Migration of covered stents from hemodialysis A‐V access to the pulmonary artery: Percutaneous stent retrieval and procedural trends

Abstract

Details are presented of two patients with end-stage renal disease (ESRD) who recently experienced migration of a Viabahn covered stent from a peripheral hemodialysis A-V access to the right lower lobe pulmonary artery. Successful percutaneous retrieval was achieved in one patient using a dual snare approach, facilitated by ex vivo product testing. The second patient was managed conservatively. A review of the institution's A-V access salvage procedures, indicated a concomitant trend toward greater use of stent-assisted procedures, and a higher utilization of covered versus uncovered stents.

Percutaneous retrieval of migrated Viabahn stent from a segmental pulmonary artery

“…In the only other published case by Dashkoff et al (Dashkoff et al, 2010), there are similarities to our case: the Viabahn stents were lost during dialysis access work, the viabahn stents lost were both 6 mm diameter × 50 mm, in both cases minimally invasive percutaneous techniques were successfully used to retrieve the stents from the pulmonary vasculature and in both cases a decision to attempt retrieval was reached after a multi-disciplinary approach by all interested stakeholder clinical specialties. The later point cannot be over emphasized given the potential harm that could be incurred to a patient during pulmonary artery stent retrieval.…”

Stent Migration and Bail-out Strategies

“…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% (3-5), though the number may be higher because of underreporting of cases. Self-expanding nitinol stents are now the de facto standard for use in the venous circulation as they have larger diameters with relatively low profiles, are more flexible and depending on the design, offer excellent conformability and minimal foreshortening.…”

“…Of these, the Amplatz GooseNeck ® snare kit (ev3, Plymouth, MN) has been the device of choice with ease of use, excellent grasp and torque control and fewer complications cited as advantages (22, 23). In most cases (an example of an exception is the Nitinol SMART™ stent, Cordis, Bridgewater, NJ), the end of these nitinol stents is the most compressible and malleable (compared to the central part of the stent) (5, 18, 24). This allows it to be crimped to a low profile cone and folded on itself as it is pulled into a sheath when snared (Fig.…”

“…2). In addition, this allows the snared stent to align itself parallel with the axis of the snare catheter as it is funneled into the sheath (5). On the other hand, if the stent is snared at its midpoint and retracted, it is perpendicular to the axis of the vessel lumen and sheath and therefore the free ends may injure the walls of the heart or vessel (24).…”

Incidental discovery of an unusual right atrial membrane in an adult patient

“…Migrations of vascular stents, particularly those placed to extend A-V access for dialysis have been reported previously. [1] The interventional radiologists and cardiothoracic surgeons were consulted during the procedure revealed an unusual membranous structure with fenestrations, best visualized in the mid-esophageal four chamber view [Figures 2 and 3; Videos 1 and 2]. The membrane stretched across the right atrium with attachments superiorly at the free wall and inferiorly at the inter-atrial septum.…”