Successful Retrieval of a Broken Intravascular Ultrasound Catheter Tip in the Coronary Artery
ABSTRACT: We report the successful retrieval of a broken intracoronary intravascular ultrasound (IVUS) catheter tip that was mostly invisible on fluoroscopy by using a snare catheter and pulling from distal to proximal. An 80-year old male had presented with effort-related angina for one month. A coronary angiogram revealed severe stenosis of the proximal portion of the left anterior descending artery (LAD). Percutaneous coronary intervention (PCI) was planned for the lesion. During pre-procedural IVUS examination, the IVUS catheter fractured leaving the tip of the IVUS catheter inside the LAD. An attempt was made to remove the IVUS catheter tip by engaging the free proximal end of the tip with a loop snare. This attempt failed due to the free proximal end of the IVUS catheter tip being invisible on fluoroscopy. A loop snare was instead delivered distal to the IVUS catheter tip through a microcatheter, and the IVUS wire of the catheter tip was manipulated into the loop. The loop snare was then pulled back securely catching the IVUS catheter tip. The broken IVUS catheter tip was subsequently removed. This novel technique is effective for retrieving intracoronary foreign bodies.
An intravascular foreign body is a rare but possible complication of percutaneous intervention.1 An attempt is usually made to retrieve the intravascular foreign body through non-surgical intervention such as using a snare catheter. The percutaneous retrieval of intravascular foreign bodies was first described in 1964 by Thomas et al.2 The percutaneous retrieval of intravascular foreign bodies has since become common practice with many case reports and studies published.1,3–6 A number of different devices and techniques have been utilized to retrieve foreign bodies, including snare catheters, basket catheters, biopsy forceps, and filter devices. The choice of device and technique used to perform foreign body retrieval is dependent on the circumstances and size of the foreign body, and considerable innovation has been shown in this choice.
Dislodged coronary stents and uncoiled guidewires are thrombogenic when left in the coronary artery and may result in acute myocardial infarction. Where possible, intracoronary foreign bodies should be removed by the interventional cardiologist.
In the reported case a broken intravascular ultrasound (IVUS) catheter tip was successfully removed from the left anterior descending artery (LAD). After employing several failed techniques in attempting to remove the IVUS catheter tip, it was eventually retrieved by pulling a loop snare catheter from a distal to proximal direction and securing the IVUS catheter tip.
Case Report. An 80-year old man presented with exertional angina for one month’s duration. Coronary computed tomography (CT) angiography revealed a severely stenotic lesion in the proximal portion of the LAD and stress thallium-201 scintigraphy revealed anterior redistribution. Elective PCI was scheduled for the proximal LAD lesion.
Coronary angiography showed severe stenosis of the proximal portion of the LAD with no significant stenosis of the large left circumflex artery (LCX) (Figure 1 A and 1B). The right coronary artery (RCA) was small.
A 7 French JL 4.0 guiding catheter (Cordis, Miami, Florida) was engaged in the left coronary artery (LCA) and a Neo’s Rinato guidewire (Asahi Intec, Santa Ana, California) was inserted into the LAD. Pre-procedural IVUS examination was attempted but the IVUS catheter (Atlantis SR Pro2, Boston Scientific, Natick, Massachusetts) failed to cross the lesion due to tortuosity. While the IVUS catheter was pulled out without resistance, the radiopaque marker of the IVUS catheter remained in the LAD (Figure 2A). We realized the tip of the IVUS catheter had broken off. An attempt was made to catch the free proximal end of the broken tip using a loop snare. The attempt failed because the free proximal end was invisible on fluoroscopy (Figure 2B). The lesion was dilated with a 3.0 mm balloon catheter (Sidekick Ozma Plus; Nipro Medical) to make more room. The tip of the IVUS catheter tip was moved on the wire to the distal LAD during this procedure. A failed attempt was made using the buddy wire technique with rotation to entangle the IVUS catheter tip and wire. Because the IVUS catheter tip was in the distal portion of the LAD there was not enough room to manipulate the snare catheter. The IVUS catheter tip needed to be pulled back to the proximal portion of the LAD to provide enough space to manipulate the snare catheter. A 2.0 mm balloon catheter was advanced distal to the IVUS catheter tip and the balloon catheter pulled from a distal to proximal direction during low pressure dilatation using the buddy wire technique and similar to a Fogarty catheter. The IVUS catheter tip was successfully moved to the mid portion of the LAD (Figures 3A and 3B). The balloon catheter was replaced with a larger 3.0 mm size balloon matching the vessel size, and an attempt was made to pull the IVUS catheter tip into the guiding catheter. The IVUS tip remained stuck at the end of the guiding catheter and could not be retrieved. Catching the free proximal end of the IVUS catheter tip with a loop snare was supposed to be impossible, so an attempt was made to catch the tip by pulling the loop snare from a distal to proximal direction. First, a microcatheter was advanced to the distal LAD and a loop snare was delivered distal to the IVUS catheter tip through the microcatheter. Second, the guidewire of the IVUS catheter tip was manipulated into the loop (Figures 3C and 3D). Third, the loop snare was pulled from a distal to proximal direction. The loop snare caught the IVUS catheter tip securely and resulting in the successful retrieval of the IVUS catheter tip (Figures 3E and 3F). IVUS examination was attempted once again and the LAD proximal lesion treated with a sirolimus-eluting stent (3.5 x 13 mm). A final angiogram revealed optimal stent expansion with TIMI III flow (Figure 4). The picture of the broken IVUS catheter shows the cross section of both ends of the broken IVUS catheter appear smooth (Figure 5).
Discussion. Stents can dislodge and balloons can tear, leading to thrombosis and acute occlusion. Vigorous attempts should be made to remove foreign bodies. There are reports that describe non–surgical techniques used to remove foreign bodies such as utilizing a snare catheter or other devices.1,3–6 While foreign bodies of metal are visible on fluoroscopy, in this reported case the foreign body was a broken IVUS catheter tip almost totally invisible on fluoroscopy, apart from a radiopaque marker at the catheter tip. In addition, we could not control the direction of the loop snare. It was decided that the loop snare should therefore come from a distal to proximal direction. As the tip of the IVUS catheter remained on the guidewire, the target could be secured simply by manipulating the guidewire into the loop snare. Securing the IVUS catheter tip with a loop snare would have been difficult had the IVUS catheter tip detached from the guidewire. Gavlick et al report a previous case of successful retrieval of a fractured Rotafloppy wire (Boston Scientific) using a snare loop. The proximal end of the fractured Rotafloppy wire was radiolucent and invisible, and successfully retrieved by deploying the snare loop distal to the fractured Rotafloppy wire and catching the distal segment of the fractured Rotafloppy wire that also had a radiopaque distal tip.
The foreign body in this reported case was neither a stent nor fractured guidewire but a broken IVUS catheter tip. To our knowledge, this is the first reported case of the retrieval of a broken IVUS catheter tip. This is also our first experience of a broken IVUS catheter. This complication is very rare.
IVUS examination during PCI provides a large amount of information about the target lesion. IVUS-guided PCI produces results superior to non-IVUS guided PCI in some respects, including lower TLR, lower mortality, and lower stent thrombosis rates.7,8 Between August 2004 and February 2007, the authors performed IVUS-guided PCI in 97% of a total of 801 cases of sirolimus-eluting stent implantation.9 The reported case is the authors’ only experience of any problems or complications arising that are related to the use of IVUS.
Conclusion. Pulling from a distal to proximal direction with a snare catheter is an effective technique for retrieving an intracoronary foreign body.
1. Bonvini R. F, Rastan A, Sixt S, et al. Percutaneous retrieval of intravascular and intracardiac foreign bodies with a dedicated three-dimensional snare: A 3-year single center experience. Catheter Cardiovasc Interv 2009;74:939–945.
2. Thomas J, Sinclair-Smith B, Bloomfield D, Davachi A. Nonsurgical retrieval of a broken segment of steel spring guide from the right atrium and inferior vena cava. Circulation 1964;30:106–108.
3. Khattab A. A, Geist V, Toelg R, Richardt G. The AngioGuard: A simplified snare? Int J Cardiovasc Intervent 2004;6:153–155.
4. Mallmann CV, Wolf KJ, Wacker FK. Retrieval of vascular foreign bodies using a self-made wire snare. Acta Radiol 2008;10:1124–1128.
5. Webb JG, Solankhi N, Carere RG. Facilitation of stent retention and retrieval with an emboli containment devices. Catheter Cardiovasc Interv 2000;50:218–220.
6. Gavlick K, Blankenship JC. Snare retrieval of the distal tip of a fractured rotational atherectomy guidewire: Roping the steer by its horns. J Invasive Cardiol 2005;17: E55–E58.
7. Oemrawsingh PV, Mintz GS, Schalij MJ, et al. Intravascular ultrasound guidance improves angiographic and clinical outcome of stent implantation for long coronary artery stenoses: Final results of a randomized comparison with angiographic guidance (TULIP Study). Circulation 2003;107:962–967.
8. Roy P, Steinberg DH, Sushinsky SJ, et al. The potential cliniocal utility of intravascular ultrasound guidance in patients undergoing percutaneous coronary intervention with drug-eluting stents. Eur Heart J 2008; 29:1851–1857.
9. Kambayashi D, Nakamura S, Miyamoto C, et al. Long-term result of elective cypher stent implantation. J Cardiol Jpn Ed 2008;2:112–118.
From the Cardiovascular Center, Kyoto-Katsura Hospital, Kyoto, Japan.
The authors report no conflicts of interest regarding the content herein.
Manuscript submitted February 3, 2010, provisional acceptance given February 16, 2010, final version accepted March 12, 2010.
Address for correspondence: Atsushi Funatsu, MD, Cardiovascular Center, Kyoto-Katsura Hospital, 17 Yamada-Hirao-cho, Nishikyo-ku, Kyoto, Japan 615-8256. E-mail: firstname.lastname@example.org