Percutaneous techniques for managing maldeployed or migrated stents

Endovascular retrieval of a migrated covered stent from the pulmonary artery

Stent migration is a rare but significant complication following endovascular procedures. Techniques for managing dislodged stents have included surgical, endovascular, and conservative approaches. This case details a patient who had a covered stent placed within the left renal vein which later migrated to the pulmonary artery causing damage to the tricuspid valve. The migrated stent was successfully removed using a percutaneous endovascular approach utilizing fluoroscopy and transesophageal echocardiogram guidance.

Stents migration into right atrium from severely calcified superior vena cava in a hemodialysis patient

Vascular calcification is common among hemodialysis patients. In this report, we presented a case of superior vena cava (SVC) stent migration during endovascular angioplasty in a 50-year-old female hemodialysis patient with severe SVC calcification. The stent migration was refractory to the deployment of a second anchor stent, which shortly resulted in pericardium tamponade and was successfully rescued by emergent thoracotomy. The potential role of vascular calcification as a risk factor to stent migration was discussed. Patients with severe vascular calcification receiving endovascular angioplasty might need a careful risk screening for stent migration.

Migration of covered stents in thoracic central vein obstruction procedures in patients with hemodialysis: Case report and literature review

OBJECTIVE

The objective of the study is to present a case of hemodialysis in which the covered stent that had migrated into the right ventricle was retrieved by exploratory thoracotomy, and to review the literature on the diagnosis and treatment of stent migration in thoracic central vein obstruction (TCVO) procedures for hemodialysis patients.

METHOD

A systematic search of the PubMed database was performed to identify clinical presentations, imaging strategies, stent types, and treatment modalities for stent migration in hemodialysis patients.

RESULTS

A total of 14 case reports on stent migration in TCVO procedures for hemodialysis patients were included and analyzed. Ten cases included migration to the cardiac chambers and the remainder migration to the pulmonary artery. The common symptoms of stent migration in TCVO procedures are reported to be chest pain and dyspnea, while three of the cases studied involved no symptoms. Echocardiography, chest X-ray, and computed tomography are the commonly used methods for the diagnosis of stent migration and identification of the precise positioning of the stent. Stent migration to the right subclavian or innominate veins was the most prevalent case (seven cases). All were bare stents. Seven cases involved retrieval by interventional surgery, while four cases involved retrieval by open heart surgery. However, there were three cases in which the "wait-and-see" approach was adopted since the patients were asymptomatic.

CONCLUSIONS

Stent migration in TCVO procedures is a rare but extremely serious complication. The causes are not fully understood. The current treatment strategies include interventional surgery, open heart surgery, and the "wait-and-see" approach.

Endoscopic Robotic Retrieval of a Migrated Subclavian Vein Stent from the Right Ventricle

A 54-year-old woman with end-stage renal disease on hemodialysis with access through a right arm arteriovenous fistula presented with right arm swelling. Venography demonstrated right subclavian vein stenosis. A balloon angioplasty of the stenotic vein was unsuccessful, and she subsequently underwent stent placement with balloon angioplasty. Ten days following the procedure, she developed acute shortness of breath. Transthoracic echocardiogram demonstrated the migration of the venous stent into the right ventricle. Using an endoscopic robotic approach, the stent was successfully extracted from the beating heart.

A covered stent used in aortic coarctation migrates proximally during deployment causing transverse arch obstruction: Transcatheter repositioning after one month

Stent angioplasty with covered stents to avoid risk of aortic injury is the preferred mode of management of coarctation of aorta in adults and older children. Severe isthmic coarctation in an adult male with uncontrolled systemic hypertension was managed at another institution using a covered stent. A proximal stent migration during deployment resulted in obstruction of transverse aortic arch and left subclavian artery and was recognized one month after the procedure. This resulted in significant aortic gradients and left arm hypoperfusion. It was managed successfully by use of snares and additional overlapping stents, the first of this type in literature. Awareness of factors leading to stent migration and techniques involved in repositioning these stents may help cardiologists who deal with these interventions. <Learning objective: Distal stent migration is a known complication of coarctation stenting, often managed by expanding the stent in descending thoracic aorta where there are no major branches. However, proximal migration of covered stent leads to aortic arch obstruction including occlusion of arch branches. Techniques of delayed percutaneous repositioning of covered stent are described in this report.>.

Bilateral Persistent Sciatic Arteries Complicated with Aneurysmal Dilatation and Thrombotic Occlusion: A Case Report

Persistent sciatic artery (PSA), a rare congenital vascular anomaly, increases susceptibility to aneurysms and accounts for 40–61% of the cases. Here, we describe a case of PSA in a 70-year-old man with a history of alcoholic liver cirrhosis. Bilateral complete PSAs were detected incidentally on computed tomography angiography during evaluation for spontaneous intramuscular bleeding in the thigh due to cirrhosis-related coagulopathy. Selective angiography of the left PSA revealed aneurysmal dilatation and thrombotic occlusion of the PSA, which was partially removed with aspiration thrombectomy. Intramuscular bleeding was succesfully managed with empirical embolization of the deep femoral artery.

Percutaneous retrieval of migrated Viabahn stent from a segmental pulmonary artery

Background

With improving and aggressive endovascular venous and dialysis techniques there is increasing use of stent grafts with different platforms available on the market. Inappropriately sized stents may displace and potentially end up in the heart or lungs as potential dangerous foreign bodies. There is single published case of successful viabahn stent graft retrieval from the pulmonary circulation.

Case presentation

We present a patient who had successful safe percutaneous retrieval of a migrated Viabahn stent from a segmental Pulmonary artery and describe a different novel safe technique of successful stent graft retrieval from the pulmonary artery with very low risk to potential damage to the cardiac valve complex.

Conclusion

This case report demonstrates that Viabahn stent grafts can be safely retrieved from the pulmonary arterial system using this endovascular technique that will significantly reduce the risk of damage to the cardiac valve complex therefore avoiding potential complex surgery.

Electronic supplementary material

The online version of this article (10.1186/s42155-018-0007-3) contains supplementary material, which is available to authorized users.

Very early great saphenous vein graft aneurysm treated by percutaneous coronary intervention under ChromaFlo imaging guidance

A 73-year-old man, who had undergone coronary artery bypass grafting (CABG) 10 days prior, presented with a great saphenous vein graft aneurysm (SVGA). CT revealed the increasing size of the aneurysm. Since the SVGA occurred immediately after CABG and there were no other complications, the aneurysm was treated percutaneously. While intravascular ultrasonography (IVUS) and optical coherence tomography failed to detect the entry point, an IVUS catheter with the addition of ChromaFlo imaging clearly revealed the entry point, size and length of the SVGA. To prevent migration and edge restenosis associated with covered stents, the covered stent (3.0×19 mm) was superimposed on a drug-eluting stent (3.0×28 mm) that covered the entry site. A follow-up study demonstrated the absence of flow into the aneurysm.

Stent Migration and Bail-out Strategies

Stent migration is an inherent complication of stent deployment. A number of factors are responsible for this dreaded complication. The stent may eventually migrate to the heart or lungs or in the process of migration damage structures en route to its final destination. A number of techniques are available to bail out interventionalists if such a situation should arise. Occasionally a wait and watch approach may be prudent.

Extravascular stent management for migration of left renal vein endovascular stent in nutcracker syndrome

Background

Nutcracker syndrome is an entity resulting from left renal vein compression by the aorta and the superior mesenteric artery, which leads to symptoms of hematuria or left flank pain. The alternative option of endovascular or extravascular stenting is very appealing because of the minimal invasive procedures. Stents in the renal vein can cause fibromuscular hyperplasia, proximal migration or embolization.

Case presentation

A 30-year-old female was diagnosed with nutcracker syndrome for severe left flank pain. After failed conservative approach, she underwent endovascular stenting and subsequently developed recurrent symptom for stent migration one month postoperatively. She underwent successful extravascular stenting with complete symptom resolution.

Conclusion

The extravascular stenting is an alternative option after migration of left renal vein endovascular stenting. The computed tomographic imaging was closely correlated to therapeutic interventions and stent migration.

Contained rupture of a celiac artery aneurysm treated with aortic endograft deployment and assisting percutaneous coil and thrombin infusion

In this report we present a case of a ruptured celiac artery aneurysm (CAA) with a thrombosed distal neck, which was treated as an emergently with a deployment of a tube thoracic endograft to the descending thoracic and upper abdominal aorta. The initial treatment was assisted with a second stage percutaneous, transhepatic, ultrasound guided needle infusion of coil and thrombin to the aneurysmal sac due to type Ib endoleak, with immediate thrombosis of the aneurysm. This technique, although not standard, could also be considered as a useful choice for the treatment of CAAs with wide proximal and patent distal neck.

Percutaneous removal of a fully expanded SMART stent from the pulmonary artery using various adjunctive techniques

A 36-year-old man with an implanted arteriovenous shunt for hemodialysis was referred for shunt malfunction. Venography of the right upper extremity showed occlusion of the subclavian vein, and a SMART stent was deployed. The fully expanded stent immediately migrated centrally into the left pulmonary artery. As initial efforts to pass a snare over the stent failed, we intentionally passed a microguidewire through stent interstices, snared the end of the microguidewire to create a loop, and pulled the stent/microguidewire/snare combination back into the right ventricle where it separated from the loop because of stent mesh destruction. As the stent remained in the right ventricle, we advanced a 0.035-in. guidewire into the stent lumen, passed an angioplasty balloon over the guidewire, inflated the balloon in the stent, and performed pull-back into the right distal external iliac artery. The stent was then surgically removed via a right inguinal incision without eliciting any complications. Although retrieval of the stent malpositioned in the pulmonary artery was difficult, we retrieved it safely by applying various adjunctive techniques.

Successful treatment of type I endoleak of common iliac artery with balloon expandable stent (Palmaz XL stent) during endovascular aneurysm repair

Type 1 endoleak of common iliac artery (type I_b endoleak) should be treated during endovascular aneurysm repair (EVAR). An 86-year-old female was diagnosed with abdominal aortic aneurysm measuring 6.6 cm in diameter and right internal iliac artery aneurysm measuring 4.0 cm in diameter. She underwent EVAR after right internal iliac artery embolization. There was type I_b endoleak, which was repaired by balloon-expandable stent, Palmaz XL stent (Cordis). We report successful treatment of type I_b endoleak with Palmaz XL stent, which may be considered as an alternative option for type I_b endoleak after EVAR.

Migration of superior vena cava stent

There has been a recent increase in the use of endovascular prostheses resulting in complex surgical and interventional complications not previously recognised. We report a case of Superior vena cava stenosis treated with a wallstent which migrated to the right atrium, necessitating a combined radiological and surgical approach to retrieve it.

Migration of an endovascular stent from superior vena cava to the right ventricular outflow tract in a patient with superior vena cava syndrome

Migration of endovascular stents is a rare problem but can be fatal. We report an unusual case of an endovascular stent in the right ventricular outflow tract, which migrated from superior vena cava in a patient with superior vena cava syndrome.

Endovascular Removal of Long-Term Hemodialysis Catheters

Central venous catheters that have been in place for a long time can become fixed to the vein wall, making them impossible to pull out. Leaving them in situ is undesirable because of the risk that they could act as a nidus for thrombosis. Moreover, inserting new catheters alongside the old ones might compromise flow in the superior vena cava, further predisposing to thrombosis. Surgical removal is likewise undesirable, as this would necessitate thoracotomy with the attendant risks. We describe a novel technique, which we were able to use to remove retained long-term hemodialysis catheters in a patient who needed new catheters and who would have been a high-risk candidate for surgery. The right internal jugular vein was punctured adjacent to the site of insertion and a guide wire was used to form a snare, which was passed around the catheters and used to saw through the fibrous attachments to the vein wall. The midsection of one catheter could not be freed but the snare was used to cut off the proximal and distal ends, which could then be removed, the latter via the femoral vein. New catheters were then inserted via the left internal jugular vein. This technique enabled successful catheter extraction and replacement in a patient who would have been a poor candidate for cardiothoracic surgery.

Embolization for a bleeding pelvic fracture in a patient with persistent sciatic artery

Emergency embolization for a bleeding pelvic fracture was performed in a patient with persistent sciatic artery, a rare anatomic variation in which the internal iliac artery continues to the popliteal artery. Successful hemostasis was achieved without complications by means of selective catheterization into each branch of the internal iliac artery. Awareness of this unusual vascular anatomy is critically important to avoid serious complication of emergency embolization.

Minimally invasive diagnosis of persistent sciatic artery by multidetector-row computed tomographic angiography

Persistent sciatic artery is a rare but potentially significant vascular anomaly that is associated with a high incidence of aneurysm formation and limb-threatening ischemic complications. The diagnosis of persistent sciatic artery has usually been made by conventional angiography. We report a case of occluded and patent persistent sciatic arteries in which multidetector-row computed tomographic angiography allowed a definitive diagnosis of this rare vascular condition.

Comparison of Two Foreign Body Retrieval Devices with Adjustable Loops in a Swine Model

The purpose of the study was to compare two similar foreign body retrieval devices, the Texan (TX) and the Texan LONGhorn (TX-LG), in a swine model. Both devices feature a < or = 30-mm adjustable loop. Capture times and total procedure times for retrieving foreign bodies from the infrarenal aorta, inferior vena cava, and stomach were compared. All attempts with both devices (TX, n = 15; TX-LG, n = 14) were successful. Foreign bodies in the vasculature were captured quickly using both devices (mean +/- SD, 88 +/- 106 sec for TX vs 67 +/- 42 sec for TX-LG) with no significant difference between them. The TX-LG, however, allowed significantly better capture times than the TX in the stomach (p = 0.022), Overall, capture times for the TX-LG were significantly better than for the TX (p = 0.029). There was no significant difference between the total procedure times in any anatomic region. TX-LG performed significantly better than the TX in the stomach and therefore overall. The better torque control and maneuverability of TX-LG resulted in better performance in large anatomic spaces.

Crimping and repositioning of a maldeployed balloon-expandable arterial stent using a gooseneck snare

PURPOSE

To describe a technique for repositioning a fully deployed iliac stent from the infrarenal aorta into the common iliac artery (CIA).

CASE REPORT

A 58-year-old man was undergoing treatment for a significant right CIA stenosis when a 7x24-mm Palmaz Genesis medium stent was mistakenly deployed in the infrarenal aorta. With the stent still over the guidewire, an 8x60-mm balloon catheter was placed coaxially in the stent. Via a left groin access, a 6-F vascular sheath was introduced retrograde, and a 2.5-cm Amplatz gooseneck snare was advanced into the infrarenal abdominal aorta and pulled back over the stent. The snare was tightly closed to crimp the stent onto the collapsed balloon; this maneuver was repeated several times until the stent was contracted along its entire length. The balloon/stent assembly was carefully pulled back into the right CIA, and the stent was deployed across the target lesion, although there was overlap of the left CIA. Color duplex sonography at 1 year showed no signs of significant iliac arterial stenoses on either side. The patient reported no claudication.

CONCLUSIONS

Using a gooseneck snare, fully deployed balloon-expandable iliac stents can be recrimped on a balloon.

A case series of inferior vena cava stenting for lower limb oedema in palliative care

Inferior vena caval obstruction (IVCO) is an occasional cause of lower limb oedema in palliative care patients with metastatic malignancy. We present five cases who underwent IVC stenting for symptomatic relief. Four of the five cases had significant reduction in their oedema but three of these four patients died within two weeks of the procedure. The procedure itself is described and the appropriateness of this intervention in patients with end-stage disease is discussed.

Congenital vascular anomalies

Congenital vascular anomalies are rare. The cardiovascular specialist should nevertheless be aware of the more common types of vascular anomalies and understand the implications for patient treatment and the likelihood of associated morbidity. The presentation of congenital arteriovenous malformations can range from asymptomatic or cosmetic lesions, to those causing ischemia, ulceration, hemorrhage, or high-output congestive heart failure. Treatment of large, symptomatic arteriovenous malformations often requires catheter-directed embolization prior to the attempt at complete surgical excision. Later recurrence, due to collateral recruitment, is frequent. Graded compression stockings and leg elevation are the mainstays of treatment for the predominantly venous congenital vascular anomalies. Most congenital central venous disorders are clinically silent. An exception is the retrocaval ureter. Retroaortic left renal vein, circumaortic venous ring, and absent, left-sided or duplicated inferior vena cava are relevant when aortic or inferior vena cava procedures are planned. The treatment of the venous disorders is directed at prevention or management of symptoms. Persistent sciatic artery, popliteal entrapment syndrome, and aberrant right subclavian artery origin are congenital anomalies that are typically symptomatic at presentation. Because they mimic more common diseases, diagnosis is frequently delayed. Delay can result in significant morbidity for the patient. Failure to make the diagnosis of persistent sciatic artery and popliteal entrapment can result in critical limb ischemia and subsequent amputation. Unrecognized aberrant right subclavian artery origin associated with aneurysmal degeneration can rupture and result in death. The treatment options for large-vessel arterial anomalies are surgical, sometimes in combination with endovascular techniques.

Late aortic dislocation of a stent following stent angioplasty for ostial renal artery stenosis

A patient with left RAS was treated by stent angioplasty followed by a multivessel percutaneous coronary intervention. Six months later, an aortic dislocation of the stent was diagnosed. The fully expanded stent was caught with a balloon catheter and fixed in the left external iliac artery. Stent migration after initially successful stent angioplasty for RAS is possible. Fully expanded, dislocated balloon-expandable stents can be secured by implanting them into the iliac artery.