Extravascular Migration Research Articles

Massive chest tube output after congenital diaphragmatic hernia repair on extracorporeal membrane oxygenation

Peripherally inserted central catheter (PICC) lines are used routinely in neonates requiring prolonged drugs and parenteral nutrition and complications are usually infectious, mechanical, or thrombotic in nature. Spontaneous extravascular migration is extremely rare, and presentation with large volume chest tube output even rarer. We present a case involving a neonate on extracorporeal membrane oxygenation (ECMO) after congenital diaphragmatic hernia (CDH) repair and discuss management strategies.

Targeting the Urokinase-Type Plasminogen Activator Receptor (uPAR) in Human Diseases With a View to Non-invasive Imaging and Therapeutic Intervention.

The interaction between the serine protease urokinase-type plasminogen activator (uPA) and its glycolipid-anchored receptor (uPAR) focalizes plasminogen activation to cell surfaces, thereby regulating extravascular fibrinolysis, cell adhesion, and migration. uPAR belongs to the Ly6/uPAR (LU) gene superfamily and the high-affinity binding site for uPA is assembled by a dynamic association of its three consecutive LU domains. In most human solid cancers, uPAR is expressed at the invasive areas of the tumor-stromal microenvironment. High levels of uPAR in resected tumors or shed to the plasma of cancer patients are robustly associated with poor prognosis and increased risk of relapse and metastasis. Over the years, a plethora of different strategies to inhibit uPA and uPAR function have been designed and investigated in vitro and in vivo in mouse models, but so far none have been implemented in the clinics. In recent years, uPAR-targeting with the intent of cytotoxic eradication of uPAR-expressing cells have nonetheless gained increasing momentum. Another avenue that is currently being explored is non-invasive imaging with specific uPAR-targeted reporter-molecules containing positron emitting radionuclides or near-infrared (NIR) florescence probes with the overarching aim of being able to: (i) localize disease dissemination using positron emission tomography (PET) and (ii) assist fluorescence guided surgery using optical imaging. In this review, we will discuss these advancements with special emphasis on applications using a small 9-mer peptide antagonist that targets uPAR with high affinity.

Extravascular migration of a peripherally inserted central catheter into the retroperitoneum in a preterm infant

Extravasation or vascular erosion into the retroperitoneum is a rare complication of central venous lines in the neonate. We present a case of a premature infant with a history of stage III necrotizing enterocolitis and deep vein thrombus who experienced an acute deterioration while advancing on enteral nutrition post-operatively. Imaging revealed a large retroperitoneal fluid collection accompanied by hydronephrosis. The underlying cause was extravasation of parenteral nutrition from a lower extremity peripherally inserted central catheter. Lower extremity venous catheters, including peripherally inserted central cathers, carry a risk of complications. Whether abdominal surgery and venous thrombosis increases the risk of vascular erosion is an area for future investigation. • Extravascular migration of an established lower extremity peripherally inserted central catheter can cause an acute decompensation. • Removal of an extravascular central catheter is typically uncomplicated and therapeutic. • Infants with complex abdominal surgical histories may be at increased risk for lower extremity central line complications.

P004 PN-943, an oral α4β7 integrin antagonist, inhibits MAdCAM1-mediated proliferation and cytokine release from CD4+ T cells independent of trafficking

Abstract Background PN-943, an oral gastrointestinal (GI) -restricted peptide antagonist of α4β7 integrin, is being developed for the treatment of inflammatory bowel disease (IBD). Blockade of α4β7 binding to mucosal addressin cell adhesion molecule-1 (MAdCAM1) is thought to treat IBD by preventing extravascular migration of blood T cells into the inflamed GI mucosa. Recent evidence suggests the involvement of other mechanisms. Saturation of circulating T-cell α4β7 by vedolizumab is not sufficient for optimal efficacy; and PTG-100, a PN-943 analogue, showed evidence of clinical and histological remission in ulcerative colitis patients at sub-saturating blood receptor occupancy (%RO). Here, we assessed the potential of a local GI-acting function of α4β7 by evaluating the ability of PN-943 to inhibit MAdCAM1-mediated CD4+ T-cell proliferation and cytokine production. Methods Primary CD4+ T cells were labelled fluorescently and incubated with plate-bound anti-CD3 alone or together with MAdCAM1 with or without inhibitors for three days. Phenotype, distribution of T-helper (Th) subsets and %RO analyses were conducted by flow cytometry. Supernatant cytokine levels were quantified by multiplex assays. Results MAdCAM1 combined with anti-CD3 markedly enhanced proliferation of CD4+ T cells compared with anti-CD3 alone (n = 7, 12–64%). Immune phenotyping revealed that proliferation occurred in both CD45RO- naïve and CD45RO+ memory T cells and was restricted to the β7+ population with successive cycles of proliferation showing increased β7 expression. Amongst the proliferated memory T cells, the percentage of the IFNγ-producing Th1 subset was higher than IL-17A-producing Th17 and IL-4-producing Th2 subsets. Multiplex profiling identified several cytokines, including but not limited to IL-6, IL-13, GM-CSF, and TNFα, whose release were promoted by MAdCAM1. PN-943 abolished MAdCAM1-mediated stimulation (n = 4, IC50 4.6 nM). The inhibitory effects were associated with lowered β7 expression indicative of internalisation by PN-943. Blockade was not observed with an inactive analogue indicating dependency on PN-943 binding to α4β7. Consistent with the requirement for a locally acting drug, 30 mg/kg oral dosing in mice demonstrated high exposure (n = 6, 39 nM) and occupancy of T-cell α4β7 (n = 6, 92%) in the GI compared within the blood. Conclusion The α4β7-MAdCAM1 interaction promoted β7+CD4+ T-cell proliferation and cytokine release, which may contribute to chronic inflammatory responses occurring in the diseased gut of IBD patients independent of T-cell trafficking. PN-943 inhibition of MAdCAM1-mediated signalling through α4β7 supports the potential therapeutic advantages for an oral GI-restricted approach, whereby PN-943 is delivered locally and directly blocks α4β7 function in the GI.

Satellite in transit metastases in a case of loco‐regional metastatic conjunctival melanoma

AbstractPurposeTo report the clinical and histopathological findings of satellite in transit metastases in one case of conjunctival melanoma with cervical and parotid lymph node spreading.MethodsCase report of a patient initially examined at Institut Curie, Paris, on September 2018, with histopathological analysis, review of the literature and discussion.ResultsA 82 year‐old woman was referred for additional treatment after the removal of a 3mm thick pigmented infiltrating conjunctival melanoma in the temporal bulbar conjunctiva of the left eye. Proton beam irradiation was planned but finally declined by the patient. TEP‐CT was prescribed and revealed cervical and parotid lymph‐node infiltration, treated by external radiotherapy in another radiotherapy center. She was referred again 8 months later for local recurrences in the left conjunctiva. We observed 11 pigmented conjunctival nodules in the temporal and supero‐nasal quadrants. We surgically removed them and proton beam irradiation of the entire invaded area was planned. Histopathological analysis of some conjunctival nodules revealed well‐delimitated subepithelial nodules of melanoma cells. These nodules were extravascular and aligned along microvascular channels, suggesting angiotropism and extravascular migratory metastases.ConclusionAngiotropism and extravascular migration seem to be implicated in satellite in transit metastases in conjunctival melanoma. It has to be recognized as according to literature it could be a marker of rapid metastatic disease progression and death of the patient.

Angiotropism, pericytic mimicry and extravascular migratory metastasis: an embryogenesis-derived program of tumor spread.

Intravascular dissemination of tumor cells is the accepted mechanism of cancer metastasis. However, the phenomenon of angiotropism, pericyte mimicry (PM), and extravascular migratory metastasis (EVMM) has questioned the concept that tumor cells metastasize exclusively via circulation within vascular channels. This new paradigm of cancer spread and metastasis suggests that metastatic cells employ embryonic mechanisms for attachment to the abluminal surfaces of blood vessels (angiotropism) and spread via continuous migration, competing with and replacing pericytes, i.e., pericyte mimicry (PM). This is an entirely extravascular phenomenon (i.e., extravascular migratory metastasis or EVMM) without entry (intravasation) into vascular channels. PM and EVMM have mainly been studied in melanoma but also occur in other cancer types. PM and EVMM appear to be a reversion to an embryogenesis-derived program. There are many analogies between embryogenesis and cancer progression, including the important role of laminins, epithelial-mesenchymal transition, and the re-activation of embryonic signals by cancer cells. Furthermore, there is no circulation of blood during the first trimester of embryogenesis, despite the fact that there is extensive migration of cells to distant sites and formation of organs and tissues during this period. Embryonic migration therefore is a continuous extravascular migration as are PM and EVMM, supporting the concept that these embryonic migratory events appear to recur abnormally during the metastatic process. Finally, the perivascular location of tumor cells intrinsically links PM to vascular co-option. Taken together, these two new paradigms may greatly influence the development of new effective therapeutics for metastasis. In particular, targeting embryonic factors linked to migration that are detected during cancer metastasis may be particularly relevant to PM/EVMM.

P1.60: Hydrothorax following delayed extravascular migration of a totally implantable venous access device in a child

P1.60: Hydrothorax following delayed extravascular migration of a totally implantable venous access device in a child

A coil in the hair\u2014a case report of percutaneous coil migration

Coil migration following cerebral aneurysm treatment has been described and may result in stroke, recurrent aneurysm, or local mass effect. Cerebral coil embolization is also applied in arteriovenous malformations and arteriovenous fistulas, but these pathologies are relatively rare and coil migration is not as well described. Furthermore, these cases are more commonly treated with combinations of multiple modalities to achieve cure. Embolization, surgery, and radiation each have risks and benefits and combinations may have synergistic risks and benefits not seen in monotherapy. We report a case of extravascular and extra-corporeal coil migration after embolization and craniectomy to treat a patient with hemorrhage from an arteriovenous fistula.

Lithium + Colchicine: A Potential Strategy to Reduce Pro-inflammatory Effects of Lithium Treatment.

Rosenblat and McIntyre (Acta Psychiatr Scand. 2015;132: 180-191) propose that immune disorders are important mediators between bipolar disorders and medical comorbidities. Rosenblat et al (Bipolar Disord. 2016;18:89-101) present a meta-analysis showing that adjunctive anti-inflammatory agents could evoke moderate antidepressant responses in bipolar disorders. We propose using the anti-inflammatory drug colchicine to improve the long-term safety and efficacy of lithium treatment for bipolar disorders. This report is based on searches of the PubMed and Web of Science databases. Bipolar disorders are associated with significant medical comorbidities such as hypertension, overweight/obesity, diabetes mellitus, metabolic syndrome, and arteriosclerosis, accompanied by enhanced release of pro-inflammatory markers during changes in mood state. During lithium therapy, granulocyte-colony stimulating factor, CD34+ hematopoietic stem/progenitor cells, and neutrophil elastase enter the circulation with activated neutrophils to promote the extravascular migration of activated neutrophils and enhance tissue inflammation. Concurrent treatment with lithium and low-dose colchicine could facilitate the responsiveness of bipolar patients to lithium by reducing leukocyte tissue emigration, the release of neutrophil elastase, and the release of leukocyte pro-inflammatory cytokines such as IL-1β that are regulated by the NLRP3 inflammasome assembly complex. Concurrent therapy with lithium and low-dose colchicine could reduce complications involving leukocyte-mediated inflammatory states in bipolar patients and promote patient acceptance and responsiveness to lithium therapy.

A Rare Cause of a Gastric Ulcer: Extra Vascular Migration of the Splenic Artery Stent into the Posterior Gastric Wall

Introduction Intravascular stent migration and splenic artery occlusion are common complications seen after stent placement for splenic aneurysm. Here in we present a rare case caused by extra vascular migration of the splenic artery stent into the stomach. Case presentation 71 year- old male with history of gallstone pancreatitis complicated by splenic pseudoaneurysm status post IR guided splenic artery stent placement was referred for upper gastro intestinal endoscopy (EGD) evaluation for possible fistulous communication between stomach and splenic artery, due to presence of intra-luminal gas within the splenic artery stent on a CT Abdomen (Figure 1). Patient had an episode of severe necrotizing biliary pancreatitis 18 months prior to this presentation, with formation of walled off necrosis and underwent surgical necrosectomy with development of a splenic pseudoaneurysm for which IR guided splenic artery endovascular graft/stent was performed. The patient did not have any symptoms and his physical exam was unremarkable. His EGD evaluation showed a non-bleeding gastric ulcer with a visible eroded splenic artery stent at the lesser curvature of the stomach with a scar in the gastric body (Figure 2). The CT scan showed evidence of splenic artery thrombosis hence there was little concern for immediate bleeding. His medical history was also notable for recurrent deep vein thrombosis and he was on anti coagulation. It was felt that patient would be at risk for bleeding especially given his anticoagulation. After discussion with the patient, a plan was made to remove the stent surgically. Patient successfully underwent laparotomy, partial gastrectomy and splenic artery stent removal/ splenic artery ligation about 7 weeks post endoscopy.Figure: Transverse section of CT scan of abdomen and pelvis which showed intraluminal gas in the splenic artery.Figure: Upper endoscopy evaluation depicting the splenic artery stent eroding through the gastric wall along with scarring.Discussion The occurrence of pseudoaneurysm in the vascular system is most commonly observed in the splenic artery. Aneurysm greater than 2 centimeter have higher rate of rupture and should be treated. Endovascular treatment for aneurysms is found to be more than 70% effective. In this case the pseudoaneurysm was most likely caused secondary to the inflammation from pancreatitis. The theory for the migration of the stent is that the necrotizing pancreatitis requiring necrosectomy with the splenic abscess requiring drainage caused the inflammation which eventually led to scarring causing the migration of the splenic artery stent and its erosion extravascularly through the multiple anatomic layers between the stomach and splenic artery.

The biological and prognostic significance of angiotropism in uveal melanoma

Angiotropism is a marker of extravascular migration of melanoma cells along vascular and other structures and a prognostic factor in cutaneous melanoma. Because of this biological and prognostic importance in cutaneous melanoma, angiotropism was studied in uveal melanoma (UM). This retrospective study performed at a single ocular oncology referral center included 89 patients from the study period 2006–2008. All patients were diagnosed with UM from the choroid and/or ciliary body. All patients underwent enucleation for prognostic purposes and definitive therapy. Clinical, histopathological, and molecular variables included patient age, gender, extraocular extension, tumor location (ciliary body or not), optic nerve invasion, angiotropism, neurotropism, melanoma cell type, BAP1 mutation, and monosomy 3. Angiotropism was defined as melanoma cells arrayed along the abluminal vascular surfaces without intravasation in the sclera and/or episcleral tissue. The study included 51 women (57.3%) and 38 men with mean and median age: 63 years (range: 25–92). Mean follow-up was 4.4 years (range: 0.2 to 11). Fifty-three (59.6%) patients developed metastases and 48 (53.9%) were dead from metastases at last follow-up. Other principal variables recorded were angiotropism in 43.8%, extraocular extension in 7.9%, epithelioid/mixed cell type in 73.1%, BAP1 mutation in 41.3%, and monosomy 3 in 53.6% of cases. On multivariate analysis, extraocular extension, angiotropism, and monosomy 3 were predictive of metastasis, whereas tumor diameter, epithelioid cell type, angiotropism, and monosomy 3 were predictive of death. Chi-square test confirmed an association between angiotropism and metastasis and death but none with BAP1 mutation and monosomy 3. In conclusion, angiotropism and monosomy 3 were independent prognostic factors for both metastases and death in UM. However, irrespective of any prognostic value, the true importance of angiotropism is its biological significance as a marker of an alternative metastatic pathway.

Satellite in transit metastases in rapidly fatal conjunctival melanoma: implications for angiotropism and extravascular migratory metastasis (description of a murine model for conjunctival melanoma)

Little information is currently available concerning loco-regional metastases such as satellite and in transit metastases and their natural history in conjunctival melanoma as compared to cutaneous melanoma. Angiotropism, a marker of extravascular migration of melanoma cells along vascular channels, often appears responsible for microscopic satellite, satellite and in transit metastases development in cutaneous melanoma. In addition, diffuse tissue microscopic satellites are correlated with widespread melanoma dissemination and death. Herein we report rapid conjunctival melanoma progression and a fatal outcome in four of five patients following recurrence as satellite in transit metastases. Five patients aged 31, 60, 63, 56, and 67 years developed primary conjunctival melanoma, histologically characterised by tumour thicknesses of 4, 4, 1.1, 3, and 2mm. Two or more conjunctival melanomas manifested ulceration, significant mitotic rates, necrosis, angiotropism, and intralesional transformation. The conjunctival melanoma recurred in a matter of months as one or more discrete satellite in transit lesions in the vicinity of the primary melanoma. Histological examination revealed well-defined micronodules containing atypical melanocytes in the subepithelial connective tissue stroma. All lesions were extravascular and most appeared angiotropic. Four of five patients subsequently developed parotid or other loco-regional nodal disease and rapidly ensuing widespread metastases and death. The time course from diagnosis to the demise of the patients averaged about 13 (range 7-20) months. Our findings suggest that satellite in transit metastases constitute an important new risk marker for possible rapid metastatic disease progression and death in patients with conjunctival melanoma. This finding appears to take on even greater significance if such lesions develop rapidly, i.e., in a matter of weeks or months following diagnosis of primary conjunctival melanoma, and if the primary melanoma manifests additional high-risk features. Additional studies are underway in order to further elucidate the mechanism of these metastases.

Review of Pericytes in Tumor Biology

Pericytes are contractile cells that surround the endothelium of capillaries and venules throughout the body. Pericytes were once thought to have a limited role in blood pressure control and angiogenesis. Today, knowledge about pericytes and other perivascular stem cells has vastly expanded. The understanding of the biologic significance of pericytes was most changed by the recognition of the perivascular identity of mesenchymal stem cells. The following review article will summarize the known functions and importance of pericytes in particular relevance to tumor biology. These roles include: 1) pericytes as the potential cell of origin for multiple soft tissue tumors, 2) the role of pericyte in regulating tumor cell vascular invasion, and 3) angiotropism or ‘pericytic mimicry’ as a mechanism of malignant tumor spread. Although not discussed, the role of pericytes in pathophysiology far exceeds the realms of tumor biology, including cardiovascular atherosclerotic disease, chronic kidney disease, fibrotic repair processes, and fibroproliferative diseases. In summary, the known roles of pericytes in tumor formation, growth, and invasion have greatly expanded. These include pericytic differentiation in soft tissue tumors, regulation of vascular invasion in solid tumors, and extravascular migratory migration of common malignancies.

Angiotropism, pericytic mimicry and extravascular migratory metastasis in melanoma: an alternative to intravascular cancer dissemination.

For more than 15years, angiotropism in melanoma has been emphasized as a marker of extravascular migration of tumor cells along the abluminal vascular surface, unveiling an alternative mechanism of tumor spread distinct from intravascular dissemination. This mechanism has been termed extravascular migratory metastasis (EVMM). During EVMM, angiotropic tumor cells migrate in a 'pericytic-like' manner (pericytic mimicry) along the external surfaces of vascular channels, without intravasation. Through this pathway, melanoma cells may spread to nearby or more distant sites. Angiotropism is a prognostic factor predicting risk for metastasis in human melanoma, and a marker of EVMM in several experimental models. Importantly, analogies of EVMM and pericytic mimicry include neural crest cell migration, vasculogenesis and angiogenesis, and recent studies have suggested that the interaction between melanoma cells and the abluminal vascular surface induce differential expression of genes reminiscent of cancer migration and embryonic/stem cell state transitions. A recent work revealed that repetitive UV exposure of primary cutaneous melanomas in a genetically engineered mouse model promotes metastatic progression via angiotropism and migration along the abluminal vascular surface. Finally, recent data using imaging of melanoma cells in a murine model have shown the progression of tumor cells along the vascular surfaces. Taken together, these data provide support for the biological phenomenon of angiotropism and EVMM, which may open promising new strategies for reducing or preventing melanoma metastasis.

Late presenting, contained rupture of the superficial femoral artery following atherectomy and stenting: Case report and literature review

Excisional atherectomy alone or followed by stenting is considered an appropriate treatment strategy for patients with lifestyle-limiting claudication due to obstructive infra-inguinal peripheral arterial disease (Ramaiah et al., J Endovasc Ther 2006;13:592-6021). We present a case of a 69-year-old man with eccentric severely calcified disease of the superficial femoral artery (SFA) treated with excisional atherectomy followed by stenting with an interwoven nitinol stent. The procedure was complicated by extravascular stent migration associated with a contained rupture presenting 30 days after the intervention. The complication was successfully treated with a stent graft. Although rare, pseudoaneurysms have been reported at the site of prior atherectomy; however, this case is the first description of a contained rupture post atherectomy associated with erosion of a nitinol stent into an extra-luminal position. The mechanism and management of this complication are discussed.

Various applications of endoscopic scissors in difficult endoscopic interventions

Endoscopic scissors offer a benefit over other devices by avoiding potential complications related to thermal and mechanical injury of surrounding structures. We describe our experience with endoscopic scissors in three difficult endoscopic interventions. A fishbone embedded in the esophageal wall penetrated very close to the pulsating aorta and the bronchus. The fishbone was cut in half by endoscopic scissors and removed without injury to adjacent organs. A gastric submucosal tumor with an insulated core that could not be resected by electrosurgical devices was cut using endoscopic scissors following endoloop placement. Extravascular coil migration after transcatheter arterial embolization resulted in a duodenal ulcer. The metallic coil on the duodenal ulcer was cut by endoscopic scissors without mechanical or thermal injury.

Endothelial-expressed leukocyte-specific protein 1 regulates intravascular and extravascular directionality of chemotaxing neutrophils (P5094)

Abstract The endothelial-expressed Ca2+- and F-actin-binding leukocyte-specific protein 1 (LSP1) was shown to play a pivotal role in the regulation of endothelial transmigratory cup formation, microvascular permeability increases, and transendothelial migration of leukocytes. Due to the complexity of leukocyte-endothelial interactions, the cell-specific role of LSP1 is incompletely understood. To elucidate the orchestration of neutrophil dynamics by endothelial LSP1 in vivo, intravital microscopy and time-lapsed video analysis were performed in the microvasculature of cremaster muscle in LSP1-deficient chimeric mice. Absence of LSP1 (Lsp1−/−) in non-hematopoietic tissue resulted in significantly impaired chemotactic directionality (chemotaxis index) but not the neutrophil migration velocity during CXCL2-elicited intraluminal crawling and extravascular migration as compared to the responses in wild type (Lsp1+/+) endothelial cells. The velocity of migration of Lsp1−/− neutrophils in extravascular tissue was significantly lower in both Lsp1+/+ and Lsp1−/− chimeric mice as compared to that of Lsp1+/+ neutrophils in these mice. Analysis of integrin expression of transmigrated neutrophils from CXCL2-induced peritonitis in chimeric mice revealed blunted expression of α6 and β1 on neutrophils only in mice with Lsp1−/− endothelial cells. In conclusion, non-hematopoietic endothelial LSP1 is a novel regulator of neutrophil directionality during neutrophil recrutment.

Hydrothorax following delayed extravascular migration of a totally implantable venous access device in a child

Totally implantable venous access devices are widely used in pediatric oncology. The authors encountered a 10-year-old boy with implantation of the device at the age of 7 years owing to acute lymphoblastic leukemia. In the recent half-year, the device was not used except for regular heparin flushing. However, hydrothorax occurred when fluid therapy was required from the device during this admission. Thoracoscopic approach showed extravascular migration and intrapleural malposition of the catheter. Intrapleural migration of the extravascular portion of the catheter owing to irritation and pressure necrosis of the pleura and gradual shortening of intravascular portion of the catheter when the child grew up may be the pathogenesis of delayed extravascular migration of the catheter.

Coronary rupture and pseudoaneurysm formation after extravascular migration of a paclitaxel eluting stent implanted in the left circumflex coronary artery

As the implantation of drug eluting stents (DES) has become one of the most common clinical practices in interventional cardiology, the complications secondary to this procedure appear to have emerged increasingly over the past decade, with many cases of development of new coronary artery true aneurysms after DES implantation being reported. Here we present a case of coil embolization of a coronary pseudoaneurysm which presumably formed after extravascular migration of a DES.

Is it safe to cut pacing wires flush with the skin instead of removing them?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is safe to cut the temporary epicardial pacing wires (TEPWs) flush with the patient's skin surface prior to discharge. Altogether 105 relevant papers were identified of which 13 case reports represented the best evidence to answer the question. The author, journal, date, country of publication, complications, the culprit TEPW and relevant outcomes are tabulated. All case reports demonstrated a wide spectrum of complications. Complications from a retained TEPW mainly arise after a long dormant period. A recent case report has demonstrated the herniation of intra-abdominal contents through a diaphragmatic defect created by the abandoned epicardial pacing wires after a few decades. In multiple case reports, the migration of TEPW was the culprit of serious complications. In two case reports, the TEPWs attached to the right chambers of the heart had migrated to the pulmonary artery via the right atrium and then the right ventricle. In one case report, a similar migration of the right ventricular TEPW to the right ventricular outflow track was observed. The TEPW migration was not limited to the right side of the heart, as in one case report the right atrial TEPW had migrated to the right carotid artery via the ascending aorta. A distant extravascular migration of TEPWs to the skin surface and intraperitoneal and pelvic cavities has also been reported. Retained TEPWs have also been reported to inflict complications locally. One case report has shown a large right-sided para-cardiac mass caused by a right atrial TEPW. In two other case reports, the bronchocutaneous fistula, lobar consolidation and bronchiectasis were the manifestations of a retained TEPW. We conclude that the retention of TEPW after cardiac surgery is not necessarily safe and may cause severe complications. We recommend that TEPWs should be completely removed when possible. If TEPWs are retained, this should be appropriately documented and the surgeon should be mindful of this when the patient presents with complications postoperatively.