Wandering Stent within the Pulmonary Circulation John D. Kakisis, Konstantinos Vassilas, Constantine Antonopoulos, George Sfyroeras, Konstantinos Moulakakis, and Christos D. Liapis, Athens, Greece
To present a case of a wandering stent within the pulmonary circulation that was managed conservatively with the ‘‘wait-and-see’’ strategy. Accidental dislodgement of a left brachiocephalic vein stent into the left lower lobe pulmonary artery occurred in an 83-year-old patient suffering from end-stage renal disease during placement of a left jugular vein catheter. The following day, a second X-ray revealed migration of the stent from the left to the right lower lobe pulmonary artery. Our patient was managed conservatively with low-molecular-weight heparin and was discharged on clopidogrel. The patient remained asymptomatic with regard to the migrated stent for four and a half years and died of old age. This is the first case of a wandering stent within the pulmonary circulation reported in the literature, supporting the ‘‘wait-and-see’’ policy in the management of such patients.
Subclavian or innominate vein stenosis is a frequent complication of central vein catheters in patients with end-stage renal disease. Such a stenosis may cause significant edema in the ipsilateral upper limb, especially when an arteriovenous fistula exists in this limb. In the past, the only possible treatment was ligation of the fistula. Nowadays, however, balloon angioplasty of the venous stenosis with stent placement to prevent elastic recoil has made possible the simultaneous treatment of the edema and the preservation of the fistula function.1e3 Instent restenosis is the most frequent complication of such stents,1e4 whereas stent migration has been occasionally reported.5e10 Herein we present a previously unreported complication of a stent migrating from the left innominate vein to the left lower lobe pulmonary
Department of Vascular Surgery, Athens University Medical School, ‘‘Attikon’’ Hospital, Athens, Greece. Correspondence to: John D. Kakisis, 1 Rimini street, Haidari, Athens 12462, Greece; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1932.e9e1932.e12 http://dx.doi.org/10.1016/j.avsg.2014.06.074 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: May 11, 2014; manuscript accepted: June 16, 2014; published online: July 11, 2014.
artery and then to the right lower lobe pulmonary artery.
CASE REPORT An 83-year-old male with end-stage renal disease on chronic hemodialysis was admitted to our hospital due to thrombosis of a left upper arm arteriovenous graft which had been placed a year before. His left upper limb had been edematous ever since the graft was placed. In his past medical history, the patient reported multiple placements of central vein catheters in both jugular, subclavian and femoral veins, with the latest efforts being unsuccessful due to inability to pass the wire. He also reported the placement of two stents in his left subclavian vein about 6 months before, which failed to resolve the edema. The patient was submitted to thrombectomy of the graft and intraoperative angiography which revealed good patency of the left subclavian vein and occlusion of the left innominate vein (Fig. 1A). Angioplasty of the innominate vein was performed with the placement of a 10 mm in diameter and 38 mm in length balloonexpandable stent (Omnilink, Abbott, IL). Postangioplasty venography revealed wide patency from the axillary vein to the right atrium (Fig. 1B). The following day, the graft was again thrombosed, so placement of a central vein catheter was decided. Due to the history of unsuccessful efforts to place a central vein catheter, a color 1932.e9
1932.e10 Case reports
Annals of Vascular Surgery
Fig. 2. Chest radiograph obtained after the introduction of a hemodialysis catheter through the left jugular vein demonstrates migration of the stent from the innominate vein to the left lower lobe pulmonary artery. molecular-weight heparin at a prophylactic dose and was followed closely. The following day, the patient was totally asymptomatic and was submitted to another chest X-ray which revealed migration of the stent into the right lower lobe pulmonary artery (Fig. 4). The patient was kept in the hospital for a week and was discharged on clopidogrel. Four years later, the patient was admitted to the hospital because of fever and bacteremia caused by Staphylococcus aureus. A CT scan of the chest was performed to check for signs of infection at the region of the displaced stent, which revealed that he stent was still in the right lower lobe pulmonary artery, still patent and without any signs of infection (Fig. 5). The patient became afebrile following removal of the central vein catheter and 3 days later, a new one was placed through a new tunnel. Half a year later, the patient died at the age of 87.
Fig. 1. (A) Digital subtraction angiography showing total occlusion of the left innominate vein. (B) Patency of the left innominate vein has been restored with the use of a 10 38-mm balloon-expandable stent.
duplex was performed which showed that the right jugular and subclavian vein and both femoral veins were occluded. Therefore, the only possible access site was the left jugular vein. Placement of a left jugular vein catheter followed, after which the patient developed left pleural pain. A postprocedure chest X-ray revealed migration of the stent from the innominate vein to the left lower lobe pulmonary artery (Fig. 2), while a spiral computed tomography (CT) scan verified the finding and showed that the artery was patent (Fig. 3). The patient received low-
DISCUSSION The study of this case along with a review of the relevant literature illustrates 3 important messages. Firstly, insertion of a central venous catheter in a patient with a stent in the subclavian or innominate vein should be avoided and, if absolutely necessary, it should be performed under radiologic guidance. Gray et al.5 have also reported 2 cases of subclavian stent migration to the pulmonary arteries during introduction of a dialysis catheter into the subclavian vein. With the expanding use of stents to treat central venous stenoses, the number of patients with stent migration may increase. Secondly, self-expanding stents should be preferred in the central veins of patients with end-
Vol. 28, No. 8, November 2014
Fig. 3. Thoracic CT scan shows the stent in the left lower lobe pulmonary artery with persistence of flow through the stent.
Fig. 4. Chest radiograph obtained one day after the introduction of the hemodialysis catheter demonstrates migration of the stent from the left lower lobe pulmonary artery to the right lower lobe pulmonary artery.
stage renal disease. The reason is that the venous stenosis in such patients is caused by previously placed dialysis catheters and is usually focal, ringlike, located at the point where the catheter was introduced. The proximal part of the vein is collapsed but will be significantly dilated after treatment of the stenosis. Under these circumstances, the best way to ensure proper apposition of the stent to the vein wall is to use a self-expandable stent with a 2e4 mm larger diameter that the diameter of the vein.6,11,12 In our patient, a balloon-expandable stent was used because of its higher, compared
Case reports 1932.e11
Fig. 5. Thoracic CT scan obtained 4 years after stent migration shows the stent in the right lower lobe pulmonary artery with persistence of flow through the stent.
with a self-expandable stent, radial strength. This decision, however, proved to be wrong. Thirdly, migration of a stent to the pulmonary arteries is not as dangerous as generally believed. Most of the authors reporting on endovascular retrieval of such stents justify their practice on the basis of a review article by Fisher and Ferreyro13 published in 1978. This study showed a 71% incidence of death or serious complications in patients from whom embolized iatrogenic foreign bodies were not removed. It should be noted, however, that the embolizing material in this review article was always a catheter fragment and not a stent and that almost all the patients who died had a catheter fragment wedged in the right cavities of the heart. Among 16 patients with catheter fragments in the pulmonary arteries, 9 (56%) were asymptomatic, 6 (38%) had nonfatal complications (usually thrombus on the catheter), and only one (6%) died due to pulmonary embolism. Over the past 15 years, several cases of stent migration to the pulmonary arteries have been reported, most of which were asymptomatic7e9,12,14 or caused mild symptoms6 and only 1 caused nonfatal pulmonary embolism.10 Several authors have adopted the ‘‘wait-and-see attitude’’ and it seems that there is not much to be seen during this follow-up because all the initially asymptomatic patients remained asymptomatic.6,8,9,12,15 Our case further supports this ‘‘wait-and-see’’ policy in the management of such patients. The uniqueness of our case is that there has not been any other report of a stent migration from one lung to the other. Although changes in body
1932.e12 Case reports
position may have helped in this migration, this is just an assumption that cannot be proved. The good outcome of our patient indicates that even such cases may be treated conservatively, although, of course, no definite conclusion can be drawn from a single case report. REFERENCES 1. Sprouse LR 2nd, Lesar CJ, Meier GH 3rd, et al. Percutaneous treatment of symptomatic central venous stenosis. J Vasc Surg 2004;39:578e82. 2. Greenberg JI, Suliman A, Angle N. Endovascular dialysis interventions in the era of DOQI. Ann Vasc Surg 2008;22: 657e62. 3. Oderich GS, Treiman GS, Schneider P, et al. Stent placement for treatment of central and peripheral venous obstruction: a long-term multi-institutional experience. J Vasc Surg 2000;32:760e9. 4. Bakken AM, Protack CD, Saad WE, et al. Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg 2007;45:776e83. 5. Gray RJ, Horton KM, Dolmatch BL, et al. Use of Wallstents for hemodialysis access-related venous stenoses and occlusions untreatable with balloon angioplasty. Radiology 1995;195:479e84. 6. Prischl FC, Weber T, Lenglinger F, et al. Conservative management of late Palmaz stent embolization to the pulmonary
Annals of Vascular Surgery
7.
8.
9.
10. 11.
12.
13.
14.
15.
arteryea complication after PTA with stent implantation of a fistula-draining right subclavian vein stenosis. Nephrol Dial Transplant 1997;12:1994e6. El Feghaly M, Soula P, Rousseau H, et al. Endovascular retrieval of two migrated venous stents by means of balloon catheters. J Vasc Surg 1998;28:541e6. Fernandez-Juarez G, Letosa RM, Mirete JO. Pulmonary migration of a vascular stent. Nephrol Dial Transplant 1999;14:250e1. Sharma AK, Sinha S, Bakran A. Migration of intra-vascular metallic stent into pulmonary artery. Nephrol Dial Transplant 2002;17:511. Sy A. Pulmonary infarction due to vascular stent migration. South Med J 2006;99:1003e4. Quinn SF, Schuman ES, Hall L, et al. Venous stenoses in patients who undergo hemodialysis: treatment with selfexpandable endovascular stents. Radiology 1992;183: 499e504. Marcy PY, Magne N, Bruneton JN. Strecker stent migration to the pulmonary artery: long-term result of a ‘‘wait-and-see attitude’’. Eur Radiol 2001;11:767e70. Fisher RG, Ferreyro R. Evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies. AJR Am J Roentgenol 1978;130:541e8. Ho JM, Kahan J, Supariwala A, et al. Vascular stent fracture and migration to pulmonary artery during arteriovenous shunt thrombectomy. J Vasc Access 2013;14:175e9. Gabelmann A, Kr€amer SC, Tomczak R, et al. Percutaneous techniques for managing maldeployed or migrated stents. J Endovasc Ther 2001;8:291e302.
To present a case of a wandering stent within the pulmonary circulation that was managed conservatively with the ‘‘wait-and-see’’ strategy. Accidental dislodgement of a left brachiocephalic vein stent into the left lower lobe pulmonary artery occurred in an 83-year-old patient suffering from end-stage renal disease during placement of a left jugular vein catheter. The following day, a second X-ray revealed migration of the stent from the left to the right lower lobe pulmonary artery. Our patient was managed conservatively with low-molecular-weight heparin and was discharged on clopidogrel. The patient remained asymptomatic with regard to the migrated stent for four and a half years and died of old age. This is the first case of a wandering stent within the pulmonary circulation reported in the literature, supporting the ‘‘wait-and-see’’ policy in the management of such patients.
Subclavian or innominate vein stenosis is a frequent complication of central vein catheters in patients with end-stage renal disease. Such a stenosis may cause significant edema in the ipsilateral upper limb, especially when an arteriovenous fistula exists in this limb. In the past, the only possible treatment was ligation of the fistula. Nowadays, however, balloon angioplasty of the venous stenosis with stent placement to prevent elastic recoil has made possible the simultaneous treatment of the edema and the preservation of the fistula function.1e3 Instent restenosis is the most frequent complication of such stents,1e4 whereas stent migration has been occasionally reported.5e10 Herein we present a previously unreported complication of a stent migrating from the left innominate vein to the left lower lobe pulmonary
Department of Vascular Surgery, Athens University Medical School, ‘‘Attikon’’ Hospital, Athens, Greece. Correspondence to: John D. Kakisis, 1 Rimini street, Haidari, Athens 12462, Greece; E-mail: [email protected] Ann Vasc Surg 2014; 28: 1932.e9e1932.e12 http://dx.doi.org/10.1016/j.avsg.2014.06.074 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: May 11, 2014; manuscript accepted: June 16, 2014; published online: July 11, 2014.
artery and then to the right lower lobe pulmonary artery.
CASE REPORT An 83-year-old male with end-stage renal disease on chronic hemodialysis was admitted to our hospital due to thrombosis of a left upper arm arteriovenous graft which had been placed a year before. His left upper limb had been edematous ever since the graft was placed. In his past medical history, the patient reported multiple placements of central vein catheters in both jugular, subclavian and femoral veins, with the latest efforts being unsuccessful due to inability to pass the wire. He also reported the placement of two stents in his left subclavian vein about 6 months before, which failed to resolve the edema. The patient was submitted to thrombectomy of the graft and intraoperative angiography which revealed good patency of the left subclavian vein and occlusion of the left innominate vein (Fig. 1A). Angioplasty of the innominate vein was performed with the placement of a 10 mm in diameter and 38 mm in length balloonexpandable stent (Omnilink, Abbott, IL). Postangioplasty venography revealed wide patency from the axillary vein to the right atrium (Fig. 1B). The following day, the graft was again thrombosed, so placement of a central vein catheter was decided. Due to the history of unsuccessful efforts to place a central vein catheter, a color 1932.e9
1932.e10 Case reports
Annals of Vascular Surgery
Fig. 2. Chest radiograph obtained after the introduction of a hemodialysis catheter through the left jugular vein demonstrates migration of the stent from the innominate vein to the left lower lobe pulmonary artery. molecular-weight heparin at a prophylactic dose and was followed closely. The following day, the patient was totally asymptomatic and was submitted to another chest X-ray which revealed migration of the stent into the right lower lobe pulmonary artery (Fig. 4). The patient was kept in the hospital for a week and was discharged on clopidogrel. Four years later, the patient was admitted to the hospital because of fever and bacteremia caused by Staphylococcus aureus. A CT scan of the chest was performed to check for signs of infection at the region of the displaced stent, which revealed that he stent was still in the right lower lobe pulmonary artery, still patent and without any signs of infection (Fig. 5). The patient became afebrile following removal of the central vein catheter and 3 days later, a new one was placed through a new tunnel. Half a year later, the patient died at the age of 87.
Fig. 1. (A) Digital subtraction angiography showing total occlusion of the left innominate vein. (B) Patency of the left innominate vein has been restored with the use of a 10 38-mm balloon-expandable stent.
duplex was performed which showed that the right jugular and subclavian vein and both femoral veins were occluded. Therefore, the only possible access site was the left jugular vein. Placement of a left jugular vein catheter followed, after which the patient developed left pleural pain. A postprocedure chest X-ray revealed migration of the stent from the innominate vein to the left lower lobe pulmonary artery (Fig. 2), while a spiral computed tomography (CT) scan verified the finding and showed that the artery was patent (Fig. 3). The patient received low-
DISCUSSION The study of this case along with a review of the relevant literature illustrates 3 important messages. Firstly, insertion of a central venous catheter in a patient with a stent in the subclavian or innominate vein should be avoided and, if absolutely necessary, it should be performed under radiologic guidance. Gray et al.5 have also reported 2 cases of subclavian stent migration to the pulmonary arteries during introduction of a dialysis catheter into the subclavian vein. With the expanding use of stents to treat central venous stenoses, the number of patients with stent migration may increase. Secondly, self-expanding stents should be preferred in the central veins of patients with end-
Vol. 28, No. 8, November 2014
Fig. 3. Thoracic CT scan shows the stent in the left lower lobe pulmonary artery with persistence of flow through the stent.
Fig. 4. Chest radiograph obtained one day after the introduction of the hemodialysis catheter demonstrates migration of the stent from the left lower lobe pulmonary artery to the right lower lobe pulmonary artery.
stage renal disease. The reason is that the venous stenosis in such patients is caused by previously placed dialysis catheters and is usually focal, ringlike, located at the point where the catheter was introduced. The proximal part of the vein is collapsed but will be significantly dilated after treatment of the stenosis. Under these circumstances, the best way to ensure proper apposition of the stent to the vein wall is to use a self-expandable stent with a 2e4 mm larger diameter that the diameter of the vein.6,11,12 In our patient, a balloon-expandable stent was used because of its higher, compared
Case reports 1932.e11
Fig. 5. Thoracic CT scan obtained 4 years after stent migration shows the stent in the right lower lobe pulmonary artery with persistence of flow through the stent.
with a self-expandable stent, radial strength. This decision, however, proved to be wrong. Thirdly, migration of a stent to the pulmonary arteries is not as dangerous as generally believed. Most of the authors reporting on endovascular retrieval of such stents justify their practice on the basis of a review article by Fisher and Ferreyro13 published in 1978. This study showed a 71% incidence of death or serious complications in patients from whom embolized iatrogenic foreign bodies were not removed. It should be noted, however, that the embolizing material in this review article was always a catheter fragment and not a stent and that almost all the patients who died had a catheter fragment wedged in the right cavities of the heart. Among 16 patients with catheter fragments in the pulmonary arteries, 9 (56%) were asymptomatic, 6 (38%) had nonfatal complications (usually thrombus on the catheter), and only one (6%) died due to pulmonary embolism. Over the past 15 years, several cases of stent migration to the pulmonary arteries have been reported, most of which were asymptomatic7e9,12,14 or caused mild symptoms6 and only 1 caused nonfatal pulmonary embolism.10 Several authors have adopted the ‘‘wait-and-see attitude’’ and it seems that there is not much to be seen during this follow-up because all the initially asymptomatic patients remained asymptomatic.6,8,9,12,15 Our case further supports this ‘‘wait-and-see’’ policy in the management of such patients. The uniqueness of our case is that there has not been any other report of a stent migration from one lung to the other. Although changes in body
1932.e12 Case reports
position may have helped in this migration, this is just an assumption that cannot be proved. The good outcome of our patient indicates that even such cases may be treated conservatively, although, of course, no definite conclusion can be drawn from a single case report. REFERENCES 1. Sprouse LR 2nd, Lesar CJ, Meier GH 3rd, et al. Percutaneous treatment of symptomatic central venous stenosis. J Vasc Surg 2004;39:578e82. 2. Greenberg JI, Suliman A, Angle N. Endovascular dialysis interventions in the era of DOQI. Ann Vasc Surg 2008;22: 657e62. 3. Oderich GS, Treiman GS, Schneider P, et al. Stent placement for treatment of central and peripheral venous obstruction: a long-term multi-institutional experience. J Vasc Surg 2000;32:760e9. 4. Bakken AM, Protack CD, Saad WE, et al. Long-term outcomes of primary angioplasty and primary stenting of central venous stenosis in hemodialysis patients. J Vasc Surg 2007;45:776e83. 5. Gray RJ, Horton KM, Dolmatch BL, et al. Use of Wallstents for hemodialysis access-related venous stenoses and occlusions untreatable with balloon angioplasty. Radiology 1995;195:479e84. 6. Prischl FC, Weber T, Lenglinger F, et al. Conservative management of late Palmaz stent embolization to the pulmonary
Annals of Vascular Surgery
7.
8.
9.
10. 11.
12.
13.
14.
15.
arteryea complication after PTA with stent implantation of a fistula-draining right subclavian vein stenosis. Nephrol Dial Transplant 1997;12:1994e6. El Feghaly M, Soula P, Rousseau H, et al. Endovascular retrieval of two migrated venous stents by means of balloon catheters. J Vasc Surg 1998;28:541e6. Fernandez-Juarez G, Letosa RM, Mirete JO. Pulmonary migration of a vascular stent. Nephrol Dial Transplant 1999;14:250e1. Sharma AK, Sinha S, Bakran A. Migration of intra-vascular metallic stent into pulmonary artery. Nephrol Dial Transplant 2002;17:511. Sy A. Pulmonary infarction due to vascular stent migration. South Med J 2006;99:1003e4. Quinn SF, Schuman ES, Hall L, et al. Venous stenoses in patients who undergo hemodialysis: treatment with selfexpandable endovascular stents. Radiology 1992;183: 499e504. Marcy PY, Magne N, Bruneton JN. Strecker stent migration to the pulmonary artery: long-term result of a ‘‘wait-and-see attitude’’. Eur Radiol 2001;11:767e70. Fisher RG, Ferreyro R. Evaluation of current techniques for nonsurgical removal of intravascular iatrogenic foreign bodies. AJR Am J Roentgenol 1978;130:541e8. Ho JM, Kahan J, Supariwala A, et al. Vascular stent fracture and migration to pulmonary artery during arteriovenous shunt thrombectomy. J Vasc Access 2013;14:175e9. Gabelmann A, Kr€amer SC, Tomczak R, et al. Percutaneous techniques for managing maldeployed or migrated stents. J Endovasc Ther 2001;8:291e302.
