Lead removal without extraction tools: a single-center experience

Abstract Introduction: Indications for cardiac devices have been increasing as well as the need for lead extractions as a result of infections, failed leads and device recalls. Powered laser sheaths, with a global trend towards the in-creasingly technological tools, meant to improve the procedure's outcome but have economic implications. Objective: The aim of this study is to demonstrate the experience of a Bra-zilian center that uses simple manual traction in most lead removals per-formed annually, questioning the real need for expensive and technically challenging new devices. Methods: This retrospective observational study included 35 patients who had a transvenous lead extraction in the period of a year between January 1998 and October 2014 at Hospital de Messejana Dr. Carlos Alberto Studart Gomes, in Fortaleza, CE, Brazil. Data were collected through a records review. They were evaluated based on age, type of device, dwelling time, indication for removal, technique used and immediate outcomes. Results: The median dwelling time of the devices was 46.22 months. Infec-tion, lead fracture and device malfunction were the most common indica-tions. Simple traction was the method of choice, used in 88.9% of the pro-cedures. Manual traction presented high success rates, resulting in com-plete removal without complications in 90% of the cases. Conclusion: This article suggests that lead extraction by simple manual traction can still be performed effectively in countries with economic diffi-culties as a first attempt, leaving auxiliary tools for a second attempt in case of failure or contraindications to the simple manual traction technique.

Removal of intramural trapped intrauterine device by cystoscopic incision of bladder wall

ABSTRACT A healthy 37 - year - old woman referred to our clinic with one - year history of recurrent urinary tract infection, dysuria and frequency. Her past medical history informed us that an IUD (Copper TCu380A) had been inserted 11 years ago. Eleven months after the IUD insertion she had become pregnant, unexpectedly. At that time, she had undergone gynecological examination and abdominal ultrasound study. However, the IUD had not been found, and the gynecologist had made the diagnosis of spontaneous fall out of the IUD. She had experienced normal pregnancy and caesarian section with no complications. On physical examination, pelvic examination was normal and no other abnormalities were noted. Urinalysis revealed microhematuria and pyuria. Urine culture was positive for Escherichia coli. Ultrasound study revealed a calculus of about 10 mm in the bladder with a hyperdense lesion. A plain abdominal radiograph was requested which showed a metallic foreign body in the pelvis. We failed to remove the IUD by cystoscopic forceps because it had strongly invaded into the uterine and bladder wall. Despite previous papers suggesting open or laparoscopic surgeries in this situation (1, 2), we performed a modified cystoscopic extraction technique. We made a superficial cut in the bladder mucosa and muscle with J - hook monopolar electrocautery and extracted it completely with gentle traction. This technique can decrease the indication of open or laparoscopic surgery for extraction of intravesical IUDs. In the other side of the coin, this technique may increase the risk of uterovesical fistula. Therefore, the depth of incision is important and the surgeon should cut the bladder wall superficially with caution. Although present study is a case report which is normally classified as with low level of evidence, it seems that our modified cystoscopic extraction technique is a safe and useful method for extraction of partially intravesical IUDs.

Rescue therapy with stent retrievers for thromboembolism during endovascular treatment of intracranial aneurysms / Terapia de resgate com stent para tromboembolismo durante tratamento endovascular de aneurismas intracranianos

ABSTRACT Thromboembolism is the most frequent complication in endovascular treatment of intracranial aneurysms, causing disability and death. As stent retrievers have achieved high rates of arterial recanalization in the management of ischemic stroke, these devices were tested as rescue therapy of thromboembolism during aneurysm embolization. We retrospectively analyzed 10 consecutive patients with transprocedural arterial occlusion, treated with mechanical thrombectomy at a single center. Good angiographic recanalization was achieved in eight cases, mTICI 3, 2b and 2a in five, three and two patients, respectively, without additional complications or any deaths. Five patients showed complete recovery (mRS 0) and all patients showed improvement of disability (average mRS 1.1) over a mean follow-up period of 31 months. Eight patients had good clinical recovery, while two remained with deficits (mRS 3 and 4). The study found that the stent retriever is a valuable, rapid and effective tool for restoring blood flow, improving the safety of endovascular treatment.

RESUMO Tromboembolismo é a complicação mais frequente no tratamento endovascular de aneurismas cerebrais, podendo causar morte ou sequelas. Como os stent retrievers alcançaram altas taxas de recanalização arterial no tratamento do acidente vascular encefálico isquêmico, testamos esses dispositivos para tratar eventos tromboembólicos ocorridos durante a embolização de aneurismas. Foram analisados retrospectivamente 10 pacientes apresentando oclusão arterial transoperatória, tratados com trombectomia mecânica em um único centro. Obtivemos recanalização angiográfica em oito casos, mTICI 3, 2b e 2a em cinco, três e dois pacientes, respectivamente, sem complicações adicionais ou óbito. Cinco casos apresentaram recuperação completa (mRS 0) e todos os pacientes apresentaram melhora dos déficits (mRS médio 1.1) durante acompanhamento médio de 31 meses. Oito pacientes apresentaram boa recuperação clínica, enquanto dois permaneceram com déficits (mRS 3 e 4). O estudo concluiu que stents são uma ferramenta valiosa, rápida e eficaz para restaurar o fluxo sanguíneo, aumentando a segurança do tratamento endovascular.

Evaluación de un nuevo método de remoción quirúrgica de implantes oseointegrados considerados en fallo / Evaluation of a new surgical removal method of failed integrated implants

OBJETIVO El objetivo del presente estudio descriptivo es la valoración de un nuevo método de remoción de implantes oseointegrados bajo una técnica mínimamente invasiva. MATERIALES Y MÉTODOS El estudio fue desarrollado sobre un grupo de 66 implantes oseointegrados de conexión interna y externa diagnosticados en falla, a los cuales se les indicó su remoción quirúrgica por presentar un diagnóstico radiográfico de pérdida ósea periimplantaria, mal posicionamiento quirúrgico con imposibilidad de rehabilitación protésica o daño del elemento de retención protésico del implante. El procedimiento quirúrgico, el cual es de carácter ambulatorio, fue llevado a cabo en un pabellón bajo anestesia local. Como primera opción de remoción quirúrgica, el procedimiento consistió en la utilización de instrumental de remoción a contra-torque, sin la apertura de un colgajo de espesor total, y como segunda opción de remoción quirúrgica la utilización de una fresa trefina, para lo cual fue necesario realizar un colgajo de espesor total que expusiera el lecho implantario. RESULTADOS Se removieron un total de 66 implantes oseointegrados, todos bajo la primera modalidad de remoción a contra-torque con el nuevo instrumento, sin colgajo y sin la necesidad de usar fresa trefina. CONCLUSIONES Con las limitaciones de este estudio preliminar planteamos que la utilización del nuevo instrumento de remoción a contra-torque de implantes oseointegrados en fallo se vislumbra como una muy buena alternativa de remoción quirúrgica mínimamente invasiva, disminuyendo los riesgos quirúrgicos del uso de una fresa trefina, el daño a los tejidos aledaños.

OBJECTIVE The aim of this study is the evaluation of a new removal method of osseointegrated implants under a minimally invasive technique. MATERIALS AND METHODS The study was conducted on a group of 66 osseointegrated internal and external connection implants that were considered unsuccesful. The surgical removal was indicated after radiologically confirming peri-implant bone loss, and poor positioning which made the prosthetic rehabilitation impossible, or would damage the prosthetic implant retainer. The surgical procedure was developed in an operating room under local anesthesia. As first surgical removal option, the procedure consisted of the use of a removal instrument that works against torque and which does not need a full thickness flap to reach the surgical site; and as a second surgical removal option a trephine bur was used. For this option, a full thickness flap was performed in order to expose the surgical site. RESULTS A total of 66 osseointegrated implants were removed under the first mode, with no full thickness flaps or Trephine burs required. CONCLUSIONS Within the limitations of this preliminary study, we propose that the use of this new, against torque, removal instrument of osseointegrated implants in failure is seen as a very good alternative to invasive surgical removal techniques, reducing surgical risks.

Breakage of a Lag Screw of Cephalomedullary Nail: A Technique of Removal

A broken lag screw of the cephalomedullary nail is a rare condition. Removal of the retained lag screw from the femoral head is also very challenging. This article describes a surgical technique and the modified instrument that was available in the operating room for removing the broken implant by closed technique.

Successful coronary stent retrieval from the ascending aorta using a gooseneck snare kit

Coronary stent dislodgement is a rare complication of percutaneous coronary intervention. We report a case of stent dislodgement in the ascending thoracic aorta. The stent was mechanically distorted in the left circumflex artery (LCX) while being delivered to the proximal LCX lesion. The balloon catheter was withdrawn, but the stent with the guide wire was remained in the ascending thoracic aorta. The stent was unable to be retrieved into the guide catheter, as it was distorted. A goose neck snare was used successfully to catch the stent in the ascending thoracic aorta and retrieved the stent externally via the arterial sheath.

A rationale method for evaluating unscrewing torque values of prosthetic screws in dental implants

OBJECTIVES: Previous studies that evaluated the torque needed for removing dental implant screws have not considered the manner of transfer of the occlusal loads in clinical settings. Instead, the torque used for removal was applied directly to the screw, and most of them omitted the possibility that the hexagon could limit the action of the occlusal load in the loosening of the screws. The present study proposes a method for evaluating the screw removal torque in an anti-rotational device independent way, creating an unscrewing load transfer to the entire assembly, not only to the screw. MATERIAL AND METHODS: Twenty hexagonal abutments without the hexagon in their bases were fixed with a screw to 20 dental implants. They were divided into two groups: Group 1 used titanium screws and Group 2 used titanium screws covered with a solid lubricant. A torque of 32 Ncm was applied to the screw and then a custom-made wrench was used for rotating the abutment counterclockwise, to loosen the screw. A digital torque meter recorded the torque required to loosen the abutment. RESULTS: There was a significant difference between the means of Group 1 (38.62±6.43 Ncm) and Group 2 (48.47±5.04 Ncm), with p=0.001. CONCLUSION: This methodology was effective in comparing unscrewing torque values of the implant-abutment junction even with a limited sample size. It confirmed a previously shown significant difference between two types of screws.

Effect of the simulated periodontal ligament on cast post-and-core removal using an ultrasonic device

ABSTRACT OBJECTIVE: The aim of this study was to evaluate the effect of simulated periodontal ligament (SPDL) on custom cast dowel and core removal by ultrasonic vibration. MATERIAL AND METHODS: Thirty-two human maxillary canines were included in resin cylinders with or without SPDL made from polyether impression material. In order to allow tensile testing, the roots included in resin cylinders with SPDL were fixed to cylinders with two stainless steel wires. Post-holes were prepared by standardizing the length at 8 mm and root canal impressions were made with self-cured resin acrylic. Cast dowel and core sets were fabricated and luted with Panavia F resin cement. Half of the samples were submitted to ultrasonic vibration before the tensile test. Data were analyzed statistically by two-way ANOVA and Tukey's post-hoc tests (p<0.05). RESULTS: The ultrasonic vibration reduced the tensile strength of the samples directly included in resin cylinders. There was no difference between the values, whether or not ultrasonic vibration was used, when the PDL was simulated. However, the presence of SPDL affected the tensile strength values even when no ultrasonic vibration was applied. CONCLUSION: Simulation of PDL has an effect on both ultrasonic vibration and tensile testing.

Effectiveness of rotary or manual techniques for removing a 6-year-old filling material

The aim of this study was to evaluate the effectiveness of manual and rotary instrumentation techniques for removing root fillings after different storage times. Twenty-four canals from palatal roots of human maxillary molars were instrumented and filled with gutta-percha and zinc-oxide eugenol-based sealer (Endofill) , and were stored in saline for 6 years. Non-aged control specimens were treated in the same manner and stored for 1 week. All canals were retreated using hand files or ProTaper Universal NiTi rotary system. Radiographs were taken to determine the amount of remaining material in the canals. The roots were vertically split, the halves were examined with a clinical microscope and the obtained images were digitized. The images were evaluated with AutoCAD software and the percentage of residual material was calculated. Data were analyzed with two-way ANOVA and Tukey's test at 5 percent significance level. There was no statistically significant differences (p>0.05) between the manual and rotary techniques for filling material removal regardless the ageing effect on endodontic sealers. When only the age of the filling material was analyzed microscopically, non-aged fillings that remained on the middle third of the canals presented a higher percentage of material remaining (p<0.05) compared to the aged sealers and to the other thirds of the roots. The apical third showed a higher percentage of residual filling material in both radiographic and microscopic analysis when compared to the other root thirds. In conclusion, all canals presented residual filling material after endodontic retreatment procedures. Microscopic analysis was more effective than radiographs for detection of residual filling material.

O objetivo deste estudo foi avaliar a efetividade da instrumentação manual e rotatória na remoção de material obturador de canais radiculares de raízes palatinas de molares superiores humanos, em dois períodos de tempo. Vinte e quatro raízes foram instrumentadas e obturadas com guta-percha, cimento de óxido de zinco e eugenol e armazenadas em solução salina durante 6 anos. Outras 24 raízes foram tratadas da mesma maneira e armazenadas por uma semana. Os canais radiculares foram retratados usando limas manuais ou instrumentos rotatórios do Sistema ProTaper Universal. Radiografias periapicais foram feitas para mensurar a quantidade de material remanescente. Posteriormente as raízes foram clivadas e imagens microscópicas obtidas a partir de um microscópio clínico operatório foram digitalizadas. As imagens foram avaliadas através do software Autocad 2004 e área de material obturador remanescente foi mensurada. A Análise da Variância (Two-way) e o Teste T demonstraram não haver diferenças estatisticamente significantes entre a técnica manual e rotatória na remoção de material obturador. O terço apical mostrou a maior percentagem de remanescentes de material obturador, na análise radiográfica e microscópica quando comparado com os outros terços radiculares. Todos os canais revelaram resíduos de material obturador após o retratamento endodôntico. A análise microscópica foi mais efetiva do que a radiográfica na detecção de remanescente de obturação do canal radicular.

Removal torque of zirconia abutment screws under dry and wet conditions

The aim of this study was to verify whether screw abutment lubrication can generate higher preload values compared to non-lubricated screws, a titanium abutment was screwed onto an implant analog and scanned with the Procera System to generate 20 zirconia abutments. MKIII Brånemark implants were clamped to a precision torque device, and the abutments were distributed in dry and wet groups with 10 specimens each. In the wet groups, the inner threads of the implants were filled with artificial saliva. All abutments were fastened with a Torqtite screw under 32 Ncm. Ten detorque measurements were performed per group pushing the reverse button of the Torque controller soon after screw tightening with values registered. The mean detorque values were calculated and compared by a Student's t test (?=0.05). The wet condition presented significantly higher mean detorque than the dry condition (31.5 ± 1.2 versus 27.5 ± 1.5 Ncm, respectively; p=0.0000024). In conclusion, there was always a loss in the initial torque values when the removal torque was measured under both conditions. The wet condition presented higher mean torque than the dry condition. Better preload values were established in the wet group, suggesting that the abutment screw must be lubricated in saliva to avoid further loosening.

A fim de verificar se a lubrificação do parafuso do pilar pode gerar valores maiores de pré-carga do que nos parafusos não lubrificados, um pilar de titânio foi parafusado no análogo do implante e escaneado pelo Sistema Procera para gerar 20 pilares de zircônia. Depois, os implantes MKIII Brånemark foram presos num dispositivo de torque. Os pilares foram distribuídos em grupos seco e úmido com 10 amostras cada. No grupo úmido, as roscas internas dos implantes foram preenchidas com saliva artificial. Então, todos os pilares foram apertados com parafuso Torqtite a 32 Ncm. Dez medidas de destorque foram realizadas por grupo apertando-se o botão reverso do Torque Controller logo depois do parafusamento, e os valores foram registrados. As medias de destorque foram calculadas e comparadas pelo teste t de Student (?=0,05). Os valores médios obtidos nas condições seca e úmida foram 27,5 ± 1,5 Ncm e 31,7 ± 1,2 Ncm, respectivamente. Diferenças estatisticamente significantes foram observadas (p=0,0000024). Observou-se sempre existir uma perda do torque inicial quando o torque de remoção é mensurado em ambas as condições. A condição úmida demonstrou um valor médio maior de torque do que a condição seca. Valores melhores de pré-carga podem ser estabelecidos no grupo úmido, sugerindo que o parafuso do pilar deve ser lubrificado em saliva para evitar seu afrouxamento.

Retirada percutânea de corpo estranho intracardíaco com técnica original / Percutaneous retrieval of intracardiac foreign body with a novel technique

Relatamos o caso de um paciente com cateter vascular de longa permanência embolizado para o ventrículo direito. Este caso ganha peculiaridade por estarem as duas extremidades do cateter indisponíveis para serem laçadas, dificultando a sua captura pelas técnicas convencionais. Descrevemos um novo método para resgatar o corpo estranho através de sua porção central, utilizando apenas um cateter com dois sistemas independentes de "laço" e de "gancho".

We report on the case of a patient with a long term vascular catheter embolized into the right ventricle. This case had unique characteristics since both ends of the catheter were inaccessible for snare, which made it difficult to capture them using conventional techniques. We describe a new method to retrieve the foreign body through its mid-point portion, using a single catheter with two independent snare and hook systems.

Evaluation of the apical seal after intraradicular retainer removal with ultrasound or carbide bur

There are situations in which intraradicular retainers have to be removed and replaced. The objective of this research was to evaluate the apical seal after the removal of a custom cast post and core with a carbide bur or with an ultrasound apparatus. Twenty five roots of extracted human incisors were used. They were endodontically treated and prepared to receive the posts. The posts and cores were cast with 2 types of dental alloys, CuAlZn and PdAg, and were cemented with zinc phosphate cement. After 24 hours, they were removed using the two above mentioned techniques. Then, the roots had their external surface made impermeable by two layers of cyanoacrylate adhesive, leaving only the cervical area for dye penetration. The teeth were immersed in rhodamine for 24 hours. They were then cut and observed under an optical microscope and analyzed with appropriate software (Imagelab). The results were submitted to ANOVA, and they evidenced that, regarding the alloy factor, PdAg posts presented a larger mean infiltration value (2.23 ± 0.48 mm) as compared to the posts made of CuAlZn (1.39 ± 0.48 mm) (p = 0.025). Regarding the technique factor, there was no significant difference (p = 0.9) between the removal of the intraradicular retainer using ultrasound (1.99 ± 0.62 mm) or using a rotating cutting instrument (1.62 ± 0.62 mm). Under these experimental conditions, it was possible to conclude that the degree of apical leakage was directly related to the alloy type, and it was present in both techniques used.

Há situações que exigem a remoção ou substituição de retentores intra-radiculares. O objetivo deste trabalho foi avaliar o selamento apical do material obturador após a remoção de pino intra-radicular metálico fundido com instrumento cortante rotatório ou com aparelho de ultra-som. Utilizaram-se 25 raízes de incisivos humanos extraídos, que foram endodonticamente tratadas e preparadas para receberem os pinos. Os retentores intra-radiculares foram fundidos com 2 tipos de ligas odontológicas, CuAlZn e PdAg, e foram cimentados com cimento de fosfato de zinco. Após 24 horas, foram removidos com as 2 técnicas citadas. Em seguida, os dentes foram impermeabilizados com cianoacrilato de etila, permitindo a entrada do corante apenas por via cervical. Os dentes foram imersos em rodamina por 24 horas, depois foram clivados e observados em microscópio óptico de luz e analisados em "software" próprio (Imagelab). Os resultados foram submetidos à análise de variância e mostraram que, para o fator liga, os pinos de PdAg geraram uma média de infiltração maior (2,23 ± 0,48 mm) do que os pinos de CuAlZn (1,39 ± 0,48 mm), com p = 0,025; para o fator técnica, não houve diferença significante, com p = 0,9, entre a remoção com ultra-som (1,99 ± 0,62 mm) e a remoção com instrumento cortante rotatório (1,62 ± 0,62 mm). Nestas condições experimentais, foi possível concluir que o grau de infiltração apical está relacionado com o tipo de liga, e a infiltração esteve presente em ambas as técnicas utilizadas.

Adesäo em ortodontia. Parte 3 / Bonding in orthodontics. Part 3

Este trabalho propöe-se a analisar, na literatura, as diferentes técnicas utilizadas para a remoçäo de brackets metálicos/cerâmicos e do material adesivo remanescente; e pretende identificar o método mais adequado para a recolagem de brackets após a sua remoçäo intencional ou descolagem acidental. Visando ao conforto do paciente e a benefícios ao esmalte, conclui-se que a utilizaçäo do alicate com pontas ativas näo-metálicas e que absorvam a força de traçäo é o mais indicado para remoçäo de brackets metálicos. Com relaçäo aos brackets cerâmicos, conclui-se que o método de remoçäo manual (alicate 444-770) é o mais indicado. Após a remoçäo do bracket, o material adesivo remanescente deve ser removido com broca tungstênio-carbide multilaminada em alta-rotaçäo, e as porçöes mais próximas ao esmalte dentário devem ser removidas com a utilizaçäo de pontas siliconizadas, as quais removem apenas o material adesivo remanescente e näo lesam o esmalte dentário