Snare Technique Research Articles

Nuclear management in manual small incision cataract surgery by snare technique

Manual small incision cataract surgery has evolved into a popular method of cataract surgery in India. However, in supra hard cataract, bringing out the whole nucleus through the sclerocorneal flap valve incision becomes difficult. A bigger incision required in such cataracts loses its value action, as the internal incision and corneal valve slips beyond the limbus into sclera. Struggling with the supra hard cataracts through a regular small incision. Phacofracture in the anterior chamber becomes a useful option in these cases. In the snare technique, a stainless steel wire loop when lassoed around the nucleus in the anterior chamber constricts from the equator, easily dividing the hardest of the nuclei into two halves. The wire loop constricts in a controlled way when the second cannula of snare is pulled. The divided halves can easily be brought out by serrated crocodile forceps. This nuclear management can be safely performed through a smaller sclerocorneal flap valve incision where the corneal valve action is retained within the limbus without sutures, and the endothelium or the incision is not disturbed. However, the technique requires space in the anterior chamber to maneuver the wire loop and anterior chamber depth more than 2.5 mm is recommended. Much evidence to this wonderful technique is not available in literature, as its popularity grew through live surgical workshops and small interactive conferences.

Pre-incisional infiltration of tonsils with dexamethasone dose not reduce posttonsillectomy vomiting and pain in children

Background and Objective:Recently, dexamethasone has been found to have a prophylactic effect on postoperative vomiting and pain in children undergoing tonsillectomy. However, few studies have examined the preemptive analgesic effects of dexamethasone after tonsillectomy. The aim of this study was to evaluate the effect of pre-incisional infiltration of tonsils with dexamethasone on the incidence and severity of postoperative pain and vomiting in children undergoing tonsillectomy under general anesthesia.Materials and Methods:In a double blinded study, 62 patients were randomly allocated to infiltrate dexamethasone (0.5 mg/kg, maximum dose, 12 mg) or an equivalent volume of saline at the peritonsillar region. All infiltrations were performed following the induction of general anesthesia and 5 minutes prior to the onset of surgery. Anesthetic agents, end-tidal carbon dioxide levels, and the administration of intravenous fluids were carefully regulated. Surgery was performed by one attending otolaryngologists using the same dissection and snare technique. The incidence of pain and vomiting, need for rescue antiemetics, and analgesic consumption were compared in both groups. Pain scores used included Children's Hospital Eastern Ontario Pain Scale, “faces”, and a 0-10 visual analogue pain scale.Results:Demographics of dexamethasone and placebo groups were similar. No statistically significant difference was found between the dexamethasone and placebo groups in pain score, nausea, vomiting, irritability, or analgesic requirement postoperatively.Conclusion:Preincisional infiltration of the tonsils with dexamethasone play a limited role in the recovery phase from tonsillectomy, but further prospective, randomized studies are needed to support it.

Colonoscopy with Polypectomy in Patients Taking Clopidogrel.

Background and AimsTo investigate the bleeding risk of colonoscopy with polypectomy in patients taking clopidogrel.MethodsRetrospective review of patients undergoing colonoscopy with polypectomy without interruption of clopidogrel. Patients with lesions larger than 1cm were generally rescheduled for polypectomy off clopidogrel. Most of the polyps were removed using cold snare technique. Endoscopic clips were routinely applied prophylactically.ResultsA total of 125 polypectomies were performed in 60 patients. The average polyp size was 5.4 ± 2.1 mm. One patient (1.7%, CI 0.3-8.9%) developed post-polypectomy bleeding that resolved without treatment. Three patients (5%, CI 1.7-14%) had immediate bleeding during the procedure and all resolved with prompt clip application.ConclusionsPolypectomy of lesions up to 1cm in size can be performed without interruption of clopidogrel.

Retrieval of vascular foreign bodies using a self-made wire snare

Foreign bodies in the vascular system have a high potential to cause embolization, perforation, and infection. Therefore, numerous commercially available percutaneous retrieval devices have been developed. To evaluate the feasibility and efficacy of a self-made wire snare for the retrieval of foreign bodies in the vascular system. 16 consecutive patients, who underwent percutaneous foreign-body retrieval between 1997 and 2007, were included in this retrospective analysis. Percutaneous extraction was performed using an adjustable wire snare that was fabricated using a 5F diagnostic Headhunter or Multipurpose catheter and a 4-m-long 0.018-g/inch standard heavy-duty wire that was bent in the middle to create an eccentric loop. Percutaneous foreign-body retrieval was successful in all 16 cases. Intraluminal materials including partially fractured venous catheters, guidewires, a stent, and a vena cava filter were removed from various locations. In six cases, mobilization of the intraluminal material via a pigtail catheter was necessary before using the wire snare for removal. Successful retrieval was investigator independent. In no cases were surgical procedures required, and no relevant complications were encountered. This snare technique is an effective, feasible, and cost-effective method to retrieve intraluminal material. It is an alternative to commercially available retrieval devices.

Techniques Used for Difficult Retrievals of the Günther Tulip Inferior Vena Cava Filter: Experience in 32 Patients

To retrospectively review experience with difficult retrievals of Günther Tulip filters (GTFs) in which various techniques were used. From December 2004 to December 2006, 32 patients were referred to a single radiology department for GTF retrieval (25 women and seven men; mean age, 40 years; range, 21-60 y). All patients were evaluated, and 22 of these patients had undergone unsuccessful filter retrieval attempts elsewhere. In the remaining patients, significant tilt of the filter (n = 8) or difficult internal jugular vein access (n = 2) discouraged retrieval attempts. There were a total of 38 filters. Twenty-five patients had a filter in the infrarenal inferior vena cava (IVC). Among the remaining seven patients, six had bilateral iliac filters and one had a left iliac filter. Retrievals were performed via conventional technique-ie, by snaring the hook of the filter without additional maneuvers-or other techniques. Thirty-seven of 38 filters were successfully removed, for a success rate of 97%. Successful retrievals were performed with conventional (n = 4), catheter twist (n = 3), modified snare (n = 15), loop snare (n = 14), and balloon dilation (n = 1) techniques. The average dwell time for filters successfully removed was 58 days (range, 22-258 d). One failure occurred in a patient who had undergone unsuccessful retrieval previously. The hook of the filter and a displaced secondary strut, which had migrated superiorly, were incorporated into the IVC wall in this case. Additional maneuvers were useful in these difficult retrievals of GTFs that might not otherwise be retrievable with the conventional method.

Percutaneous rescue of left ventricular embolized amplatzer septal occluder device

Transcatheter atrial septal defect (ASD) closure has proven to be safe and effective, and it is rapidly becoming the standard treatment for secundum-type ASDs. However, device embolization occurs in about 0.55% of cases, regardless of ASD and device size and/or physician's expertise. Percutaneous retrieval of the embolized device is possible in about 50% of cases, and several techniques have been described, including the use of large sheaths, gooseneck snares, or bioptomes. This is the first successful and reported case of retrieval of an embolized amplatzer septal occluder (ASO) from the left ventricle that was achieved by using a modified snare technique. This was done after an unsuccessful attempt at retrieval with a bioptome that led to a never previously reported complication. Of the 32 reported cases of ASO embolization, percutaneous retrieval was successful in 16 cases (50%) and none were obtained following left ventricular embolization. Even in experienced hands, the observed rate of embolization when using an ASO device is not negligible. Percutaneous retrieval is also possible from the left ventricle but in some cases nonstandardized devices and strategies may be required.

Modified Snare Technique for Transvaginal Intrauterine Device Removal in a Patient with Refractory Cervical Stenosis

Pyometra and infected hematometra are rare but potentially serious conditions with associated risks of gynecologic morbidities, infertility, and death (1,2). Moreover, patients with an obstructed or distorted cervical canal caused by a tumor, earlier surgery, radiation therapy, congenital uterine anomaly, or postmenopausal cervical stenosis are far more susceptible to these serious complications (3).

MONORAIL SNARE TECHNIQUE FOR THE RETRIEVAL OF AN ADHERENT MICROCATHETER FROM AN ONYX CAST

Abstract Objective: Microcatheters retained after Onyx (eV3 Neurovascular, Inc., Irvine, CA) embolization represent a potential source of thromboembolic complications. Catheter retention depends on the degree of Onyx reflux and vessel tortuosity. To overcome this problem, we have adapted a previously described monorail snare technique for stretched coils to remove an adherent microcatheter from the occipital artery during Onyx embolization of a dural arteriovenous fistula. Clinical Presentation: We used this technique successfully in a 62-year-old man with a posterior fossa dural arteriovenous fistula. An Echelon-10 microcatheter (eV3 Neurovascular, Inc.) system became adherent in the right occipital artery because of reflux and vessel tortuosity. Significant stretching of the microcatheter was observed during attempted removal. Intervention: A 2-mm Amplatz Goose Neck microsnare (Microvena Corp., White Bear Lake, MN) was placed through a Rapid Transit microcatheter (Cordis Corp., Miami, FL). The hub of the indwelling Echelon microcatheter was cut off and the snare advanced over the outside of the microcatheter. The snare and Rapid Transit microcatheter were then advanced into the guiding catheter (6-French) as a unit over the indwelling Echelon microcatheter. Using the adherent Echelon as a “monorail” guide, the snare and Rapid Transit microcatheter were advanced distally into the occipital artery and the snare was retracted to engage the microcatheter. The microcatheters and snare were then easily removed because of the second vector of force placed by the snare system on the adherent microcatheter very close to the point of adherence. Conclusion: The monorail snare technique represents a simple and safe way to remove an adherent microcatheter from an Onyx cast during the embolization of dural arteriovenous fistulas. Prospective knowledge of this technique will facilitate more aggressive embolization without the reservation that a retained microcatheter could require surgical removal or anticoagulation.

Monorail snare technique for the retrieval of an adherent microcatheter from an onyx cast: technical case report.

Microcatheters retained after Onyx (eV3 Neurovascular, Inc., Irvine, CA) embolization represent a potential source of thromboembolic complications. Catheter retention depends on the degree of Onyx reflux and vessel tortuosity. To overcome this problem, we have adapted a previously described monorail snare technique for stretched coils to remove an adherent microcatheter from the occipital artery during Onyx embolization of a dural arteriovenous fistula. We used this technique successfully in a 62-year-old man with a posterior fossa dural arteriovenous fistula. An Echelon-10 microcatheter (eV3 Neurovascular, Inc.) system became adherent in the right occipital artery because of reflux and vessel tortuosity. Significant stretching of the microcatheter was observed during attempted removal. A 2-mm Amplatz Goose Neck microsnare (Microvena Corp., White Bear Lake, MN) was placed through a Rapid Transit microcatheter (Cordis Corp., Miami, FL). The hub of the indwelling Echelon microcatheter was cut off and the snare advanced over the outside of the microcatheter. The snare and Rapid Transit microcatheter were then advanced into the guiding catheter (6-French) as a unit over the indwelling Echelon microcatheter. Using the adherent Echelon as a "monorail" guide, the snare and Rapid Transit microcatheter were advanced distally into the occipital artery and the snare was retracted to engage the microcatheter. The microcatheters and snare were then easily removed because of the second vector of force placed by the snare system on the adherent microcatheter very close to the point of adherence. The monorail snare technique represents a simple and safe way to remove an adherent microcatheter from an Onyx cast during the embolization of dural arteriovenous fistulas. Prospective knowledge of this technique will facilitate more aggressive embolization without the reservation that a retained microcatheter could require surgical removal or anticoagulation.

Endoscopic Resection of 107 Large Sessile Polyps: Outcome and Predictors of Cure

Background: Large sessile colorectal adenomas (LSAs) (≥2 cm in size) resected piecemeal have a 14-55% rate of residual adenoma at first follow-up. Guidelines recommend inspection of the polypectomy site 3-6 months after resection. Some patients with a negative exam at 3-6 months have a subsequent “late” recurrence. Few studies have reported long term follow-up in these patients. Methods: LSAs were identified by review of an endoscopic database. Polyps were resected by piecemeal snare technique; flat areas that could not be snared were treated with argon plasma coagulation. Only patients who completed a first follow-up exam at 3-6 months and a second follow-up exam ≥1 year after initial resection were included. Endoscopic and pathologic data at both follow-ups were reviewed. Groups of patients with and without adenoma recurrence/persistence were compared. Results: During the study period, 105 patients (52 Female) with 107 LSAs (mean size 33.2 mm) were included. The recurrence/persistence rate at first follow-up was 20.1%; 22 patients (Group A) had persistent or recurrent adenomas, of which 15 had visible polyps and 7 had no visible polyps but biopsy of the polypectomy scar showed adenomatous tissue. Of the 85 polyps (Group B) with no evidence of recurrence at first follow-up, 70 had no visible adenoma and a normal scar biopsy and 15 had no visible adenoma but did not undergo scar biopsy. A total of 6 patients (5.8%) had polyp recurrence/persistence at 1 year, including 4 patients (18.2 %) from group A and 2 patients (2.4%) from group B (p = 0.004). Of the 70 patients from group B who had a normal scar biopsy at first follow-up, only 1 patient had an adenoma at 1 year (1.4%). All 6 recurrent/persistent polyps at 1 year were snare resected and there was no evidence of any further recurrence/persistence after an additional 6 to 12 months of follow-up. The mean size at baseline of the polyps that recurred/persisted at first follow-up was significantly larger than that of the polyps that did not (41.8 mm vs. 31 mm, p = 0.003). Conclusion: Endoscopic piecemeal resection and ablation of LSAs is effective though some patients require >2 sessions to achieve and ensure complete eradication. The lowest recurrence/persistence rates were among patients with smaller polyps and those who had no visible adenoma and a negative polypectomy scar biopsy at 3-6 months. Absence of visible adenoma and a negative scar biopsy at 3-6 months follow-up are predictive of long term cure.

Stepwise Radical Endoscopic Resection for Complete Removal of Barrett's Esophagus with Early Neoplasia: An International Multicenter Study

Objectives: Endoscopic resection (ER) of high-grade dysplasia (HGD) or intramucosal cancer (IMC) in Barrett's esophagus (BE) is an effective and safe alternative to surgical treatment. After ER as monotherapy, recurrent lesions may develop elsewhere in the residual BE during follow-up (FU). Stepwise radical endoscopic resection (SRER) allows for removal of the whole BE by subsequent ERs with histological correlation and has been shown effective and safe in small-sized single-center studies. The aim of this study was to evaluate the efficacy and safety of SRER for BE-HGD/IMC in 4 European tertiary referral centres that used a prospective SRER protocol in the past years. Methods: Patients with HGD or IMC in BE ≤5 cm, without signs of submucosal infiltration or lymph node metastases on endoscopy or endosonography, were included. Patients underwent ER sessions (cap, multiband mucosectomy or simple snare technique) with intervals of 4-8 weeks until complete eradication of BE. Results: 151 BE patients with HGD or IMC, treated between Jan 2000 and Sept 2006 were included. Two patients discontinued treatment due to unrelated comorbidity. Complete eradication of early neoplasia was achieved in 148/149 patients (99%) after a median number of two ER sessions (IQR 2-3). One patient with persisting IMC after 6 therapeutic sessions was referred for esophagectomy. Complete removal of all intestinal metaplasia (IM) was achieved in 145/149 (97%) patients. Complications occurred in 1% of ER procedures: 2 perforations treated conservatively and 2 delayed bleedings treated with endoscopic hemostatic techniques. Symptomatic stenosis occurred in 79 patients (52%) and was effectively treated by endoscopic dilatations. There was a significant trend in stenosis rate with increasing BE length (Chi square for trend; p = 0.04). Two patients had a perforation during endoscopic dilatation that was treated by stenting and esophagoectomy. During a median FU of 18 mo (IQR 7-31), 4 (3%) patients had recurrence of neoplasia, treated with repeat ER in 3 and curative surgery in one. Seven patients (5%) had recurrence of visible BE mucosa (generally small islands) and 12 (8%) patients had IM detected distal to neo-z-line. Subsquamous IM was found in 9 patients (6%), all had undergone additional APC. Discussion: SRER for BE-HGD/IMC <5 cm allows for removal of the whole BE with histological correlation and is associated with a low recurrence rate during FU. Severe complications are rare but about 50% of patients develop an esophageal stenosis.

Abstract No. 26: Snare Technique for the Placement of Peripherally Inserted Central Catheters (PICC) in Neonatal-Pediatric Patients

Abstract No. 26: Snare Technique for the Placement of Peripherally Inserted Central Catheters (PICC) in Neonatal-Pediatric Patients

Percutaneous Lithotripsy for Removing Difficult Bile Duct Stones Using Endoscopy

Purpose: To describe efficacy of percutaneous lithotripsy for removing difficult bile duct stones using endoscopy. Materials and Methods: A total of 88 patients with difficulties for the removal of bile duct stones using endoscopy (an impacted stone, stone size >15 mm, intrahepatic duct (IHD) stone, stone size to bile duct diameter ratio >1.0), were enrolled in this study. A 12 Fr sheath was inserted through the percutaneous transhepatic biliary drainage (PTBD) tract, and then nitrol stone baskets and a 0.035” snare wire were used to capture, fragment and remove the stones. The technical and clinical success rates were analyzed, together with an analysis of any complications. Results: The overall technical success rate of stone removal was achieved in 79 of 88 patients (89.8%). In five of nine patients with failed stone removal, small residual IHD stones were noted on a cholangiogram. Even if stone removal failed in these cases, cholangitic symptoms were improved and the drainage catheter was successfully removed. Therefore, clinical success was achieved in 84 of 88 patients (95.5%). There were no significant procedure-related complications, except for sepsis in one case. Conclusion: Billiary stone removal using the stone basket and guide-wire snare technique through the PTBD tract is a safe and effective procedure that can be used as a primary method in patients with difficulties for the removal of bile duct stones using endoscopy.

Multiple endobronchial lipomas which were treated by bronchoscopical resection

Bronchial benign tumors are very rare; however, endobronchial lipomas are responsible for 0.1–0.5% of all lung tumors (1,2). Clinical symptoms depend on the severity of bronchial obstruction and the effects on parenchyma. It is more common in men and more frequently observed in the right bronchial system (3). We present a 76-year-old woman with two separate endobronchial lipomas in the upper lobe and intermediary bronchi, who applied with cough and sputum. The patient was successfully treated with electrocautery snare technique. After this procedure, thorax CT showed bronchiectasis of right lower zone. Thoracotomy was not taken into consideration. After 2-year follow-up the patient has no complaint.

Loop-Snare Technique for Difficult Inferior Vena Cava Filter Retrievals

Retrievable inferior vena cava (IVC) filters are generally retrieved without difficulties. However, when filters are tilted against the IVC wall, engaging the tip or hook of the filter can be difficult with the use of standard techniques. This report describes an alternative method of successful IVC filter retrieval by creating a wire loop between the filter legs, including the tip of the filter. This loop snare was successfully applied in eight cases after filter retrieval failed with the Recovery Cone or simple snare technique.

Gastric Polyps Causing Intermittent Gastric Outlet Obstruction

Purpose: A 40-year-old Caucasian male with a history of GERD and Osgood-Schlatter disease presented with acute-onset of abdominal bloating, nausea and vomiting for one month. His daily symptoms were worse at night, usually resolving by the next morning. He denied any worsening heartburn, weight loss, appetite changes, dietary changes or modification of bowel habits. He had been on long-term proton-pump inhibitor therapy for GERD and was taking NSAIDs for osteochondritis. Elective gastroscopy showed multiple large gastric polyps occupying the gastric fundus and body. Two of these polyps were pedunculated and were prolapsing into the pyloric channel, presumably causing intermittent gastric outlet obstruction. We endoscopically removed two 3.5 cm hyperplastic polyps by snare technique. The patient's symptoms completely resolved following this intervention. Proton-pump inhibitors are widely used in clinical practice and are associated with an increased incidence of hyperplastic gastric polyps via stimulation of enterochromaffin-like cells. Gastric polyps causing gastric outlet obstruction should be considered in the differential diagnoses of abdominal distention.[figure1][figure2]FigureFigure

Percutaneous Transgastric Snaring for Repositioning of a Dislocated Internal Drain from a Pancreatic Pseudocyst

Pancreatic pseudocysts may occur in up to 10% of patients with acute or chronic pancreatitis. Symptomatic, persistent, and infected pancreatic pseudocysts require interventional therapy. We present the case of a patient with complete dislocation of a double pigtail catheter into an infected pseudocyst and the repositioning of the drainage catheter using a transgastric snaring technique. The combination of CT-guided percutaneous puncture and fluoroscopic snaring permitted minimally invasive management of this rare complication.

Polypectomy devices

Polypectomy devices

Fibrin sheath removal from central venous catheters: an internal snare manoeuvre

Dysfunction of haemodialysis catheters is most commonly due to a narrowing of the catheter lumen and/or formation of a fibrin sheath around the catheter tip. Reported methods for restoring patency of the catheter lumen include passage of a J-tipped guide wire, passage of a biopsy brush through the catheter, or infusion of a thrombolytic agent into the catheter. While these methods are often effective, they suffer from several limitations. We present a minimally invasive technique to remove thrombi and debris from within the lumen of a partially thrombosed haemodialysis catheter while simultaneously stripping the fibrous sheath. A 0.089 cm nitinol wire is bent to create a loop, which is then inserted via the catheters. Upon exiting the lumen of the catheters, the nitinol wire forces a snare open, which disrupts the fibrin sheath and catches intraluminal thrombi and debris. The technique requires no anaesthesia or recovery time. Initial clinical success in our series was achieved in all patients (7/7) as evidenced by restoration of target flow rates on subsequent haemodialysis. None of the patients experienced any complications as a result of the procedure. The catheter 2-, 4-, and 6-week primary success rates were 100% (8/8), 100% (8/8), and 100% (8/8) respectively with a mean duration of 17.1 weeks (range 8-40 weeks). The internal snare technique is an effective, inexpensive and minimally invasive approach to restoring patency to failed central venous access catheters.

Fluoroscopy-Guided Transurethral Removal and Exchange of Ureteral Stents in Female Patients: Technical Notes

To describe simple and safe techniques for transurethral removal and for exchange of ureteral stents in female patients under fluoroscopic guidance. During a period of 33 months, the authors removed 4 and exchanged 34 double-J ureteral stents in 17 female patients. Four techniques were implemented to remove or exchange these stents: simple snare technique, modified snare technique, guide-wire lasso technique, and direct grasping technique. All stents were either exchanged or removed successfully. The average time elapsed per procedure was 21.5 minutes. Simple snare techniques were used with 19 (50%) stents, and modified snare techniques were used with 13 (34%) stents where grasping the tip of a stent was not possible with the snare alone. Lasso and direct grasping techniques were each used with three (8%) stents. Self-limited microscopic hematuria was observed in all subjects after the procedure, but none reported gross hematuria. Fluoroscopy-guided transurethral removal and exchange of ureteral stents is a safe and effective procedure, and it can be considered as an alternative to cystoscopic removal and exchange.