Radiology_Aug04 Abstract During the past 4 years, 15 patients have undergone intravascular removal of foreign bodies — 9 central venous line fragments, 3 guidewires, 2 pace- maker leads and 1 misplaced emboli- sation coil. Ten foreign bodies (including 2 guidewires, 2 pacemaker leads and 6 central venous catheter fragments) were recovered from the big veins and right heart, 3 (central venous line fragments) from the pul- monary arterial system and 2 (an embolisation coil and a guidewire) from the arterial system. The percuta- neous removal of foreign bodies is efficient with few complications. Surgery should only be considered for patients in whom removal attempts with endovascular interventional techniques have failed. Introduction In the past, intravascular foreign bodies had to be removed surgically, but the percutaneous retrieval of intravascular foreign bodies has become a frequently used technique since it was first described 40 years ago,1 largely replacing open surgical removal. Commonly encountered intravascular foreign bodies include fragments of central venous catheters (most common), knotted pulmonary artery (Swan Ganz) catheters, lost guidewires or guidewire fragments, misplaced embolisation coils and metallic stents. An estimated 0.1% of venous catheters suffer breakage2 but no data are available for other types of intravascular objects. The rate of serious complications caused by foreign body embolism is as high as 71%, with the mortality rate ranging from 24% to 60%.3,4 In the case of intravenous foreign objects, such as a fragment of a central venous catheter, it is important that the pro- cedure be done as soon as possible. Attempts at removal from the venous system prior to migration into the pulmonary circulation has the lowest morbidity and the highest chance of success (Figs 1a and 1b).5 Method A vascular sheath big enough to allow removal of the foreign body in question must be used. Sometimes it is helpful to cut the sheath tip oblique- ly in order to increase the cross-sec- tional diameter of the opening allow- ing a bigger object to be pulled into CASE REPORTS 31 SA JOURNAL OF RADIOLOGY • August 2004 Endovascular foreign objects retrieved by inter- ventional radiolo- gists at Universitas Hospital H F Potgieter MB ChB E Loggenberg MMedRad (D) Department of Diagnostic Radiology University of the Free State and Universitas Hospital Bloemfontein Fig. 1a. Infusoport without catheter. Fig. 1b. Lost central venous line in IVC and right atrium. the sheath (Fig. 2).5 The most useful device in foreign body retrieval is the nitinol goose neck snare.6 Advantages of this device include the predefined loop diameter, the shape-memory properties of the nitinol, and the abil- ity to develop a variable amount of force in the loop. Other devices that may be useful in this procedure include dormia-type baskets, self- made wire-snares (looped guidewire in a diagnostic catheter), biopsy for- ceps and purpose-designed fragment graspers. As a standard procedure the Microvena goose neck snare (Fig. 3) was used with different guiding catheters in a Siemens Multistar inter- ventional unit. The goose neck snare was manipulated over the free floating end of the lost object, which was snared and then removed through the sheath. Results At Universitas Hospital radiology unit 15 patients have undergone intra- vascular removal of foreign bodies during the past 4 years. This included 9 central venous line fragments, 3 guidewires (Figs 4a and 4b), 2 pace- maker leads and 1 misplaced emboli- sation coil. Ten foreign bodies (including 2 guidewires, 2 pacemaker leads and 6 central venous catheter fragments) were recovered from the big veins and right heart, 3 (central venous line frag- ments) from the pulmonary arterial system and 2 (an embolisation coil and a guidewire) from the arterial sys- tem. All but 1 of the foreign bodies were removed successfully during the first attempt. The recovery of a 3 cm central line fragment from the pul- monary artery of 1 patient failed ini- tially, but the second attempt 1 week later was successful. No serious adverse events were recorded during the procedures or immediately there- after. Discussion Results continue to prove that per- cutaneous removal of foreign bodies is highly efficient (success rates more than 90% in most studies) with few complications. The added attraction of the procedure is that many serious- ly ill patients with iatrogenic foreign bodies do not have to be exposed to the increased surgical/anaesthetic risk. Owing to the associated complication risk, surgery should only be consid- ered when removal attempts with endovascular interventional tech- niques have failed. References 1. Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Non-surgical retrieval of a broken segment of steel spring guide from the right CASE REPORTS 32 SA JOURNAL OF RADIOLOGY • August 2004 Fig. 2. Snared line fragment being recovered through sheath. Fig. 3. Microvena goose neck snare. Fig. 4a. Lost guidewire in IVC. Fig. 4b. Guidewire in snare. atrium and inferior vena cava. Circulation 1964; 30: 106-108. 2. Burri C, Henkemeyer H, Passler HH. Catheter embolism. Schweiz Med Wochenschr 1971; 101: 1575-1577. 3. Fisher RG, Ferreyro R. Evaluation of current techniques for nonsurgical removal of intravas- cular iatrogenic foreign bodies. Am J Roentgenol 1978; 130: 541-548. 4. Richardson JD, Grover FL, Trinkle JK. Intravenous catheter emboli. Experience with twenty cases and collective review. Am J Surg 1974; 128: 722-727. 5. Allison DJ, Jackson JE. Vascular interventional techniques in the thorax. In: Grainger RG, Allison DJ, eds. Grainger and Allison's Diagnostic Radiology: A Textbook of Medical Imaging. 4th ed. London: Churchill Livingstone, 1997: 607 - 621. 6. Cekirge S, Weiss JP, Foster RG, Neiman HL, McLean GK. Percutaneous retrieval of foreign bodies: experience with the nitinol goose neck snare. J Vasc Interv Radiol 1993; 4: 805-810. CASE REPORTS 33 SA JOURNAL OF RADIOLOGY • August 2004