Intravascular pulmonary migration of a subdermal contraceptive implant

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.

Nexplanonectomy-the surgical removal of an embolized implanted contraceptive device: a case report and review of the literature

BACKGROUND

Nexplanon implants are a common hormonal contraceptive modality. Though rare, these devices can embolize into the injured wall of the basilic vein, through the right heart, and finally wedge itself into a pulmonary artery. With adherence to the arterial wall over time, it becomes less amenable to endovascular retrieval. Patients may present with symptoms mimicking a pulmonary embolism, or without any symptoms at all. In asymptomatic cases, endovascular retrieval and/or surgery is required when patients wish to begin having children prior to biological inactivity. The current literature showed as little as nine case reports detailing lung tissue removal in the aim of reversing a patient's implanted contraceptive device.

CASE PRESENTATION

A 22-year-old asymptomatic active-duty Caucasian female presented for elective outpatient Nexplanon removal. The suspicion of possible implant migration arose when it was discovered to be non-palpable in her left arm. After plain film x-rays failed to localize the implant, a chest x-ray and follow-up Computed Tomography (CT) scan revealed that the Nexplanon had migrated to a distal branch of the left pulmonary artery. Due to the patient's strong desires to begin having children, the decision was made for removal. Initial endovascular retrieval failed due to Nexplanon encapsulation within the arterial wall. Ultimately, the patient underwent a left video-assisted thoracoscopic surgery (VATS) for exploration and left lower lobe basilar S7-9 segmentectomy, which successfully removed the Nexplanon.

CONCLUSIONS

Implanted contraceptive devices can rarely result in migration to the pulmonary vasculature. These radiopaque devices are detectable on imaging studies if patients and clinicians are unable to palpate them. An endovascular approach should be considered first to spare lung tissue and avoid chest-wall incisions, but can be complicated by encapsulation and adherence to adjacent tissue. A VATS procedure with single-lung ventilation via a double-lumen endotracheal tube allows surgeons to safely operate on an immobilized lung while anesthesiologists facilitate single-lung ventilation. This patient's case details the uncommon phenomenon of Nexplanon migration, and the exceedingly rare treatment resolution of lung resection to remove an embolized device.

Endovascular retrieval of a migrated contraceptive implant into the pulmonary artery : case report and review of literature

BACKGROUND

The migration of contraceptive devices into pulmonary arteries is extremely rare, reported to be 1 in 100,000.

CASE PRESENTATION

A 19-year-old female presented no sensation of a contraceptive implant in her arm which had been placed one year prior. A CT scan confirmed that the implant had migrated into the left lower segmentary pulmonary artery. After a multidisciplinary meeting, an endovascular approach was attempted. Following right femoral venous access, a 8F NeuronMax® introducer was placed into the left pulmonary artery under fluoroscopic guidance. The contraceptive device was removed using a 25-mm loop snare, with a proximal capture technique. The patient was discharged the following day, with no reported complications.

CONCLUSION

In cases of contraceptive device migration, the first medical decision involves deciding between removal or 'watching and waiting'. Previous reports describe two removal options: endovascular or surgical approaches. Fourteen reports have been published, with high technical success and low rates of complications. The loop snare technique is described as the optimal technique for an endovascular approach. Due to their invasive nature, surgical approaches should be reserved for cases of endovascular removal failure, after evaluating risks and benefits.

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.

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.

A French survey of contraceptive implant migration to the pulmonary artery

OBJECTIVE(S)

To quantify implant migration to the pulmonary artery in France since 2012 and to describe the diagnoses and treatments.

STUDY DESIGN

We surveyed 780 physicians of the French national implant-referral network, the French Society of Chest and Cardiovascular Surgery, and the French Radiology Society about diagnosis of implant migration to the pulmonary artery vasculature. We evaluated total implant insertions in France using data from the Medic'AM database.

RESULTS

We identified 12 cases from 2012 to 2017. Ten of the cases were asymptomatic. Five devices were removed via interventional radiology, five surgically, and two were left in place. The number of insertions in France during the same years was approximately 1,200,000.

CONCLUSION(S)

Pulmonary artery migration following contraceptive implant insertion is rare with a migration incidence of 1 in 100,000. Most cases were diagnosed incidentally.

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.

Embolization of a contraceptive implant into the pulmonary vasculature in an adolescent female

Nexplanon is a long-acting 4cm radio-opaque rod shaped contraceptive device implanted in the subdermal layer of the inner, upper arm. Complications from implantation are uncommon and mostly local and minor, including infection at the implantation site with resulting cellulitis or abscess, hematoma, abnormal scar formation, or local damage to nerves and blood vessels. Intravascular insertion is estimated to be at 1.3 per million Nexplanon implants, and migration and embolization is a rare complication of this device. We present a case report of a 16year old female who presented to the pediatric emergency department with subjective dyspnea and an embolized contraceptive device within a subsegmental branch of the left lower lobe pulmonary artery. After discussion with consultants, interventional radiology was able to successful retrieve the device without complication.

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.