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226 PART 2: General Management of the Patient

Objects that have embolized in the vascular system cause septic com- Endovascular foreign body retrieval success rates are estimated at bet-
plications, perforating injuries of the vessel wall, and/or can serve as a ter than 90%. Failure can be due to endothelialization of the object into
nidus for thrombus formation and subsequent emboli. Cardiopulmonary the vessel wall or endocardium. In many of these instances, the retained
migration of foreign bodies poses risk of cardiac arrhythmias or perfora- foreign body presents a low risk to the patient and may be followed
tion. If a right-to-left shunt is present, such as with a patent foramen with imaging.
74
ovale, there is also a risk of paradoxic emboli and stroke.
Foreign body embolization is commonly asymptomatic and may be
unrecognized until incidentally noted on a diagnostic imaging study. On
the other hand, symptomatic migration may also manifest with palpita- KEY REFERENCES
tions, chest pain, cough, or dyspnea. Catheter dysfunction, including • Boyer TD, Haskal ZJ. American Association for the Study of Liver
inability to aspirate or localized pain or swelling with flushing, can hint Diseases Practice Guidelines: the role of transjugular intrahepatic
at catheter fracture and/or embolization. A plain radiograph is the best portosystemic shunt creation in the management of portal hyper-
74
initial diagnostic study to evaluate positioning and integrity of medical tension. J Vasc Interv Radiol. 2005;16:615-629.
devices. Venous catheter and filter fragments tend to embolize centrally • Burke CT, Mauro MA. Bronchial artery embolization. Semin
to the right heart and pulmonary outflow tract. Hence, a chest radio- Interven Radiol. 2004;21:43.
graph is most appropriate. In contrast, objects lost in the arterial system
will embolize peripherally. CT may be helpful in some instances to plan • Eriksson L, Ljungdahl M, Sundbom M, Nyman R. Transcatheter
endovascular retrieval or to assess vessel perforation of foreign body arterial embolization versus surgery in the treatment of upper gas-
identified on radiograph. trointestinal bleeding after therapeutic endoscopy failure. J Vasc
When considering endovascular retrieval one should first compare Interv Radiol. 2008;19:1413-1418.
the risk of complications that may arise during attempted removal • Farrel TA, Hicks ME. A review of radiologically guided per-
against the risk of leaving the object in place. Complications associated cutaneous nephrostomies in 303 patients. J Vasc Interv Radiol.
with endovascular retrieval include access site hemorrhage, vascular 1997;8:769-774.
wall trauma, including dissection and perforation, and injury to cardiac • Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E. Randomized trial
valves. Foreign bodies that have been present for prolonged periods of of laparoscopic versus open cholecystectomy for acute and gangre-
weeks to months may become incorporated into the wall of a vessel or nous cholecystitis. Lancet. 1998;351:321-325.
in the endocardium, and may serve as a nidus for thrombus formation.
Attempts at grasping such objects can disrupt and embolize thrombus • Lorenz J, Thomas JL. Complications of percutaneous fluid drain-
or cause vessel wall injury. age. Semin Intervent Radiol. 2006;23:194.
■ TECHNIQUE • Ouriel K, Veith FJ, Sasahara AA. A comparison of recombinant
urokinase with vascular surgery as initial treatment of acute arterial
Preprocedural considerations, including the use of moderate sedation occlusion of the legs. Thrombolysis or Peripheral Arterial Surgery
and correction of coagulation parameters, are similar to other cases (TOPAS) Investigators. N Engl J Med. 1998;338:1105-1111.
in interventional radiology. Particular attention is given to cardiac • Saad WEA, Wallace MJ, Wojak JC, et al. Quality improvement guide-
monitoring due to the risk of inducing arrhythmias when manipulating lines for percutaneous transhepatic cholangiography, biliary drain-
retrieval instruments and foreign bodies within the heart. Intravenous age, and percutaneous cholecystostomy. JVIR. 2010;21:789-795.
contrast is rarely necessary. The common femoral vein or internal jugu- • Streiff MB. Vena caval filters: a review for intensive care specialists.
lar vein are the most common access sites for endovascular retrieval. J Intensive Care Med. 2003;18:59-79.
Sheath size is chosen so that it can accommodate the foreign body once • Wu L, Xu J, Yin Y, Qu X. Usefulness of CT angiography in diag-
it is trapped. Commonly employed sheath sizes range from 6 to 16 nosing acute gastrointestinal bleeding: a meta-analysis. World J
French. In some cases, a second access is needed to allow for a second Gastroenterol. 2010;16(31):3957-3963.
instrument to help positioning the foreign body for successful retrieval.
A snare device is most commonly used. Other options include retrieval
baskets and grasping forceps. Once captured, the foreign body is pulled
out through the vascular sheath. Rarely, a vascular cut down is necessary REFERENCES
to deliver the object if it is too large or not sufficiently pliable to pass
through the vascular sheath. Complete references available online at www.mhprofessional.com/hall

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