Endoscopy 2017; 49(S 01): E70-E72
DOI: 10.1055/s-0042-123704
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© Georg Thieme Verlag KG Stuttgart · New York

Intra-arterial migration of a fractured endoscopic needle

Edward Lake
1   Department of Radiology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
,
Joanne Puleston
2   Department of Gastroenterology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
,
Finn Farquharson
1   Department of Radiology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
› Author Affiliations
Further Information

Corresponding author

Edward Lake, MD
Department of Radiology
Manchester Royal Infirmary
Grafton Street
Manchester
M13 9WL
UK   

Publication History

Publication Date:
30 January 2017 (online)

 

A 53-year-old man with chronic pancreatitis presented with abdominal pain and sepsis. Imaging revealed a liver abscess secondary to distal biliary obstruction. Following drainage of his abscess, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with placement of a fully covered metal biliary stent across a 2-cm suspicious shouldered and irregular low common bile duct stricture. A pancreatic head malignancy was suspected at ERCP and on computed tomography (CT) imaging. The regional specialist hepatobiliary multidisciplinary team (MDT) recommended endoscopic ultrasound with fine needle aspiration (EUS-FNA).

EUS-FNA was difficult because of the changes of severe chronic calcific pancreatitis, duodenal stenosis, increased pancreatic head vascularity, and metal stent artefact. Five needle passes were made with a 22-gauge needle (Boston Scientific, Marlborough, Massachusetts, USA) using standard technique. Cytology was consistent with pancreatitis, with no evidence of malignancy.

A routine chest radiograph 6 months later revealed a new linear density in the heart ([Fig. 1]). The interim abdominal CT imaging was re-reviewed ([Fig. 2]). Although not recognized at the time, owing to the highly calcified pancreas, it became clear that a fractured EUS-needle tip had migrated from the duodenal wall into the epigastrium ([Fig. 3]), then through the diaphragm and into the left ventricle. On a subsequent chest radiograph, the needle had disappeared and a further CT scan revealed that it had migrated to the aortic bifurcation ([Fig. 4 a]).

Zoom Image
Fig. 1 Chest radiograph showing a needle within the left ventricle (linear density within the red ellipse).
Zoom Image
Fig. 2 Axial computed tomography (CT) scan showing the needle (red arrow) that was not identified originally among the pancreatic calcifications.
Zoom Image
Fig. 3 Obliquely reformatted computed tomography (CT) images showing: a the needle extending through the duodenal wall; b the needle having moved to the epigastrium.
Zoom Image
Fig. 4 Further imaging shortly before and during removal of the needle. a A volume-rendered computed tomography (CT) angiogram showing the needle at the aortic bifurcation. b The needle was snared from above with balloon occlusion below. c The needle was snared from below and was removed through a sheath.

The needle was retrieved endovascularly via bilateral common femoral artery access. It was first snared from above with a protective occlusion balloon placed below in the left iliac artery ([Fig. 4 b]). The balloon was deflated, the needle was snared from below and was then removed through the left groin sheath ([Fig. 4 c]; [Video 1]). The patient made an uneventful recovery after the procedure.

Video 1: Endovascular removal of an intra-arterial fractured needle. The needle was snared from above with a protective occlusion balloon below in the left iliac artery. The balloon was deflated, then the needle was snared from below and removed through the groin sheath.

Quality:

Endoscopic needle fracture has been previously described in the upper gastrointestinal tract [1] [2] and in a bronchoscopy setting [3]. Fractured metal sharps such as orthopedic fixation wires have been known to migrate into the arterial circulation, including into the heart [4]. This is the first known case of an endoscopic needle migrating intra-arterially.

Endoscopy_UCTN_Code_CPL_1AJ_2AZ


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Competing interests

None

  • References

  • 1 Rimbaș M, Attili F, Andrade Zurita S. et al. Fractured needle during endoscopic ultrasound-guided fine-needle aspiration of a pancreatic head mass. Endoscopy 2015; 47 (Suppl. 01) E432
  • 2 DeWitt J, Sherman S, Lillemoe KD. Fracture of an EUS-guided FNA needle during an attempted rendezvous for an inaccessible pancreatic duct. Gastrointest Endosc 2011; 73: 171-173
  • 3 Özgül MA, Çetinkaya E, Tutar N. et al. An unusual complication of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): the needle breakage. Ann Thorac Cardiovasc Surg 2014; 20 Suppl: 567-569
  • 4 Leonardi F, Rivera F. Intravascular migration of a fractured cerclage wire into the left heart. Orthopedics 2014; 37: e932-e935

Corresponding author

Edward Lake, MD
Department of Radiology
Manchester Royal Infirmary
Grafton Street
Manchester
M13 9WL
UK   

  • References

  • 1 Rimbaș M, Attili F, Andrade Zurita S. et al. Fractured needle during endoscopic ultrasound-guided fine-needle aspiration of a pancreatic head mass. Endoscopy 2015; 47 (Suppl. 01) E432
  • 2 DeWitt J, Sherman S, Lillemoe KD. Fracture of an EUS-guided FNA needle during an attempted rendezvous for an inaccessible pancreatic duct. Gastrointest Endosc 2011; 73: 171-173
  • 3 Özgül MA, Çetinkaya E, Tutar N. et al. An unusual complication of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): the needle breakage. Ann Thorac Cardiovasc Surg 2014; 20 Suppl: 567-569
  • 4 Leonardi F, Rivera F. Intravascular migration of a fractured cerclage wire into the left heart. Orthopedics 2014; 37: e932-e935

Zoom Image
Fig. 1 Chest radiograph showing a needle within the left ventricle (linear density within the red ellipse).
Zoom Image
Fig. 2 Axial computed tomography (CT) scan showing the needle (red arrow) that was not identified originally among the pancreatic calcifications.
Zoom Image
Fig. 3 Obliquely reformatted computed tomography (CT) images showing: a the needle extending through the duodenal wall; b the needle having moved to the epigastrium.
Zoom Image
Fig. 4 Further imaging shortly before and during removal of the needle. a A volume-rendered computed tomography (CT) angiogram showing the needle at the aortic bifurcation. b The needle was snared from above with balloon occlusion below. c The needle was snared from below and was removed through a sheath.