UNASSIGNED: After coronary sinus (CS) lead extraction in patients with cardiac resynchronization therapy (CRT), occlusion of the branch vessel from which CS lead was extracted is a major obstacle to re-implantation, particularly if that vessel is the only optimal vessel for resynchronization.
UNASSIGNED: A 75-year-old female who underwent CRT implantation 11 years prior presented with worsening dyspnoea, right ventricle-only pacing rhythm, and increased CS lead pacing threshold. Because she was a CRT responder, we decided to replace the malfunctioning CS lead. After successful extraction, the vessel from which CS lead was extracted was not visualized, and guidewire re-insertion attempts failed. No other branch vessels suitable for re-implantation were observed. Fortunately, distal portion of the target vessel was viewed by a retrograde flow of contrast. A guidewire was advanced retrograde into the target vein via a connecting vessel, and the distal end of the guidewire was snared around CS ostium and then pulled out of the sheath. A new CS lead was inserted through the distal end of the guidewire and successfully implanted antegrade into the same target vein using a veno-venous loop of the guidewire (\'anti-dromic snare technique\'). The patient was discharged 2 days after the procedure without complications.
UNASSIGNED: Antegrade re-implantation of CS lead may not be possible after extracting CS leads with long dwell times, possibly due to extraction-induced vessel occlusion. If the occluded vessel is the only proper vessel for CS lead re-implantation, the anti-dromic snare technique could be a safe and effective bail-out strategy.

Central venous obstruction following pacemaker implantation is not uncommon and can prove challenging in the case of a system upgrade to a cardiac resynchronization therapy pacemaker (CRT-P). We describe the case of a patient who underwent a successful upgrading procedure of a pacemaker to a CRT-P in the presence of an occluded left subclavian vein and superior vena cava, using collateral veins that drained into right atrium.

Totally implantable venous access ports (TIVAPs) are widely used for chemotherapy and other purposes in patients with cancer. Their convenience and safety make them ideal for long-term use. However, sometimes there are cases in which TIVAPs remain in the vessel following the completion of long-term chemotherapy and are difficult to remove due to the adhesion of the catheter to the vessel wall. In this study, we encountered a case in which a TIVAP catheter adhering to a blood vessel was fractured during removal and the catheter left in the vessel could not be retrieved by a snare because it had no free end. Finally, the catheter was successfully removed using a peel-away sheath. No complications or residual catheters were associated with the removal procedure.

Although snares are useful devices to retrieve an intravascular foreign body, the control of snares is often difficult. We present a safe and effective technique to adjust snare position in the tortuous vessel for coil retrieval during endovascular coil embolization.
We describe a case of a protruding coil during coil embolization that was successfully retrieved using a unique technique to adjust snare position and discuss additional intraprocedural bailout strategies for retrieving a coil during endovascular coil embolization.
The patient was a 44-year-old female with unruptured right internal carotid artery (ICA) aneurysm that had grown over a 1.5-year period. Coil embolization was performed. After detachment of final coil and microcatheter removal, the final coil protruded into the ICA and floated. Coil retrieval using a snare was attempted, but the snare could not be placed around the coil tail and coil retrieval could not be achieved. The following technique was used to allow adjustment of snare position. First, a microguidewire and a microcatheter were guided into the M2 and M1 segment of the middle cerebral artery as monorail guides of the snare, respectively. Next, the snare was advanced over the microcatheter. Around C2 segment of the ICA, the microcatheter and the snare were manipulated as a unit. Thus, the snare could be placed around the protruding coil tail and the coil was retrieved successfully.
This technique may be widely adapted for various situations when using a snare.

UNASSIGNED: Placing an intracardiac echocardiogram (ICE) catheter in the left atrium allows for excellent visualization of the left atrial appendage to guide left atrial (LA) appendage occlusion (LAAO). Nonetheless, it requires a separate septal puncture or a unique set of skills to navigate the ICE through a previously prepared septal puncture, which can be challenging.
UNASSIGNED: This report describes a novel method to insert an ICE in the left atrium through a single septal puncture utilizing a snare technique. A 76-year-old male underwent LAAO by ICE guidance. After obtaining a standard atrial septal puncture, we were unable to advance the ICE into the left atrium. Therefore, we used a loop snare to grasp the ICE catheter-tip in the right atrium and direct it into the left atrium via the prepared septal puncture by tracking a pigtail wire that we routinely place as part of the procedure. Afterward, the left atrial appendage was successfully occluded with a Watchman device (Boston Scientific, Galway, Ireland), and the patient was discharged home without complications.
UNASSIGNED: The described technique could be a helpful tool for ICE placement to the left atrium in a controlled fashion, especially when challenging anatomy is encountered.

UNASSIGNED: Impella RP (Abiomed, Danvers, MA, USA) is indicated for right ventricular failure after left ventricular assist device insertion or biventricular shock. Once the peel-away sheath is removed, Impella RP repositioning can only be achieved with manual manipulation of the catheter itself. This method does not always accomplish appropriate positioning of the catheter and can result in continued haemodynamic instability.
UNASSIGNED: A young male presented to our institution with recurrent ventricular fibrillation and ST-elevation myocardial infarction that underwent emergent coronary intervention but was in progressive cardiogenic shock requiring implantation of Impella 5.0 and Impella RP. After insertion of the right ventricular support, the patient stabilized transiently then became unstable once more, and repeat fluoroscopy demonstrated that the Impella RP had \'fallen back\' into the right ventricle. Due to continued instability, we improvised a previously undescribed method of repositioning of the Impella RP catheter with the use of a goose-neck snare.
UNASSIGNED: The snare-manoeuvre-prolapse method of Impella RP repositioning is a relatively novel approach at the management of Impella RP retrograde migration into the right ventricle and prevents the need for large-bore venous closure and re-access and the use of a new Impella RP catheter while providing rapid improvement of haemodynamics.

The coronary sinus reducer migration during implantation procedure is a rare complication with no standard bailout strategy. Transfemoral extraction of the reducer can be a safe and successful method, as demonstrated by this case report.

BACKGROUND: Open surgery can be required or even fatal if incomplete deployment of stent graft (SG) occurs. We herein report the first case in which a snare was successfully used to perform endovascular therapeutic troubleshooting on the proximal portion of a Zenith Alpha thoracic endovascular graft proximal component that showed incomplete deployment.
METHODS: The patient was an 80-year-old woman. She underwent thoracic endovascular aortic repair (TEVAR) for subacute phase Stanford type B ulcer-like projection aortic dissection. Although the ulcer-like projection disappeared, a follow-up computed tomography angiogram (CTA) obtained approximately 1 year postoperatively showed type Ia and Ib endoleaks. Since there is a high risk of rupture as the aneurysm diameter increases, we determined that an additional SG was indicated. An attempt was made to place the SG in Zone 3, but as the lesser curvature side of the proximal portion stopped in a position that was perpendicular to the vascular wall (downward facing), the SG proximal portion did not completely expand. A guiding sheath was inserted into the aortic arch via the left brachial artery, and, using a snare that we inserted via the femoral artery, we grasped the guiding sheath. A catheter and guidewire (GW) were inserted via the guiding sheath and then rotated under the lesser curvature of the SG proximal portion; the GW was then passed through the loop of the snare. This allowed us to insert the hard loop structure under the SG proximal portion, which in turn allowed successful repair of the incomplete deployment of the SG. Type Ia and Ib endoleaks remained but were less than those before additional TEVAR. One week later, she was discharged. One year later, CT showed no interval change in the size of aortic aneurysm with dissection, and she has been followed on an outpatient basis.
CONCLUSIONS: When the endovascular diameter of the proximal aortic arch is large, incomplete deployment of the proximal portion of a Zenith Alpha thoracic endovascular graft can occur, but bailout is possible through the use of the snare technique as endovascular therapy.

BACKGROUND: Although snaring technique is a commonly used tool in the interventional radiologists\' armamentarium, there are no reports of its use in an extra-vascular space to achieve access across a pseudoaneurysm that was otherwise non-traversable.
METHODS: We describe a case of an iliac-enteric fistula between a ruptured pseudoaneurysm of the external iliac artery and a surrounding contained colonic perforation, where access across the pseudoaneurysm was achieved only after snaring of the microwire from within the contained colonic perforation and back into the intra-vascular space, allowing the placement of a covered stent and control of the bleeding.
CONCLUSIONS: The described technique may be useful in situations where other, more conventional, endovascular techniques fail to achieve access across the bleeding pseudoaneurysm. While it was life-saving in this case, this technique should only be used in very limited scenarios, specifically in the palliative setting and when surgical management is not an option.

MitraClip is used for reduction of mitral insufficiency in patients who are not good surgical candidates, but with expanding indications, the use of MitraClip and the number of complications will increase. Here is presented a case of a single leaflet device attachment that worsened the patient\'s mitral insufficiency, as well as the technique for stabilizing the valve followed by retrieval of the device. A special focus is placed on removing the using a two-snare technique to avoid the need for a surgical cutdown and repair.