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Intraspinal Iliac Venous Stent Migration with Lumbar Nerve Root Compression
Journal Pre-proof Intra-spinal iliac venous stent migration with lumbar nerve roots compression: a case report Mélissa Di Santo, MD, Asmae Belhaj, MD, PHD, Benoit Rondelet, MD, PHD, Thierry Gustin, MD PII:
S1878-8750(20)30293-X
DOI:
https://doi.org/10.1016/j.wneu.2020.02.028
Reference:
WNEU 14303
To appear in:
World Neurosurgery
Received Date: 10 November 2019 Revised Date:
3 February 2020
Accepted Date: 4 February 2020
Please cite this article as: Di Santo M, Belhaj A, Rondelet B, Gustin T, Intra-spinal iliac venous stent migration with lumbar nerve roots compression: a case report, World Neurosurgery (2020), doi: https:// doi.org/10.1016/j.wneu.2020.02.028. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
Manuscript title: Intra-spinal iliac venous stent migration with lumbar nerve roots compression: a case report Author and coauthors: Mélissa Di Santo¹, MD, Asmae Belhaj², MD, PHD, Benoit Rondelet², MD, PHD and Thierry Gustin¹, MD. Neurosurger y¹ and Vas cul ar S urger y² Departm ents , CHU Universi t y Hospital Center, Université Catholique de Louvain (UCL),Yvoir, Namur, Belgium Corresponding Author contact information: Name : Di Santo Mélissa, M.D., Address1: Department of Neurosurgery CHU University Hospital Center, (Mont-Godinne) Université Catholique de Louvain (UCL), Avenue du Dr Gaston Thérasse, 1, 5530 Yvoir, Belgium Mailing address: [email protected] Telephone number: +32 (0)81 423 191 Fax number: +32 (0)81 42.33.34 Key words: Ectopic intra-spinal stent, endovascular stent, stent migration. Short title: I n t r a - s p i n a l i l i a c v e n o u s s t e n t m i g r a t i o n Limits : None No financial interest, or support. Diclosure of funding : The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Portions of this work were presented in poster form at the Belgian Society of Neurosurgery n.p.o. (BSN meeting) on March 17, 2018, in Leuven, with BSN 2018 best Poster prize. 1
Present address :
Saint Luc academic hospital, Université Catholique de Louvain (UCL) Avenue Hippocrate, 10 1200 Woluwe-Saint-Lambert, Belgium
I n t r a - s p i n a l i l i a c v e n o u s s t e n t mi s p l a c e me n t w i th l u mb a r n e r v e r o o t s c o mp r e s s io n : a c a s e r e p o r t Abstract Background Venous stenting is a common treatment for chronic peripheral venous disease. The most frequent complications caused by this technique are stent misplacement and intra-cardiac or intra-vascular stent migration. In this publication, we will describe the first case of an intra-spinal stent misplacement, leading to lumbar nerve root compression. Case Description Our patient is a 20-year-old woman with a bilateral pulmonary embolism caused by a right common iliac vein thrombosis and a severe compression of the left common iliac vein by the right common iliac artery (May-Thurner or Cockett syndrome). She underwent an endovascular stenting of the left iliac vein. A few days later, she reported some pain in the right L5 radicular, showed signs of hypoesthesia of the left leg and of paresis of the left extensor hallucis longus muscle. A lumbar computed tomography scan showed a stent misplacement into the spinal canal through the left L5 foramen with nerve root compression. She underwent a surgical removal of the stent through a unilateral L5-S1 laminarthrectomy. The postoperative follow-up showed a complete clinical recovery and a control lumbar CT-scan confirmed the L5 nerve roots decompression. Conclusion The intra-spinal misplacement of a venous stent is a rare complication which may cause nerve root injury. It requires a prompt treatment. Surgically removing the stent by a posterior approach seems to be a simple and safe therapeutic option. KEY WORDS: Ectopic intra-spinal stent, endovascular stent, stent migration
Main text Introduction Common iliac vein stenting is a frequent procedure to treat post-thrombotic syndrome or other chronic venous diseases 1-6. One of the complications caused by this technique are the migration of the stent into the heart or into a large vessel 7-10. However, intra-spinal deployment of a stent through a lumbar vein is a very rare complication, which was never described before. It can lead to severe nerve root compression. We report the first case of a symptomatic patient and describe the surgical technique used to remove the stent through a posterior approach. Case description A 20-year-old woman with a history of multiple sclerosis was admitted to our hospital for a bilateral pulmonary embolism. Radiological investigations showed a right common iliac vein thrombosis and a severe compression of the left common iliac vein by the right common iliac artery (May-Thurner or Cockett syndrome). Hematological tests also revealed a thrombophilia related to a factor V of Leyden mutation. After six months of anticoagulation, the right iliac vein was permeable again. The patient then underwent an endovascular stenting procedure (Wallstent ®, size 18mm x 60mm, Boston Scientific, MA 01760-1537 USA) of the left iliac vein in order to remove the arterial compression. The procedure was technically difficult. After deploying the stent, a satisfying venous 1
opacification could not be obtained despite several attempts. The procedure was therefore interrupted, as the stent seemed well placed and projected along the common iliac vein on frontal xrays (Figure 1). However, no lateral x-rays were performed. A few days later, the patient started to feel some pain in the right L5 radicular and showed signs of hypoesthesia of the left leg and of paresis of the left extensor hallucis longus muscle. A lumbar computed tomography (CT)-scan was made and showed that the stent had entered a lumbar vein and had been deployed into the spinal canal through the left L5 foramen in which the nerve root was severely compressed. The stent had crossed the spinal canal beforehand and ended up under the right L5 root emergence (figure 2.A-C). An electromyography confirmed a severe L5 radiculopathy on the left side. Despite the risk of venous rupture, intra-spinal bleeding or root injury, an attempt was made to perform an endovascular extraction of the stent. However, the iliac phlebography did not show any opacification of the lumbar vein, suggesting its occlusion. We decided therefore to surgically remove the stent through a left unilateral L5-S1 laminarthrectomy. The intra-spinal and foraminal part of the stent was easily exposed. The vein wall was very thin and the vessel was no longer permeable. There was no haematoma in the spinal canal or foramen. The stent was cut with scissors at the lateral part of the spinal canal and was then progressively removed wire by wire (Figure 3.A). The left L5 root was completely released (Figure 3.B). There was no cerebrospinal fluid leak and no bleeding from the lumbar vein. In the postoperative course, radicular pain disappeared and sensibility of the left leg improved. A control lumbar CT-scan confirmed the L5 nerve roots decompression (Figure 4.A) and showed only a few small metallic particles remaining in the spinal canal (figure 4.B). At the last follow-up, one year after the surgery, clinical recovery was complete. Discussion Peripheral venous stenting is an increasingly used procedure to treat chronic venous diseases. It has obtained good results, as reported in the literature 1-5. Stent migration or misplacement is a potentially dramatic complication of this technique and can sometimes be fatal 8. However, only a few cases were described in the litterature7-10. In most reported cases, the stent migrated into the inferior vena cava, the heart or the pulmonary artery 7-10. An intra-spinal deployment or migration of a venous stent was however never described. In our case, the guiding catheter probably penetrated into a lumbar vein that followed the same trajectory as the iliac vein. The hypothesis that the stent was initially deployed in the iliac vein and migrated secondarily into a lumbar vein is very unlikely because of the difference in caliber of the two vessels. The inaccurate deployment of the stent into this small vessel likely prevented its opacification and the fact that stent had been misplaced was therefore not detected at the end of the procedure. The absence of lateral x-rays during the procedure was crucial and may explain this pitfall. This case demonstrates that the placement of a venous stent should be continuously monitored by doing a frontal but also lateral fluoroscopy with different obliquities. Stent migration into the spinal canal can result in a severe nerve root lamination, due to high radial forces exerted by the self-expanding Wallstent (1.5 to 2 N/mm). Because of the severity of the radicular symptoms, the stent should be retrieved as soon as possible. Unlike cases where the stent migrates into the heart or large veins, the percutaneous endovascular extraction of the stent was impossible in our patient. Removing it surgically was therefore the only option. In the case of a braided stent, a small unilateral posterior approach in which the stent is cut in its middle seems easy 2
and safe. For a stent composed of welded struts however, the exposure would be much larger, and the procedure could be more difficult. Due to the risk of proximal venous rupture during the stent removal, a radiologist or a vascular surgeon should be ready to intervene by an endovascular or open surgical route. Conclusion The intra-spinal misplacement of a venous stent causing nerve root injury is a rare complication. However, it might be more frequent in the future because of the increasing use of this technique. Vascular surgeons and neurosurgeons should be aware of this complication which requires a prompt treatment. Surgically removing the stent through a small laminarthrectomy is feasible, safe and effective. Source of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict(s)-of-Interest/Disclosure(s): The authors report no conflicts of interest and have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Abbreviations list CT: Computed tomography N/mm: newton/millimeter References list 1. Falcoz MT, Falvo N, Aho-Glélé S, et al; Burgundy Research; Study Group on Treatment of Venous Diseases. Endovascular stent placement for chronic post-thrombotic symptomatic iliofemoral venous obstructive lesions: a single-center study of safety, efficacy and quality-of-life improvement. Quant Imaging Med Surg. 2016;6(04):342–352. DOI: 10.21037/qims.2016.07.07 2. Razavi MK, Jaff MR, Miller LE. Safety and effectiveness of stent placement for iliofemoral venous outflow obstruction: systematic review and meta-analysis. Circ Cardiovasc Interv . 2015;8: e002772. DOI: 10.1161/CIRCINTERVENTIONS.115.002772. 3. Neglén P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stentrelated outcome, clinical, and hemodynamic result. J Vasc Surg. 2007; 46:979-90. DOI: 10.1016/j.jvs.2007.06.046. 4. Hartung O, Otero A, Boufi M, De Caridi G, Barthelemy P, Juhan C, Alimi YS. Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease. J Vasc Surg. 2005;42:1138-44. DOI: 10.1016/j.jvs.2005.08.012. 5. Schwarzbach MH, Schumacher H, Böckler D, Fürstenberger S, Thomas F, Seelos R, Richter GM, Allenberg JR. Surgical thrombectomy followed by intraoperative endovascular
3
reconstruction for symptomatic ilio-femoral venous thrombosis. Eur J Vasc Endovasc Surg. 2005;29:58-66. DOI: 10.1016/j.ejvs.2004.09.022. 6. Mahnken AH, Thomson K, de Haan M, O’Sullivan GJ. CIRSE Standards of Practice Guidelines on Iliocaval Stenting. Cardiovasc Intervent Radiol. 2014;37:889–897. Doi: 10.1007/s00270-014-0875-4. 7. Holst T, Großwendt T, Laham MM, Roosta-Azad M, Zandi A, Kamler M. Acute Stent Migration into the Right Ventricle in a Patient with Iliac Vein Stenting. Thorac Cardiovasc Surg. 2018;7 (1):e7-e8. DOI: 10.1055/s-0038-1629898. 8. Steinberg E, Gentile C, HellerM, Kaban N, Bang E, Li T. Intracardiac venous stent migration: emergency department presentation of a catastrophic complication. J Emerg Med. 2017;53(01): e11–e13. DOI : 10.1016/j.jemermed.2017.01.053 9. Ashar RM, Huettl EA, Halligan R. Percutaneous retrieval of a Wallstent from the pulmonary artery following stent migration from the iliac vein. J Interv Cardiol. 2002;15(02):101–106. https://doi.org/10.1111/j.1540-8183.2002.tb01040.x. 10. Wu Z, Zheng X, He Y, et al. Stent migration after endovascular stenting in patients with nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 2016;4(02):193–199. DOI: 10.1016/j.jvsv.2015.10.005
Figures Legends Figures 1: Intraoperative frontal X ray showing the projection of the stent along the left iliac vein trajectory
Figures 2 A-C: Preoperative CT scan (sagittal, coronal and axial views) showing stent ( ) deployment into the spinal canal through the left L5 foramen Figure 2.A. Sagittal view Figure 2.B Coronal view Figure 2.C Axial view Figure 3 A-B: Intraoperative microscope images of the stent cut with scissors at the lateral part of the spinal canal and the left L5 root completely released. Figure 3.A: Exposition of the foraminal part of the stent. DM, Dura mater ; R, L5 root ; S, stent
Figure 3.B : The L5 root completely released 4
DM, Dura mater ; R, L5 root
Figure 4 A-B: Postoperative CT-Scan showing complete decompression of the L5 left foramen (A) and a few metallic fragments remaining in the spinal canal (B).
Figure 4.A: Sagittal view Figure 4.B : Axial view
5
Abbreviations list
CT: Computed tomography N/mm: newton/millimeter
Declaration of interests ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
S1878-8750(20)30293-X
DOI:
https://doi.org/10.1016/j.wneu.2020.02.028
Reference:
WNEU 14303
To appear in:
World Neurosurgery
Received Date: 10 November 2019 Revised Date:
3 February 2020
Accepted Date: 4 February 2020
Please cite this article as: Di Santo M, Belhaj A, Rondelet B, Gustin T, Intra-spinal iliac venous stent migration with lumbar nerve roots compression: a case report, World Neurosurgery (2020), doi: https:// doi.org/10.1016/j.wneu.2020.02.028. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
Manuscript title: Intra-spinal iliac venous stent migration with lumbar nerve roots compression: a case report Author and coauthors: Mélissa Di Santo¹, MD, Asmae Belhaj², MD, PHD, Benoit Rondelet², MD, PHD and Thierry Gustin¹, MD. Neurosurger y¹ and Vas cul ar S urger y² Departm ents , CHU Universi t y Hospital Center, Université Catholique de Louvain (UCL),Yvoir, Namur, Belgium Corresponding Author contact information: Name : Di Santo Mélissa, M.D., Address1: Department of Neurosurgery CHU University Hospital Center, (Mont-Godinne) Université Catholique de Louvain (UCL), Avenue du Dr Gaston Thérasse, 1, 5530 Yvoir, Belgium Mailing address: [email protected] Telephone number: +32 (0)81 423 191 Fax number: +32 (0)81 42.33.34 Key words: Ectopic intra-spinal stent, endovascular stent, stent migration. Short title: I n t r a - s p i n a l i l i a c v e n o u s s t e n t m i g r a t i o n Limits : None No financial interest, or support. Diclosure of funding : The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. Portions of this work were presented in poster form at the Belgian Society of Neurosurgery n.p.o. (BSN meeting) on March 17, 2018, in Leuven, with BSN 2018 best Poster prize. 1
Present address :
Saint Luc academic hospital, Université Catholique de Louvain (UCL) Avenue Hippocrate, 10 1200 Woluwe-Saint-Lambert, Belgium
I n t r a - s p i n a l i l i a c v e n o u s s t e n t mi s p l a c e me n t w i th l u mb a r n e r v e r o o t s c o mp r e s s io n : a c a s e r e p o r t Abstract Background Venous stenting is a common treatment for chronic peripheral venous disease. The most frequent complications caused by this technique are stent misplacement and intra-cardiac or intra-vascular stent migration. In this publication, we will describe the first case of an intra-spinal stent misplacement, leading to lumbar nerve root compression. Case Description Our patient is a 20-year-old woman with a bilateral pulmonary embolism caused by a right common iliac vein thrombosis and a severe compression of the left common iliac vein by the right common iliac artery (May-Thurner or Cockett syndrome). She underwent an endovascular stenting of the left iliac vein. A few days later, she reported some pain in the right L5 radicular, showed signs of hypoesthesia of the left leg and of paresis of the left extensor hallucis longus muscle. A lumbar computed tomography scan showed a stent misplacement into the spinal canal through the left L5 foramen with nerve root compression. She underwent a surgical removal of the stent through a unilateral L5-S1 laminarthrectomy. The postoperative follow-up showed a complete clinical recovery and a control lumbar CT-scan confirmed the L5 nerve roots decompression. Conclusion The intra-spinal misplacement of a venous stent is a rare complication which may cause nerve root injury. It requires a prompt treatment. Surgically removing the stent by a posterior approach seems to be a simple and safe therapeutic option. KEY WORDS: Ectopic intra-spinal stent, endovascular stent, stent migration
Main text Introduction Common iliac vein stenting is a frequent procedure to treat post-thrombotic syndrome or other chronic venous diseases 1-6. One of the complications caused by this technique are the migration of the stent into the heart or into a large vessel 7-10. However, intra-spinal deployment of a stent through a lumbar vein is a very rare complication, which was never described before. It can lead to severe nerve root compression. We report the first case of a symptomatic patient and describe the surgical technique used to remove the stent through a posterior approach. Case description A 20-year-old woman with a history of multiple sclerosis was admitted to our hospital for a bilateral pulmonary embolism. Radiological investigations showed a right common iliac vein thrombosis and a severe compression of the left common iliac vein by the right common iliac artery (May-Thurner or Cockett syndrome). Hematological tests also revealed a thrombophilia related to a factor V of Leyden mutation. After six months of anticoagulation, the right iliac vein was permeable again. The patient then underwent an endovascular stenting procedure (Wallstent ®, size 18mm x 60mm, Boston Scientific, MA 01760-1537 USA) of the left iliac vein in order to remove the arterial compression. The procedure was technically difficult. After deploying the stent, a satisfying venous 1
opacification could not be obtained despite several attempts. The procedure was therefore interrupted, as the stent seemed well placed and projected along the common iliac vein on frontal xrays (Figure 1). However, no lateral x-rays were performed. A few days later, the patient started to feel some pain in the right L5 radicular and showed signs of hypoesthesia of the left leg and of paresis of the left extensor hallucis longus muscle. A lumbar computed tomography (CT)-scan was made and showed that the stent had entered a lumbar vein and had been deployed into the spinal canal through the left L5 foramen in which the nerve root was severely compressed. The stent had crossed the spinal canal beforehand and ended up under the right L5 root emergence (figure 2.A-C). An electromyography confirmed a severe L5 radiculopathy on the left side. Despite the risk of venous rupture, intra-spinal bleeding or root injury, an attempt was made to perform an endovascular extraction of the stent. However, the iliac phlebography did not show any opacification of the lumbar vein, suggesting its occlusion. We decided therefore to surgically remove the stent through a left unilateral L5-S1 laminarthrectomy. The intra-spinal and foraminal part of the stent was easily exposed. The vein wall was very thin and the vessel was no longer permeable. There was no haematoma in the spinal canal or foramen. The stent was cut with scissors at the lateral part of the spinal canal and was then progressively removed wire by wire (Figure 3.A). The left L5 root was completely released (Figure 3.B). There was no cerebrospinal fluid leak and no bleeding from the lumbar vein. In the postoperative course, radicular pain disappeared and sensibility of the left leg improved. A control lumbar CT-scan confirmed the L5 nerve roots decompression (Figure 4.A) and showed only a few small metallic particles remaining in the spinal canal (figure 4.B). At the last follow-up, one year after the surgery, clinical recovery was complete. Discussion Peripheral venous stenting is an increasingly used procedure to treat chronic venous diseases. It has obtained good results, as reported in the literature 1-5. Stent migration or misplacement is a potentially dramatic complication of this technique and can sometimes be fatal 8. However, only a few cases were described in the litterature7-10. In most reported cases, the stent migrated into the inferior vena cava, the heart or the pulmonary artery 7-10. An intra-spinal deployment or migration of a venous stent was however never described. In our case, the guiding catheter probably penetrated into a lumbar vein that followed the same trajectory as the iliac vein. The hypothesis that the stent was initially deployed in the iliac vein and migrated secondarily into a lumbar vein is very unlikely because of the difference in caliber of the two vessels. The inaccurate deployment of the stent into this small vessel likely prevented its opacification and the fact that stent had been misplaced was therefore not detected at the end of the procedure. The absence of lateral x-rays during the procedure was crucial and may explain this pitfall. This case demonstrates that the placement of a venous stent should be continuously monitored by doing a frontal but also lateral fluoroscopy with different obliquities. Stent migration into the spinal canal can result in a severe nerve root lamination, due to high radial forces exerted by the self-expanding Wallstent (1.5 to 2 N/mm). Because of the severity of the radicular symptoms, the stent should be retrieved as soon as possible. Unlike cases where the stent migrates into the heart or large veins, the percutaneous endovascular extraction of the stent was impossible in our patient. Removing it surgically was therefore the only option. In the case of a braided stent, a small unilateral posterior approach in which the stent is cut in its middle seems easy 2
and safe. For a stent composed of welded struts however, the exposure would be much larger, and the procedure could be more difficult. Due to the risk of proximal venous rupture during the stent removal, a radiologist or a vascular surgeon should be ready to intervene by an endovascular or open surgical route. Conclusion The intra-spinal misplacement of a venous stent causing nerve root injury is a rare complication. However, it might be more frequent in the future because of the increasing use of this technique. Vascular surgeons and neurosurgeons should be aware of this complication which requires a prompt treatment. Surgically removing the stent through a small laminarthrectomy is feasible, safe and effective. Source of Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict(s)-of-Interest/Disclosure(s): The authors report no conflicts of interest and have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. Abbreviations list CT: Computed tomography N/mm: newton/millimeter References list 1. Falcoz MT, Falvo N, Aho-Glélé S, et al; Burgundy Research; Study Group on Treatment of Venous Diseases. Endovascular stent placement for chronic post-thrombotic symptomatic iliofemoral venous obstructive lesions: a single-center study of safety, efficacy and quality-of-life improvement. Quant Imaging Med Surg. 2016;6(04):342–352. DOI: 10.21037/qims.2016.07.07 2. Razavi MK, Jaff MR, Miller LE. Safety and effectiveness of stent placement for iliofemoral venous outflow obstruction: systematic review and meta-analysis. Circ Cardiovasc Interv . 2015;8: e002772. DOI: 10.1161/CIRCINTERVENTIONS.115.002772. 3. Neglén P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stentrelated outcome, clinical, and hemodynamic result. J Vasc Surg. 2007; 46:979-90. DOI: 10.1016/j.jvs.2007.06.046. 4. Hartung O, Otero A, Boufi M, De Caridi G, Barthelemy P, Juhan C, Alimi YS. Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease. J Vasc Surg. 2005;42:1138-44. DOI: 10.1016/j.jvs.2005.08.012. 5. Schwarzbach MH, Schumacher H, Böckler D, Fürstenberger S, Thomas F, Seelos R, Richter GM, Allenberg JR. Surgical thrombectomy followed by intraoperative endovascular
3
reconstruction for symptomatic ilio-femoral venous thrombosis. Eur J Vasc Endovasc Surg. 2005;29:58-66. DOI: 10.1016/j.ejvs.2004.09.022. 6. Mahnken AH, Thomson K, de Haan M, O’Sullivan GJ. CIRSE Standards of Practice Guidelines on Iliocaval Stenting. Cardiovasc Intervent Radiol. 2014;37:889–897. Doi: 10.1007/s00270-014-0875-4. 7. Holst T, Großwendt T, Laham MM, Roosta-Azad M, Zandi A, Kamler M. Acute Stent Migration into the Right Ventricle in a Patient with Iliac Vein Stenting. Thorac Cardiovasc Surg. 2018;7 (1):e7-e8. DOI: 10.1055/s-0038-1629898. 8. Steinberg E, Gentile C, HellerM, Kaban N, Bang E, Li T. Intracardiac venous stent migration: emergency department presentation of a catastrophic complication. J Emerg Med. 2017;53(01): e11–e13. DOI : 10.1016/j.jemermed.2017.01.053 9. Ashar RM, Huettl EA, Halligan R. Percutaneous retrieval of a Wallstent from the pulmonary artery following stent migration from the iliac vein. J Interv Cardiol. 2002;15(02):101–106. https://doi.org/10.1111/j.1540-8183.2002.tb01040.x. 10. Wu Z, Zheng X, He Y, et al. Stent migration after endovascular stenting in patients with nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 2016;4(02):193–199. DOI: 10.1016/j.jvsv.2015.10.005
Figures Legends Figures 1: Intraoperative frontal X ray showing the projection of the stent along the left iliac vein trajectory
Figures 2 A-C: Preoperative CT scan (sagittal, coronal and axial views) showing stent ( ) deployment into the spinal canal through the left L5 foramen Figure 2.A. Sagittal view Figure 2.B Coronal view Figure 2.C Axial view Figure 3 A-B: Intraoperative microscope images of the stent cut with scissors at the lateral part of the spinal canal and the left L5 root completely released. Figure 3.A: Exposition of the foraminal part of the stent. DM, Dura mater ; R, L5 root ; S, stent
Figure 3.B : The L5 root completely released 4
DM, Dura mater ; R, L5 root
Figure 4 A-B: Postoperative CT-Scan showing complete decompression of the L5 left foramen (A) and a few metallic fragments remaining in the spinal canal (B).
Figure 4.A: Sagittal view Figure 4.B : Axial view
5
Abbreviations list
CT: Computed tomography N/mm: newton/millimeter
Declaration of interests ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. ☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: