Severe Tricuspid Regurgitation Secondary to Subclavian Vein Stent Migration

Article Outline

• Abstract
• Introduction
• Case Report
• Discussion
• References
• Copyright

Long term central venous access is associated with many complications such as central venous stenosis which can occur in up to half of long term central lines. Many treatment modalities are employed such as transluminal angioplasty, arthrectomy and stents to improve vascular flow. We report a case of a subclavian vein stent migration to the right atrium causing tricuspid valve regurgitation. The patient was asymptomatic and therefore treated conservatively.

Keywords: Subclavian vein thrombosis, Vascular stent migration, Tricuspid regurgitation

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Introduction 

Iatrogenic stenosis of the subclavian and internal jugular veins is common in patients needing central lines long term for dialysis or as part of treatment/monitoring on the intensive care unit, with an incidence of up to 50%.¹ Treatment is difficult as these veins respond poorly to angioplasty alone and often require metallic stents to ensure patency.² These stents are not without complications. Reports of stent fracture, thrombosis and vessel rupture abound in the literature. Stent migration can occur when used in large central veins leading to severe consequences such as pulmonary infarction and tricuspid regurgitation and right side heart failure.³, ⁴

We report a case of a subclavian vein stent which migrated into the right heart and lodged in the tricuspid valve causing severe tricuspid regurgitation and florid physical signs. We also discuss the management options.

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Case Report 

A 65 year old male presented to the vascular surgery unit at the New Cross Hospital, Wolverhampton with a pulsatile swelling of the right groin. This was diagnosed as a false femoral artery aneurysm. He had end stage renal failure and was on haemodialysis three times a week via a right brachiocepahic fistula. He also suffered from peripheral vascular disease, ischaemic heart disease and had a previously repaired abdominal aortic aneurysm, right carotid endarterectomy and a right femoro- popliteal bypass graft. His previous central line access had caused a stenosis and this was treated with a 14×70 mm wall stent three years previously.

On examination he had a right brachiocephalic arteriovenous fistula (AVF), prominent peripheral vein in the superior vena cava territory, a pulsatile liver and pulsatile left long saphenous vein (LSV). Since there was a false aneurysm of the left femoral artery it was assumed at this stage that the pulsatile nature of LSV was probably due to formation of an AVF between the femoral artery and the LSV. A CT scan did not show any communication between these vessels; however an echo reported left ventricular hypertrophy, mild mitral regurgitation and severe tricuspid regurgitation and a grossly dilated and pulsatile inferior vena cava. It also demonstrated a hollow device in the right atrium in close proximity to the tricuspid valve complex, which was preventing the closure of this valve hence the presence of tricuspid regurgitation.

In retrospect a CT scan a few years earlier had shown the presence of the stent in the right atrium (Fig. 1, Fig. 2) but the patient remained asymptomatic. Over the next few days the LSV stopped pulsating and the patient remained asymptomatic. Therefore wait and watch policy was deployed.

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• Fig. 1 

  Axial CT scan showing a wall stent (arrow) in the right atrium.

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• Fig. 2 

  A coronal CT showing a wall stent in right atrium (arrow) impinging on tricuspid valve.

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Discussion 

About 50% of patients with long term catheters will develop central venous stenosis.¹ A number will require insertion of metallic stents and so the overall incidence of stent migration will increase. The cause of stent migration is not quite clear but poor insertion technique and excess mobility e.g. around the shoulder joint with the stent working its way loose have been implicated.

If the migrated stent causes no immediate life threatening complications watchful waiting has been advised.⁵ However, possible intracardiac thrombosis, embolisation into the pulmonary artery branches with possible lung infarction and infection are indications for intervention.³, ⁶ Our patient's regurgitation settled spontaneously and so far he has not developed any of these complications. Intervention when needed is usually by percutaneous image guided snaring of the migrated stent.

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References 

1. Scillinger F, Schillinger D, Montagnac R, Micent T. Post-Catheterisation vein stenosis in haemodialysis: comparative angiographic studying 50 subclavian +50 jugular access. Nephrol Dial Transplant. 1991;6:722–724
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2. Haage P, Vorwerk D, Piroth W, Schuermann K, Guenther RW. Treatment of haemodialysis related central venous stenosis or occlusion: result of primary wallstent placement. Radiology. 1999;212:175–180
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3. Sharma AK, Sinha S, Bakran A. Migration of intravascular metallic stent into pulmonary artery. Nephrol Dial Transplant. 2002;17(3):511
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4. 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 Sep 20;112(2):e48–e49[Epub 2006 Jul 24]
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5. Marcy P, Magie R, Bruneton JN. Strecker stent migration into pulmonary artery: long term result of wait and see attitude. Eur Radiol. 2001;11:767–770
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6. Linka AZ, Jenni R. Migration of intrahepatic potosystemic stent into right ventricle: an unusual cause of trisuspid regurgitation. Circulation. 2001;103:161
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