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CASE20191012_001
ENDOVASCULAR - Complications
Retrieval of Foreign Body During a Diagnostic Procedure
Kamal Pasha1
Square Hospitals Ltd Dhaka, Bangladesh1,
[Clinical Information]
- Patient initials or identifier number:
Mrs. JA
-Relevant clinical history and physical exam:
Presentation:Mrs.JA, a 40 years old lady presented to us with left sided hemiparesis due toischemic stroke 3 days ago. She also gave history of exertionaldyspnea.  Herpulse was 92 bpm, regular, symmetrical and of normal character. BP- 140/90mmHg  on Rt arm. Diminished motor function of left upper and lower limbs.Equivocal planter response on left side.  CADRisk Factors: Hypertension,DM T2.
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-Relevant test results prior to catheterization:
Lab Investigations: CBC, ESR – Normal. Blood glucose - Fasting –8.4 mmol/L, 2 hours post prandial – 10.2 mmol/L.Bleeding Time – 2 min. 45 sec.  Serum creatinine – 1.1 mg/dL. Serumelectrolytes – normal.Chest Xray P/A view – unremarkable. ECG –Non-specefic T wave changes.Echo 2D – No regional wall motion abnormalitywith LVEF – 55% and stage 1 LV diastolic dysfunction.
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- Relevant catheterization findings:
Angiographic findings:Coronary angiogram and Cerebral DSA wasperformed without any unremarkable findings.
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[Interventional Management]
- Procedural step:
Complication:For cerebral DSA H1 diagnostic catheter wasused. Someunexpected complication occurred after completion of the procedure whilebringing out the catheter. The distal 4-5 cm of the H1 catheter brokenspontaneously and separated from the rest of the catheter, was moving towardsthe right subclavian artery and apparently settled at the right axillary arteryregion.Itried to push the broken cath-tip with a regular J-tipped guide wire. Idea wasto send it to the brachial A.  And bringit out by brachial A. cut down. But soon we realized that it would be a wrongapproach. Wethen took a coronary guide wire through the main catheter and passed it throughthe broken part as well. Afterthat  a 1.5 X 10  mm balloon was taken and slightly inflated itwithin the dislodged catheter so that it can be pulled and hold  against the main catheter. Whole system wasthen pulled altogether. Unfortunately, the broken part dislodged again. Thebroken part was broken once again and both parts settled in the Right FemoralA. Another approach was made through Left Femoral A.  AJR catheter was taken through Left femoral A. A coronary guide wire was takenthrough it as well as through the embolized part. A 2.0X9 mm balloon was takenover it and inflated distal to the broken segment. Another attempt was taken tobring out the embolized part. Butsucceeded partially in doing so.
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- Case Summary:
Conclusions:Embolization of tip of catheter is unusual.Especially if occurs in such large caliber vessel without any tortuosity, itraises suspicion of the integrity of  the material (catheter, in this case) – inrespect of its composition, manufacturing, expiry date etc.  Sometimes,sterilization process/multiple use also responsible for weakening cathetermaterial subjecting it vulnerable to such an adverse complication. Examining the hard wires physically before usingis important for many preventable complications. Keeping retrieval equipment(s) ready (e.g.Snare – we didn¡¯t have at that time) is always necessary.
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