Iliac Vein Stent Migration to the Heart in Patients With Chronic Venous Insufficiency

Case Study and Review

Submitted on Mon, 11/20/2017 - 16:56
Authors

Jenny Plácido-Disla, MD; Bora Toklu, MD; Ramita N. Gowda; Ramesh M. Gowda, MD

1Mount Sinai Heart, Mount Sinai Beth Israel, New York, New York; 2College of New Jersey, Ewing, New Jersey

Citation
VASCULAR DISEASE MANAGEMENT 2017;14(11):E231-E234
Abstract

In recent years, iliac vein stenting is more frequently performed for the treatment of chronic venous insufficiency. Although it has been described as a relatively safe procedure with high success rate, several cases of stent migration to the heart, causing significant morbidity and mortality, have been reported in the medical literature. Stent migration to the heart is a rare but life-threatening complication, which may lead to cardiac arrhythmias, valve injury, and even myocardial perforation. Therefore, urgent retrieval of the migrated stent is of paramount importance. Our purpose is to discuss indications for revascularization in chronic venous insufficiency, complications associated with venous stent placement, and the risk factors for venous stent migration. We have performed a literature search to assess the retrieval approach chosen in various cases of intracardiac migration of venous stents. The literature search has revealed both endovascular and surgical retrieval approaches as feasible options to consider. While the endovascular approach is identified to have the highest overall success rate as described in the literature, the surgical approach was preferred for complex cases where the stent has migrated across the tricuspid valve or into the pulmonary vasculature. Additionally, we also describe 2 cases of stent migration to the heart that presented to our institution within 24 hours of iliac vein stent placement. 

Key words: iliac vein stenting, venous stent migration, chronic venous insufficiency

Chronic venous insufficiency (CVI) has various clinical presentations, including telangiectasia, varicose veins or reticular veins, edema, skin changes (pigmentation, eczema, lipodermatosclerosis), healed venous leg ulceration, and active venous leg ulceration.1-3 Its severity can be classified based on CEAP (Clinical-Etiology-Anatomy-Pathophysiology) score. CVI can be caused by nonthrombotic or thrombotic venous insult, which may present as venous reflux or obstruction.1 Iliocaval venous obstruction is one of the most common causes of CVI. Obstruction occurring at the iliac vein where it crosses the right iliac artery is known as May-Thurner syndrome.4 

Although compression therapy is the first-line therapy for CVI, interventional therapy with endovascular stenting has also been shown to be beneficial.5 Revascularization with endovenous stenting has recently revolutionized the treatment approach for chronic venous obstruction, especially in the femoroiliocaval system.6-8 Furthermore, patients with CEAP class 3 and above, including edema, skin changes, and venous ulceration (healed or active), have been shown to  benefit from revascularization based on 2014 CIRSE standards of practice guidelines on iliocaval stenting.1 This treatment approach has been described as a safe and effective intervention for chronic venous obstruction, but there have been various complications reported, including stent thrombosis, venous perforation, and stent migration.9-11

Case 1

A 55-year-old woman with past medical history of chronic venous insufficiency manifesting as varicose veins presented to our emergency department with sudden onset chest pain and an altered mental status. The morning before the day of presentation, she underwent bilateral common iliac vein and suprarenal inferior vena cava stenting for the management of varicose veins, without any reported complications. The patient was discharged home on the same day without any issues. 

However, hours after discharge, she developed severe chest pain, prompting the family to call emergency medical services. Upon arrival to the emergency department (ED), the patient was minimally responsive and was hypotensive with systolic blood pressure in the 60s. She was intubated preemptively for airway protection, and vasopressors were initiated for hemodynamic support. An electrocardiogram (ECG) showed right bundle branch block with left anterior fascicular block. Cardiology was consulted, and an urgent bedside echocardiogram was performed, which showed a foreign object in the right atrium consistent with a stent. Computed tomography angiogram confirmed findings of a stent extending from the inferior vena cava into the right atrium. 

At that time, cardiothoracic surgery was consulted for emergent retrieval of a migrated intracardiac stent in the setting of cardiogenic shock. During evaluation, the patient continued to deteriorate and became pulseless. Cardiopulmonary resuscitation and advanced cardiac life support were performed but failed to achieve return of spontaneous circulation. Approximately 24 hours after having an elective bilateral common iliac vein stenting, the patient was pronounced dead due to cardiac rupture associated with intracardiac migration of one of the venous stents. 

Case 2 

A 37-year-old male-to-female transgender patient with past medical history of chronic venous insufficiency manifesting as varicose veins presented to our ED with chest pain and syncope. Three days prior to admission, the patient underwent an elective left common iliac vein stent placement for management of varicose veins without any complications reported. 

One day after the procedure, the patient had sudden onset of chest pain and an episode of syncope while walking up the stairs. Chest pain was described as right-sided, intermittent, radiating to the back and neck, and worsened by upper body movement. Upon arrival to the ED, the patient was found to be hemodynamically stable, alert, and oriented. A transthoracic echocardiogram was performed, which showed a tubular foreign body in the right atrium. The foreign body was approximately 6 cm in length and crossed the tricuspid leaflet with impingement into the right ventricular septum (Figure 1). Given the patient’s history and imaging findings, migration of a left common iliac vein stent was suspected. 

Endovascular rather than surgical approach was considered for stent removal. Due to the location of the stent and its entanglement in the tricuspid leaflet and chordae, the interventionalist deemed endovascular retrieval to be at higher risk for structural damage to the tricuspid valve. Therefore, surgery was consulted for retrieval. The patient underwent a complex surgical repair, which included retrieval of the nitinol stent located in the right atrial free wall (Figure 2), atrial free wall repair, tricuspid valve repair, and drainage of hemorrhagic pericardial effusion. Postoperative course was uncomplicated, and the patient was discharged home.

Figures 1 and 2

Conclusion

In this report, we have presented 2 cases in which patients underwent an elective left common iliac vein stent placement for management of CVI. One of the cases had a fatal outcome due to stent migration into the right heart. 

Venous stent migration into the cardiopulmonary system is a life-threatening complication, given its risk of pulmonary infarction, tricuspid regurgitation, and potential right-sided heart failure.9,12,13 Fortunately, it is a rare complication with only a 3% incidence rate.9 

There have been several cases reported (Table 1) of stent migration causing significant structural damage and conduction abnormalities (eg, arrhythmias) that increase mortality risk. Stent migration usually occurs when stents are placed inappropriately as a result of inaccurate measurement of stent or vessel circumference, malapposition of the stent, or choice of lesion without significant degree of obstruction.14,15 In recent years, there have been pioneering interventional approaches that have emerged, given the high mortality rate of 24% to 60% in foreign body embolization.14-17 These innovative approaches have addressed the need for timely intervention in order to prevent severe complication such as cardiac arrhythmias, valve injury, and/or myocardial perforation.18,19 

There have been 2 interventional approaches described for migrated stent retrieval — endovascular and surgical retrieval.15 Based on recent literature, the endovascular approach has shown a clear superiority, with a 90% success rate compared with the surgical technique, which is associated with high mortality.16 However, in cases in which the stent has migrated beyond the tricuspid valve or pulmonary vasculature, the surgical approach should be considered.15 In the case described above, the surgical approach was preferred since it offered better visualization and maneuverability in the complex stent location. This approach reduced potential cardiac or vascular injury. Table 1

It is of prime importance to follow appropriate indications and procedural technique in order to avoid potentially life-threatening complications. Given the growing rate of venous stenting and associated life-threatening potential complications, updated guidelines with clear criteria for endovenous stenting are needed.  

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted August 28, 2017; accepted October 16, 2017.

Address for correspondence: Jenny Plácido-Disla, MD; Beth Israel Medical Center, Seymour J Phillips Library, New York, New York; Email: jedisla@mountsinai.org

References 

1. Mahnken AH, Thomson K, de Haan M, O’Sullivan GJ. CIRSE standards of practice guidelines on iliocaval stenting. Cardiovasc Intervent Radiol. 2014;37(4):889-897.

2. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 Suppl):2S-48S. 

3. Porter JM, Moneta GL Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg. 1995;21(4):635-645.

4. Raju S,  Neglén P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg. 2006;44(1):136-144. 

5. Neglén P, Thrasher TL,  Raju S. Venous outflow obstruction: an underestimated contributor to chronic venous disease. J Vasc Surg. 2003;38(5):879-885. 

6. Raju S, Mcallister S, Neglén P. Recanalization of totally occluded iliac and adjacent venous segments. J Vasc Surg. 2002;36(5):903-911.

7. Raju S, Owen S, Neglén P. The clinical impact of iliac venous stents in the management of chronic venous insufficiency. J Vasc Surg. 2002;35(1):8-15. 

8. Neglén P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg. 2007;46(5):979-900. 

9. Bani-Hani S, Showkat A, Wall BM, Das P, Huang L, Al-Absi AI. Endovascular stent migration to the right ventricle causing myocardial injury. Semin Dial. 2012;25(5):562-564. 

10. Mussa FF, Peden EK, Zhou W, Lin PH, Lumsden AB, Bush RL. Iliac vein stenting for chronic venous insufficiency. Tex Heart Inst J. 2007;34(1):60–66.

11. Bloomfield DA. The nonsurgical retrieval of intracardiac foreign bodies—an international survey. Cathet Cardiovasc Diagn. 1978;4(1):1-14. 

12. Antonucci F, Salomonowitz E, Stuckmann G, Stiefel M, Largiadèr J, Zollikofer CL. Placement of venous stents: clinical experience with a self-expanding prosthesis. Radiology. 1992;183(2):493-497.

13. Morgan R, Walser E, eds. Handbook of Angioplasty and Stenting Procedures. London, England: Springer-Verlag London Limited; 2010.

14. Taylor JD, Lehmann ED, Belli AM, et al. Strategies for the management of SVC stent migration into the right atrium. Cardiovasc Intervent Radiol. 2007;30(5):1003-1009.

15. Kang W, Kim IS, Kim JU, et al. Surgical removal of endovascular stent after migration to the right ventricle following right subclavian vein deployment for treatment of central venous stenosis. J Cardiovasc Ultrasound. 201;19(4):203-206.

16. El Feghaly M, Soula P, Rousseau H, et al. Endovascular retrieval of two migrated venous stents by means of balloon catheters. J Vasc Surg. 1998;28(3):541-546. 

17. Toyoda N, Torregrossa G, Itagaki S, Pawale A, Reddy R. Intracardiac migration of vena caval stent: decision-making and treatment considerations. J Card Surg. 2014;29(3):320-332.

18. Bernhardt LC, Wegner GP, Mendenhall JT. Intravenous catheter embolization to the pulmonary artery. Chest. 57(4):329-332. 

19. Gabelmann A, Kramer S, Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. AJR Am J Roentgenol. 2001;176(6):1509-1513.

20. Ashar RM, Huettl EA, Halligan R. Percutaneous retrieval of a Wallstent from the pulmonary artery following stent migration from the iliac vein. 2002. J Interv Cardiol. 2002;15(2):101-106.

21. Ibrahim M, Badin A, Mungee S. Fight ventricle foreign body: a case of a migrating iliac stent entrapped in the tricuspid valve. Journal of Medical Cases. 2014;5(12):636-638. 

22. Hoffer E, Materne P, Désiron Q, Marenne F, Lecoq E, Boland J. Right ventricular migration of a venous stent: An unusual cause of tricuspid regurgitation and ventricular tachycardia. Int J Cardiol.2006;112(2):e48-e49.

23. Mullens W, De Keyser J, Van Dorpe A, et al. Migration of two venous stents into the right ventricle in a patient with May–Thurner syndrome. Int J Cardiol. 2006;110(1):114-115.

24. Haskal ZJ. Massage-induced delayed venous stent migration. J Vasc Interv Radiol. 2008;19(6):945-949.