Occurrence and Management Strategies for Catheter Entrapment with Onyx Liquid Embolization

Abstract

In June 2012, Food and Drug Administration (FDA) issued a warning about the risk of catheter entrapment associated with Onyx embolization. We used our experience, literature review, and FDA Manufacturer and User Facility Device Experience (MAUDE) data review to identify five strategies to address catheter entrapment: 1/. Surgical resection of vessel at point of entrapment of catheter and retraction from exterior portion at the femoral region; 2/. Advancing and closing the loop of snare over the entrapped catheter followed by retraction; 3/. Advancing the distal access catheter over the entrapped catheter and retraction with forward movement of the distal access catheters; 4/. Inflation of balloon catheter coaxial to the entrapped catheter with subsequent retraction; and 5/. Intravascular retention and internalization of microcatheter. In the MAUDE data, there were 77 reports of catheter entrapment with Onyx embolization; microcatheter was retracted by surgical excision in 15, endovascular snare or other retriever devices in 5, deliberately entrapped inside the vessel using stent in 1, and left without intervention within intravascular compartment in 27 patients.

Keywords: Catheter entrapment; Onyx; copolymer; intravascular; liquid embolic system; microcatheter.

Figure 1. Angiographic images of the hemangioblastoma and arterial feeders into the vascular tumor bed.: A. Pre-embolization lateral view and feeding arteries from posterior inferior cerebellar artery (arrow indicating the feeder of interest).: B. The entrapped microcatheter during retraction in lateral view (arrow indicates straightening of posterior inferior cerebellar artery loop and lack of arterial flow).: C. The entrapped microcatheter in relaxed position in lateral view (arrow indicates reconstitution of posterior inferior cerebellar artery loop and resteroration of arterial flow).

Figure 1. Angiographic images of the hemangioblastoma and arterial feeders into the vascular tumor bed.: A. Pre-embolization lateral view and feeding arteries from posterior inferior cerebellar artery (arrow indicating the feeder of interest).: B. The entrapped microcatheter during retraction in lateral view (arrow indicates straightening of posterior inferior cerebellar artery loop and lack of arterial flow).: C. The entrapped microcatheter in relaxed position in lateral view (arrow indicates reconstitution of posterior inferior cerebellar artery loop and resteroration of arterial flow).

Figure 1. Angiographic images of the hemangioblastoma and arterial feeders into the vascular tumor bed.: A. Pre-embolization lateral view and feeding arteries from posterior inferior cerebellar artery (arrow indicating the feeder of interest).: B. The entrapped microcatheter during retraction in lateral view (arrow indicates straightening of posterior inferior cerebellar artery loop and lack of arterial flow).: C. The entrapped microcatheter in relaxed position in lateral view (arrow indicates reconstitution of posterior inferior cerebellar artery loop and resteroration of arterial flow).

Figure 2. Postsurgical resection T2-weighted MRI transverse section. The void anterior to the cerebellum is the intravascular component of the entrapped microcatheter.

Figure 3. Rotational movement of the catheter allowed entanglement of the existing microcatheter and retraction into the left iliac artery.