Retrieval of Entrapped Guide Wire in an IVC Filter Facilitated with Use of a Myocardial Biopsy Forceps and Snare Device

Editor: Entrapment of a guide wire in an inferior vena cava (IVC) filter is an infrequent predicament that usually occurs during blind or emergent central venous catheter placement. Forceful attempts to free the wire without imaging guidance pose the risk of filter dislodgement or caval perforation. Several authors have described clever interventional methods for safely releasing an entrapped guide wire from the filter (1–6). We describe an innovative approach for removing a guide wire entrapped in the cone of a titanium Greenfield IVC filter: a modified monorail technique with the additional use of a snare device and myocardial biopsy forceps. A 19-year-old man, who was a restrained driver in a motor vehicle accident, sustained multiple orthopedic injuries and a closed head injury with traumatic subarachnoid hemorrhage. A prolonged stay in the intensive care unit followed. On hospital day 14, the patient was diagnosed with left iliofemoral deep vein thrombosis. A titanium Greenfield filter (Boston Scientific/Medi-tech, Watertown, MA) was surgically placed the same day in an infrarenal location because anticoagulation was contraindicated as a result of the patient’s intracranial hemorrhage. Six days later, during a left subclavian vein catheter exchange without fluoroscopy in the intensive care unit, the introducer wire became entangled in the cone of the IVC filter. Manual attempts at freeing the wire by the operator resulted in unraveling of the outer wire off the mandrel, leaving 7 cm of the uncoiled wire and the mandrel protruding from the subclavian insertion site. The interventional radiology department was consulted for assistance with removal of the wire. The patient was brought to the interventional suite, where multiple attempts were made to free the wire under imaging guidance with gentle pulling and pushing techniques. These initial attempts were unsuccessful in disengaging the wire, which was firmly entangled within the apex of the filter (Fig 1). A variation of the “monorail technique” described by Morgan and Sussman (2) was then used in an attempt to free the wire. Because the wire fragment would advance only a short distance through the end hole of the 5-F multipurpose catheter, a small side hole was made approximately 6 cm above the end hole with use of a cutting device. The catheter was guided over the short segment of coiled wire and mandrel protruding from the insertion site, with the external wire segments exiting through the side hole of the catheter. The catheter was advanced over the wire to just above the apex of the filter. Attempts at passing a stiff 0.035-inch guide wire through the catheter to release the wire were unsuccessful. The catheter was then used as a buttress to provide counter force during attempts to free the entangled portion of wire. Unfortunately, despite all these maneuvers, the wire could not be disengaged from the filter. At this point, the left internal jugular vein was accessed under US guidance with subsequent placement of an 8-F, 30-cm vascular sheath (Cook, Bloomington, IN). The sheath tip was placed just above the cone of the filter. A 5-F myocardial biopsy forceps device (Cordis, Miami, FL) was advanced through the sheath and used to grasp the entangled wire near its point of entry into the filter. The intent was to cut the wire with the biopsy forceps just above the point of entanglement; however, this was unsuccessful. However, the stiffness of the biopsy device was sufficient to free the wire by pushing the catheter and wire below the level of the Figure 1. The “J-tip” of a guide wire is entrapped in the apex of a Greenfield IVC filter (arrow). Letter to the Editor