063 - Intra-operative Decision Making for Needle Embolism After Intravenous Drug Use
Anthony Lemaire, MD – Faculty, Cardiothoracic Surgery, Rutgers Robert Wood Johnson University Hospital; Saum Rahimi, MD – Division Chief, Vascular Surgery, Rutgers Robert Wood Johnson University Hospital
Purpose: Nearly 1 million people have reported intravenous drug use (IVDU) in the past year, with a record high mortality of over 70,000 deaths in 2018 according to the Centers for Disease Control and Prevention (CDC). While there is a myriad of health impacts associated with IVDU, needle breakage has been reported in as high as 20% of subjects. When a needle breaks, the fragments can remain embedded in the soft tissues of the affected region, however, there is a rare chance of systemic embolization if the fragment escapes into the vascular system. Only 12 cases of needle fragment embolization to the heart have been reported from 1988 to 2019, leaving time-critical decision-making up to the experience of the surgeon with limited available literature. Our case describes a 32-year-old man with a history of intravenous drug abuse, with recent use at 3am on the day of admission, who reported using a 3-cm-long, 25-gauge needle to inject heroin into his right internal jugular vein which had broken off when he withdrew the syringe.
Material and Methods: The broken hypodermic needle was confirmed on preoperative axial imaging but was unable to be located during operative exploration. Intraoperative x-ray imaging was obtained to guide further exploration, and if embolization had occurred, to locate the fragments' new position. After failure to identify the fragment during exploration and intraoperative imaging, the procedure was aborted and formal postoperative cat (CT) scans were performed, which confirmed embolization of the fragment to the heart.
Results: Ultimately, the patient required a median sternotomy with cardiac bypass to successfully retrieve the fragment. The needle was specifically identified in the right atrium within the septal leaflet of the tricuspid valve. There was no injury to the leaflet and no resulting valvular pathology. He subsequently did well and was discharged home on postoperative day number 4.
Conclusions: The case report highlights the dangers of dislodged and migrating objects in the body. A 3-cm needle ultimately led to two surgical procedures for extraction. In conclusion, repeat imaging of the neck while in the operating room, but prior to incision, may have confirmed the location or possible embolization of the fragment and expedited evaluation by cardiothoracic surgery, potentially eliminating an exploration of the original injection site.