CARDIOMEMS ENDOSURE DELIVERY SYSTEM

Description of Event or Problem

THIS WAS A PERCUTANEOUS CASE TO TREAT TWO ABDOMINAL AORTIC ANEURYSMS THAT WERE IN AN HOUR GLASS FORMATION. THE PLAN WAS TO PLACE THE SENSOR IN THE LOWER ANEURYSM JUST ABOVE THE BIFURCATION. AFTER ACCESS WAS GAINED, A HEAVILY CALCIFIED ILIAC, WHICH WAS NOT VISIBLE UNDER FLUOROSCOPY, CAUSED DIFFICULT ACCESS AND BENT THE PROTECTIVE CAPSULE SECTION OF THE DELIVERY SYSTEM. THIS BEND CAUSED THE TETHER TO KINK WHILE ATTEMPTING TO ADVANCE FORWARD. THE SENSOR DID ADVANCE UP TO THE LOWER ANEURYSM SAC. UPON REMOVAL OF THE DELIVERY SYSTEM, THE BEND IN THE DELIVERY SYSTEM CAPSULE CAUSED THE SENSOR AND TETHER TO BE PULLED BACK INTO THE ILIAC AND THEN FEMORAL ARTERY. THE PHYSICIAN THEN ATTEMPTED TO PULL THE SENSOR OUT THROUGH THE PERCUTANEOUS ACCESS SIGHT AND ACCIDENTALLY RELEASED THE SENSOR IN THE FEMORAL ARTERY. A CUTDOWN WAS PERFORMED AND THE SENSOR WAS RETRIEVED.