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Relevant clinical history and physical exam
A 73 year-old female admitted to our hospital due to intermittent claudication, resting pain and cyanosis of her right leg. She under went endovascular therapy (EVT) for her right superficial femoral artery (SFA) and below the knee artery (BTK) 1 year ago.
Relevant test results prior to catheterization
Both perforation of SFA after implantation of a stent and femoral arterial access complications due to a vascular closure device happened during those procedures, but we could manage to recover the situations and symptoms were improved. Nevertheless, she had the recurrence of intermittent claudication, resting pain and cyanosis of her rt. leg again. Ankle-brachial index was immeasurable and 0.95 on the right and left side, respectively. Skin perfusion pressure (SPP) was 15 mmHg and 11 mmHg in the dorsal and plant arregions of her right leg, respectively. CT angiography and duplex echo revealed a restenosis in the right SFA and occlusions in the below the knee arteries. Both bypass graft surgery and EVT were suggested as a method of treatment and, following obtaining informed consent, she selected EVT.
Relevant catheterization findings
A 6Fr, 45cm-long Parent plus sheath (Medikit, Tokyo, Japan) was inserted from her right common femoral artery (CFA) with difficulty due to severe calcification.Initial angiography showed similar findings to what CT angiography and duplex echo revealed beforehand.
A 0.014 guide wire was successfully advanced from SFA to dorsalis pedis artery (DPA). Balloon angioplasty used by 6.0 x 40 mm balloon and 2.0 x 220 mm balloonat SFA and anterior tibial artery, respectively, was performed. Final angiography revealed successful revascularization from SFA to DPA. To exchange fora vascular closure device, the Parent plus sheath was removed with difficulty leaving the 0.035 guide wire in the vessel. We immediately took notice of the fracture of the Parent plus sheath and could confirm that a the tip of the sheath was still in the vessel using fluoroscopy. Immediately, after the complication we performed distal protection by external compression with a tourniquet below the knee in order to prevent the tip from being carried away distal. A 6Fr, 11 cm-long sheath was inserted from her right CFA, but, unfortunately, the tip migrated to the distal part of SFA during this procedure. A 0.014 guidewire was advanced through the tip and a low profile balloon was passed through and pulled back while being inflated in order to retrieve the tip, but we failed. After that procedures, A 3 Fr retrieval forceps was inserted and we could trap the tip, but only the radio paque marker came free, leaving the tip behind. Subsequently, we used a 5.5Fr biopsy forceps to catch and hold it tightly and successfully retrieved it out of the body with nothing left behind.
Complications related to breakages of angioplasty hardware such as guiding sheaths, a guiding catheters, guide wires, balloon catheters, and stents have remained an un ignorable problem. Although various methods and devices have been invented to decrease those complications,we still must manage to bail out by using alternative techniques when encountering those situations.
Failure to retrieve those hardware fragments may lead to surgical solutions, or result in a serious problem such as major amputation especially in patients with critical limb ischemia. Here in we present a first case report of a fractured guiding sheath and a novel endovascular technique to retrieve the broken tip utilizing a biopsy forceps.