Citation: Reyes J. Cool County Cases - You Found What Where?: A Discussion of Intravascular Foreign Bodies [Internet]. Cook County Emergency Medicine Residency;Available from: https://cookcountyem.com/blog/2023/9/8/cool-county-cases-you-found-what-where-discussion-of-intravascular-foreign-bodies
The Case:
The patient was a 27-year-old male with a past medical history of insulin-dependent type 1 diabetes and prior ICU hospitalization in 2006, presenting with one day of isolated right lower quadrant pain. He endorsed compliance with his insulin. The patient was afebrile with isolated tachycardia to 120 bpm without hypotension or other vital sign abnormalities. His exam was notable for McBurney’s point tenderness and left lower extremity varicose veins. The patient’s blood work was notable for hyperglycemia without ketosis or acidosis in addition to mild leukocytosis. A CT abdomen-pelvis was notable for uncomplicated appendicitis and was incidentally positive for intravascular foreign bodies within the inferior vena cava (Figure 2). A CXR was obtained after, noting foreign bodies of unspecified locations of the thorax but clinically conistent with SVC and IVC intravascular foreign bodies (Figure 1).
Figure 2. CT abdomen/pelvis with IV contrast positive for a perforated appendicitis and multiple intravascular foreign bodies located in the both the thoracic IVC and infrarenal IVC extending into the right internal iliac vein.
The patient was evaluated by general surgery, cardiothoracic surgery, and vascular surgery. Cardiothoracic surgery and vascular surgery opted for conservative management with watchful waiting given greater than a decade since initial foreign body insertion and given the patient was without evidence of complication. The patient was treated proceeded to have a laparoscopic appendectomy the following day, had his hyperglycemia managed, and was discharged. He followed up 3 weeks later and was stable without new vascular or cardiothoracic complications.
Discussion:
The patient’s case provides an example of a minimally symptomatic guidewire. Given the wire was asymptomatic, chronic in terms of its placement, and its being in a central position, the patient’s team elected to withhold retrieval of the object. The patient underwent an appendectomy, which was uncomplicated. The patient followed with vascular and continued experience mild symptoms in the right lower extremity which did not result in changes to the patient’s quality of life or significant harm.
This case serves as an example of approaches to intravascular foreign bodies. Initial evaluation should focus on evaluation of complications including ischemia, thrombosis, infection, or migration into adjacent structures which may result in a potentially fatal hemorrhage. If no complications are identified, the following step is evaluation by a vascular surgeon on an urgent basis if the patient stable and there is low risk for a complication which is dependent on the location of the foreign body. For example, a migrated IV catheter palpable in soft tissue is less likely to induce ischemia or significant migration as opposed to an embolization coil migrating which can result in a spontaneous and severe GI bleed.
After evaluation, vascular surgery will decide between endovascular retrieval or conservative management, with difficulty in foreign body retrieval, size of the foreign body, chronicity, and potential for complications all being considered [2, 3]. For the EM physician, it is important to know that these can be incidental and asymptomatic. In the symptomatic patient, emergent discussion with vascular surgery is merited after evaluating for complications. In the incidental identification of a vascular foreign body without signs of complication, urgent evaluation and conservative management can be considered.
Author: Jose Reyes, MD
Resources:
1. Rodrigues, R., et al., Endovascular Removal of Foreign Bodies. Rev Port Cir Cardiotorac Vasc, 2017. 24(3-4): p. 109.
2. Schechter, M.A., P.J. O'Brien, and M.W. Cox, Retrieval of iatrogenic intravascular foreign bodies. J Vasc Surg, 2013. 57(1): p. 276-81.
3. Wojda, T.R., et al. Foreign Intravascular Object Embolization and Migration: Bullets, Catheters, Wires, Stents, Filters, and More. 2017.