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Guilbert É, Arguin H, Bélanger M. Migration of etonogestrel subcutaneous contraceptive implants: systematic review and recommendations for practice. EUR J CONTRACEP REPR 2024; 29:115-130. [PMID: 38712717 DOI: 10.1080/13625187.2024.2342919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/05/2024] [Indexed: 05/08/2024]
Abstract
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.
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Affiliation(s)
- Édith Guilbert
- Direction of the Development of Individuals and Communities, Quebec National Institute of Public Health, Montreal, Quebec, Canada
- Department of Obstetrics, Gynecology and Reproduction, Faculty of Medicine, Laval University, Quebec, Quebec, Canada
| | - Hélène Arguin
- Direction of the Development of Individuals and Communities, Quebec National Institute of Public Health, Montreal, Quebec, Canada
| | - Mathieu Bélanger
- Department of Obstetrics and Gynecology, University of Montreal, Montreal, Quebec, Canada
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Maybury EK, Affrin ZC, Popa C, Fowler M, Laliberte BD, Clarke SC. Nexplanonectomy-the surgical removal of an embolized implanted contraceptive device: a case report and review of the literature. J Med Case Rep 2024; 18:234. [PMID: 38698425 PMCID: PMC11064350 DOI: 10.1186/s13256-024-04547-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/05/2024] [Indexed: 05/05/2024] Open
Abstract
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.
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Affiliation(s)
- Edward K Maybury
- Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA, 92134, USA.
| | - Zachary C Affrin
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Christian Popa
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Max Fowler
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Bryan D Laliberte
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
| | - Sarah C Clarke
- Darnall Medical Library, Walter Reed National Military Medical Center, Bethesda, MD, 20814, USA
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Grange R, Magand N, Grand N, Leroy S, Corsini T, Azarnoush K, Grange S. Endovascular retrieval of a migrated contraceptive implant into the pulmonary artery : case report and review of literature. CVIR Endovasc 2024; 7:35. [PMID: 38581571 PMCID: PMC10998818 DOI: 10.1186/s42155-024-00450-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/27/2024] [Indexed: 04/08/2024] Open
Abstract
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.
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Affiliation(s)
- Rémi Grange
- Department of Radiology, University Hospital of Saint-Etienne, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France.
| | - Nicolas Magand
- Department of Radiology, University Hospital of Saint-Etienne, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France
| | - Nathalie Grand
- Department of Anesthesiology, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Stéphanie Leroy
- Department of Anesthesiology, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Thomas Corsini
- Department of Gynecology, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Kasra Azarnoush
- Department of Cardiac Surgery, University Hospital of Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Sylvain Grange
- Department of Radiology, University Hospital of Saint-Etienne, Avenue Albert Raimond, 42270, Saint-Priest-en-Jarez, France
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Clermidy H, Fabre D, Hugues JN, Alonso CG, Mitilian D, Mercier O, Brenot P, Charbonneau P, Fadel E. Management of etonogestrel implant migration into the pulmonary artery. Contraception 2022; 113:62-67. [PMID: 35351447 DOI: 10.1016/j.contraception.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Hugo Clermidy
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Paris Saclay University, Le Plessis Robinson, France
| | - Dominique Fabre
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Paris Saclay University, Le Plessis Robinson, France..
| | - Jean Noel Hugues
- Unit of Reproductive Medicine, Department of Obstetrics-Gynaecology, Hopital Jean Verdier, Assistance Publique des Hôpitaux de Paris (AP-HP), Brondy, France
| | - Carlos Garcia Alonso
- Department of Interventional Radiology, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Paris Saclay University, Le Plessis Robinson, France
| | - Delphine Mitilian
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Paris Saclay University, Le Plessis Robinson, France
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Paris Saclay University, Le Plessis Robinson, France
| | - Philippe Brenot
- Department of Interventional Radiology, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Paris Saclay University, Le Plessis Robinson, France
| | - Philippe Charbonneau
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Paris Saclay University, Le Plessis Robinson, France
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie-Lannelongue Hospital, Groupe Hospitalier Paris Saint-Joseph, Paris Saclay University, Le Plessis Robinson, France
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FSRH Guideline (February 2021) Progestogen-only Implant. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:1-62. [PMID: 33593815 DOI: 10.1136/bmjsrh-2021-chc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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6
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Carraro do Nascimento V, De Villiers L, Chia GS, Rice H. Aspiration technique for percutaneous endovascular retrieval of contraceptive device embolized to the pulmonary vasculature. Radiol Case Rep 2020; 16:571-574. [PMID: 33384758 PMCID: PMC7772520 DOI: 10.1016/j.radcr.2020.12.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Simon C, Maurier A, Gaboriau L, Vrignaud L, Dayani P, Vaillant T, Andrée Bos-Thompson M, Jonville-Bera AP. Incidence and characteristics of intravascular pulmonary migration of etonogestrel implants: A French nationwide study. Contraception 2020; 102:186-189. [PMID: 32417204 DOI: 10.1016/j.contraception.2020.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 03/06/2020] [Accepted: 05/07/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Corinne Simon
- Regional Pharmacovigilance Center, Department of Pharmacosurveillance, CHRU de Tours, 37044 Tours, France
| | - Ana Maurier
- Regional Pharmacovigilance Center, Department of Pharmacosurveillance, CHRU de Tours, 37044 Tours, France
| | - Louise Gaboriau
- Regional Pharmacovigilance Center, Department of Medical Pharmacology, CHRU de Lille, Lille, France
| | - Laura Vrignaud
- Regional Pharmacovigilance Center, Department of Pharmacosurveillance, CHRU de Tours, 37044 Tours, France
| | - Pauline Dayani
- French National Agency for Medicines and Health Products Safety (ANSM), 93285 Saint-Denis Cedex, France
| | - Tiphaine Vaillant
- French National Agency for Medicines and Health Products Safety (ANSM), 93285 Saint-Denis Cedex, France
| | - Marie Andrée Bos-Thompson
- Regional Pharmacovigilance Center, Department of Medical Pharmacology and Toxicology, CHRU de Montpellier, Montpellier, France
| | - Annie-Pierre Jonville-Bera
- Regional Pharmacovigilance Center, Department of Pharmacosurveillance, CHRU de Tours, 37044 Tours, France; Université de Tours, Université de Nantes, INSERM, SPHERE U1246 Tours, France.
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Rael CT, Martinez M, Giguere R, Bockting W, MacCrate C, Mellman W, Valente P, Greene GJ, Sherman SG, Footer KHA, D'Aquila RT, Carballo-Diéguez A, Hope TJ. Transgender Women's Concerns and Preferences on Potential Future Long-Acting Biomedical HIV Prevention Strategies: The Case of Injections and Implanted Medication Delivery Devices (IMDDs). AIDS Behav 2020; 24:1452-1462. [PMID: 31654172 PMCID: PMC7181384 DOI: 10.1007/s10461-019-02703-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
There are several long-acting biomedical HIV prevention products in the development pipeline, including injections and implanted medication delivery devices (IMDDs). It is critical to understand concerns and preferences on the use of these products in populations that shoulder a disproportionate burden of the HIV epidemic, such as transgender women. This will allow researchers and public health professionals to construct interventions tailored to the needs of these women to promote optimal use of these tools. In studies of other biomedical HIV prevention products (e.g., oral PrEP) it is clear that transgender women have unique concerns related to the use of these strategies. This may have an impact on this group's uptake and sustained use of longacting HIV prevention products. This study conducted four focus groups with N = 18 transgender women in New York City to understand their concerns and preferences on long-acting PrEP injections and IMDDs. Findings showed that participants were overwhelmingly positive about long-acting HIV prevention strategies, though they had some apprehensions. Overall, participants felt that injections and IMDDs could help address adherence challenges, and that transgender-specific needs should be addressed during clinical trials. Also, there were concerns related to injection or IMDD logistics, concerns about injections' or IMDDs' presence in the body, and familiarity with these products affected participants' opinions on them. Findings from this work can be used to inform protocols, measures, materials, and adherence interventions in future initiatives for transgender women using PrEP injections or IMDDs.
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Affiliation(s)
- Christine Tagliaferri Rael
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA.
| | - Michelle Martinez
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - Rebecca Giguere
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA
| | - Walter Bockting
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
| | - Caitlin MacCrate
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- CUNY School of Public Health, New York, NY, USA
| | - Will Mellman
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
| | - Pablo Valente
- Program for the Study of LGBT Health at the New York State Psychiatric Institute/Columbia Psychiatry and the Columbia University School of Nursing, New York, NY, USA
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - George J Greene
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Susan G Sherman
- Department of Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Katherine H A Footer
- Department of Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Richard T D'Aquila
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alex Carballo-Diéguez
- HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University, 1051 Riverside Dr., New York, NY, 10032, USA
| | - Thomas J Hope
- Northwestern University Feinberg School of Medicine, and Biomedical Engineering in the McCormick School of Engineering and Applied Sciences, Chicago, IL, USA
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Hindy JR, Souaid T, Larus CT, Glanville J, Aboujaoude R. Nexplanon migration into a subsegmental branch of the pulmonary artery: A case report and review of the literature. Medicine (Baltimore) 2020; 99:e18881. [PMID: 31977894 PMCID: PMC7004701 DOI: 10.1097/md.0000000000018881] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Joya-Rita Hindy
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Tarek Souaid
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | | | - Joanne Glanville
- Department of General Surgery at Johnston-Willis Hospital, Richmond, VA, USA
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Ohannessian A, Levy A, Jaillant N, Tanguy Le Gac Y, D'Journo X, Vidal V, Agostini A. A French survey of contraceptive implant migration to the pulmonary artery. Contraception 2019; 100:255-257. [PMID: 31194964 DOI: 10.1016/j.contraception.2019.05.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
| | | | - Noémie Jaillant
- Service de chirurgie vasculaire, Hôpital le Bocage CHRU de Dijon, France
| | - Yan Tanguy Le Gac
- Pôle de gynécologie obstétrique, hôpital Paule-de-Viguier, CHU de Toulouse, France
| | - Xavier D'Journo
- Service de chirurgie thoracique, Chemin des Bourrely, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix-Marseille University, France
| | - Vincent Vidal
- Department of Medical Imaging, Assistance Publique Hôpitaux de Marseille, La Timone Hospital, Aix Marseille University, France
| | - Aubert Agostini
- Department of Gynecology and Obstetrics, La Conception Hospital, Marseille, France.
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11
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Wilcox KK, Turcer F, Soltes GD, Shin DS. Endovascular retrieval of contraceptive implant embolized to pulmonary artery. Radiol Case Rep 2018; 13:1285-1288. [PMID: 30275923 PMCID: PMC6161411 DOI: 10.1016/j.radcr.2018.08.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 08/27/2018] [Accepted: 08/28/2018] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Kyle K Wilcox
- Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
| | - Filip Turcer
- Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
| | - George D Soltes
- Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
| | - David S Shin
- Department of Radiology, University of Washington, 1959 NE Pacific St, Box 357115, Seattle, WA 98195, USA
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12
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Akhtar MM, Bhan A, Lim ZY, Akhtar MA, Sekhri N, Bharadwaj P, Mullen M. Percutaneous extraction of an embolized progesterone contraceptive implant from the pulmonary artery. Open Access J Contracept 2018; 9:57-61. [PMID: 30140161 PMCID: PMC6054767 DOI: 10.2147/oajc.s165827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammed Majid Akhtar
- Institute of Cardiovascular Sciences, University College London, London, UK, .,Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
| | - Amit Bhan
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
| | - Zhan Yun Lim
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
| | - Mohammed Abid Akhtar
- Department of Cardiology and Cardiac Transplantation, Harefield Hospital, Royal Brompton & Harefield NHS Trust, London, UK
| | - Neha Sekhri
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
| | - Preeti Bharadwaj
- Community Gynaecology and Sexual & Reproductive Health Department, Waltham Forest, North East London Foundation Trust, London, UK
| | - Michael Mullen
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK,
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Chung M, Loudill C, Wieler M, Farnam J, Ahn SH. Endovascular Retrieval of Nexplanon from the Distal Pulmonary Artery. J Vasc Interv Radiol 2018; 28:466-467. [PMID: 28231925 DOI: 10.1016/j.jvir.2016.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 09/07/2016] [Accepted: 09/08/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- Maggie Chung
- Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903
| | - Cameron Loudill
- Department of Diagnostic Imaging Warren Alpert Medical School of Brown University, Rhode Island Hospital Providence, Rhode Island
| | - Matthew Wieler
- Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903
| | - Joseph Farnam
- Division of Interventional Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital Providence, Rhode Island; Department of Diagnostic Imaging Warren Alpert Medical School of Brown University, Rhode Island Hospital Providence, Rhode Island
| | - Sun Ho Ahn
- Division of Interventional Radiology, Warren Alpert Medical School of Brown University, Rhode Island Hospital Providence, Rhode Island; Department of Diagnostic Imaging Warren Alpert Medical School of Brown University, Rhode Island Hospital Providence, Rhode Island
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14
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Etonogestrel implant migration to the vasculature, chest wall, and distant body sites: cases from a pharmacovigilance database. Contraception 2017; 96:439-445. [DOI: 10.1016/j.contraception.2017.08.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 11/17/2022]
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15
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Scher D, Broderick S, Holly B. Retrieval of an Essure Device from the Pulmonary Arterial System. J Vasc Interv Radiol 2017; 28:1297-1299. [PMID: 28841942 DOI: 10.1016/j.jvir.2017.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/23/2017] [Accepted: 03/24/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Daniel Scher
- Department of Vascular and Interventional Radiology, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287
| | - Stephen Broderick
- Department of Vascular and Interventional Radiology, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287
| | - Brian Holly
- Department of Vascular and Interventional Radiology, Johns Hopkins Hospital, 1800 Orleans Street, Baltimore, MD 21287
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16
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Distal migration of contraceptive device in a sub-segmental branch of the pulmonary artery. Eur J Obstet Gynecol Reprod Biol 2017. [PMID: 28625675 DOI: 10.1016/j.ejogrb.2017.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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17
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Kew EP, Senanayake E, Djearaman M, Bishay E. Migration of contraceptive implant into the left pulmonary arterial system. Asian Cardiovasc Thorac Ann 2017; 25:537-539. [PMID: 28605952 DOI: 10.1177/0218492317716589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Ee Phui Kew
- 1 Department of Cardiothoracic Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | - Eshan Senanayake
- 2 Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, UK
| | - Madava Djearaman
- 3 Department of Radiology, Birmingham Heartlands Hospital, Birmingham, UK
| | - Ehab Bishay
- 2 Department of Thoracic Surgery, Birmingham Heartlands Hospital, Birmingham, UK
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18
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Migration of a contraceptive subdermal device into the lung. Obstet Gynecol Sci 2017; 60:314-317. [PMID: 28534019 PMCID: PMC5439282 DOI: 10.5468/ogs.2017.60.3.314] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/24/2016] [Accepted: 11/09/2016] [Indexed: 11/23/2022] Open
Abstract
A single-rod subdermal contraceptive implant is usually located around the insertion site, has been usually known to migrate within less than 2 cm of the insertion site and the true migration over 2 cm has been rarely reported. We report a case of migrated radiopaque subdermal contraceptive implant into lung in a 37-year-old woman. On conducted chest computed tomography, subdermal contraceptive implant was in subsegmental branch in left posterior basal segment of lung. Removal of subdermal contraceptive implant in left posterior basal segment of lung by mini-thoracotomy was performed by a chest surgeon. Complications with insertion and removal of subdermal contraceptive implant are rare in the hands of medical professionals familiar with the techniques and these procedures should only be undertaken by those with relevant training. The migration over 2 cm should not occur if the correct subdermal insertion procedure is followed and carried out by a properly trained individual.
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19
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Intravascular migration of contraceptive implants: two more cases. Contraception 2017; 95:211-214. [DOI: 10.1016/j.contraception.2016.07.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 07/18/2016] [Accepted: 07/18/2016] [Indexed: 11/18/2022]
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20
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The US etonogestrel implant mandatory clinical training and active monitoring programs: 6-year experience. Contraception 2017; 95:205-210. [DOI: 10.1016/j.contraception.2016.07.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/12/2016] [Accepted: 07/18/2016] [Indexed: 11/19/2022]
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21
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Gallon A, Fontarensky M, Chauffour C, Boyer L, Chabrot P. Looking for a lost subdermal contraceptive implant? Think about the pulmonary artery. Contraception 2016; 95:215-217. [PMID: 27888047 DOI: 10.1016/j.contraception.2016.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 11/07/2016] [Accepted: 11/16/2016] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- A Gallon
- Radiology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - M Fontarensky
- Radiology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France.
| | - C Chauffour
- Gynecology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - L Boyer
- Radiology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - P Chabrot
- Radiology service - Centre Hospitalier Universitaire Gabriel Montpied, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
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22
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23
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Simon C, Agier MS, Béné J, Muller C, Vrignaud L, Marret H, Jonville-Bera AP. [Safety profile of etonogestrel contraceptive implant (Nexplanon ® and Implanon ®) reported in France]. ACTA ACUST UNITED AC 2016; 45:1074-1082. [PMID: 27125380 DOI: 10.1016/j.jgyn.2016.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/18/2016] [Accepted: 03/22/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of the study was to assess the incidence of adverse effects (AE) reported with etonogestrel contraceptive implant in France (Implanon® and Nexplanon®). MATERIALS AND METHODS All cases of AE or unintended pregnancies reported to health authorities or to the firm were analyzed. RESULTS During 10 years, 5433 AE and 789 unintended pregnancies were reported. Only 388 (7 %) were serious. There were 1137 reports of difficulties to remove, failure to locate or migration, 430 of insertion difficulties and 203 of deformation or expulsion of the implant. Among other AE, the most common were 1694 gynecological AE, 524 skin reactions and 437 metabolic AE. Since the marketing of Nexplanon® which causes less deep insertions, the incidence of migrations, removal or insertion difficulties has decreased overall (0.92 vs. 1.31/1000 patients), particularly the incidence of removal difficulties, location failures or migrations (0.12 vs 1.01/1000). The infrequent but serious AE were infectious complications at the implant site and pregnancies. When the circumstances of the pregnancy were known, the contraceptive failure was due to the apparent inefficiency of the implant (n=224), to a technique failure (n=203) or to a drug-drug interaction (n=59). CONCLUSION This study confirms that AE of this implant are frequent but not serious, except for the pregnancies. The incidence of complications related to insertion decreased with Nexplanon®. Among other preventable AE, unintended pregnancies due to a drug-drug interaction would require to be better known by the practitioner.
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Affiliation(s)
- C Simon
- Service de pharmacologie, centre régional de pharmacovigilance, de pharmacoépidémiologie et d'information sur le médicament, CHRU, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - M S Agier
- Service de pharmacologie, centre régional de pharmacovigilance, de pharmacoépidémiologie et d'information sur le médicament, CHRU, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - J Béné
- Service de pharmacologie, centre régional de pharmacovigilance, CHRU de Lille, 59045 Lille, France
| | - C Muller
- Centre régional de pharmacovigilance, hôpital Civil, 67091 Strasbourg, France
| | - L Vrignaud
- Service de pharmacologie, centre régional de pharmacovigilance, de pharmacoépidémiologie et d'information sur le médicament, CHRU, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - H Marret
- Service de gynécologie, CHRU, 2, boulevard Tonnellé, 37044 Tours cedex 9, France; Université François-Rabelais, 37032 Tours, France
| | - A P Jonville-Bera
- Service de pharmacologie, centre régional de pharmacovigilance, de pharmacoépidémiologie et d'information sur le médicament, CHRU, 2, boulevard Tonnellé, 37044 Tours cedex 9, France.
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