Remembering Interventional Radiology
Days
Image at left shows me in 2001, wearing a sterile surgical gown performing a percutaneous nephrostomy in the Interventional Radiology Suite. Note the plexiglass radiation shield suspended above the patient on the right, and the xray fluoroscope machine is at the upper right corner. The plastic bag at the lower right collects the urine from the nephrostomy tube in place in the kidney. Note that the urine in the bag is somewhat bloody, which is quite common immediately after puncturing the kidney. The urine clears to a more suitable amber color after a few hours of drainage. My assistant at the left was later promoted to administrative head of the radiology department.
A Fragment Lost in the Pulmonary Artery
The chest xray to the left is such a case which shows a swan ganz catheter fragment which has broken loose and ended up in the right pulmonary artery. This represents a foreign body, and if allowed to remain in place, causes infection, sepsis and ultimately death. The catheter fragment must be removed. How to Remove the Foreign Body
There are two methods used for removal. The first, rather extreme method, is open heart surgery performed under general anesthesia in the operating room. The chest is opened, pulmonary artery clamped, an incision made into the artery, and the catheter fragment retrieved.
Alternatively, they call the Interventional Radiologist to remove the lost catheter fragment in a much simpler procedure. This is done percutaneously, through a skin incision in the groin under local anesthesia in the X-Ray Department using the Snare Technique while the patient is awake and talking.(1)
The Snare Technique for
Intravascular Foreign Body Removal
At left is the "Snare". This is a loop wire-snare protruding from the angiographic catheter (dark green). This snare is looped around the fragment much like a cowboy would lasso a stray calf, pulled tight around its neck, and then the whole thing can be pulled. In this case, pulled out of the patient.
The Wire-Snare Technique for intravascular foreign body removal was well known. A major advantage is the percutaneous approach which involves puncturing the large vein at the right groin (the femoral vein), advancing a long angiographic catheter from there to the heart, through the heart and into the right pulmonary artery. Going through the heart was the tricky part because of all the pulsations and cardiac movement.(1)
Once in the pulmonary artery in the vicinity of the foreign body, a wire snare can be advanced through the angiographic catheter. This wire snare forms a loop as it protrudes from the end of the angiographic catheter (see image at upper left), and this loop can be manipulated around the foreign body. Once in position around the foreign body, the wire snare can then be pulled back which then closes the loop tightly upon the foreign body, and the whole thing can be pulled out safely.(4)
Chest Xray showing catheter fragment in the right pulmonary artery just before retrieval procedure.Unfortunately, I did not record the video of the critical part of the procedure, the snaring the foreign body. However, here is a link to a similar video from another hospital which shows the same thing.
(published in NEJM).
Pulling Out the Foreign Body
(upper yellow arrow shows snare in place pulling the fragment)
The above Chest Xray shows the catheter with the wire-snare (lower yellow arrow) going though the right ventricle of the heart. The tip of the snare (upper yellow arrow) protrudes from the angiographic catheter and loops around the foreign body fragment (red circle), holding it tightly.
Close up image at left showing the wire snare holding onto the catheter fragment which has been pulled back to the main pulmonary artery.
The snare (yellow arrow) holds the swan catheter fragment (red circle) tightly like a cowboy's lasso.
Foreign Body Safely Pulled Down to the Inferior Vena Cava
Image at left at the level of the L2 vertebral body shows the snare firmly pulling the swan catheter fragment down through the inferior vena cava. Both the snare and catheter fragment were easily pulled out of the right femoral vein puncture site through a sheath.
Click Here to Watch a Video Clip of the Procedure (5)
(this procedure was performed by Andreas J. Morguet, M.D. Berlin Germany)
Removing a Wire Lost inside the Patient
I remember another patient who came from another hospital with a diagnosis of infection in the blood with positive blood cultures. The chest x-ray had been repeatedly read as "normal" by many other doctors. However, when I looked at the chest xray, I saw a small white line over the right pulmonary artery that looked like a scratch on the x-ray film. This wasn't a scratch, it was a thin metal wire lodged in the artery which had been cut off and lost in the patient after a removing a central line at the previous hospital. This foreign body was causing the sepsis and positive blood cultures. We brought the patient down to the xray department into the Interventional Angiographic Suite and did a percutaneous removal with the snare technique. This was successful, and the patient had an uneventful recovery and shortly went home.(2)
Removing the The Knotted Swan Ganz Catheter - Inventing a New Technique
Another problem I encountered while doing my fellowship in angiography at Jackson Memorial hospital in 1980-1981 involved a patient who had a "knotted" swan ganz catheter. Occasionally in the ICU, the CVP catheters become so coiled up while in the pulmonary circulation, they loop and form a knot which prevents the ICU doctor from removing the catheter. This is a special problem called the "knotted swan ganz catheter", and after trying a few ideas, the knotted catheter was removed using a large polyethylene sheath which protected the soft tissues as the catheter knot weas pulled out. I actually published an article describing the invented technique which allowed removal of knotted catheters without major surgery.(7)
Gallbladder Drainage in the ICU
A totally different case I recall involved an old man who was septic in the ICU from a severely infected gallbladder which was usually treated with a surgical operation. However, in this case, the surgeon was unwilling to operate because of the patient's poor clinical condition made it unlikely the patient would survive surgery. As the interventional radiologist on call, it was my task to place a drainage tube into the gallbladder which could drain off the infected material and save the patient's life. Normally this procedure is done with combined ultrasound and fluoroscopic guidance in the X-ray department, in the interventional suite with benefit of all the imaging equipment. However, the patient was much too sick to leave the intensive care unit, so we had to get by with limited imaging at the bedside.
The gall bladder drainage procedure had to be done in the ICU, and the only available imaging equipment was a bedside portable ultrasound machine. I had been doing gallbladder ultrasound studies for 20 years, using ultrasound hands on for many interventional procedures to guide needle placement for biopsies and drainage procedures. This past experience made me more comfortable doing the procedure in the ICU with limited imaging.
The ultrasound machine allowed visualization of the gallbladder fairly easily and it was not difficult advancing the needle into the gallbladder. Correct needle placement was confirmed by returning green/black bile from the needle hub. Once bile was obtained from the needle, it was fairly straight forward to advance a guidewire through the needle into the gallbladder. The only problem was making sure the wire would stay inside the gallbladder while the larger drainage catheter was advanced over it. There was a risk that the guidewire would become dislodged and the drainage catheter slide out of the gallbladder into the subhepatic space. This, of course, would mean disaster because the leaking bile would cause bile peritonitis, and the patient's demise.
This disastrous bile leakage was avoided by advancing enough wire so that it coiled nicely into the gallbladder. Normally this was done under fluoroscopic guidance, but in the ICU, there was no fluoroscope, so this had to be done "blind " without imaging going by the "feel" of the guidewire. I had enough experience over the years, so I knew the distinctive feel for each step. Luckily everything went well, and when the guidewire was removed from the drainage catheter, green bile was aspirated from the catheter indicating correct placement, later confirmed with a portable radiograph. The surgeon congratulated me for a procedure well done which saved the patient's life. For me, it was all in a day's work.
My Second Medical Career in Natural Medicine
Do I miss the excitement and challenge of the Interventional Radiology days? Of course I do. However, because of my detached retina and multiple eye surgeries to correct the detachment, I no longer have the eagle eye required for my old job in radiology. I took this "time out" opportunity to attend meetings and retrain in a second medical career, which is natural medicine and bio-identical hormone therapy. About two years ago, I founded the TrueMedMD Clinic in Hollywood, Florida, devoted to the practice of natural medicine. Gratefully, the response of the community has been overwhelming with a schedule now booked well in advance. Our product is simple, we deliver a level of health care surpassing conventional mainstream medicine. Our medical practice is indeed, "The Revolution in Modern Medicine", a tentative title for my new book underway and soon to be published.
Jeffrey Dach MD
7450 Griffin Rd Suite 180/190
Davie, FL 33314
Phone: 954-792-4663
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References
(1) http://www.ajronline.org/cgi/content/full/176/6/1509
percutaneous Retrieval of Lost or Misplaced Intravascular Objects
Andreas Gabelmann1, Stefan Kramer and Johannes Gorich University Clinics of Ulm Germany. AJR 2001; 176:1509-1513
(2) http://bja.oxfordjournals.org/cgi/content/full/88/1/144
British Journal of Anaesthesia, 2002, Vol. 88, No. 1 144-146
Loss of the guide wire: mishap or blunder? W. Schummer1, C. Schummer2, E. Gaser2 and R. Bartunek3
(3) http://www.cookmedical.com/di/dataSheet.do?id=391
Needle’s Eye Snare For use in the percutaneous retrieval of indwelling catheters, cardiac leads, fragments of catheter tubing or wire guides, and other foreign objects.
A transfemoral grasping tool that forms a basket snare around the lead body. It is delivered to the vicinity of the lead through a long, flexible 12 Fr cannula that is placed coaxially within a larger outer cannula which has a hemostasis valve at its proximal end. (Two sizes of grasping tip. Requires no extra handle. 16 French Straight Femoral Introducing Equipment included.)
(4) http://www.hemodinamiadelsur.com.ar/journals/journal_124.asp
Transfemoral Snaring of Broken Catheters From the Right Heart in Small Infants
Kyung J. Chung, MD, Harvey L. Chernoff, MD, Lucian L. Leape, MD, and Marshall B. Kreidberg, MD
(5) http://content.nejm.org/cgi/content/full/352/4/e3/DC1#a2
Video Clip of Intravascular Foreign Body Removal with snare technique
Supplement to: Morguet AJ and Schultheiss H-P. Embolization of the Tip of a Central Venous Catheter into the Pulmonary Artery. N Engl J Med 2005;352(4):e3.
(6) http://content.nejm.org/cgi/content/full/352/4/e3
Embolization of the Tip of a Central Venous Catheter into the Pulmonary Artery
NEJM Volume 352:e3 January 27, 2005 Number 4 Andreas J. Morguet, M.D. Heinz-Peter Schultheiss, M.D. Charité–Campus Benjamin Franklin
12200 Berlin, Germany
(7) http://www.ajronline.org/cgi/reprint/137/6/1274
AJR Am J Roentgenol. 1981 Dec;137(6):1274-5. The knotted Swan-Ganz catheter: new solution to a vexing problem.Dach JL, Galbut DL, LePage JR.
(8) http://www.mirs.org/rounds/ir_retrievefrm.htm
Endovascular Retrieval of a Central Venous Catheter Fragment Todd Bostwick, MD
(9) http://journals.tubitak.gov.tr/medical/issues/sag-99-29-1/sag-29-1-17-97171.pdf
Percutaneous Retrieval of Broken Port Catheter Entrapped in the Right Atrium
(10) http://www.cookmedical.com/di/dataSheet.do?id=60
Curry Intravascular Retriever Sets Used to snare a foreign body and withdraw it to a peripheral vascular location. The special wire guide snare “folds” at midpoint and forms a loop when passed through the catheter.
Jeffrey Dach MD
7450 Griffin Road Suite 190
Davie, Florida 33314
954-792-4663
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