Endovenous removal of dislodged left renal vein stent in a patient with nutcracker syndrome
Muhammad A. Rana
, Gustavo S. Oderich
Corresponding Author Information
, Haraldur Bjarnason
Stent migration and dislodgment is a potential complication after endovenous stenting of the left renal vein (LRV) for nutcracker syndrome. Our purpose is to describe the technique for endovenous removal of such a dislodged stent that was used in a 36-year-old woman with nutcracker syndrome initially treated with renal vein transposition. Recurrent renal vein compression and symptoms developed and a 14 × 20-mm self-expanding stent was placed in the LRV and was noted to be dislodged into the inferior vena cava on the first post-procedure day. Through right internal jugular access, the stent was stabilized by cannulating a cell of the stent using a guide wire and an angled angiographic catheter. A 20Fr sheath was then placed via right femoral vein access into the inferior vena cava. The stent lumen was cannulated from femoral approach and the stent straightened with a stiff wire. An 18-mm angioplasty balloon was then used to capture the stent. The stent was then compressed with two 25-mm loop snares while simultaneously deflating the balloon as it was pulled into the 20Fr sheath and removed. The LRV was restented with an 18 × 40-mm self-expanding stent. Stenting of LRV for nutcracker syndrome can result in stent migration. Endovenous removal of such a dislodged self-expanding stent is feasible. Our technique emphasizes stent stabilization with cell cannulation and capture over a larger diameter balloon.
Some patients with CCSVI are also diagnosed with left renal vein compression, aka nutcracker syndrome, which redirects flow from the left renal vein into the cerebrospinal venous drainage veins. Treatment for this is a left renal vein stent. In this patient, who was not a CCSVI patient, the left renal vein stent came loose and ended up in the inferior vena cava. The doctor was able to go in through the right jugular vein and catch the stent and remove it. Amazing. The left renal vein was then restented with a larger stent. But this impressive technique is dependent on there being a follow-up examination the day after the procedure, or they might not have caught the stent migration. In CCSVI, there often isn't a follow-up exam. Also, I'd be adverse to having an IR go in through the right jugular vein, which would mean puncturing the jugular and risking a clot forming at the puncture site. Things to think about. If the stent size is determined by using IVUS to measure the vein, stent migration may be reduced as a risk.