This narrative revolves around a medical event, articulated in straightforward language to engage a broader audience.

How should I characterize my role as an Interventional Radiologist? Essentially, I act as a minimally invasive surgeon. Utilizing specialized technology, including wires, balloons, and devices such as catheters and stents, I conduct procedures within patients' bodies, guided by medical imaging.

One common procedure I perform involves maintaining high-flow blood vessels created surgically in patients experiencing kidney failure who are undergoing hemodialysis, a method for filtering blood.

Surgeons sometimes implant grafts—synthetic U-shaped tubes—beneath the skin of the forearm to link an artery to a vein at the elbow. This setup allows blood to flow swiftly from the artery through the graft to the vein, making it accessible for dialysis technicians. They insert large needles attached to tubes to extract blood for filtration in a dialysis machine, which mimics kidney function. The purified blood is then rapidly returned to the body (see image below).

My responsibility is to ensure these grafts remain functional. I compare this to performing routine maintenance on a vehicle: every three months or after 3,000 miles. Patients routinely visit my operating room every 3 to 6 months for graft maintenance, which may involve balloon dilation or stent placement to prevent blockages and ensure smooth operation, allowing them to continue their dialysis treatments. If we neglect these narrowings, known as stenoses, the graft could become occluded, leading to more complex procedures that may not always succeed. Thus, we encourage regular visits to address these issues proactively.

A memorable incident from early in my career, about a year after my training, involved a patient coming in for a scheduled graft maintenance check. I donned my lead apron and sterile gown as usual. The patient was positioned on the movable table under the x-ray arm, with his grafted forearm extended. After the standard sterile preparation and lidocaine injection, I accessed the graft with a needle, inserted an injection catheter, and performed an angiogram using live x-ray imaging. We use intermittent live x-ray to minimize radiation exposure for both patients and staff. The angiogram revealed a narrowing at the venous end of the graft, commonly seen over time (refer to the image below, where the arrow indicates the black narrowing at the venous end of the graft).

I proceeded to dilate the narrowing with a balloon. Although the post-dilation angiogram showed improvement, it wasn't optimal. I decided to use a new type of covered stent to maintain the patency of the graft for the next three months. A clinical sales representative from the company was present to assist with sizing.

Unfortunately, both of us were relatively inexperienced with this new stent. Based on the angiogram, he suggested a 5 mm diameter covered stent, which we prepared to deploy.

After opening the package, flushing the stent with saline, and positioning it over the pre-placed wires, I deployed it under live x-ray. Initially, it looked excellent! The post-deployment angiogram indicated that the narrowing had resolved, and blood flow was satisfactory with the patient's arm straightened. I removed my safety wire, knowing the stent was flexible and would be positioned at the bendable elbow joint. I wanted to verify the angiogram with the elbow flexed.

However, as I bent the patient’s elbow to check the x-ray before injecting contrast dye for the next angiogram, I noticed that the covered stent had vanished! Where did it go?

It's crucial to note that a graft carries arterial blood, flowing rapidly under high pressure. The fast-moving blood had displaced the stent, creating a dangerous situation because we had improperly sized the device. It was now an unwanted foreign object in the bloodstream. And where does blood in the venous system flow? To the heart, of course! When foreign objects reach the heart, dire consequences can occur within moments.

Just five seconds after realizing the stent was missing, the nurse monitoring the patient behind the glass shouted that the patient was experiencing ventricular ectopy and instructed to "Grab the crash cart NOW!" Suddenly, it felt like a scene from a medical drama, as the patient was on the brink of death due to the stent lodged in his heart, causing erratic heart rhythms that the nurse recognized as dangerously abnormal. The patient was in imminent danger, and the responsibility lay squarely with me.

The room erupted into chaos as everyone scrambled to prepare for chest compressions and defibrillation (electrical shocks to the chest, just like you see on TV). The patient yelled, "I feel like I’m gonna pass out!" and "My chest is killing me!"

I stood frozen, my own heart racing, fearing I was about to lose this patient with no means to intervene! I imagined telling his distraught wife that her husband had died due to my negligence. I braced for the lawsuit that could ruin my career.

Then, in a stroke of luck, he spontaneously reverted to a normal heart rhythm. Relief flooded over me! The patient reported feeling fine, and his chest pain disappeared!

But what had happened to the stent that had just moments ago been lodged in his heart? The device was flexible, and the force of the blood flowing through his heart had shifted it. When I turned on the live x-ray while repositioning the patient, I saw the stent crumpled and lodged in the left pulmonary artery, the main vessel supplying blood to the left lung, crucial for oxygen and carbon dioxide exchange. If that crumpled stent caused a blockage, the patient could quickly suffocate.

I turned to my interventional radiology technologist, who was stunned, and firmly instructed, "Prep the groin NOW!"

One of the tools in my arsenal is a snare device—a retractable wire loop capable of lassoing objects, much like a cowboy would. I could use it to extract the stent as long as I secured it properly.

I instructed my tech to prepare for accessing the femoral vein, which drains blood from the leg. Blood from both arms and legs converge in the heart's right atrium, making this a suitable and efficient approach to send the snare up into the pulmonary artery to retrieve the stent before any clotting could occur.

Within minutes, we were set to proceed. I swiftly accessed the vein and positioned my equipment. Soon, I had my snare adjacent to the stent.

In just a few minutes, I successfully snared it! I then retracted it through the pulmonary arteries, back through the heart, and down to the groin. Remarkably, the patient felt nothing!

Once the stent was back at the groin, I realized I had made a mistake in my haste. The incision I made in the vein was too small to extract the stent. The stent measured 5 mm in diameter, while my opening was only 3 to 4 mm! I thought, "Oh no!" However, I reassured myself that a slight increase in size could be tolerated. I gripped my equipment tightly and pulled with force! Despite having adequately sedated the patient, he still felt discomfort as I extracted the stent. My attentive tech quickly applied pressure to the site to prevent excessive bleeding.

Disaster averted! We removed our instruments and applied the necessary dressings. I decided to release the patient without a properly sized stent at the venous anastomosis. I believed he had a fair chance of recovery, and honestly, my nerves were frayed—I didn't want to perform any further procedures that day. When he returned three months later, his graft remained open, albeit with some narrowing. This time, wiser from experience, I successfully placed a correctly sized 7 mm covered stent without any issues, and he did well.

This incident has remained etched in my memory for the past 19 years, reminding me never to underestimate stent sizing, regardless of what a representative may suggest. Thankfully, I have not encountered any similar situations since, for the benefit of both my patients and myself.