A Simple “Involute” Technique for Successful Removal of a Caudally Migrated “Viatorr” Stent Graft

Inadvertent misplacement or migration of a “Viatorr” stent graft (W.L. Gore & Associates, Inc. Flagstaff, AR) during transjugular intrahepatic portosystemic shunt (TIPS) creation can occur either during stent deployment or subsequent manipulation of balloons or catheters within the stent.[1] [2] [3] Minor degrees of stent migration in the cephalad or caudal direction often have no clinical consequence. However, major cephalad migration of the stent graft can result in outflow obstruction of the inferior vena cava or problems during hepatic venous anastomosis of the transplanted liver.[4] The reported techniques for the removal of a centrally migrated stent graft involve using a loop snare to capture the cephalad portion of the stent and retrieving it into a large caliber sheath,[2] using forceps-like device for holding the proximal end to allow subsequent passage of a snare,[5] or forceful pulling of the stent into the sheath and surgical removal of the stent graft.[3]

Caudal migration of the stent graft can result in occlusion of the major portal vein branch. Major caudal migration can result in diverting the entire portal flow into the TIPS. It can also interfere with portal vein anastomosis during liver transplantation. Removal of caudally migrated TIPS stent is often difficult as the cranial segment of the stent graft is within the parenchymal tract, limiting the ability to snare the hepatic venous end of the stent graft for retrieval. Balloon-assisted repositioning of the stent graft is rarely successful. In this case, we report successful removal of a caudally migrated TIPS stent with the “involute” technique.

Other Conflicts of Interest

S.P.K. reports grants from NIH, BD, Black Swan, and Trisalus for Institution; reports royalties from Elsevier, Springer, and Thieme for himself; reports consulting fees from Penumbra, Okami Medical, Boston Scientific, Medtronic, Instylla, and BD for himself; reports stock from Biogen Inc, Clover Health Investments Corp, Inovio Pharmaceuticals, Moderna Inc, Pfizer Inc, Novavax Inc., Orphazyme, Cassava Sciences Inc., Vivos Therapeutics Inc., Ardelyx Inc., Althea Health, Sarepta Therapeutics, Clover Health Investments Corp., CureVac BV, Immunoprecise Antibodies Ltd., Infinity Pharmaceuticals Inc., Zymergen Inc., BioNTech SE, Trillium Therapeutics Inc., Theravance Biopharma Inc., Doximity Inc., Eargo Inc., Allogent Therapeutics Inc., NRx Pharmaceuticals Inc., Atea pharmaceuticals Inc., for himself and spouse.

Publication History

Article published online:
14 March 2024

• References

• 1 Ferguson E, Cwikiel W. Percutaneous removal of two self-expanding stent grafts following failed deployment. Acta Radiol 2006; 47 (07) 667-671
• 2 Ray MJ, Savage C, Klintmalm GB, Rees CR. Endovascular caudal retraction of the cranial end of a misplaced Viatorr TIPS prior to liver transplantation. Proc Bayl Univ Med Cent 2012; 25 (04) 341-343
• 3 Cwikiel W, Bergenfeldt M, Keussen I. Endovascular removal of the Viatorr stent-grafts. Report of two cases. Pol J Radiol 2015; 80: 277-280
• 4 Suhocki PV, Lungren MP, Kapoor B, Kim CY. Transjugular intrahepatic portosystemic shunt complications: prevention and management. Semin Intervent Radiol 2015; 32 (02) 123-132
• 5 Vu J, Kim SK. Percutaneous retrieval of a misplaced transjugular intrahepatic portosystemic shunt stent using the rigid endobronchial forceps. Int J Gastrointest Interv 2016; 5: 156-158
• 6 Curry JL. Recovery of detached intravascular catheter or guide wire fragments. A proposed method. Am J Roentgenol Radium Ther Nucl Med 1969; 105 (04) 894-896
• 7 Rubenstein L, Chun AK, Chew M, Binkert CA. Loop-snare technique for difficult inferior vena cava filter retrievals. J Vasc Interv Radiol 2007; 18 (10) 1315-1318
• 8 Greenfield DH, McMullan GK, Parisi AF, Askenazi J. Snare retrieval of a catheter fragment with inaccessible ends from the pulmonary artery. Cathet Cardiovasc Diagn 1978; 4 (01) 87-90
• 9 Burke CT, Dixon RG, Stavas JM. Use of rigid bronchoscopic forceps in the difficult retrieval of the Günther Tulip inferior vena cava filter. J Vasc Interv Radiol 2007; 18 (10) 1319-1323
• 10 Egglin TK, Dickey KW, Rosenblatt M, Pollak JS. Retrieval of intravascular foreign bodies: experience in 32 cases. AJR Am J Roentgenol 1995; 164 (05) 1259-1264