- Email: [email protected]
Stent fracture in the left brachiocephalic vein
Cardiovascular Revascularization Medicine 8 (2007) 103 – 106
Case Report
Stent fracture in the left brachiocephalic vein Masamichi Wada4, Masaya Yamamoto, Masanori Shiba, Takahiro Tsuji, Raisuke Iijima, Rintaro Nakajima, Takashi Yoshitama, Hidehiko Hara, Hisao Hara, Taro Tsunoda, Masato Nakamura Division of Cardiovascular Medicine, Toho University Ohashi Medical Center Hospital, Tokyo, Japan Received 17 March 2006; accepted 27 March 2006
Abstract
A 68-year-old male hemodialysis patient presented with severe congestion in his left arm. Left arm venography showed a completely occluded left brachiocephalic vein. We chose a self-expandable stent for treating this vein. However, restenosis occurred once at 8 months and again after six additional months. The cause of the restenosis was considered to be a stent fracture. On the first restenosis, we performed redilation with a balloon; on the second restenosis, we chose stent-in-stent with a balloonexpandable stent. At least 9 months after the stent-in-stent procedure, there has been no edema in his left arm. Therefore, stent-in-stent is one of the useful strategies for stent fracture in central venous obstruction. D 2007 Published by Elsevier Inc.
Keywords:
Central vein; Stent fracture; Self-expandable stent
1. Introduction
2. Case report
Central vein obstruction in patients who have a history of hemodialysis is considered to be due to injury during or after insertion of a temporary or tunneled dialysis access catheter placed in a jugular–subclavian route. This vein obstruction can be efficiently treated by angioplasty and stent placement [1]. Stent compression or fracture has been described in the treatment of the subclavian vein for Paget–Schrotter syndrome. This condition results from compression of the subclavian vein in the thoracic outlet between the first rib and the clavicle. There have been only a few reports about stent compression in the brachiocephalic vein. The present report describes a case of stent fracture that occurred while treating an occluded brachiocephalic vein in a hemodialysis patient.
A 68-year-old male presented with swelling of his left arm and of a superficial collateral vein around his left
4 Corresponding author. Division of Cardiovascular Medicine, Toho University Ohashi Medical Center Hospital, 2-17-6 Ohashi, Meguro, Tokyo 153-8515, Japan. Tel.: +81 3 3468 1251; fax: +81 3 3468 1269. E-mail address: [email protected] (M. Wada). 1553-8389/07/$ – see front matter D 2007 Published by Elsevier Inc. doi:10.1016/j.carrev.2006.03.104
Fig. 1. Venography showing total occlusion of the LBV. The flow of the left internal jugular vein went backward (white arrow).
104
M. Wada et al. / Cardiovascular Revascularization Medicine 8 (2007) 103 – 106
Fig. 2. (A) A 1460-mm SMART stent (Cordis) was deployed in the LBV with sufficient postdilation using a 12-mm-diameter balloon. (B) After the first intervention. The flow of the left internal jugular vein followed the normal direction.
shoulder and chest. History includes hemodialysis for the past 16 years due to nephrosclerosis. He has a native left radial arteriovenous (AV) fistula for hemodialysis. In March 2004, he was admitted to our hospital. Venography revealed a total occlusion of the left brachiocephalic vein (LBV). Both the left brachial and the right femoral approaches were taken, and simultaneous injection was performed both proximal and distal to the occluded site. The flow of the left internal jugular vein went backward, and the contrast medium returned from the right internal jugular vein (Fig. 1). Superficial collateral flow was observed. An angulated 0.035-in. Radifocus guide wire (Terumo) crossed the lesion quite smoothly. The strategy for the occluded brachiocephalic vein consisted of predilatation with a 420-mm SYNERGY balloon (Boston Scientific), followed by a
1460-mm self-expandable nitinol SMART stent (Endvascular; Cordis, Warren, NJ, USA) with postdilatation at a high inflation pressure rate of 10 atm using a 1240-mm SYNERGY balloon (Boston Scientific). The stent was dilated sufficiently, and then the flow of the left internal jugular vein followed the normal direction (Fig. 2). The swelling of his left arm dramatically decreased in a few days. However, the patient returned with recurrent edema 8 months after the initial intervention. Fluoroscopy demonstrated a stent fracture at the body of the stent. Venography revealed restenosis at the fracture site of the stent (Fig. 3). Repeat angioplasty was performed with a 14-mm-diameter balloon, and the patient became free from swelling in his left arm. Four months after the repeat angioplasty, computed tomography was performed to observe the condition of the
Fig. 3. (A) Stent fracture occurred 8 months after the initial intervention. A complete separation of stent segments could be observed. (B) Venography revealed restenosis at the fracture site of the stent.
M. Wada et al. / Cardiovascular Revascularization Medicine 8 (2007) 103 – 106
Fig. 4. Reconstruction from enhanced spiral computed tomography 4 months after the second intervention. The implanted stent straddled the RBA, showing stent narrowing at the point that crossed the two vessels: the LBV and the right brachiocephalic artery.
105
stenosis of the venous lumen caused by central venous catheters. Schumacher et al. [2] and Haage et al. [3] reported that the incidence rates of central venous stenosis and occlusion in their hemodialysis population were 14% and 17%, respectively. Surgical management of central venous obstruction in the upper extremity tends to be difficult because the vessel lies deep in the thorax [4]. Percutaneous transluminal angioplasty and stent placement have been popular therapeutic alternatives to open surgery. However, their use remains controversial because multiple reinterventions are usually required to maintain stent patency. In the study of 14 hemodialysis patients who had stents placed in their central vein, Aytekin et al. [5] reported that patency rates were 92.8% at 1 month, 85.7% at 3 months, 50% at 6 months, and 14.3% at 1 year. 3.2. Mechanisms of stent restenosis in veins
stent (Fig. 4). The implanted stent straddled the right brachiocephalic artery (RBA), showing stent narrowing at the point that crossed the LBV and the RBA. At this time, he had no symptoms in his left arm. However, the edema of his left arm recurred 2 months later in May 2005. Venography revealed re-restenosis exactly at the same fracture site of the first restenosis. Intravascular ultrasound (IVUS) was performed, and the compressed site of the stent was observed (Fig. 5). This time, we chose stent-in-stent with Palmaz (8.040 mm, Endvascular; Cordis), of which the center was placed at the fracture site (Fig. 6).
3. Discussion 3.1. Central venous obstruction Central venous obstruction is one of the most common reasons for shunt dysfunction in chronic hemodialysis patients. This obstruction is considered to be due to high flow states, turbulence, platelet aggregation, fibrosis, and
Stent occlusion or restenosis is usually caused by excessive proliferation of the neointima. Thrombus or stent fracture can be another reason for restenosis. Stent compression or fracture has been identified in lesions prone to external compression (neck, groin, and limbs), including subclavian veins. To our knowledge, there has been only one report of stent compression in the LBV [6]. Hammer et al. suggest that the particular anatomic location of the LBV is the only explanation for stent compression. This vein passes through a space delineated anteriorly by the posterior osseous cortical of the manubrium, posteriorly by the aortic arch, and cranially by the emerging RBA. Pulsation of arterial vessels, in conjunction with respiratory motions of the chest wall, reduces the space between the sternum and the aortic arch during expiration and could thus explain the mechanical constraints that rapidly lead to an external twopoint compression of the stent in the anteroposterior axis. We agree with this statement; however, we consider that the following two reasons also play a role in stent fracture: pulsation of the RBA and stiffness of the aorta and arteries
Fig. 5. IVUS images of the compressed site of the stent. (A) Longitudinal view. (B) Axial view.
106
M. Wada et al. / Cardiovascular Revascularization Medicine 8 (2007) 103 – 106
Fig. 6. (A) Fluoroscopy after stent-in-stent with a 8.040-mm Palmaz stent. (B) IVUS images after stent-in-stent.
due to severe calcification. Stents that straddle the calcified hard vessel, which is constantly bent by respiratory motions of the chest wall, may finally cause stent fracture.
radial force. This is one of the useful strategies for central venous obstruction.
3.3. Clinical implications
References
Hemodialysis-related venous stenosis and central venous occlusion after prolonged use of dialysis catheters are not rare complications. According to the literature, closure of an ipsilateral dialysis AV fistula should be considered to treat these complications in the first place [6] because reconstructive venous surgery for central venous obstruction is highly invasive, technically challenging, and associated with high morbidity. In the real clinical situation, however, making a decision on whether to close an AV fistula is not easy not only for patients but also for physicians. If better stents (which are able to prevent compression and restenosis) can be developed, stenting may become a first choice for central venous obstructions. In this case, we chose stent-in-stent with a balloonexpandable stent at the fracture site in order to get a stronger
[1] Petersen BD, Uchida HT. Long-term results of treatment of benign central venous obstructions unrelated to dialysis with expandable Z stents. J Vasc Interv Radiol 1999;10:757 – 66. [2] Schumacher KA, Wallner B, Weidenmaier W, Friedrich JM. Shuntferne venose okklusionen als storungsfaktor bei der hamodialyse. ROFO 1989;150:198 – 201. [3] Haage P, Vorwerk D, Piroth W, Schuermann K, Guenther RW. Treatment of hemodialysis-related central venous stenosis or occlusion: results of primary Wallstent placement and follow-up in 50 patients. Radiology 1999;212:175 – 80. [4] Currier CB, Widder S, Ali A, Kuusisto E, Sidawy A. Surgical management of subclavian and axillary vein thrombosis in patients with a functioning arteriovenous fistula. Surgery 1986;100:25 – 8. [5] Aytekin C, Boyvat F, Yagmurdur MC, Moray G, Haberal M. Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients. Eur J Radiol 2004;49:81 – 5. [6] Hammer F, Becker D, Goffette P, Mathurin P. Crushed stent in benign left brachiocephalic vein stenoses. J Vasc Surg 2000;32:392 – 6.
Case Report
Stent fracture in the left brachiocephalic vein Masamichi Wada4, Masaya Yamamoto, Masanori Shiba, Takahiro Tsuji, Raisuke Iijima, Rintaro Nakajima, Takashi Yoshitama, Hidehiko Hara, Hisao Hara, Taro Tsunoda, Masato Nakamura Division of Cardiovascular Medicine, Toho University Ohashi Medical Center Hospital, Tokyo, Japan Received 17 March 2006; accepted 27 March 2006
Abstract
A 68-year-old male hemodialysis patient presented with severe congestion in his left arm. Left arm venography showed a completely occluded left brachiocephalic vein. We chose a self-expandable stent for treating this vein. However, restenosis occurred once at 8 months and again after six additional months. The cause of the restenosis was considered to be a stent fracture. On the first restenosis, we performed redilation with a balloon; on the second restenosis, we chose stent-in-stent with a balloonexpandable stent. At least 9 months after the stent-in-stent procedure, there has been no edema in his left arm. Therefore, stent-in-stent is one of the useful strategies for stent fracture in central venous obstruction. D 2007 Published by Elsevier Inc.
Keywords:
Central vein; Stent fracture; Self-expandable stent
1. Introduction
2. Case report
Central vein obstruction in patients who have a history of hemodialysis is considered to be due to injury during or after insertion of a temporary or tunneled dialysis access catheter placed in a jugular–subclavian route. This vein obstruction can be efficiently treated by angioplasty and stent placement [1]. Stent compression or fracture has been described in the treatment of the subclavian vein for Paget–Schrotter syndrome. This condition results from compression of the subclavian vein in the thoracic outlet between the first rib and the clavicle. There have been only a few reports about stent compression in the brachiocephalic vein. The present report describes a case of stent fracture that occurred while treating an occluded brachiocephalic vein in a hemodialysis patient.
A 68-year-old male presented with swelling of his left arm and of a superficial collateral vein around his left
4 Corresponding author. Division of Cardiovascular Medicine, Toho University Ohashi Medical Center Hospital, 2-17-6 Ohashi, Meguro, Tokyo 153-8515, Japan. Tel.: +81 3 3468 1251; fax: +81 3 3468 1269. E-mail address: [email protected] (M. Wada). 1553-8389/07/$ – see front matter D 2007 Published by Elsevier Inc. doi:10.1016/j.carrev.2006.03.104
Fig. 1. Venography showing total occlusion of the LBV. The flow of the left internal jugular vein went backward (white arrow).
104
M. Wada et al. / Cardiovascular Revascularization Medicine 8 (2007) 103 – 106
Fig. 2. (A) A 1460-mm SMART stent (Cordis) was deployed in the LBV with sufficient postdilation using a 12-mm-diameter balloon. (B) After the first intervention. The flow of the left internal jugular vein followed the normal direction.
shoulder and chest. History includes hemodialysis for the past 16 years due to nephrosclerosis. He has a native left radial arteriovenous (AV) fistula for hemodialysis. In March 2004, he was admitted to our hospital. Venography revealed a total occlusion of the left brachiocephalic vein (LBV). Both the left brachial and the right femoral approaches were taken, and simultaneous injection was performed both proximal and distal to the occluded site. The flow of the left internal jugular vein went backward, and the contrast medium returned from the right internal jugular vein (Fig. 1). Superficial collateral flow was observed. An angulated 0.035-in. Radifocus guide wire (Terumo) crossed the lesion quite smoothly. The strategy for the occluded brachiocephalic vein consisted of predilatation with a 420-mm SYNERGY balloon (Boston Scientific), followed by a
1460-mm self-expandable nitinol SMART stent (Endvascular; Cordis, Warren, NJ, USA) with postdilatation at a high inflation pressure rate of 10 atm using a 1240-mm SYNERGY balloon (Boston Scientific). The stent was dilated sufficiently, and then the flow of the left internal jugular vein followed the normal direction (Fig. 2). The swelling of his left arm dramatically decreased in a few days. However, the patient returned with recurrent edema 8 months after the initial intervention. Fluoroscopy demonstrated a stent fracture at the body of the stent. Venography revealed restenosis at the fracture site of the stent (Fig. 3). Repeat angioplasty was performed with a 14-mm-diameter balloon, and the patient became free from swelling in his left arm. Four months after the repeat angioplasty, computed tomography was performed to observe the condition of the
Fig. 3. (A) Stent fracture occurred 8 months after the initial intervention. A complete separation of stent segments could be observed. (B) Venography revealed restenosis at the fracture site of the stent.
M. Wada et al. / Cardiovascular Revascularization Medicine 8 (2007) 103 – 106
Fig. 4. Reconstruction from enhanced spiral computed tomography 4 months after the second intervention. The implanted stent straddled the RBA, showing stent narrowing at the point that crossed the two vessels: the LBV and the right brachiocephalic artery.
105
stenosis of the venous lumen caused by central venous catheters. Schumacher et al. [2] and Haage et al. [3] reported that the incidence rates of central venous stenosis and occlusion in their hemodialysis population were 14% and 17%, respectively. Surgical management of central venous obstruction in the upper extremity tends to be difficult because the vessel lies deep in the thorax [4]. Percutaneous transluminal angioplasty and stent placement have been popular therapeutic alternatives to open surgery. However, their use remains controversial because multiple reinterventions are usually required to maintain stent patency. In the study of 14 hemodialysis patients who had stents placed in their central vein, Aytekin et al. [5] reported that patency rates were 92.8% at 1 month, 85.7% at 3 months, 50% at 6 months, and 14.3% at 1 year. 3.2. Mechanisms of stent restenosis in veins
stent (Fig. 4). The implanted stent straddled the right brachiocephalic artery (RBA), showing stent narrowing at the point that crossed the LBV and the RBA. At this time, he had no symptoms in his left arm. However, the edema of his left arm recurred 2 months later in May 2005. Venography revealed re-restenosis exactly at the same fracture site of the first restenosis. Intravascular ultrasound (IVUS) was performed, and the compressed site of the stent was observed (Fig. 5). This time, we chose stent-in-stent with Palmaz (8.040 mm, Endvascular; Cordis), of which the center was placed at the fracture site (Fig. 6).
3. Discussion 3.1. Central venous obstruction Central venous obstruction is one of the most common reasons for shunt dysfunction in chronic hemodialysis patients. This obstruction is considered to be due to high flow states, turbulence, platelet aggregation, fibrosis, and
Stent occlusion or restenosis is usually caused by excessive proliferation of the neointima. Thrombus or stent fracture can be another reason for restenosis. Stent compression or fracture has been identified in lesions prone to external compression (neck, groin, and limbs), including subclavian veins. To our knowledge, there has been only one report of stent compression in the LBV [6]. Hammer et al. suggest that the particular anatomic location of the LBV is the only explanation for stent compression. This vein passes through a space delineated anteriorly by the posterior osseous cortical of the manubrium, posteriorly by the aortic arch, and cranially by the emerging RBA. Pulsation of arterial vessels, in conjunction with respiratory motions of the chest wall, reduces the space between the sternum and the aortic arch during expiration and could thus explain the mechanical constraints that rapidly lead to an external twopoint compression of the stent in the anteroposterior axis. We agree with this statement; however, we consider that the following two reasons also play a role in stent fracture: pulsation of the RBA and stiffness of the aorta and arteries
Fig. 5. IVUS images of the compressed site of the stent. (A) Longitudinal view. (B) Axial view.
106
M. Wada et al. / Cardiovascular Revascularization Medicine 8 (2007) 103 – 106
Fig. 6. (A) Fluoroscopy after stent-in-stent with a 8.040-mm Palmaz stent. (B) IVUS images after stent-in-stent.
due to severe calcification. Stents that straddle the calcified hard vessel, which is constantly bent by respiratory motions of the chest wall, may finally cause stent fracture.
radial force. This is one of the useful strategies for central venous obstruction.
3.3. Clinical implications
References
Hemodialysis-related venous stenosis and central venous occlusion after prolonged use of dialysis catheters are not rare complications. According to the literature, closure of an ipsilateral dialysis AV fistula should be considered to treat these complications in the first place [6] because reconstructive venous surgery for central venous obstruction is highly invasive, technically challenging, and associated with high morbidity. In the real clinical situation, however, making a decision on whether to close an AV fistula is not easy not only for patients but also for physicians. If better stents (which are able to prevent compression and restenosis) can be developed, stenting may become a first choice for central venous obstructions. In this case, we chose stent-in-stent with a balloonexpandable stent at the fracture site in order to get a stronger
[1] Petersen BD, Uchida HT. Long-term results of treatment of benign central venous obstructions unrelated to dialysis with expandable Z stents. J Vasc Interv Radiol 1999;10:757 – 66. [2] Schumacher KA, Wallner B, Weidenmaier W, Friedrich JM. Shuntferne venose okklusionen als storungsfaktor bei der hamodialyse. ROFO 1989;150:198 – 201. [3] Haage P, Vorwerk D, Piroth W, Schuermann K, Guenther RW. Treatment of hemodialysis-related central venous stenosis or occlusion: results of primary Wallstent placement and follow-up in 50 patients. Radiology 1999;212:175 – 80. [4] Currier CB, Widder S, Ali A, Kuusisto E, Sidawy A. Surgical management of subclavian and axillary vein thrombosis in patients with a functioning arteriovenous fistula. Surgery 1986;100:25 – 8. [5] Aytekin C, Boyvat F, Yagmurdur MC, Moray G, Haberal M. Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients. Eur J Radiol 2004;49:81 – 5. [6] Hammer F, Becker D, Goffette P, Mathurin P. Crushed stent in benign left brachiocephalic vein stenoses. J Vasc Surg 2000;32:392 – 6.