Endovascular retrieval of a fractured Lightning Bolt 7 Catheter from the femoral vein using the ClotTriever Thrombectomy System

Abstract

As large-bore mechanical thrombectomy is increasingly used to treat deep vein thrombosis (DVT), uncommon device-related adverse events, including catheter deformation, fracture, and retained intravascular foreign bodies, may be encountered. This study describes the case of a 60-year-old man with right lower-extremity DVT and pulmonary embolism in whom a Lightning Bolt 7 catheter (Penumbra) fractured during aspiration thrombectomy, resulting in a retained catheter fragment within the femoral vein that was refractory to snare retrieval attempts. During a subsequent procedure, the ClotTriever BOLD Thrombectomy System (Inari Medical), was used to successfully achieve simultaneous extraction of the embedded catheter fragment in its entirety and acute thrombus, restoring inline venous flow. This case highlights a salvage strategy using a large-bore, mechanically distinct thrombectomy device to retrieve a retained catheter fragment while simultaneously treating acute DVT.

Large-bore mechanical thrombectomy has become an increasingly used treatment for deep vein thrombosis (DVT), providing rapid thrombus removal and restoration of inline venous flow while potentially reducing post-thrombotic sequelae.^1,2 A variety of aspiration and mechanical thrombectomy systems are commercially available for the treatment of DVT, including the Lightning Bolt/Indigo System (Penumbra), FlowTriever and ClotTriever Thrombectomy Systems (Inari Medical), and AlphaVac System (AngioDynamics).^2,3 As utilization of these devices expands, uncommon, but clinically significant, device-related adverse events may be encountered, including catheter deformation, fracture, and retained intravascular foreign bodies.³ Endovascular retrieval of retained thrombectomy device fragments in the setting of acute venous thrombosis may be particularly challenging because of associated thrombus burden, vessel occlusion, limited endovascular accessibility, and restricted device maneuverability, occasionally necessitating open surgical extraction. This report describes the successful retrieval of a fractured Lightning Bolt 7 Aspiration Catheter fragment (Penumbra) from a thrombosed femoral vein using the ClotTriever Thrombectomy System (Inari Medical). Patient consent was obtained for this publication. Institutional Review Board approval was not required for the preparation of this report.

Case report

A 60-year-old man with hypertension presented to an outside hospital with 7 days of progressive right lower-extremity swelling and pain. Computed tomographic (CT) pulmonary angiography demonstrated moderate volume pulmonary emboli within the left lower lobe, whereas right lower-extremity venous duplex ultrasound study revealed large volume iliofemoral, femoropopliteal, and tibial deep vein thromboses. The patient was started on therapeutic anticoagulation with intravenous heparin without improvement. Given the persistent symptoms and extensive thrombus burden, the patient underwent attempted right lower-extremity mechanical thrombectomy. Following antegrade popliteal vein access, successful aspiration thrombectomy was performed along the femoropopliteal and iliofemoral venous segments using the CAT16 Aspiration Catheter (Penumbra) resulting in extraction of a large volume of thrombus. To improve inflow from the thrombosed tibial deep veins, an additional retrograde common femoral vein access was obtained, through which a Lightning Bolt 7 Catheter (Penumbra) was used for aspiration thrombectomy. During removal of the aspiration catheter, the distal tip of a Lightning Bolt 7 Catheter (Penumbra) kinked and sheared against the vascular sheath, resulting in an approximately 3-cm fractured fragment within the femoral vein. Attempts to retrieve the fragment using a percutaneous snare were unsuccessful. The procedure was further complicated by rethrombosis of the right lower-extremity deep venous system. The patient was subsequently transferred to a higher level of care.

Repeat CT imaging at the quaternary care center demonstrated recurrent deep vein thromboses involving the right iliofemoral, femoropopliteal, and tibial veins with an angulated retained catheter fragment embedded within the thrombus at the junction of the common femoral and femoral veins. Therapeutic anticoagulation with intravenous heparin was continued. Given the persistent thrombus burden and retained foreign body, the patient underwent repeat thrombectomy.

The patient was positioned supine with the right lower extremity in frog-legged position. The occluded right popliteal vein was accessed under ultrasound guidance using a micropuncture system. Initial spot radiographs and venography demonstrated large volume occlusive thrombus extending from the popliteal vein through the external iliac vein, with the retained fractured catheter fragment lodged within the right femoral vein (Fig, A and B). Following placement of a 16F ClotTriever Sheath (Inari Medical), mechanical thrombectomy was performed using the ClotTriever BOLD Thrombectomy System (Inari Medical). Using this device, with its atraumatic coring mechanism and self-expanding collection bag designed to capture organized wall-adherent thrombus and acute thrombus en block, resulted in extraction of acute thrombus and restoration of inline venous flow. During thrombectomy, the retained Lightning Bolt 7 Catheter (Penumbra) fragment was successfully captured and removed in its entirety (Fig, C-E). Intravascular ultrasound was not used as venography provided adequate guidance for, and confirmation of, thrombus extraction and foreign body retrieval. Completion venography demonstrated inline patency of the right lower-extremity venous system without residual thrombus or catheter fragment (Fig, F).

Fig.

Endovascular retrieval of a fractured Lightning Bolt 7 Catheter from the femoral vein using the ClotTriever Thrombectomy System. A, Spot radiograph demonstrating the fractured Lightning Bolt 7 Catheter within the femoral vein (solid white arrow). B, Right lower-extremity ascending venography demonstrating the fractured Lightning Bolt 7 Catheter (solid white arrow) within the thrombosed femoral vein (dashed white arrow). C, The ClotTriever Thrombectomy System (dashed white arrow) was used to capture the fractured Lightning Bolt 7 Catheter (solid white arrow). D, The fractured Lightning Bolt 7 Catheter (solid white arrow) was removed within the ClotTriever Thrombectomy System (dashed white arrow). E, Photograph demonstrating the fractured Lightning Bolt 7 Catheter (solid white arrow) ensnared within the ClotTriever Thrombectomy System (dashed white arrow). F, Completion right lower-extremity ascending venography demonstrating brisk inline flow throughout the femoral vein (solid white arrow).

During the procedure, the patient experienced rigors, transient hypotension, and intermittent narrow and wide-complex tachyarrhythmias, presumably because of transient bacteremia from repeat thrombectomy instrumentations. Symptoms improved following administration of intravenous vancomycin, piperacillin/tazobactam, meperidine, and acetaminophen. Subsequent CT pulmonary angiography did not demonstrate new pulmonary embolus or clot in transit. The patient was subsequently monitored in the intensive care unit postprocedure, and therapeutic anticoagulation was continued. The patient was discharged 2 days later.

Discussion

Retained intravascular foreign bodies during venous thrombectomy are uncommon but potentially serious adverse events that may result in vessel injury, infection, recurrent thrombosis, or loss of venous patency.⁴ Endovascular retrieval using aspiration thrombectomy systems has previously been described for pulmonary arterial foreign bodies and embolized arterial closure devices.^5,6 However, foreign body retrieval in the setting of acute, high burden DVT presents distinct technical challenges. Extensive thrombus may obscure retained device fragments, limit visualization, and complicate separation and retrieval of the foreign body from adherent thrombus without risking central migration or embolization to the pulmonary circulation.

In the present case, repeat thrombectomy using the ClotTriever Thrombectomy System (Inari Medical), which uses a mechanically distinct mechanism of action, enabled simultaneous removal of extensive thrombus and retrieval of the retained catheter fragment while avoiding further vessel injury, fragment migration, and open surgical intervention. The ClotTriever BOLD Catheter (Inari Medical), used in conjunction with the 16F ClotTriever Sheath (Inari Medical), facilitated en bloc extraction of the thrombus and embedded catheter fragment from the occluded venous segment. This approach simultaneously addressed the retained foreign body and underlying acute venous thrombosis in a single endovascular procedure.

As the use of large-bore thrombectomy devices continue to expand, operators should remain aware of potential device-related adverse events and available endovascular salvage strategies. Kinking or shearing of smaller bore thrombectomy catheters may result in catheter fracture and fragment retention, particularly during manipulation or withdrawal without over the wire support. Maintaining wire access when feasible and avoiding excessive torque or force during catheter manipulation and withdrawal may reduce this risk. Close patient monitoring and assurance of therapeutic anticoagulation are fundamentals of conservative management. Utilization of a larger-bore thrombectomy device with a mechanically distinct mechanism of action may provide an effective salvage strategy, permit retrieval of the retained fragment while simultaneously treating the underlying DVT. Familiarity with the mechanisms, mechanical properties, coring capabilities, calibers, sheath compatibility, and procedural behavior of available thrombectomy systems is important for managing device-related adverse events and developing a comprehensive DVT intervention practice.

Funding

This study was not supported by any funding.

Compliance with ethical standards

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Consent for publication

This study was not Institutional Review Board-approved and the need for informed consent was waived. Patient consent was obtained for publication.

Availability of data and material

Data for this study is available from the corresponding author upon reasonable request.

Disclosures

J.F.B.C. is a consultant for Inari Medical and Stryker. The remaining authors have no disclosures.