraction (TLE). METHODS: Retrospective cohort analysis of 202 consecutive patients who underwent TLE using either TightRail sheath and/or GlideLight laser sheath (Philips) in our hospital. The study population was divided into three groups: Group A underwent TLE with laser sheath only (N = 157), Group B with TightRail sheath only (N = 22), and Group C with both sheaths (N = 23). RESULTS: During this period, 375 leads in 202 patients were extracted, including 297 leads extracted by laser sheath alone, 45 leads by TightRail sheath alone, and 33 by both TightRail sheath and laser sheaths. The most common indications included device infection (44.6%) and lead-related complications (44.1%). The median age of leads was 8.9 years. TightRail sheath (Group B) achieved similar efficacy as a primary extraction tool compared with laser sheath (Group A), with complete procedure success rate of 93.3% (vs. 96.6%, P = .263) and clinical success rate of 100.0% (vs. 98.1%, P = .513). Among 32 leads in which Tightrail was used after laser had failed (Group C), the complete procedure success rate was 75.8%. No significant difference in procedural adverse events was observed. CONCLUSION: Our single-center experience confirms that the TightRail system is an effective first-line and second-line method for TLE. Further investigation is required to guide the selection of mechanical and laser sheaths in lead extraction cases.

Mechanical extraction of cardiac implantable electronic devices leads with long dwell time: Efficacy and safety of the step up approach.

The aim of this study was to evaluate the efficacy and safety of the stepwise mechanical transvenous lead extraction approach in a patient population with chronically implanted transvenous leads with a long dwell time. From January 2014 till December 2018, all lead extractions with lead dwell time ≥5 years performed at our tertiary centre were retrospectively analysed. A total of 173 leads, from 78 patients (median age 68 years; 81% male) with a median dwell time of 9 years (interquartile range [IQR] 5) were extracted, with three or more leads in 42% of the patients. Right atrial leads: 41%; right ventricular pacing leads: 16%; implantable cardioverter-defibrillator (ICD) leads: 31% (72% dual coil); coronary sinus leads: 12%. The majority (75%) of the leads had an active fixation. Most frequent indication for extraction was pocket infection/erosion (76%). Overall clinical success was 97%, and complete procedural success was 93%. Venous patency, assessed with venous angiography, was well preserved in 93% of the cases. The overall procedural complication rate was 3.8% (2.6% major and 1.3% minor). Despite the complexity of the population and a very long dwell time (median 9 years), a clinical success rate of 97% was achieved with the stepwise mechanical approach. Analysis of impeding progression of pectoral extraction suggests that dense fibrosis and sharp lead curvature in the transvenous trajectory pose a challenge. Complication rate was low, and acute venous patency was generally well preserved.

An Effective Method for Percutaneous Removal of Venoarterial Extracorporeal Membrane Oxygenation by a Combination of Balloon Dilatation in Endovascular Therapy and the Perclose Proglide™ Closure Device.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be undertaken surgically, but there are various problems with this method. METHODS AND CASE REPORT: We removed the arterial cannula of VA-ECMO percutaneously by combining intravascular balloon dilatation and the Perclose ProGlide™ (PP) closure device in a short amount of time and the extent of bleeding was extremely small. Simultaneously, the venous cannula was removed by suturing and manual compression. We report a series of cases of percutaneous removal of VA-ECMO using intravascular balloon dilatation and PP. CONCLUSIONS: By using this method, VA-ECMO removal was possible in a very short amount of time with minimal invasiveness.

Quick cuts: A comparative study of two tools for ring tourniquet removal.

BACKGROUND: Ring tourniquet occurs when a ring becomes entrapped due to swelling or trauma. As the finger expands the blood flow restriction causes additional swelling, which can lead to nerve damage and other complications. Ring tourniquet can be an emergency that requires rapid ring removal. Standard devices for ring removal have been described but rarely tested. We conducted a randomized study to compare removal time, user and participant satisfaction and complications between a motorized diamond disc ring cutter (MDDRC) and a ring cutter attached to trauma shears (TS). METHODS: In pairs, emergency medicine providers removed rings using both devices and wore randomized rings to be removed (silver or steel). Each effort was timed from initiation to removal. After each effort both user and subject rated their satisfaction with the device, using a visual analog scale and reported any complications. Median and interquartile ranges were generated for the primary and secondary outcomes with 95% confidence intervals where applicable. Wilcoxon Rank Sum tests were calculated with a = 0.05 to compare removal time and secondary outcomes between the two tools. RESULTS: Thirty subjects completed the study. Median time to ring removal was significantly lower with the TS compared to the MDDRC (7.7 vs 67.0 s, p < .0001). Device user satisfaction (9.7/10 vs 3.8/10, p < .0001) and participant satisfaction (9.7/10 vs 6.8/10, p < .0001) were significantly higher with the TS, while participant discomfort was significantly lower with the TS (0.0/10 vs 2.2/10, p < .0001). CONCLUSION: This study is the first to compare efficacy, satisfaction and complications of two standard tools for removal of ring tourniquets. The TS took significantly less time than the GEM MDDRC and demonstrated significantly better satisfaction for both the ring wearer and ring remover.

Novel Technique for Removing a Well-Fixed Cemented Cup with a Dedicated Original Device during Revision Total Hip Arthroplasty: Surgical Technique.

The improved cemented cup technique has attained excellent long-term results in primary total hip arthroplasty. When cup revision surgery was performed, the cemented cup, which was loosened at the bone-cement interface, was easily removed. However, with a well-fixed bone-cement interface, it remains difficult to remove the cemented cup for a revision in the event of a recurring dislocation. In addition, protrusions in the cement can cause unpredictable bone defects. A new removal device was created and used successfully to remove a well-fixed cemented cup safely and efficiently. This report introduces the device and the technique used in cemented cup removal.

A Simple Percutaneous Retrieval Technique for an Embolized Watchman Left Atrial Appendage Closure Device in the Thoracic Aorta Using a Homemade Snare.

A 60-year old male with paroxysmal atrial fibrillation underwent a combined procedure of left atrial appendage occlusion and pulmonary vein isolation. However, an acute intraprocedural 24-mm Watchman device dislodgement occurred, and thus a decision for urgent surgery was made. However, it was noted during the surgery that the device had migrated further to the descending aorta, just distal to the left subclavian artery. Since a right sternotomy access for retrieval was not feasible, a percutaneous approach was justified. A homemade snare was created using a combination of a long sheath, J-wire, and a regular snare, and the device was successfully retrieved without significant difficulty.

Double Twist.

A rare complication about "Twiddler syndrome" is reported, and an interesting image about "double twist" is presented. A 78-year-old woman received a single-chamber implantable cardioverter defibrillator (ICD) for secondary prevention of ventricular arrhythmia. After she played mahjong (a traditional Chinese board game) overnight, her ICD lead sense amplitude decreased suddenly and did not recover. The intracardiac electrogram of ICD also found ventricular lead noise before this episode. Chest radiography revealed a twisted lead at the ICD pocket and a twisted and retracted ICD lead in the right atrium. An old ICD lead could not be straightened and removed, and a new ICD lead was implanted at the right ventricle. Anti-coagulation was used to prevent thrombosis for the old ICD lead.

Percutaneous retrieval of a dislocated LAmbre left atrial appendage occluder in a canine model.

BACKGROUND: Dislocated left atrial appendage (LAA) occluders can be retrieved by percutaneous intervention when performing device embolization into the left atrium (LA), aorta (AO), or left ventricle (LV). However, few reports exist regarding LAmbre LAA occluder dislocation. OBJECTIVE: The study was aimed to explore the outcome of retrieving dislocated LAmbre LAA occluder. METHODS: Sixteen healthy dogs received LAmbre implants. After implantation of an occlusion device (not released), the occlusion device was completely retrieved. Subsequently, the device was released in the LA, resulting in the dislocation of the device. Angiography and transesophageal echocardiography (TEE) were performed to check the occluders position. Disposable grasping rat-tooth forceps were used to percutaneously retrieve the LAA occluder. RESULTS: All the 16 dogs were successfully implanted with the LAmbre LAA occluder and the success rate was 100%. After the occluder was released, TEE and angiography confirmed that the device was located in the LA in eight cases (50%), in the AO in five cases (31%), and in the LV in three cases (19%). One subject died due to cardiogenic shock before the retrieval procedure was complete as the device fell into the LV. Two cases of device-related aortic valve injury occurred during the retrieval procedure when the device was located in the LV. No complications were observed when the device was located in the LA or AO. CONCLUSIONS: Device retrieval is feasible in most cases. However, potentially lethal complications may occur once the device is dislocated into the LV/AO.

Use of a clot aspiration system during transvenous lead extraction.

INTRODUCTION: The optimal approach to the extraction of leads with large vegetations remains uncertain. METHODS: High-risk patients with lead associated vegetations undergoing device extraction at Vanderbilt Hospital with concomitant use of the Penumbra Aspiration System (Penumbra Inc, Alameda, CA) are described. An 8.5 Fr Agilis NXT (Abbott Inc, St. Paul, MN) was advanced to the right atrium, through which a Penumbra Indigo Cat-8 catheter was advanced. Using intracardiac echocardiography, the Penumbra was positioned directly on the vegetation, suction was applied until adherent, and the Indigo catheter and Agilis sheath were then removed en-bloc and aspirated debris flushed out. This was repeated until debulking was considered successful. RESULTS: Eight cases were performed. The median vegetation size was 2 cm. Pathogens were Enterococcus, Staphylococcus, Candida, Cutibacterium, and Enterobacter. In seven of eight cases, aspiration successfully reduced vegetations to less than 1 cm before successful percutaneous cardiac implantable electronic device removal. One patient underwent surgical removal via thoracotomy. There were no acute complications related to the Penumbra catheter. Three patients had CT evidence of small pulmonary emboli postprocedure. The length of stay was 3 to 27 days. One patient died on POD 1 of refractory ventricular tachycardia unrelated to the procedure. One patient died of ongoing sepsis 2 weeks postextraction. CONCLUSIONS: The Penumbra Indigo Aspiration system can be useful for vegetation debulking before transvenous lead extraction.

The use of a sentinel cerebral protection system during Impella CP removal in a patient with left ventricular thrombus.

Percutaneous mechanical circulatory support (pMCS) devices are commonly being utilized for hemodynamic support in patients undergoing high-risk percutaneous coronary interventions or stabilization for those in cardiogenic shock. Left ventricular (LV) to ascending aorta (Ao) rotodynamic pumps such as the Impella devices allow for rapid hemodynamic stabilization or support in such instances. The use of such devices is contraindicated in patients with known LV thrombus. However, it remains unclear on how to manage patients who develop an LV thrombus while on prolonged Impella support. While there are currently no cerebral embolic protection devices (CEPDs) approved for use in conjunction with LV to Ao pMCS devices or other short-term mechanical support devices, there is a theoretical benefit for the use of such technology in the right circumstances. We present a case describing the use of the sentinel cerebral protection system (SCPS) in a patient who developed LV thrombus while on Impella CP support. The use of the SCPS in this patient suggests a potential role for CEPD in prevention of thromboembolism while on Impella support.

Ureteral stents: the good the bad and the ugly.

PURPOSE OF REVIEW: Ureteral stents are necessary in the routine practice of an urologist. Choosing the correct stent and being aware of the options available will allow urologists to provide the best possible care for patients and value to the healthcare system. This review seeks to educate urologists regarding improvements in stent technology currently available or in development. RECENT FINDINGS: Research from around the world is underway to discover an ideal stent - one that is comfortable for patients, resists infection and encrustation and is affordable for hospital systems. Stent design alterations and stent coatings are revealing reductions in encrustation and bacterial colonization. Biodegradable stents and magnetic stents are being tested to prevent the discomfort of cystoscopic removal. Intraureteral stents are proving efficacious while eliminating an irritating coil from the bladder and the symptoms associated with it. SUMMARY: The studies highlighted in this review provide encouraging results in the pursuit of the ideal stent while opening discussion around new concepts and further areas of research.

An Effective Method Combining Various Endoscopes in the Treatment of Intravesical Migrated Intrauterine Device.

OBJECTIVE: To introduce an effective method combining various endoscopes in the treatment of intravesical migrated intrauterine device (IUD). DESIGN: A step-by-step explanation of the surgery using video, approved by the Shengjing Hospital of China Medical University. SETTING: Shengjing Hospital of China Medical University. INTERVENTIONS: A 39-year-old young woman, in whom an IUD was inserted 2 months prior, presented with frequent urination after IUD insertion. Cystoscope and pelvic computed tomography were performed, and the results showed an IUD in the bladder. The migrated IUD was found partly in the uterus and partly in the bladder by hysteroscope and cystoscope. Management of the migrated IUD consists of 4 steps: (1) lysing the adhesion between the bladder and uterus, (2) suturing the bladder and taking the IUD part out of the bladder, (3) removing the IUD part in the uterus, and (4) suturing the bladder again to reinforce it and suturing the uterus. CONCLUSION: The migrated IUD in the bladder was successfully and completely extracted by the method combining various endoscopes; operative time was 56 minutes. In the follow-up period the patient did not report any symptoms of frequency urination. This surgical process has the following characteristics: Preoperative examination should be performed to clarify the ectopic site of the IUD, various endoscopes should be combined for diagnosis and treatment, and endoscopic surgery is an effective treatment method for migrated IUD.

A Novel Robotic Endoscopic Device Used for Operative Hysteroscopy.

To trial the use of a novel endoscopic robot that functions using concentric tube robots, enabling 2-handed surgery in small spaces, in a bioengineering laboratory. This was a feasibility study of the endoscopic robot for hysteroscopic applications, including removal of a simulated endometrial polyp. The endoscopic robot was successfully used to resect a simulated endometrial polyp from a porcine uterine tissue model in a fluid environment. The potential advantages of this platform to the surgeon may include improved exposure, finer dissection capability, and use of a 2-handed surgical technique. Further study regarding the safe, efficient, and cost-effective use of the endoscopic robot in gynecology is needed.

Efficient approach to superior vena cava baffle stenosis following the Mustard procedure: Expanding the role of a mechanical rotating dilator sheath for lead extraction.

INTRODUCTION: In adult congenital patients with transposition of the great arteries originally treated with the Mustard (atrial switch) procedure, the most common reason for re-intervention is baffle stenosis. This may be exacerbated by permanent transvenous pacemaker lead placement across the baffle. CASE REPORT: A 47-year-old female status post Mustard procedure performed at 15 months old presented with a high-grade stenosis of the superior vena cava (SVC) baffle from the SVC to the left atrium, with a nonfunctional permanent pacemaker lead passing through the baffle. A mechanical rotating dilator sheath was used for attempted lead extraction, relieving the baffle stenosis almost completely as a secondary effect, before the placement of a 10 × 27 mm Visipro balloon-expandable stent in the SVC baffle. CONCLUSIONS: Use of the mechanical rotating dilator sheath is an evolving treatment strategy in adult congenital heart disease to minimize the risk of bleeding, trauma to surrounding structures, and death. Its ability to fully alleviate baffle stenosis even when full lead extraction is not feasible or is associated with significant procedural risk, further demonstrates its expanded role in this patient population. A multidisciplinary approach and great diligence must be employed to avoid potential complications.

"Turn the tail, not the head": a simple, quick and inexpensive technique for the safe removal of jammed/stripped locking screws.

A jammed screw is a well-known complication of locking plates. Noncompliance to the standard techniques, nonusage of torque limiting screwdrivers and manufacturer-specific instrumentations are the common causes of jammed locking screw heads. Previously, various techniques have been described for the retrieval of jammed locking screws by damaging the screw head, using conical reverse threaded drill bits and often cutting off the plates at jammed screw sites that often generate metal debris and cause bone and soft tissue damage of unknown extent. We present a simple technique and a novel device that does not damage the screw head or the plate, and therefore, no metal debris is generated. The threads on the terminal part of the screw are used to disengage the jammed locking screw head from its locking hole.

A novel device for the endoscopic management of buried bumper syndrome.

BACKGROUND: Buried bumper syndrome (BBS) is a complication of percutaneous endoscopic gastrostomy (PEG) in which the internal bumper is overgrown by the gastric mucosa. Apart from loss of patency of the PEG tube, the buried bumper may evoke symptoms such as abdominal pain or peritubular leakage. While the management of an incompletely buried bumper is fairly straightforward, this is not the case for a completely buried bumper. Different approaches to remove completely buried bumpers have been described, including endoscopic knife- or papillotome-based techniques. However, these devices are used off-label and the procedures can be laborious. METHODS: The Flamingo device has recently been introduced as the first tool specifically designed to remove a completely buried bumper. RESULTS: We describe the technique and our first experience in five patients with a completely (n = 4) or almost completely (n = 1) buried bumper. Fast and save removal of the buried bumper was obtained in all patients. CONCLUSION: We believe that this device has the potential to become the standard first-line tool for the management of completely buried bumpers.