Abstract 12175: A Migrated External Iliac Stent - To Retrieve or Not to Retrieve

Abstract

Endovascular venous stenting has become a more favorable intervention for occlusive, symptomatic deep vein thromboses (DVTs), especially given its decreased complication rate and shorter recovery time than its predecessor, open venous bypass. Risks, however, still exist and can include stent fragmentation and dislodgement causing cardiopulmonary complications. A 57-year-old man with bilateral lower extremity DVTs status post left external ilio-femoral stent and inferior vena cava (IVC) filter placement presented with one month of atypical chest discomfort. CT chest showed migration of his 40cm iliac stent to the IVC and right atrium. Interventional radiology visualized both a patent stent and IVC, however, attempted endovascular removal from the distal margin failed with initial retrieval of fragments only. Other fragments subsequently embolized to the pulmonary and lower lobe arteries and right ventricles. Extraction of more distal fragments was deferred due to risks of structural damage, arrhythmias, and pulmonary vasculature perforation. Fragment analysis by pathology demonstrated evidence of clot, yet cardiothoracic surgical intervention was deferred.The patient continued to experience chest pain and underwent a repeat CT chest three months later that demonstrated the stent extending from the right atrial junction to the infrahepatic IVC. Fragmented portions of the filter in the right ventricle and multiple stent fragments retained in the right upper and bilateral lower pulmonary lobes remained as prior with no evidence of pulmonary embolism (PE), pericardial effusion, or tamponade. Although rare, stent removal complications can occur with increased risk of long-term sequelae. Stent fracturing and dislodgement can result in foreign bodies showering the pulmonary vasculature and cardiac chambers, ultimately placing patients at risk for arterial perforation or dissection, pulmonary hemorrhage, intracardiac damage, tamponade, PE, and chronic thromboembolic pulmonary hypertension (CTEPH). The consideration of such risks, in addition to early involvement of interdisciplinary teams and thorough risk-benefit discussions between patients and providers are essential when undergoing stent removal and related interventions.