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

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.

Migration of a Contraceptive Subdermal Device Into the Lung

Subdermal contraceptive implants are usually inserted subdermally and carry the possibility to migrate within a small range, usually less than 2 cm from the insertion sites; significant migration over 2 cm is rare. This paper discusses the case of a 38-year-old female patient with a migrated subdermal Implanon contraceptive implant in the left pulmonary artery. On chest computed tomography, roughly a 4 cm long linear hyperdensity foreign body in the left lower lobe was found and was favored to be a migrated Implanon in a subsegmental pulmonary artery branch. An interventional radiologist performed an endovascular removal of the left pulmonary artery Implanon using a right common femoral vein access. Very few cases have been reported of complications with inserting and removing the subdermal contraceptive implants as it is considered a reasonably safe procedure in the hands of physicians familiar with the technique. Therefore, if a properly trained individual had carried out the correct procedure of inserting a subdermal implant, the migration of an implant over 2 cm should not occur.

Characteristics of Patients Requiring Surgical Removal of Subdermal Contraceptive Implants: A Case-Control Study

Purpose

Etonogestrel subdermal implants are a commonly used contraceptive device placed in the medial upper arm. Plastic and orthopedic surgeons may be consulted for difficult implant removals. We performed a case–control study comparing patients undergoing surgical and uncomplicated in-office removal at our institution.

Patients and Methods

We identified patients who underwent operative removal of implantable contraceptive devices by plastic or orthopedic surgeons at our institution from January 2014 to October 2019. Patients who underwent uncomplicated office removal during the same time were compared. Demographic and surgical variables were collected, and descriptive statistics were calculated. Univariate and multivariate logistic regression was performed with surgical versus outpatient removal as the outcome of interest.

Results

A total of 669 patients undergoing etonogestrel subdermal implant removals were identified during the five-year study period, of which thirteen patients required surgical removal (1.9%) and 326 were selected as uncomplicated removal comparisons. There were no significant differences in median (IQR) body mass index (BMI) (31.1 [28.2, 35.2] versus 29.3 [24.0, 35.1], p = 0.19), median (IQR) weight gain since device placement (5 [−0.6, 14.7] kilograms versus 1.6 [−1.2, 5.8] kilograms, p = 0.15), or length of time since device insertion (2.3 [0.8, 2.8] years versus 1.0 [0.4, 2.2] years, p = 0.17). Of those who needed surgical removal, the most common indication for implant removal was device expiration (n = 5, 38.5%). Devices placed by OBGYN attendings were less likely to require surgical removal (p = 0.02). Family medicine attendings were more likely to refer patients for surgical removal (p = 0.02). No significant findings were detected on univariate or multivariate regression. Among surgical removals, radiography was the most frequently used imaging modality. Implants were most frequently subdermal (n = 11, 84.6%) though intramuscular placement was also identified (n = 2, 15.4%). Only one patient had residual paresthesia along the length of the incision. No other complications were identified.

Conclusion

We did not identify risk factors associated with the difficult removal of etonogestrel subdermal implants. Practitioners should consult upper extremity surgeons if they encounter difficult removals.

Alternative Insertion Site of Nexplanon: Description of a Case Report and Systematic Review of the Literature

The etonogestrel (ENG) implant is among the most effective reversible contraceptives. It can be a good option for patients with different chronic diseases due to no clinically significant effects on lipid metabolism or liver function. Some limitations in the use of this type of device are represented by social and psychiatric disorders, where the easy accessibility of the device becomes a negative feature. In these patients several cases of self-removal or damage to the device have been reported. We report the successful insertion of the Nexplanon^® device into the scapular region in a young woman with a chronic psychiatric disorder. To verify the presence in the literature of other possible implantation sites, we performed a systematic review of the literature on Pubmed, Google scholar and Scopus from 2000 to 2021 using different combinations of the following terms: (Nexplanon), (contraceptive implant), (insertion). Two manuscripts with three cases were detected. Nexplanon^® was implanted in the upper back. In all cases, there were no complications during the insertions and the follow up demonstrated no side effects with contraceptive efficacy. Our report and review is a further confirmation that the scapular region can become a valid insertion site, maintaining good efficacy and safety of the subcutaneous device.

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.

Migration of a subdermal contraceptive implant into a subsegmental pulmonary artery and etonogestrel serum concentration over time - a case report

Nexplanon is a single-rod contraceptive implant that should be placed subdermally at the inner side of the upper nondominant arm approximately 8-10 cm above the medial epicondyle of the humerus. Insertion guidelines were recently updated to place of insertion superficial of the triceps muscle to lower risk of insertion into vessels and nerves. If migration however occurs, it is most commonly around the insertion site. Migration above 2 cm is rarely reported [Ismail H, Mansour D, Singh M. Migration of implanon®. BMJ Sexual Reproduct Health. 2006;32:157-159]. This is a case report of a 24-year-old caucasian woman who presented with an impalpable Nexplanon implant that was, with the help of chest radiography and CT, located in a posterior basal subsegmental pulmonary artery in the left lower lobe of the lung. An attempt to remove the contraceptive implant by endovascular approach was unsuccessful. The implant remains in situ. Etonogestrel and oestradiol concentrations were followed over time.

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.

Safety and Benefits of Contraceptives Implants: A Systematic Review

Progestin-only contraceptive implants provide long-acting, highly effective reversible contraception. We searched the medical publications in PubMed, CENTRAL, and EMBASE for relevant articles on hormonal implants published in English between 1990 and 2021. Levonorgestrel (LNG) 6-capsule subdermal implants represented the first effective system approved for reversible contraception. The etonogestrel (ENG) single rod dispositive has been widely employed in clinical practice, since it is a highly effective and safe contraceptive method. Abnormal menstrual bleeding is a common ENG side effect, representing the main reason for its premature discontinuation. Emerging evidence demonstrated that it is possible to extend the use of the ENG implant beyond the three-year period for which it is approved. The ENG implant could be an effective and discrete alternative to the IUD in young girls, such as post-partum/post-abortion. Implants should be inserted by trained skilled clinicians who previously provide adequate counselling about their contraceptive effect, benefits, and any possible adverse events. More studies are needed to validate the extended use of the ENG implant for up to 5 years.

A case of needle embolism in a drug abuser, a diagnostic and therapeutic challenge

Background

Needle embolism is a rare complication of intravenous habit. Clinical manifestations include recurrent pericarditis, tamponade, cardiac perforation, and infective endocarditis. We describe the case of needle embolization in a young intravenous opiate abuser.

Case presentation

We describe a rare complication of intravenous misuse in a 23-year-old patient. He presented at the emergency department with chest pain and shortness of breath. He complained of remittent fever ensued 6 months before. Echocardiographic and radiologic images revealed pericardial effusion and a needle fragment inside the pericardium. The needle was removed through left-anterior mini-thoracotomy, after CT-guided carbon tracking.

Conclusions

The presence of a foreign body within the heart resulted from the migration of a needle fragment from a peripheral vessel. It caused fever and recurrent pericarditis. In similar cases, surgical extraction is the therapy of choice.