Article, Surgery

A foreign body in the blood vessel: A diagnostic and therapeutic dilemma

a b s t r a c t

Foreign body(FB) in soft tissue is a common injury in trauma, but it is rare for FB to enter the blood vessel. Typical causes of intravascular FB include iatrogenic and non-iatrogenic factors.A 65-year-old Chinese worker’s left hand was hit by two colliding metal blocks while operating a machine tool. Then, he referred to our hospital’s emer- gency department of orthopedics. The X-rays showed that metal FB could be seen in trapezium bone regions of the left hand. During the operation, the FB was found in the cephalic vein of his left hand, so the FB was re- moved by surgery. After six weeks of follow-up, he has returned to normal working conditions.The purpose of this article is to describe the diagnosis and treatment of a Rare condition in the emergency department. In our emergency work, it is easy to miss the diagnosis of intravascular FB caused by trauma. To our knowledge, this is the third reported intravascular FB caused by trauma and the first reported intravascular FB was located in the vein of the hand. Detailed medical history and auxiliary examinations are the key to the diagnosis of FB in the blood vessels.

(C) 2020

Introduction

The residual foreign body(FB) in the body after trauma is mostly in soft tissue and rarely in vasculature. Among the intravascular FB, intraarterial FB is more common than intravenous. Intraarterial FB is easy to cause limb necrosis, and intravenous FB is more likely to cause pulmonary embolism [[1]].Clinically, the main causes of intravascular FB are iatrogenic factors and non-iatrogenic factors. Iatrogenic FB is more common, most of which are fractures of catheters or cannulas into the vein [2]. In non-iatrogenic factors, the shrapnel scattered after the trauma enters the vein, which are easy to be confused with the soft tissue FB, so it is easy to be ignored by the clinician. Therefore, rapid diagnosis and surgical treatment are particularly important in clinical practice. Here, we systematically report a rare case of intrave- nous FB caused by trauma, which is unique.

Case report

A 65-year-old male went to the emergency department of orthope- dics on September 08, 2019.Patient’s left hand was bandaged with gauze,Exudation is obvious. The wound swelled slightly was been

? No conflict of interest exits in the submission of this manuscript, and manuscript is approved by all authors for publication.

* Corresponding author at: No. 678 Furong Road, Hefei, Anhui, China.

E-mail address: [email protected] (J. Jing).

1 These authors contributed equally to this study.

between the thumb and index after removing the gauze. The patient complained that he was injured by operating the machine tool 2 h be- fore admission. Two metal blocks collided and smashed to his left hand, and a large amount of blood was seen.The patient immediately pressed the wound to the local community clinic for treatment, then the doctor was debrided and bandaged. The patient went to our hospital for further treatment. Clinically, the patient had no discomfort except for a slight swelling and bleeding around the wound periphery. In order to confirm the diagnosis, patient performed left-hand posteroanterior and oblique X-rays, and the radiograph showed that metal FB could be seen in trapezium bone regions of the left hand (Fig. 1).Therefore, it is suspected that FB was inlaid on trapezium bone.The FB was planned to be removed by surgery. Preoperative twelve-lead ECG and chest x-ray were normal. After brachial plexus an- esthesia, the patient’s left upper limb was fixed with a tourniquet. After the disinfection, the original wound was slightly expanded to about 1 cm. The superficial fascia, deep fascia and muscle layer were cut layer by layer. Up to the surface of trapezium bone, no obvious FB remained. Then we used a C-arm machine to look for FB, and we can see that the FB moved slightly to the left wrist(Fig. 2). We repeatedly searched for FB in the soft tissue and constantly flushed the operation area. Finally, the abnormal head vein caught our attention, and a sub- stance was saw in the blood vessel which was not similar to a thrombus or sinus. We clamped the distal and proximal ends of the diseased blood vessel with a vascular clip, and another C-arm examination confirmed that the metal FB remained in the cephalic vein. After the blood vessel was ligated, the metal FB was removed. The size of the FB was

https://doi.org/10.1016/j.ajem.2020.04.047

0735-6757/(C) 2020

1697.e6 C. Meng et al. / American Journal of Emergency Medicine 38 (2020) 1697.e51697.e7

six months after surgery, the patient has returned to normal life and work.

Discussion

Fig. 1. Imaging examination before foreign body removal. X-rays demonstrating metal foreign body in trapezium bone area of left hand. The size of the FB was approximately:

3.4 x 2.4 mm. (Red arrow is a foreign body.)

approximately: 3.4 x 2.4 mm(Fig. 2). The entire process lasted for 1 h. The patient had no postoperative injuries and complications. A chest X-rays and a left-hand x-rays were performed the next day, and no ab- normalities were found(Fig. 3). The patient was discharged after anti- infection treatment for 3 days. During the follow-up period of nearly

This case provides a difficult and interesting point about the diagno- sis and treatment of this rare disease. Due to the concealment of the lo- cation of FB, it is easy to cause us to miss the diagnosis. Reviewing the literature, there are only two cases of intravascular FB caused by trauma. Gschwind [3] has reported two cases where FB was originally thought to be in the soft tissue of the forearm. In fact, the FB was present in the blood vessels of the forearm. One case remained in place and the other migrated to the right ventricle. Mingzhi Song [4] reported a case where the FB was originally found in the soft tissue of the left forearm, and the FB was found in the cephalic vein of the left forearm during sur- gery. Fortunately, FB migration was not found. Generally speaking, In- travascular FB caused by iatrogenic factors is more common, the common types of FB are needles [5], intravenous cannulas [6], guidewires [7], stents [8], and inferior vena cava fifilter [9]. It can be seen that the more common types of FB in blood vessels are iatrogenic, but non-iatrogenic FB in blood vessels is more easily ignored by us.

In terms of clinical symptoms, local symptoms are mainly pain and bleeding, but with the migration of FB in blood vessels, it can cause thrombophlebitis, sepsis, arrhythmia, myocardial damage, bacterial en- docarditis, vascular occlusion, ischemia and heart perforatione [10].For the auxiliary examination of FB in the body, it is relatively simple. We Usually take imaging examination (X-ray and CT), intravascular angiog- raphy and ultrasound examination. However, how to determine the presence of FB in the blood vessels is still a problem. For high-density FB, we often use its imaging examination to get a diagnosis. For low- density FB, only intravascular angiography and ultrasound can be used. However, how to determine whether the FB is located in the blood vessel is still a problem. Considering that the local bleeding at the time of injury is very helpful for our diagnosis, we need to inquire about the medical history in detail and combine relative auxiliary exam- inations to avoid the omission of FB in the blood vessel.

In terms of treatment, it is mainly divided into invasive treatment (surgery and Vascular intervention) and conservative treatment

Fig. 2. (a)C-arm examination shows foreign body moved to left wrist side during operation. (b)Photograph showing the retrieved foreign body post-operation.

C. Meng et al. / American Journal of Emergency Medicine 38 (2020) 1697.e51697.e7 1697.e7

Fig. 3. Postoperative X-rays demonstrating that the foreign body had been completely removed.

(based on patient selection). Fortunately, in this case, the FB only mi- grated slightly to the proximal end. After analyzing the advantages and disadvantages, we ligated and removed some of the cephalic vein. Generally, when FB stay at or near the injured area, we can usually de- tect and remove them by surgery.However, we can see that the FB in blood vessels is more likely to migrate when consulting the literature. In untreated cases, the incidence of death or serious complications is 60% to 71% [11,12].There are many clinical methods to remove the FB in blood vessels [10], such as Loop Snare, Proximal Grab Technique, Dis-

tal Wire Grab Technique, Coaxial Snare Technique, Lateral Grasp Tech- nique, Stone Retrieval Baskets/Dormia Baskets, Small Balloon Catheter Technique, Guide Wire Techniques, Guide Wire as a Snare, Hairpin Trap Technique, Two-wire Technique, Intravascular Retrieval Forceps, and Biliary or Myocardial Biopsy Forceps. Finally, in clinical practice, the judgment of a cardiothoracic surgeon is more important.

Clinical diagnosis of intravascular FB remains a tricky prospect and a challenging diagnosis.A high index of clinical suspicion is needed to de- tect the soft tissue foreign body caused by trauma and expedited treat- ment is required to ensure a favourable outcome.Although residual foreign bodies in the blood vessels are relatively rare but it can be en- countered clinically.The clinician should be aware of the possibility of intravascular FB.

Funding

Funding acquisition.

Ethical approval

Not needed.

Declaration of competing interest

The authors declare that there is no conflict of interest.

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