Ann Thorac Surg 2009;87:1937-1939. doi:10.1016/j.athoracsur.2008.10.069
© 2009 The Society of Thoracic Surgeons
Case Reports
Thoracoscopic Management of a Pericardial Migration of a Breast Biopsy Localization Wire
Fouad Azoury, MD*,
Paul Sayad, MD,
Andre Rizk, MD
Department of Cardiothoracic Surgery, Division of General Surgery, Division of Hematology-Oncology, American Hospital Dubai, Dubai, United Arab Emirates
Accepted for publication October 21, 2008.
* Address correspondence to Dr Azoury, Department of Cardiothoracic Surgery, American Hospital Dubai, Dubai, 5566, United Arab Emirates (Email: fazoury{at}hotmail.com).
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Abstract
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Intrathoracic migration of a breast biopsy localization wire is relatively rare and most of the wires end up in the pleural cavity. We report the first case of almost total intrapericardial migration of a monofilament hooked wire that was lost during the breast biopsy procedure. The case was successfully managed by video-assisted thoracoscopic surgery. Postulated mechanisms of migration of such wires are reviewed and a new mechanism is proposed.
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Introduction
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Migration of a breast biopsy localization wire remains relatively rare, despite its wide use. There are several reports of pleural migration with or without pneumothorax [1–3]. Other unusual destinations have also been reported, such as the neck muscles [4], gluteal region [5], and intra-abdominal [6]. We report the first case of an almost total intrapericardial migration of a monofilament hooked wire and its unique thoracoscopic management.
A 60-year-old woman underwent a left breast biopsy under needle localization for a mammographic suspicious nonpalpable density in the upper-inner quadrant. The breast lesion localization needle–wire used in this case (DHBL 22-9.0 [Cook Medical, Bloomington, IN]) consisted of a 22-gauge needle used for localization, through which a 25-gauge, 15-cm long monofilament wire with a distal hook was inserted and left in the breast as the needle was totally withdrawn. A specimen roentgenogram as routinely practiced, failed to show the suspicious density and the wire was in the specimen. Further review of the localization films showed evidence of geographical misplacement of the initial wire lateral to the mass. With the patient still under general anesthesia, another identical wire was inserted, but under ultrasound guidance this time, in the left breast at the 11:00 o'clock position. A second incision centered on the wire was performed and as the surgeon was undermining skin edges close, but not in contact with the wire, a spark was observed resulting in transection of a 7-cm proximal segment of the wire. The rest of the wire was unaccounted for despite the operative field search. Wide excision proceeded down to the pectoralis fascia with the assumption that the rest of the wire would be in the breast. The second specimen roentgenogram did show that the initial suspicious density was totally excised with sufficient margins, but there was no trace of the remaining wire. The patient was subsequently extubated and a recovery room portable chest roentgenogram did not show a pneumothorax or evidence of the wire. A noncontrast computed tomographic scan of the chest demonstrated a small left-sided pneumothorax and appeared to show that most of the remaining wire had penetrated the pericardium and was lying across the left ventricle. The most proximal aspect of the transected wire appeared to be embedded in the pleuro-pericardial fat (Fig 1). An emergent echocardiography ruled out the presence of hemopericardium and could not visualize the wire in relation to the cardiac chambers. A rapid fluoroscopic examination in the catheterization laboratory that is adjacent to the operating room distinctly showed the wire. Reviewing the fluoroscopy, we had our doubts that the wire could have penetrated the heart as the wire was moving freely and not in conjunction with each heart beat. Had the wire penetrated across the heart, one would expect the wire to move synchronously with it. In addition, the image on computed tomography, showing the wire across the left ventricle could certainly be explained by volume averaging.
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Fig 1. Computed tomographic scan of the chest showing the wire (white arrows) across the left ventricle.
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With full sternotomy and cardiopulmonary bypass capabilities as back-up, an initial thoracoscopic approach was selected. With the left chest elevated 30°, left-sided thoracoscopy was performed. Initial findings consisted of a small amount of hemothorax over the aortopulmonary window area, and no wire could be found at the initial search. Antero-medial lifting of the pericardial fat revealed the short extra-pericardial segment of the wire (Fig 2A). Before attempting retrieval, we created a safety pericardial window (Fig 2B). There was no hemopericardium found, which reinforced our suspicion of an extracardiac position of the wire. With that, the wire was grasped at its short extra-pericardial segment and gently retrieved with only a slight final resistance as the hooked tip straightened, as it was being pulled back across the pericardium (Fig 2C). No arrhythmia was noted. Several minutes of observation ensued with no evidence of blood in the pericardium. The patient made an uneventful recovery and was discharged home 48 hours later.
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Fig 2. Intraoperative thoracoscopic views: (A) extra-pericardial segment of wire partly in the pericardial fat (arrow); (B) pericardial window (circle); (C) wire as it was pulled out and the chest wall at the hematoma site of wire penetration (arrowhead). (W = wire.)
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Comment
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Inward migration of a monofilament hooked wire is a recognized pitfall of its design. Its hooked sharp tip could help prevent outward but not inward dislodgment, therefore some sort of proximal fixation to the skin or bending has been recommended. Factors that could contribute to a forward migration are contraction of the pectoralis muscle causing a ratcheting effect on the wire pulling it inward, the negative intrathoracic pressure that can further pull in the wire once it crosses the parietal pleura, and movement of the lung against the chest wall. This case is particular, as the second wire was inserted under general anesthesia, which is an uncommon scenario with specific implications. Muscular contractions could not have contributed to the migration. More so, no "pulling in" effect by the negative intrathoracic pressure could be responsible, as the patient was under positive mechanical ventilation with no spontaneous breathing reported by the anesthesiologist. The tip of the wire could have certainly been placed initially deep beyond the parietal pleura allowing it to be pulled in mechanically by the movement of the lung against the chest wall before formation of the pneumothorax. However, it is unlikely that such a mechanism could have created enough forward momentum for the wire to pierce the thick pleuro-pericardial fat pad and the pericardium. Although wire transection is easily explained by electrical-thermal energy from direct contact of the cautery with the wire or by formation of an electrical arc with it, it is the distant wire migration that remains enigmatic. We hypothesize in this particular case that the burst of energy released by fracture of the overheated wire resulted in propelling the distal long fragment across several layers, including the pericardium. Movement of the heart against the pericardium could have helped pull the wire further inward. This hypothesis remains purely speculative and difficult to validate.
Only one previous report of pericardial violation by a hook wire could be found after a literature search [7]. The clinical scenario and the radiologic pictures in that particular case point to a simple direct deep placement of the tip of the wire, which once recognized was pulled back in the intensive care unit rather than migration of a wire segment leading to an almost total intrapericardial location warranting surgical retrieval, as in our case.
Surprisingly, the thoracoscopic approach has been seldom pursued in reported cases of intrathoracic wire migration. After an extensive literature search, we found only one previous report of a thoracoscopic retrieval of an intrapleural wire [8], not an intrapericardial one. All other reported cases were managed by conventional thoracotomy.
Finally, this case illustrates the need to pursue "lost" wires and try to account for them, despite negative conventional chest roentgenogram. Recently, our radiology colleagues switched to using a thicker braided wire, less prone to transection and more readily detected by conventional radiography.
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Acknowledgments
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We would like to thank our graphic designer Mr Rabih Hourani for his valuable technical assistance in preparing the figures.
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References
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- Bristol JB, Jones PA. Transgression of localizing wire into the pleural cavity prior to mammography Br J Radiol 1981;54:139-140.[Abstract/Free Full Text]
- Banitalebi H, Skaane P. Migration of the breast biopsy localization wire to the pulmonary hilus Acta Radiol 2005;46:28-31.[Medline]
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- Owen AC, Nanda Kumar E. Migration of localizing wires used in guided biopsy of the breast Clin Rad 1991;43:251.[Medline]
- Grassi R, Romano S, Massimo M, Maglione M, Cusati B, Violini M. Unusual migration in abdomen of a wire for surgical localization of breast lesions Acta Radiol 2004;45:254-258.[Medline]
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- Van Susante JL, Barendregt WB, Bruggink ED. Migration of the guide-wire into the pleural cavity after needle localization of breast lesions Eur J Surg Oncol 1998;24:446-448.[Medline]
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Abstract
Introduction
