EXTREME IR
Massive Coil Nest Migration:
Endovascular Retrieval
Kumar Kempegowda Shashi, MD, Gulraiz Chaudry, MD, Ahmad Alomari, MD, FSIR, and
Rush Chewning, MD
An 11-year-old boy with Klippel-Trenaunay syndrome with right lower
extremity and pelvic venous ectasia underwent prophylactic embolization
of persistent sciatic vein and markedly ectatic internal iliac vein using 24
coils (20 mm x 20 cm to 12 mm x 14 cm) (Nester; Cook Inc, Bloomington,
Indiana) (Fig 1) to reduce risk of pulmonary embolism. He presented to the
emergency department 3 days later with mild chest discomfort. Scout image
from computed tomography (CT) pulmonary angiogram showed
completely displaced coil nest in the chest (Fig 2). A 14-Fr sheath was
placed in the left common femoral vein and pulmonary angiogram was
performed, demonstrating occluded left lower lobe segmental arteries
(Fig 3). A 5-Fr vertebral catheter supported by a 6-Fr Envoy catheter was
advanced into the main pulmonary artery. The coil nest was snared with a
Figure 1. Fluoroscopic image demonstrating coil nest after embolization
of persistent sciatic and internal iliac veins (white arrow). Coil nest was
anchored by extending coils (black arrow) into a small tributary to reduce
risk of coil migration. Note coil in right inferior gluteal vein from previous
embolization (white arrowhead).
From the Department of Radiology, Division of Vascular and Interventional
Radiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston,
Massachusetts, 02115. Received March 4, 2019; final revision received March
19, 2019; accepted March 20, 2019. Address correspondence to K.K.S.;
E-mail: drkumargowda@gmail.com
None of the authors have identified a conflict of interest.
25-mm gooseneck snare (Fig 4) and retracted into the inferior vena cava.
An additional coaxial 25-mm snare was used to secure the distal end of
the coil nest for enhanced stability. The coil nest was then pulled down into
the left external iliac vein; however, it was too large to be removed through
the sheath (Fig 5). It was removed in its entirety through an open femoral
venotomy by a vascular surgeon in the interventional radiology procedure
room (Fig 6). The patient was discharged home the next day on
therapeutic dose of enoxaparin. CT pulmonary angiogram performed 3
Figure 2. CT scout image showing completely migrated coil nest in the
chest (white arrow). Note intact coil in right hip region from prior embolization (white arrowhead).
© SIR, 2019
J Vasc Interv Radiol 2019; 30:1610–1611
https://doi.org/10.1016/j.jvir.2019.03.011
Volume 30 ▪ Number 10 ▪ October ▪ 2019
1611
Figure 3. Catheter pulmonary angiogram showing non-opacification of
left lower lobe segmental arteries and protrusion of the other end of the
coil nest into the proximal right pulmonary artery.
Figure 6. Entire retrieved coil nest.
Figure 4. Snaring (white arrow) the coil nest in the right pulmonary
artery.
Figure 7. 3-dimensional volume-rendered image from CT pulmonary
angiogram 3 weeks after coil nest retrieval demonstrating patency of left
(white arrow) and right (white arrowhead) pulmonary arteries and their
branches.
weeks after the procedure showed patency of the left pulmonary artery and
its branches (Fig 7). He remained asymptomatic at 3-month clinical followup visit.
Figure 5. The coil nest was successfully retrieved to left external iliac
vein. Note that the coil nest is significantly larger than the 14-Fr sheath.