case_images: PMC2713984_01
case_images: Ex-vivo study of the retrieval of a large-bore sheath fragment (8-F internal diameter and 10-F outer diameter) using a modified coaxial snare technique.. A. In the large-bore fragmented vascular sheath, the simple coaxial snare technique does not allow engagement between the fragment and the 10-F or 12-F introducer sheath. The overall profile of the coaxial retrieval system is more than 14-F, with a shoulder between the 10-F introducer sheath (black arrow) and the sheath fragment (white arrows).. B. The loop snare introduced through the smaller sheath (10-F) captures the fractured vascular sheath. Separate access is obtained via the larger sheath (12-F), and the central lumen of the fractured sheath is located with an angiographic catheter and guidewire.. C. After engaging a dilator (small black arrow) at its end, the fragmented sheath (white arrow) is seen to be smoothly aligned with the introducer sheath (large black arrow).
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case_images: PMC2713984_01_kjr-3-30-g003.jpg
case_images: F3
case_images: To this end, we used the modified coaxial technique illustrated in the ex-vivo study (Figs. 3B, 3C), inserting another 12-F vascular sheath (13 cm in length).
case_images: Relocation of a stent employed in a TIPS procedure using the coaxial snare technique.. A. The deployed nitinol stent has migrated caudad to the main portal vein. The inflated gastric balloon signifies that the patient is actively bleeding.. B. The loop of an Amplatz gooseneck snare is introduced over the preexisting guidewire and positioned around the stent.. C. After a loop snare was used to squeeze the proximal end of the stent, this was pulled back and relocated to its appropriate position.. D. A digital subtraction angiogram obtained after relocation shows rapid flow from the superior mesenteric vein to the right atrium via the created TIPS tract.
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case_images: PMC2713984_01_kjr-3-30-g004.jpg
case_images: F4
case_images: Watertown, Mass., U.S.A.). We tried to place a 10 mm-diameter, 8 cm-long Niti-S stent (Taewoong, Seoul, Korea) in the tract, but during deployment it migrated caudad to the main portal vein (Fig. 4A). Amplatz gooseneck snare, its loop 25 mm in diameter, was introduced over it and positioned around the stent (Fig. 4B). After capturing and pulling the far proximal end of the stent by tightening the loop (Fig. 4C), we were able to relocate the stent to its appropriate position (Figs. 4C, 4D).
case_images: Retrieval of a large-bore sheath fragment using a modified coaxial snare technique.. A. During bedside placement of an internal jugular venous catheter, the tip of this sheared off and lodged in the right atrium. The fragment was captured by a gooseneck snare and pulled back into the inferior vena cava.. B. The femoral vein was punctured a second time, just above the puncture site for the loop snare, and a 12-F vascular sheath was introduced. With the assistance of a loop snare, the fragment has successfully engaged with the dilator of the vascular sheath.. C. The whole system was slowly withdrawn until the sheath fragment appeared at the puncture site. The linear mark represents the puncture site for the loop snare.
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case_images: PMC2713984_01_kjr-3-30-g005.jpg
case_images: F5
case_images: Under fluoroscopic guidance, we inserted a 10-mm gooseneck snare through the right common femoral vein, successfully grasping the fragment and carefully pulling it back into the inferior vena cava (Fig. 5A). The puncture site was more cranial to the previous one, used for insertion of the loop snare; the central lumen of the fragment was carefully located using an angiographic catheter and guidewire, and the dilator for the vascular sheath was then introduced over the guidewire (Fig. 5B). It was grasped with forceps and successfully extracted after release of the loop snare and careful compression of the puncture site (Fig. 5C).
case_images: Retrieval of a catheter fragment (10.2-F) from the renal pelvis using the coaxial snare technique.. A. Because the fragmented catheter was tightly attached to the wall of the pelvocalyceal system, other method failed to capture it.. B. After passing a guidewire through the catheter lumen, the end of the catheter was easily captured by a loop snare introduced coaxially over the guidewire. A second small fragmented catheter tip is also seen.. C. Photograph of the entire extracted retrieval system. The catheter fragment is firmly grasped by the retracting loop snare, and for smooth extraction, a 10-F dilator has been introduced into the catheter fragment over the guidewire.
case_images: kjr-3-30-g006.jpg
case_images: PMC2713984_01_kjr-3-30-g006.jpg
case_images: F6
case_images: We used a homemade loop snare and Amplatz gooseneck snare, also employing the 'in-situ loop snare' technique, as described by Savader et al., but because the fragment was tightly wedged against the wall, were unable to withdraw any part of it (Fig. 6A). Amplatz loop snare over the guidewire and easily capturing the proximal tip of the catheter fragment coaxially (Fig. 6B). A dilator was introduced over the guidewire to eliminate the shoulder between it and the cut catheter end and to allow smooth extraction with minimal injury to the access route. The entire system was successfully extracted by simultaneously withdrawing the snare and dilator through the tract (Fig. 6C).