the discovery of intra - vascular foreign bodies is increasing and their associated danger is well recognized .
endovascular retrieval of intravascular foreign bodies offers a high success rate with minimal morbidity and mortality .
a variety of tools are available to the interventionist to aid in foreign body extraction ; however , a thorough knowledge of available devices and techniques is necessary to minimize the associated complications of endovascular retrieval .
we describe the endovascular retrieval of an unusual intravascular foreign body , an irrigation cannula , from the thoracic aorta following cardiac surgery .
an 81 year old male underwent coronary artery bypass grafting and aortic valve replacement . during the procedure
, the ascending aorta had been irrigated several times with heparinized saline using a syringe capped with a stainless - steel olive tip irrigation cannula . when the syringe was handed back to the nursing staff ,
prior to closure of the sternum , the pericardium and the surgical field were searched again for the irrigating tip and thus the chest was closed .
the missing instrument prompted a chest radiograph that demonstrated a metal irrigation cannula superimposed on the cardiac silhouette ( fig .
right common femoral artery access was obtained and a thoracic aortogram was performed demonstrating the cannula to be lodged in the descending thoracic aorta ( fig .
, we felt it was imperative to rule out an unidentified aortic abnormality at this location .
an 8-french intravascular ultrasound ( ivus ) catheter ( volcano corporation , san diego , ca ) was then used to evaluate the descending thoracic aorta .
no aortic abnormality was identified that may have prevented the caudal migration of the cannula .
we surmised , then , that the cannula was lodged obliquely between the anterior and posterior aortic walls .
a tri - lobed snare , en snare ( merit medical systems , south jordan , ut ) was used to grasp the cannula at its tip and withdraw it into the distal aorta . at the aortic bifurcation ,
order dislodge the cannula and allow retraction into the right iliac system , we advanced and rotated the snare .
these maneuvers allowed further rotation of the cannula and successful withdrawal into the right iliac system . due to its large size , the irrigating cannula could not be retrieved further than the distal external iliac artery ( fig .
3 ) . the olive tip measures 45  mm in length and 5.5  mm in width .
the cannula was successfully removed through a transverse arteriotomy in the distal right external iliac artery .
he was discharged to a skilled nursing facility and had no adverse vascular complications noted on post - operative follow up .
as the use of endovascular techniques and procedures have risen , so have the reports of intravascular foreign bodies .
our report highlights an endovascular approach to retrieve an unusual aortic foreign body lost after open cardiac surgery .
following our review of the literature , we believe this to be the only such case of an intra - aortic irrigation cannula successfully retrieved by an endovascular means .
described the endovascular retrieval of a migrated patent foramen ovale occluder from the descending thoracic aorta .
this case , while similar in some respect , differs from ours as the authors found it was necessary to use both a 5.5-french multipurpose biopsy forcep ( cordis corporation , a johnson & johnson company ; bridgewater , nj ) as well as an amplatz gooseneck snare ( ev3 peripheral vascular , part of covidien ; plymouth , minn ) to remove a large intra - aortic foreign body .
we believe that our case , along with the report from basoor et al . , highlights that an endovascular snare is the preferred tool for intra - aortic foreign body extraction .
this is also emphasized by the reports of others that have shown the snare to be useful in the retrieval of other , more common , foreign bodies such as fractured port catheters , introducer fragments , microcoils , dislocated stents , fragments of guidewires , pacemaker transducers , and vena cava filters , , , , .
prior to these reports , the majority of the literature focused on the open surgical extraction of pedicle spinal fixation screws from the thoracic aorta .
one unique case involved endovascular stent graft exclusion followed by extraction via a left anterolateral fourth intercostal space thoracotomy . while interesting as it allowed extraction without aortic cross clamping , this approach still subjected the patient to the morbidity associated with a thoracotomy . in our case
, open extraction would have required a thoraco - abdominal incision to access the descending thoracic aorta and removal of the irrigation cannula .
this would not only increase the potential morbidity of the case but also add substantial health care costs .
lastly , we feel it important to mention that after the case , we discovered that a 22-french sheath would have been able to accommodate the irrigation cannula .
in retrospect , a double - proglide ( abbott vascular , abbott park , illinois ) preclose technique followed by insertion of a long 22-french sheath insertion may have allowed successful extraction of the cannula percutaneously , thus avoiding a groin incision .
endovascular retrieval of intravascular foreign bodies is minimally invasive , relatively simple , and carries minimal morbidity compared to conventional open surgical techniques .
this unusual case of a thoracic aortic foreign body demonstrates the importance of a working knowledge of endovascular techniques and instruments necessary for safe and effective extraction of atypical intravascular foreign bodies .
biju k. thomas : study concept , data collection , data interpretation , writing paper .
james r. elmore : study concept , data collection , data interpretation , writing paper .
robert p. garvin : study concept , data collection , data interpretation , writing paper .
evan j. ryer : study concept , data collection , data interpretation , writing paper .
 highlightsendovascular techniques to retrieve intra - vascular foreign bodies are a necessary component of the vascular surgeon s skill set.endovascular retrieval of intravascular foreign bodies is minimally invasive , relatively simple , and carries minimal morbidity compared to conventional open surgical techniques.it is important to have a working knowledge of techniques and instruments required for retrieval of intravascular foreign bodies . 
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