Hydrophilic polymer emboli: an under-recognized iatrogenic cause of ischemia and infarct

Abstract

With the increased use of percutaneous intravascular diagnostic and therapeutic devices, there is potential for embolization of materials introduced into the vasculature. We report nine cases of foreign body emboli in patients who underwent vascular procedures using hydrophilic-coated medical devices. The procedures performed included cardiac catheterization (four cases), diagnostic cerebral angiography (two cases), therapeutic cerebral angiography with coil embolization of intracerebral aneurysm (one case), lower extremity angiography (one case), and/or orthotopic cadaveric organ transplantation (three cases). Other procedures in these patients included hemodialysis and peripheral arterial or central venous catheterization. Clinical sequelae ranged from undetectable (no symptoms) to pulmonary infarction, stroke, ongoing gangrene, and/or death occurring within days to weeks of suspected embolization of foreign material. Microscopic findings in biopsy or autopsy tissue revealed aggregates of amorphous or lamellated, non-refractile, non-polarizable, predominantly basophilic foreign substances occluding intrapulmonary, intracerebral, or peripheral arteries. This is the largest series documenting embolization of polymer gel materials. Polymer gel is now widely used on several devices for interventional procedures worldwide, and we suspect that complications associated with iatrogenic embolization of this substance are under-recognized.

Cerebral Protection During Catheter Ablation of Ventricular Tachycardia in Patients With Ischemic Heart Disease

“…Although no further discrimination of foreign material was performed in this examination, we assume that the material most likely arose from hydrophilic polymer coatings used on guidewires, catheters, and previously implanted ICD leads, which is consistent with previously identified materials in patients undergoing endovascular procedures 22. A further source of foreign material might be the transseptal needle when advanced through the dilator and transseptal sheath for the antegrade approach, which has been shown to produce clinically relevant particles 25.…”

“…Maleki et al reported 9% thrombus formation on transseptal sheaths despite adequate anticoagulation 21. The thrombogenicity of guidewires during endovascular procedures has been described in vivo and in vitro 22, 23. For example, the rate of significant thrombus formation on guidewires used in routine percutaneous coronary interventions was reported to be 48% 24.…”

Foreign Body Emboli following Cerebrovascular Interventions: Clinical, Radiographic, and Histopathologic Features

“…8,10,11 Both clinical and radiographic courses were similar to those in the case series of Cruz et al 3 Our management relies on corticosteroid modulation of the inflammatory response and empiric titration of antiplatelets to balance the risks of hemorrhagic conversion and thromboembolism. Most patients report headache and/or malaise throughout the postoperative period.…”

Enhancing Brain Lesions after Endovascular Treatment of Aneurysms

“…[5][6][7] There are isolated reports of foreign body emboli to the brain parenchyma after diagnostic and therapeutic cerebral angiograms, but only a few include the imaging characteristics of these lesions. [8][9][10][11] We describe a short series of nonischemic, enhancing parenchymal lesions appearing after EVT of intracranial aneurysms.…”