Late systemic desaturation after transcatheter device closure of atrial septal defect.

Transcatheter device closure has emerged as the preferred treatment for ostium secundum atrial septal defects with adequate margins, occasionally requiring surgical intervention to manage complications. We report a case of a young female patient who presented with systemic desaturation and exertional dyspnoea 5 years after device closure. Evaluation demonstrated anterior malposition of the septal occluder, with the right atrial rim of the device diverting the blood from the inferior vena cava to the left atrium. She underwent surgical extraction of the device and pericardial patch closure of the atrial septal defect.

Transcatheter retrieval of atrial septal defect and patent ductus arteriosus occluder: a guidance for device retrieval based on comprehensive bench tests.

OBJECTIVES: The aim of this study is to establish a guidance for device retrieval based on comprehensive bench tests. BACKGROUND: Device embolisation remains a major complication in transcatheter closure of atrial septal defect and patent ductus arteriosus. Although percutaneous retrieval is feasible in the majority of cases, surgical retrieval may be required in complicated circumstances. However, the methods of transcatheter device retrieval have not been completely established. METHODS: Bench tests of device retrieval were performed to verify the appropriate retrieval method according to device type/size. The devices used for testing were Amplatzer Septal Occluder (Abbott, Chicago, IL, United States of America), Figulla Flex II (Occlutech GmbH, Jena, Germany), Amplatzer Duct Occluder-I (Abbott), Amplatzer Duct Occluder-II (Abbott), and Amplatzer Vascular Plug-II (Abbott). The retrieval equipment constituted diagnostic catheters (multipurpose catheter and right Judkins catheter, 4-Fr or 5-Fr, Gadelius Medical, Tokyo, Japan), delivery sheath and cables for each device, Amplatz goose neck snares (Medtronic, Minneapolis, MN, United States of America), OSYPKA CATCHER (Osypka ag, Rheinfelden-Herten, Germany), and OSYPKA LASSOS (Osypka). We investigated the retrieval equipment and sheath sizes required for a successful retrieval procedure for variously sized devices. RESULTS: For patent ductus arteriosus devices, the type of snare and the snaring position are considered important. For atrial septal defect devices, simple snare capture or a double-snare technique with a sufficiently large sheath is effective. Special care should be taken when using the OSYPKA CATCHER for device retrieval. CONCLUSIONS: The results of this study may assist in the selection of both capture devices and a retrieval sheath or a catheter for complete retrieval.

Strategies for Recovering an Embolized Percutaneous Device.

PURPOSE OF REVIEW: Device embolization is a rare but potentially life-threatening complication of transcatheter structural heart interventions and may require prompt intervention. The present work aims to provide an overview of strategies for device retrievals in order to better guide the evaluation and management of device embolization. RECENT FINDINGS: Although the evolution of transcatheter device therapies has had a tremendous impact on the management in structural heart disease, availability of various retrieval devices, knowledge in how to use them, and multidisciplinary collaboration are key for successful device retrieval. Understanding the reasons for embolization, strategies to avoid embolization, and the techniques for retrieval of devices used in structural heart disease should be appreciated by the treating physician.

Retrieval of large Occlutech Figula Flex septal defect occluders using a commercially available bioptome: proof of concept.

OBJECTIVES: This study aimed to develop a method for retrieval of the new meshed nitinol atrial septal defect occluders - Ceraflex and Occlutech. BACKGROUND: The newly developed atrial septal defect occluders have potential benefits considering implantation, but concerns regarding their removal in case of embolisation have been raised. METHODS: Over 21 years, 1449 patients underwent interventional atrial septal defect occlusion in our institution. We reviewed the cases of embolisation of the device, developed a strategy for device removal, and tested it on the benchside and in animal tests. RESULTS: In 11 patients (0.8%), the intended atrial septal defect occlusion was complicated by an embolisation of the device. In contrast to the Amplatzer septal occluders, retrieval of Occlutech devices larger than 16 mm with snare techniques was impossible. In benchside tests, this was confirmed and a new method for removal of large meshed devices was developed. This involved the commercially available Maslanka® biopsy forceps. The feasibility of this technique in vivo was tested in a pig model. During animal tests, using the Maslanka biopsy forceps it was possible to interventionally retrieve embolised Ceraflex and Occlutech devices of different sizes - 10, 16, 30, and 40 mm - into a 12-F sheath. CONCLUSION: It was impossible to retrieve Occlutech and Ceraflex devices larger than 16 mm into a large sheath in vivo and during benchside tests. However, this was feasible on the bench and in vivo using the Maslanka biopsy forceps even with the largest available devices.

Pseudoaneurysm of aorta after transcatheter closure of patent ductus arteriosus.

Aortic pseudoaneurysm is a rare but life-threatening complication after transcatheter closure of patent ductus arteriosus (PDA) with only a few reported cases in literature. We report a case of an 18-month-old child who was diagnosed to have pseudoaneurysm of the aorta after 6 months of transcatheter closure of PDA. It was diagnosed on routine follow-up on echocardiography evaluation. Computed tomography chest is the imaging modality of choice for evaluation of these patients which showed large saccular aneurysm arising from distal aortic arch beyond origin of left subclavian artery. Any aneurysm more than 30 mm should be treated irrespective of symptoms. Treatment modalities are surgical resection of the aneurysm (as in our patient) or thoracic endovascular aortic repair. In our case, surgical resection of aneurysm was performed. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01619-z.

Dealing With a Nightmare: A Case Report of Successful Percutaneous Treatment of an Embolized Occluder Device Complicating a Minimal-Fluoroscopy Patent Ductus Arteriosus Closure.

Patent ductus arteriosus (PDA) is one of the most prevalent acyanotic congenital heart diseases. Percutaneous closure of PDA has been the preferred treatment recommended by the guidelines due to relatively low complications and rapid patient recovery. However, device emboli remain the most frequent and disastrous complication, necessitating percutaneous or surgical treatment. We present a case of a large PDA closure in pulmonary arterial hypertension paediatric patients complicated with device emboli that was successfully retrieved using the snaring technique. Transcatheter retrieval, although technically challenging, is a feasible treatment and offers the advantage of avoiding the need for surgical intervention.

Prevention of Migrating Atrial Septal Occluder in Large Hole Atrial Septal Defect Intervention by Snare.

Migrating Amplatzer Septal Occluder (ASO) is a rare complication due to insufficient margins, especially large-hole Atrial Septal Defect (ASD). After deploying, ASO occasionally exposes the low margins, resulting in dislocated devices and embolization. The majority of embolizations happen right away after release. The embolized device must be removed using extended fluoroscopy and occasionally by open heart surgery. The device is released by unscrewing the cable while the snare holds the screw end. On Transesophageal Echocardiography (TEE), the device position is once again validated. If the device is stable, the snare is then removed.

Post myocardial infarction ventricular septal rupture-protracted hemolysis due to missed additional ventricular septal defect.

Hemolysis is a known and usually self-limiting complication of transcatheter device closure of post-myocardial infarction ventricular septal rupture (VSR). Multiple defects, serpiginous pathways, friable margins, left ventricular aneurysms, and improper size of the device have been described as causes for persistent residual shunt across the device. We report a case of protracted hemolysis after device closure of VSR requiring surgical intervention. During device retrieval and patch closure, a muscular band was observed dividing the VSR into two, allowing residual shunt across the second defect. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-022-01470-8.

Adjustment of Malpositioned Woven EndoBridge Device Using Gooseneck Snare: Complication Management Technique.

The Woven EndoBridge (WEB) is an intrasaccular flow-disrupting device for the treatment of wide-necked saccular cerebral aneurysms. As with any neuroendovascular device, complications in the form of malpositioning and migration must be managed quickly and safely. Few studies have reported complication management techniques in instances of dislocated or migrated WEB devices. We retrospectively describe a case of a malpositioned WEB device that was successfully adjusted with the use of a gooseneck snare. Multiple other intra-procedural bailout strategies for management of WEB malposition and migration were considered, and are herein discussed. Operators should be aware of the causes of WEB malposition and a variety of bailout strategies.

Balloon-assisted Tracking of Guide Extension Catheter: A Novel Technique to Retrieve a Carotid Embolic Protection Device.

Embolic protection devices are used to minimize the risk of stroke by preventing the migration of emboli during carotid artery stenting (CAS). After the successful conclusion of the CAS procedure, these devices are meant to be retrieved. Sometimes retrieval of the filter can be difficult. This difficulty in retrieval can be due to multiple factors such as incomplete stent expansion, stent fracture, vasospasm, and vessel tortuosity causing pseudostenoses. In this case report, an under-expanded proximal carotid stent strut contributed to the filter not being retrievable in spite of maneuvers to retrieve the filter. An innovative approach was used; a coronary guide extension catheter was used to enhance support and balloon-assisted tracking of the extension catheter then permitted advancement of the retrieval device and ultimate retrieval of the filter. This technique to retrieve a carotid filter has not been previously described in the literature.

Materials and techniques for percutaneous retrieval of intravascular foreign bodies.

The presence of an intravascular foreign body represents a well-known risk of serious complications. While in the past surgical removal of intravascular foreign body was the most common intervention, nowadays a percutaneous approach in the retrieval of an intravascular foreign body is widely accepted as the first-line technique. In the literature, many case reports describe different techniques and materials. This article summarizes and illustrates the main materials and techniques currently applied for percutaneous retrieval of intravascular foreign body, providing a simplified tool with different interventional possibilities, adaptable to different clinical situations.

Lessons learnt from a series of hemodynamic and interventional complications during pulmonary valvotomy and device closure of ventricular septal defect.

In an adolescent girl with coexistent valvar pulmonary stenosis (PS) and muscular ventricular septal defect (VSD) causing right to left shunt and severe cyanosis, a series of complications were encountered during transcatheter intervention. After balloon pulmonary valvotomy (BPV) and device closure of the VSD, dynamic infundibular hypercontractility elevated the right ventricular (RV) systolic pressures leading to embolization of the device into the left ventricle. During retrieval of the device from the left ventricular outflow tract (LVOT), there was injury to the atrioventricular nodal tissue resulting in transient complete heart block. Even though the device was successfully retrieved out from the right femoral arterial access, there was a retroperitoneal hematoma causing severe anemia. A combination of dynamic infundibular obstruction, intravascular volume depletion caused by hemorrhage, low oxygen carrying capacity due to anemia, and inotropes resulted in a life-threatening hypercyanotic spell. Once this combination of suicidal hypercontractile right ventricle, anemia, and dehydration was recognized; management of the pathophysiology resulted in recovery of the patient. On a subsequent day, device closure of the VSD was complicated by unstable device position, but was finally achieved by an innovative device stabilization technique. We propose to explain the basis of hemodynamic and procedural complications, their recognition, and management. During preparatory stage before interventions in patients with multiple defects, which are linked by strong hemodynamic interdependence, meticulous planning should be done and multiple untoward events should be foreseen. While a few complications were completely unanticipated, some others could have been predicted.

A novel snare assistance safeguards against early embolization of devices and facilitates quick retrieval of malpositioned devices in atrial septal defects with deficient margins.

BACKGROUND: Embolization might complicate device closure of large atrial septal defects (ASDs) with deficient margins. When margins are deficient, a precariously placed device can appear to be held in good position by the rigid delivery cable. Once the cable is unscrewed, the device adopts the natural lie of the interatrial septum. This can occasionally expose the inadequately captured margins and lead to device embolization. Most embolizations occur immediately after release. Retrieval of the embolized device required prolonged fluoroscopy and sometimes open heart surgery. OBJECTIVE: To evolve a new strategy of retrieval of a malpositioned device after unscrewing the cable before impending embolization. MATERIALS AND METHODS: After deploying the device in place, a snare is passed through the delivery sheath around the cable to grip the screw on the right atrial disc of the device. With the snare holding the screw end, the device is released by unscrewing the cable. The device position is reconfirmed on echocardiography. The snare is subsequently removed if the device was stable. In case of device migration, the same snare is used to retrieve the device before it embolizes completely. RESULTS: Snare assistance was used in 24 patients considered as high-risk for device embolization. Its usefulness was demonstrated in two patients with deficient posterior margin and small inferior margin where the device got malpositioned immediately after release. As the snare was still holding on to the screw end, the device could be retrieved into the sheath easily. CONCLUSION: This novel snare assisted device release strategy safeguards against device embolization in large ASDs with deficient rims and allows simplified retrieval.

Rescrewing the embolized duct occluder using the delivery cable.

We report the successful re-screwing of the embolized duct occluder (DO) in three children for retrieval and to attempt redeployment. The DO was embolized into descending aorta immediately after the deployment in one child and within 24 h after the procedure in two further patients. The DO was re-screwed back by the DO delivery cable, using "sheath in sheath" in all three cases; however, successful retrieval could be done only in two. Repositioning in the patent ductus arteriosus (PDA) was done using the same device in those two children and surgical removal was needed in third child with perimembranous ventricular septal defect.