Intrapulmonary migration of a fractured acupuncture needle: a case report.

BACKGROUND: Acupuncture, a traditional Chinese medical treatment, has been gaining popularity over the years. However, it also presents certain risks. We report a case of a patient who discovered a foreign body in their lung several years after undergoing acupuncture. CASE PRESENTATION: A middle-aged woman presented to our hospital with chest pain. An X-ray revealed a needle-like foreign body in the middle lobe of her right lung. The patient had previously undergone acupuncture treatment for local pain in her lower back and lower extremities many years prior. Based on the imaging findings and her medical history, we hypothesized that the foreign body in her lung was a result of a dislodged acupuncture needle. Through preoperative 3-dimensional reconstruction and indocyanine green localization, we were able to locate the foreign body in the lateral segment of the right middle lobe. We successfully removed the foreign body via wedge resection, and the patient made a smooth recovery post-surgery. CONCLUSION: Acupuncturists and surgeons should remain vigilant about the potential risks associated with acupuncture.

Loss of Prosthetic Aortic Valve during TAVI Procedure: Endovascular Treatment in Emergent Setting.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has proven over the years to be a viable alternative to open surgery. A rare but severe complication is represented by the valve migration. We report a case of TAVI complication due to the loss of the prosthetic valve in the abdominal aorta treated by endovascular approach. METHODS: An 88-year-old patient with severe aortic valve stenosis, symptomatic for dyspnea was proposed for a TAVI because considered at high risk for surgery. During the TAVI procedure, the undeployed device (Edwards SAPIEN 3 - Edwards Lifesciences, Irvine, CA, USA) detached from its delivery system. Several attempts to withdraw the valve fluctuating in the aorta into its supporting system were performed without success. An emergency endovascular treatment was promptly planned to obtain the exclusion from the flow of the embolized valve. Under local anaesthesia, through the percutaneous femoral access already present, a tube aortic endograft (EndurantTM II, Medtronic, Santa Rosa, CA; ETTF2828C70EE) was successfully introduced and deployed in the infrarenal aorta without any related complications. The embolized valve was completely covered by the endgraft and thus fixed to the aortic wall. The first postoperative computer tomography angiography (CTA) confirmed the correct placement of the endograft, the exclusion of the valve from the flow and the patency of the great vessels. No perioperative or postoperative complications were recorded. The patient was discharged on the ninth postoperative day with the indication to a new attempt of TAVI, through transapical access. CONCLUSIONS: In case of intraprocedural loss of an undeplyed valve during TAVI, the valve fixing through endograft deployment in infrarenal aorta is a possible solution.

Effects of early detection of peritoneal catheter migration on clinical outcomes: 15-years experiences from a single centre.

AIM: Catheter migration is an important cause of catheter malfunction in peritoneal dialysis (PD). The purpose of this study was to investigate the effect of early detection of catheter migration on clinical outcomes. METHODS: A retrospective review of 135 consecutive patients initiating PD immediately following catheter insertion from 2002 to 2017 was undertaken. In order to detect catheter migration without malfunction early, serial abdominal-pelvic radiographic examinations were performed according to a predefined protocol. Conservative management with rigorous catharsis was undertaken to correct catheter migration. A Kaplan-Meier method was used to calculate survival rate. RESULTS: Mean follow-up period was 42.8 ± 34.9 months. Catheter migration occurred in 62.4%. Among them, 85.9% occurred within the first 2 weeks after catheter insertion. There were no significant associations between catheter migration and variables such as gender, obesity, DM and type of catheter. Success rate of conservative management with rigorous catharsis was 91.1%. Catheter survival at 1 and 5 years were 91.5% and 64.6% in the migration group and 81.2% and 69.9% in the non-migration group, respectively (Log-rank test, P = 0.915). Patient survival at 1 and 5 years were 96.8% and 85.8% in the migration group and 91.9% and 82.3% in the non-migration group, respectively (P = 0.792). CONCLUSION: Early detection of PD catheter migration allowed the migrated tip to be easily corrected with conservative management. Once the migrated catheter tip was restored, catheter migration itself did not affect catheter survival. These findings suggest that early detection and correction of catheter migration is important for improving clinical outcomes.

Analysis of the position of EndoAnchor implants in therapeutic use during endovascular aneurysm repair.

OBJECTIVE: The aim of this study was to analyze the penetration depth, angles, distribution, and location of deployment of individual EndoAnchor (Medtronic Vascular, Santa Rosa, Calif) implants. METHODS: Eighty-six primary and revision arm patients (procedural success, 53; persistent type IA endoleak, 33) treated for type IA endoleaks with a total of 580 EndoAnchor implants from a subset of the Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR) were included in this study. Procedural success was defined as the absence of a type IA endoleak on the first postprocedural computed tomography scan after the EndoAnchor implantation procedure. Endograft malapposition along the circumference was assessed at the first postoperative computed tomography scans and expressed as clock-face range and width in degrees and normalized such that the center was translated to 0 degrees. The position and penetration of each EndoAnchor implant were measured as the clock-face orientation. EndoAnchor implant penetration into the aortic wall was categorized as follows: good penetration, ≥2 mm; borderline penetration, <2 mm or ≥2-mm gap between the endograft and aortic wall; or no penetration. The orthogonal and longitudinal angles between the EndoAnchor implant and the interface plane of the aortic wall were determined. Location of deployment was investigated for each EndoAnchor implant and classified as maldeployed when it was above the fabric or in a gap >2 mm between the endograft and aortic wall due to >2-mm thrombus or positioning of the EndoAnchor implant below the aortic neck. RESULTS: A total of 170 (29%) EndoAnchor implants had maldeployment and were therefore beyond recommended use and not useful. After EndoAnchor implantation, the procedural success and persistent type IA endoleak groups had 3 (1%) and 4 (2%) EndoAnchor implants positioned above the fabric as well as 60 (18%) and 103 (42%) placed in a gap >2 mm, respectively. The amount of EndoAnchor implants with good, borderline, and no penetration was significantly different between both groups (success vs type IA endoleak) after exclusion of maldeployed EndoAnchor implants (235 [87.4%], 14 [5.2%], and 20 [7.4%] vs 97 [68.8%], 18 [12.8%], and 26 [18.4%], respectively; P < .001). Good penetration EndoAnchor implants were more closely aligned with a 90-degree orthogonal angle than the borderline penetration and nonpenetrating EndoAnchor implants. The longitudinal angle was more distributed, which was observed through all three penetration groups. CONCLUSIONS: In this subcohort of ANCHOR patients, almost 30% of the EndoAnchor implants had maldeployment, which may be prevented by careful preoperative planning and measured intraoperative deployment. If endoleaks are due to >2-mm gaps, EndoAnchor implants alone may not provide the intended sealing, and additional devices should be considered.

Broken Sacral Neuromodulation Lead Migration Into the Sigmoid Colon: A Case Report.

Sacral neuromodulation is an effective treatment of urinary incontinence, fecal incontinence, and idiopathic urinary retention. The procedure is considered low risk with overall low complication rates. This report describes a 40-year-old woman who underwent sacral neuromodulation explant and full-system implant for weaning efficacy of her device. During device removal, the tined lead broke and was left in situ. Four months later, she was diagnosed as having a wound infection at the site of the retained lead. Imaging revealed lead fragment migration into the sigmoid colon. A colocutaneous fistula was noted soon thereafter. The retained lead was removed during a colonoscopy and the fistula healed. A retained lead can result in migration through the peritoneum and into the colon. This can be managed with assistance from colorectal or gastroenterology consultants.

Hypoglossal nerve stimulator generator migration: INSPIRE device reimplantation with parallels to cardiac implantable electronic devices.

Implantation rates of hypoglossal nerve stimulators, such as INSPIRE, are increasing. The device is still in its early stages of complication reporting, which to date includes implant related infection requiring device removal, and stimulation lead cuff dislodgement requiring replacement. Here we present a 48-year-old female who experienced generator migration and stimulator lead tension requiring an additional operation in order to resecure the generator device. This proved unsuccessful and a second surgery was performed with complete relocation of the device generator to inhibit device migration. This is the first documented case of INSPIRE migration to date, though the implant generator has comparable likeness to cardiovascular implantable electronic devices (CIEDs) where migration risk factors are better studied. Given our patient's case, we identify obesity and abundant breast tissue as potential risk factors for device migration. We believe such factors can be identified prior to initial device implantation to avoid migration and the need for surgical revision. Superior positioning of the generator proved successful, and can be a solution in those with similar body habitus as TYRX pouching and additional security sutures were ineffective. Also, for revisions requiring tunneling of the stimulation lead as in this case we recommend the use of zero degree endoscope for ease of adhesion lysis.

Influence of aortic neck characteristics on successful aortic wall penetration of EndoAnchors in therapeutic use during endovascular aneurysm repair.

OBJECTIVE: This study sought to quantify EndoAnchor (Medtronic Vascular, Santa Rosa, Calif) penetration into the aortic wall in patients undergoing endovascular abdominal aortic aneurysm repair and to assess predictors of successful penetration and its relationship to postprocedural type IA endoleak. METHODS: A subset of patients from the Aneurysm Treatment Using the Heli-FX Aortic Securement System Global Registry (ANCHOR) were included if they met the following criteria: the indication for EndoAnchor use was to treat a type IA endoleak, and postprocedure contrast-enhanced computed tomography (CT) scans of sufficient quality were available for core laboratory review. Patients undergoing implantation of cuffs or stents during the EndoAnchor implantation procedure were excluded. Baseline anatomic characteristics were recorded. The cohort was divided into patients with and without persistent type IA endoleaks at the first postoperative CT scan. Penetration of each EndoAnchor measured on this CT scan was defined as good penetration when the EndoAnchor penetrated ≥2 mm into the aortic wall, borderline penetration when EndoAnchor penetration was <2 mm or a gap remained between the endograft and aortic wall, or no penetration when the EndoAnchor did not penetrate into the aortic wall. Differences between the groups were analyzed with the Mann-Whitney U test or Fisher exact test. Multivariate analyses were performed to identify independent predictors of EndoAnchor penetration, and procedural success was defined by absence of type IA endoleak. RESULTS: Eighty-six patients of the primary (n = 61 [71%]) and revision (n = 25 [29%]) arms of the ANCHOR registry were included. There were 53 (62%) without and 33 (38%) with persistent type IA endoleaks on the first postprocedural CT scan. The median number of EndoAnchors with good penetration was significantly greater in the cohort without endoleaks, 4 (interquartile range, 3-5) vs 3 (interquartile range, 1.5-4), respectively (P = .002). A multivariate model for EndoAnchor penetration identified use of a Medtronic Endurant endograft as a factor associated with good penetration (P = .001), whereas poor penetration was associated with a larger aortic neck diameter 10 mm distal to the lowest renal artery (P < .001) and greater proximal neck calcium thickness (P = .004). EndoAnchor penetration was the only variable that attained significance (P < .001) in the multivariate model for successful treatment of a type IA endoleak. CONCLUSIONS: Adequate EndoAnchor penetration into the aortic wall is less likely when the aortic neck diameter is large or when the neck contains significant mural calcium. No penetration of the EndoAnchor was the only factor predictive of postprocedural type IA endoleak. This study stresses the importance of careful selection of patients based on preoperative assessment of the infrarenal neck on CT angiography and emphasizes careful deployment of EndoAnchors into the aortic wall to improve successful treatment of type IA endoleaks.

Stranded seed displacement, migration, and loss after permanent prostate brachytherapy as estimated by Day 0 fluoroscopy and 4-month postimplant pelvic x-ray.

PURPOSE: The aim of the study was to determine the incidence of local displacement, distant seed migration to the chest, and seed loss after permanent prostate brachytherapy (PPB) with stranded seeds (SSs) using sequential two-dimensional fluoroscopic pelvic and chest x-rays. METHODS AND MATERIALS: Between October 2010 and April 2014, a total of 137 patients underwent PPB and 4-month followup pelvic and chest x-ray imaging. All patients had exclusively SSs placed and an immediate postimplant fluoroscopic image of the seed cluster. Followup x-ray images were evaluated for the number, location, and displacement of seeds in comparison to Day 0 fluoroscopic images. Significant seed displacement was defined as seed displacement >1 cm from the seed cluster. Followup chest x-rays were evaluated for seed migration to the chest. RESULTS: Seed migration to the chest occurred in 3 of the 137 patients (2%). Seed loss occurred in 38 of the 137 patients (28%), with median loss of one seed (range, 1-16), and total seeds loss of 104 of 10,088 (1.0%) implanted. Local seed displacement was seen in 12 of the 137 patients (8.8%), and total seeds displaced were 0.15% (15/10,088). CONCLUSIONS: SS placement in PPB is associated with low rates of substantial seed loss, local displacement, or migration to the chest. Comparing immediate postimplant fluoroscopic images to followup plain x-ray images is a straightforward method to supplement quality assurance in PPB and was found to be useful in identifying cases where seed loss was potentially of clinical significance.

Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature.

OBJECTIVE: Spinal cord and peripheral neurostimulation techniques have been practiced since 1967 for the relief of pain, and some techniques are also used for improvement in organ function. Neuromodulation has recognized complications, although very rarely do these cause long-term morbidity. The aim of this article is to present a review of complications observed in patients treated with neurostimulation techniques. METHODS: A review of the major recent publications in the literature on the subjects of spinal cord, occipital, sacral, and peripheral nerve field stimulation was conducted. RESULTS: The incidence of complications reported varies from 30% to 40% of patients affected by one or more complications. Adverse events can be subdivided into hardware-related complications and biological complications. The commonest hardware-related complication is lead migration. Other lead related complications such as failure or fracture have also been reported. Common biological complications include infection and pain over the implant. Serious biological complications such as dural puncture headache and neurological damage are rarely observed. CONCLUSIONS: Spinal cord and peripheral neurostimulation techniques are safe and reversible therapies. Hardware-related complications are more commonly observed than biological complications. Serious adverse events such as neurological damage are rare.

Retained embolized fragment of totally implantable central venous catheter in right ventricle: it is really necessary to remove?

INTRODUCTION: Central venous catheters are often required in oncologic patients for long-term safe administration of chemotherapeutic agents, antibiotics, and parenteral nutrition. Rupture of these devices and intracardiac migration is a rare complication. METHODS: We report one spontaneous rupture and embolization of a totally implantable vascular access device (TIVAD) in an asymptomatic patient. RESULTS: A 50-year-old woman received a TIVAD silicone catheter 8 FR for adjuvant chemotherapy. After 3 years of port time in situ, during a follow-up control, a catheter malfunction was found and radiologic investigations showed a rupture and migration of the catheter to the right ventricle. The attempt to remove the fragment under fluoroscopic control using the femoral route was unsuccessful. We did not try a surgical approach because of the complete absence of symptomatology and hemodynamic impairment. CONCLUSIONS: The catheter rupture and intracardiac embolization is a rare complication associated with totally implantable or tunneled central venous catheters. When such an event happens, the patient should be managed by expert hemodynamists or interventional radiologists making an effort to remove the fragment without surgical measures. When the intravascular percutaneous route fails, the possibility to leave the fragmented catheter in heart chambers should be evaluated, being surgery questionable in asymptomatic patients.

A tale of early Reel syndrome caused by an over-enthusiastic masseuse.

Twiddler syndrome is a form of pacemaker lead dislocation caused by the coiling of the pacemaker leads due to pulse generator rotation on its long axis. Similar to Twiddler syndrome, Reel syndrome occurs due to rotation of the pulse generator on its transverse axis, leading to lead dislocation or fracture, followed by clinical symptoms of dislodged leads. We report a case of 75 years old woman with Reel syndrome presenting with syncope.

Cupping of the left atrial disc: a new echocardiographic pointer towards atrial septal defect-device mismatch.

We report a case of percutaneous atrial septal defect closure (ASD) in which, despite careful device selection and successful shunt closure, a number of adverse echocardiographic features developed, necessitating surgical extraction of the device and patch closure of the defect. Lessons regarding case selection, device choice, appropriate follow-up and recognition of adverse echocardiographic features can be learned from this experience.

An acupuncture needle remaining in a lung for 17 years: case study and review.

The case of a 67-year-old patient with an acupuncture needle remaining in his left lung is described. This foreign body was a remnant of a procedure performed by a doctor 17 years previously for osteoarthritic back pain. On the basis of this case, a review was performed of literature available in the PubMed database dealing with acupuncture needles remaining in a patient's body. A total of 25 articles were found. The articles describe needles found in the bladder, shoulder girdle, spinal cord, right ventricle, L5 nerve root, medulla oblongata, skin, carpal tunnel, nuchal and occipital area, calf and paraspinal muscle. Migration of needle fragments to the liver, pancreas, stomach, colon, breast, kidney, muscles, and spinal cord has been reported in the literature. In cases where patients were operated on, the needles were removed without subsequent complications and the patients recovered fully.

Surgical treatment for intra-thoracic migration of acupuncture needles.

The aim of this study was to introduce the experience of diagnosis and treatment for patients with migrated acupuncture needle to pleural cavity and or lung parenchyma. We had treated 5 patients who had acupuncture needles in their thoracic cavity from January 2000 to September 2009. The mean age was 55.8 yr old. All patients suffered from the sequelae of the cerebrovascular accident and had been treated with acupuncture. They had drowsiness and hemiplegic or quadriplegic motor activity. Fever and dyspnea were main symptoms when referred to us. Diagnosis was made by the chest radiography and chest computed tomography which revealed straight metallic materials in their thoracic cavity. The needles were removed via thoracotomy or thoracoscopic procedures. Pleural decortications were also needed in four patients. Thoracoscopic surgery was successfully performed in two patients. After the removal all patients became symptomless. Although we experienced only five patients who have migrated acupuncture needles in thoracic cavity, we suggest that thoracoscopic removal of the needle with or without pleural decortication is the most optimal modality of treatment in those patients.