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Image of Vascular Surgery

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Image of Vascular Surgery

Vasc Specialist Int (2021) 37:33

Published online September 28, 2021 https://doi.org/10.5758/vsi.210054

Copyright © The Korean Society for Vascular Surgery.

Salvage of a Floating Thrombosed Undersized Venous Stent by Crushing with New Stents

Taimur Saleem

The Rane Center for Venous and Lymphatic Diseases at St. Dominic’s Hospital, Jackson, MS, USA

Correspondence to:Taimur Saleem, The Rane Center for Venous and Lymphatic Diseases at St. Dominic’s Hospital, 971 Lakeland Drive, Suite 401, Jackson, MS 39216, USA
Tel: 1-601-939-4230, Fax: 1-601-664-6694, Email: taimur@gmail.com, https://orcid.org/0000-0003-4467-3090

Received: July 16, 2021; Revised: August 12, 2021; Accepted: September 9, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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A 53-year-old male patient had symptoms of chronic venous insufficiency on the left leg, including previous venous ulceration (Clinical-Etiological-Anatomical-Pathophysiological classification C5), pain and swelling that caused limitations in his daily life despite the use of conservative measures. He had a history of left iliac venous stenting. Computed tomography venography scan showed a thrombosed 10-mm nitinol iliac venous stent that did not appear well apposed to the venous walls (Fig. 1). Furthermore, it showed an occluded stent with venous flow around it (Fig. 2A). A wire was maneuvered between the stent wall and the venous wall (Fig. 2B, C). The occluded nitinol stent was crushed by a large (22 mm×40 mm), high pressure balloon against the scaffold of the venous wall towards the left (Fig. 3). Next, two Wallstents (22 mm×70 mm each) and a Z-stent (30 mm×50 mm) were deployed (Fig. 4 and 5). The Z-stent (Cook Medical, Bloomington, IN, USA) was used with the Wallstent (Boston Scientific, Marlborough, MA, USA) to provide additional radial force at the iliocaval confluence and to reduce the incidence of contralateral deep venous thrombosis [1-3]. Post-procedurally, the patient reported adequate symptom relief.

Figure 1. Initial computed tomography images. (A) An axial view showed undersized iliac venous stent (arrow) with flow around it. (B) A coronal reformat showed a thrombosed iliac vein stent (arrow) that was not well apposed to the venous walls circumferentially.

Figure 2. (A) Venography showed a thrombus in stent and the venous flow around the “floating” stent (arrow). (B) Anteroposterior view showed a glide wire (arrow) between the venous wall and the stent wall. (C) Intravascular ultrasonography catheter located between the stent wall and the iliac vein wall in the center of the image (solid arrow). The dotted arrow indicates the location of the undersized stent which was not apposed to the vein wall circumferentially.

Figure 3. Angioplasty balloon (arrow) was used to displace the previous nitinol stent to one side.

Figure 4. Two Wallstents (22 mm×70 mm) and one Z-stent (30 mm×50 mm) were deployed to restore complete luminal venous patency (arrow).

Figure 5. Intravascular ultrasonography images after stenting. (A) Wallstent in the common femoral vein. (B) Wallstent in the external iliac vein. (C) Wallstent in common iliac vein. Note that the displaced previous stent can no longer be seen as a discrete circular ring.

Accurate sizing of peripheral venous stents is critical for adequate decompression of peripheral venous hypertension. Undersized stents may embolize, migrate, or thrombose, as observed in this case. However, oversized stents may also lead to occlusions and in-stent restenosis due to disturbances in shear stress, edge restenosis, and size mismatch between native and stented vein. Intravascular ultrasound is crucial in guiding iliac venous interventions and sizing of venous stents [4,5].

Fig 1.

Figure 1.Initial computed tomography images. (A) An axial view showed undersized iliac venous stent (arrow) with flow around it. (B) A coronal reformat showed a thrombosed iliac vein stent (arrow) that was not well apposed to the venous walls circumferentially.
Vascular Specialist International 2021; 37: https://doi.org/10.5758/vsi.210054

Fig 2.

Figure 2.(A) Venography showed a thrombus in stent and the venous flow around the “floating” stent (arrow). (B) Anteroposterior view showed a glide wire (arrow) between the venous wall and the stent wall. (C) Intravascular ultrasonography catheter located between the stent wall and the iliac vein wall in the center of the image (solid arrow). The dotted arrow indicates the location of the undersized stent which was not apposed to the vein wall circumferentially.
Vascular Specialist International 2021; 37: https://doi.org/10.5758/vsi.210054

Fig 3.

Figure 3.Angioplasty balloon (arrow) was used to displace the previous nitinol stent to one side.
Vascular Specialist International 2021; 37: https://doi.org/10.5758/vsi.210054

Fig 4.

Figure 4.Two Wallstents (22 mm×70 mm) and one Z-stent (30 mm×50 mm) were deployed to restore complete luminal venous patency (arrow).
Vascular Specialist International 2021; 37: https://doi.org/10.5758/vsi.210054

Fig 5.

Figure 5.Intravascular ultrasonography images after stenting. (A) Wallstent in the common femoral vein. (B) Wallstent in the external iliac vein. (C) Wallstent in common iliac vein. Note that the displaced previous stent can no longer be seen as a discrete circular ring.
Vascular Specialist International 2021; 37: https://doi.org/10.5758/vsi.210054

References

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