This document reviews techniques for retrieving intravascular foreign bodies (IFBs). It discusses that as endovascular therapies increase, so does the incidence of lost or embolized foreign objects. IFBs most commonly result from embolized central line fragments. The percutaneous approach is widely considered the best method for removing IFBs as it is minimally invasive with high success rates and low morbidity compared to open surgery. The document outlines general considerations for IFB retrieval including preventative measures, imaging techniques to locate the IFB, preparation for removal, and various removal techniques and devices commonly used like loop snares and intravascular forceps.
Foreign body removal during cardiac catheterizationRamachandra Barik
The removal of foreign bodies from the heart and vasculature has shifted from the domain of the radiologist and even the thoracic or vascular surgeon to the terventional cardiologist and, in turn, from the radiographic suite or operating room to the cardiac catheterization Laboratory.
Foreign body removal during cardiac catheterizationRamachandra Barik
The removal of foreign bodies from the heart and vasculature has shifted from the domain of the radiologist and even the thoracic or vascular surgeon to the terventional cardiologist and, in turn, from the radiographic suite or operating room to the cardiac catheterization Laboratory.
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
Patients with peripheral arterial disease (PAD) and critical limb ischemia are at risk for limb amputation and require urgent management to restore blood flow. Patients with PAD often have several comorbidities, including chronic kidney disease, diabetes mellitus, and hypertension. Diagnostic and interventional angiography using iodinated contrast agents provides excellent image resolution but can be associated with contrast-induced nephropathy (CIN). The use of carbon dioxide (CO2) as a contrast agent reduces the volume of iodine contrast required for angiography and reduces the incidence of CIN. However, CO2 angiography has been underutilized due to concerns regarding safety and image quality. Modern CO2 delivery systems with advanced digital subtraction angiography techniques and hybrid angiography have improved imaging accuracy and reduced the incidence of CIN. Awareness of the need for optimal imaging conditions, contraindications, and potential complications have improved the safety of CO2 angiography. This review aims to highlight current technological advances in the delivery of CO2 in vascular angiography for patients with PAD and critical limb ischemia, which result in limb preservation while preventing kidney damage.
Diagnostic catheters for coronary angiography Aswin Rm
Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
Patients with peripheral arterial disease (PAD) and critical limb ischemia are at risk for limb amputation and require urgent management to restore blood flow. Patients with PAD often have several comorbidities, including chronic kidney disease, diabetes mellitus, and hypertension. Diagnostic and interventional angiography using iodinated contrast agents provides excellent image resolution but can be associated with contrast-induced nephropathy (CIN). The use of carbon dioxide (CO2) as a contrast agent reduces the volume of iodine contrast required for angiography and reduces the incidence of CIN. However, CO2 angiography has been underutilized due to concerns regarding safety and image quality. Modern CO2 delivery systems with advanced digital subtraction angiography techniques and hybrid angiography have improved imaging accuracy and reduced the incidence of CIN. Awareness of the need for optimal imaging conditions, contraindications, and potential complications have improved the safety of CO2 angiography. This review aims to highlight current technological advances in the delivery of CO2 in vascular angiography for patients with PAD and critical limb ischemia, which result in limb preservation while preventing kidney damage.
Diagnostic catheters for coronary angiography Aswin Rm
Overview of diagnostic catheters used in coronary angiography
Guide catheters not included
History of coronary catheters
Radial techniques and catheters
Describe lo observado durante la práctica relacionado a los cursos de Planeación Educativa, Prácticas Sociales del Lenguaje, Observación y Análisis de la Práctica Escolar, Exploración del Medio Natural en el Preescolar, Bases Psicológicas del Aprendizaje y Forma, Espacio y Medida
Grant Young's presentation at Web Directions South, 14-Oct-2010. Explores how social networks and the sharing economy are increasing wellbeing and sustainability. PDF of presentation (along with notes, links and pointers to more information) are available at http://zum.io/wds2010
PR 2.0: How to use a social media release like PressDocProudly Represents
How to use a social media release tool like PressDoc in your PR 2.0 campaign to launch a product? In this case study for 123people I as a PR-consultant have put together some key learnings, basic rules and useful tips for using a social media release as a marketing tool, in which you can upload text, video, images and twitter.
2012 BMW 7 Series For Sale NJ | BMW Dealer In EatontownJoseph Falotico
2012 BMW 7 Series brochure provided by Circle BMW in Eatontown, NJ. Find the 2012 BMW 7 Series for sale in New Jersey. Call us about our current sales and incentives at (888) 553-3958. http://www.circlebmw.com
LifePlan is such a policy. It offers you a bespoke range of protection benefits to perfectly fit your family’s specific needs. No two LifePlans are ever the same, and in this sense you and your trusted adviser will truly create a comprehensive policy suitable for your life now
and in the future.
Moving Beyond Reverse Auctions for Scalable, Sustainable ValueEmptoris, Inc
Learn how companies are stepping back from the one-size fits-all application of the reverse auction and leveraging more advanced sourcing solution that better support their sourcing strategies to generate sustainable savings of 7% in categories repeatedly sourced year after year.
For more information, please visit:
Emptoris website: http://www.emptoris.com/
Emptoris blog: http://emptorisinc.blogspot.com/
YouTube channel : http://www.youtube.com/emptoris
Vascular Access Part 1: Reducing risk and increasing catheter longevityCoda Change
The aim of having a structured decision matrix in the approach to vascular access is to reduce catheter-associated complications and to increase device longevity. There are over 15,000 central venous catheters placed in Australia annually. The actual insertion process for placing a central line only accounts for a small part of the 'life span' of that line (approximately 1%), but the choices made at the time of insertion have a huge impact on the longevity of the device and the associated complications. In this introductory talk Evan Alexandrou outlines the top ten tips for reducing complications associated with vascular access devices:
1. Always use ultrasound: Never do a blind puncture
2. Ensure with the site chosen for the catheter that it exits the skin on a flat surface.
3. Consider the Axillary vein in preference for the subclavian vein
4. Use micro-puncture techniques
5. Avoid using a scalpel if possible
6. Avoid catheters being inserted all the way to the hub
7. Use impregnated dressings when possible
8. Use sutureless securing techniques
9. Secure the dressing on a flat surface (refer rule 2)
10. Ensure optimal positioning of the catheter tip by utilising ultrasound or intracavitary ECG
Vertebral artery pseudo-aneurysms and dissections are known to occur as a result of mechanical
manipulations of the cervical region, traumatic injury, spontaneously and iatrogenic injury because of central
venous catheterization. Central venous lines have become an integral part of patient care, but they are
not without complications. Vertebral artery injury (leading to pseudo-aneurysm and dissection) is one of
the rarer complications of central venous catheter placement. We report a case of inadvertent vertebral
artery catheterization during a dialysis catheter placement which subsequently demonstrated arterial
blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery catheterization.
It was successfully treated with open surgical technique by the vascular surgeon because of the size of
catheter and subsequent requirement of artery repair. There were no neurological sequelae. Open surgical
repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudo-aneurysms
has been described with promising outcomes, but long-term results are lacking. This case report describes
the rare iatrogenic event of vertebral artery injury and reviews its etiology, diagnosis, complications, and management.
Prosthetic paravalvular leaks (PVL) is an uncommon but serious complication after surgical valve replacement. Although surgery has been the traditional treatment of choice in hemodinamically significant PVL, percutaneous transcatheter closure is emerging as a novel and less invasive option for patients with high operative risk. Cardiac imaging, especially two- and three-dimensional transoesophageal echocardiography, plays an essential role in the diagnosis, guidance of intervention and subsequently in the evaluation of the outcomes of the procedure. The aim of this manuscript is to review the role of cardiac imaging techniques in the interventional management of patients with symptomatic PVL.
Cardiac imaging in prosthetic paravalvular leaksPaul Schoenhagen
Abstract: Prosthetic paravalvular leaks (PVL) is an uncommon but serious complication after surgical valve replacement. Although surgery has been the traditional treatment of choice in hemodynamically significant PVL, percutaneous transcatheter closure is emerging as a novel and less invasive option for patients with high operative risk. Cardiac imaging, especially two- and three-dimensional transoesophageal echocardiography, plays an essential role in the diagnosis, guidance of intervention and subsequently in the evaluation of the outcomes of the procedure. The aim of this manuscript is to review the role of cardiac imaging techniques in the interventional management of patients with symptomatic PVL.
Surgical Management for a Stuck up and fracture angioplasty devices in Vivo during PCI in a Complex LAD Artery Lesion: A Case Report and Literature Review.
Md. Abir Tazim Chowdhury1, Sohail Ahmed2, Md. Zulfiqur Haider2
Abstract
Background: Stuck up and fracture of coronary angioplasty devices are uncommon complications of percutaneous coronary interventions (PCI) for which surgical rescue and management is once in a while needed.
Case description: Here, we present one case of a 59-year-old diabetic, a hypertensive gentleman, who attended the emergency room (ER) with central chest pain for several hours and, after physical and diagnostic evaluation, was diagnosed as a case of Acute ST-segment elevated Myocardial Infarction (AMI) with stable hemodynamic. The findings mentioned above were initially treated with the thrombolytic agent in the ER and followed by admission to the cardiac care unit for monitoring and further invasive coronary evaluation by coronary angiogram (CAG). It was demonstrated essentially Single Vessel Disease (SVD) with complex Left Anterior Descending (LAD) artery lesion, where PCI attempted but failed with unfortunate stuck up and broken of the delivery shaft, and left inside the coronary system. Immediate judgment and surgical retrieval of lost angioplasty device and correction of the coronary lesion with its revascularization save the patient life from grave complications. This article describes all the critical, challenging events and our management approaches to this very complex coronary artery lesion.
.
Conclusion: Coronary angioplasty hardware should be regulated gently, carefully, and precisely according to the manufacturers' instructions for use, and it should be inspected for its integrity once brought out of the patient's body. In vivo trap of angioplasty hardware, fracture, and retention during the PCI are infrequent. Percutaneous retrieval of specifically complex bifurcation lesions constantly presents limits and risks. In those cases, it will be crucial to thoroughly inform the patient concerning the hazard of the procedure and consider surgical revascularization.
Address of Correspondence:
Name: Dr. Md. Abir Tazim Chowdhury
Designation: Specialist, Department of Cardiothoracic and Vascular Surgery
Institution: Evercare Hospital Dhaka, Bangladesh.
e-mail: chowdhuryabir0@gmail.com
Introduction: Radiofrequency Ablation (RF) of Nodal Reentry Tachycardia (AVNRT) requires precision to avoid AV block. 3D Electro-Anatomic Mapping (EAM) systems allowed to reduce radiological exposure. We sought to evaluate safety and effi cacy of AVNRT ablation, analyzing tip stability with a EAM
system aiming a Minimal Fluoroscopic Approac (MFA).
Similar to Techniques for intravascular foreign body retrieval (20)
Wellens syndrome. Wellens syndrome (also referred to as LAD coronary T-wave syndrome) refers to an ECG pattern specific for critical stenosis of the proximal left anterior descending artery. The anomalies described occur in patients with recent anginal chest pain, and do not have chest pain when the ECG is recorded.
Congenital defects can put a strain on the heart, causing it to work harder. To stop your heart from getting weaker with this extra work, your doctor may try to treat you with medications. They are aimed at easing the burden on the heart muscle. You need to control your blood pressure if you have any type of heart problem.
Changing your lifestyle can help control and manage high blood pressure. Your health care provider may recommend that you make lifestyle changes including:
Eating a heart-healthy diet with less salt
Getting regular physical activity
Maintaining a healthy weight or losing weight
Limiting alcohol
Not smoking
Getting 7 to 9 hours of sleep daily
CRISPR technologies have progressed by leaps and bounds over the past decade, not only having a transformative effect on
biomedical research but also yielding new therapies that are poised to enter the clinic. In this review, I give an overview of (i)
the various CRISPR DNA-editing technologies, including standard nuclease gene editing, base editing, prime editing, and epigenome editing, (ii) their impact on cardiovascular basic science research, including animal models, human pluripotent stem
cell models, and functional screens, and (iii) emerging therapeutic applications for patients with cardiovascular diseases, focusing on the examples of Hypercholesterolemia, transthyretin amyloidosis, and Duchenne muscular dystrophy.
A post-splenectomy patient suffers from frequent infections due to capsulated bacteria like Streptococcus
pneumoniae, Hemophilus influenzae, and Neisseria meningitidis despite vaccination because of a lack of
memory B lymphocytes. Pacemaker implantation after splenectomy is less common. Our patient underwent
splenectomy for splenic rupture after a road traffic accident. He developed a complete heart block after
seven years, during which a dual-chamber pacemaker was implanted. However, he was operated on seven
times to treat the complication related to that pacemaker over a period of one year because of various
reasons, which have been shared in this case report. The clinical translation of this interesting observation
is that, though the pacemaker implantation procedure is a well-established procedure, the procedural
outcome is influenced by patient factors like the absence of a spleen, procedural factors like septic measures,
and device factors like the reuse of an already-used pacemaker or leads.
Transcatheter closure of patent ductus arteriosus (PDA) is feasible in low-birth-weight infants. A female baby was born prematurely with a birth weight of 924 g. She had a PDA measuring 3.7 mm. She was dependent on positive pressure ventilation for congestive heart failure in addition to the heart failure medications. She could not be discharged from the hospital even after 79 days of birth, and even though her weight reached 1.9 kg in the neonatal intensive care unit. We attempted to plug the PDA using an Amplatzer Piccolo Occluder, but the device failed to anchor. Then, the PDA was plugged using a 4-6 Amplatzer Duct Occluder using a 6-Fr sheath which was challenging.
Accidental misplacement of the limb lead electrodes is a common cause of ECG abnormality and may simulate pathology such as ectopic atrial rhythm, chamber enlargement or myocardial ischaemia and infarction
A Case of Device Closure of an Eccentric Atrial Septal Defect Using a Large D...Ramachandra Barik
Device closure of an eccentric atrial septal defect can be challenging and needs technical modifications to avoid unnecessary complications. Here, we present a case of a 45-year-old woman who underwent device closure of an eccentric defect with a large device. The patient developed pericardial effusion and left-sided pleural effusion due to injury to the junction of right atrium and superior vena cava because of the malalignment of the delivery sheath and left atrial disc before the device was pulled across the eccentric defect despite releasing the left atrial disc in the left atrium in place of the left pulmonary vein. These two serious complications were managed conservatively with close monitoring of the case during and after the procedure.
Trio of Rheumatic Mitral Stenosis, Right Posterior Septal Accessory Pathway a...Ramachandra Barik
A 57-year-old male presented with recurrent palpitations. He was diagnosed with rheumatic mitral stenosis, right posterior septal accessory pathway and atrial flutter. An electrophysiological study after percutaneous balloon mitral valvotomy showed that the palpitations were due to atrial flutter with right bundle branch aberrancy. The right posterior septal pathway was a bystander because it had a higher refractory period than the atrioventricular node.
Percutaneous balloon dilatation, first described by
Andreas Gruentzig in 1979, was initially performed
without the use of guidewires.1 The prototype
balloon catheter was developed as a double lumen
catheter (one lumen for pressure monitoring or
distal perfusion, the other lumen for balloon inflation/deflation) with a short fixed and atraumatic
guidewire at the tip. Indeed, initially the technique
involved advancing a rather rigid balloon catheter
freely without much torque control into a coronary
artery. Bends, tortuosities, angulations, bifurcations,
and eccentric lesions could hardly, if at all, be negotiated, resulting in a rather frustrating low procedural success rate whenever the initial limited
indications (proximal, short, concentric, noncalcified) were negated.2 Luck was almost as
important as expertise, not only for the operator,
but also for the patient. It is to the merit of
Simpson who, in 1982, introduced the novelty of
advancing the balloon catheter over a removable
guidewire, which had first been advanced in the
target vessel.3 This major technical improvement
resulted overnight in a notable increase in the procedural success rate. Guidewires have since evolved
into very sophisticated devices.
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
Brugada syndrome (BrS) is an inherited cardiac disorder,
characterised by a typical ECG pattern and an increased
risk of arrhythmias and sudden cardiac death (SCD).
BrS is a challenging entity, in regard to diagnosis as
well as arrhythmia risk prediction and management.
Nowadays, asymptomatic patients represent the majority
of newly diagnosed patients with BrS, and its incidence
is expected to rise due to (genetic) family screening.
Progress in our understanding of the genetic and
molecular pathophysiology is limited by the absence
of a true gold standard, with consensus on its clinical
definition changing over time. Nevertheless, novel
insights continue to arise from detailed and in-depth
studies, including the complex genetic and molecular
basis. This includes the increasingly recognised
relevance of an underlying structural substrate. Risk
stratification in patients with BrS remains challenging,
particularly in those who are asymptomatic, but recent
studies have demonstrated the potential usefulness
of risk scores to identify patients at high risk of
arrhythmia and SCD. Development and validation of
a model that incorporates clinical and genetic factors,
comorbidities, age and gender, and environmental
aspects may facilitate improved prediction of disease
expressivity and arrhythmia/SCD risk, and potentially
guide patient management and therapy. This review
provides an update of the diagnosis, pathophysiology
and management of BrS, and discusses its future
perspectives.
The Human Developmental Cell Atlas (HDCA) initiative, which is part of the Human Cell Atlas, aims to create a comprehensive reference map of cells during development. This will be critical to understanding normal organogenesis, the effect of mutations, environmental factors and infectious agents on human development, congenital and childhood disorders, and the cellular basis of ageing, cancer and regenerative medicine. Here we outline the HDCA initiative and the challenges of mapping and modelling human development using state-of-the-art technologies to create a reference atlas across gestation. Similar to the Human Genome Project, the HDCA will integrate the output from a growing community of scientists who are mapping human development into a unified atlas. We describe the early milestones that have been achieved and the use of human stem-cell-derived cultures, organoids and animal models to inform the HDCA, especially for prenatal tissues that are hard to acquire. Finally, we provide a roadmap towards a complete atlas of human development.
The treatment of patients with advanced acute heart failure is still challenging.
Intra-aortic balloon pump (IABP) has widely been used in the management of
patients with cardiogenic shock. However, according to international guidelines, its
routinary use in patients with cardiogenic shock is not recommended. This recommendation is derived from the results of the IABP-SHOCK II trial, which demonstrated
that IABP does not reduce all-cause mortality in patients with acute myocardial infarction and cardiogenic shock. The present position paper, released by the Italian
Association of Hospital Cardiologists, reviews the available data derived from clinical
studies. It also provides practical recommendations for the optimal use of IABP in
the treatment of cardiogenic shock and advanced acute heart failure.
Left ventricular false tendons (LVFTs) are fibromuscular
structures, connecting the left ventricular
free wall or papillary muscle and the ventricular
septum.
There is some discussion about safety issues during
intense exercise in athletes with LVFTs, as these
bands have been associated with ventricular arrhythmias
and abnormal cardiac remodelling. However,
presence of LVFTs appears to be much more common
than previously noted as imaging techniques
have improved and the association between LVFTs
and abnormal remodelling could very well be explained
by better visibility in a dilated left ventricular
lumen.
Although LVFTsmay result in electrocardiographic abnormalities
and could form a substrate for ventricular
arrhythmias, it should be considered as a normal
anatomic variant. Persons with LVFTs do not appear
to have increased risk for ventricular arrhythmias or
sudden cardiac death.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Techniques for intravascular foreign body retrieval
1. REVIEW
Techniques for Intravascular Foreign Body Retrieval
Joe B. Woodhouse • Raman Uberoi
Received: 5 June 2012 / Accepted: 3 September 2012 / Published online: 17 October 2012
Ó Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2012
Abstract As endovascular therapies increase in fre-
quency, the incidence of lost or embolized foreign bodies is
increasing. The presence of an intravascular foreign body
(IFB) is well recognized to have the potential to cause
serious complications. IFB can embolize and impact criti-
cal sites such as the heart, with subsequent significant
morbidity or mortality. Intravascular foreign bodies most
commonly result from embolized central line fragments,
but they can originate from many sources, both iatrogenic
and noniatrogenic. The percutaneous approach in removing
an IFB is widely perceived as the best way to retrieve
endovascular foreign bodies. This minimally invasive
approach has a high success rate with a low associated
morbidity, and it avoids the complications related to open
surgical approaches. We examined the characteristics,
causes, and incidence of endovascular embolizations and
reviewed the various described techniques that have been
used to facilitate subsequent explantation of such materials.
Keywords Device removal Á Endovascular procedures Á
Foreign bodies Á Interventional radiology
Introduction
The intravascular embolization of foreign material is an
uncommon occurrence, but with the increasing range of
endovascular therapies, the incidence of a lost intravascular
foreign body (IFB) is becoming a more frequent clinical
problem. The first described fatality directly attributable to
a lost migrated IFB occurred in 1954. The case report
detailed an intravascular catheter that had been found
within a patient’s right atrium at autopsy. It was known to
have recently migrated from the cubital vein and had
caused the patient’s death by perforating the heart [1]. In
1964, Thomas et al. [2] reported the first successful per-
cutaneous retrieval of an IFB, where a fragment of broken
guide wire was retrieved percutaneously from a patient’s
right atrium with a rigid bronchoscope forceps through a
sheath. The technique was quickly adopted as an alterna-
tive to open surgical removal, and a percutaneous approach
is now widely accepted as the first-line method for
retrieving IFBs.
IFBs can originate form a variety of sources but are
usually iatrogenic. Most commonly IFBs are embolized
central line fragments, but guide wires, catheter fragments,
embolization coils, inferior vena cava filters, coils, cardiac
valve fragments, sheaths, pacing wires, occluder devices,
and projectile fragments have been described [3–9].
Appropriate knowledge of available equipment and the
various techniques, as well as experience, are key factors in
achieving a successful outcome. Egglin et al. [10] found
that in up to 25 % of cases, more than one retrieval system
or technique was needed to achieve successful removal of
an IFB.
Here we detail the range of considerations and tech-
niques that may be beneficial in this predicament.
General Considerations
Preventative Measures
Primary prevention is much better than a secondary suc-
cessful retrieval of a lost IFB. Although not all IFB are
J. B. Woodhouse Á R. Uberoi (&)
Oxford University Hospitals, Headley Way, Headington, Oxford,
Oxfordshire OX3 9DU, UK
e-mail: raman.uberoi@orh.nhs.uk
123
Cardiovasc Intervent Radiol (2013) 36:888–897
DOI 10.1007/s00270-012-0488-8
2. iatrogenic, catheter or device loss is usually preceded by a
number of difficulties running up to the attempt at device
delivery or deployment. Poor guide catheter/guide wire
support, proximal vessel tortuosity, and vessel calcification
are risk factors that can result in device (e.g., stent) loss.
Eggebrecht et al. [11] reviewed the results of 2211 con-
secutive coronary artery stenting procedures (4066 stents)
and found a incident rate of stent embolization of 0.9 % per
patient (or 0.49 % per stent). They also demonstrated that
manually crimped balloon-mounted stents embolize more
often than premounted balloon stents—1.04 % vs. 0.24 %,
respectively.
A high proportion of lost IFBs result from a technical
error on the part of the operator as opposed to equipment
failure, although both occur. Catheters are often displaced
as a result of the lack of experience of the operator. In our
experience, several migrated lines have resulted from
tunneled catheters being inappropriately cut by inexperi-
enced staff at the time of attempted line removal. Good
training and knowledge of the devices being used are vital
to avoid this complication. Good case planning with
appropriate equipment in the range of the operator’s
experience and training will avoid the majority of lost
IFBs.
Imaging to Find the Lost IFB
The first crucial step in achieving the successful retrieval
of a lost IFB is to obtaining a accurate history, including
identifying the object’s size, shape, and current location.
This is usually done via plain film, fluoroscopy, or both.
Catheter fragments are generally poorly visible fluoro-
scopically because they are small and are made of
material that attenuates x-rays poorly. Overlying tissues
and movement-related artefacts (e.g., cardiac motion)
further reduce fluoroscopic image clarity. Increasing the
pulse/frame rate can help, but at the cost of increased
patient exposure to radiation. Our practise is to use
computed tomography (CT) as a first-line investigation,
but this also comes at the expense of considerable radi-
ation exposure. Catheter fragments may be small, and
they are hard to identify even on CT. Magnetic resonance
imaging (MRI) has been used judiciously in circum-
stances where peripheral embolization has occurred and
where the foreign body is known to be MRI compatible.
In the case of metallic lost IFBs, a gradient echo
sequence will result in susceptibility artefact. Many MRIs
of IFBs may provide poor visualization of the IFB, and
MRIs may be contraindicated in some cases. Ultrasound
is feasible but seldom is practicable. Once localized, the
interval to subsequent attempted device retrieval should
be minimized to mitigate against further device
migration.
Preparation for Removal of Devices
Review of previous imaging is essential. Most devices can
be removed percutaneously; however, it may not always be
appropriate to remove lost IFB endovascularly, and a
multidisciplinary team discussion is required (Fig. 1).
Liaison with the anesthetic team to ensure an adequate
level of patient sedation/anesthesia may be needed. Fully
informed consent is vital, and the potential complications
should be carefully considered. Risks and potential com-
plications will inevitably depend on the vascular territory
involved.
Fig. 1 A 16-year-old girl had an OptEase temporary filter (Cordis)
positioned at another institution but attended with us for its removal.
A Venography revealed exoluminal positioning of some of the device
struts. B Efforts to collapse the device caused the patient pain. Further
efforts at endovascular device extraction were not attempted. C–E
Subsequent CT (axial and coronal reformats) revealed extensive
neointimal hyperplasia. Multidisciplinary team discussion resulted in
a decision to advise an open surgical retrieval, primarily as a result of
the young age of the patient, making leaving it in situ a suboptimal
long-term option
J. B. Woodhouse, R. Uberoi: Intravascular Foreign Body Retrieval 889
123
3. It can be useful to obtain an identical device to work
with ex vivo. In a case of a lost catheter fragment that had
embolized into right atrium, we successfully snared this via
the internal jugular vein; however, the catheter proved too
rigid to fold back over on itself (with the snare and the tip
of the sheath used as the fulcrum points). Ex vivo testing
demonstrated that a significantly larger sheath size was
needed to allow the catheter fragment to be folded back
over on itself. Ex vivo testing may have highlighted this
issue before we commenced the procedure that avoids
more complicated maneuvers once the IFB has been cap-
tured. It is important to ensure that commonly used devices
are available, such as snares, intravascular forceps, large
sheaths, guide wires, shaped catheters, and balloons
(Fig. 2), and that they are appropriately sized for the vessel
they are to be used within. For venous access, we advocate
the right femoral vein because it affords ease of access, it is
a large-caliber vessel that thus provides easier handling,
and it permits good postprocedure compression after
removal of potentially large sheaths [10]. If it is anticipated
that more than one vascular access point may be required,
then optimizing patient position and preparation at the
outset of the procedure can save time later. For example,
the anesthetists could be asked to avoid using a specific
arm for their venous access it if this access point may be
required later. Thinking about the route that the IFB will
travel will highlight areas of potential difficulty. Rigid IFB
can snag at vessel branch points and acute bends, so
avoiding these is preferable. Once an item is retrieved, it
should be sent for bacteriological evaluation so that sub-
sequent septic complications can be avoided.
Removal Techniques and Devices
Loop Snare
The loop snare is frequently the first choice of device used
to attempt removal of an IFB [12, 13]. Over the years,
the loop snare has undergone several design iterations. The
initial design was a retractable loop that emerged from the
end hole of a guide catheter; the loop was thus in the same
plane as the catheter. This meant that manipulation of the
loop itself was difficult, and consequently device success
was lower. Modern designs allow the loop to emerge at 90°
to the catheter, which greatly facilitates manipulation of the
loop to aid capture of the lost IFB. Nitinol shape memory
properties provides wire kink resistance. There are a range
of snare devices and sizes, including microsnares (e.g.,
Radius Medical technologies, MA, USA) measuring 2 mm
and in gradations up to 35 mm, as well as single-loop
designs (e.g., gooseneck, ev3, Minneapolis, MN; Welter
retrieval loop, Cook, Letchworth, UK; and trefoil,
EnSnare/TriSnare, Merit Medical, South Jordan, UT). All
brands are modeled on the same principle: the use of a
moveable Nitinol wire loop passing through a catheter. In
the absence of a purpose-built loop snare, a homemade
snare can be constructed with a narrow-gauge wire, such as
0.018- or 0.014-inch wire, and a selective catheter with
either an end hole or a side hole, such as a Cobra catheter.
Mallmann et al. [14] reported 100 % success at retrieving
IFB with self-made snares; retrievals comprised 16 of 16
consecutive IFB and included partially fractured venous
catheters, guide wires, a stent, and a vena cava filter, which
Fig. 2 There are a range of
purpose-designed devices now
available. A Amplatz gooseneck
snare (ev3). B Trefoil En-Snare
(Merit Medical). C Dormia
baskets. D, E Alligator retrieval
forceps (Cook Medical and
ev3). F Myocardial biopsy
forceps (Cook)
890 J. B. Woodhouse, R. Uberoi: Intravascular Foreign Body Retrieval
123
4. were all removed from various locations. Snares have an
excellent safety profile and are relatively atraumatic. They
are simple to use and are effective for achieving a good
success rate of IFB retrieval, even in inexperienced hands.
The loop snare provides good perceptual feedback: oper-
ators have a good feel for the purchase they have on the
ensnared device.
Proximal Grab Technique
The proximal grab technique is the basic technique in using
a snare. An appropriately sized snare for the vessel is
used—that is, a snare loop size equal to or slightly smaller
than the vessel diameter. This is delivered via a straight
guide catheter, typically either a 4F or 6F guide catheter.
Once the snare is in position within the target vessel, the
outer catheter is withdrawn, allowing the snare to open
fully within the caliber of the vessel. The whole system is
then advanced to position the open loop around (or around
a selected part of) the lost IFB. The loop is closed by
advancing the catheter to tightly trap the IFB, and the
whole system and IFB are retrieved back to the sheath.
A prerequisite for this technique to be successful is a free
end on the IFB on which to grasp. If this is not the case,
then there are two options: either approach from a different
direction (via another puncture site), or use a shaped
catheter such as a SOS Omni or a balloon that can be used
alongside the snare to tilt or displace the IFB in a con-
trolled manner to allow a free end to be present itself. The
main drawback with the snare is that once the IFB is
captured and the loop is closed, the IFB will want to rotate
into a position perpendicular to the snare catheter (Figs. 3,
4). This is not a problem with nonrigid IFBs that can fold in
half (Figs. 4, 5). However, this can be a significant problem
with rigid IFB and can prevent the negotiation of these IFB
through narrow vasculature, and across vascular junctions
without risk of vessel damage or perforation. To offset this,
it is better to grasp the object at one end so that there is a
natural trailing edge that helps keep objects aligned with
the vessel axis. Even when vessels have been negotiated it
may still prove impossible to retract into even a large
sheath. To facilitate retrieval into a sheath, a second snare
can be used from a different vascular access point to apply
Fig. 3 Proximal grasp technique. When a snare is used to grasp an
object, it tends to pull that object perpendicular to the axis of the
catheter/constraining vessel (A, B). It is better to grasp the object at
one end so that there is a natural trailing edge that helps keep objects
aligned with the vessel axis (C). This is the most basic use of a snare
Fig. 4 A fragment of catheter sheared off in the left external iliac
artery during an angioplasty procedure and was retrieved using a
snare via a sheath in the right common femoral artery. The catheter is
seen to be turning to an axis perpendicular to the vessel/snare
catheter. However, it could still be retrieved because it was flexible.
More rigid objects risk causing vessel wall damage in this situation
J. B. Woodhouse, R. Uberoi: Intravascular Foreign Body Retrieval 891
123
5. a rotation torque to a IFB (Fig. 6). Snares can also ‘‘cheese
wire’’ soft catheters in half if too much force is used
turning one IFB into two.
Distal Wire Grab Technique
The distal wire grab approach can be attempted if a guide
wire can pass through the IFB. A microsnare is used to
track alongside and past the IFB, and then the snare is used
to capture the distal end of the guide wire that crosses the
IFB. In this manner, the IFB is constrained between the
guide wire and the snare catheter. This technique is useful
to keep a IFB aligned parallel to the catheter/vessel axis.
A stiff guide wire is advantageous (e.g., the Amplatz super-
stiff wire) (Fig. 7A, B).
Coaxial Snare Technique
The coaxial snare technique uses a guide wire and a snare
to reduce the angulation between the foreign body, the
snare, and the sheath. This technique is only possible with
tubular foreign bodies. The goal is to pass a guide wire
through the lumen of the IFB. The snare is then positioned
around the guide wire that then becomes a monorail to
guide the snare loop distally. At the proximal pole of the
tubular IFB, the snare loop is opened and is used to capture
the IFB and the guide wire together. The guide wire is now
entrapped within the snare loop, and traction can be used to
provide torque and to guide the proximal pole of the IFB
into the sheath (Fig. 7C). Seong et al. [15] demonstrated in
seven cases that this technique could be used to reliably
reposition various lost tubular IFBs such that a snare and a
minimum-sized sheath could be used to retrieve lost IFBs
without the need to fold the IFB.
Lateral Grasp Technique
The lateral grasp technique is a variation on the distal grasp
technique. In this approach, the snare is deployed distal to
the IFB and opened widely. Next, a rigid guide wire is
passed around the other side of the IFB and then through
the snare loop. The snare is closed and grasps the guide
Fig. 5 The catheter segment of a Port-A-Cath detached from the
subcutaneous hub and migrated into the right pulmonary artery.
AnEnSnare (white arrow) device was used to retrieve the catheter
fragment (black arrows) because it provided excellent flexibility
tonegotiate the cardiac chambers. A Pulmonary angiogram revealing
catheter fragment. B, C, D The EnSnare grasping and retrievingthe
trailing catheter fragment
Fig. 6 In a domestic accident, a builder’s nail became a high-velocity
projectile and perforated the patient’s skin. It was eventually located
in the right hepatic vein. A A snare (Amplatz gooseneck snare, ev3)
using the proximal grasp technique was used to capture the nail.
Although it could be negotiated back to the sheath in the right femoral
vein, it would not enter the sheath. B, C A second snare (EnSnare,
Merit Medical) was used via the left femoral vein to snare the other
end of the nail and provide counter traction, allowing the nail to be
aligned with the sheath, and the nail was successfully explanted
892 J. B. Woodhouse, R. Uberoi: Intravascular Foreign Body Retrieval
123
6. wire. Both guide wire and snare catheter pinch grip the IFB
between their shafts (Fig. 7D, E).
Stone Retrieval Baskets/Dormia Baskets
The Dormia basket is a well-known device that is often
used in the biliary system, but it can also be used for
endovascular retrievals [8, 12, 13]. It is made from two
loops of Nitinol wire spirals that unfurl on deployment
without significant risk of vessel wall damage. A sheath is
used to open and close the basket and can easily be used
by a single operator with one hand. The device provides
good haptic feedback and is narrow (less than 3F), so it
can be passed down a narrow guide catheter and access
small-caliber vessels. It can unfurl, providing a wide loop
that is advantageous to encircling the IFB. Because it is
not a device dedicated to IFB retrieval, it is also relatively
cheap (in contrast to the snare). In our personal experi-
ence, we found it particularly useful, especially in larger-
caliber vessels. The disadvantage of baskets is that they
are difficult to guide. Some makes of Dormia basket also
have a rigid tip that poses a risk of endothelial wall
damage.
Sheth et al. [16] reported a series of IFB retrieval with
the use of Dormia baskets reporting 100 % success with
percutaneously grasping the IFB, and a subsequent retrie-
val rate of 96 % (success in 25 of 26 procedures). They
found that it was possible to remove virtually all IFBs with
a Dormia basket by itself or in combination with a Side-
winder catheter, which was used to mobilize the IFB to a
point where it could be captured. The IFBs included stents,
embolization coils, guide wires, a pacemaker lead, and
catheter fragments. Their only case of unsuccessful IFB
removal was a guide wire that had been lost in a leg vein
and not noticed for over a year. They reported no proce-
dural complication after prolonged follow-up.
Small Balloon Catheter Technique
The small balloon technique is useful in the retrieval of lost
stents [13, 17, 18]. This technique necessitates that a guide
wire traverses through (part of) the IFB. This guide wire
can then be used to guide a low-profile-design noncom-
pliant balloon catheter within or distal to the lost IFB. It is
important to select an appropriate retrieval balloon. If it is
too big, the balloon will not pass through the IFB and will
push the IFB further. If it is too small, the balloon will not
capture the IFB once inflated.
The balloon is inflated within the stent to a low pressure
only sufficient to engage the stent but not to expand it. If the
Fig. 7 A, B Distal wire grab
technique. The guide wire is
passed through the foreign
body. The snare is passed
distally alongside the foreign
body and captures the guide
wire distally. The foreign body
is maintained in alignment with
the vessel axis. C Coaxial grasp
technique. A stiff guide wire
through the foreign body helps
maintain the axis of the
construct along the line of the
guide catheter and constraining
vessel. D, E Lateral grasp
technique, demonstrated with a
stent. The wire and the snare
pass on either side of the foreign
body (i.e., the wire need not
pass though the foreign body).
The guide catheter is then
advanced to close the
construction and entrap the
foreign body
J. B. Woodhouse, R. Uberoi: Intravascular Foreign Body Retrieval 893
123
7. balloon is deployed distal to the lost IFB, then it is gently
pulled back until it engages with the IFB and the whole unit
can then be gently trawled back to either the sheath or a
suitable proximal landing zone. In cases of maldeployed or
misdeployed stents, a balloon of suitable size can then be
used to fully deploy the stent in a suitable alternative landing
site. If the device cannot be retrieved into a large peripheral
access sheath, then the balloon can be left inflated to secure
the IFB until it can be accessed via open surgery.
It is important to avoid the guide wire passing through
the struts of the stent and to have the guide wire pass
directly through the stent lumen. If this occurs, it is still
acceptable to use the balloon to dilate a path through the
stent wall to allow distal delivery of a retrieval balloon.
The small balloon technique can also be used in con-
junction with a loop snare to facilitate getting the snare loop
fully around an open stent [19]. The loop snare is positioned
around the proximal aspect of the angioplasty balloon that is
then inflated within the presenting part of the stent. This
brings the snare loop into alignment with the stent. The
snare can then be advanced over the inflated balloon and
stent (Fig. 8). The snare can then be used to either grip the
balloon and stent together to apply traction and reposition
the stent, or the balloon can be removed and snare used to
crimp down the stent over the guide wire (Fig. 9). The
haptic feedback with this technique is limited, but despite
this limitation, this technique has a good success rate for
stent retrieval of approximately 50–70 % [11, 20].
Guide Wire Techniques
IFBs have been successfully retrieved without the use of a
specialized retrieval device by only utilizing a guide wire
[13]. In some, the guide wire succeeded where a special-
ized retrieval devices had failed.
Guide Wire as a Snare
As discussed previously, a guide wire can be used with a
catheter to construct a homemade loop snare. Lee
described a technique in which a guide wire was used to
capture a lost coil from the distal middle cerebral artery.
An attempt at using a 2-mm gooseneck snare had
already failed and had pushed the lost coil further dis-
tally. Consequently, a microcatheter was manoeuvred
distal to the coil, and a 0.010-inch microwire, the tip of
which had been manually shaped into a pigtail, was
introduced through the microcatheter. The microcatheter
was then pulled back proximal to the coil and the
microwire pulled proximally until the shaped tip came
into contact with the coil. The microwire was then
rotated so that the pigtail entwined with the coil, and the
guide catheter was advanced to capture the coil with the
guide wire tip [21].
Hairpin Trap Technique
The hairpin trap technique, described by Brilakis et al.
[22], was used to capture a misplaced stent. The distal
centimeters of a narrow guide wire (e.g., a 0.010- or
0.014-inch wire) is folded over to make a hairpin shape.
This is inserted into a guide catheter and is passed through
the stent, then pulled back and used to hook the lost stent.
The distal tip of the wire is then guided back into the
guiding catheter, where it is then trapped by a balloon,
forming a hairpin trap. The entire system is subsequently
withdrawn.
Two-wire Technique
With the two-wire technique, one guide wire is passed
through the stent lumen and another, stiffer wire was pas-
sed into the stent with the expectation that the stiff wire
would pass through the stent struts and not through its
lumen. Once this second wire transfixes the stent, both
wires are held together by a torque device and then rotated
around each other multiple times until the rotation of the
entwined wires is seen to reach the lost stent. This
Fig. 8 Small balloon technique used in conjunction with a loop snare
to capture a stent. An appropriately sized balloon is used over a guide
wire through the stent. A snare can be railroaded over the balloon to
the proximal end of the stent. Once in position, the balloon is inflated
to bring the loop snare flush with the presenting aspect of the stent.
The snare loop is then advanced to encircle the stent
894 J. B. Woodhouse, R. Uberoi: Intravascular Foreign Body Retrieval
123
8. intertwining of the wires produces sufficient force to cap-
ture the lost stent to allow retrieval from the coronary
vessel [13]. For this technique to work, the guide wire must
be of sufficient stiffness to apply a pincer-like grip around
the lost stent
Intravascular Retrieval Forceps, and Biliary
or Myocardial Biopsy Forceps
Dedicated intravascular forceps are now available with a
variety of slightly different constructions. They have side-
opening jaws and are able to pass within guiding catheters
and have shapeable guide wire tips to help steer. They
come in a range of sizes from 12F down to 3F. The
advantage of forceps is that they do not need to have a free
edge presenting, like a snare requires. The risk with forceps
is causing vessel wall damage or perforation. These devices
are still relatively high risk for causing iatrogenic damage
and should be used judiciously; adequate training is needed
for efficient and safe use. Before the development of
dedicated intravascular forceps, the use of biliary, urolog-
ical, or myocardial biopsy forceps was described by several
authors to retrieve lost IFBs (Fig. 10) [12, 13, 23, 24].
Eggebrecht et al. [11] utilized myocardial biopsy forceps in
3 of 20 cases of lost stent retrieval and had primary success
in of 2 of these cases. In the third case, a gooseneck snare
had already failed to retrieve the stent, and the stent was
finally retrieved via the small balloon technique. The
technique for using intravascular forceps is to use multi-
planar fluoroscopy to carefully position the forceps adja-
cent to the IFB, to then grasp the IFB and retract the system
en bloc [25]. Resistance should raise concerns about the
inadvertent entrapment of vessel wall, and forced reposi-
tioning should not then be attempted.
Discussion
The low incidence of IFBs means that there is a paucity of
robust data in the literature. In most case series, IFB
explantation is associated with 100 % survival [26]. In
untreated cases, the incidence of death or serious compli-
cation is reported to range 60 % to 71 % [26, 27]. Com-
plications include thrombophlebitis, sepsis, arrhythmia,
myocardial injury, bacterial endocarditis, vessel occlusion,
ischemia, and cardiac perforation.
Undoubtedly, primary prevention of IFB is the ideal.
Approaches to this end should encompass adequate training
of staff manipulating percutaneous part-intravascular
devices, because inappropriate device handling is often the
root cause of subsequent device failure and embolization.
Some of the devices or techniques cited above are infre-
quently used (e.g., endovascular forceps), and thus ade-
quate training is a key aspect in preventing further
Fig. 9 The small balloon technique was used to reposition this
displaced transjugular intrahepatic portosystemic shunt stent. A The
Viatorr stent is initially deployed into satisfactory position. B The
stent graft is inadvertently dislodged distally into the portal conflu-
ence. C The balloon is inflated across the proximal end of the stent,
facilitating snare placement. D The whole system has been slowly
withdrawn into the parenchymal track. E The balloon has been
deflated and the snare removed. Venography reveals satisfactory
position. Reproduced with permission from Kirby et al. [19]
J. B. Woodhouse, R. Uberoi: Intravascular Foreign Body Retrieval 895
123
9. complications that may result from the inappropriate or
unskilled utilization of unfamiliar devices.
If preventative strategies fail, the best management is
usually to obtain timely and urgent retrieval of a lost IFB.
Clearly the risks and benefits should be judiciously bal-
anced, and our view is that multidisciplinary team/peer
discussion is advisable in all cases. It is important to
remember that it may not always appropriate or possible to
retrieve a lost IFB by the endovascular approach. Open
surgical retrieval may be required in approximately
6–10 % of cases [10, 20, 28].
Once the decision has been made to attempt retrieval via
an endovascular approach, it is essential to adequately plan
the procedure. Percutaneous access sites should be care-
fully considered, and access sheaths should be of sufficient
size. In the case of lost stents, frequently it is easier, safer,
and quicker to identify a suitable vascular bed within which
the lost stent can be safely and permanently parked. This
strategy can help minimize patient trauma and radiation
dose. The construction of the IFB is important to consider.
Palmaz stents can be crimped down again with a snare, but
this is arduous; repositioning the stent is simpler. Nitinol
stents will be refractory to crimping down or to overex-
pansion because of Nitinol’s thermal memory properties.
With Nitinol stents, the deployment of a second rigid stent
within the first can allow overdilation of the Nitinol stent
and facilitate its repositioning. Once retrieved, the speci-
men should be sent for bacteriological evaluation.
Conclusion
The rise in the frequency of endovascular therapies has
meant that complications, including IFBs, have increased.
Interventionalists need to have a range of techniques,
equipment, and tricks available to facilitate the retrieval of
these items. The endovascular approach has repeatedly
been demonstrated to have a high success rate with a low
associated morbidity, and it avoids complications related to
open surgical approaches.
Conflict of interest The authors declare that they have no conflict
of interest.
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