Successful Endovascular Retrieval Of Migrated Covered Stent From Left Main Pulmonary Artery During Dialysis Access Intervention
Ahmed K. Ghamraoui, DO, MS, Slee L. Yi, MD, Alireza Daneshpajouh, DO, Joseph J. Ricotta, II, MD, MS
Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL
DEMOGRAPHICS: Stent migration is considered a major immediate procedure-related complication following deployment in an arteriovenous (AV) circuit and can lead to serious long-term sequelae if left untreated. With a reported incidence of 2-5%, stent migration can vary from a distal shift in the AV circuit to free migration into the venous system, resulting in stent lodgment in the heart or pulmonary arteries. Consequence of migration can range from reduced therapeutic value of the device to serious cardiopulmonary complications such as perforation, thromboembolism, and pulmonary infarction. Described herein is the case of a covered stent which migrated to the left main pulmonary artery during dialysis access intervention and was successfully retrieved.
HISTORY: A 93-year-old male presented to the emergency department with a thrombosed right upper extremity brachial artery-axillary vein AV graft. With a past medical history of lower extremity deep vein thrombosis and pulmonary embolism, he had undergone remote inferior vena cava (IVC) filter placement, performed elsewhere, as he was considered a poor candidate for anticoagulation due to recurrent gastrointestinal bleeding. Following percutaneous mechanical thrombectomy and balloon angioplasty of the AV graft, residual stenosis was identified at the venous anastomosis. This was treated with deployment of a self-expanding covered stent. At time of attempted post-dilation, this stent was noted to no longer be present at the venous anastomosis and had migrated to the left main pulmonary artery.
PLAN: Following successful completion of the primary procedure with restoration of blood flow in the AV graft, the right common femoral vein was accessed. The left main pulmonary artery was cannulated, and using a trilobed snare, the stent was successfully snared and removed from the pulmonary artery. The stent was then sequentially re-snared and crushed in order to pass through the struts of the IVC filter. This was then removed through an 18-French sheath in the right common femoral vein without incident or sequelae.
DISCUSSION: Stent migration to the pulmonary arteries after deployment in an AV circuit can lead to significant long-term complications. Although case reports have described successful management when left in-situ with long-term anticoagulation, retrieval was deemed necessary in this patient due to contraindications to anticoagulation. This was successfully accomplished through a right common femoral vein approach despite the presence of an IVC filter
Back to 2021 Abstracts