Management of Etonogestrel implant migration into the pulmonary artery

Clermidy, Hugo; Fabre, Dominique; Hugues, J.-N.; Alonso, Carlos Garcia; Mitilian, Délphine; Mercier, Olaf; Brenot, Philippe; Charbonneau, Philippe; Fadel, Élie

doi:10.1016/j.contraception.2022.03.017

Cited by 5 publications

(5 citation statements)

References 30 publications

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“… Transparenchymal thoracoscopic retrieval of a contraceptive implant pulmonary embolism [ 5 ] 21 RLL SRWC via thoracoscopic arteriotomy Removal occurred 4 years after implantation 2022 Kafi Mallak, F. Migration of a subdermal contraceptive implant into a subsegmental pulmonary artery and etonogestrel serum concentration over time—a case report [ 2 ] 24 Posterior basal LLL EI unsuccessful. Implant remains in situ Etonogestrel and estradiol concentrations were followed over time 2022 Clermidy, H. Management of etonogestrel implant migration into the pulmonary artery [ 1 ] Various (8) 4 LLL, 1 RLL, 1 RUL, 1 LUL, 1 RML SRWC via EI (3). EI unsuccessful, SRWC via MT (5) 5 pts had variations of CP and dyspnea.…”

Section: Discussionmentioning

confidence: 99%

“…A minimally invasive approach, such as endovascular retrieval should then be considered if the patient strongly desires implant removal, or if the patient is symptomatic because of the embolized device. Endovascular approaches have the benefit of sparing lung tissue and avoiding the pain of chest-wall incisions, but can be complicated by the Nexplanon’s tendency to encapsulate and adhere to adjacent tissue [ 1 – 3 , 6 , 12 , 13 ]. This encapsulation is by design and is meant to prevent a Nexplanon from leaving its primary placement site, but can be problematic if it occurs after the device has moved.…”

Section: Discussionmentioning

confidence: 99%

“…As seen in this case, this encapsulation can occur at the wall of a vessel, and thus make the device adherent and not amenable to endovascular removal. There are only a handful of studies correlating the duration of time since implantation in relation to successful endovascular retrieval [ 1 , 3 , 6 , 12 ]. Utilizing patient history in regard to how long the implant has been in place is not a reliable measure to predict endovascular fibrosis and trapping.…”

Section: Discussionmentioning

confidence: 99%

“…As the vascular diameter narrows, the device can wedge into a pulmonary artery, preventing blood supply similar in nature to a pulmonary embolism. When these devices migrate, a patient can become suddenly symptomatic, gradually symptomatic, or not symptomatic as all [ 1 , 5 – 8 , 11 , 14 ]. This varied presentation is a product of the ultimate end-location of the migrated device, and the patient’s overall health.…”

Section: Introductionmentioning

confidence: 99%

“…This varied presentation is a product of the ultimate end-location of the migrated device, and the patient’s overall health. Upon the discovery that a device has migrated, typically by failure to palpate the implant, imaging studies are employed, which reflects the actions taken in this case [ 1 – 15 ]. Following Computed Tomography (CT) chest imaging, the device was confirmed to be located in the left lower lobe, highly suspicious of migration via the left upper extremity (LUE) basilic vein.…”

Section: Introductionmentioning

confidence: 99%

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

Maybury,

Affrin,

Popa

et al. 2024

J Med Case Reports

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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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