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Bronchoscopic extraction of a migrated endovascular coil
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  1. John Doan1,
  2. Kavya Puchhalapalli1,
  3. Parag J Patel2,3,
  4. Mario Gasparri4,
  5. Jonathan S Kurman5,
  6. Bryan S Benn5
  1. 1Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  2. 2Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  3. 3Department of Radiology, Division of Vascular & Interventional Radiology, Milwaukee, Wisconsin, USA
  4. 4Department of Thoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  5. 5Department of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
  1. Correspondence to John Doan, Medical College of Wisconsin, Milwaukee, WI 53226-0509, USA; jodoan{at}mcw.edu

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Case presentation

A 32-year-old man presented with a 3-week history of productive cough and intermittent haemoptysis. 14 months prior, he underwent tricuspid valve replacement, pacemaker insertion, and coil embolisation of bilateral mycotic aneurysms due to endocarditis complicated by pulmonary and septic emboli in the setting of intravenous drug use. Chest X-ray (CXR) revealed right middle lobe (RML) consolidation with a coil extending centrally into the trachea (figure 1A).

Figure 1

Chest x-ray showing (A) a migrated and uncoiled right middle lobe pulmonary pseudoaneurysm embolisation coil (red arrows). (B) Interval removal without residual coil in the airway immediately postprocedure, and (C) no further migration of remaining coils 7 weeks postprocedure.

He was evaluated by interventional radiology (IR) for management of the migrated coil and referred to interventional pulmonology (IP) and thoracic surgery. Multidisciplinary consensus was to proceed with bronchoscopic removal with thoracic surgery available to convert to a surgical approach in case of severe haemorrhage.

After general anaesthesia induction, the patient was intubated with a 12 mm outer diameter rigid bronchoscope (Lymol Medical, Woodburn, Massachusetts). Flexible bronchoscopy (BF-T190, Olympus Corporation, Japan) through the rigid bronchoscope showed the coil in the distal trachea (figure 2A) extending down to the RML lateral subsegment (figure 2B). No active bleeding or significant mucus was seen.

Figure 2

Bronchoscopic images of the uncoiled coil. (A) View in the distal trachea. (B) View of the right middle lobe lateral segment before and (C) after coil extraction. (D) Right middle lobe fifth generation bronchus with residual coil.

Phenylephrine 1:100 000 (0.1 μg/mL) was then instilled in the RML lateral segment and allowed to dwell for ~3 minutes to promote vasoconstriction. After ensuring end tidal oxygen was less than 40% in case urgent coagulation or electrocautery were needed, a grasping forceps (Radial Jaw 4 Forceps, Boston Scientific, Boston, Massachusetts) was used to remove the visible coil. No significant bleeding was seen after extracting 61 cm of coil (figure 2C). A slim bronchoscope (BF-P190, Olympus Corporation, Japan) with saline lavage was used for distal inspection, revealing an additional coil distal to the fifth generation bronchus (figure 2D). As this coil appeared well-seated, tightly coiled, and without surrounding haemorrhage, it was left in place with plans to closely monitor.

Intraoperative CXR confirmed migrated coil removal, absence of residual airway coil, and unchanged placement of the endovascular coils (figure 1B). The patient was discharged the same day in stable condition. At his follow-up visit ~7 weeks later, the patient reported no further haemoptysis with CXR showing stability of the remaining coils (figure 1C).

Discussion

Endobronchial coil migration is rare with only seven other case reports.1–5 Complications may be significant, including secondary infection, localised trauma, embolization, infarction and death. Most patients present with haemoptysis and cough, with two patients expectorating the coils. Chest imaging reveals migration usually into the mainstem bronchi. Management strategies include observation, coil retrieval with loop cutters, and surgical intervention including lobectomy and segmentectomy.

In our case, we employed minimally invasive IP techniques, including rigid bronchoscopy and forceps extraction, without needing other tools to fragment the coil, such as a loop cutter. We were able to extract the coil safely in one elongated, intact piece. We used a multidisciplinary team including IP, IR and thoracic surgery to develop a consensus plan beginning with a minimally invasive approach that could rapidly and safely escalate to a maximally invasive approach if needed. We suggest prioritising these discussions in future cases to avoid delays in communication, facilitate collaborative care, and ensure optimal patient outcomes.

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References

Footnotes

  • Contributors JD, KP and BSB were responsible for data collection and accuracy of data. All authors contributed to analysis of results, finalisation of the manuscript, and approval of the submitted article. JD, KP, and BSB conceived and wrote the manuscript. BSB takes responsibility for the integrity of the work as a whole. All authors read and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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