Migration of Intrahepatic Portosystemic Stent into Right Ventricle
An Unusual Cause of Tricuspid Regurgitation
A 65-year-old woman with terminal liver disease and portal hypertension secondary to alcohol-induced cirrhosis underwent an elective transjugular intrahepatic portosystemic shunt procedure. A self-expanding, 100×80-mm Nitinol (Jomed AG) stent was implanted and extended cranially using an additional 40×12-mm Wallstent (Boston Scientific). During the same admission, she was evaluated and accepted for liver transplantation, which was performed 4 days later when an organ was available. In the explanted liver, one patent intraparenchymal stent was described by the pathologist. Three weeks after surgery, she was referred to a rehabilitation facility. The new organ showed good function, but she had a recurrence of ascites that was managed medically, and she returned home 6 weeks after liver transplantation. In the seventh postoperative week, however, the amount of ascites increased, which necessitated the drainage of several liters of peritoneal fluid. About 8 weeks after surgery,she became increasingly dyspneic. A chest radiograph at that time showed no evidence of pleural effusion or consolidation but, surprisingly, it did reveal a radio-opaque stent-like structure projected over the right ventricle. Doppler echocardiography (Figure 1⇓ and 2⇓) was performed, and it revealed a stent in the right ventricle caught within the subvalvular tricuspid apparatus, leading to severe tricuspid regurgitation.
The stent was removed at surgery, and the tricuspid valve was reconstructed because the stent had perforated the septal leaflet. She had an uneventful postoperative recovery, without recurrence of ascites.
It was concluded that the second Wallstent had dislodged during the perioperative period, most likely during the transplantation itself. In retrospect, the stent was seen on the first postoperative chest radiograph performed on the day of surgery.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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