Anchor Wire Localization Retained In Vivo for 9 Days Prior to Wedge Resection of a Ground-Glass Nodule a case report

Anchor Wire Localization Retained In Vivo for 9 Days Prior to Wedge Resection of a Ground-Glass Nodule a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Anchor Wire Localization Retained In Vivo for 9 Days Prior to Wedge Resection of a Ground-Glass Nodule a case report Chongyin Zhang, Dayong Deng, Xiaoning Gao, Libin Xu, Dingli Ye This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8776523/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract CT-guided lung nodule localization technique have matured significantly. It has now become the standard approach for preoperative localization of pulmonary nodules before thoracoscopic resection. To date, no instance of acute-onset arrhythmia following CT-guided lung nodule localization has been reported. And there is limited experience in managing such situations. We report the case of a 71-year-old man scheduled for thoracoscopic resection of a nodule in the left lower lobe. After preoperative CT-guided localization with a novel positioning needle, the patient experienced sudden cardiac arrhythmia. Antiarrhythmic and coronary vasodilator therapy was initiated first. After the patient returned to normal sinus rhythm, the anesthesiology team recommended canceling the immediate operation. The patient was transferred to the intensive care unit for close monitoring. Following nine days of comprehensive medical management and conditioning, a thoracoscopic wedge resection of the lung was performed. During surgery, the resection margin was determined based on the positioning of the anchor wire, resulting in wedge resection of the left lower lobe. The procedure proceeded smoothly, and the patient recovered well. This case report provides a reference for similar situations in the future. Anchor localization Glass nodule Paroxysmal ventricular tachycardia case report Figures Figure 1 Figure 2 Introduction CT-guided localization is being used increasingly in thoracoscopic pulmonary nodule resection. The technique is simple, minimally invasive, safe, and highly accurate, and it is now widely accepted. Nevertheless, unexpected events can occur. We report a recent case in which ventricular arrhythmia developed immediately after CT-guided placement of a novel localization needle prior to thoracoscopic nodule resection. Patient Information A 71-year-old male patient was admitted for surgical intervention after a follow-up examination one month ago revealed enlargement of a nodule in the left lower lobe, which was initially detected during a routine health checkup one year prior. The patient has a history of coronary atherosclerotic heart disease. Seventeen years ago, he underwent coronary stent placement (1 site in the left anterior descending artery) due to chest tightness and shortness of breath. Nine years ago, he experienced another episode and underwent additional coronary stent placement (2 sites in the right coronary artery). Postoperatively, he has been on long-term oral anticoagulation therapy with aspirin and rivaroxaban, along with oral statin therapy with rosuvastatin and beta-blocker bisoprolol, which he continues to this day. The patient has a history of type 2 diabetes mellitus, managed with oral dapagliflozin for glycemic control. His current fasting blood glucose is approximately 6.8 mmol/L, with postprandial 2-hour glucose levels fluctuating between 12-13 mmol/L. The patient also has a history of hypertension, managed with oral valsartan and amlodipine, achieving well-controlled blood pressure. On admission, the patient presented without chest tightness, dyspnea, cough, sputum production, hemoptysis, anterior chest or back pain, fever, or night sweats. Post-admission investigations revealed: ECG: Sinus bradycardia with mild ST-segment depression. Cardiac Doppler echocardiography: - Reduced left ventricular diastolic function - Mitral and tricuspid valve regurgitation. Chest CT scan with contrast revealed a ground-glass nodule in the medial basal segment of the left lower lobe (Figure 1.A), measuring approximately 1.3 cm in longest dimension, with slightly blurred margins, internal air cavities, and visible small vessels traversing the lesion. Abdominal color Doppler ultrasound demonstrated fatty liver. Lung cancer tumor markers and laboratory tests showed no significant abnormalities. Based on the results of all examinations, the following diagnoses are made: (1) High likelihood of lung cancer in the left lower lobe, (2) Coronary atherosclerotic heart disease, following coronary stent placement, (3) Arrhythmia - sinus bradycardia, heart function class 2, (4) Type 2 diabetes mellitus, (5) Hypertension stage 1, (6) Fatty liver. On this surgical admission, aspirin was withheld and anticoagulation was transitioned to subcutaneous nadroparin. After excluding contraindications and obtaining the patient's informed consent, the planned procedure involved percutaneous CT-guided anchor wire localization for lung nodule localization(Figure 1.B) followed by thoracoscopic wedge resection. The procedure was completed successfully. An immediate post-operative chest CT scan revealed no complications such as pneumothorax or bleeding. In the operating room, a double-lumen endotracheal tube was inserted, a urinary catheter was placed, and the patient was connected to continuous cardiac monitoring. The ECG revealed paroxysmal ventricular tachycardia. Antiarrhythmic and coronary vasodilator therapy was administered: intravenous injection of 0.1g lidocaine hydrochloride and 5mg sodium phosphate dexamethasone, and intravenous infusion of 150mg amiodarone hydrochloride and and 10 mg of isosorbide dinitrate. The patient subsequently recovered a normal sinus rhythm. After consultation with the anesthesiology team, the operation was cancelled. The patient was transferred to the intensive care unit (ICU) for continued observation. Upon ICU admission, the patient remained under anesthesia with adequate peripheral oxygenation. ECG monitoring showed sinus rhythm, and blood pressure and pulse were stable. After 1 hour and 10 minutes, the patient regained consciousness with effective coughing and sputum production. The endotracheal tube was removed, and high-flow oxygen therapy was initiated, maintaining good oxygen saturation. The patient's pain score was 3. Following ICU analgesia guidelines, remifentanil was selected for opioid analgesia and dexmedetomidine for sedation to mitigate stress response. Nutritional risk screening via the NRS-2002 assessment yielded a score of 2; the patient was encouraged to eat and nutritional support was intensified. The patient was classified as high risk for VTE (Padua score) among medical inpatients and received low molecular weight heparin for anticoagulation to prevent thrombosis, while maintaining fluid and electrolyte balance. On postoperative day 2, oral antiarrhythmic therapy was initiated under specialist guidance, along with prophylactic anti-inflammatory treatment and anti-coagulant/coronary dilation therapy. Postoperative day 5 Holter monitoring revealed paroxysmal complete left bundle branch block. The patient treated with isosorbide dinitrate for coronary dilation and resolved by postoperative day 6. A follow-up CT scan on postoperative day 8 suggested a high likelihood of nodular adenocarcinoma in the left lower lobe(Figure 1.C). The positioning guidewire remained adjacent to the lesion. Compared with the immediate postoperative CT, no significant displacement, pneumothorax, hemorrhagic changes, infection, or other abnormal findings were observed. The patient is in good condition. It was decided to perform a thoracoscopic wedge resection on the 9th day after positioning surgery. Sedation and acid suppression were administered the night before surgery to prevent stress ulcers, and the patient was kept fasting and abstaining from fluids on the day of surgery. Prophylactic antibiotics were administered 30 minutes prior to surgery. Defibrillation equipment was prepared during the procedure, and an ICU specialist participated throughout the surgery. Upon entering the operating room, the patient received combined intravenous anesthesia and successful double-lumen endotracheal intubation. Rapid pathology: Lung tissue shows consolidation, fibrous tissue proliferation, inflammatory cell infiltration, and alveolar epithelium with atypical hyperplasia, suggestive of adenocarcinoma. Primary surgical procedures completed. Postoperatively, the patient regained consciousness and was transferred to the ICU. Bedside monitoring revealed complete left bundle branch block. The patient received intravenous pump infusion of 30 mg isosorbide dinitrate for coronary vasodilation, intravenous infusion of 1 mg remifentanil plus 50 μg sufentanil for analgesia, and intravenous pump infusion of 0.2 mg dexmedetomidine for sedation to attenuate the stress response. On postoperative day 1, ECG showed complete left bundle branch block with occasional recovery to sinus rhythm. Chest X-ray revealed adequate left lung expansion. The left thoracic drainage tube is patent. Treatment continued with anti-inflammatory, expectorant, acid-suppressing, anticoagulant, and coronary vasodilator medications. The chest tube was removed on postoperative day 3. The patient reported no significant discomfort. A follow-up ECG showed restoration of sinus rhythm. The patient recovered well over the subsequent days with no major complications and was discharged on postoperative day 7. Pathology results: non-mucinous minimally invasive adenocarcinoma(Figure 1.D). Patient’s treatment timeline shown in Figure 2. Discussion With heightened public health awareness and the widespread adoption of low-dose computed tomography (LDCT), the detection rate of pulmonary nodules has significantly increased. Studies indicate that the detection rate of pulmonary nodules in China ranges from 9.6% to 79.79% [1,2] . According to the Chinese Expert Consensus on Multidisciplinary Minimally Invasive Diagnosis and Treatment of Pulmonary Nodules (2023) and the Chinese Guidelines for Lung Cancer Screening and Early Diagnosis and Treatment (2021) [3,4] , surgical intervention is recommended for high-risk pulmonary nodules or those suspected of being early-stage NSCLC. In patients whose thoracic and cardiovascular anatomy is normal and who have no operative contraindications, a minimally invasive approach—video-assisted thoracoscopic or robotic—should be considered whenever it can be performed without deviating from the therapeutic principles. Due to the high technical difficulty and cost of robotic surgery, widespread adoption remains challenging at present. Video-assisted thoracoscopic surgery (VATS) is currently the most widely used surgical approach for pulmonary nodules. Although associated with reduced surgical trauma and expedited convalescence, the technique is accompanied by inherent limitations. Nodule localization is excessively time-consuming. Because thoracoscopy cannot visualize and the surgeon’s finger cannot feel tiny nodules, particularly in single-port access. And to ensure complete resection, larger volumes of lung tissue are often removed which can compromise postoperative lung function. To overcome these limitations and achieve precise nodule resection while maximizing preservation of healthy lung tissue, preoperative localization techniques have emerged [5] . With the continuous advancement of localization technology and the ongoing innovation of localization needles, preoperative localization techniques for thoracoscopic lung nodule resection have become increasingly mature. CT-guided novel localization needles (i.e., anchor wire localization needles) offer advantages such as high safety, ease of operation, and fewer complications. After deployment within the lung, the four-pronged anchor claws securely grip adjacent lung tissue while simultaneously minimizing significant damage to surrounding lung tissue and small blood vessels. More importantly, the connected flexible suture can be advanced into the pleural cavity after placement. This prevents stress on the anchor claws caused by patient respiratory movements or position changes, effectively reducing the incidence of displacement [6,7,8] . Studies have demonstrated success rates ranging from 97.2% to 100% [9,10] . However, unexpected situations may arise in clinical practice. As illustrated in this case report, the patient experienced sudden ventricular tachycardia following CT-guided anchor wire-assisted lung nodule localization which has not been reported. We hypothesize this may be related to the interaction between vagus-sympathetic reflexes, acute hemodynamic changes, and underlying cardiac disease. First, this patient was elderly and had a history of coronary atherosclerotic heart disease and sinus bradycardia. Additionally, intercostal nerve injury during the biopsy procedure may have disrupted sympathetic-vagal balance, triggering ventricular tachycardia. Furthermore, anxiety and tension related to the procedure could have contributed to the arrhythmia. Following the onset of ventricular tachycardia, we immediately administered 150 mg of amiodarone intravenously followed by a 1 mg/min infusion to correct the arrhythmia. After consultation with the anesthesiologist, we decided to terminate the procedure. We planned to reassess the patient and resume surgery once the arrhythmia was corrected and hemodynamics stabilized. Another significant concern at the time was that the patient had already undergone preoperative localization, with the anchor wire in place. Prolonged placement carried risks of wire displacement, pulmonary infection, and bleeding. Therefore, we administered analgesia, sedation, and prophylactic antimicrobial therapy, while maintaining continuous ECG monitoring and closely observing the patient's condition. Fortunately, a follow-up plain chest CT scan on the 8th day post-placement showed no anchor wire displacement, pulmonary infection, or hemorrhage. Reassessment revealed no significant contraindications for surgery, and the patient underwent thoracoscopic wedge resection of the lung. The procedure was uneventful, and the patient recovered well postoperatively with good lung expansion. Postoperatively, the patient developed complete left bundle branch block. Isosorbide dinitrate was administered for coronary vasodilation. By postoperative day 3, the ECG showed restoration of sinus rhythm. The patient was discharged on postoperative day 7. Therefore, when arrhythmia occurs during CT-guided lung nodule localization, our primary task is to terminate the procedure and correct the patient's arrhythmia. Subsequently, stress-response attenuation, prophylactic anticoagulation, and antimicrobial therapy were then instituted. For the new anchor wire localization needle, its position within the lung is relatively stable, with a low probability of displacement within a short timeframe. Research by Hao Zhang et al. indicates that the displacement rate of localization needles after anchor wire-guided lung nodule localization is 0% [11,12,13] . However, all patients in their series underwent thoracoscopic surgery within 6 h after localization. Cases in which the anchor-wire marker remained in situ for as long as 9 days, as described herein, have never been reported. Postoperative ambulatory ECG monitoring is recommended for patients with a history of cardiovascular disease. If arrhythmia is detected, targeted anti-arrhythmic therapy should be initiated. For patients requiring elective surgery due to unexpected complications after localization, prophylactic anti-infective therapy is advised. Prior to elective thoracoscopic surgery, a repeat chest CT scan should be performed to confirm wire placement and assess for pulmonary infection, hemorrhage, pleural effusion, or hemothorax. This case report describes a patient who developed acute arrhythmia immediately after CT-guided anchor-wire localization of a pulmonary nodule. The relevant management process is described in detail. We hope it provides useful guidance and reference for clinical practice. Declarations Ethics Statement : Written informed consent was obtained from all the paticipants prior for the publication of this case report. Consent Statement : Consent for publication was obtained from the participants. The patient has written informed consent for their personal or clinical details along with any identifying images to be published in this study. Conflict-of-interest statement : There are no conflicts of interest in this study. Author contribution statement : Zhang and Deng participated in the conception of the article. Zhang, Deng, Xu and Ye collected relevant data. Zhang and Gao contributed to drafting the manuscript. Deng revised it critically for important intellectual content. Data availablity statement :The data that support the findings of this study are available from the corresponding author upon reasonable request. Acknowledgement ：We express our gratitude to Lei Yang for his guidance in the research approach and assistance in daily work. Clinical trial number: not applicable. References Xu GH, Huang HX, Chen B, et al. A study on the first chest low-dose CT screening and susceptible factors of pulmonary nodules in 23 695 physical examinees in a medical examination center. Fudan Univ J Med Sci. 2020;47(5):654–659668. 10.3969/j.issn.1672-8467.2020.05.003 . Ting T, Jing L, Wei Z et al. Associations of systemic inflammation markers with identificationof pulmonary nodule and incident lung cancer in Chinese population.[J]. Cancermedicine,2022,11(12). Lung Cancer Medical Education Committee of China Medical Education Association. Chinese experts consensus on multidisciplinary minimally invasive diagnosis and treatment of pulmonary nodules [J/OL]. Chin J Clin Thorac Cardiovasc Surg 2023:1–14. 10.7507/1007-4848.202306006http: //kns.cnki.net/kcms/detail/51.1492.r.20230705.1321.030.html He J, Li N, Chen WQ, et al. China Guideline for the Screening and Early Detection of Lung Cancer (2021, Beijing). China Cancer. 2021;30(2):81–111. 10.11735/j.issn.1004-0242.2021.02.A001 . Expert consensus on preoperative adjunctive localization techniques for small pulmonary nodules. (2019 edition). Chinese Journal of Clinical Thoracic and Cardiovascular Surgery. 2019;26(2):109–113. 10.7507/1007-4848.201812072 Fan L, Yang H, Yu L, Wang Z, Ye J, Zhao Y, Cai D, Zhao H, Yao F. Multicenter, prospective, observational study of a novel technique for preoperative pulmonary nodule localization. J Thorac Cardiovasc Surg. 2020;160(2):532–e5392. 10.1016/j.jtcvs.2019.10.148 . Epub 2019 Nov 14. PMID: 31866078. Mayo JR, Clifton JC, Powell TI, English JC, Evans KG, Yee J, McWilliams AM, Lam SC, Finley RJ. Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection. Radiology. 2009;250(2):576 – 85. 10.1148/radiol.2502080442 . PMID: 19188326. Meng Q, Wang J, Wang X, Sun Q. Preoperative computed tomography-guided localization for pulmonary nodules: a systematic review and meta-analysis of soft hook-wire and coil localization. Quant Imaging Med Surg. 2025;15(8):6705–12. 10.21037/qims-2025-56 . Epub 2025 Jul 25. PMID: 40785912; PMCID: PMC12332689. Guo JX, Zhang H, Xiao WQ et al. Preliminary study of preoperative needle localization of pulmonary nodules. Diagn Imaging Interv Radiol. 2020;29(5):349–355. DOI: 10.3969 ༏ j.issn.1005-8001.2020.05.006. Zhang H, Guo JX, Xiao WQ et al. Mid-term study of CT-guided needle localization of pulmonary nodule before video-assisted thoracoscopic excision surgery. Diagn Imaging Interv Radiol. 2021;30(5):364–370. DOI: 10.3969 ༏ j.issn.1005-8001.2021.05.008. Liu D, Zhang R, Yu X, Liao L, Shi S, Chen L. Comparison of two methods for CT-guided pulmonary nodule location before thoracoscopic surgery. Wideochir Inne Tech Maloinwazyjne. 2023;18(4):680–9. 10.5114/wiitm.2023.133073 . Epub 2023 Nov 20. PMID: 38239574; PMCID: PMC10793156. Wang Y, Jing L, Liang C, Liu J, Wang S, Wang G. Comparison of the safety and effectiveness of the four-hook needle and hook wire for the preoperative positioning of localization ground glass nodules. J Cardiothorac Surg. 2024;19(1):35. 10.1186/s13019-024-02497-1 . PMID: 38297385; PMCID: PMC10829251. Zhang H, Zhang C, Li L, Qi J, Yang GH, Li YQ, Gong CQ. Small pulmonary nodule localization techniques in the era of lung cancer screening: a narrative review. Int J Surg. 2025;111(3):2624–32. PMID: 39869367; PMCID: PMC12372730. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8776523","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":590605617,"identity":"fc8a635f-39f5-4907-a9a7-a0abf92f2b4b","order_by":0,"name":"Chongyin Zhang","email":"","orcid":"","institution":"Jilin Cancer Hospital(high-tech zone campus)","correspondingAuthor":false,"prefix":"","firstName":"Chongyin","middleName":"","lastName":"Zhang","suffix":""},{"id":590605620,"identity":"7fb026b1-8c31-465a-9a23-0162af22f939","order_by":1,"name":"Dayong Deng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBACeWbmA4d//vvPzM/eQKQWw/a2xMMMbMzskj0HiLXmzBljkBZ+gxsJROpgnJFjcLiAh02a4ebjjTcYamyiCWphl0grODxDgseYcXZasQXDsbTcBsK2JG84wGMgkcwsnWMmwdhwmLAWhhsJBgd4Egzq2yTPEKvlzBGDwzwHEph5JHiI1AIM5ISDMxsOMEvwAP2SQIxfgFF5+MNHoBb744c33vhQY0OEw5CAgUQCKcohWkjVMQpGwSgYBSMDAADTL0D9BQdbWwAAAABJRU5ErkJggg==","orcid":"","institution":"Jilin Cancer Hospital(high-tech zone campus)","correspondingAuthor":true,"prefix":"","firstName":"Dayong","middleName":"","lastName":"Deng","suffix":""},{"id":590605621,"identity":"459bc563-f86e-402a-a587-f70b54900e2a","order_by":2,"name":"Xiaoning Gao","email":"","orcid":"","institution":"Jilin Cancer Hospital(Huguang campus)","correspondingAuthor":false,"prefix":"","firstName":"Xiaoning","middleName":"","lastName":"Gao","suffix":""},{"id":590605622,"identity":"d446d240-8aec-4018-9009-6e9dd66fb608","order_by":3,"name":"Libin Xu","email":"","orcid":"","institution":"Jilin Cancer Hospital(high-tech zone campus)","correspondingAuthor":false,"prefix":"","firstName":"Libin","middleName":"","lastName":"Xu","suffix":""},{"id":590605623,"identity":"e46c265d-fa8e-4221-a6e9-41bac2836e26","order_by":4,"name":"Dingli Ye","email":"","orcid":"","institution":"Jilin Cancer Hospital(high-tech zone campus)","correspondingAuthor":false,"prefix":"","firstName":"Dingli","middleName":"","lastName":"Ye","suffix":""}],"badges":[],"createdAt":"2026-02-03 13:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8776523/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8776523/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103001452,"identity":"1cc2697a-59e5-41a1-9935-dcd126d195ff","added_by":"auto","created_at":"2026-02-19 13:42:47","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":635424,"visible":true,"origin":"","legend":"\u003cp\u003ePatient CT images and pathology: A. CT image before localization: A ground-glass nodule is observed in the lower lobe of the left lung. B. CT image during the CT-guided localization: The positioning hook is located at the edge of the lesion, and the distance from the lesion is less than 1cm (the red arrow points to the localization hook). C. CT image before resection: The localization hook did not show any displacement, and no pneumothorax, hemorrhage, or infection was observed in the lung. D. Postoperative pathological image of patient D (HE × 200): non-mucinous minimally invasive adenocarcinoma.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8776523/v1/49e8e894ba48d46bf6a348a4.png"},{"id":103001453,"identity":"29c80917-064b-404e-953f-e43500cea94b","added_by":"auto","created_at":"2026-02-19 13:42:47","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":166183,"visible":true,"origin":"","legend":"\u003cp\u003ePatient’s treatment timeline\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8776523/v1/c200c10db026c4bc28fe9113.png"},{"id":108182305,"identity":"37787dad-a846-49da-9ea0-1b597773866c","added_by":"auto","created_at":"2026-04-30 08:59:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":932240,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8776523/v1/29377f27-3938-4921-88bc-d30b39059b9b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anchor Wire Localization Retained In Vivo for 9 Days Prior to Wedge Resection of a Ground-Glass Nodule a case report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCT-guided localization is being used increasingly in thoracoscopic pulmonary nodule resection. The technique is simple, minimally invasive, safe, and highly accurate, and it is now widely accepted. Nevertheless, unexpected events can occur. We report a recent case in which ventricular arrhythmia developed immediately after CT-guided placement of a novel localization needle prior to thoracoscopic nodule resection.\u003c/p\u003e"},{"header":"Patient Information","content":"\u003cp\u003eA 71-year-old male patient was admitted for surgical intervention after a follow-up examination one month ago revealed enlargement of a nodule in the left lower lobe, which was initially detected during a routine health checkup one year prior. The patient has a history of coronary atherosclerotic heart disease. Seventeen years ago, he underwent coronary stent placement (1 site in the left anterior descending artery) due to chest tightness and shortness of breath. Nine years ago, he experienced another episode and underwent additional coronary stent placement (2 sites in the right coronary artery). Postoperatively, he has been on long-term oral anticoagulation therapy with aspirin and rivaroxaban, along with oral statin therapy with rosuvastatin and beta-blocker bisoprolol, which he continues to this day. The patient has a history of type 2 diabetes mellitus, managed with oral dapagliflozin for glycemic control. His current fasting blood glucose is approximately 6.8 mmol/L, with postprandial 2-hour glucose levels fluctuating between 12-13 mmol/L. The patient also has a history of hypertension, managed with oral valsartan and amlodipine, achieving well-controlled blood pressure. On admission, the patient presented without chest tightness, dyspnea, cough, sputum production, hemoptysis, anterior chest or back pain, fever, or night sweats. Post-admission investigations revealed: ECG: Sinus bradycardia with mild ST-segment depression. Cardiac Doppler echocardiography: - Reduced left ventricular diastolic function - Mitral and tricuspid valve regurgitation. Chest CT scan with contrast revealed a ground-glass nodule in the medial basal segment of the left lower lobe (Figure 1.A), measuring approximately 1.3 cm in longest dimension, with slightly blurred margins, internal air cavities, and visible small vessels traversing the lesion. Abdominal color Doppler ultrasound demonstrated fatty liver. Lung cancer tumor markers and laboratory tests showed no significant abnormalities. Based on the results of all examinations, the following diagnoses are made: (1) High likelihood of lung cancer in the left lower lobe, (2) Coronary atherosclerotic heart disease, following coronary stent placement, (3) Arrhythmia - sinus bradycardia, heart function class 2, (4) Type 2 diabetes mellitus, (5) Hypertension stage 1, (6) Fatty liver. On this surgical admission, aspirin was withheld and anticoagulation was transitioned to subcutaneous nadroparin. After excluding contraindications and obtaining the patient\u0026apos;s informed consent, the planned procedure involved percutaneous CT-guided anchor wire localization for lung nodule localization(Figure 1.B) followed by thoracoscopic wedge resection. The procedure was completed successfully. An immediate post-operative chest CT scan revealed no complications such as pneumothorax or bleeding. In the operating room, a double-lumen endotracheal tube was inserted, a urinary catheter was placed, and the patient was connected to continuous cardiac monitoring. The ECG revealed paroxysmal ventricular tachycardia. Antiarrhythmic and coronary vasodilator therapy was administered: intravenous injection of 0.1g lidocaine hydrochloride and 5mg sodium phosphate dexamethasone, and intravenous infusion of 150mg amiodarone hydrochloride and and 10 mg of isosorbide dinitrate. The patient subsequently recovered a normal sinus rhythm. After consultation with the anesthesiology team, the operation was cancelled. The patient was transferred to the intensive care unit (ICU) for continued observation. Upon ICU admission, the patient remained under anesthesia with adequate peripheral oxygenation. ECG monitoring showed sinus rhythm, and blood pressure and pulse were stable. After 1 hour and 10 minutes, the patient regained consciousness with effective coughing and sputum production. The endotracheal tube was removed, and high-flow oxygen therapy was initiated, maintaining good oxygen saturation. The patient\u0026apos;s pain score was 3. Following ICU analgesia guidelines, remifentanil was selected for opioid analgesia and dexmedetomidine for sedation to mitigate stress response. Nutritional risk screening via the NRS-2002 assessment yielded a score of 2; the patient was encouraged to eat and nutritional support was intensified. The patient was classified as high risk for VTE (Padua score) among medical inpatients and received low molecular weight heparin for anticoagulation to prevent thrombosis, while maintaining fluid and electrolyte balance. On postoperative day 2, oral antiarrhythmic therapy was initiated under specialist guidance, along with prophylactic anti-inflammatory treatment and anti-coagulant/coronary dilation therapy. Postoperative day 5 Holter monitoring revealed paroxysmal complete left bundle branch block. The patient treated with isosorbide dinitrate for coronary dilation and resolved by postoperative day 6. A follow-up CT scan on postoperative day 8 suggested a high likelihood of nodular adenocarcinoma in the left lower lobe(Figure 1.C). The positioning guidewire remained adjacent to the lesion. Compared with the immediate postoperative CT, no significant displacement, pneumothorax, hemorrhagic changes, infection, or other abnormal findings were observed. The patient is in good condition. It was decided to perform a thoracoscopic wedge resection on the 9th day after positioning surgery. Sedation and acid suppression were administered the night before surgery to prevent stress ulcers, and the patient was kept fasting and abstaining from fluids on the day of surgery. Prophylactic antibiotics were administered 30 minutes prior to surgery. Defibrillation equipment was prepared during the procedure, and an ICU specialist participated throughout the surgery. Upon entering the operating room, the patient received combined intravenous anesthesia and successful double-lumen endotracheal intubation. Rapid pathology: Lung tissue shows consolidation, fibrous tissue proliferation, inflammatory cell infiltration, and alveolar epithelium with atypical hyperplasia, suggestive of adenocarcinoma. Primary surgical procedures completed. Postoperatively, the patient regained consciousness and was transferred to the ICU. Bedside monitoring revealed complete left bundle branch block. The patient received intravenous pump infusion of 30 mg isosorbide dinitrate for coronary vasodilation, intravenous infusion of 1 mg remifentanil plus 50 \u0026mu;g sufentanil for analgesia, and intravenous pump infusion of 0.2 mg dexmedetomidine for sedation to attenuate the stress response. On postoperative day 1, ECG showed complete left bundle branch block with occasional recovery to sinus rhythm. Chest X-ray revealed adequate left lung expansion. The left thoracic drainage tube is patent. Treatment continued with anti-inflammatory, expectorant, acid-suppressing, anticoagulant, and coronary vasodilator medications. The chest tube was removed on postoperative day 3. The patient reported no significant discomfort. A follow-up ECG showed restoration of sinus rhythm. The patient recovered well over the subsequent days with no major complications and was discharged on postoperative day 7. Pathology results: non-mucinous minimally invasive adenocarcinoma(Figure 1.D). Patient\u0026rsquo;s treatment timeline shown in Figure 2.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWith heightened public health awareness and the widespread adoption of low-dose computed tomography (LDCT), the detection rate of pulmonary nodules has significantly increased. Studies indicate that the detection rate of pulmonary nodules in China ranges from 9.6% to 79.79% \u003csup\u003e[1,2]\u003c/sup\u003e. According to the Chinese Expert Consensus on Multidisciplinary Minimally Invasive Diagnosis and Treatment of Pulmonary Nodules (2023) and the Chinese Guidelines for Lung Cancer Screening and Early Diagnosis and Treatment (2021)\u003csup\u003e\u0026nbsp;[3,4]\u003c/sup\u003e, surgical intervention is recommended for high-risk pulmonary nodules or those suspected of being early-stage NSCLC. In patients whose thoracic and cardiovascular anatomy is normal and who have no operative contraindications, a minimally invasive approach—video-assisted thoracoscopic or robotic—should be considered whenever it can be performed without deviating from the therapeutic principles. Due to the high technical difficulty and cost of robotic surgery, widespread adoption remains challenging at present. Video-assisted thoracoscopic surgery (VATS) is currently the most widely used surgical approach for pulmonary nodules. Although associated with reduced surgical trauma and expedited convalescence, the technique is accompanied by inherent limitations. Nodule localization is excessively time-consuming. Because thoracoscopy cannot visualize and the surgeon’s finger cannot feel tiny nodules, particularly in single-port access. And to ensure complete resection, larger volumes of lung tissue are often removed which can compromise postoperative lung function. To overcome these limitations and achieve precise nodule resection while maximizing preservation of healthy lung tissue, preoperative localization techniques have emerged\u003csup\u003e[5]\u003c/sup\u003e.\u0026nbsp;With the continuous advancement of localization technology and the ongoing innovation of localization needles, preoperative localization techniques for thoracoscopic lung nodule resection have become increasingly mature. CT-guided novel localization needles (i.e., anchor wire localization needles) offer advantages such as high safety, ease of operation, and fewer complications. After deployment within the lung, the four-pronged anchor claws securely grip adjacent lung tissue while simultaneously minimizing significant damage to surrounding lung tissue and small blood vessels. More importantly, the connected flexible suture can be advanced into the pleural cavity after placement. This prevents stress on the anchor claws caused by patient respiratory movements or position changes, effectively reducing the incidence of displacement \u003csup\u003e[6,7,8]\u003c/sup\u003e. Studies have demonstrated success rates ranging from 97.2% to 100% \u003csup\u003e[9,10]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eHowever, unexpected situations may arise in clinical practice. As illustrated in this case report, the patient experienced sudden ventricular tachycardia following CT-guided anchor wire-assisted lung nodule localization which has not been reported. We hypothesize this may be related to the interaction between vagus-sympathetic reflexes, acute hemodynamic changes, and underlying cardiac disease. First, this patient was elderly and had a history of coronary atherosclerotic heart disease and sinus bradycardia. Additionally, intercostal nerve injury during the biopsy procedure may have disrupted sympathetic-vagal balance, triggering ventricular tachycardia. Furthermore, anxiety and tension related to the procedure could have contributed to the arrhythmia. Following the onset of ventricular tachycardia, we immediately administered 150 mg of amiodarone intravenously followed by a 1 mg/min infusion to correct the arrhythmia. After consultation with the anesthesiologist, we decided to terminate the procedure. We planned to reassess the patient and resume surgery once the arrhythmia was corrected and hemodynamics stabilized. Another significant concern at the time was that the patient had already undergone preoperative localization, with the anchor wire in place. Prolonged placement carried risks of wire displacement, pulmonary infection, and bleeding. Therefore, we administered analgesia, sedation, and prophylactic antimicrobial therapy, while maintaining continuous ECG monitoring and closely observing the patient's condition. Fortunately, a follow-up plain chest CT scan on the 8th day post-placement showed no anchor wire displacement, pulmonary infection, or hemorrhage. Reassessment revealed no significant contraindications for surgery, and the patient underwent thoracoscopic wedge resection of the lung. The procedure was uneventful, and the patient recovered well postoperatively with good lung expansion. Postoperatively, the patient developed complete left bundle branch block. Isosorbide dinitrate was administered for coronary vasodilation. By postoperative day 3, the ECG showed restoration of sinus rhythm. The patient was discharged on postoperative day 7.\u003c/p\u003e\n\u003cp\u003eTherefore, when arrhythmia occurs during CT-guided lung nodule localization, our primary task is to terminate the procedure and correct the patient's arrhythmia. Subsequently, stress-response attenuation, prophylactic anticoagulation, and antimicrobial therapy were then instituted. For the new anchor wire localization needle, its position within the lung is relatively stable, with a low probability of displacement within a short timeframe. Research by Hao Zhang et al. indicates that the displacement rate of localization needles after anchor wire-guided lung nodule localization is 0% \u003csup\u003e[11,12,13]\u003c/sup\u003e. However, all patients in their series underwent thoracoscopic surgery within 6 h after localization. Cases in which the anchor-wire marker remained in situ for as long as 9 days, as described herein, have never been reported. Postoperative ambulatory ECG monitoring is recommended for patients with a history of cardiovascular disease. If arrhythmia is detected, targeted anti-arrhythmic therapy should be initiated. For patients requiring elective surgery due to unexpected complications after localization, prophylactic anti-infective therapy is advised. Prior to elective thoracoscopic surgery, a repeat chest CT scan should be performed to confirm wire placement and assess for pulmonary infection, hemorrhage, pleural effusion, or hemothorax.\u003c/p\u003e\n\u003cp\u003eThis case report describes a patient who developed acute arrhythmia immediately after CT-guided anchor-wire localization of a pulmonary nodule. The relevant management process is described in detail. We hope it provides useful guidance and reference for clinical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Statement\u003c/strong\u003e: Written informed consent was obtained from all the paticipants prior for the publication of this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent Statement\u003c/strong\u003e: Consent for publication was obtained from the participants. The patient has written informed consent for their personal or clinical details along with any identifying images to be published in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict-of-interest statement\u003c/strong\u003e: There are no conflicts of interest in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution statement\u003c/strong\u003e: Zhang and Deng participated in the conception of the article. Zhang, Deng, Xu and Ye collected relevant data. Zhang and Gao contributed to drafting the manuscript. Deng revised it critically for important intellectual content.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availablity statement\u003c/strong\u003e:The data that support the findings of this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e：We express our gratitude to Lei Yang for his guidance in the research approach and assistance in daily work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eXu GH, Huang HX, Chen B, et al. A study on the first chest low-dose CT screening and susceptible factors of pulmonary nodules in 23 695 physical examinees in a medical examination center. 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PMID: 39869367; PMCID: PMC12372730.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anchor localization, Glass nodule, Paroxysmal ventricular tachycardia, case report","lastPublishedDoi":"10.21203/rs.3.rs-8776523/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8776523/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCT-guided lung nodule localization technique have matured significantly. It has now become the standard approach for preoperative localization of pulmonary nodules before thoracoscopic resection. To date, no instance of acute-onset arrhythmia following CT-guided lung nodule localization has been reported. And there is limited experience in managing such situations. We report the case of a 71-year-old man scheduled for thoracoscopic resection of a nodule in the left lower lobe. After preoperative CT-guided localization with a novel positioning needle, the patient experienced sudden cardiac arrhythmia. Antiarrhythmic and coronary vasodilator therapy was initiated first. After the patient returned to normal sinus rhythm, the anesthesiology team recommended canceling the immediate operation. The patient was transferred to the intensive care unit for close monitoring. Following nine days of comprehensive medical management and conditioning, a thoracoscopic wedge resection of the lung was performed. During surgery, the resection margin was determined based on the positioning of the anchor wire, resulting in wedge resection of the left lower lobe. The procedure proceeded smoothly, and the patient recovered well. This case report provides a reference for similar situations in the future.\u003c/p\u003e","manuscriptTitle":"Anchor Wire Localization Retained In Vivo for 9 Days Prior to Wedge Resection of a Ground-Glass Nodule a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-19 13:42:36","doi":"10.21203/rs.3.rs-8776523/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0532ba1c-4eda-45cb-a8ff-6478ef486882","owner":[],"postedDate":"February 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T18:53:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-19 13:42:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8776523","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8776523","identity":"rs-8776523","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}