Editorial Comment

Unintentional Endotrash!‘‘It’’ Happens

Victor Lucas, MD

Section Head, Pediatric Cardiology,Ochsner Clinic Foundation,New Orleans, Louisiana

Dr. Kuan-Ming Chiu reports an interesting case ofan embolized self-expanding SVC stent managed ‘‘con-servatively’’ with a good long-term outcome. As back-ground, it can be sobering to simply Google ‘‘stentembolization and retrieval’’ and enjoy the plethora ofinteresting experiences reported. Happily, malpositionand embolization of self-expanding stents have becomeless common problems with the newer nitinol stentsand improved delivery systems but still can occur atthe time of implant and later with stent migration. Themost striking feature herein is that the embolized stentwas left within the right atrium with no obviousadverse effects.

Cardiologists with experience hand-mounting earlygeneration balloon expandable stents soon realized thepotential to relocate embolized stents to a relativelysafe position (e.g., IVC, branch pulmonary arteries,iliac arteries) and expand the stent further to fix it inplace. Even very large balloon expandable stents canbe crushed and retrieved, albeit often requiring fairlylarge sheaths and even groin dissection to exteriorizethe mangled stent. Self-expanding stents may be more

well suited for the very dynamic, thin, and tortuous ve-nous vessels but can be difficult to impossible toremove percutaneously if malposition is encountered.

A strategy to fix an embolized self-expanding stent ina safer location than within the heart still seems prudent.Imagination, patience, and a well-stocked inventory willbe required. Starting with a deep breath and, if in thesystemic circulation, more anticoagulation may be ad-visable as a careful plan is devised. Having more thanone experienced operator is often quite helpful. As anexample of the ingenuity required, Prischl et al. (1997)reported fixing a self expanding stent in the IVC abovea chronic vena cava filter with a second vena cava filter.More ‘‘routinely,’’ passing a guidewire through the cen-ter of the stent into the target vessel (IVC, PA) allowsintroduction of a balloon catheter to help pass the stentto its final safer resting place. A small J-tip wire such asa Rosen wire can help avoid crossing the stent inter-stices. A stiffer wire can then be placed. A very compli-ant low pressure balloon can be helpful to allow balloonoversizing relative to the stent (without dilating thestent) to facilitate forward progress. A larger self-expanding stent can be placed within the first stent tohelp fix it in place more securely if needed.

Interventional cardiologists and stent companies stillawait the development of the perfect stent. Recently,characteristics such as deliverability, radial strength,coverage, visibility, and drug delivery have improveddramatically. As stent development progresses, consid-eration of retrievability characteristics needs to beencouraged.

Correspondence to: Victor Lucas, Section Head, Pediatric Cardiol-

ogy, Ochsner Clinic Foundation, 1315 Jefferson Hwy., New Orleans,

Louisiana. E-mail: vlucas@ochsner.org

Received 26 September 2007; Revision accepted 26 September 2007

DOI 10.1002/ccd.21419

Published online 12 November 2007 in Wiley InterScience (www.

interscience.wiley.com).

' 2007 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 70:801 (2007)