Proximal aortic stent migration

Abstract

A 21-year-old man underwent stent implantation (8Z45CP stent on 18 mm BiB-balloon, Numed, Hopkinton, NY) for a recurrent aortic obstruction, after previous repair of an aortic interruption type A. At the age of two weeks after birth an end-to-side anastomosis of the descending aorta onto the distal arch (left subclavian artery) was performed. Diagnosis of restenosis was based upon upper limb hypertension, a diastolic run-off with echo-Doppler, and an invasive systolic gradient of 36 mmHg (Fig. 1). Stenting was followed by post-dilatation with a 20 mm high pressure balloon. The peak systolic gradient decreased from 15 to 0 mmHg and the diameter increased from 11 to 17 mm (Fig. 1). One year later, transthoracic echocardiography (TTE) suggested a more proximal position of the stent, which was confirmed with a CT scan (Figs. 2 and 3). Systolic gradients were measured during diagnostic catheterisation (Fig. 1) and with angiography the position of the stent was further visualised. The case was discussed within our team and with external experts. Two treatment options were considered. One option was fixation of the stent with one or two distal stents including redilatation of the narrowed segment. The second option was surgical removal of the stent with reconstruction of the aortic arch. Although the votes were divided, surgical intervention was our preferred approach. At surgery the stenotic part of the aorta was resected and the stent removed. In the ascending aorta an unexpected ulceration due to an eroding effect of the proximal stent end was found. This potentially lethal lesion was included in the resection as well. Aortic arch reconstruction was performed with interposition of a 24 mm vascular graft between the ascending and descending aorta, with replantation of the subclavian artery in the prosthesis. Surgery was successful and postoperative recovery was uncomplicated (Fig. 2). Four years after surgery no further complications occurred and the patient was normotensive without medication. The anatomical situation assessed with CT was excellent (Fig. 3).