transcatheter closure of patent ductus arteriosus ( pda ) by use of the amplatzer duct occluder shows good results in properly selected patients.1 the advantages of the amplatzer duct occluder device include a user - friendly delivery system , the ability to retrieve or reposition the device when required , and a high complete closure rate ( > 99% complete occlusion of pda within 6 months of implant).2 although embolization of an amplatzer duct occluder is rare , it can occur .
we present a case of retrieval of an embolized amplatzer duct occluder by use of a percutaneous method in a young man .
transthoracic two - dimensional echocardiography and computed tomography ( ct ) confirmed pda ( fig .
, we deployed the amplatzer duct occluder ii ( 9-pda2 - 05 - 06 , aga med .
, usa ) after confirmation of the proper position by repeated angiogram . however , 5 min after successful deployment , the amplatzer duct occluder device was suddenly embolized into the branch of the right pulmonary artery ( rpa ) ( fig . 2a ) . before surgical removal
, we decided to remove the embolized device by use of a percutaneous method after obtaining consent from the patient 's relatives .
multiple attempts at removal by use of guidewire twisting , a goose - neck snare , and a radiofrequency ablation catheter were unsuccessful .
because the embolized device was floating in the branch of the rpa , it moved into the distal portion of the rpa after several attempts of retrieval with the snare and ablation catheter . in order to stabilize the embolized device ,
a 5.020 mm balloon catheter was placed just distal to the embolized device and inflated .
endomyocardial biopsy forceps ( cordis corp . , usa ) were introduced from the left femoral vein through an 8-fr sheath .
after multiple attempts , we caught the screw attachment tip of the embolized device and removed it into the 8-fr shuttle sheath ( fig .
subsequently , an amplatzer duct occluder 8 - 6 ( 9-pda-005 ) was carefully deployed via a venous route .
the device was confirmed to be properly positioned across the defect by echocardiography and the ct angiogram ( fig .
neither clinical complications nor a residual shunt was observed during the 6-month follow - up .
transcatheter pda closure is currently the standard of therapy and is performed with high success rates and few complications.3 although the rate of device embolization is rare ( < 0.5% ) , this remains a major complication requiring urgent surgical management.4 the most common cause of embolization is the use of an undersized device .
therefore , exact pda sizing and the use of the proper size of device is essential to avoid this potential complication .
careful attention must be paid to imperfect alignment or malposition of the device or excessive tension on the delivery cable ; performing the wiggle procedure may reduce the acute failure rate of the procedure.5 excessive tension on the delivery cable was the main cause of embolization in our patient . in this case , stabilizing the floating device by balloon inflation played a pivotal role in success .
the use of a larger 8-fr sheath during retrieval could make easier device entry into the sheath after capture of the embolized device .
in general , the following techniques are recommended to increase the chances of successful retrieval : the use of a sheath 2 fr sizes larger than the delivery sheath , the use of stiff sheaths to avoid kinking , and cutting a bevel or notch at the end of the sheath to facilitate the entrance of the embolized device.6 our case illustrates a practical transcatheter removal technique for an embolized amplatzer duct occluder . even in procedures performed by the most experienced operators ,
thus , physicians have to keep in mind both the possibility and the treatment of this severe complication during pda closure .
 transcatheter closure of patent ductus arteriosus with the amplatzer duct occluder shows excellent results . however , there is a risk of device embolization after deployment . 
 we report the case of a 33-year - old man in whom an embolized amplatzer device was retrieved from the right pulmonary artery by a percutaneous method . 
 we also review this uncommon severe complication and offer technical tips for percutaneous removal . 