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Surgical removal of brachiocephalic junction endovascular stent migrated to the right atrium in a high risk patient

A 70-year-old male with multiple co-morbidities including dialysisdependent renal failure following a failed transplant, hepatitis B, and a liver transplant, was admitted for revision of a severe stenosis at the right subclavian-brachiocephalic vein junction caused by an old Tesio line. Balloon dilation was unsuccessful so that twoWallstents (Boston Scientific, Natick, MA, USA) were inserted and positioned at the stenosed vein junction, extending to the proximal superior vena cava (SVC). Following the removal of the old and the insertion of a new Tesio line (MedCOMP, Harleysville, PA, USA), it was noted on a computed tomography scan (Figure 1) and angiogram (Figure 2) that the inferior stent had migrated into the right atrium (RA). A transthoracic echocardiogram showed a moderate pericardial effusion, but no tamponade. A median sternotomy was performed and a tense, bloody pericardial effusion was evacuated and a bleeding site (caused possibly by the migrated stent) was sutured on the medial aspect of the RA. The patient was placed on cardiopulmonary bypass with cannulas in the ascending aorta and the SVC and inferior vena cava (IVC). Following SVC and IVC occlusion, an incision was made in the RA and the stent was removed (Figure 3). The patient tolerated the procedure well and was able to resume dialysis.