Migrated brachiocephalic venous stent into the right atrium - can it be left alone? A case report and review of the literature.

Case Report A 60-year-old man was admitted to hospital with a myocardial infarction and was incidentally found to have a right posterior thoracic mass on chest-radiograph. Computed tomography (CT) confirmed a large posterior thoracic mass with pleural thickening. No mediastinal lymphadenopathy or pulmonary metastasis was seen. He had a coronary artery bypass grafting and returned 2 months later for biopsy of the mass where histological diagnosis of a malignant solitary fibrous tumour of the pleura was made. A week following biopsy, he presented with stridor. Repeat CT showed an increase in tumour size with invasion of the superior mediastinum and significant compression of the distal trachea and right main bronchus. A rigid bronchoscopy and stenting (Ultraflex®) of the distal trachea and bronchus intermedius was performed. He was not a surgical candidate owing to his multiple comorbidities and recent myocardial infarction and hence commenced on palliative radiotherapy with good symptomatic relief. Five months following completion of radiotherapy, he presented with severe chest pain, breathlessness and left arm swelling. He had dilated neck veins and telangectasia of the chest wall with decreased air entry in the right hemithorax. A repeat CT showed the tumour invading the superior mediastinum and compressing the trachea and right upper lobe bronchus, despite the tracheal stent in situ. Catheter venography demonstrated stenosis of both brachiocephalic veins. A 14mm x 60mm Nitinol self expanding stent (Smart stent Cordis®) was deployed in the right brachiocephalic vein and a 12mm x 80mm stent (Smart stent) was deployed in the left brachiocephalic vein. Both stents were confirmed to be in a satisfactory position and patent at the end of the procedure. He received a further course of radiotherapy with good symptomatic relief. He defaulted clinical follow-up and presented one year later with heamoptysis, dyspnoea, spiking temperature and reduced air entry in the right hemithorax. CT showed the tumour almost completely filling the right hemithorax with collapse of the right lung, small right pleural effusion, small pericardial effusion and oesophageal and tracheal compression and deviation to the left. The left brachiocephalic venous stent was in a satisfactory position. However, the right brachiocephalic venous stent had dislodged and migrated into the right atrium where it was seen closely related to the roof, posterior wall and floor of the right atrium (Fig. 1). The stent was presumably dislodged by the growing tumour compressing on the right brachiocephalic vein. His electrocardiogram tracing