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BACKGROUND

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Unintended loss of material during catheter-based cardiovascular procedures is uncommon but may have serious consequences. Occasionally, a lost or embolized item ends up in a small peripheral vessel, where it can be left in place safely. More often, retrieval of the lost material is desired to reduce risks of thrombosis, infection, and perforation.

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The problem of lost foreign bodies in blood vessels is long-standing; early reports of percutaneous vascular foreign body removal first appeared 50 years ago.1,2 A review of the published literature in 1991 found nearly 200 reported cases with a percutaneous retrieval success rate of 90%.3 A more recent review concluded that percutaneous retrieval of peripheral intravascular foreign bodies has a high success rate and minimal morbidity and is preferable to open vascular surgical removal.4 All manner of gear has been liberated into blood vessels (filters, plugs, coils, torn balloon fragments, rotational atherectomy burrs, fractured catheters, percutaneous heart valves), but in the adult catheterization laboratory, losses most often involve retention of fractured coronary guide wire fragments or unexpanded coronary stents that have been stripped free of their delivery balloon catheters. Stent loss and attempts at their retrieval are associated with increased rates of complications, including need for coronary artery bypass grafting surgery, myocardial infarction, and death.5 Loss of foreign bodies in the coronary arteries has been reported to occur in slightly less than 1% of cases,6 but retention and embolization events are likely to be significantly underreported. As radial artery access gains in popularity, retrieval of lost foreign bodies may prove more difficult, although the techniques described herein have proven useful in this setting.7 Optimal management of lost interventional products requires (1) judgment about when to leave retained components in place and when to remove them; (2) knowledge of those techniques proven to be effective and efficient at foreign body removal; and (3) competency with a few specialty devices designed to assist in component removal.

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AGGRESSIVE OR CONSERVATIVE MANAGEMENT

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Significant harm can befall a patient with a retained component. Although late infection, perforation, and even material toxicity are concerns, the principal anxiety is thrombosis; occurring in a coronary artery or similar sensitive vessel, thrombosis around a foreign body can be fatal.8 However, extraction of foreign bodies from the vascular system carries risk. Thus, before attempting to retrieve a misplaced or embolized component, it is reasonable to ask, “Can I just leave the foreign body where it is?”

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Several factors must be considered in the decision process:

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  1. Is the retained component in a location that is highly sensitive to the impact of thrombosis? A sudden thrombotic event in any blood vessel is unwanted but is more easily tolerated in noncritical locations. Fragments left in the left main coronary artery; the proximal portions of the left anterior descending arteries or dominant left circumflex or right coronary arteries; ...

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