PRACA KAZUISTYCZNA

Successful percutaneous retrieval of a dislodged J-tip guide wire by a self-constructed snare in a 75-year-old patient: a safe and feasible approach

Skuteczne usunięcie przemieszczonego prowadnika z końcówką w kształcie „J” za pomocą samodzielnie skonstruowanej pętli u 75-letniego pacjenta — bezpieczna i dostępna metoda

Santosh Kumar Sinha, Mukesh Jitendra Jha, Divendu Khanra, Avinash Kumar Singh, Vikas Mishra, Pradyot Tiwari, Ramesh Thakur

Department of Cardiology, LPS Institute of Cardiology, G.S.V.M. Medical College, Kanpur, India

Address for correspondence: Santosh Kumar Sinha MD, FAESC, Asst. Professor, Department of Cardiology, LPS Institute of Cardiology, G.S.V.M. Medical College, G.T. Road, Kanpur, Uttar Pradesh 208002, India, e-mail: fionasan@rediffmail.com

Introduction

Temporary pacing lead insertion is done before permanent lead implantation. Complications may arise in as many as 5–8% of these procedures, although loss of the guide wire is rare. Non-invasive retrieval of intravascular foreign bodies has become a preferred approach for intravascular objects removal since the first report by Thomas et al. in 1964 [1]. Further efforts with various techniques have lead to higher success rates and low complications. Herein, we report retrieval of a dislodged J-tip guide-wire by self-constructed snare in a 75-year-old woman.

Case report

A 75-year-old woman was admitted with recurrent episodes of syncope following post pacemaker implantation two weeks back. Her electrocardiogram was showing complete heart block with the right bundle branch block (RBBB) type of ventricular escape and there was loss of pacemaker capture. Her pulse rate was 30/min. Her vitals were stable with normal biochemistry. Echocardiogram was normal. There was dislodgement of lead which was evident on fluoroscope (Figure 1).

Figure 1. Dislodgement of permanent pacing lead (red arrow), embolised J-tip guide wire (black arrow) and temporary pacing lead (black arrowhead)

Temporary pacemaker implantation was done through the femoral route after obtaining proper consent as bail out procedure. After infiltrating the skin with 2% xylocaine as local anaesthesia, the femoral vein was punctured. A 6 F 11 cm INPUTTM TS introducer sheath (Medtronic, USA) was inserted into the femoral vein. Temporary pacing lead was put and regular pacing was obtained but J-shaped 0.038’’ wire was left inadvertently (Figure 1, 2). Fluoroscopy was performed to check for dislodgement. Distal fragment was found in the right superior vena cava whereas proximal was in inferior vena cava (Figure 2).

Figure 2. Distal fragment of J-tip guide wire was seen in the right superior vena cava

The patient was asymptomatic. Retrieval was planned, but we had no snare available at that time. The right cephalic vein was punctured using extra-thoracic technique under fluoroscope and a 7 F 11 cm INPUTTM TS introducer sheath (Medtronic, USA) was inserted taking utmost care not to injure the permanent pacing lead. A 0.014” 180 cm percutaneous transluminal coronary angioplasty wire was taken and its loop was passed through standard 6 F JR4 Proflo® guiding catheters (Medtronic, USA), the lengths of which were shortened by cutting 20 cm from the tip to accommodate the loop, as the length of both the JR4 and the loop was 90 cm, and thus a snare was constructed by catching both free ends with arterial forceps (Figure 3).

Figure 3. Self-constructed snare being caught by both free ends with arterial forceps

Guiding catheter was passed into the venous sheath over 0.035’’ terumo straight tip wire and parked into inferior vena cava below the proximal tip of venous wire. Terumo wire was then withdrawn. Customised snare was passed through guiding catheter and the embolized fragment was tried to be retrieved but failed (Figure 4).

Figure 4. Snare was passed through guiding catheter and the embolized fragment was tried to be retrieved but failed

Snare was removed then and a small curve was provided 2–3 cm. proximal to distal tip (Figure 3). This snare was re-introduced into the inferior vena cava under fluoroscopic guidance and the embolized fragment was successfully retrieved (Figures 5, 6). Ventricular pacing lead (passive fixation lead-Selox ST 60, Biotronik) was repositioned and parameters were tested. The patient was discharged in stable condition after one week with regular capture and regularly following up since then.

Figure 5. Embolized fragment was successfully trapped by snare

Figure 6. Snare with embolized fragment after successful retrieval

Discussion

Percutaneous retrieval of intravascular foreign bodies was first introduced in 1964 by Thomas et al. [1], presenting non-surgical retrieval of a broken segment of steel spring guide from right atrium and inferior vena cava. Today it is a more frequently applied technique as varieties of intravascular foreign bodies (including coils, stents, vena cava filters, etc) has increased because of numbers of interventional procedures has skyrocketed [2]. So, multiple options in the form of snares, biopsy forceps, dormia basket or tip deflecting wires are being utilized as retrieval tools depending on the need [3–5]. Retrieval of foreign objects by snare is more convenient but manier times commercial nitinol gooseneck micro snare are not available. Infection, thrombogenicity, distal ischemia, perforation of chambers and thromboembolism are the usual complications depending on the type of foreign object. Guide wires in venous system can damage or embolize the vessel’s wall,so requires their immediate removal [6]. Patients with cardiopulmonary localization of foreign objects are at risk of severe complications varying from cardiac arrhythmia to perforation of cardiac chambers [7]. The success rate of retrieval of dislodged guide wires about 90% [8]. Self-constructed snare as in our case offers a great chance of rotational capabilities and a wider diameter to grasp the foreign object. Its profile also makes it extremely handy to guide into desired position. In addition, its cost-effectiveness makes it less of a burden to the patient. When snare was straight, it was not able to catch-hold the embolised wire but once it was little angled by a providing a proximal curve, job was easily done. Greatest advantages of self-constructed snares are that they can be shaped depending on the need. Percutaneous removal should be the first choice in the management of intravascular foreign bodies and should be performed as soon as the diagnosis is made.

Conflict of interest(s)

Authors declared no conflict of interest(s).

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