Endovascular stent fracture and migration is an extremely rare complication of arteriovenous shunt thrombectomy.
Technique
We report a case of endovascular stent fracture following repeat arteriovenous graft thrombectomy, which was complicated by migration of a 26 millimeter stent fragment to the left main pulmonary artery. Attempts at percutaneous transvenous retrieval were unsuccessful, and an open thoracotomy to extract the stent fragment was performed.
Conclusions
Although there is no consensus for the management of endovascular stents that have migrated to the pulmonary arteries, stent retrieval may be necessary in cases where arterial flow is compromised or heavy clot burden is a concern. Moreover, steps toward prevention of stent fracture and migration should be considered in order to preclude such occurrences – avoidance of puncturing the stent for hemodialysis access, discontinuation of use of the Arrow-Trerotola device through or near stents, and consideration of short segment angioplasty for regional intrastent stenosis rather than typical long segment venous angioplasty.
U.S Renal Data System.USRDS 2009, Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States.National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2009.
2.
SlonimS.M., DakeM.D., RazaviM.K.Management of misplaced or migrated endovascular stents.J Vasc Interv Radiol.1999; 10(7): 851–859. doi: 10.1016/S1051-0443(99)70127-2. Medline
3.
YevzlinA., AsifA.Stent placement in hemodialysis access: historical lessons, the state of the art and future directions.Clin J Am Soc Nephrol.2009; 4(5): 996–1008. doi: 10.2215/CJN.04040808. Medline
4.
SzolarD.H., SaeedM., WendlandM.F.MR imaging characterization of postischemic myocardial dysfunction (“stunned myocardium”): relationship between functional and perfusion abnormalities.J Magn Reson Imaging.1996; 6(4): 615–624. doi: 10.1002/jmri.1880060410. Medline
5.
PhillipsM.S., GosainS., BonattiH.Enteral stents for malignancy: a report of 46 consecutive cases over 10 years, with critical review of complications.J Gastrointest Surg.2008; 12(11): 2045–2050. doi: 10.1007/s11605-008-0598-4. Medline
MarcyP.Y., MagnéN., BrunetonJ.N.Strecker stent migration to the pulmonary artery: long-term result of a “wait-and-see attitude”.Eur Radiol.2001; 11(5): 767–770. doi: 10.1007/s003300000658. Medline
8.
SyA.Pulmonary infarction due to vascular stent migration.South Med J.2006; 99(9): 1003–1004. doi: 10.1097/01. smj.0000232191.23818.3b. Medline
9.
AsharR.M., HuettlE.A., HalliganR.Percutaneous retrieval of a Wallstent from the pulmonary artery following stent migration from the iliac vein.J Interv Cardiol.2002; 15(2): 101–106. doi: 10.1111/j.1540-8183.2002.tb01040.x. Medline
10.
GrossoM., SpallutoF., MuratoreP., CristoferiM., VeltriA.Palmaz stent dislodgement into the left pulmonary artery complicating TIPS: percutaneous retrieval and extraction after venotomy.Cardiovasc Intervent Radiol.1995; 18(2): 106–108. doi: 10.1007/BF02807232. Medline
11.
RhodesE.S., SilasA.M.Dialysis needle puncture of Wallgrafts placed in polytetrafluoroethylene hemodialysis grafts.J Vasc Interv Radiol.2005; 16(8): 1129–1134. doi: 10.1097/01. RVI.0000167852.14245.05. Medline
12.
VeselyT.M.Role of stents and stent grafts in management of hemodialysis access complications.Semin Vasc Surg.2007; 20(3): 175–183.
13.
VeselyT.M.Use of stent grafts to repair hemodialysis graft-related pseudoaneurysms.J Vasc Interv Radiol.2005; 16(10): 1301–1307. doi: 10.1097/01. RVI.0000175903.38810.13. Medline
14.
HauseggerK.A., TiessenhausenK., KlimpfingerM., RaithJ., HauserH., TaussJ.Aneurysms of hemodialysis access grafts: treatment with covered stents: a report of three cases.Cardiovasc Intervent Radiol.1998; 21(4): 334–337. doi: 10.1007/s002709900271. Medline
