Contraceptive implant embolism into the pulmonary artery

Migration of etonogestrel subcutaneous contraceptive implants: systematic review and recommendations for practice

INTRODUCTION

Migration is a rare but serious complication of the etonogestrel contraceptive implant, and little is known about its extent.

PURPOSE

To document and characterise cases of etonogestrel contraceptive implant migration in the scientific literature.

METHODS

A systematic review of Medline, Embase and Global Health databases was carried out between January 2000 and January 2023 to identify articles presenting implant migrations. Narrative reviews, conference abstracts and articles not written in English or French were excluded.

RESULTS

Forty-five articles, mostly published since 2016, were identified (eight case series and 37 case reports), for a total of 148 independent cases of migration: in pulmonary blood vessels (n = 74), in non-pulmonary blood vessels (n = 16) and extravascular (n = 58). Many patients are asymptomatic and migration is often an incidental finding. A non-palpable implant and symptoms related to implant location (intra- or extra-vascular) may be indicative of migration. Inadequate insertion and normal or underweight appear to increase the risk of migration. Scientific societies and authors offer practical strategies to deal with implant migration.

CONCLUSION

Professionals who insert and remove contraceptive implants must be adequately trained. They need to be on the lookout for implant migration, and promptly refer patients to appropriate care if migration is suspected.

Management of etonogestrel implant migration into the pulmonary artery

OBJECTIVES

To evaluate the relationship between time since contraceptive implant placement and retrieval outcomes in patients with implant migration into the pulmonary artery.

STUDY DESIGN

We reviewed all cases of pulmonary artery implant migration referred to the Marie Lannelongue hospital from 2015 through 2020. Using our hospital database, we collected patients' clinical data and removal information to assess the success of therapeutic management according to the delay between implant insertion and removal.

RESULTS

We identified eight cases. Physicians located two in the upper and six in the lower lobe. Five patients had associated pulmonary symptoms, most commonly, chest pain and dyspnea. Physicians attempted an endovascular procedure in all cases with successful removal in three patients. In the five failures, angiography displayed arterial thrombosis distal to the implant. These patients had successful removal with an open mini-thoracotomy (<5 cm). None of the eight patients had serious post-operative complications.  For the three patients with successful endovascular retrieval, two had early diagnosis (≤ 3 months).

CONCLUSION

Endovascular approach with angiography should be performed as a first line treatment modality. Endothelialization and fibrosis within the vessel represent the principal limitations of endovascular strategy, but a retrieval could be attempted anyway with caution. In case of failure, an open approach is required.

IMPLICATIONS STATEMENT

When a migration into the pulmonary artery is diagnosed, health care professionals should refer patients as soon as possible to a tertiary center with a vascular surgery/interventional radiology and thoracic surgery departments.

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance is effective, quick, and safe

Objectives

The aim of this study was to assess the feasibility, performance, and complications of a non-surgical, minimally-invasive procedure of deep contraceptive implant removal under continuous ultrasound guidance.

Methods

The ultrasound-guided procedure consisted of local anesthesia using lidocaine chlorhydrate 1% (10 mg/mL) with a 21-G needle, followed by hydrodissection using NaCl 0.9% (9 mg/mL) and implant extraction using a Hartmann grasping microforceps. The parameters studied were the implant localization, success and complication rates, pain throughout the intervention, volumes of lidocaïne and NaCl used, duration of the procedure, and size of the incision. Between November 2019 and January 2021, 45 patients were referred to the musculoskeletal radiology department for ultrasound-guided removal of a deep contraceptive implant and were all retrospectively included.

Results

All implants were successfully removed en bloc (100%). The mean incision size was 2.7 ± 0.5 mm. The mean duration of the extraction procedure was 7.7 ± 6.3 min. There were no major complications (infection, nerve, or vessel damage). As a minor complication, 21 patients (46.7%) reported a benign superficial skin ecchymosis at the puncture site, spontaneously regressing in less than 1 week. The procedure was very well-tolerated, with low pain rating throughout (1.0 ± 1.5/10 during implant extraction).

Conclusions

Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, effective, and safe. In the present cohort, all implants were successfully removed, whatever the location, with short procedural time, small incision size, low pain levels, and no significant complications. This procedure could become a gold standard in this indication.

Key Points

• Minimally invasive removal of deep contraceptive implants under continuous ultrasound guidance alone is feasible, which led to a success rate of 100% whatever the location (even close to neurovascular structures), with only a small skin incision (2.7 ± 0.5 mm).

• The procedure was safe, quick, without any major complications, and very well tolerated in terms of pain.

• This minimally invasive ultrasound-guided procedure could become the future gold standard for the removal of deep contraceptive implants, as an alternative to surgical extraction, even for implants in difficult locations such as subfascial ones or those close to neurovascular structures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08263-4.

Contraceptive implant migration to the lung

A 27-year-old female presented with a 'missing' contraceptive implant. Chest imaging demonstrated a 4-cm linear opacity in a subsegmental branch of the pulmonary artery to the left lower lobe consistent with a migrated contraceptive implant. A mini-thoracotomy and arteriotomy was performed. The artery was opened distally to its third division. However, it was not possible to retrieve the implant, and the decision was made to proceed to segmentectomy. After resection, it was noted that the foreign body had significantly endothelialised within the wall of the artery and required sharp dissection for removal. This is the first case report to demonstrate the complete endothelialisation and subsequent difficulty in removal of an embolised contraceptive implant. We hope this report adds to the growing body of literature to guide management of this extremely rare but serious complication.

Aspiration technique for percutaneous endovascular retrieval of contraceptive device embolized to the pulmonary vasculature

Contraceptive implant migration into the pulmonary circulation is an uncommon, but potentially serious complication. We describe an "aspiration" technique for percutaneous retrieval of a contraceptive implant from a subsegmental pulmonary artery, using a Penumbra Neuron MAX 088 guiding catheter and a Merit Medical VacLok Vacuum Pressure Syringe, as an alternative to the previously described snare technique. Our patient had an uneventful recovery and was discharged home on the same day.

Incidence and characteristics of intravascular pulmonary migration of etonogestrel implants: A French nationwide study

OBJECTIVE(S)

To describe the features of etonogestrel implant (Nexplanon and Implanon) migration into the pulmonary vasculature and to estimate its incidence in France.

STUDY DESIGN

We retrospectively reviewed French cases of implant migration into the pulmonary vasculature reported up to 2018. Patient clinical data were collected. The annual incidence of migration was estimated from the number of cases reported and number of implants sold.

RESULTS

Twenty-seven cases of migration into the pulmonary vasculature were identified. In 19 cases (70%) it was stated that this was into the pulmonary artery (nine into the left branch, four into the right branch and six unspecified) and in the other eight cases (30%) it was it not specified whether this was into the pulmonary artery or one of its branches. The migration was discovered following a request for implant removal in 59% of cases, following respiratory complaints in 24%, and because the implant was no longer palpable in 17%. In the 24 cases for which information on removal (or not) was available, the implant was removed in 15 (60% by an endovascular procedure and 40% by invasive surgery); in the remainder it was left in situ. The incidence of migration into the pulmonary vasculature was 1.23 per 100,000 implants sold [95% CI 0.25-3.58] in 2014, increasing to 3.17 per 100,000 implants sold [1.37-6.24] in 2017. In 2016, the French National Agency for Medicines and Health Products Safety (ANSM) had recommended performing a systematic search for non-palpable implants, including at thorax level.

CONCLUSIONS

The incidence of migration into the pulmonary vasculature is low. Nonetheless, because the consequences are potentially serious, in December 2019 the ANSM made recommendations to reduce this risk.

Nexplanon migration into a subsegmental branch of the pulmonary artery: A case report and review of the literature

INTRODUCTION

Nexplanon is a 4 cm rod-shaped barium sulphate coated contraceptive implant with a usual subdermal insertion in the inner non-dominant upper arm. Complications proper to subdermal contraceptive implants are unusual and principally localized and minor, comprising infection at the site of implantation, hematoma, abnormal scar development, or local nerve and blood vessel injuries. Infrequently, contraceptive implant migration can happen, though habitually not far from the site of insertion. Pulmonary embolization of the device is remarkably rare and can present with symptoms such as chest pain or dyspnea.

PATIENT CONCERNS AND DIAGNOSIS

We report one of the rare cases of asymptomatic Nexplanon pulmonary embolism in a 26-year-old female.

INTERVENTIONS AND OUTCOMES

An endovascular intervention successfully retrieved the device from the lateral segment right middle lobe pulmonary artery without any complications.

CONCLUSION

Several cases of contraceptive implant migration into the pulmonary artery have been reported to this day. Preventing this life-threatening complication is challenging, and yet, no clear guidelines have been established.

Endovascular retrieval of contraceptive implant embolized to pulmonary artery

Embolization of subdermally implanted contraceptive devices is a rare but potentially serious event. Timely removal of the embolized foreign body should be considered to prevent possible hemodynamic, respiratory, or hormonal complications. We present a case of a 22-year-old woman with a contraceptive implant embolized to her right lower lobar pulmonary artery, which was successfully managed by endovascular retrieval.

Percutaneous extraction of an embolized progesterone contraceptive implant from the pulmonary artery

The Nexplanon^® implant is a commonly used radiopaque contraceptive device that contains progestogen associated with an ethylene vinyl-acetate copolymer resulting in a slow release of the active hormonal ingredient. It is inserted into the subdermal connective tissue and provides contraceptive efficacy for up to 3 years. Device removal for clinical, personal or device “end-of-life span” reasons is straightforward. In rare cases, implant migration can occur locally within centimeters of the insertion site. Distant device embolization is extremely rare and can result in complications including chest pain, dyspnoea, pneumothorax and thrombosis or prevent conception until the active ingredient is depleted. We present one such case, where a Nexplanon^® implant embolized into the pulmonary artery of a young female patient. We describe the initial “missed” diagnosis of embolized device on a chest radiograph and subsequent successful percutaneous removal once distant embolization was diagnosed.

Contraceptive Implant Migration and Removal by Interventional Radiology

As the reversible contraceptive arm implants grow more popular, there is an increasing need to recognize the complications resulting from implant migration and removal. This review summarizes the findings of imaging and removal methods. When an implant is lost, the axillary region should be investigated first. If the implant still cannot be found, visualization though different methods have been employed for non-radiopaque implants. Real-time fluoroscopic-guided localization and removal can be accomplished for radiopaque Nexplanon. Once the implant has been located, standard removal method and other modified techniques can be used to safely remove the implant depending on the implant's location.

Removal of a subdermal contraceptive implant (Implanon NXT) that migrated to the axilla by C-arm guidance: A case report and review of the literature

RATIONALE

To report the distant migration of a subdermal contraceptive implant and to suggest that C arm-guided technique is one of the feasible options for removal of the device migrated to the axilla.

PATIENT CONCERNS

A 41-year-old multipara with tingling sensation in the left axilla was referred for removal of an Implanon NXT which could not be palpated by physical examination or detected by ultrasound scanning. Finally, the device was detected by computed tomography and found migrating to the left axilla.

DIAGNOSIS

Migration of Implanon NXT to the left axilla abutting the brachial plexus.

INTERVENTIONS

The device was removed by C arm-guiding.

OUTCOMES

The patient went home without any procedure-related complications.

LESSONS

The incidence of distant migration of a subdermal implant is possible and should be checked up regularly. If the device cannot be palpated or detected by ultrasound at the original implanting site, this should be concerned. Since the single-rod subdermal implant is radiopaque, it can be detected by roentgenography. In this case the distant migration was detected in the axilla, therefore using C arm-guided technique is feasible for the removal of the migrating device. After reviewing the literature, totally 10 cases of distant migration were reported including 2 cases of migration which were advanced further to the pulmonary artery as an embolization.

Migration of contraceptive implant into the left pulmonary arterial system

An 18-year-old woman had an etonogestrel implant inserted into her left upper arm 2 years earlier for menorrhagia. Her symptoms were not well controlled and she requested the implant to be removed. However, clinicians were unable to locate the implant on her left arm. Computed tomography showed that the implant had migrated to a sub-lobar branch of the left lower lobe pulmonary artery. The long-term effect of leaving an etonogestrel implant in the pulmonary arterial system is unknown. This report adds to the small body of evidence on intravascular migration of a subdermally placed contraceptive implant.

Contraceptive Implant Embolism Into the Pulmonary Artery: Thoracoscopic Retrieval

An 18-year old woman had migration of a subdermal contraceptive implant in a subsegmental branch of her left lower lobe pulmonary artery. She was managed successfully through a conservative surgical approach, as the implant was removed from the pulmonary artery thoracoscopically, thereby avoiding the need of thoracotomy or lung resection.

Peripheral venous catheter fracture with embolism into the pulmonary artery

Peripheral vein catheterization is generally considered a harmless procedure. Venous catheter rupture associated with pulmonary embolism is an unlikely but potentially serious complication. We report a case of a peripheral venous catheter (PVC) fracture with pulmonary artery embolization in the left lower lobe treated successfully by a surgical approach. The positioning of a PVC is not always a harmless procedure. Every time there are difficulties in positioning or in removal of a catheter device, it should be carefully inspected to verify integrity. The advisability of removal of these small foreign bodies is debated; percutaneous retrieval is preferred, while surgery should be discussed case by case.

Looking for a lost subdermal contraceptive implant? Think about the pulmonary artery

This case highlights a rare but potentially life-threatening complication of a contraceptive implant insertion that was corrected by a noninvasive endovascular procedure. This procedure requires a quick intervention to be successful.