Mystery ring: a case of TIPS stent migration

Abstract

DescriptionWe present a 50-year-old man with history of end-stage liver disease secondary to hepatitis C, who frequently presents to the hospital with ascites. He recently underwent Trans jugular Intrahepatic Portosystemic Shunt (TIPS) stent placement after becoming resistant to diuresis and large volume therapeutic paracentesis. He presented to the emergency room with altered mental status due to hepatic encephalopathy. On physical exam, he was noted to have a systolic murmur; hence, a transthoracic echocardiogram was ordered. It showed an echo dense ring-like shadow in the right atrium close to intra-atrial septum (figure 1). Transoesophageal echocardiogram was obtained for better visualisation, and it showed a migrated TIPS stent entering the right atrium from the inferior vena cava with its cephalad end close to the intraatrial septum (figure 2). There was no evidence of mechanical complication related to stent migration by echocardiography. The patient declined percutaneous retrieval. He was doing fine on subsequent follow-ups.Stent misplacement and migrations are rare but potentially life-threatening complications of TIPS. Prior case reports in the literature show that stents displaced to distal areas such as right atrium, right ventricle and pulmonary artery. It can also cause conduction abnormalities, valvular damage, perforation and death. [1][2][3] Literature review showed one similar case diagnosed by echocardiography in a 57-year-old male patient, who had cardiac ectopy, where the misplaced stent did not cause acute mechanical complication and was managed in the outpatient setting. 2Our case highlights the role of echocardiography to diagnose such complication of TIPS procedure and evaluate for its consequences. Echocardiography could also help guide the treatment approach including endovascular or surgical stent retrieval.

Rings Flying Around: A rare complication of Transjugular Intrahepatic Portosystemic Shunt

“…Stent misplacement and migrations are rare but potentially life threatening complications of TIPS. Multiple case reports have shown stents to be displaced to distal areas such as the right atrium, right ventricle and the pulmonary artery rarely [ 6 , 7 ]. Such complications may result in conduction abnormalities, valvular damage, perforation and possible death.…”

“…Cephalad migration into the cardiac chambers or inferior vena cava (IVC) may result in cardiac arrhythmias, atrial perforation, aorto-atrial fistula or IVC thrombosis. In some cases, delayed stent migration may be seen as well, with two case reports showing 3 week stent migration, post deployment in an 11 year old child [ 6 , 7 ]. Given these complications, stent extraction is difficult due to its own associated complications including possible valvular damage, myocardial penetration, cardiac arrhythmia or pericardial tamponade.…”

“…Stent may also migrate inferiorly into the main portal vein, further resulting in complications in procedures such as liver transplant in the future [ [6] , [7] , [8] ].…”