Intravascular "fenestration" and "triangular anchoring" techniques: A case of uncaptured central venous retrograde stent placement and a literature review.
TL;DR
A 61-year-old woman with stenosis at the left brachiocephalic vein-superior vena cava junction and symptomatic retrograde migration of a bare-metal stent impacted in the axillary vein is presented and an innovative endovascular rescue was performed: intrastent fenestration with triangular-complex anchoring.
Abstract
Central venous stent migration is a rare complication in hemodialysis patients. While antegrade migration toward the heart or pulmonary arteries has been documented, the mechanism and management of retrograde migration toward the distal axillary vein remain unreported. We present a 61-year-old woman with stenosis at the left brachiocephalic vein-superior vena cava junction and symptomatic retrograde migration of a bare-metal stent impacted in the axillary vein. After a systematic review excluded 10 conventional strategies, an innovative endovascular rescue was performed: intrastent fenestration with triangular-complex anchoring. Technical and clinical success was achieved with restored flow and complete symptom resolution. At the last follow-up (2 years and 4 months postoperatively), the patient had no recurrence of swelling, dialysis blood flow remained stable at 250 mL/min, and duplex ultrasound confirmed stable stent-complex position without restenosis. Beyond this singular case, our work provides a comprehensive review of management strategies, synthesizes them into a practical decision-making algorithm, and proposes an analysis of the factors driving retrograde migration. For highly selected cases of complex central venous stent migrations that are uncapturable and uncrossable, this technique represents a feasible and effective endovascular salvage option.