Canadian Journal of Anesthesia 51:173 (2004)
© Canadian Anesthesiologists' Society, 2004
Cardiothoracic Anesthesia, Respiration and Airway
Images in Anesthesia: A right atrial foreign body
Lei Yao, MD PhD,
Anna Maria Veytsman, MD and
M. Saeed Dhamee, MD
Milwaukee, Wisconsin
A 27-yr-old male patient on hemodialysis for end stage renal disease presented for surgical removal of a fractured A-V fistular stent, which had migrated from the left upper extremity fistula site to the right atrium. A polytetrafluoroethylene loop graft had been placed in the left arm in 1999 with revision a year later. During hemodialysis, an increase in the venous pressure was observed and a venogram was performed. It revealed the stent overlapping the occluded left subclavian, axillary and brachiocephalic veins with a portion of the stent extending into the superior vena cava (SVC) and the right atrium (RA; Figure 1
). Preoperative transesophageal echocardiography revealed a tubular structure 1.7 cm in diameter in the SVC and extending into the RA abutting its lateral aspect below the tricuspid valve (Figure 2). No thrombus was noted. On cardiopulmonary bypass a right atriotomy was performed and findings were that of severe fibrosis over the innominate vein and a fractured stent located in the SVC with a distally detached portion extending into the RA and inferior vena cava. The stent was a 7-cm long wire mesh with a 10-cm long inner silicone catheter. The stent was removed from the RA. Migration of a dialysis fistula stent to the atrium is a rare complication.1–3 They are dangerous as they might migrate to the right ventricle, embolize in the pulmonary tree or serve as a source of recurrent pulmonary emboli.2
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FIGURE 1 Venography shows a detached piece of stent in the right atrium which is fractured from the stent in the left subclavian vein.
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References
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1 Amaouche A. Stent migration in a hemodialysis patient (French). Nephrologie 2001; 22: 47.[Medline]
2 Schillinger F, Montagnac R, Milccnt T, Chancrin JP, Mahmandar A, Pernet P. Pulmonary migration of an axillary stent in a chronic hemodialysis patient (French). Nephrologie 2001; 22: 49–51.[Medline]
3 Felner JM, Churchwell AL, Murphy DA. Right atrial thromboemboli: clinical, echocardiographic and pathophysiologic manifestations. J Am Coll Cardiol 1984; 4: 1041–51.[Abstract]
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