Intra-arterial migration of a fractured endoscopic needle.

A 53-year-old man with chronic pancreatitis presented with abdominal pain and sepsis. Imaging revealed a liver abscess secondary to distal biliary obstruction. Following drainage of his abscess, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) with placement of a fully covered metal biliary stent across a 2-cm suspicious shouldered and irregular low common bile duct stricture. A pancreatic head malignancy was suspected at ERCP and on computed tomography (CT) imaging. The regional specialist hepatobiliary multidisciplinary team (MDT) recommended endoscopic ultrasound with fine needle aspiration (EUS-FNA). EUS-FNA was difficult because of the changes of severe chronic calcific pancreatitis, duodenal stenosis, increased pancreatic head vascularity, and metal stent artefact. Five needle passes were made with a 22-gauge needle (Boston Scientific, Marlborough, Massachusetts, USA) using standard technique. Cytology was consistent with pancreatitis, with no evidence of malignancy. A routine chest radiograph 6 months later revealed a new linear density in the heart (▶Fig. 1). The interim abdominal CT imaging was re-reviewed (▶Fig. 2). Although not recognized at the time, owing to the highly calcified pancreas, it became clear that a fractured EUS-needle tip had migrated from the duodenal wall into the epigastrium (▶Fig. 3), then through the diaphragm and into the left ventricle. On a subsequent chest radiograph, the needle had disappeared and a further CT scan revealed that it had migrated to the aortic bifurcation (▶Fig. 4 a). The needle was retrieved endovascularly via bilateral common femoral artery access. It was first snared from above with a protective occlusion balloon placed below in the left iliac artery (▶Fig. 4b). The balloon was deflated, the needle was snared from below and was then removed through the left groin sheath (▶Fig. 4 c; ▶Video1). The patient made an uneventful recovery after the procedure. Endoscopic needle fracture has been previously described in the upper gastrointestinal tract [1, 2] and in a bronchoscopy setting [3]. Fractured metal sharps such as orthopedic fixation wires have been known to migrate into the arterial circulation, including into the heart [4]. This is the first known case of an endoscopic needle migrating intra-arterially.