Novel Application of Ultrasound for Retrieval of Retained Pacing Wire

Multimodal imaging techniques are often used for the identification of retained pacing wires. While fluoroscopy is considered the gold standard for intraoperative removal, ultrasound guidance serves as a valuable alternative capable of identifying 90% of foreign bodies[1]. A 48-year-old man with a history of uncontrolled diabetes and coronary artery disease presented to the outpatient department with a one-month history of fever and chest pain. The patient had undergone coronary artery bypass surgery one year ago, followed by multiple sternal wound reexplorations and sinus tract excision, and removal of all six sternal wires. Sternal wound culture confirmed methicillin-resistant staphylococcal infection, and the patient was started on targeted antibiotic therapy. Vital signs were normal except for intermittent fever. Physical examination was also normal except for the presence of two ulcerating lesions near the lower sternal body. However, cardiac computed tomography revealed an unclear accumulation around the retained pacing wire in the right ventricle. [Figure 1a and b]. This wire was extending toward the apex, causing medullary sclerosis in the lower sternal body and overlying skin.Figure 1: (a) 3D Reconstruction of Retained Pacing Wire. Green arrow showing retained wire. (b) Computed Tomography guided depth assessment from skin to retained pacing wire. (c) Visualisation of Retained Pacing Wire with Real Time Ultrasound. (d) Retrieved epicardial pacing wireTo avoid surgical risks, a percutaneous extraction procedure was performed, with access made through the existing sternal wound. The procedure was conducted under general anesthesia using a laryngeal mask for airway management. With ultrasound guidance, the wire was successfully located and removed from the area near the ulcer, which had posed initial challenges in blind access. The wire was found approximately 1.2 cm below the surface. [Figure 1c and d] [Video 1]. The wound was then closed, and the patient’s recovery was unremarkable. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_rvwycpjx"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Temporary epicardial pacing wires are frequently inserted during cardiac surgeries. Usually, the epicardial wires are removed by 4–6th postoperative day when patient’s hemodynamics gets stabilized. Constant traction is given during its removal. If resistance is encountered during traction, wire is cut flushed with skin.[2] Although complications are rare, retained wires can migrate to aortic arch, left heart, right lung, etc., and can become the nidus for infections.[3] Blind reexploration is inefficient and often time-consuming. Dynamic ultrasound imaging shows a promising role as an alternative primary imaging technique in such conditions. Retained pacing wires can be located directly beneath the point, where the transducer meets skin in perpendicular orientation. Depth of retained wires can be measured in centimeters from the skin surface using ultrasound. Retained pacing wires typically appear as bright or white structures that disrupt the normal echo texture of surrounding soft tissues.[1] The technique has significant advantages in the form of easy accessibility, real-time structure tracking, shorter surgery duration, reduced surgical risks associated with a second median sternotomy, decreased anesthesia duration, and avoidance of ionizing radiation.[1] To conclude, dynamic ultrasound imaging holds a pivotal role as an alternate diagnostic imaging technique for minimally invasive surgeries. Declaration of patient’s consent A written informed consent was obtained from the patient and his family for publication of this article. This article adheres to the Enhancing the Quality and Transparency of Health Research (EQUATOR) guidelines. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.