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.

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.

Robotic Magnetic Sphincter Augmentation Device Removal.

Although most patients with reflux can be managed with medical therapy, some require surgical intervention to manage their disease. Newer technologies, such as magnetic sphincter augmentation (MSA), have been promoted as the replacement of fundoplication. However, as time has elapsed, our institution noticed the need for the removal of MSA devices. Although a few reports have described MSA device removals, we provide a deeper explanation of how to perform a robotic device removal. Our article describes the technical steps and includes a video to demonstrate how to complete the surgery robotically.

Retrieval of broken K-wires by overdrilling using hypodermic needle.

Breakage of K-wires within the metacarpals and phalanges due to metal fatigue and overly aggressive joint movements are encountered occasionally. We established a simple and feasible technique for K-wire retrieval by overdrilling using a hypodermic needle.Level of evidence: IV.

[Unilateral mandibular fracture in horse - Treatment with fixateur externe, a complication during implant removal and procedure for removal of implant fragments]. / Unilaterale Mandibulafraktur bei einem Pferd.

The first part of this case report describes the surgical treatment of a unilateral mandibular fracture in the standing horse by using a fixateur type I. By the time of implant removal, the fracture had completely healed. However, during implant removal, an implant failure of 2 of the 4 implants occurred with fragments remaining in the bone. The second part of the report focuses on the development of a special surgical instrument that was designed for removal of the implant fragments. Furthermore, the surgical method allowing the entire extirpation of the fragments within a second surgery is described.According to the authors' knowledge, this is the first case report showing the use of the presented surgical technique for the treatment of a mandibular fracture in the standing horse. Additionally, this report also provides an approach for removing implant fragments from the depth of the bone which may occur in case of implant breakage as a potential complication of the described surgery.

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.

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.

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.

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.

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.

Flexible cystoscopy for ureteral stent removal without antimicrobial prophylaxis. A prospective observational study.

OBJECTIVE: Flexible cystoscopy for ureteral stent removal after ureteroscopy is widely performed. In this scenario, the real need for antimicrobial prophylaxis is still uncertain. Aim of this study is to determine the urinary tract infections rate after 4 weeks from outpatient flexible cystoscopies for ureteral stent removal without antimicrobial prophylaxis. PATIENTS AND METHODS: A prospective observational study was performed between November 2017 and August 2018 in a single, high-volume Institution.Risk factors for UTIs were recorded. Immediately before cystoscopy, each patient submitted a voided urine specimen. Antibiotics were not given before or after cystoscopy. About 7 and 28 days after cystoscopy all the patients underwent abdomen US, urine analysis and culture, and clinical evaluation to assess possible symptoms of UTI. RESULTS: A total of 192 patients were enrolled in the study, 76 patients (39.2%) were female. Median age was 55 years [IQR 47- 68]. Median BMI was 24.2 [22.9-26.7]. Eighteen patients (9.4%) had asymptomatic bacteriuria before cystoscopy and 39 (20.3%) had positive culture at 7 days. About 21 patients (10.9%) were diagnosed with febrile UTI in the 28 days FU period. The 28.6 % of the Febrile patients had asymptomatic bacteriuria before the stent removal (p < 0.001), this group was slightly older (p = 0.085) and with higher BMI (p = 0.036).Forty-eight patients had positive urine culture at 7 days, of whom 27 (14.1%) were asymptomatic and were classified as asymptomatic bacteriuria. Multivariate analysis shows that only high BMI and bacteriuria before the procedure were significantly associated with developing a febrile UTI, none of the other risk factors was significant. CONCLUSION: Our data show a high rate of UTI after flexible cystoscopies for ureteral stent removal without antimicrobial prophylaxis especially in patients with asymptomatic bacteriuria, in those with high BMI and in the elderly; in these subgroups, antimicrobial prophylaxis should be recommended.