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Patient initials or identifier number
Relevant clinical history and physical exam
An 84-year-old female patient with history of end stage renal disease, diabetes, cerebralinfarction and hypertension presented to emergency department with fever (39.2 °C) and dyspnea.
Hemodialysis is done three times per week from Oct, 7, 2013.Repeated percutaneous transluminal angioplasty was performed for brachiobasillic fistula stenosis and peripheral stent (Epic, 14 mm x 6 cm) was inserted fifty days ago.
Relevant test results prior to catheterization
Laboratory data notable for increased white blood cell count, high sensitivity CRP and ESR. Chest x ray and low dose chest CT revealed about 6 cm sized stent was lodged in right ventricle. Echocardiogram showed the presence of a metallic stent across the tricuspid valve that was causing severe tricuspid regurgitation.
Relevant catheterization findings
Percutaneous endovascular retrieval of stent was performed. Under fluoroscopic andechocardiographic guidance, multiple attempts to encircle the stent with a goose-neck snare, intending the lodged stent to buckle, were unsuccessful.After careful attempts of wiring, the migrated stent could be removed with 15 mm multi snare through 16-Fr ultimumum sheath.
1) Approach : Rt.femoral and Rt. internal jugular vein approach
2) Sheath : 7Fr sheath è 16Fr ultimatum sheath (Rt. femoral)
3) GW : .035 Terumowire 150 cm (angled), 0.35 Amplatz extra stiff wire 260 cm(cook), Terumo 0.35 x 300 cm Wire
4) Catheter: 6Fr CN catheter, 7Fr JR 4.0 Launcher Guiding Catheter
5) After 6Fr CN catheter was inserted to right atrium, catheter was changed from CN catheter to 7Fr JR guiding catheter. We try to capture previous stent by eV3 Amplatz goose neck snare kit, but it didn't work.After careful attempts of wiring, the migrated stent could be removed with 15 mm multi snare through 16-Fr ultimatum sheath.
Blood culture and retrieved stent culture confirmed methicillin susceptible staphylococcus aureus. After proper antibiotic therapy (nafcillin), clinical symptoms were improved and blood tests were normalized. Follow up culture showed no growth of any bacteria.
As endovascular stent placement becomes more frequently utilized by interventional physician.And the incidence of post procedural complications is likely to increase.
We successfully treated ineffective endocarditis due to migrated stent by percutaneous retrieval of stent and proper antibiotic therapy.