Management of Migration of a SVC Wallstent into the Right Atrium

Abstract

Computed tomography (CT) demonstrated a large right upper lobe mass and mediastinal lymphadenopathy compressing the SVC (Fig. 1). The tumor was too advanced for radical radiotherapy. SVC stenting was performed via the right common femoral vein. The SVC was easily traversed using a Headhunter catheter (Torcon NB Advantage Hinck; William Cook, Europe) and a 3-mm ‘J’ guidewire (Inwire, 0.035-in.; Merit Medical, Galway, Ireland). A SVC cavogram was performed by injection of contrast via a 4-Fr pigtail catheter in the right brachiocephalic vein. This confirmed 80% stenosis of the SVC due to external compression by the tumor. After predilation with a 16 9 40mm balloon (XXL balloon dilation catheter; Boston Scientific, Galway, Ireland), a 16 9 40-mm Wallstent (Boston Scientific) was advanced and deployed over a 260cm (0.035-in.) Amplatz guidewire (Boston Scientific) via a 10-Fr introducer (Super Sheath XL; Boston Scientific). However, the stent migrated on deployment, so that only a short segment was within the SVC lesion and about 90% within the right atrium (Fig. 2). The Amplatz guidewire was still in a satisfactory position traversing the lumen of the stent. No mechanism of retrieving the stent was thought suitable, and so to stabilize the stent a second, 16 9 60mm Wallstent was deployed superior to and overlapping the first stent. While the degree of overlap initially appeared satisfactory, the second stent subsequently shortened such that there was insufficient overlap. Therefore a third, 16 9 40-mm Wallstent was deployed across the junction of the two indwelling stents to form a brace. A 16 9 40-mm balloon dilation catheter (Boston Scientific) was serially inflated within the overlapping stents to maximize the interlock. An SVC cavogram (Fig. 3), via a pigtail catheter in the right brachiocephalic vein, showed good flow through the stents, with little filling of collateral vessels. Another SVC cavogram, at 8 frames per second, showed no significant movement of the stents. The patient was commenced on warfarin to reduce the chance of thrombus formation. Transthoracic echocardiography performed 24 h postprocedure also confirmed that there was no significant stent motion during the cardiac cycle. The patient obtained good symptomatic relief from her SVCO and underwent palliative radiotherapy. CT performed 1 month later showed no significant change in the position of the stents or thrombus formation. Subsequently she developed recurrent right pleural effusion and died 6 weeks following the procedure from causes unrelated to the SVC stent. M. J. Warren (&) Diagnostic Imaging, Luton and Dunstable NHS Foundation Trust Hospital, Lewsey Road, Luton LU4 ODZ, UK e-mail: martin.warren@ldh.nhs.uk