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INTERESTING IMAGE
Year : 2018  |  Volume : 2  |  Issue : 3  |  Page : 191-192

Immediate and delayed distal stent migration in congenital coarctation of the aorta: Sliding over an elephant trunk!


1 Department of Cardiology, Maxcure-Mediciti Hospitals, Hyderabad, Telangana, India
2 Department of Cardio-Thoracic Surgery, Maxcure-Mediciti Hospitals, Hyderabad, Telangana, India
3 Department of Cardiac Anaesthesia, Maxcure-Mediciti Hospitals, Hyderabad, Telangana, India
4 Department of Radiodiagnosis, Maxcure-Mediciti Hospitals, Hyderabad, Telangana, India

Date of Web Publication10-Dec-2018

Correspondence Address:
Dr. Pankaj Jariwala
Maxcure.Mediciti Hospitals, Opposite Secretariat, Saifabad, Hyderabad - 500 063, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_20_18

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How to cite this article:
Jariwala P, Kale SS, Sepur L, Kesava Rao RC. Immediate and delayed distal stent migration in congenital coarctation of the aorta: Sliding over an elephant trunk!. J Indian Acad Echocardiogr Cardiovasc Imaging 2018;2:191-2

How to cite this URL:
Jariwala P, Kale SS, Sepur L, Kesava Rao RC. Immediate and delayed distal stent migration in congenital coarctation of the aorta: Sliding over an elephant trunk!. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2018 [cited 2019 Jan 16];2:191-2. Available from: http://www.jiaecho.org/text.asp?2018/2/3/191/247026



A 19-year-old adolescent girl presented with shortness of breath on exertion New York Heart Association (NYHA) Class III for 3 months. A diagnosis of the coarctation of the aorta (CoA) was made for 2 years as she complained of a recurrent headache. General examination revealed a higher blood pressure of both upper limbs and feeble lower-limb pulsations. She underwent angioplasty of CoA segment using a 20 mm × 80 mm self-expanding stent at another hospital. Stent migrated in the abdominal aorta during retrieval of the postdilatation balloon into the abdominal aorta. It was left in the abdominal aorta with postdilatation to ensure the complete apposition to the aortic wall. The procedure was completed using another 16 mm × 40 mm self-expanding stent without postdilatation. There was a reduction of gradient from 90 to 20 mmHg. The patient had relief of her symptoms with improvement in functional class to NYHA Class I.

Now, she had a recurrence of her symptoms with a systolic bruit over the epigastric region. Her computed tomography aortography demonstrated the migration of both the stents with the first stent in the midportion of abdominal aorta across the renal arteries, causing 90% ostial stenosis of the left renal artery and aneurysmal dilatation of aorta [Figure 1]c, [Figure 1]d, and [Figure 2]a, [Figure 2]c. The second stent migrated to the midportion of the thoracic aorta with a patent lumen [Figure 1]b and [Figure 2]a, [Figure 2]d. The coarcted segment of the aorta showed dissection flap and 80% residual stenosis [Figure 1]a and [Figure 2]a, [Figure 2]b.
Figure 1: Computed tomography angiography of the aorta at the level of pulmonary artery bifurcation showing curvilinear residual dissection at the site of coarctation after second stent migration (dashed arrow, Panel a). Patent migrated second stent in the axial cross-sectional view of the descending thoracic aorta behind the left atrium (Panel b). The axial cross-sections of the abdominal aorta at the renal level showed aneurysmal dilatation (Panel c) and at the level of renal arteries showed the ostial stenosis of the left renal artery (solid black arrow, Panel d). RA: Right atrium, RV: Right ventricle, LA: Left atrium, LV: Left ventricle, RPA: Right pulmonary artery, MPA: Main pulmonary artery

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Figure 2: Three-dimensional reconstructed volume-rendered aortic angiography (Panel a) showing the native coarctation of the aorta with localized dissection flap (zoomed view, Panel b) with migrated second stent into the thoracic aorta with disruption of middle part of the stent struts (zoomed view, Panel d) and aneurysmal dilatation of the abdominal aorta across the renal and visceral arteries with distorted stent struts (zoomed view, Panel c)

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She refused any interventional management and underwent surgical repair of the CoA using interposition Dacron graft with no residual stenosis. Small abdominal aortic aneurysm with the migrated stent and renal artery stenosis were followed up with the help of screening ultrasound abdomen. The patient did well postoperatively, and her symptoms improved with normalization of blood pressure and palpable peripheral pulses.

An observational study by the Congenital Cardiovascular Interventional Study Consortium compared the safety and efficacy of the balloon angioplasty, stent implantation, and surgical management among 350 patients with native coarctation of the aorta. They encountered stent migration in six patients, of which three patients had during the procedure.[1] Forbes et al. reported stent migration in 4.8% of cases in a multi-institutional registry encompassing 588 procedures.[2] Migration of aortic stent was defined in various clinical trials and case series as cranial or caudal movement of the device, relative to a vascular landmark of >4 mm.[3]

Stent migration is seen when there is oversizing or undersizing of the balloon or secondary to the rupture of the balloon and commonly seen with the balloon-expandable stents.[4] To prevent stent migration, one should use a stent with an anti-migration design may be preferred. If self-expandable stents are used for CoA as in our case, postdilation must be performed with adequate balloon angioplasty, which exerts lateral pressure and avoids stent migration.[5] The use of the Balloon-in-Balloon catheter (BIB, NuMED Inc., Hopkinton, NY, USA) may provide more control of the inflation using the better anchoring mechanism of the inner smaller balloon that is inflated first and then outer balloon inflates which prevents the slippage of balloon.[6] Furthermore, rapid pacing while the implantation of the stent can prevent the stent dislodgment.

As self-expandable stents have firm apposition with the aortic wall, they are of choice when there is a dilated thoracic aorta either proximal or distal to the coarctation site.[7]

There are hemodynamic causes of migration of aortic stents. As per the hemodynamic studies, the force exerted by the blood flow against the vessel wall at a single point is proportional to the square of the velocity of flow at that point. Thus, flow velocity is increased in tortuous arteries which leads to blood columns directly to impact on larger surface of the kinked stents and increases the chances of distal displacement.[8] However, in our case, there was no tortuosity or kink in the stent.


  Conclusion Top


In conclusion, deployment of self-expanding stent of sufficient length and proper diameter and postdilatation using BIB catheter with the help of rapid pacing can avoid migration of aortic stents.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Forbes TJ, Kim DW, Du W, Turner DR, Holzer R, Amin Z, et al. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: An observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol 2011;58:2664-74.  Back to cited text no. 1
    
2.
Forbes TJ, Garekar S, Amin Z, Zahn EM, Nykanen D, Moore P, et al. Procedural results and acute complications in stenting native and recurrent coarctation of the aorta in patients over 4 years of age: A multi-institutional study. Catheter Cardiovasc Interv 2007;70:276-85.  Back to cited text no. 2
    
3.
England A, García-Fiñana M, Fisher RK, Naik JB, Vallabhaneni SR, Brennan JA, et al. Migration of fenestrated aortic stent grafts. J Vasc Surg 2013;57:1543-52.  Back to cited text no. 3
    
4.
Kische S, D'Ancona G, Stoeckicht Y, Ortak J, Elsässer A, Ince H, et al. Percutaneous treatment of adult isthmic aortic coarctation: Acute and long-term clinical and imaging outcome with a self-expandable uncovered nitinol stent. Circ Cardiovasc Interv 2015;8. pii: e001799.  Back to cited text no. 4
    
5.
Seker T, Acele A, Topuz M, Colkesen Y. Delayed displacement of aortic coarctation stent. JACC Cardiovasc Interv 2016;9:e103-4.  Back to cited text no. 5
    
6.
Hamdan MA, Maheshwari S, Fahey JT, Hellenbrand WE. Endovascular stents for coarctation of the aorta: Initial results and intermediate-term follow-up. J Am Coll Cardiol 2001;38:1518-23.  Back to cited text no. 6
    
7.
Ghazi P, Haji-Zeinali AM. Management of stent dislodgment in coarctoplasty of aorta with three overlapping self-expandable nitinol stents. Hellenic J Cardiol 2010;51:264-6.  Back to cited text no. 7
    
8.
de Almeida MJ, Yoshida WB, Hafner L, dos Santos JH, Souza BF, Bueno FF, et al. Factors involved in the migration of endoprosthesis in patients undergoing endovascular aneurysm repair. J Vasc Bras 2010;9:61-71.  Back to cited text no. 8
    


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