Late migration of a left atrial appendage closure device to the bifurcation of common iliac arteries: a case report and novel percutaneous retrieval technique

Abstract

Transcatheter left atrial appendage closure (LAAC) serves as a mechanical stroke prevention strategy for patients with non-valvular atrial fibrillation (NVAF) who are unsuitable for long-term oral anticoagulation. Although device dislodgement following LAAC is rare, it carries potentially life-threatening risks. This case report describes a 65-year-old male with permanent atrial fibrillation (CHA2DS2-VASc = 4, HAS-BLED = 3) who underwent LAAC with an 18 mm LAmbre occluder. Despite confirmed proper positioning at 1-month follow-up, device migration to the iliac bifurcation was detected at 105 days post-procedure, potentially associated with interim chest trauma. Percutaneous retrieval was performed via a novel approach: catheter-based endothelial detachment followed by bidirectional traction, avoiding large-bore sheaths. A Watchman FLX device was subsequently implanted successfully.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-026-05589-z.

Background

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias. Patients with AF and an elevated stroke risk (as assessed by scores such as CHA₂DS₂-VASc) often require long-term anticoagulation therapy for stroke prevention [1]. The left atrial appendage (LAA) is the most thrombogenic site in AF patients [2]. Transcatheter left atrial appendage closure (LAAC) serves as a mechanical stroke prevention strategy for patients with non-valvular atrial fibrillation (NVAF) who are unsuitable for long-term oral anticoagulation [3]. Although device dislodgement following LAAC is rare, it carries potentially life-threatening risks [4]. The majority of device embolizations after LAAC occurs early [5], this report describes a case of late-onset device migration to the iliac artery bifurcation post-LAAC. The patient maintained regular follow-up with confirmed proper device positioning at 1-month post-procedure. However, at 105-day follow-up, device dislodgement was detected. After multidisciplinary evaluation, percutaneous retrieval was performed using catheter-based slow endothelial detachment of the device, followed by successful extraction through a bidirectional kissing traction technique. A new LAA occluder was subsequently implanted during the same procedure.

Case description

A 65-year-old male patient with permanent atrial fibrillation (CHA2DS2-VASc score = 4, HAS-BLED score = 3) underwent LAAC closure procedure. Preoperative cardiac CT angiography and transesophageal echocardiography revealed a chicken-wing shaped LAA with maximum ostium width of 21.8 mm, height of 23.8 mm, and depth of 38.3 mm. We have analyzed our case using the proposed CT-based risk score [6] and determined it to be at low risk for embolization. Prior to device deployment, the left atrial pressure was measured at 13 mmHg. Pre-procedural assessment revealed a landing zone of 14–16 mm and an ostial diameter of 18–20 mm. In accordance with our institutional protocol of oversizing the device by 2–6 mm relative to the landing zone, and considering the anatomical features of a small ostium, strong contractility, and a prominent muscular ridge, a LAmbre occluder (Lifetech Scientific, Shenzhen, China) was selected. The device, featuring an 18 mm fixation disc (representing a + 2 mm oversizing) and a 24 mm sealing disc, was successfully implanted. Its stable position was confirmed by standard intraoperative testing (Video 1). Following device deployment, standard release criteria were assessed by TEE and fluoroscopy, including a stable position, a tug test confirming secure engagement, and the absence of significant peri-device leak (> 3 mm). All release criteria were met satisfactorily before the device was fully released. The patient remained hemodynamically stable throughout the procedure without complications. Postoperative transthoracic echocardiography on day 1 confirmed proper device positioning.

One-month follow-up at our outpatient clinic showed maintained device position on echocardiography. However, at 105-day follow-up, both transthoracic echocardiography and cardiac CT angiography revealed device absence in the LAA. Digital subtraction angiography (DSA) demonstrated device migration to the bifurcation of common iliac arteries (Fig. 1). A review of the patient’s medical history documented an instance of minor chest compression from a fall after the first follow-up. This traumatic event is hypothesized to have contributed to the device dislodgement.

Fig. 1.

Migration of a left atrial appendage closure device to the bifurcation of common iliac arteries

After multidisciplinary consultation with vascular surgery, percutaneous retrieval was performed. Via right femoral artery access, an 14-French Watchman delivery sheath (Boston Scientific) was advanced below the device. A 6-Fr MPA catheter was used to gently push the device into the abdominal aorta. Simultaneously, a 6-Fr MPA catheter was introduced through right brachial artery to approach the device, where a basket wire successfully captured and stabilized it. Initial attempts using an endoscopic grasping tool through the 11-Fr sheath to engage the umbrella surface were unsuccessful. After replacement of the Watchman sheath with a 23 F Micra introducer sheath, the proximal disc of the LAmbre occluder was engaged with grasping forceps. Multiple manipulations were then performed, which allowed for the complete retrieval of the device into the sheath (Fig. 2). Post-procedural aortography confirmed the absence of aortic dissection (Video 2).

Fig. 2.

Post-removal status of the displaced left atrial appendage closure device

Subsequently, via right femoral venous access, the 14-French Watchman delivery sheath (Boston Scientific) was used, a repeat LAA closure procedure was performed with implantation of an 18 mm Watchman FLX device (Boston Scientific, Marlborough, Massachusetts) in same procedure. Final DSA and transesophageal Echocardiography (TEE) confirmed optimal positioning, with follow-up TTE and CT angiography demonstrating proper device placement (Video 3). A follow-up left atrial CTA at 3 months demonstrated that the device was in a stable and correct position. The patient was asymptomatic and reported no significant discomfort.

Discussion

Device dislodgement of left atrial appendage occluders is a rare complication, with an average incidence ranging from 0.6% to 0.7% [7, 8]. The risk of embolization is influenced by a combination of factors, primarily operator-dependent decisions regarding device sizing and positioning, which must account for the patient’s specific LAA anatomy [4]. Even to this day, consistent predictors of LAAC device embolization have not been firmly established. Some patient-specific factors such as significant thoracic trauma may linked to late embolization, this association lacks robust validation. In this case, the device migration was considered be associated with a history of chest compression postoperatively. Therefore, in addition to medication instructions, lifestyle guidance is equally important for postoperative care. If patients experience chest compression after device implantation, immediate medical attention can facilitate early detection of device migration and prevent serious consequences caused by device displacement.

Device migration may lead to severe adverse events such as valve laceration, embolism, thrombosis, and even life-threatening conditions [9–11]. Most migrations occur intraoperatively or during the acute postoperative phase [12], with possible displacement into the left atrium, left ventricle, or aorta. In this case, although regular follow-up and early echocardiography confirmed proper device positioning, migration was detected at the 105-day postoperative follow-up. Current literature reports various retrieval techniques, including thoracoscopic surgery, percutaneous snare or bioptome extraction [10, 11]. For unstable patients, more invasive procedures such as sternotomy may be required [13, 14]. Supporting these efforts, the ELAACC recently issued a consensus statement detailing optimal management strategies for LAAC device embolization [15].

After device migration and endothelialization, complications such as thrombus formation and embolism may occur. Percutaneous device retrieval may lead to adjacent vascular dissection, rupture, or thrombus displacement. The risk of vascular complications during late percutaneous retrieval may be higher due to device endothelialization. Swaans et al. [16] reported an asymptomatic device dislodgement to the abdominal aorta detected by TEE at 3-month follow-up, which was successfully retrieved percutaneously. Marco R et al. [17] identified device migration at 12 months postoperatively and achieved successful percutaneous retrieval. In this case, device migration was detected at 105 days postoperatively. Considering the endothelialization of the device, careful catheter-based detachment from the vascular endothelium was performed first, followed by successful retrieval using a bidirectional traction technique.

Conclusion

For late-onset left atrial appendage occluder dislodgement, percutaneous device retrieval is a feasible approach. During the procedure, gradual catheter-based detachment can first be employed to separate the device from the vascular endothelium, followed by retrieval using a bidirectional traction technique. This method not only reduces the risk of vascular injury at the anchoring site and secondary vascular damage caused by device movement, but also minimizes the potential for femoral artery injury associated with using larger-diameter sheaths.

Abbreviations

AF

Atrial fibrillation

LAA

Left atrial appendage

LAAC

Transcatheter left atrial appendage closure

NVAF

Non-valvular atrial fibrillation

DSA

Digital subtraction angiography

TEE

Transesophageal Echocardiography

Authors’ contributions

Ruchao Ma, Pengyang Lin and Xin Lin were the primary surgeon, managed the patient, collected the data, and wrote the initial draft of the manuscript. Gang Chen, Guiqing Ma, Shu Liu and Ruixia Song assisted in the surgery, conducted the literature review, and prepared the figures. Xin Lin conceived the idea for the case report, provided critical supervision during the surgery, and critically reviewed and edited the manuscript for important intellectual content.

Funding

This research received no external funding.

Data availability

No datasets were analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing interests

The authors declare no competing interests.