Teaching Case

A right internal jugular central venous line was inserted for antibiotherapy. The procedure was complicated by the inability to remove the guidewire. A surgical approach was attempted in the first intention because of the absence of an interventional radiologist in the hospital of origin, but it was unsuccessful. The guidewire was fixed to the skin to prevent it from moving and the interventional radiologist was called.

Plain film showed the intracranial position of the guidewire (figure 1).

Venous-phase contrast-enhanced CT showed the guidewire within the left transverse cerebral sinus. The distal extremity was impacted in bone through the intraosseous venula (figure 2).

No intracranial haemorrhage or venous thrombosis was detected.

The patient was asymptomatic and curative anticoagulation therapy was administered.

A 4-French right femoral arterial approach and a 7-French right femoral venous approach were used. The femoral arterial approach was used to obtain venography of the cerebral sinuses.

Right common carotid artery DSA (digital subtraction angiography) showed a kinking of the right internal jugular vein (RIJV) (figure 3).

RIJV catheterization was impossible because of its tortuosity, as well as capturing the distal extremity of the guidewire through the left internal jugular vein. Thus, we decided on a surgical approach.

The vascular surgeon removed the proximal extremity of the guidewire from the skin and the vein.

A purse-string suture was done around the guidewire for preclosure and a selfmade 5French introducer was threaded onto the guidewire (Figure 4).

A 5 mm snare (Snare Kit, Amplatz Goose Neck, EV3) was slid along the wire and the distal extremity was extracted by unhooking from the intraosseous venula.

The purse-string suture was closed and the surgical approach was sutured.

A cone-beam CT at the end of the procedure eliminated any intracranial bleeding.

Inserting a central venous line is a common procedure, with wide indications.

However, there may be different complications, such as thrombosis, infection and catheter or guidewire migration.

A lost guidewire is one of the most common intravascular foreign bodies [1] and indicates its removal.

Percutaneous extraction is the reference method.

Percutaneous extraction of intravascular foreign bodies has become a relatively common act, mainly due to the increased use of minimally invasive endovascular procedures.

The migration of intravenous devices can cause infectious, rhythmic, thrombotic and mechanical complications, depending on the location of the foreign body.

The rate of symptomatic patients with a fractured or embolized device is approximately 6% according to the literature. [2] [3]

Catheter extraction indications depend on the localization, time of migration and patient comorbidities.

Emergent indications for the extraction of foreign bodies are infection, cardiac rhythm disorders, vessel wall perforation and thrombotic risk. [4]

The migration of guidewires is mainly at risk of infection and perforation of the vascular wall.

Historically, open surgery was the only therapeutic option for the removal of foreign bodies. However more recently, percutaneous techniques have become available and are now considered as the reference method because of their efficiency and low rate of complications.

A snare loop is the most frequently used technique for percutaneous extraction, and is considered safe and efficient: 90% success rates have been reported with rare and minor complications.[3][5][6]

A right femoral approach is chosen in the majority of cases.

However, different approaches can be used, as in this report, to mobilise and extract the foreign body.

The snare loop passes around the foreign body before being tightened on itself to retrieve the foreign body. Using a snare loop requires a free extremity of the foreign body that is smaller than the diameter of the vessel and the snare loop.

Without a free distal extremity, a PigTail catheter can be used to remove the foreign body. [5]

A hybrid approach, combining surgical and percutaneous techniques, could help to overcome cases of impossibility to retrieve a foreign body using a classical approach.

Take-home messages

• Percutaneous techniques are the reference method for the removal of intravascular foreign bodies.
• Snare loop is the most frequently used technique.
• A hybrid approach combining surgical and percutaneous techniques can help to overcome cases of impossibility to extract the foreign body using a classical approach.

Written informed patient consent for publication has been obtained.