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DECLARATION OF CONFLICT OF INTEREST

A. Pichard, MD Director Cath Labs,

Washington Hospital Center Professor of Medicine (Cardiology),

Georgetown University. Washington, DC

Device loss and foreign body retrieval.

Best Strategy

Preventing Device Loss in the CV system is key to a successful practice of CV Intervention.

1) Stents should reach the lesion without any pushing!

2) Septal defects should have “good parameters” for effective closure with a device.

3) Common sense should prevail when closing heart/vascular defects with devices.

Needles in the Heart

IV Drug Abuse User with

Tamponade

Intracardiac Needles Literature Review. Talwar 2003

Retrieval of IVC Filter from RA

IVC filter Strut Fracture + Migration

Patient Year Presentation Location Intervention Reference

47M 2010 Myopericarditis RV free wall

CT Surgery Nathani JIC 2010

31F 2009 Tamponade RV free wall

CTS Kalavakunta JIC 11/09

56F 2009 Tamponade RV free wall

CTS Rogers Circ 2009

40F 2008 Chest pain RV free wall

CTS (offpump)

Kumar JCS 6/08

53M 2008 Tamponade RV CTS Chandra SMJ 11/08

66F 2006 Tamponade RV free wall

CTS Saeed CVIR 4/06

Knotted Swan Ganz

Retrieval of Wire in Aorta

Implantable Port Catheters

• Embolization in 0.2-4.2%

• “Pinch-off Syndrome”:

chronic compression between

clavicle and first rib, with

rupture of the catheter.

• Mostly asymptomatic. Can result in arrhythmia, infection, thromboembolic events, myocardial perforation.

• They should be snared and retrieved.

Capture of lost device in PVL case. Courtesy Dr Daniel Aguirre

Large ASD Device

Device lost in PA

Device Retrieved

PDA Closure Embolization

Device Retrieval

Embolized Stents

Retrieval Techniques:

• If wire still across: advance small balloon past the stent, inflate and retrieve unexpanded stent.

• Twist 2(3) wires around stent and retrieve.

• Snare the stent

• Crush against the wall with new stent.

Outcome of Embolized or Misplaced Stents. Kozman et al. AJC 2001;88:630-4

23 cases in 4 years, compared to matched group of 23 patients.

Predictors of embolization:

- angulation >45º

- passage through previous stent

Outcome:

- 16/23 in coronary circulation: 8 retrieved. 7 embolized: all had MACE in 36 months.

- 1/8 embolized to peripheral circulation had possible vascular insufficiency.

Outcome of Embolized or Misplaced Stents. Kozman et al. AJC 2001;88:630-4

Embolized Stents. German Registry. Bolte et al. Circ 1999;100:I-233

432 cases of stent embolization.

28% event rate on follow up.

1/210 stents lost in the peripheral circulation had events.

Device Retrieval Tools

Material

Device Retrieval

Soutenir Micro Snare. Miyashita et al. J Inv Card 2011;23:E161-3

Goes into a 0.020 lumen microcatheter. Used to retrieve thrombus in the cerebral circulation. Used to pull wire from retrograde access in CTO. Size of the Soutenir basket: 3,5 and 7 mm.

Asahi

Soutenir Retrieval Catheter

Angiovac

for Large Intracardiac Masses

21 F sheath for aspiration cannula. 18F sheath in other vein to re-infuse blood

Complete Occlusion of IVC and

Iliac Veins. Prior IVC Filter

Filter 1 Filter 2

IVC Thrombus

This patient is a 60-year-old obese male who had recent spine surgery. A large

saddle PE was confirmed with CT scan.

PE removed from filter

Pulmonary Embolism

55 yo with Factor Leiden Deficiency. 3 sternotomies (2

Pulm. Embolectomies, 1 for large RA thrombus)

TEE of Mass in RA

Angiovac Aspirate

TEE of RA at end of Procedure

Intraoperative TTE showing large right atrial mass

(fungal TV endocarditis) and CT evidence of PE

AngioVac advanced through Rt Internal

Yugular. Return line through Rt Femoral Vein

Intraoperative TTE Post-AngioVac

showing no evidence of residual mass

Conclusions

• Device loss needs to be prevented!.

• Most devices embolized can be retrieved.

• Small devices (wire tips, small stents) produce unlikely to be harmful if left in the vascular system.

• New systems for retrieval of large masses are now available.

• Team approach for creative device retrieval required.

The end