Bail out strategies after accidental Wallstent dislocation into the right atrium in patients with superior vena cava syndrome

Transcription

1 Bail out strategies after accidental Wallstent dislocation into the right atrium in patients with superior vena cava syndrome Poster No.: C-0613 Congress: ECR 2014 Type: Educational Exhibit Authors: P. I. Kalmar, F. Schmid, O. C. Dörfler, R. H. Portugaller, P. Schedlbauer, H. A. Deutschmann; Graz/AT Keywords: DOI: Foreign bodies, Stents, Removal, Fluoroscopy, Veins / Vena cava, Vascular, Thorax /ecr2014/C-0613 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Learning objectives In this educational poster a summary is given of possible bail out strategies as well as important clues to prevent a caudal stent dislocation into the right atrium when treating superior vena cava syndrome. Background Although trans-venous stent insertion is a common procedure for the treatment of superior vena cava obstruction, there is a small risk of caudal dislocation after stent implantation. Stent displacement and miscalculation of the device length aside, potentially fatal dislocation into the right atrium might be caused by accidental contact of the struts with the distal tip of the delivery system (Fig. 1). Images for this section: Page 2 of 10

3 Fig. 1: Figure 1 - Wallstent with delivery system. Careful removal of the delivery system after stent placement is advised since the tip may engage the struts (circle). Page 3 of 10

4 Findings and procedure details In the unfortunate event of stent dislocation into the right atrium (Fig. 2), the following endovascular approaches have been successful. Vascular access is achieved via one of the common femoral veins. If the guidewire is still in place, it is of capital importance to keep its tip in the superior vena cava. Bridging to the inferior vena cava Additional stents are deployed in order to overlap the cranial end as well as the caudal end of the migrated stent. That way, the dislocated stent is fixed in the atrium. Particular attention should be given to maintain sufficient overlapping zones. Snaring An Amplatz goose neck snare which is provided by several companies is passed over the guide wire ("monorail") and used to lasso the stent (Fig. 3). Tightening the loop of the snare around the lower end of the stent - thereby compressing and securing it -, the stent can be dragged into the iliac veins or into the common femoral vein. If the guide wire is still inside the lumen of the migrated stent, an additional snare passed from the left groin can be used to catch the guide wire above the stent, alleviating the drag ("double-loop"). Balloon-Assisted Snaring If the above described should fail, e.g. because the whole circumference cannot be lassoed, an adequately sized angioplasty balloon - preferably with long balloon shoulders - is inflated inside the dislocated stent. This facilitates the snaring and the dragging, which should be performed as a whole unit. Removal through a femoral vascular sheath Depending on the location and the condition of the relocated stent in the iliac or femoral vein, removal through a sufficiently dimensioned vascular introducer sheath can be performed, with surgical extraction as a bail-out strategy. Images for this section: Page 4 of 10

5 Fig. 2: The Wallstent is dislocated into the right atrium. (straight arrow: superior vena cava; curved arrow: inferior vena cava) Page 5 of 10

6 Fig. 3: The "monorail method": a goose neck snare is brought within proximity of the caudal stent ending across the guide wire (a). The caudal stent struts are caught with the goose neck snare. Optionally an endoplasty balloon is inflated. Page 6 of 10

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8 Fig. 4: The Wallstent has been pulled back safely into the right common and external iliac vein. Page 8 of 10

9 Conclusion With an approximate prevalence of 2%, migration of a Wallstent or other metallic stents into the right atrium is a rare but potentially fatal complication of stenting in patients with superior vena cava syndrome. It can mostly be prevented by considering adequate device length and precise placement. Moreover, it is important to carefully remove the delivery system after placement, which is facilitated by prior balloon dilatation of the stenosis. If migration occurs, prompt management is mandatory. If the guidewire is still inside the stent lumen, it should be secured at all times since it prevents further dislocation of the stent towards the right ventricle with potential devastating consequences. Consider Heparin and analgo- sedation before relocating the stent. After successful relocation, the blood count should be determined on close follow-up to rule out venous perforation. Furthermore, postprocedure transthoracic echocardiography should be performed on the following day. Depending on the patient's comorbidities, the admission of Warfarin should be discussed. Personal information References 1. Taylor JD, Lehmann ED, Belli A-M, Nicholson AA, Kessel D, Robertson IR, et al. Strategies for the management of SVC stent migration into the right atrium. Cardiovasc Intervent Radiol. 30(5): Warren MJ, Sen S, Marcus N. Management of migration of a SVC Wallstent into the right atrium. Cardiovasc Intervent Radiol. 31(6): Bagul NB, Moth P, Menon NJ, Myint F, Hamilton G. Migration of superior vena cava stent. J Cardiothorac Surg Jan;3: Martin M, Baumgartner I, Kolb M, Triller J, Dinkel H-P. Fatal pericardial tamponade after Wallstent implantation for malignant superior vena cava syndrome. J Endovasc Ther Oct;9(5): Page 9 of 10

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