Management of Central Venous Stent Migration in a Patient with a Permanent Inferior Vena Cava Filter

Silent Migration of a Left Common Iliac Venous Stent to the Right Atrium: A Case Report and Review of Literature

In the past decade, percutaneous endovenous stenting has emerged as the primary procedure for treating symptomatic venous outflow obstruction. Stent migration is a rare but serious and well-recognized complication of venous stenting. Cardiopulmonary complications following stent migration can manifest in a number of ways, including damage to the valves, arrhythmias, endocarditis, tamponade, and acute heart failure. Both extracardiac and intracardiac dislodgement of stents may be treated with catheter-directed extraction, stent redeployment, or surgical extraction. The decision on the type of procedure depends on multiple factors including the location of the stent, the size and accessibility of the stent, the symptoms, the extent of damage to the vital structures, and the overall health of the patient. We present the case of a 68-year-old male who presented with tachycardia. On further evaluation and workup, he was found to have an iliac venous stent that had migrated to the right atrium.

A review of the incidence, outcome and management of venous stent migration

INTRODUCTION

Percutaneous endovenous stenting has emerged during the last decade as the primary method of treating symptomatic venous outflow obstruction. A recognised complication of venous stenting is stent migration. The aim of this systematic review was to identify the number of cases reported in the published literature describing stent migration, to recognise risk factors that may be associated with this complication, and outcomes following migration.

METHODS

A review was conducted following MOOSE and PRIMSA guidelines and registered on PROSPERO. MEDLINE, EMBASE, and PubMed databases and key references were searched using specified keywords. All relevant data for primary procedure and subsequent presentation with stent migration was retrieved. Data was assessed as too low quality to allow for statistical analysis.

RESULTS

Between 1994 and 2020, 31 articles were identified comprised of 29 case reports and 2 case series providing data for 54 events of venous stent migration with 47/54 providing some data for stent used. Mean age of patients in who migration occurred was 50 years (range 19-88) and 57.6% (n=30) were male. Most reported cases were 60mm or less in length (38/46, 82.6%) and only 3 of the reports were stents greater than 14mm in diameter (3/47, 3.6%). None of the papers reported migration of stents of more than 100mm in length. In 85% of the migrated stent events, retrieval was attempted with 56% via an endovascular approach. The immediate outcome was satisfactory in 100% of the reported attempts whether by endovascular or open surgical approaches.

CONCLUSIONS

This literature review would suggest that the risk of migration is rare but may be underreported. The majority of reported cases are shorter and smaller diameter stents. The paucity of published data and the short term follow up provided suggest more formal data collection would provide a truer reflection of incidence however clear strategies to avoid migration need to be followed to prevent this complication from occurring.

Central Venous Interventions

Central venous stenosis or occlusion is a common and vexing problem in patients undergoing hemodialysis. Typical presenting symptoms include arm swelling and prolonged bleeding after hemodialysis. Despite multiple treatment approaches, these stenoses tend to recur and progress over time. A thorough preprocedure evaluation, methodical procedural approach and awareness of potential complications are all essential to try to preserve vascular access and improve patients' quality of life.

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.

Massage-induced delayed venous stent migration

Catheter-directed therapies in chronic deep vein thromboses can help improve leg function by mechanically addressing residual obstruction in lower extremity or pelvic veins, although the reported use of stents in leg veins is relatively unusual. The author reports a case of this type with long-term patency and clinical success, culminating in asymptomatic delayed venous migration of a stent to the right atrium after 3 years. Open heart surgery was required to remove the embedded stent fragments. The attributed mechanism was deep tissue massage of the thigh.

Strategies for the Management of SVC Stent Migration into the Right Atrium

PURPOSE

Stent migration into the right atrium is a potentially fatal complication of stenting in the venous system and is most likely to occur during the treatment of superior vena cava obstruction. Endovascular approaches that can salvage this hazardous situation are described and the keys to successful treatment are highlighted.

MATERIALS AND METHODS

Four different strategies are reviewed: (1) snaring the stent directly, (2) angioplasty balloon-assisted snaring of the stent, (3) guide wire-assisted snaring of the stent, and (4) superior vena cava-to-inferior vena cava bridging stent.

RESULTS

These techniques have been employed in the successful management of four cases. No short- or long-term complications as a result of these maneuvers have been identified. Additional treatment of the underlying disease was possible at the same time in each case.

CONCLUSION

We conclude that prompt management of right atrial stent migration is essential and can be successfully achieved by a variety of "bale-out" techniques which are within the technical range of most interventional radiologists.