Case Report
Wallstent Migration Following Deployment in Right and Left Bile Andrea F. Abramson, MD Daniel J. Javit, MD Harold A. Mltty, MD John S. Train, MD Sol J. Dan, MD
The Wallstent biliary endoprosthesis has recently been approved for treatment of malignant bile duct obstruction. Although minor changes in position have occurred, migration of these stents has been uncommon. The authors report a case in which migration occurred when stents were simultaneously deployed in the right and left bile ducts. Several mechanisms for this complication are postulated. -
--
Index terms: Bile ducts, interventional procedures, 76.1229 Bile ducts, prostheses, 76.1229, 76.4613 Bile ducts, stenosis or obstruction, 76.289 Stents, 76.4613
T H E Wallstent biliary endoprosthesis
(Schneider, Minneapolis) has recently been approved for treatment of malignant bile duct obstruction. Although minor changes in stent position have occurred, migration has been uncommon. We report a case in which migration occurred when stents were deployed simultaneously in the right and left bile ducts.
CASE REPORT
From the Department of Radiology, Box 1234, Mount Sinai Medical Center, City University of New York, 1Gustave L Levy Pl, New York, NY 10029-6574. Received November 4, 1991; revision requested December 29; revision received January 31, 1992; accepted February 10. Address reprint requests to A.F.A. SCVIR, 1992
A 53-year-old woman had a 3-month history of mid-epigastric pain, anorexia, diarrhea, fever, and chills. She became progressively jaundiced and underwent two operative procedures in Central America. Three weeks later she presented in our hospital with chills, epigastric pain, diarrhea, and a fever of 102.6"F (39.2"C).A surgically placed catheter was draining bile. The patient's family provided the history, clinical course, and a formalin-fixed surgical specimen. Diagnosis at microscopic pathologic study indicated gallbladder carcinoma. On admission, laboratory values were as follows: white blood cell count, 17,300/mm3(17.3 x 10g/L);total bilirubin level, 11.4 mg/dL (195 kmol/L); direct bilirubin level, 6.9 mg/dL (118 kmol/L); alkaline phosphatase level, 1,475 U/L; alanine aminotransferase level, 66 UIL. Injection of contrast material through the surgically placed drainage catheter showed its tip at the level of a high-grade stenosis at the bifurcation of the bile ducts (Fig 1).The distal com-
mon bile duct was patent, and contrast material flowed into the duodenum. Bilateral percutaneous biliary drainage procedures were performed, as access was not technically possible through the existing catheter. One week following drainage, the patient was afebrile. Laboratory values decreased to the following: white blood cell count, 6,200/mm3 (6.2 x 109/L); total bilirubin level, 2.4 mg/dL (41 pmol/L); direct bilirubin level, 1.7 mg/dL (29 p,mol/L); alkaline phosphatase level, 562 U/L; alanine aminotransferase level, 23 U/L. A cholangiogram once again showed the high-grade stenosis. Preliminary balloon dilations (8 mm, 3 cm) were performed to create an adequate lumen for easy passage of the Wallstent system. A repeat cholangiogram showed slightly larger channels. The stents (10 mm in diameter, 68 mm long) were inserted successfully. The stent was easily deployed in the right biliary duct, and the distal end projected through the papilla of Vater. Deployment of the stent in the left duct was finally achieved despite some difficulty in retracting the covering membrane, a problem that has been previously reported (1).A spot radiograph showed both stents in proper position and expanded at this time (Fig 2). During preparation for the final step of balloon dilation, the right duct stent migrated distally. The proximal ends of the steel filaments lodged in the papilla of Vater, and the remainder of the stent was in the duodenum. A catheter was left in place through the migrated right
464
Journal of Vascular and Interventional Radiology
August 1992
Figure 1. Injection of contrast material through a surgically placed drainage catheter shows its tip at the level of a highgrade stenosis at the bifurcation of the bile ducts (long straight arrow). The distal common biie ductwas patent, and conmaterial flowed into the duodenum (short straight arrow)' An extrabiliary was formed of contrast by tracking along the catheter (curved arrow).
stent lumen to prevent further distal migration. The left stent also migrated a few centimeters but remained within the common bile duct (Fig 3). The migrated Wallstent was retrieved, and another stent was placed endoscopically in the right duct.
DISCUSSION Endoprostheses made of polyethylene, polyurethane, and other polymers have been associated with a 6%-10% incidence of migration (14).The flared, sharp, steel filaments on the ends of the proximal and distal parts of the Wallstent are designed to anchor the stent to the duct wall. Additionally, the outward radial force of the self-expandable metallic mesh closely applies the stent to the duct wall. One of the reasons for this design is to prevent migration. It is thought that the distal end of the stent may protrude slightly across the papilla of Vater. In addition, placement across a choledochojejunos-
2.
3.
Figures 2,3. (2) Side-by-sidestents are seen in good position. Distal end of stent from right hepatic duct projects through the papilla of Vater (arrows). (3) Stent from the right hepatic duct has migrated into the duodenum (arrows).Left stent remains in good position.
tomy is also described as acceptable (1). Mueller et al reported changes in position in five patients and one migration into the duodenum in 22 stent placements (5). In two large series, reported by Adam et a1 (41 patients) and Gilliams et a1 (45 patients), no migrations of the Wallstent were reported (1,4). LaBerge et a1 (20 patients) described simultaneous placement of Wallstents for drainage of right and left ductal systems for patients with hilar obstruction. No migrations were documented (6). We believe migration occurred partly because the distal flared ends of the stent were beyond the papilla of Vater, thereby providing no anchoring effect within the distal common bile duct. Further, it is likely that the side-by-side array of the two stents may have facilitated a slipping action of one stent over the other. LaBerge et a1 point out that when side-by-side Wallstents are deployed, each opens to less than its full diameter; and, as a result, there is elongation of the stent (6). These factorssuboptimal distal anchoring, slipping
action, and stent elongation coupled with the antegrade pull of duodenal peristalsis-overcame the stabilization provided by the anchored proximal ends and the radial forces of the stent. Theoretically, it is possible that the right stent could have been placed too far into the system and expansion1 shortening could have resulted in too distal a placement of the stent. In this case, however, special attention was exercised in positioning the proximal stent end above the lesion because the access to the biliary tree was quite central, permitting only a small length of stent above the lesion. The stent was not permitted to drift distally during deployment. Use of the Wallstent in relieving biliary obstruction seems promising. The self-expandable meshwork and flaredend design may address some of the problems encountered with prior endoprostheses. I t remains to be seen if placement of side-by-side stents and deployment across the papilla of Vater may increase the incidence of Wallstent migrations.
Abramson et a1
465
Volume 3 Number 3
References 1. Adam A, Chetty N, Roddie M, Yeung E, Benjamin IS. Self-expandable stainless steel endoprosthesis for treatment of malignant bile duct obstruction. AJR 1991; 156:321-325. 2. Mueller PR, Ferrucci JT, Teplick SK, et al. Biliary stent endoprosthesis: analysis of complications in 113 patients. Radiology 1985; 156:637-639.
3. Lammer J , Neumayer K. Biliary drainage endoprostheses: experience with 201 placements. Radiology 1986; 159:625629. 4. Gilliams, Dick R, Dooley JS, Wallsten H, El-Din A. Self-expandable stainless steel braided endoprosthesis of biliary drainage. Radiology 1990; 174:137-140. 5. Mueller PR, Tegtmeyer CJ, Sanjay S, et al. Metallic biliary stents: early experi-
ence (abstr). Radiology 1990; 177(P): 138. 6. LaBerge JM, Doherty M, Gordon RL, Ring EJ. Hilar malignancy: treatment with an expandable metallic transhepatic biliary stent. Radiology 1990; 177: 793-797.
Wallstent Migration Following Deployment in Right and Left Bile Andrea F. Abramson, MD Daniel J. Javit, MD Harold A. Mltty, MD John S. Train, MD Sol J. Dan, MD
The Wallstent biliary endoprosthesis has recently been approved for treatment of malignant bile duct obstruction. Although minor changes in position have occurred, migration of these stents has been uncommon. The authors report a case in which migration occurred when stents were simultaneously deployed in the right and left bile ducts. Several mechanisms for this complication are postulated. -
--
Index terms: Bile ducts, interventional procedures, 76.1229 Bile ducts, prostheses, 76.1229, 76.4613 Bile ducts, stenosis or obstruction, 76.289 Stents, 76.4613
T H E Wallstent biliary endoprosthesis
(Schneider, Minneapolis) has recently been approved for treatment of malignant bile duct obstruction. Although minor changes in stent position have occurred, migration has been uncommon. We report a case in which migration occurred when stents were deployed simultaneously in the right and left bile ducts.
CASE REPORT
From the Department of Radiology, Box 1234, Mount Sinai Medical Center, City University of New York, 1Gustave L Levy Pl, New York, NY 10029-6574. Received November 4, 1991; revision requested December 29; revision received January 31, 1992; accepted February 10. Address reprint requests to A.F.A. SCVIR, 1992
A 53-year-old woman had a 3-month history of mid-epigastric pain, anorexia, diarrhea, fever, and chills. She became progressively jaundiced and underwent two operative procedures in Central America. Three weeks later she presented in our hospital with chills, epigastric pain, diarrhea, and a fever of 102.6"F (39.2"C).A surgically placed catheter was draining bile. The patient's family provided the history, clinical course, and a formalin-fixed surgical specimen. Diagnosis at microscopic pathologic study indicated gallbladder carcinoma. On admission, laboratory values were as follows: white blood cell count, 17,300/mm3(17.3 x 10g/L);total bilirubin level, 11.4 mg/dL (195 kmol/L); direct bilirubin level, 6.9 mg/dL (118 kmol/L); alkaline phosphatase level, 1,475 U/L; alanine aminotransferase level, 66 UIL. Injection of contrast material through the surgically placed drainage catheter showed its tip at the level of a high-grade stenosis at the bifurcation of the bile ducts (Fig 1).The distal com-
mon bile duct was patent, and contrast material flowed into the duodenum. Bilateral percutaneous biliary drainage procedures were performed, as access was not technically possible through the existing catheter. One week following drainage, the patient was afebrile. Laboratory values decreased to the following: white blood cell count, 6,200/mm3 (6.2 x 109/L); total bilirubin level, 2.4 mg/dL (41 pmol/L); direct bilirubin level, 1.7 mg/dL (29 p,mol/L); alkaline phosphatase level, 562 U/L; alanine aminotransferase level, 23 U/L. A cholangiogram once again showed the high-grade stenosis. Preliminary balloon dilations (8 mm, 3 cm) were performed to create an adequate lumen for easy passage of the Wallstent system. A repeat cholangiogram showed slightly larger channels. The stents (10 mm in diameter, 68 mm long) were inserted successfully. The stent was easily deployed in the right biliary duct, and the distal end projected through the papilla of Vater. Deployment of the stent in the left duct was finally achieved despite some difficulty in retracting the covering membrane, a problem that has been previously reported (1).A spot radiograph showed both stents in proper position and expanded at this time (Fig 2). During preparation for the final step of balloon dilation, the right duct stent migrated distally. The proximal ends of the steel filaments lodged in the papilla of Vater, and the remainder of the stent was in the duodenum. A catheter was left in place through the migrated right
464
Journal of Vascular and Interventional Radiology
August 1992
Figure 1. Injection of contrast material through a surgically placed drainage catheter shows its tip at the level of a highgrade stenosis at the bifurcation of the bile ducts (long straight arrow). The distal common biie ductwas patent, and conmaterial flowed into the duodenum (short straight arrow)' An extrabiliary was formed of contrast by tracking along the catheter (curved arrow).
stent lumen to prevent further distal migration. The left stent also migrated a few centimeters but remained within the common bile duct (Fig 3). The migrated Wallstent was retrieved, and another stent was placed endoscopically in the right duct.
DISCUSSION Endoprostheses made of polyethylene, polyurethane, and other polymers have been associated with a 6%-10% incidence of migration (14).The flared, sharp, steel filaments on the ends of the proximal and distal parts of the Wallstent are designed to anchor the stent to the duct wall. Additionally, the outward radial force of the self-expandable metallic mesh closely applies the stent to the duct wall. One of the reasons for this design is to prevent migration. It is thought that the distal end of the stent may protrude slightly across the papilla of Vater. In addition, placement across a choledochojejunos-
2.
3.
Figures 2,3. (2) Side-by-sidestents are seen in good position. Distal end of stent from right hepatic duct projects through the papilla of Vater (arrows). (3) Stent from the right hepatic duct has migrated into the duodenum (arrows).Left stent remains in good position.
tomy is also described as acceptable (1). Mueller et al reported changes in position in five patients and one migration into the duodenum in 22 stent placements (5). In two large series, reported by Adam et a1 (41 patients) and Gilliams et a1 (45 patients), no migrations of the Wallstent were reported (1,4). LaBerge et a1 (20 patients) described simultaneous placement of Wallstents for drainage of right and left ductal systems for patients with hilar obstruction. No migrations were documented (6). We believe migration occurred partly because the distal flared ends of the stent were beyond the papilla of Vater, thereby providing no anchoring effect within the distal common bile duct. Further, it is likely that the side-by-side array of the two stents may have facilitated a slipping action of one stent over the other. LaBerge et a1 point out that when side-by-side Wallstents are deployed, each opens to less than its full diameter; and, as a result, there is elongation of the stent (6). These factorssuboptimal distal anchoring, slipping
action, and stent elongation coupled with the antegrade pull of duodenal peristalsis-overcame the stabilization provided by the anchored proximal ends and the radial forces of the stent. Theoretically, it is possible that the right stent could have been placed too far into the system and expansion1 shortening could have resulted in too distal a placement of the stent. In this case, however, special attention was exercised in positioning the proximal stent end above the lesion because the access to the biliary tree was quite central, permitting only a small length of stent above the lesion. The stent was not permitted to drift distally during deployment. Use of the Wallstent in relieving biliary obstruction seems promising. The self-expandable meshwork and flaredend design may address some of the problems encountered with prior endoprostheses. I t remains to be seen if placement of side-by-side stents and deployment across the papilla of Vater may increase the incidence of Wallstent migrations.
Abramson et a1
465
Volume 3 Number 3
References 1. Adam A, Chetty N, Roddie M, Yeung E, Benjamin IS. Self-expandable stainless steel endoprosthesis for treatment of malignant bile duct obstruction. AJR 1991; 156:321-325. 2. Mueller PR, Ferrucci JT, Teplick SK, et al. Biliary stent endoprosthesis: analysis of complications in 113 patients. Radiology 1985; 156:637-639.
3. Lammer J , Neumayer K. Biliary drainage endoprostheses: experience with 201 placements. Radiology 1986; 159:625629. 4. Gilliams, Dick R, Dooley JS, Wallsten H, El-Din A. Self-expandable stainless steel braided endoprosthesis of biliary drainage. Radiology 1990; 174:137-140. 5. Mueller PR, Tegtmeyer CJ, Sanjay S, et al. Metallic biliary stents: early experi-
ence (abstr). Radiology 1990; 177(P): 138. 6. LaBerge JM, Doherty M, Gordon RL, Ring EJ. Hilar malignancy: treatment with an expandable metallic transhepatic biliary stent. Radiology 1990; 177: 793-797.
