Veins, stenosis or obstruction, Stents and prostheses

A 60-year-old women

End stage renal disease diagnosed since December 1999 with a long-standing diabetes mellitus and hypertension. Peritoneal dialysis for 6 months and hemodialysis from June 2000 due to the aggravation of uremic symptoms were done. Hemodialysis was initially done with permanent catheter through the left and right subclavian veins (SCV), but discontinued due to SCV stenosis. Left AVF was created but failed; subsequently, right side AVF was created for hemodialysis. The patient was admitted for PTA of the right SCV.

Right subclavian vein stenosis and stent migration

Initial venogram obtained prior to any intervention treatment shows a focal stenosis of the right innominate vein (Fig. 1). A 240-cm long exchangeable guidewire was snared and retrieved from the puncture site in the femoral vein. PTA was then performed with a 12×20-mm balloon, but the stenotic portion was not relieved. A 16×50mm Wallstent (Boston Scientific, Watertown, MA, U.S.A.) was then deployed to cover from the right SCV to the right innominate vein followed by poststenting dilatation with a 12×20mm balloon (Boston Scientific, Natick, MA, U.S.A.) (Fig. 2). Venogram taken immediately following the complete deployment of the stent shows the relief of stenosis as well as patent venous flow (Fig. 3). However, followup Chest PA taken on the following day showed (not shown here) the downward migration of the stent, and venogram taken on the following day shows the downward migration of the stent, locating in the SVC and persistent stenosis in the same costoclavicular region, at the distal end of the previously inserted stent(Fig. 4). Subsequently, an additional, 16×50mm sized, Wallstent was again deployed followed by the poststenting dilatation with a 12×40mm balloon(Boston Scientific, Natick, MA, U.S.A.) (Fig. 5 and 6). Venogram taken after the insertion of the second stent shows patent venous flow throughout the stents with the disappearance of collateral vessels (Fig. 7).

According to the study done by Kalman et al, the most common cause of upper extremity central vein stenosis/occlusion was secondary to an indwelling catheter, followed by so called, “thoracic outlet syndrome”. Treatment modalities applied in radiologic intervention to relieve upper extremity central vein stenosis/occlusion include thrombolysis, balloon angioplasty and stent. Among them, stent insertion is the last resort to relieve stenosis, especially when balloon angioplasty and surgical decompression fail, and Wallstents are preferred due to its radial flexibility with arm motion. In deployment of a stent in the costoclavicular region, the issue of stent fracture or extrinsic compression at the thoracic outlet causing stenosis or venous occlusion has been a concern. Thoracic outlet syndrome occurs when mechanical compression of the subclvian vein (SCV) by the scalenus anticus tendon posteriorly, subcalvius tendon anteriorly, and exostoses that can arise from the superior margin of the first rib at the thoracic outlet. The degree of impingement is aggravated with abduction of the arm. Successful surgical decompression by first-rib resection, scalenectomy and circumferential venolysis has been documented. Moreover, a case with successful interventional treatment solely with metallic stent has been published. However, in this case, instead of kinking or compression or fracture, a migration of the stent occurred, and it was successfully treated by the insertion of an additional stent. Therefore, when the deployment of a stent across the costoclavicular region to relieve stenosis/occlusion, all the possible complications arising from it should be taken into consideration seriously, and a careful follow-up is advised.

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