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Transcatheter retrieval of a fully dislodged atrial septal defect occluder from the descending aorta using the “retained super-stiff guide wire” technique

Published online by Cambridge University Press:  15 July 2026

Jiawang Xiao Open the ORCID record for Jiawang Xiao [Opens in a new window] ,
Jingsong Geng ,
Jianmin Wang ,
Zhongchao Wang Open the ORCID record for Zhongchao Wang [Opens in a new window]  and
Qiguang Wang
Jiawang Xiao
Affiliation:
Department of Congenital Heart Disease, General Hospital of Northern Theatre Command, Shenyang, China
Jingsong Geng
Affiliation:
Department of Congenital Heart Disease, General Hospital of Northern Theatre Command, Shenyang, China
Jianmin Wang
Affiliation:
Department of Congenital Heart Disease, General Hospital of Northern Theatre Command, Shenyang, China
Zhongchao Wang
Affiliation:
Department of Congenital Heart Disease, General Hospital of Northern Theatre Command, Shenyang, China
Qiguang Wang*
Affiliation:
Department of Congenital Heart Disease, General Hospital of Northern Theatre Command, Shenyang, China
*
Corresponding author: Qiguang Wang; Email: wqg1993@126.com
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Abstract

Device embolisation is one of the most feared early complications of percutaneous atrial septal defect closure. We report a 40-year-old woman in whom a 12-mm atrial septal defect occluder was accidentally displaced into the descending aorta 24 hours after an apparently successful procedure. The dislodged device was retrieved percutaneously through a 12-F long sheath that was continuously railroaded over a super-stiff guide wire. This “retained super-stiff guide wire” technique secured sheath stability, avoided aortic wall trauma, and allowed the occluder to be slipped into the sheath without change of its orientation. A larger 16-mm small-waist–big-edge device was subsequently implanted uneventfully. The technical details and advantages of keeping the sheath constantly over a super-stiff guide wire are highlighted to facilitate safe trans-arterial retrieval of embolised cardiac devices.

Keywords

atrial septal defectdevice embolisationtranscatheter retrievalsuper-stiff wiredescending aorta

Information

Type
Case Report
Information
Cardiology in the Young , Volume 36 , Issue 7 , July 2026 , pp. 1524 - 1527
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Copyright
© The Author(s), 2026. Published by Cambridge University Press

Introduction

Transcatheter closure has become the treatment of choice for secundum atrial septal defect, with procedural success rates >95%.Reference Rigatelli, Gianese and Zuin1–Reference Geva, Martins and Wald2 Device embolisation occurs in 0.4–1.1% of cases and usually mandates immediate retrieval.Reference Crawford, Naidu, Shah, Davila and Stone3 A variety of snaring techniques have been described,Reference Manolis4–Reference Goel, Kapoor, Batra and Khanna6 but little attention has been paid to the role of sheath and super-stiff guide wire interactions during extraction. We report the use of the same large-bore delivery sheath, kept constantly over a super- stiff guide wire, to retrieve an occluder that had embolised to the descending aorta, highlighting technical advantages that have not been fully emphasised in the literature.

Case presentation

A 40-year-old asymptomatic woman was referred for elective closure of a secundum atrial septal defect. Transthoracic echocardiography (Figure 1 a – c ): 8-mm central atrial septal defect, deficient aortic rim, remaining rims ≥5 mm (superior, inferior, posterior, superior vena cava, inferior vena cava), slight right-heart enlargement, estimated systolic pulmonary artery pressure 35 mmHg. Pre-procedural evaluation for transcatheter atrial septal defect closure was completed, confirming that the patient fulfilled the indications for interventional occlusion.

Figure 1.

TTE before and after transcatheter ASD closure. ( a – c ) Pre-procedure: ( a ) parasternal short-axis view of the great arteries, ( b ) apical four-chamber view, and ( c ) subcostal bicaval view demonstrating the ASD and left-to-right shunt. ( d – f ) After the first device deployment: ( d ) parasternal short-axis, ( e ) apical four-chamber, and ( f ) subcostal bicaval views documenting the initial device position and no residual shunt. ( h – j ) After retrieval and implantation of a larger device: ( h ) parasternal short-axis, ( i ) apical four-chamber, and ( j ) subcostal bicaval views confirming stable device position with no residual shunt. White arrow, atrial septal defect; red arrow, atrial septal defect occluder.

Echocardiograms showing atrial septal defect before and after device deployment.

Under 1% lidocaine local anaesthesia, the right femoral vein was punctured, and a 6-F MPA2 catheter was advanced through the inferior vena cava—right atrium—right ventricle—pulmonary artery, recording a pulmonary artery pressure of 32/12 (mean 18) mmHg. The catheter was withdrawn to the right atrium, passed across the atrial septal defect into the left atrium, and then into the left superior pulmonary vein. A super-stiff guide wire was introduced into the left superior pulmonary vein, and a 9-F 100-cm delivery sheath was railroaded over this wire into the left atrium. A 12-mm atrial septal defect occluder (Lifetech Scientific Co., Ltd., Shenzhen, China) was deployed uneventfully, with a normal tug test, and the device was released (Figure 2 a , b ). The patient experienced no discomfort post-procedurally.

Figure 2.

Intraprocedural fluoroscopy during transcatheter ASD closure. ( a ) Postero-anterior (PA) and ( b ) left anterior oblique (LAO) views showing satisfactory position of the initial 12-mm device. ( c ) Device embolisation into the descending aorta. ( d – i ) Step-wise fluoroscopic frames demonstrating percutaneous snare retrieval of the embolised occluder via the femoral artery. ( j ) Immediate image after delivery of the 16-mm replacement device. ( k ) PA and ( l ) LAO views confirming stable final position of the 16-mm “small-waist–large-disc” device without residual shunt. Red arrow, atrial septal defect occluder.

Fluoroscopy images showing transcatheter atrial septal defect (ASD) closure procedure.

Routine transthoracic echocardiography the next day showed absence of the device within the atrial septum; subsequent fluoroscopy revealed a metallic double-disc structure in the descending aorta at the first lumbar level (Figure 2 c ). The patient remained haemodynamically stable without chest pain or neurological deficit.

Interventional retrieval and re-closure

Vascular access

  • • Right femoral artery: 12-F 100-cm delivery sheath for device retrieval.

  • • Right femoral vein: 12-F 100-cm delivery sheath for re-closure.

“Retain super-stiff guide wire” technique

  1. 1. A 260-cm 0.035-inch Amplatz Super-Stiff™ wire (Boston Scientific, USA) was positioned in the ascending aorta through a 6-F MPA2 catheter.

  2. 2. The 12-F delivery sheath was railroaded over the stiff guide wire up to the level of the embolised device (Figure 2 d , e ). The stiff wire was left in situ throughout the procedure, acting as a fixed rail.

  3. 3. Through the sheath, a 6-F MPA2 diagnostic catheter carrying a 20-mm goose-neck snare was advanced and opened just distal to the occluder; the right-atrial disc rivet of the device was engaged and the snare tightened (Figure 2 f ).

  4. 4. By gently withdrawing the snare while simultaneously securing the sheath, the occluder was gradually slipped into the sheath lumen, maintaining coaxial alignment enforced by the stiff wire (Figure 2 g – i ). No rotation or tilting of the device occurred.

  5. 5. The super-stiff guide wire was left in place, and the entire unit (sheath + captured device) was removed as a single piece; a 10-F vascular sheath was then advanced over the wire. After completion of the procedure and confirmatory angiography, hemostasis was achieved with an Angio-Seal vascular closure device followed by brief manual compression.

Second atrial septal defect closure (same session)

Transthoracic echocardiography confirmed the original 8-mm defect. A 16-mm atrial septal defect occluder (Lifetech Scientific Co., Ltd., Shenzhen, China) was initially selected. Fluoroscopy revealed a slim device profile (Figure 2 j ), while transthoracic echocardiography confirmed the absence of the characteristic “Y-shaped” aortic clamp. In view of the previous device-embolisation episode, the occluder was recaptured and replaced with a 16-mm small-waist–big-edge atrial septal defect occluder (40 mm left-atrial disc and 32 mm right-atrial disc) (LEPU ScienTech Medical Technology Co., Ltd., Shanghai, China), achieving successful closure (Figure 2 k , l ). Transthoracic echocardiography showed a stable position and no residual shunt.

Transthoracic echocardiography (Figure 1 e – g ) on the first post-operative day showed the device in a stable position with no residual shunt; the aortic side exhibited a “Y-shaped” configuration. Repeat electrocardiography revealed no arrhythmias or ischaemic changes, and the patient reported no discomfort. The vascular puncture site had healed well. The patient was discharged 72 hours later on dual antiplatelet therapy for 6 months. Transthoracic echocardiography at 1, 3, and 6 months demonstrated an intact device, regression of right-heart size, no residual shunt, or aortic pathology (Figure 1 h – j ).

Discussion

Device embolisation after atrial septal defect closure is uncommon and usually results from a combination of an undersized occluder, deficient rims—especially the aortic margin—that fail to provide stable collar support, and prominent cardiac motion in the first 24 hours before endothelial ingrowth.Reference Lee, Fang, Huang, Lin, Wu and Fang7–Reference Martínez-Quintana and Rodríguez-González8 Additional contributors include large left-to-right shunts with high septal excursion, improper deployment angle, and inadequate grasp of the atrial septal tissue by the device discs.Reference Lee, Fang, Huang, Lin, Wu and Fang7–Reference Martínez-Quintana and Rodríguez-González8 Our case met the first two criteria; the 12-mm device was probably too small and relied solely on superior/inferior rims. Re-evaluation with a larger 16-mm small-waist–big-edge device has so far proved successful. Operators should be aware that even a negative tug test does not fully exclude late dislodgement, and early transthoracic echocardiography before discharge is advisable whenever the aortic rim is deficient.

Previous series have described free snaring with subsequent sheath advancement or surgical removal.Reference Manolis4–Reference Goel, Kapoor, Batra and Khanna6,Reference Yates and Anderson9 Large-bore sheaths (≥12 F) are mandatory to accommodate a folded double-disc. However, when the occluder lies perpendicular or oblique to the aortic axis, or when retraction is not perfectly smooth, the sheath can lose controlled contact and injure the intima. Although super-stiff guidewires are routinely used in aortic endografting, their deliberate retention within the retrieval sheath to shield the aortic wall from an embolised atrial septal occludeer and to facilitate auxiliary device retrieval has not, to our knowledge, been reported. To our knowledge, this is the first report emphasising the value of continuously railroading the arterial sheath over a super-stiff guidewire for the retrieval of an atrial septal defect occluder embolised to the aorta. By keeping the 12-F delivery sheath constantly railroaded over a super-stiff guide wire, we combined several advantages:

  1. 1. Sheath stability plus uninterrupted flow: The stiff wire acts as an immobile track, preventing “whipping” of the sheath when traction is applied to the device; this is particularly important in the tortuous descending aorta. Retaining the super-stiff guidewire offers an additional theoretical safeguard: it usually prevents the occluder from fully occluding the aorta. Should the device tilt perpendicular to the lumen and threaten complete obstruction, the retained guidewire would allow immediate balloon advancement to modify device orientation and promptly restore aortic flow.

  2. 2. Aortic wall protection: Because the sheath tip is always coaxial to the vessel axis, the risk of inadvertent intimal injury by the sheath edge or device struts is minimised.

  3. 3. Facilitated device ingestion: Once the occluder is snared, gentle forward pressure on the sheath while maintaining wire position allows the device to glide en face into the lumen without folding or tilting, thereby reducing the chance of entrapment at the sheath mouth, markedly shortening retrieval time.

  4. 4. Single-piece extraction: Device and sheath are removed together, avoiding the need to withdraw an uncovered occluder through the iliac axis and diminishing the risk of secondary embolisation or vascular trauma.

Conclusion

The “Retained Super-Stiff Guide Wire” technique is a safe, elegant, and inexpensive method for percutaneous recovery of atrial septal defect occluders embolised to the aorta. Continuous rail support guarantees sheath stability, protects the aortic wall, and markedly lowers the technical difficulty of device ingestion. Operators should consider this approach whenever rigid cardiac devices need trans-arterial retrieval.

Acknowledgements

None.

Financial support

None.

Competing interests

The authors declare no conflicts of interest related to this manuscript.

References

Rigatelli, G, Gianese, F, Zuin, M. Secundum atrial septal defects transcatheter closure: an updated reappraisal. Cardiovasc Revasc Med 2022; 44: 92–97. DOI: 10.1016/j.carrev.2022.06.002.10.1016/j.carrev.2022.06.002CrossRefGoogle ScholarPubMed
Geva, T, Martins, JD, Wald, RM. Atrial septal defects. Lancet 2014; 383(9932): 1921–1932. DOI: 10.1016/S0140-6736(13)62145-5.10.1016/S0140-6736(13)62145-5CrossRefGoogle ScholarPubMed
Crawford, DA, Naidu, SG, Shah, AA, Davila, VJ, Stone, WM. Endovascular retrieval of an embolized atrial septal occluder device from the abdominal aorta. Vasc Endovascular Surg 2018; 52(8): 669–673. DOI: 10.1177/1538574418790393.10.1177/1538574418790393CrossRefGoogle ScholarPubMed
Manolis, AS. Percutaneous retrieval of a dislodged Amplatzer septal occluder device from the pulmonary artery with sole use of a snare and device lassoing. Hellenic J Cardiol 2018; 59(1): 57–59. DOI: 10.1016/j.hjc.2017.08.004.10.1016/j.hjc.2017.08.004CrossRefGoogle ScholarPubMed
Lee, YT, Lam, TH, Lam, LT et al. Percutaneous antegrade retrieval of an atrial septal occluder dislodged into the left ventricle. J Invasive Cardiol 2026; 38(2). DOI: 10.25270/jic/25.00220.Google ScholarPubMed
Goel, PK, Kapoor, A, Batra, A, Khanna, R. Transcatheter retrieval of embolized AMPLATZER Septal Occluder. Tex Heart Inst J 2012; 39(5): 653–656.Google ScholarPubMed
Lee, WC, Fang, CY, Huang, CF, Lin, YJ, Wu, CJ, Fang, HY. Predictors of atrial septal defect occluder dislodgement. Int Heart J 2015; 56(4): 428–431. DOI: 10.1536/ihj.15-065.10.1536/ihj.15-065CrossRefGoogle ScholarPubMed
Martínez-Quintana, E, Rodríguez-González, F. Risks factors for atrial septal defect occlusion device migration. Int J Angiol 2016; 25(5): e63–e65. DOI: 10.1055/s-0034-1395976.Google ScholarPubMed
Yates, MT, Anderson, DR. Safe surgical retrieval of embolized atrial septal defect closure device. Ann Thorac Surg 2017; 103(2): e213–e214. DOI: 10.1016/j.athoracsur.2016.08.028.10.1016/j.athoracsur.2016.08.028CrossRefGoogle ScholarPubMed
Figure 0

Figure 1. TTE before and after transcatheter ASD closure. (a–c) Pre-procedure: (a) parasternal short-axis view of the great arteries, (b) apical four-chamber view, and (c) subcostal bicaval view demonstrating the ASD and left-to-right shunt. (d–f) After the first device deployment: (d) parasternal short-axis, (e) apical four-chamber, and (f) subcostal bicaval views documenting the initial device position and no residual shunt. (h–j) After retrieval and implantation of a larger device: (h) parasternal short-axis, (i) apical four-chamber, and (j) subcostal bicaval views confirming stable device position with no residual shunt. White arrow, atrial septal defect; red arrow, atrial septal defect occluder.

Figure 1

Figure 2. Intraprocedural fluoroscopy during transcatheter ASD closure. (a) Postero-anterior (PA) and (b) left anterior oblique (LAO) views showing satisfactory position of the initial 12-mm device. (c) Device embolisation into the descending aorta. (d–i) Step-wise fluoroscopic frames demonstrating percutaneous snare retrieval of the embolised occluder via the femoral artery. (j) Immediate image after delivery of the 16-mm replacement device. (k) PA and (l) LAO views confirming stable final position of the 16-mm “small-waist–large-disc” device without residual shunt. Red arrow, atrial septal defect occluder.