BACKGROUND: Migration of subdermal contraceptive devices is extremely rare. We successfully extracted an embolised contraceptive device in the right pulmonary artery via minimally invasive thoracoscopic approach.METHODS: A 22-year-old lady presented with frequent short duration chest pains. She underwent a contraceptive device implant in her left arm two years ago. Thorough investigations including fluoroscopy and computed tomography (CT) (A) revealed the migrated device in the right pulmonary artery distal to take off of the truncus anterior. Surgical approach was via right trans-axillary mini-thoracotomy (B) through the 4th intercostal space.
The patient was put in a slightly elevated left lateral position. The incision was made just lateral to the breast. The right main pulmonary artery was identified and truncus anterior was traced. Cardiopulmonary bypass was established via femoral access. Arteriotomy was performed over the right main PA. The device was heavily endothelialised making the extraction difficult. The device was removed in toto (C, E) and arteriotomy was closed. She made an uneventful recovery.
DISCUSSION:Subdermal contraceptive devices are generally implanted in the non-dominant upper arm. The chance of intravascular migration is approximately 1.3 per million implants. The embolization has to occur immediately around the time of implantation via the basilic vein to reach the pulmonary artery. Migration following a period after implantation is rare as fibrosis would have occurred around the device. Low BMI and placement along the sulcus between the biceps and triceps carries a risk of intravascular implantation. Interventional removal has been successful. However, it’s difficult once the device has endothelialised to the artery. A trans axillary approach (D) was planned to avoid sternotomy and its cosmetic implications. CONCLUSIONS:Implantation of these devices following exact guidelines would avoid embolization. Frequent self-palpation in the initial period helps in detection of missing devices. Once missed, extensive study with fluoroscopy and CT may help in early detection amenable to interventional removal. Complex surgery such as a minimally invasive thoracotomy with bypass is the last resort to explant these devices.
LEGEND: A: CT -device in right pulmonary artery B: Intraop C: Surgical removal D: Post op wound E: The device
