(P27) A Curious Case of Chest Pain

Chief Complaint : Chest Pain

History of Present Illness : This is a 49-year-old male with HTN, type 2 DM (with neuropathy), ESRD (HD T Th Sa, last today), HIV (unsure of compliance), foot infections, and PVD with amputations of R 1st-3rd toes sent into the ED after an echocardiogram performed at Montefiore on showed possible stent entanglement in his tricuspid valve. The patient is working with the Montefiore transplant team (kidney) and as part of his workup had an outpatient transesophageal echocardiogram. They called him today and advised him to come to the ED. The patient states that he began having r. sided chest "pressure" since finding out he needed to come to the hospital. The pressure is non-radiating and not accompanied by shortness of breath, nausea, vomiting, or diaphoresis.

Pertinent Physical Exam: GENERAL: Awake, alert, and fully oriented, no acute distress.
HEENT: Normocephalic, atraumatic. PERRLA, EOMI. No conjunctival pallor. Moist mucous membranes.
NECK: Normal ROM and supple. No lymphadenopathy, JVD, or masses.
CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2. Fistula in LUE, palpable thrill
PULMONARY: No respiratory distress. Breath sounds equal, and clear to auscultation bilaterally.
ABDOMEN: Soft, non-tender.
EXTREMITIES: Normal range of motion, no edema or erythema, no calf tenderness.
NEUROLOGICAL: Cranial nerves II through XII are grossly intact. Normal speech, normal gait
SKIN: Warm, Dry, normal turgor, no rashes or lesions noted. Normal capillary refill.
PSYCHIATRIC: Appropriate affect.

Pertinent Laboratory Data: Troponin <.02
EKG: Sinus rhythm, rate of 162. Possible R. atrial enlargement.

Echocardiogram
A tubular echogenic structure with a foreign body is noted entangled to the tricuspid valve and protruding into the right ventricle. This likely represents an embolized foreign body such as a venous stent.

Cardiac CT w/ contrast
There is a fractured stent in the right ventricle. The medial fragment measures 10mm with struts attached to the basal septal ventricular septum at the tricuspid septal leaflet hinge point and attached to the anterior tricuspid leaflet. The lateral fragment measures 18mm attached to the free lateral wall.

Case Discussion: The possible consequences of endovascular stent placement include stenosis, infection, fracture, and migration. In general, migration occurs at the time of stent placement, however, it can also be delayed. Fractures can occur when the stents are in areas exposed to crushing and bending. In addition, renal access grafts are a high-flow system, and the resulting central vein dilation promotes the risk of migration. It is likely that this patient's stent migrated at the time of placement, or shortly after, as the stent can be seen on chest X-rays as far back as 2018. The patient was evaluated by cardiothoracic surgery as well as interventional radiology. The risks were considered to be higher than the benefits and both recommended no further intervention at this time. Although this is a rare case of stent migration, consider a foreign body as a cause of patients presenting with chest pain. Additionally, this stent was only seen on lateral chest X-rays. Whenever possible opt for a PA/lateral chest X-ray rather than a portable image.

References and Acknowledgements (Optional): Bani-Hani S, Showkat A, Wall BM, Das P, Huang L, Al-Absi AI. Endovascular stent migration to the right ventricle causing myocardial injury. Semin Dial. 2012 Sep-Oct;25(5):562-4. doi: 10.1111/j.1525-139X.2011.01039.x. Epub 2012 Feb 20. PMID: 22348654.
Blais JM, Letourneau M, Hinojos A, Sandy R, Gray T, Miller T. I'll Stay a While: An Unusual Case of a Chronic Migrated Upper Extremity Endovascular Stent. CASE (Phila). 2019 Apr 26;3(3):100-102. doi: 10.1016/j.case.2019.02.006. PMID: 31286087; PMCID: PMC6588836.
Cohen MH, Kyriazis DK. Wallstent migration into the right ventricle causing severe tricuspid regurgitation and right ventricular perforation. Tex Heart Inst J. 2012;39(2):271-2. PMID: 22740751; PMCID: PMC3384044.