A review of the incidence, outcome, and management of venous stent migration.

BACKGROUND: Percutaneous endovenous stenting has emerged during the past decade as the primary method of treating symptomatic venous outflow obstruction. A recognized complication of venous stenting is stent migration. The aim of the present systematic review was to identify the number of cases of stent migration in reported studies to recognize the risk factors that might be associated with this complication and the outcomes following migration. METHODS: A review was conducted in accordance with the MOOSE (meta-analyses of observational studies in epidemiology) and PRIMSA (preferred reporting items for systematic review and meta-analysis) guidelines and registered in the PROSPERO. MEDLINE, EMBASE, and PubMed databases. Key references were searched using specified keywords. All relevant data for the primary procedure and subsequent presentation with stent migration were retrieved. The data were assessed as too low in quality to allow for statistical analysis. RESULTS: Between 1994 and 2020, 31 studies were identified, including 29 case reports and 2 case series, providing data for 54 events of venous stent migration with some data provided regarding the stent used for 47 of the events. The mean age of the 52 patients with stent migration was 50 years (range, 19-88 years) and 30 were men (57.6%). The stents for most of the reported cases were ≤60 mm in length (38 of 46; 82.6%). Only three of the reports were of stents >14 mm in diameter (3 of 47; 3.6%). None of the studies had reported migration of stents >100 mm long. In 85% of the migrated stent events, retrieval was attempted, with 65.2% via an endovascular approach. The immediate outcome was satisfactory for 100% of the reported attempts, whether by an endovascular or open surgical approach. CONCLUSIONS: The findings from our literature review suggest that the risk of migration is rare but might be underreported. Most of reported cases had occurred with shorter and smaller diameter stents. The paucity of reported data and the short-term follow-up provided suggest that more formal data collection would provide a truer reflection of the incidence. However, clear strategies to avoid migration should be followed to prevent this complication from occurring.

Removal of Intravascular Foreign Bodies With a Simple Low-Cost Method: A Report of 5 Cases.

PURPOSE: Intravascular embolization of hemodialysis and central venous catheters is a rare but potentially serious complication. With the increasing use of catheters in medical practice, we are often faced with this type of complication. Novel, simple, and low-cost techniques are needed for foreign body extraction in order to reduce cardiovascular risks. CASE REPORT: We describe the approach of 5 foreign body embolization cases. Case 1: a 57-year-old woman with end-stage renal failure with a complete fracture and migration of the distal extremity of a hemodialysis catheter. Case 2: a 55-year-old man with an accidental embolization of the distal portion of a hemodialysis catheter. Case 3: a 76-year-old woman with stage IV breast cancer and an accidental embolization of a central venous catheter guidewire. Cases 4 and 5: a 71-year-old woman and a 2-year-old boy with a port-a-cath embolization. All the patients underwent successful minimally invasive removal of the foreign bodies from the thoracic site using 5Fr pigtail catheters. Additional surgery was not required. No further complications, such as damage to the vascular wall, were noted. CONCLUSION: Our experience with the interlacing and traction pigtail show that it is a simple, practical, and low-cost technical alternative and its benefits should be widespread.

Costs and complications of hospital admissions for inferior vena cava filter malfunction.

OBJECTIVE: Inferior vena cava filter (IVCF) malfunction can result from penetration, fracture, or migration of the device necessitating retrieval. Endovascular and open retrieval of IVCF have been described in institutional series without comparison. This study examines national hospital admissions for IVCF malfunction and compares the outcomes of open and endovascular retrieval. METHODS: The National Inpatient Sample database (2016-2017) was reviewed for admissions with International Classification of Diseases, Tenth Revision (ICD-10) codes specific for IVCF malfunction. All ICD-10 procedural codes were reviewed, and patients were divided based on open or endovascular IVCF retrieval. Patient characteristics, outcomes, and costs of hospitalization were compared between the two groups. RESULTS: There were 665 patients admitted with a diagnosis of IVCF malfunction. Open IVCF retrieval was performed in 100 patients and endovascular removal in 90 patients. Of those undergoing open surgery, 45 patients (45%) required median sternotomy and 55 (55%) required abdominal surgeries. Most patients were white females with a mean age of 54.4 years (range, 49.3-59.6 years) with a history of deep venous thrombosis (55.3%) or pulmonary embolism (31.6%). Most patients with IVCF malfunction were treated in large (81.6%) or urban teaching (94.7%) hospitals situated most commonly in the South (42.1%) and Northeast (29.0%) with no difference in characteristics of the patients or the centers between the two groups. Patients undergoing open IVCF retrieval were more likely to undergo surgery on an elective basis compared with endovascular IVCF retrieval (75.0% vs 11.1%; P < .001). Open IVCF retrieval was associated with a higher likelihood of thromboembolic complication compared with endovascular retrieval (20% vs 0%; P = .04). There was a trend toward higher infectious complications and overall complications with endovascular removal, but this difference did not reach statistical significance. Open retrieval was associated with a mortality of 5.0% compared with no inpatient mortality with endovascular retrieval (P = .33). The mean hospital length of stay was no difference between the two groups. Open retrieval was associated with significantly higher hospital costs than endovascular retrieval ($34,276 vs $19,758; P = .05). CONCLUSIONS: Filter removal for patients with IVCF malfunction is associated with significant morbidity and cost, regardless of modality of retrieval. The introduction of specific ICD-10 codes for IVCF malfunction allows researchers to study these events. The development of effective tools for outpatient retrieval of malfunctioning IVCF could decrease related hospitalization and have potential savings for the healthcare system.

Permanent inferior vena cava filters offer greater expected patient utility at lower predicted cost.

OBJECTIVE: Retrievable inferior vena cava (IVC) filters were first approved for use in the United States in 2003 to address the long-term complications of migration, thrombosis, fracture, and perforation observed with permanent IVC filter implantation. Although Food and Drug Administration approval of retrievable IVC filters includes permanent implantation, the incidence of complications from long-term implantation appears to be greater than that reported with existing permanent IVC filters. Also, only a small fraction of such retrievable IVC filters are ever retrieved. The purpose of the present study was to determine the threshold retrieval rate at which the use of retrievable IVC filters could be justified. METHODS: A Markov decision tree was constructed comparing retrievable and permanent IVC filters regarding their effectiveness and cost. A review of the reported data provided outcome probabilities, and the Tufts Medical Center Cost-Effectiveness Analysis Registry was the source of the utility values for the various potential outcomes. Medicare reimbursement rates served as a proxy for costs. A sensitivity analysis was performed for various parameters, primarily to determine the retrieval rate threshold at which the use of retrievable IVC filters would outperform the use of permanent IVC filters. RESULTS: Base case analysis demonstrated a greater predicted effectiveness for permanent compared with retrievable IVC filter implantation (5.41 quality-adjusted life-years [QALY] vs 5.33 QALY) at a lower cost ($2070 vs $4650). Monte Carlo simulation at 10,000 iterations confirmed the expected utility (5.4 ± 3.0 QALY vs 5.3 ± 3.0 QALY; P = .0002) and cost ($1900 ± $7400 vs $4800 ± 9900; P < .0001) to be statistically superior for permanent IVC filters. A sensitivity analysis for the filter retrieval rate demonstrated that the strategy of using a retrievable IVC filter was never preferable for utility or cost. The superiority of permanent IVC filter placement for effectiveness and cost persisted, regardless of anticipated patient-predicted annual mortality. A two-way sensitivity analysis for both IVC filter removal rate and annual patient mortality confirmed the superiority of permanent IVC filter placement at all levels. CONCLUSIONS: The predicted effectiveness of permanent IVC filters was greater and the predicted cost lower than those for retrievable IVC filters, regardless of the IVC filter retrieval rate. This interpretation of existing reported data using Markov decision analysis modeling supports the argument that unless the long-term complication rate of retrievable IVC filters can be significantly improved, their use should be abandoned in favor of currently available permanent IVC filters.

Guidewire fracture during orbital atherectomy for peripheral artery disease: Insights from the Manufacturer and User Facility Device Experience database.

BACKGROUND/OBJECTIVES: Orbital atherectomy (OA) is routinely being used for plaque modification to facilitate percutaneous revascularization in patients with peripheral arterial disease (PAD) and arterial calcification. Guidewire fracture (GWF) during OA, though anecdotally described, has not been studied in a systematic manner. We conducted a review of the Manufacturer and User Facility Device Experience (MAUDE) database to study the reports of wire fracture and its management and consequences. METHODS: We queried the MAUDE database for all events involving the current generation of the OA device: "Diamondback 360 Peripheral Orbital Atherectomy System", and "Stealth 360° Orbital PAD System". RESULTS: We identified 62 reports of GWF during OA for PAD. The superficial femoral artery was the most commonly involved atherectomy site. The wire fractured at the soft tip in a majority of cases (68%). Embolized wire fragments were left in the patient in 36 cases (58%), retrieved percutaneously in 10 cases (16%), and trapped by a stent against the arterial wall in eight cases (13%). Lastly, eight patients (13%) underwent surgery for removal of the wire fragment. CONCLUSIONS: This is the first published report to study the complication of GWF during peripheral OA. GWF is an uncommon but has significant procedural and clinical consequences. It results in a high rate of ancillary rescue procedures (including surgery) and is associated with a higher risk of arterial thrombosis and complications from wire retrieval attempts. The risk of wire fracture may be avoided with carefully adherence to the IFU.

Repositioning of central venous access devices using a high-flow flush technique - a clinical practice and cost review.

BACKGROUND: Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions.The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning. METHODS: This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia.7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions. RESULTS: There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition. CONCLUSIONS: Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.

Migration of Central Venous Catheters in Neonates: A Radiographic Assessment.

Objective This study aims to determine the frequency that umbilical venous catheters (UVCs) and peripherally inserted central catheters (PICCs) migrate into the cardiothymic silhouette after initial verification of correct placement. Study Design This is a single-center, retrospective study in neonates in whom a PICC or UVC was placed. The frequency of catheter tip migration into the cardiothymic silhouette requiring catheter manipulation was determined radiographically at 1 and 24 hours, respectively, after insertion. Results At 1 and 24 hours, 36 and 23% of UVCs (n = 41) migrated into the cardiothymic silhouette, respectively. At 1 and 24 hours, 23 and 11% of PICCs (n = 63) migrated into the cardiothymic silhouette, respectively. Migration was not associated with birth weight, weight at insertion, or postnatal age at insertion. Conclusion UVCs and PICCs frequently migrate into the cardiothymic silhouette increase the risk for development of a pericardial effusion. Serial radiographic assessment of catheter tip location is needed to assess catheter migration within the first 24 hours of line placement.

Migration of retrievable expandable metallic stents inserted for malignant esophageal strictures: incidence, management, and prognostic factors in 332 patients.

OBJECTIVE: The purpose of this study was to evaluate the incidence, prognostic factors, and secondary management of stent migration in patients with malignant esophageal strictures. MATERIALS AND METHODS: A retrospective study was performed in a single tertiary referral university hospital to identify the incidence, management, and prognostic factors for stent migration in 332 consecutive patients with placement of a retrievable expandable metallic stent. Stent migration was classified into four patterns as locations of a migrated stent: pattern I, partially migrated in the proximal direction; pattern II, partially migrated in the distal direction; pattern III, completely migrated into the stomach; and pattern IV, completely migrated into the bowel. RESULTS: Stent migration occurred in 42 (12.6%) of 332 patients. Migration was partial (n = 21) or complete (n = 21), and nine (21%), 12 (29%), 11 (26%), and 10 (24%) patients had patterns I, II, III, and IV, respectively. Multivariate analysis identified the following prognostic factors: esophagogastric junction strictures caused by cancer of the gastric cardia (odds ratio 1.330; p = 0.004), patients who underwent anticancer treatment after stent placement (17.514; p < 0.001), and patients with a longer survival time (1.994; p < 0.001). Secondary management was needed for 33 of 42 patients. The strictures in the remaining nine patients improved throughout follow-up. CONCLUSION: Stent migration occurs most commonly in patients with cancer of the gastric cardia, patients with longer survival time, and those who underwent anticancer treatment after stent placement. Stent migration is successfully managed by further intervention. Accurate knowledge of the pattern of stent migration is important for successful management.

Optimal management of Riata leads with no known electrical abnormalities or externalization: a decision analysis.

INTRODUCTION: Riata and Riata ST implantable cardioverter-defibrillator (ICD) leads (St. Jude Medical, Sylmar, CA, USA) can develop conductor cable externalization and/or electrical failure. Optimal management of these leads remains unknown. METHODS AND RESULTS: A Markov model compared 4 lead management strategies: (1) routine device interrogation for electrical failure, (2) systematic yearly fluoroscopic screening and routine device interrogation, (3) implantation of new ICD lead with capping of the in situ lead, and (4) implantation of new ICD lead with extraction of the in situ lead. The base case was a 64-year-old primary prevention ICD patient. Modeling demonstrated average life expectancies as follows: capping with new lead implanted at 134.5 months, extraction with new lead implanted at 134.0 months, fluoroscopy with routine interrogation at 133.9 months, and routine interrogation at 133.5 months. One-way sensitivity analyses identified capping as the preferred strategy with only one parameter having a threshold value: when risk of nonarrhythmic death associated with lead abandonment is greater than 0.05% per year, lead extraction is preferred over capping. A second-order Monte Carlo simulation (n = 10,000), as a probabilistic sensitivity analysis, found that lead revision was favored with 100% certainty (extraction 76% and capping 24%). CONCLUSIONS: Overall there were minimal differences in survival with monitoring versus active lead management approaches. There is no evidence to support fluoroscopic screening for externalization of Riata or Riata ST leads.

Embolization of patent foramen ovale closure devices: incidence, role of imaging in identification, potential causes, and management.

Transcatheter patent foramen ovale (PFO) closure is an alternative to antiplatelet or anticoagulative therapy in patients with cryptogenic stroke, and it is associated with a small incidence of periprocedural sequelae. Because embolization of PFO closure devices is a very rare procedural complication, data on its frequency, causes, and management are sparse. We sought to review the medical literature and the cases of PFO closure-device embolization at our institution with the aim of identifying likely problems and reporting potential solutions. Out of 310 adult patients who underwent transcatheter PFO closure from June 2002 through April 2011, there were 2 cases (0.6%) of PFO closure-device embolization. In both patients, hypermobile septum primum and thick septum secundum were present. In one patient, failure to use a sizing balloon might have resulted in an underestimation of the PFO's size. In both patients, device embolization was identified in a timely fashion, the embolized device was safely retrieved, and the PFO was percutaneously closed with success. The incidence of PFO closure-device embolization is very low. The cases described here underscore the importance of imaging in the identification of morphologic predispositions to closure-device malpositioning, in the recognition of impending embolization, and in the timely management of embolization.