ULTRA ICE PLUS - PI

Description of Event or Problem

IT WAS REPORTED THAT ADVANCEMENT DIFFICULTIES WERE ENCOUNTERED RESULTING IN STENT MIGRATION REQUIRING ADDITIONAL INTERVENTION. A 16 X 90 X 100 VICI SELF EXPANDING STENT WAS SELECTED FOR A LEFT COMMON ILIAC STENTING PROCEDURE. THE NON-THROMBOTIC SECTION TO BE TREATED WAS 20-30 MM. DURING THE PROCEDURE, THE STENT WAS IMPLANTED WITH NO COMPLICATIONS. THE LEADING EDGE OF THE STENT WAS PLACED IN THE PROXIMAL LCIV AND EXTENDED TO PROXIMAL LEIV. THE PHYSICIAN THEN ATTEMPTED TO ADVANCE MULTIPLE CATHETERS INTO THE STENT AND WAS MET WITH RESISTANCE AT THE PROXIMAL OSTIUM OF THE STENT. WHEN THE PHYSICIAN WAS ATTEMPTING TO ADVANCE THE ULTRA ICE CATHETER INTO THE STENT TO VISUALIZE IT, THE VESSEL WAS SO TORTUOUS THAT THE CATHETER PUSHED AGAINST THE END OF THE STENT AND IT DISLODGED FROM WHERE IT WAS ORIGINALLY IMPLANTED. THE LEADING EDGE OF THE STENT WAS NOW IN THE DISTAL IVC EXTENDING INTO THE LCIV. A BALLOON WAS USED TO PULL THE STENT DOWN AND AN APPOSING STENT WAS PLACED FROM THE DISTAL IVC INTO THE RIGHT CIV AND THE STENT ON THE LEFT WAS EXTENDED INTO THE LEIV. NO FURTHER PATIENT COMPLICATIONS WERE REPORTED.