The stent delivery system is not long enough: an easy trick to solve the problem

Clinical History

This 85-year-old man with a malfunctioning dialysis fistula of the right arm came to our observation for recurrent stenosis of the right innominate vein. PTA failed to achieve satisfactory result; we decided to try to deploy a self-expandable stent. However, the delivery stent system available was shorter than needed.

Imaging Findings

A left groin access was chosen. After confirmation of the stenosis on the right innominate vein (Fig. 1a) a dilatation was performed with a 16 mm PTA balloon catheter. Check phlebogram showed improvement of calibre of the vein, however, residual stenosis was present (Fig. 1b). Considering that this was a recurrent stenosis we decided to try to deploy a stent using the groin access. In our stock we had only one 14x50 mm self-expandable stent (Luminexx-Bard) on a 60 cm delivery-system. We verified that the length of delivery-system was insufficient and to solve the problem we decided to insert a long introducer-sheath (7F-90cm) (Fig. 2a), deploy the stent inside the sheath (Fig. 2b), cut the point of the inner catheter in order to use it as "pusher" (Fig. 2c), advance the stent inside the sheath to the stenosis (Fig. 2 d,e), pull-back the sheath and have the stent open (Fig. 2 f,g).

Discussion

Stenting of superior vena cava or innominate veins has been reported in literature for many years with better long terms results for benign or malignant lesions than for haemodialysis patients (Smayra T et al). However, the goal of this case report is to show a quite easy solution to an apparently unsolvable problem such as a shorter deploy stent system than needed. We know that an alternative solution could be to change access (right arm), but in this particular case the patient was really not cooperative and to prolong the procedure for a second access could be a problem. Furthermore we started from groin because our program was to use large PTA balloon catheter which needs introducer sheath larger than usual (7-8 Fr) and for this reason we wanted to avoid access from arterialised vein on the right arm. A good rule is to check always if you have the material you need for a scheduled case, but this size of stent in our activity is not frequently used and we had only one piece in our stock. We believe that the solution shown here may be helpful for young or "less experienced" interventional radiologists who live daily practice and in a situation like this are "in trouble" and could decide to stop the procedure. In any case it must be underlined that a manoeuvre like the one shown here has to be done with extreme care evaluating risks and benefits.

Differential Diagnosis List

Final Diagnosis

Innominate-vein stenosis treatment by stenting with a short delivery system

URL:	https://eurorad.org/case/9010
DOI:	10.1594/EURORAD/CASE.9010
ISSN:	1563-4086