Intravascular foreign bodies that cannot be retrieved are associated with a high morbidity and mortality rate, reaching rates as high as 71% (Fisher and Ferreyro 1978). Most reported cases of broken catheter retrievals involve the venous circulation, where larger fragments may migrate into the right ventricle and pulmonary circulation. Intra-arterial cases, on the other hand, migrate more distally as a result of blood flow and are at a higher risk for bleeding and embolization during retrieval. Despite the high incidence of broken catheters within arterial vasculature, the retrieval of these foreign objects is rarely reported (Ramachandran et al. 2016; Gupta et al. 2005). Turning to surgical options are associated with high morbidity as well, especially if patients are critically ill and require less invasive approaches (Hehir et al. 1992).
Percutaneous removal provides a variety of options and is considered safer with less morbidity. Various techniques are available for percutaneous removal of intravascular foreign bodies such as loop snare, proximal and distal grab technique, coaxial snare technique, lateral grasp technique, dormie baskets, and small balloon catheter technique. Of these various techniques, the loop snare method is most frequently employed (Egglin et al. 1995; Carroll et al. 2013). Loop snares are widely available and have the advantage of being flexible enough to follow a variety of curvatures related to vascular anatomy (Tytle et al. 1995; Koseoglu et al. 2004). The inception of nitinol-based loop snares have added additional flexibility as they are able to maintain their shape within the blood vessels. However, loop snaring is limited by their variable gripping ability and can be of limited utility if the free ends of the foreign body are not available to snare. Out of the reported failures of the catheter snaring strategy, getting the fragment ends onto the same plane as the snare is a commonly cited difficulty (Gupta et al. 2005; Rossi 1970).
The balloon-assisted strategy has certain advantages that should be highlighted, particularly when working within the arterial system. With small, more delicate foreign objects, there is always the concern that forceful pulling, either via snaring or blunt pulling, will cause further fragmentation, which can account for up to 60% of endovascular loss during retrieval (Carroll et al. 2013). A prior study demonstrated 40% of patients with arterial foreign bodies using snare technique suffered occlusive arterial spasms or repositioning to another vessel that was amenable to surgical cutdown (Egglin et al. 1995). The balloon assembly would minimize the risk for further comorbidities by not localizing the traction to any particular point on the catheter or vascular wall. The balloon technique described here has previously been utilized for retrieving lost stents, primarily in the setting of interventional cardiology procedures (Gupta et al. 2005; Karaca et al. 2016; Mehta et al. 2014). In a prior study, only 2/24 (8.3%) endovascular retrievals were performed using balloon catheters, both of which were used to retrieve broken catheter sheaths. Out of these two procedures, only one was successfully performed, while the other was left in place (Carroll et al. 2013). The benefits of inline balloon retraction of foreign bodies over snare-based techniques have been described by Gupta et al. (Gupta et al. 2005). The technique described here builds upon that principle by advancing the ballon past the distal end of the catheter fragment; this allows 1) more secure capture of the fragment, 2) requires less inflation of the balloon, and 3) minimizes potential trauma to the vascular endotherium and intima.