Central venous catheterization has become an important technique for the diagnosis and management of patients requiring intensive medical care.1–3 The use of devices to perform this procedure has been accompanied by a corresponding increase in complications.3,4 The embolization of foreign bodies to the venous system is not a rare event. This is a report on the transluminal effective and relatively easy removal of a sheath fragment from the right ventricle using standard angioplasty tools.

       Case Report. A 51-year-old male was referred to our center because a fractured 9 Fr sheath, 7 cm long, inserted in the right vena jugularis interna migrated to the right ventricle. Both ends of the broken sheath impinged against the tricuspid chordal attachments and the right ventricular apex, respectively (Figure 1). A 10 Fr sheath was placed in the right femoral vein. A 6 Fr diagnostic pigtail catheter (Impulse,

Figure 1

Fluoroscopic PA view of the fragmented sheath in the right ventricle.

Boston Scientific Corp., Natick, Massachusetts) was advanced close to the fragment and gently rotated in an attempt to pull the foreign body toward the inferior vena cava. However, the sheath embolized to a secondary inferior left pulmonary branch (Figure 2). Thus the pigtail catheter was exchanged for a 8 Fr JR4 guiding catheter (Wiseguide, Boston Scientific), which was advanced and positioned near the proximal end of the broken sheath. We attempted to snare the proximal free end of the fragment with a 4 mm nitinol snare (Amplatz GooseNeck^®, ev3, Inc., Plymouth, Minnesota), but the loop was not big enough to catch the sheath. Thus a 0.014 inch coronary guidewire (Hi-Torque Balance MiddleWeight™, Guidant Corp., Indianapolis, Indiana) was introduced in the “missed” sheath through its proximal tip up to its distal edge, with the intention cross the distal end of the sheath and snare it with the 4 mm GooseNeck loop. This could not be done because the distal tip was crimped, so the snare was retrieved and a 4 x 12 mm

Figure 2

Embolization of the fragmented sheath in a pulmonary artery branch from the right ventricle.

balloon dilation catheter (Maverick™, Boston Scientific) was advanced over the guidewire and positioned in the center of the fragmented sheath. The balloon was inflated to its nominal size, and the entire system (fragmented catheter, inflated balloon, guiding catheter and guidewire) was pulled back as a unit

Figure 3

Retrieval of the broken catheter through the left branch and the main pulmonary artery. The arrow shows the inflated coronary balloon inside the sheath.

through the right-sided chambers and inferior vena cava without complications (Figures 3 and 4). Once in the right iliac vein, we were unable to get the entire system into the sheath. For that reason, a 12 Fr sheath was placed in the left femoral vein and a basket (Dotter Intravascular Retriever, Cook, Inc., Bloomington, Indiana) was advanced to retrieve the broken sheath, which was successfully removed. The

Figure 4

Fragmented sheath located in the right atrium and inferior vena cava after retrieval from the inferior pulmonary artery branch.

guiding catheter, deflated balloon and guidewire were pulled back and removed from the right side.

Discussion
       A significant variety of techniques for retrieving foreign bodies have been described in the literature. Most of them involve the use of snares, biopsy forceps, baskets, pigtail catheters or even surgical interventions.5–8 In this report, we describe the effective removal of a sheath fragment utilizing standard coronary angioplasty tools. We initially attempted to remove the sheath from the pulmonary branch with a snare, but the snare’s diameter was too small to lasso the sheath. After that, we tried to cross the proximal and distal tips of the sheath with a coronary guidewire to capture the guidewire with the snare (coaxial snare technique), but again we failed (the distal edge was “closed”). As a result, we advanced a coronary balloon over the wire and inflated the dilation catheter inside the sheath, pulling back the entire system through the right-sided chambers without complications. To our knowledge, the present case is the first to describe the removal of a fragmented sheath using this technique.

Conclusion
       Percutaneous extraction of embolized catheter fragments should always be the first-choice method because it has high technical success and low complication rates. In this particular case, we have shown that retrieval of a fragmented sheath can be done safely and effectively with the use of standard angioplasty tools.

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