Percutaneous retrieval of a shard of metal from the right ventricular apex after an industrial accident.

A 29-year-old man suffered from an industrial accident as a piece of metal of a die-cutter burst and shards of metal penetrated his right upper arm. One shard was localized via x-ray and computer tomography within the apex of the right ventricle. Here we report on a successful retrieval of this shard of metal by aspirating it via a 6F multipurpose (MP) catheter.

Introduction

The field of cardiovascular interventions has experienced continuous technical progress in recent years. An increasing number of implantable or insertable devices have been developed with an increasing amount of implantations in patients. Therefore, the amount of devices lost or broken during procedures gains attention [1]. Several strategies for the retrieval of medical products from a patient are available [2]. We report on a case of a young adult who suffered from an industrial accident where a shard of metal got stuck in his right ventricle.

Case report

A 29-year-old man without medical history suffered from an industrial accident as a piece of metal of a die-cutter burst and shards of metal penetrated his right upper arm. In an external hospital most of the shards were removed by orthopedic surgeons. During this local operation one shard of metal penetrated into the brachial vein and got stuck—visualized by x-ray—in the subclavian vein. The patient was then initially admitted to our hospital for vascular surgery. In the x-ray of the right arm no shard of metal could be found, rather it was localized at the apex of the right ventricle (RV) with a chest x-ray (Fig.1A and B). To determine the exact position, we performed a computer tomography (CT) scan of the thorax, where the presumed position in the RV apex was confirmed (Fig. 2). We discussed the case in our heart-team, arguing for the alternatives to either leave the shard in place, to surgically operate on the patient, or to retrieve the shard with a forceps via a percutaneous approach. As the shard of metal had a diameter of only 3 × 5 mm the use of a snare system did not seem promising. Finally, we decided not to leave the unsterile piece of metal in its position, as it could potentially lead to pericardial effusion, arrhythmias, or inflammatory processes. In the next step we attempted to catch the shard with a flexible myocardial biopsy forceps (Cook Medical, Bloomington, IN, USA) via a jugular sheath (7F Ultimum, SJM). As the shard was stuck deep in the trabecular system of the right ventricle (Fig. 3) we were unable to get hold of it (Fig. 4). We accidentally touched the shard which moved it forward to the mid ventricle, where we still were unable to catch it. As the diameter was small and flat we decided to take a 6F multipurpose catheter (Medtronic, Minneapolis, MN, USA) with a 30-mL syringe and try to aspirate the shard of metal into the catheter. After a careful approach with the catheter, we finally succeeded in aspirating the shard into the syringe (Fig. 5). The shard of metal was already covered by a small layer of tissue (Fig. 6). Finally we removed the catheter and the sheath and excluded pericardial effusion via echocardiography. The patient was discharged the next day.

Figure 1

X-ray with the shard of metal in the right ventricular apex (green arrow). (A) Anterior-posterior view. (B) Lateral view.

Figure 2

Computer tomography with the shard of metal in the right ventricular apex (green arrow).

Figure 3

Fluoroscopy in right anterior oblique view showing the shard of metal (green arrow).

Figure 4

Fluoroscopy showing the flexible myocardial biopsy forceps close to the shard of metal (green arrow).

Figure 5

Fluoroscopy proving the location of the shard of metal in the syringe (green arrow).

Figure 6

Photography of the shard of metal in a container.

Discussion

Due to an increasing number of cardiac interventions, multiple cases of lost or broken devices or stents have been reported [1] and several strategies to retrieve these items have been developed such as employing forceps or snare systems [2], [3], [4]. Here we report on a successful retrieval of a shard of metal from the RV in a young patient. He was presented to us after a rare complication during removal of the penetrating shards from his arm when one shard moved into the venous system. We aspirated the foreign material with a 6F multipurpose catheter as the use of a forceps failed and the piece was too small for a snare system. In our opinion a transjugular percutaneous approach was the safest and best noninvasive way to get hold of the shard. Other options would have been an operation by thoracic surgery or else to leave the metal in place. Our concerns were that a sharp piece of metal, which was unsterile, could lead to pericardial effusion or other harm in the heart or lung. Inflammation or arrhythmias would have also been further possible complications. During the manufacturing process in which the industrial accident occured, the metal used is neither sterile nor heated (information obtained via personal communication with the patient). Of course, the probability of an infection occurring remains unclear. However, several studies and case reports refer to short- or long-term appearance of inflammation after exposure to foreign bodies. Lee et al. [5] report on a hepatic abscess after perforation of the stomach due to an ingested piece of metal wire. Brawanski et al. [6] report on a case of cerebral granuloma with seizures due to a metal-like foreign body where histopathological examination showed areas of acute granulocytic inflammatory reaction. Another neurosurgical manuscript reports a case of glioblastoma 37 years after injury with a metal splinter where histological examination showed a chronic abscess [7]. In ophthalmology, several cases regarding endophthalmitis after penetrating eye injury have been described [8]. Another study examined 159 patients from 1997 to 2009 who still retained foreign bodies from injuries sustained in World War II. They found long-term complications in 2% of the patients [9]. In our opinion these studies and reports show that there might have been a risk of inflammation during follow-up for the young patient if the shard was left in place.

In conclusion, our study reports a safe and successful way of retrieving a shard of metal from the right ventricle