Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 6  |  Page : 188-192

Subclavian arterial stent migration from technical error and effective strategic bail out


Department of Peripheral Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Submission02-Jun-2021
Date of Decision29-Jun-2021
Date of Acceptance02-Jul-2021
Date of Web Publication20-Jan-2022

Correspondence Address:
B Nishan
Department of Peripheral Vascular and Endovascular Surgery, Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_62_21

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  Abstract 


Stent migration is an inherent complication of stent deployment. Numerous factors are responsible for this dreaded complication. Various techniques are available to bail out the migrated stent.

Keywords: Bail out, deployment, migration


How to cite this article:
Nishan B, Pavan B K, Mamata S H, Anand V. Subclavian arterial stent migration from technical error and effective strategic bail out. Indian J Vasc Endovasc Surg 2021;8, Suppl S2:188-92

How to cite this URL:
Nishan B, Pavan B K, Mamata S H, Anand V. Subclavian arterial stent migration from technical error and effective strategic bail out. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jul 4];8, Suppl S2:188-92. Available from: https://www.indjvascsurg.org/text.asp?2021/8/6/188/336029




  Introduction Top


Stent placement has become an integral part of endovascular surgery to treat stenotic lesions in the subclavian artery.[1] Stent utilization harbors a number of inherent complications such as stent fracture, migration, and infection, in stent stenosis. The Society of Vascular Surgery defines device migration as a movement of ≥10 mm relative to anatomical landmarks or any migration leading to symptoms or requiring therapy.[2] The reported incidence of this complication is 2%–3%.[3],[4],[5] Inaccurate vessel measurement, rapid deployment, and improper removal of delivery system may cause stent to jump forward.[6] Devices used for stent retrieval include loop snares, retrieval baskets, and forceps.[7],[8]


  Case Report Top


A 40-year-old female, no comorbidities, presented with left index finger cyanosis for 1 month. On evaluation by computed tomography (CT) angiogram, the proximal subclavian artery showed atherosclerotic soft plaque causing 70%–80% stenosis from ostia to around 15 mm length with good flow in rest of the subclavian artery and vertebral artery [Figure 1]. She was planned for left proximal subclavian artery primary stenting under local anesthesia. The patient was placed in the supine position. Left upper limb and chest were painted and draped in standard fashion. Perioperative antibiotic was administered. Left BA retrograde access was taken under ultrasonography guidance, and a 6F × 11 cm sheath was inserted. Injection heparin 5000 IU was given through the sheath. Sheath angiogram showed similar findings as CT angiogram [Figure 2]. Stenotic lesion in proximal subclavian artery was crossed using Terumo 0.035 guidewire with 5 Fr vertebral catheter support, later vertebral catheter exchanged for 5Fr pigtail catheter, with the wire placed in aorta, catheter tip was placed beyond the lesion and angiogram was obtained, which showed 80% stenosis in the proximal subclavian artery, length of stenosis being around 15mm. 0.035 Terumo wire was passed through the pigtail catheter and parked in the descending aorta and pig tail catheter was taken out. An 8 mm × 27 mm balloon-mounted stent (Express LD) was passed over the wire under fluoroscopy up to the ostial lesion in the left proximal subclavian artery and deployed up to nominal pressure (without predilatation) [Figure 3]. The 0.035” guidewire was then removed and sheath angiogram was taken postdeployment, which showed stent in the deployed position with no flow of contrast across the stent. For better visualization, 5 Fr vertebral catheter was parked distal to the stent and angiogram showed no flow across the stent. With 5Fr vertebral catheter support, the 0.035 Terumo guidewire was reinserted and an attempt was made to cross the stent, resistance was encountered at the distal end of the stent, and 5Fr vertebral catheter was then pushed and manipulated to traverse the stent, during which the stent was displaced from its original deployed position to the level of aortic bifurcation [Figure 4]. Salvage options were considered, and plan was made to reposition the stent to the proximal subclavian artery.
Figure 1: Proximal subclavian artery at the ostia showing atherosclerotic soft plaque causing 70%–80% stenosis

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Figure 2: Intraoperative angiogram showing similar findings

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Figure 3: Proximal subclavian artery primary stenting (without predilatation) with 8 mm × 27 mm balloon-mounted stent (Express LD)

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Figure 4: Stent got displaced from its original deployed position to the level of aortic bifurcation

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Guidewire was then passed through the same left brachial access and passed through the lumen of the stent [Figure 5]; 8 mm × 30 mm balloon was passed over the wire and placed within the stent and inflated so that the balloon snuggly fits the stent [Figure 6]. Balloon with stent was then slowly retracted under fluoroscopic guidance and positioned back at the proximal subclavian artery and reinflated to its rated burst pressure [Figure 7],[Figure 8],[Figure 9]. Angiogram showed accurate positioning of the stent with good flow across [Figure 10]. Postprocedure, the patient had palpable radial and ulnar artery.
Figure 5: Terumo guide wire was passed through the lumen of the stent

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Figure 6: 8 mm × 27 mm balloon was passed over the wire and placed within the stent and inflated so that the balloon snuggly fits the stent

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Figure 7: Balloon with stent was then slowly retracted under fluoroscopic guidance and positioned back at the proximal subclavian artery and reinflated to its rated burst pressure

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Figure 8: Balloon with stent was then slowly retracted under fluoroscopic guidance and positioned back at the proximal subclavian artery and reinflated to its rated burst pressure

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Figure 9: Balloon with stent was then slowly retracted under fluoroscopic guidance and positioned back at the proximal subclavian artery and reinflated to its rated burst pressure

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Figure 10: Angiogram showing accurate positioning of the stent with good flow across

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  • Probable reason for no flow through the stent initially – Plaque/thrombus at the distal end of the stent obstructing the flow
  • Probable reason for stent migration – guidewire faced considerable resistance at the distal end of stent due to plaque/thrombus and guidewire later got entangled within the struts of the stent, and when vertebral catheter was being pushed over the wire at the distal end of stent, it got migrated from its original position to the level of aortic bifurcation along the flow. Written informed consent was obtained from the patient for publication of this case report and accompanying images.



  Discussion Top


“Stent migration infuriates and infuses the endovascular surgeon with an adrenaline rush.”[3]

Management options include [Table 1]:
Table 1: Clinical and technical aspects of cases in which misplaced or migrated endovascular stents were managed percutaneously

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  1. Retrieval and repositioning - Stents can be retrieved with the help of snares; Dashkoff et al. have reported using a dual snare technique to retrieve a 6 cm × 50 mm Viabahn stent that had migrated to the right lower lobe pulmonary artery.[5] Lipton et al. have reported the use of a single snare technique to retrieve a 10 mm × 42 mm wall stent from the right atrium. Another technique described is the balloon-mounted snare technique that can be used for bare metal stents[9]
  2. Leave it alone - Marcy et al. reported a case of a 61-year-old lady with stage 4 breast cancer with migration of stent to the right pulmonary artery.[10] There has been another case reported by Ahamed et al. of a migrated brachiocephalic venous stent into the right atrium; the patient was treated conservatively[11]
  3. Surgical removal - Wook Kang et al. reported a case of stent migration to the right ventricle in a 40-year-old male patient which was surgically removed.[12]


Management additionally depends on:

  1. Stent structure-covered or bare, with different techniques described for retrieval of covered and bare stents
  2. Stent visibility, orientation, and how far and where it has migrated so as to formulate the right bail out strategy
  3. Access route and device used to capture the stent
  4. Risk–benefit ratio of using percutaneous removal techniques versus leaving the migrated stent alone (wait-and-watch policy - asymptomatic stent embolization, severe complications with retrieval, poor life expectancy, patient refusal for any further intervention).


If the guide wire is still within the lumen of the stent, a low-profile angioplasty balloon is passed over the guide wire into the stent. The balloon should be the same diameter or 1 mm larger than as the stent. Once the balloon is inflated, the stent adheres to the inflated balloon and can be pulled back as a unit to a safer area. The bare stent with its interrupted skeleton offers good purchase with the surface of inflated balloon.[3],[8]

The stent may compromise the lumen of the vessel for which it was intended, providing a nidus for thrombus formation and vessel occlusion. It may threaten more hazardous embolization to peripheral vessel.[13],[14]

Attention should be paid to maintain wire access across the stent. There is a potential for vascular injury as inflated balloons and stents are pulled and pushed through native vessels. Consideration must also be given to the problem that led to original stent placement.[15]


  Conclusion Top


Vessel measurement should be accurate before stent selection and deployment. Deploy the stent slowly across the lesion. If stent is still over the wire, situation is nearly always salvageable. Stents do not have to always be retrieved; in extreme cases, wait-and-watch policy can be a better option.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yevzlin A, Asif A. Stent placement in hemodialysis access: Historical lessons, the state of the art and future directions. Clin J Am Soc Nephrol 2009;4:996-1008.  Back to cited text no. 1
    
2.
Chaikof EL, Blankensteijn JD, Harris PL, White GH, Zarins CK, Bernhard VM, et al. Hoc committee for standardized reporting practices in vascular surgery of the Society for Vascular Surgery/American Association for Vascular Surgery. Reporting standards for endovascular aortic aneurysm repair. Vasc Surg 2002;35:1048-60.  Back to cited text no. 2
    
3.
Slonim SM, Dake MD, Razavi MK, Kee ST, Samuels SL, Rhee JS, et al. Management of misplaced or migrated endovascular stents. J Vasc Interv Radiol 1999;10:851-9.  Back to cited text no. 3
    
4.
Gabelmann A, Krämer SC, Tomczak R, Görich J. Percutaneous techniques for managing maldeployed or migrated stents. J Endovasc Ther 2001;8:291-302.  Back to cited text no. 4
    
5.
Dashkoff N, Blessios GA, Cox MR. Migration of covered stents from hemodialysis A-V access to the pulmonary artery: Percutaneous stent retrieval and procedural trends. Catheter Cardiovasc Interv 2010;76:595-601.  Back to cited text no. 5
    
6.
Sequeira A, Abreo K. The structure and function of endovascular stents: A primer for the interventional nephrologist. Semin Dial 2014;27:E10-20.  Back to cited text no. 6
    
7.
Seong CK, Kim YJ, Chung JW, Kim SH, Han JK, Kim HB, et al. Tubular foreign body or stent: Safe retrieval or repositioning using the coaxial snare technique. Korean J Radiol 2002;3:30-7. doi: 10.3348/kjr.2002.3.1.30.  Back to cited text no. 7
    
8.
Kirby JM, Guo XF, Midia M. Repositioning of covered stents: The grip technique. Cardiovasc Intervent Radiol 2011;34:615-9.  Back to cited text no. 8
    
9.
Lipton M, Cynamon J, Bakal CW, Sprayregen S. Percutaneous retrieval of two Wallstent endoprostheses from the heart through a single jugular sheath. J Vasc Interv Radiol 1995;6:469-72.  Back to cited text no. 9
    
10.
Marcy PY, Magné N, Bruneton JN. Strecker stent migration to the pulmonary artery: Long-term result of a “wait-and-see attitude”. Eur Radiol 2001;11:767-70.  Back to cited text no. 10
    
11.
Ahamed SH, Venkatesh SK, Tan LK. Migrated brachiocephalic venous stent into the right atrium - Can it be left alone? A case report and review of the literature. Ann Acad Med Singap 2011;40:512-3.  Back to cited text no. 11
    
12.
Wook Kang MD, Il-Soo Kim MD, Ji-Ung Kim MD, Ji-Hyun Cheon MD1, Seon-Kwang Kim MD, Sung-Hyun Ko MD. Surgical removal of endovascular stent after migration to the right ventricle following right subclavian vein deployment for treatment of central venous stenosis. J Cardiovasc Ultrasound 2011;9:203-6.  Back to cited text no. 12
    
13.
Sanchez RB, Roberts AC, Valji K, Lengle S, Bookstein JJ. Wallstent misplaced during transjugular placement of an intrahepatic porto-systemic shunt: Retrieval with a loop snare. AJR 1992;159:129-30.  Back to cited text no. 13
    
14.
Cekirge S, Foster RG, Weiss JP, McLean GK. Percutaneous removal of an embolized Wall stent during a transjugular intrahepatic portosystemic shunt procedure. JVIR 1993;4:559-60.  Back to cited text no. 14
    
15.
Prahlow JA, O'Bryant TJ, Barnard JJ. Cardiac perforation due to Wallstent embolization: A fatal complication of the transjugular intrahepatic portosystemic shunt procedure. Radiology 1997;205:170-2.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1]



 

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