Introduction:

  • Percutaneous procedures have a documented efficacy of 92.3% to 96.6% in the pediatric population.
  • Consequently, a rise in intravascular procedures have increased the risk of foreign body embolization in the form of broken or disconnected catheter fragments.
  • While surgical approaches were traditionally favored, recent years have seen a shift towards percutaneous retrieval techniques.
  • Pulmonary arteries are a common site of embolization for these foreign bodies and can lead to serious complications like thrombosis, sepsis and arrythmias.
  • To treat these, percutaneous interventions, owing to their safety and efficacy, have become increasingly necessary to prevent these complications.

Indications:

  • Removal of embolized catheter fragments.
  • Removal of coils and embolic materials
  • Cases when surgical intervention is not indicated.

Contraindications:

  • Avoided in patients with unstable medical conditions.
  • Contraindicated in cases of severe coagulopathy.

Equipment used:

  1. Guide wires (Glidewire, Amplatz, Cope)
  2. Needles
  3. Catheters ranging from 4 to 8 Fr (Envoy, Pigtail, Vertebral, Kumpe, C1, C2, Vert, Sim on, SOS)
  4. Sheaths ranging from 4 to 14 Fr
  5. Retrieval devices (Gooseneck snare, aspiration catheter, negative suction device, pigtail catheter, Dormia basket). A 15-25 mm gooseneck snare is sufficient for most catheter fragment retrievals.

Preprocedural evaluation:

  • EKG to evaluate for arrhythmia and right heart strain if fragment is in the heart or pulmonary arteries.
  • Coagulation tests, CBC and type and screen are helpful.
  • Detailed imaging to locate the foreign body.
  • Assessment of patient's overall health.
  • Planning the route and method of retrieval.
  • Evaluating potential risks and complications.
  • Discussion of the procedure with the patient's guardians.

Procedure:

Preparation and Patient Evaluation: 
  • Conduct a thorough pre-procedural assessment including patient's medical history, imaging studies, and identification of the foreign body's location and characteristics.
  • Radiographs or angiography can be used to identify the foreign body.
Sterile Setup and Anesthesia: 
  • Prepare the procedural area under sterile conditions.
  • Administer local or general anesthesia as appropriate. General anesthesia is usually preferred.
Vascular Access: 
  • Gain vascular access, typically via the femoral vein, using ultrasound guidance. In some instances, internal jugular vein can be used as the access site.
  • Insert a guidewire followed by a vascular sheath. The size of the access sheath is particularly important for the removal of the foreign body.
  • Typically, 4-14 Fr sheaths are used.
Fluoroscopy and Navigation: 
  • Utilize fluoroscopy to navigate catheters and guidewires to the site of the foreign body.
  • A variety of catheters (Envoy, Pigtail, Vertebral, Kumpe, C1, C2, Vert, Sim on, SOS) can be used depending on the needs ranging from 4-8 Fr. 
Foreign Body Retrieval: 
  • Employ retrieval devices like snares or baskets to capture and securely hold the foreign body.
  • Most used devices for pulmonary vasculature foreign body retrieval are 0.035 Gooseneck snare used alone or sometimes in combination with aspiration catheter or negative suction device depending on the type of foreign body.
  • Carefully maneuver the device to avoid vessel trauma.
Extraction and Hemostasis: 
  • Extract the foreign body through the sheath.
  • Achieve hemostasis at the access site post retrieval. Hemostasis is usually obtained through manual compression.

Figure:

​4-year-old with catheter fragment (straight arrow) dislodged in the right pulmonary artery. Dislodged fragment is being removed using a Gooseneck snare device (curved arrow)

Complications:

  • Generally low complication rates.
  • Risks include infection and arrhythmias.

Post-procedural care and follow-up:

  • Monitor the patient for complications.
  • Perform follow-up imaging to confirm the complete removal of the foreign body and assess for any vascular injury.

References:

  1. Pazinato LV, Leite TFdO, Bortolini E, Pereira OI, Nomura CH, da Motta-Leal-Filho JM. Percutaneous retrieval of intravascular foreign body in children: a case series and review. Acta Radiol. 2022;63(5):684-691. doi:10.1177/02841851211006904. Epub 2021 Apr 8. PMID: 33832338.
  2. Duman D, Aykan HH, Ertuğrul İ, Ardiçli B, Aypar E, Alehan D, Karagöz T. Percutaneous Transcatheter Retrieval of Central Venous Port Fragments in Pediatric Patients; A Single-center Experience From the Pediatric Cardiology Department. J Pediatr Hematol Oncol. 2023;45(8):e959-e965. doi:10.1097/MPH.0000000000002761. Epub 2023 Oct 2. PMID: 37782316.
  3. Surov A, Wienke A, Carter JM, et al. Intravascular embolization of venous catheter–causes, clinical signs, and management: a systematic review. JPEN J Parenter Enteral Nutr. 2009;33(6):677–685.
  4. Fuenfer MM, Georgeson KE, Cain WS, et al. Etiology and retrieval of retained central venous catheter fragments within the heart and great vessels of infants and children. J Pediatr Surg. 1998;33(3):454–456.
  5. Tutar E, Aypar E, Atalay S, et al. Percutaneous transcatheter retrieval of intracardiac central venous catheter fragments in two infants using Amplatz Goose Neck snare. Turk J Pediatr. 2009;51(5):519–523.
  6. Cahill AM, Ballah D, Hernandez P, et al. Percutaneous retrieval of intravascular venous foreign bodies in children. Pediatr Radiol. 2012;42(1):24–31.
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