Stent dislodgement during withdrawal attempt into the guiding-catheter: A step-by-step retrieval technique.

Catheter-induced stent dislodgement may occur when attempting to withdraw the stent into the guide-catheter particularly in cases of guiding-catheter co-axiality issues. We present the management of a catheter-induced stent dislodgement with simultaneous loss of wire position.

Retrieval of a left appendage device from the left ventricle using a large bore steerable catheter.

Left atrium appendage closure is a safe and effective therapy for patients with atrial fibrillation and high thromboembolic and hemorrhagic risks. Prosthesis embolization is a potential major complication with an incidence of 0.07%. We report a case of migration of an Amplatzer Amulet (Abbott) device that was successfully retrieved in an innovative way (4).

Percutaneous retrieval of an embolized Watchman device on a papillary muscle in the left ventricle.

The use of left atrial appendage occlusion (LAAO) devices have gained prominence as an alternative to long-term anticoagulation therapy in patients with atrial fibrillation at risk of stroke and high risk of bleeding. While these devices have shown efficacy in reducing stroke risk, there have been reported cases of embolization of the Watchman device. There are very few cases of successful percutaneous retrieval of embolized Watchman devices from the left ventricle (LV), as many of these cases require open heart surgery for safe removal. We are presenting a case of an 80-year-old male whose Watchman device embolized to the LV and was entrapped on the LV papillary muscle that was then successfully retrieved via percutaneous methods, which shows the percutaneous options remain a viable strategy to retrieve LAAO devices from the LV.

Percutaneous Removal of Migrated Gastrointestinal Stents Using Gastrostomy Access.

This report describes the experience of removing migrated gastrointestinal (GI) stents using a gastrostomy (G) access. Four male patients aged 23-62 years (mean, 42 years) had 6 migrated stents removed using an existing (n = 3) or new (n = 1) G access. Removed stents included 5 covered esophageal stents that migrated into the stomach and 1 distal noncovered duodenal stent that migrated into the proximal duodenum. One patient had 2 stents removed during the same session. All stents were removed successfully without adverse events. Techniques used included the folding technique using a wire in 3 stents and forceps in 2 stents. Eversion technique was used in the duodenal stent. The G or gastrojejunostomy tubes were replaced after stent removal and used for enteral feedings. In conclusion, removing migrated GI stents using an existing or new G access was technically successful and safe.

Midterm single-center results after endovascular aneurysm sealing reveal a high rate of stent graft migration, secondary aneurysm ruptures, and device-related reinterventions.

OBJECTIVE: To report procedural results and mid-term follow-up outcomes of patients treated with endovascular aneurysm sealing (EVAS) for abdominal aortic disease. METHODS: In this retrospective observational study, all patients treated with EVAS between March 2013 and January 2018 for abdominal aortic aneurysm (AAA) or abdominal penetrating aortic ulcer were included. The datasets included demographics, aneurysm morphology, and procedural and clinical surveillance outcomes. Furthermore, patients treated within the original instructions for use (IFU-group) were compared with patients treated outside the IFU (non-IFU-group) with regard to survival, reintervention-free survival, freedom from type I endoleak, and freedom from stent graft migration. RESULTS: Seventy patients were included (67 male; median age, 72.5 years). Sixty-five patients were treated for AAA and 5 patients for abdominal penetrating aortic ulcer. Sixty-nine cases were treated electively (98.6%). Technical success was achieved in 68 cases (97.1%). The median clinical follow-up was 50.5 months (interquartile range, 29.3-62.7 months) with a median computed tomography angiographic follow-up of 38.5 months (interquartile range, 17.1-60.2 months). There were five deaths during the study period (7.1%), four of which were aneurysm related (5.7%). Five secondary AAA ruptures were detected (7.1%). Overall, 25 of 70 patients (35.7%) underwent 35 reinterventions, mostly owing to thrombotic complications (18.6%), stent graft migration (17.1%), and type I endoleak (12.9%). Fifteen patients were treated outside of the IFU (non-IFU-group) (21.4%). The estimated reintervention-free survival for the entire cohort at 30 days and 1, 3, and 5 years was 94.3%, 88.5%, 72%, and 56.9%, respectively. Freedom from stent graft migration at 1, 3, and 5 years was 98.6%, 82.0%, and 47.3%, respectively. The estimated freedom from type I endoleak at 30 days and 1, 3, and 5 years in the IFU-group was 100%, 100%, 94.9% and, 91.1% and significantly different when compared with the non-IFU-group with 79.5%, 72.2%, 72.2%, and 72.2% (P = .012). CONCLUSIONS: Although the technical and initial results were satisfying, the mid-term results were disappointing. The enforcement of a close follow-up protocol for all patients treated with EVAS, especially vigilant for stent graft migration to prevent secondary type I endoleak and rupture, is strongly recommended.

Removal of Intravascular Foreign Bodies With a Simple Low-Cost Method: A Report of 5 Cases.

PURPOSE: Intravascular embolization of hemodialysis and central venous catheters is a rare but potentially serious complication. With the increasing use of catheters in medical practice, we are often faced with this type of complication. Novel, simple, and low-cost techniques are needed for foreign body extraction in order to reduce cardiovascular risks. CASE REPORT: We describe the approach of 5 foreign body embolization cases. Case 1: a 57-year-old woman with end-stage renal failure with a complete fracture and migration of the distal extremity of a hemodialysis catheter. Case 2: a 55-year-old man with an accidental embolization of the distal portion of a hemodialysis catheter. Case 3: a 76-year-old woman with stage IV breast cancer and an accidental embolization of a central venous catheter guidewire. Cases 4 and 5: a 71-year-old woman and a 2-year-old boy with a port-a-cath embolization. All the patients underwent successful minimally invasive removal of the foreign bodies from the thoracic site using 5Fr pigtail catheters. Additional surgery was not required. No further complications, such as damage to the vascular wall, were noted. CONCLUSION: Our experience with the interlacing and traction pigtail show that it is a simple, practical, and low-cost technical alternative and its benefits should be widespread.

Percutaneous Retrieval of Venous Bullet Embolism.

PURPOSE: Bullet fragment embolization is a rare but potentially fatal complication of traumatic gunshot injury. Herein, we present a case of a patient who demonstrated migration of a bullet fragment from the lower chest into the left common iliac vein. Continual identification of foreign bodies on trauma imaging is of the utmost importance. Identifying and treating this rare entity can help vascular interventionalists improve patient outcomes. CASE REPORT: Our patient presented to the emergency room after sustaining 2 gunshot wounds to the right axilla. Initial imaging demonstrated 2 bullet fragments: one in the right axilla and another in the lower chest overlying the heart. A subsequent trauma computed tomography was performed 13 minutes later and demonstrated a bullet fragment in the left common iliac vein, which had embolized from the original location in the lower chest. Interventional radiology was consulted to perform foreign body removal. A transcutaneous approach was utilized, and the bullet embolus was removed successfully without complication. CONCLUSION: Bullet fragment embolization is a rare entity with complications ranging from critical limb ischemia to venous thrombosis or obstruction. This case helps to demonstrate the importance of identifying and accounting for bullet fragments in gunshot trauma imaging.

Progressive Device Failure at Long Term Follow Up of the Nellix EndoVascular Aneurysm Sealing (EVAS) System.

OBJECTIVE: High rates of midterm failure of the Nellix EndoVascular Aneurysm Sealing (EVAS) System resulted in device withdrawal from the UK market. The study aim was to report long term Nellix EVAS outcomes and management of a failing device. METHODS: A retrospective review of EVAS procedures at a tertiary unit was performed. Device failure was defined as a triad of stent migration, stent separation, and secondary sac expansion, or any intervention for type 1 endoleak, device rupture, or explant. RESULTS: 161 (male n = 140, female n = 21) patients with a median follow up of 6.0 (IQR 5.0-6.6) years were included. Freedom from all cause mortality estimate at six years was 41.5%. There were 70 (43.5%) device failures with a freedom from device failure estimate at six years of 32.3%. Failure was the result of sac expansion (n = 41), caudal stent migration (n = 36), stent separation (n = 26), and secondary AAA rupture (n = 15). A substantial number of type 1 endoleaks was present (1a n = 33, 1b n = 11), but the type 2 endoleak rate was low at 3.7%. Some 36 (22.4%) patients required re-intervention. Twenty-one patients underwent explant with no 30 day deaths. Six patients underwent Nellix-in-Nellix application (NINA) with one early death from bowel ischaemia and one patient who died later from non-aneurysm related cause. Two NINA patients have ongoing sac expansion and two have had thrombosis of a Nellix limb or visceral stent. Proximal embolisation was only successful in one of six cases. CONCLUSION: The long term failure rate of Nellix EVAS is high. All patients with a device must be informed and be enrolled in enhanced surveillance. EVAS explant is an acceptable technique with favourable outcomes. Management by open explant, if the patient is fit, should be considered early and offered to those with device failure.

Loss of Prosthetic Aortic Valve during TAVI Procedure: Endovascular Treatment in Emergent Setting.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has proven over the years to be a viable alternative to open surgery. A rare but severe complication is represented by the valve migration. We report a case of TAVI complication due to the loss of the prosthetic valve in the abdominal aorta treated by endovascular approach. METHODS: An 88-year-old patient with severe aortic valve stenosis, symptomatic for dyspnea was proposed for a TAVI because considered at high risk for surgery. During the TAVI procedure, the undeployed device (Edwards SAPIEN 3 - Edwards Lifesciences, Irvine, CA, USA) detached from its delivery system. Several attempts to withdraw the valve fluctuating in the aorta into its supporting system were performed without success. An emergency endovascular treatment was promptly planned to obtain the exclusion from the flow of the embolized valve. Under local anaesthesia, through the percutaneous femoral access already present, a tube aortic endograft (EndurantTM II, Medtronic, Santa Rosa, CA; ETTF2828C70EE) was successfully introduced and deployed in the infrarenal aorta without any related complications. The embolized valve was completely covered by the endgraft and thus fixed to the aortic wall. The first postoperative computer tomography angiography (CTA) confirmed the correct placement of the endograft, the exclusion of the valve from the flow and the patency of the great vessels. No perioperative or postoperative complications were recorded. The patient was discharged on the ninth postoperative day with the indication to a new attempt of TAVI, through transapical access. CONCLUSIONS: In case of intraprocedural loss of an undeplyed valve during TAVI, the valve fixing through endograft deployment in infrarenal aorta is a possible solution.

Nephrostomy Tube Misplaced into the Right Atrium: An Extremely Rare Case and Review of the Literature.

Although percutaneous nephrolithotomy is generally safe, it has various complications. We present an extremely rare case in which the nephrostomy tube pierced renal parenchyma, proceeded through the right renal vein and inferior vena cava, finally reaching the right atrium. Such a tube misplaced to atrium level was firstly reported, which was safely withdrawn using a 2-step process under fluoroscopic monitoring. We also recommend the tube be marked with different color lines to maintain awareness of the tube length that has passed the peel-away sheath. Such information might help to avoid such complication.

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.

An unusual shot-retrograde transthoraco-abdominal venous bullet embolization.

A 72-year-old gentleman was brought to the emergency department, after sustaining an allegedly accidental airgun-shot injury to the right side of his neck. A chest radiograph and plain CT chest revealed the bullet lodged deeply in the soft tissues of the right side of the neck. He was taken up for an emergency neck exploration for foreign body removal. Peroperatively, the bullet was observed to be lodged in the right internal jugular vein. During the attempt to retrieve the bullet, it inadvertently migrated downstream. An intraoperative fluoroscopy revealed the bullet in the thorax near the level of the diaphragm. A subsequent CT chest revealed an intracardiac location of the bullet in the right atrium, at its junction with the inferior vena cava. When it was decided to attempt a percutaneous endovascular retrieval strategy, fluoroscopic imaging of the chest in the cardiac catheterization lab, revealed that the bullet was no longer in the thorax, and had migrated again, and was found to be located in the left side of the pelvis. A subsequent venogram showed the bullet to be lodged in a tributary of the left external iliac vein. It was then snared percutaneously, through the left femoral vein, and delivered through a venotomy. Vascular bullet embolization is a rare phenomenon, especially, as in this case, a retrograde venous embolization with a transthoraco-abdominal course. The treatment of bullet embolization, whether surgical or endovascular, depends on the final destination site, symptomatic status and propensity for complications.

Retrieval of a MitraClip from the left atrium using a two-snare technique: Case report and review of the literature.

MitraClip is used for reduction of mitral insufficiency in patients who are not good surgical candidates, but with expanding indications, the use of MitraClip and the number of complications will increase. Here is presented a case of a single leaflet device attachment that worsened the patient's mitral insufficiency, as well as the technique for stabilizing the valve followed by retrieval of the device. A special focus is placed on removing the using a two-snare technique to avoid the need for a surgical cutdown and repair.

Late discovery of left atrial appendage occluder device embolization: a case report.

BACKGROUND: Left atrial appendage (LAA) closure has been well evaluated in the prevention of stroke in patients with atrial fibrillation. Device embolization remains one of the most common complications. To the best of our knowledge, there have been no reports of late discovery of LAA occluder device embolization at 1.5 years after implantation. CASE PRESENTATION: We describe the case of a 77-year-old man who underwent uneventful LAA closure. Echocardiography performed the next day showed the device in place. The patient was discharged but was then lost to follow-up. 1.5 years later, he was admitted for ischemic stroke. Transesophageal echocardiography showed the absence of the occluder device in the LAA. Computed tomography scan of the abdomen showed the device in the abdominal aorta. Due to the high cardiovascular risk, the device was kept in place and the patient was treated medically. CONCLUSIONS: Per-procedural and late device embolization are not uncommon. Review of the literature however showed no report of late discovery of device embolization at 1.5 years. Follow-up echocardiography is mandatory for the detection of endothelialization or embolization.

Early Real-World Experience with EndoAnchors by Indication.

BACKGROUND: The Heli-FX EndoAnchor (EA) system is a transmural aortic fixation device with Federal Drug Administration (FDA) approval for treatment of endoleaks, endograft migration, or high-risk seal zones. Published data are primarily from industry-sponsored registries highlighting safety and efficacy. Our objective is to evaluate real-world outcomes of EA usage after FDA approval across a variety of stent grafts and indications at a single institution. METHODS: We retrospectively reviewed our prospectively maintained aneurysm database for patients undergoing endovascular aortic repair (EVAR) with Heli-FX EAs. Technical success was defined as successful EA deployment, while procedural success was defined as absence of endoleak on completion aortogram. Cohorts were divided by indication and outcomes assessed via review of clinical and radiographic data. RESULTS: From 2016 to 2018, 37 patients underwent EA fixation. We divided the cohort by indication: Group A (prior EVAR with endoleak), B (intraoperative type 1A endoleak), C (high-risk seal zone), and D (thoracic EVAR). In Group A (n = 11), all endoleaks were type 1A and a mean of 10 EAs were deployed with 100% technical and 45.4% procedural success. Two perioperative reinterventions were performed (translumbar coil embolization and proximal graft extension with bilateral renal artery stents). At a mean 10.6 months of follow-up, 45.4% of patients had persistent endoleaks, with 100% aortic-related survival. In Group B (n = 10), a mean of 8.7 EAs were used with 100% technical and procedural success. One immediate adverse event occurred (right iliac dissection from wire manipulation, treated with a covered stent). At 13.6-month mean follow-up, there was significant sac regression (mean 9.75 mm) with no type 1A endoleaks. In Group C (n = 10), a mean of 9.5 EAs were deployed with 100% technical and procedural success. At 11.2-month mean follow-up, there were no residual endoleaks and significant sac regression (mean 3.4 mm). Overall survival was 100%. In Group D (n = 6), a mean of 8.3 EAs were used with 83.3% technical and 66.6% procedural success. One immediate adverse event occurred, in which an EA embolized to the left renal artery. At 9.4-month mean follow-up, overall survival was 83.3% with a mean 2.2-mm increase in sac diameter. CONCLUSIONS: Early experience suggests that EAs effectively treat intraoperative type 1A endoleaks and high-risk seal zones, with significant sac regression and no proximal endoleaks on follow-up. In patients treated for prior EVAR with postoperative type 1A endoleaks, fewer than half resolved after EA attempted repair. Further experience and longer term follow-up will be necessary to determine which patients most benefit from postoperative EA fixation.

Retroperitoneal Hematoma Caused by Suprarenal Stent Perforation Two Years after Ovation Abdominal Stent-Graft Implantation.

Retroperitoneal hematoma due to late perforation of aortic wall endograft deployment is a rare but, potentially, fatal event. We report a case of symptomatic retroperitoneal hematoma due to aortic perforation by free flow barbs of Ovation Prime stent graft. The patient was successfully treated by celiac trunk embolization and aortic cuff placement. The patient was discharged with no further treatment. At 3-month follow-up, no complications were detected.

Effects of early detection of peritoneal catheter migration on clinical outcomes: 15-years experiences from a single centre.

AIM: Catheter migration is an important cause of catheter malfunction in peritoneal dialysis (PD). The purpose of this study was to investigate the effect of early detection of catheter migration on clinical outcomes. METHODS: A retrospective review of 135 consecutive patients initiating PD immediately following catheter insertion from 2002 to 2017 was undertaken. In order to detect catheter migration without malfunction early, serial abdominal-pelvic radiographic examinations were performed according to a predefined protocol. Conservative management with rigorous catharsis was undertaken to correct catheter migration. A Kaplan-Meier method was used to calculate survival rate. RESULTS: Mean follow-up period was 42.8 ± 34.9 months. Catheter migration occurred in 62.4%. Among them, 85.9% occurred within the first 2 weeks after catheter insertion. There were no significant associations between catheter migration and variables such as gender, obesity, DM and type of catheter. Success rate of conservative management with rigorous catharsis was 91.1%. Catheter survival at 1 and 5 years were 91.5% and 64.6% in the migration group and 81.2% and 69.9% in the non-migration group, respectively (Log-rank test, P = 0.915). Patient survival at 1 and 5 years were 96.8% and 85.8% in the migration group and 91.9% and 82.3% in the non-migration group, respectively (P = 0.792). CONCLUSION: Early detection of PD catheter migration allowed the migrated tip to be easily corrected with conservative management. Once the migrated catheter tip was restored, catheter migration itself did not affect catheter survival. These findings suggest that early detection and correction of catheter migration is important for improving clinical outcomes.

A foreign body in the blood vessel: A diagnostic and therapeutic dilemma.

Foreign body(FB) in soft tissue is a common injury in trauma, but it is rare for FB to enter the blood vessel. Typical causes of intravascular FB include iatrogenic and non-iatrogenic factors.A 65-year-old Chinese worker's left hand was hit by two colliding metal blocks while operating a machine tool. Then, he referred to our hospital's emergency department of orthopedics. The X-rays showed that metal FB could be seen in trapezium bone regions of the left hand. During the operation, the FB was found in the cephalic vein of his left hand, so the FB was removed by surgery. After six weeks of follow-up, he has returned to normal working conditions.The purpose of this article is to describe the diagnosis and treatment of a rare condition in the emergency department. In our emergency work, it is easy to miss the diagnosis of intravascular FB caused by trauma. To our knowledge, this is the third reported intravascular FB caused by trauma and the first reported intravascular FB was located in the vein of the hand. Detailed medical history and auxiliary examinations are the key to the diagnosis of FB in the blood vessels.

Spinal Cord Stimulation with Surgical Lead Improves Pain and Gait in Parkinson's Disease after a Dislocation of Percutaneous Lead: A Case Report.

Spinal cord stimulation (SCS) is receiving increasing interests for treating pain and gait disorders in patients with Parkinson's disease (PD). In an SCS study, it is hard to apply a double-blind approach, especially at low frequencies, as the stimulation normally induces paresthesia which can be perceived by the patient. We herein demonstrate a case treated with SCS in which a blinding design was accomplished by an accidental dislocation of a stimulation lead. A 73-year-old man with PD was admitted to our hospital because of relapsed low back pain. This was due to the dislocation of a previously implanted SCS lead, which caused a decrease in its effectiveness in alleviating pain (from 81 to 43% measured by King's Parkinson's Disease Pain Scale) and improving gait (from 35 to 28% measured by the timed up and go test). A second SCS surgery using a paddle lead solved this problem, with improvements in pain and gait rebounded to 81 and 45%. In this case, the paresthesia induced by SCS (using either a paddle lead or percutaneous leads) was below the threshold of perception when the patient was sitting and standing, and a dislocation of one previously implanted percutaneous lead did not cause evident changes in his sensation of paresthesia. At last follow-up, the patient's quality of life had improved by 40% as measured by the 8-item Parkinson's Disease questionnaire (PDQ-8). This study could serve partly as a proof that low-frequency SCS is effective in improving pain as well as gait problems in PD patients, which was unlikely a result of a placebo effect.

The POP (Pull on Pipe) Maneuver: A Technical Note for Rescuing a Prolapsed Pipeline Device.

BACKGROUND: Flow diverters have revolutionized the treatment of large aneurysms. However, prolapse of the device into the aneurysm is a known complication that may have fatal consequences. CASE: We present a case of a 21-year-old male with a giant aneurysm located in the cavernous segment of the right internal carotid artery. After Pipeline Embolization Device (PED) deployment, while retrieving the PED wire, the proximal end of the stent shortened, resulting in prolapse of the device into the aneurysm. We utilized the Pull on Pipe (POP) maneuver, characterized by the deployment of a second PED inside the lumen of the prolapsed device and gentle traction to restore the initial flow diverter into its proper position. The maneuver also allows for the immediate deployment of the second PED to improve proximal purchase and overall construct stability. CONCLUSION: The POP maneuver is a novel strategy for salvaging herniated flow diverters and establishing a more stable PED construct.