Common Iliac Artery Stent Migration Post Intervention

Abstract

Background

Peripheral arterial disease affects over 230 million people worldwide, presenting as intermittent claudication or critical limb ischemia. Endovascular revascularization, with self-expanding stents, has proven effective in treating iliac artery occlusions. However, rare complications like stent migration can occur. We report a rare case of common iliac artery stent migration across the aortic bifurcation.

Case Summary

A 64-year-old man with diabetes and hypertension was evaluated for ischemic rest pain. He underwent iliac artery stenting and later developed worsening leg pain. Angiography revealed stent migration across the aortic bifurcation eventually managed percutaneously.

Discussion

Stent migration while rare has been reported in the venous system, but reports of retrograde arterial stent migration are very rare. This case offers valuable insights into endovascular management of complex complications of iliac artery stenting while avoiding surgical intervention.

Take-Home Messages

Retrograde arterial stent migration, while rare, can be managed percutaneously. Adequate vessel preparation with intravascular imaging is crucial for prevention.

Graphical Abstract

Peripheral arterial disease affects over 230 million worldwide.¹ Patients can present with intermittent claudication, acute or critical limb ischemia (CLI).

Endovascular revascularization is a recognized limb-salvage procedure in CLI, and self-expanding stents are effective treatment for aortoiliac disease. Stents, however, can thrombose or very rarely migrate forced by the bloodstream or due to inappropriate dimensions.² We report a case of iliac artery stenting complicated by a very unusual upstream migration. To our knowledge, this is the first reported case of a stent migration (up to 80 mm length) against aorto-iliac blood flow.

Take-Home Messages

• •Appropriate vessel preparation, stent sizing, and deployment including the use of intravascular imaging are critical during stenting of calcified vessels.
• •Prompt recognition and timely intervention are crucial in preventing adverse outcomes.

History of Presentation

A 64-year-old man was evaluated for Rutherford class 4 ischemic rest pain of the legs (L>R) of 3 months duration. He also complained of exertional chest pain associated with dizziness and dyspnea. Outpatient medications include losartan 100 mg, atorvastatin 20 mg, aspirin 81 mg daily, cilostazol 100 mg, and metformin 500 mg twice daily.

Past Medical History

He had stage 2 hypertension, type 2 diabetes mellitus, dyslipidemia, and prior stroke with no residual weakness. He was a habitual smoker, with no other significant medical conditions.

Differential Diagnosis

The differential diagnosis included lumbar spinal stenosis, peripheral neuropathy, and vasculitis.

Investigation

His vitals were stable, and lower-extremity examination was remarkable for faint dorsalis pedis and posterior tibial pulses bilaterally. Cardiac workup included electrocardiogram (Figure 1) and nuclear stress test which were abnormal. Echocardiogram revealed a normal ejection fraction with normal valvular function. He had abnormal ankle brachial indices of 0.5 on the left and 0.7 on the right with monophasic waveforms and elevated velocities on doppler ultrasound. A diagnosis of typical chest pain with abnormal stress test and CLI was made. Coronary and lower-extremity angiogram was scheduled.

Figure 1.

Electrocardiogram

Management

Coronary angiography showed significant coronary artery disease treated with standard stenting technique. Abdominal angiogram revealed patent bilateral renal arteries with no aneurysm or stenosis of the abdominal aorta. Peripheral angiogram revealed significant heavily calcified left common iliac artery (CIA) stenosis (Figure 2A) with a 20-mm systolic translesional gradient, calcified left internal and external arteries with mild disease, calcified left superficial femoral artery with moderate disease, and patent left common femoral and popliteal arteries. The anterior tibial and peroneal arteries were occluded with single-vessel runoff to the left foot via patent posterior tibial artery. On the right, the CIA was calcified without stenosis, the internal iliac artery had mild diffuse disease, the external iliac and superficial femoral arteries were calcified with moderate disease, and the common femoral and popliteal arteries were patent. The anterior tibial and peroneal arteries were occluded with single-vessel runoff to the right foot via a patent posterior tibial artery. Endovascular revascularization of the left CIA was performed the following week. After placement of a 7-F sheath with standard anticoagulation, the left CIA lesion was serially dilated with 7 × 60-mm and 8.0 × 80-mm balloons to avoid vessel perforation. We could not perform appropriate vessel sizing with intravascular ultrasound (IVUS) prior to intervention due to the lack of a functioning machine at our center. We therefore had to rely on a visual angiographic estimate of the vessel size. We chose an 8 × 80-mm self-expanding stent with a possibility of post-dilatation with a larger-sized balloon if needed. The stent was deployed successfully across the lesion and post-dilated with an 8 × 80-mm balloon at high pressure. Repeat angiogram demonstrated good angiographic result with no complication (Figure 2B). The sheath was removed after satisfactory access angiogram and manual pressure applied. He was discharged on 81 mg aspirin daily with 2.5 mg rivaroxaban twice daily.

Figure 2.

Significant Left Common Iliac Artery Stenosis Before and After Placement of Self Expanding Stent

(A) Left common iliac artery stenosis. (B) Left common iliac artery following deployment of a self-expanding stent.

A week later, he presented with worsening bilateral lower-extremity rest pain L>R. Lower-extremity examination revealed diminished left femoral artery and posterior tibial arterial pulses. Duplex ultrasonography also revealed diminished waveforms in the left lower extremity.

He was readmitted, and an angiogram performed through the 6-F sheath placed in the left groin showed migration of the left CIA stent across the aortic bifurcation (Figure 3A).

Figure 3.

Migrated Common Iliac Artery Stent Before and After Balloon Stenting Against the Vessel Wall

(A) Retrogradely migrated stent across aortic bifurcation. (B) Final angiogram of the retracted stent walled off with the implanted balloon expandable stent.

He was anticoagulated, and the sheath was upsized to a 7-F sheath. A right ventricular biopsy forceps was used to hold the stent with an attempt to pull it back in place, but the stent kept springing back into the aorta (Video 1). After multiple attempts, the stent was pulled back into the left CIA. Distortion of the stent was noted at this point. The sheath was then upsized to a 12-F sheath. This facilitated placement of a 0.035-inch advantage glide wire next to the right ventricular biopsy forceps. The stent was then pulled down, and a 9.0 × 40-mm balloon was used to control it in place against the arterial wall. Next, a 10 × 37-mm balloon expandable stent was deployed to push this stent against the wall. Completion angiogram showed good results with excellent blood flow in the vessel (Figure 3B). The 12-F sheath was removed, and arteriotomy site was closed with a Perclose Proglide Closure Device (Abbot Vascular). No complication was noted during or immediately after this procedure.

Outcome and Follow-Up

Patient's symptoms improved significantly post procedure with increased walking distance and performance on outpatient follow-up. He continued with his antiplatelet, statins, and anticoagulation therapy.

Discussion

Stent migration is a rare but serious, well-recognized complication of venous stenting with a prevalence of 0.9% to 4.3% in analyzed studies of venous occlusive disease.³ Common iliac vein stent migration to the right atrium has been reported by Pokhriyal et al.⁴ However, there are few reports of this complication involving arterial vessels of the lower extremity.

Self-expanding stents are effective treatment options for aorto-iliac disease. However, stents are prone to complications including thrombosis and migration, which is a rare but potentially serious complication.

Stent migration can be influenced by stent location and size.⁴ It is more commonly seen in stents <60 mm in length⁵ and less commonly seen in upper-extremity veins. Sayed et al.⁵ encountered 54 cases over a 26-year period, with only 3 cases of stent migration but none with stent length >100 mm.

Slonim et al⁶ in 1999 reported a 2.5% rate of stent mal-deployment in peripheral vessels, and of the 27 misplaced or migrated endovascular stents evaluated, only 1 involved an artery (iliac artery). Most of the migrated stents in that study were managed percutaneously with repositioning and deployment in a different location.

Civilini et al⁷ reported a case of iliac artery stent migration managed percutaneously with balloon stenting of the repositioned stent against the wall. In their study, an oversized stent of 70 mm length was initially used, and they postulated that with resolution of the initial arterial spasm, the re-perfused artery gradually enlarged to its normal diameter, and the radial force of the stent became insufficient, allowing mobilization of the stent. Our patient was also managed percutaneously with balloon stenting of the repositioned stent against the wall avoiding surgical intervention. Initially, we tried pulling the stent back into the left CIA, but it kept springing back into the aorta, which finally resulted in distortion of the stent. We eventually had to balloon stent it against the wall of the vessel.

We speculate that in our patient, heavy calcification resulted in stent underexpansion and mal-apposition, which could have been confirmed and avoided with IVUS. This is a crucial step especially in calcified vessels where visual angiographic estimation of vessel size can be misleading, predisposing to migration of the stent. Unfortunately, this was not available at the time of the procedure. This coupled with a pulsatile wall motion and turbulence of the aortic bifurcation resulted in upward migration of the stent.⁸ These unexpected upstream forces have been thought to also apply to aortic endografts where the presence of the fabric and the aneurysm increase the risk of iliac branch migration.⁹

The dynamic variation of the venous diameter depending on the venous return is a potential factor for stent migration in large-diameter central veins.¹⁰ Stent migration can occur immediately after the procedure or later.¹⁰ It can be subtle, asymptomatic, and incidentally discovered or with varied symptoms depending on dislodgement site. Ischemic pain and leg swelling can accompany distal migration while chest pain and shortness of breath can accompany cardiac migration with venous stents.¹⁰ Distal peripheral arterial stents rarely migrate upwards due to the opposing upstream forces. Appropriate vessel sizing during the procedure with the use of IVUS is critical to facilitate optimal stent deployment and avoid stent malapposition, which could eventually lead to stent migration. Prompt recognition and diagnosis is critical to prevent adverse outcomes.

Conclusions

While rare, CIA stent migration can occur following endovascular revascularization, particularly in calcified lesions with stent malposition and sizing. Although endovascular stenting is often considered a generally safe procedure, silent stent migration leading to delayed diagnosis can result in device loss not amenable to endovascular retrieval. Multimodality and multidisciplinary approaches are required for management and prevention of devastating complications.

Visual Summary.

Timeline of the Case

Timeline	Events	Take Home Points
Day 1	65-year-old man evaluated for Rutherford class 4 ischemic rest pain of the legs (L>R) chest pain and dyspnea
Day 2	Evaluation revealed abnormal ankle brachial indices of 0.5 (L) and 0.7 (R). Doppler USS showed monophasic waveforms and elevated velocities.
Day 4	Coronary and peripheral angiography performed revealing CAD and significant left common iliac artery disease. Coronary stenting was performed, and endovascular revascularization of left CIA staged.
Day 11	Left CIA stenting performed	IVUS should have been used pre and post intervention for proper vessel and stent sizing as well confirmation of stent mal apposition after deployment. This was however unavailable at time of procedure
Day 18	Patient complained of worsening rest pain symptoms of the left leg.	Prompt recognition of possible complication due to worsening symptoms post procedure helped diagnose problem and enable prompt management.
Day 19	Repeat angiogram showed migrated stent across aortic bifurcation. Stent repositioned and walled off with a balloon expandable stent	Highlights importance of procedural adaptability to ensure optimal outcomes.
Day 26	Follow-up at 14 d showed improved symptoms.	Crucial follow-up important to ensure resolution of symptoms.

CAD = coronary artery disease; CIA = common iliac artery; IVUS = intravascular ultrasound; USS = ultrasound scan.

Equipment List.

Coronary, Peripheral Angiogram, and Iliac Artery Stenting

Access	•Micropuncture needle and wire •0.35-inch J wire, 6-and 7-F sheaths •1 Proglide (Abbott Vascular) •Hi-Torque Supra Core stiff guide wire (Abbott Vascular) •12-F Cook sheath (Cook Medical, USA)
Angiogram, PCI and common iliac artery stenting	•6-F Judkins right catheter JR4 •6-F Judkins left catheter JL4 •4-F modified hook catheter •3.0 × 15 mm drug eluting stent (Xience) •8 × 80 mm self-expanding stent •8 × 80 mm balloon
Stent retraction, positioning and stenting	•Right ventricular biopsy forceps •9 × 40 mm balloon •10 × 37 mm balloon expandable stent

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Left Common Iliac Artery Stent Retraction With Right Ventricular Biopsy Forceps