Introduction
Percutaneous closure is the treatment of choice for type 2 atrial septal defects with sufficient rims. Device embolisation or malpositioning is rare, and although it can sometimes be challenging, transcatheter retrieval is possible in most cases.Reference Khosravi, Mirbod and Boshtam1 However, retrieval of large Occlutech Figulla® Flex II atrial septal defects occluders (Occlutech International AB, Sweden) can be challenging due to the gooseneck snare easily slipping off the right atrial-ball shaped hub during retraction of the device into the sheath. Other retrieval devices are available, such as different types of snares, biopsy forceps, or the original Occlutech delivery forceps. But even with this armamentarium, retrieval of large devices often can be difficult or even impossible.Reference Georgiev, Tanase and Genz2 We present 3 paediatric patients who underwent successful retrieval of Occlutech Figulla Flex II atrial septal defect occluders >16 mm with a single snare technique using a Multi-Snare® device (PFM Medical, Inc., USA).
Patient 1
Our first patient is a 14-year-old girl (48 kg, 172 cm) with a large secundum-type atrial septal defects. Preintervention transoesophageal echocardiography demonstrated an oval-shaped 28 x 17 mm defect with a 7 mm inferior rim (Figure 1( a )). We do not perform routine balloon sizing. An Occlutech Figulla Flex II 27 mm atrial septal defect occluder (our systematically used device type) was chosen for closure because of the oval shape. The device was delivered through a 12 French (Fr) sheath via the standard technique. However, we could not obtain a stable position. Thereafter, a 30 mm occluder was successfully delivered through the same sheath, with a stable position during the Minnesota wiggle manoeuvre. Unfortunately, a few minutes after device release, it embolised to the right ventricle, with the right atrial hub pointing anteriorly.
( a ) Atrial septal defect 2 and 3D sizing showing an oval-shaped 28 x 17 mm defect. ( b) Anteroposterior angiographic view of the embolised atrial septal defects device to the right ventricle and the Lunderquist wire in the right pulmonary artery for support of the Multi-snare. ( c ) Lateral angiographic view of the anteriorly pointing right atrial hub of the device, caught by the Multi-snare.
A 16 Fr 64 cm Entrant™ introducer sheath was placed in the opposite femoral vein (as the 12 Fr sheath had already been removed), and a stable position was attained by positioning a Lunderquist® wire (Cook Medical, Ireland) in the right pulmonary artery (Figure 1( b )). Upscaling of the sheath size with 4 Fr instead of the routine 2 Fr was done for two reasons. First, to keep a stable position with the Lunderquist wire during retrieval, and second, to optimise the retrieval chance of the whole device in the right ventricle, minimising the chance of damaging the tricuspid valve.
The right atrial hub of the device could only be reached with a 5 Fr DxTerity™ left coronary catheter (Medtronic, USA) over the device, and through this catheter, a 30 mm Multi-snare was placed successfully around the right atrial hub (Figure 1( c )). Following this manoeuvre, the device could be retrieved into the sheath in the right ventricle itself, avoiding damage to the tricuspid valve (Video 1). The Lunderquist wire was removed before retrieving the device with biplane fluoroscopy to avoid catching the hub at the entrance to the sheath. When the hub was carefully placed in the sheath under biplane fluoroscopy, the device could be retrieved uneventfully. The total fluoroscopy time was 36 minutes. She later underwent successful surgical closure.
Patient 2
Patient 2 is a 5-year-old girl (15 kg, 105 cm) with a 16.5 mm secundum-type atrial septal defects with a 5 mm inferior rim (Figure 2( a )). It was closed with an 18 mm Occlutech Figulla Flex II atrial septal defect occluder through a 9 Fr sheath. A few moments after release, the device slipped towards the mitral valve, leading to restricted movement of the leaflet (Figure 2( b )), warranting device retrieval. After upscaling to an 11 Fr sheath, the device was captured at the right atrial hub with a 20 mm Multi-Snare through the 6 Fr Multi-snare catheter and retracted into the sheath in the right atrium at the second attempt (Video 2). The total fluoroscopy time was 19 minutes. It was decided that a device larger than 18 mm would have an unacceptable risk of erosion, so this was not attempted.
( a ) Echocardiographic image of the atrial septal defect size. ( b ) Echocardiographic image of the displaced device towards the mitral valve after release.
Patient 3
Patient 3 is a 4-year-old boy (18 kg, 108 cm) with a 15 mm secundum-type atrial septal defect. A 16.5 mm Occlutech Figulla Flex II atrial septal defect occluder was delivered through a 9 Fr sheath. After device release, the aortic side of the device was still very mobile, with significant space between the two discs (Figure 3( a ) and ( b )). The decision was made to snare the device with a 20 mm Multi-snare after upscaling the sheath to 11 Fr. With the snare fitting securely around the right atrial hub, the device was retrieved in the right atrium on the first attempt.
( a ) Echocardiographic image of the malpositioned device with a significant space between the two discs (arrow). ( b ) Radiographic image of the malpositioned device being snared with the Multi-snare.
The decision was made to repeat closure with an 18 mm occluder device through the same 11 Fr sheath. However, the same problem reoccurred. After release, the space between the discs was too wide, and the device was too mobile on the aortic side. The same technique was applied to snare the 18 mm device in the right atrium (total fluoroscopy time of 18 min), and the patient was referred for surgical closure. A multifenestrated defect was seen during surgery (which was not visible on preprocedural echocardiography) possibly explaining the distorted morphology of the device.
Discussion
Atrial septal defects account for 7% of all CHD, with transcatheter closure being the first-line treatment.Reference Nakayama, Takaya and Akagi3 The Occlutech Figulla Flex II atrial septal defect occluder has proven to be an efficient device with similar closure and complication rates as the Amplatz septal occluder (St. Jude Medical, USA). It is preferred in patients with a deficient aortic rim or septal malalignment because of its flexibility due to the connecting right atrial ball-shaped hub and a reduced amount of material, as there is no hub on the left atrial disc. This allows a tilted angle of 30–40 degrees, making delivery easier because of better alignment with the septum and decreased traction on the device.Reference Nakayama, Takaya and Akagi3,Reference Pedra, Pedra and Costa4 However, the ball-shaped right atrial hub, rather than the screw thread right atrial hub of the Amplatz septal occluder, makes it difficult to grab and stabilise the device before retracting it into a long sheath, especially with larger devices. With this case series, we want to emphasise the fact that, in the unfortunate case of device embolisation or malpositioning, > 16 mm Occlutech Figulla Flex II retrieval using one Multi-Snare is feasible, contradicting the previous experiences of other groups.Reference Georgiev, Tanase and Genz2,Reference Fujii, Sugiyama, Kanazawa, Hara, Muneuchi and Yazaki5
Benchside tests have shown the impossibility of Occlutech Figulla Flex II device retrieval >16 mm using a single-gooseneck snare technique, even into 18 Fr sheaths. The snaring itself was not a major issue, but the snare slipped off the right atrial hub when attempting to pull it back into the sheath. Retrieval of the 24- and 36-mm devices was only possible using an Osypka Lassos® snare(Osypka AG, Germany).Reference Georgiev, Tanase and Genz2,Reference Fujii, Sugiyama, Kanazawa, Hara, Muneuchi and Yazaki5
Real-world reports of large Occlutech Figulla Flex II snare retrieval are scarce. From their personal experience, Georgiev et al. concluded that large (> 16 mm) Occlutech Figulla Flex II could not be withdrawn into a 12 or 14 Fr sheath using a single snare. Shebani et al. described the same difficulties retrieving large devices but had some success. In 7/15 snaring attempts, retrieval was successful by snaring the right atrial pin; however, multiple attempts were required in 4 cases. The largest retrieved device was a 24 mm Occlutech Figulla Flex II with a 10-mm gooseneck snare, after funnelling the device into the inferior caval vein before retraction into the sheath. They advised not to try to retract the device into the sheath with a one-snare technique because of the likelihood of slipping off.Reference Shebani, Rehman and Taliotis6 Other techniques, with double and triple snares or the use of other material like the delivery cable or forceps, have been described. Sometimes a combined use of devices is needed, like for example, retraction of the hub in the sheath with a snare and externalisation by using the delivery cable.Reference Sadiq, Rehman and Mehmood7–Reference Koo and Ha9
Our retrieval procedure consists of at least upscaling the original sheath with a 2 Fr larger sheath than minimally required for device delivery. Thereafter, we use a ≥ 20 mm Multi-Snare to grab the right atrial hub, sometimes placing the snare through a left or right coronary catheter instead of the snare delivery catheter. We also stabilised the long sheath with a stiff wire once for support (case 1). The advantage of this Multi-Snare, in comparison to a gooseneck snare, is the increased retrieving efficiency due to the dual-plane design. After firmly grabbing the device, the most important next step is to get the snared hub into the tip of the long sheath without it getting caught by the lip of the long sheath. We carefully perform this step with biplane fluoroscopy and reposition the sheath if necessary. With little force, the devices were all successfully retrieved with this technique. Case 1 demonstrates the efficacy of our technique even after a left coronary catheter had to be used to cross the device to get the snare to the right atrial hub. The embolised 30 mm atrial septal defect device could be retrieved and retracted into the long sheath with careful alignment of the snared device and the opening of the long sheath.
Conclusion
Retrieval of >16 mm Occlutech Figulla Flex II atrial septal defect occluders, in the rare case of malpositioning or embolisation, is feasible with a one-snare technique. Using a large Multi-Snare in combination with an at least 2 Fr sheath upscaling is a reliable, safe, and relatively simple retrieval technique, with 100% success in our experience.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1047951126113882.
Financial support
The authors did not receive support from any organisation for the submitted work.
Competing interests
The authors declare no conflict of interest.
Ethical standard
Informed consent was obtained from the patients or their parents. Approval was obtained from the Ghent University Hospital Ethics Committee (CR-2025-0006).
