Additional Stent Placement Research Articles

Technical Feasibility and Application of Mechanical Thrombectomy with the Solitaire FR Revascularization Device in Acute Basilar Artery Occlusion

Acute BAO is a devastating neurological condition associated with a poor clinical outcome and a high mortality rate. Recanalization has been identified as a major prognostic factor for good outcome in BAO. Mechanical thrombectomy using retrievable stents is an emerging treatment option for acute stroke. First clinical trials using stent retrievers have shown promising high recanalization rates. However, these studies mainly included large artery occlusions in the anterior circulation with only a few or single cases of BAO. Therefore, the purpose of this study was to evaluate technical feasibility, safety, and efficacy of mechanical thrombectomy using retrievable stent in the treatment of acute BAO. Fourteen consecutive patients with BAO undergoing endovascular therapy using retrievable stents (Solitaire FR Revascularization Device) were included. Additional multimodal treatment approaches included thromboaspiration, intravenous and/or intra-arterial thrombolysis, and PTA/ permanent stent placement. Recanalization rates after multimodal therapy and stent retrieval were determined. Clinical outcome and mortality were assessed 3 months after treatment. Median patient age was 64.5 years (range 55-85). Median NIHSS score at presentation was 21 (range 5-36). Overall, successful recanalization (TICI 3 or 2b) was achieved in all patients (TICI 3 in 78.6%, 11/14). In 4 patients (28.6%), insufficient recanalization after stent retrieval was due to an underlying atherosclerotic stenosis. Additional deployment of a permanent intracranial stent was performed in 3 patients (21.4%) and PTA alone in 1 patient (7.1%), resulting in final TICI 3 in 1 patient and TICI 2b in 3 patients. Stent retrieval alone was performed in 4 patients (28.6%). Average number of device passes was 1.3 (range 1-3). Median procedure time to maximal recanalization was 47 minutes (range 10-252). No device-related complications or thromboembolic occlusion of a previously unaffected artery occurred. There was no symptomatic intracranial hemorrhage. At 3 months, good functional outcome (mRS 0-2) was observed in 28.6% (4/14); overall mortality was 35.7% (5/14). A multimodal endovascular approach using retrievable stents in BAO has high recanalization rates, with very low complication rates. Underlying atherothrombotic stenotic lesions of the basilar artery may still necessitate additional permanent stent placement to achieve complete recanalization.

Life-threatening Cerebral Edema Caused by Acute Occlusion of a Superior Vena Cava Stent

A71-year-old man with advanced lung cancer developed a life-threatening cerebral edema caused by the acute occlusion of a superior vena cava (SVC) stent and was successfully treated by an additional stent placement. Although stent occlusion is a common early complication, no life-threatening situations have been reported until now. Our experience highlights the fact that acute stent occlusion can potentially lead to the complete venous shutdown of the SVC, resulting in life-threatening cerebral edema, after SVC stent placement. Immediate diagnosis and countermeasures are required.

SUPERvised Exercise Therapy or Immediate PTA for Intermittent Claudication in Patients with an Iliac Artery Obstruction – A Multicentre Randomised Controlled Trial; SUPER Study Design and Rationale

IntroductionTreatment of intermittent claudication (IC) due to peripheral arterial disease (PAD) is aimed at improving walking distance and includes secondary prevention of cardiovascular disease. Both supervised exercise therapy (SET) and percutaneous transluminal angioplasty (PTA) have proven to be effective in increasing maximum and pain-free walking distance in IC. However, the optimal treatment strategy in patients with IC due to iliac artery stenosis or occlusion remains unclear. ObjectiveTo compare the (cost-) effectiveness of initial PTA versus initial SET in patients with disabling IC due to an iliac artery obstruction. DesignIn a multicentre randomised controlled trial 400 consecutive patients with IC will be randomly assigned to PTA (with additional stent placement on indication) or SET. Primary outcomes are maximum walking distance and health-related quality of life measured using the disease-specific VascuQol instrument after 1 year. Secondary outcomes are pain-free walking distance, functional status, generic quality of life, complications related to each of the interventions, additional interventions, treatment failures and costs (cost-effectiveness and cost-utility) after 1 year. Conclusion and implicationsBased on the results of this proposed large study well-founded adjustments of existing guidelines on the treatment of iliac artery occlusive disease can be implemented (Clinical Trials.gov NCT01385774; Nederlands Trial Register NTR2776).

Mesenteric artery complications during angioplasty and stent placement for atherosclerotic chronic mesenteric ischemia

The purpose of this study was to describe the incidence, management, and outcomes of mesenteric artery complications (MACs) during angioplasty and stent placement (MAS) for chronic mesenteric ischemia (CMI). We retrospectively reviewed the clinical data of 156 patients treated with 173 MAS for CMI (1998-2010). MACs were defined as procedure-related mesenteric artery dissection, stent dislodgement, embolization, thrombosis, or perforation. End points were procedure-related morbidity and death. There were 113 women and 43 men (mean age, 73 ± 14 years). Eleven patients (7%) developed 14 MACs, including distal mesenteric embolization in six, branch perforation in three, dissection in two, stent dislodgement in two, and stent thrombosis in one. Five patients required adjunctive endovascular procedures, including in two patients each, catheter-directed thrombolysis or aspiration, retrieval of dislodged stents, and placement of additional stents for dissection. Five patients (45%) required conversion to open repair: two required evacuation of mesenteric hematoma, two required mesenteric revascularization, and one required bowel resection. There were four early deaths (2.5%) due to mesenteric embolization or myocardial infarction in two patients each. Patients with MACs had higher rates of mortality (18% vs 1.5%) and morbidity (64% vs 19%; P <.05) and a longer hospital length of stay (6.3 ± 4.2 vs 1.6 ± 1.2 days) than those without MACs. Periprocedural use of antiplatelet therapy was associated with lower risk of distal embolization or vessel thrombosis (odds ratio, 0.2; 95% confidence interval, 0.06-0.90). Patients treated by a large-profile system had a trend toward more MACs (odds ratio, 1.8; 95% confidence interval, 0.7-26.5; P = .07). MACs occurred in 7% of patients who underwent MAS for CMI and resulted in higher mortality, morbidity, and longer hospital length of stay. Use of antiplatelet therapy reduced the risk of distal embolization or vessel thrombosis. There was a trend toward more MACs in patients who underwent interventions performed with a large-profile system.

Thrombus aspiration alone during primary percutanous coronary intervention as definitive treatment in acute ST‐elevation myocardial infarction

In some patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutanous coronary intervention (pPCI) with thrombus aspiration, residual stenosis after thrombus aspiration is non-significant and additional balloon dilatation or stent placement may be unnecessary. We investigated the angiographic, procedural, and clinical outcomes of these patients in our single center pPCI-database. In addition, to gain insight in the pathological mechanisms of coronary thrombosis in these patients, we established the histopathological characteristics and age of the aspirated material. This study consists of STEMI patients who underwent pPCI with thrombus aspiration alone in our institution. Thrombus material was collected and processed and the sections were analyzed for the presence of fresh (<1 day) or older thrombus (>1 day) and plaque components. One year clinical follow-up was obtained and vital status was assessed up to March 2010. We identified 16 STEMI patients who underwent thrombus aspiration alone as the definitive treatment during pPCI. Acceptable flow with minimal non-significant residual stenosis immediately after thrombus aspiration was present in 14 patients (88%). In four patients (25%) repeat angiography was performed after several days and disappearance of the residual thrombus could be confirmed in three patients. During follow-up, repeat target lesion revascularization was performed in one patient at 53 days. No recurrent myocardial infarction was observed. Two patients died 1,166 and 1,228 days after the index-event from non-cardiac causes. In selected STEMI patients undergoing pPCI, thrombus aspiration alone is feasible and safe on the short-term and there appears to be no high risk of recurrent ischemic events during follow-up. Our results suggest that additional balloon inflation or stent implantation may be unnecessary in selected patients, when there is no significant residual stenosis after thrombus aspiration.

Stenting Techniques for Patients With Bifurcation Coronary Artery Disease

Atherosclerotic lesions at the bifurcation of coronary arteries are associated with higher rates of restenosis following stenting, and can be technically challenging when performing percutaneous coronary intervention (PCI). Many techniques have arisen for PCI of these lesions, often incorporating the use of multiple balloons and the placement of two or more stents. A technique commonly used for bifurcations is kissing balloon angioplasty, in which two balloons are inflated simultaneously to prevent the shifting of plaque into the side branch. Provisional side branch stenting is the technique of using a stent for the main branch, and stenting the side branch only if necessary. Multiple-stent techniques include T-stenting, crush technique, culotte, simultaneous kissing stents, V-stenting, and Y-stenting; the goal of these techniques is to provide maximal apposition to the vessel wall with effective drug delivery in the case of drug-eluting stents. Additionally, dedicated bifurcation stents also exist, with apertures that allow placement of additional stents. Debulking techniques such as atherectomy can be employed as stand-alone procedures or to debulk lesions prior to bifurcation stenting. Despite these many options for PCI of bifurcation lesions, there are currently inadequate data to indicate which of these techniques is superior, and many trials have found that complex stenting techniques provide no additional benefits when compared with provisional side branch stenting. Additional, well-designed randomized trials evaluating specific stenting techniques are necessary to determine the best practice for bifurcation lesions.

Reestablishing Biliary Drainage after Through-Wall Migration of a Fully Coated Biliary Self-Expanding Biliary Metal Stent (SEMS)

Purpose: Coated SEMS have been marketed in the hopes of superior patency and potential removability compared to uncoated SEMS. Several studies have reported incidents of coated stent out and in-migration. We report a new form of migration. Case Report: A 64 y.o. male presented with obstructive jaundice with an obvious unresectable pancreatic head mass. ERCP brush proved adenocarcinoma, and a fully coated SEMS was placed with success, resulting in resolution of jaundice. Recurrence of jaundice was noted after one month. CT revealed internal through-wall migration and he was referred. At ERCP, the proximal 2 cm of the stent was obviously outside the confines of the common bile duct and the lower end was partially in-migrated. Removal was not attempted due to fear of involvement of deeper structures, especially the portal vein or hepatic artery. Drainage was re-established using the following sequence of techniques: First, a high-pressure balloon occlusion cholangiogram ruptured the coated stent membrane, resulting in filling of the CBD (see image). A partially tensed papillotome was then positioned at a right angle to the rupture and a guidewire was passed through the sidewall of stent wires into the common bile duct. The puncture site was then opened with an 8.5Fr Soehendra screw extractor, and a 7Fr argon plasma circumferential coagulation probe was advanced up the duct and through the sidewall opening. Upon gently pulling the probe back, the tip would “catch” on the stent wires. Brief bursts of 90W were then applied, cutting the wires one by one. An optical fiber (SpyGlass, BostonSci) was placed through a 035 sphincterotome and used as a tiny 6Fr baby endoscope to confirm adequacy of the opening for additional stent placement. At the close, an uncoated SEMS was placed over the guidewire positioned across the fenestration into the true lumen. No complication occurred. The jaundice rapidly cleared. Summary: This case documents both through-wall migration through the upper common bile duct wall as well as in-migration into the lower duct. The re-establishment of drainage endoscopically required several unusual techniques. Fenestration of the metal wires with intraductal APC may be a unique use of this technology.Figure: Balloon occlusion cholangiogram with rupture of the membrane and filling of the common bile duct.

One-year multicenter results of 100 abdominal aortic aneurysm patients treated with the Endurant stent graft

The Endurant (Medtronic, Minneapolis, Minn) is a new stent graft specifically designed to make more patients anatomically eligible for endovascular aneurysm (EVAR). This study presents the 1-year results of 100 consecutive patients with abdominal aortic aneurysms (AAAs) treated with the Endurant stent graft in real-life practice. All clinical preoperative, operative, postoperative, and 1-year follow-up data of patients with the Endurant stent graft from three tertiary centers were prospectively collected. Patients underwent computed tomographic angiography (CTA) preoperatively, at 1 month, and at 1-year post-EVAR. The first 100 patients with an implantation date at least 1 year before our date of analysis and complete information were included. Clinical data, AAA characteristics, presence of endoleaks, graft migration, and other EVAR-related complications were noted. All values are stated as mean ± SD (range). This study included 100 patients with AAAs (88 men) with a mean age of 73 ± 8 years (47 to 87 years), an AAA size of 61 ± 10 mm (31 to 93 mm), an AAA volume of 210 ± 122 mL (69 to 934 mL), a proximal neck length of 33 ± 14 mm (9 to 82 mm), and an infrarenal angulation of 44 ± 25° (0°-108°). Nineteen of the 100 included patients had at least one anatomic characteristic that was considered a violation of the instructions for use (IFU) of the Endurant stent graft. A primary technical success was achieved in 98% of the patients (one additional stent placement in renal artery was required; one unplanned aorto-uni-iliac device placed), with no primary type I or III endoleaks or conversions. A secondary technical success was achieved in all cases. The 30-day mortality was 2% and the first postoperative CTA documented 16 endoleaks (16%; 16 type II). One-year follow-up showed three iliac limb occlusions (3%), one infected stent graft (causing a type Ia endoleak), and five endovascular reinterventions (5%; three to treat iliac limb occlusions, one proximal extension cuff; and one stent in the renal artery). The 1-year all-cause mortality rate was 12% (12 patients) and the AAA-related mortality was 3%. The mean AAA size was significantly smaller after 1 year (diameter, 54 ± 11.8 [32-80] mm; P < .01; volume, 173 ± 119 [42-1028] mL; P < .01), and one graft migration >5 mm and 13 endoleaks were noted (12 type II, 1 type I [neck dilatation]). The treatment of patients with AAAs with the Endurant stent graft seems to be successful and durable during the first year after EVAR. Despite the wider inclusion criteria for the Endurant, and with 19% of our patients treated outside the IFU, the AAA-related mortality, number of type I or III endoleaks, and reintervention rates are comparable to the results of other stent grafts.

Management for Prostate Cancer Treatment Related Posterior Urethral and Bladder Neck Stenosis With Stents

Prostate cancer treatment has the potential to lead to posterior urethral stricture. These strictures are sometimes recalcitrant to dilation and urethrotomy alone. We present our experience with the Urolume® stent for prostate cancer treatment related stricture. A total of 38 men with posterior urethral stricture secondary to prostate cancer treatment were treated with Urolume stenting. Stents were placed in all men after aggressive urethrotomy over the entire stricture. A successfully managed stricture was defined as open and stable for greater than 6 months after any necessary secondary procedures. The initial success rate was 47%. After a total of 31 secondary procedures in 19 men, including additional stent placement in 8 (18%), the final success rate was 89% at a mean ± SD followup of 2.3 ± 2.5 years. Four cases (11%) in which treatment failed ultimately requiring urinary diversion (3) or salvage prostatectomy (1). Incontinence was noted in 30 men (82%), of whom 19 (63%) received an artificial urinary sphincter a mean of 7.2 ± 2.4 months after the stent. Subanalysis revealed that irradiated men had longer strictures (3.6 vs 2.0 cm, p = 0.003) and a higher post-stent incontinence rate (96% vs 50%, p < 0.001) than men who underwent prostatectomy alone but the initial failure rate was similar (54% vs 50%, p = 0.4). Urolume stenting is a reasonable option for severe post-prostate cancer treatment stricture when patients are unwilling or unable to undergo open reconstructive surgery. Incontinence should be expected. The need for additional procedures is common and in some men may be required periodically for the lifetime of the stent.

Long-Term Outcome of Endovascular Popliteal Artery Aneurysm Repair

Popliteal artery aneurysms have traditionally been repaired with an open surgical approach. However, endovascular popliteal artery repair (EVPAR) has been used in selected patients because of its less invasive nature. In this report, we present our long-term outcomes for EVPAR. Retrospective review of all patients who underwent EVPAR at a single academic institution between September 2002 and March 2006. These patients were evaluated for patency, need for secondary intervention, amputation-free survival, and overall survival. A total of 15 limbs in 13 patients were treated with EVPAR during the study period. All EVPAR were performed using the Viabahn(®) endoprostheses, with an average of 1.67 stents per limb. The mean age of the patients was 74.6 years (range, 66-84). Technical success was achieved in 100% and all limbs had initial postoperative ankle-arm indices of ≥ 1.0. Mean duration of follow-up was 54 months (range, 42-70). Two patients died of unrelated causes at 3 and 38 months with intact limbs, and one patient was lost to follow-up. Two limbs developed type I or III endoleaks, and were successfully treated with additional endovascular stent placement, resulting in a primary patency rate of 84.6% and secondary patency rate of 100%. There were no instances of limb loss during the follow-up period, yielding both amputation-free survival and overall survival rates of 85.7%. Long-term follow-up of this cohort of EVPAR patients suggests that in selected patients, this is a durable technique, capable of achieving excellent patency rates and limb preservation. Further large-scale clinical trials are warranted to help define optimal candidates for this technique.

Cryoplasty Offers No Advantage Over Standard Balloon Angioplasty for the Treatment of In-Stent Restenosis

In-stent restenosis is the primary failure mode of endovascular treatment of occlusive disease in the femoropopliteal segment. Cryoplasty has been proposed to reduce intimal hyperplasia through induction of apoptosis. We sought to evaluate the efficacy of cryoplasty for treatment of in-stent restenosis compared with conventional balloon angioplasty (CBA). After IRB approval, a retrospective record review was performed of reinterventions for in-stent restenosis by a single vascular surgery group at a university hospital. Reinterventions involving cryoplasty and CBA were evaluated at 1, 3, 6, and 12 months after intervention with duplex imaging to identify significant recurrent stenosis utilizing established velocity criteria. Data collected included basic demographic information and comorbidities as well as time to restenosis. Statistical analysis was performed using Kaplan-Meier survival curves with the log rank test, Wilcoxon rank test, and Cox proportional hazards models. From December 2004 to November 2009, 76 reinterventions were performed using CBA (n = 39) or cryoplasty (n = 37) for in-stent restenosis without placement of additional stents. Periprocedural technical success (<30% residual stenosis) was 100% for both groups, with no complications. The two cohorts were statistically similar in mean age, gender distribution, comorbidities (including active tobacco use), and use of statins, aspirin, and Plavix. However, the mean lesion length was significantly longer in the cryoplasty cohort (CBA: 140.9 mm, Cryo: 191.7 mm; P = .032). The mean time to recurrent stenosis or need for additional secondary intervention was significantly shorter for the cryoplasty cohort than for the CBA, 4.09 and 10.79 months, respectively (P = .0001). Recurrent stenosis-free survival was significantly lower in the cryoplasty cohort at 3 months (CBA: 96.9%, Cryo: 88.9%) and 6 months (CBA: 84.0%, Cryo: 43.8%; P = .0089). Cryoplasty as a modality for treatment of in-stent stenosis in the femoropopliteal segment offers no benefit over CBA.

Comparison study of Doppler ultrasound surveillance of expanded polytetrafluoroethylene‐covered stent versus bare stent in transjugular intrahepatic portosystemic shunt

This prospectively randomized controlled study aimed to assess with Doppler ultrasound (US) the shunt function of expanded polytetrafluoroethylene (ePTFE)-covered transjugular intrahepatic portosystemic shunt (TIPS) stent versus bare stent and to evaluate the usefulness of routine TIPS follow-up of ePTFE-covered stents. Sixty consecutive patients were randomized for bare or covered transjugular TIPS stenting in our institution between April 2007 and April 2009. Data of follow-up Doppler US, angiography, and portosystemic pressure gradient measurements were collected and analyzed. The follow-up period was 8.34 + or - 4.42 months in the bare-stent group and 6.16 + or - 3.89 months in the covered-stent group. Baseline clinical characteristics were similar in both groups. Two hundred three US studies were performed in 60 patients, with a mean of 3.4 per patient, and demonstrated abnormalities in 28 patients (21 bare stents, 7 ePTFE-covered stents), 19 of them (13 in bare-stent group, 6 in covered-stent group) showing no clinical evidence of recurrence. Ten of 13 patients in the bare-stent group underwent balloon angioplasty or additional stent placement, whereas only one of six patients in the covered-stent group needed reintervention for intimal hyperplasia. The average peak velocity in the midshunt of ePTFE-covered stent was 139 + or - 26 cm/s after TIPS creation and 125 + or - 20 cm/s during follow-up, which was significantly higher than the bare-stent group (p < 0.05). The main portal vein and hepatic artery showed higher flow velocities in the ePTFE-covered stent group than in the bare-stent group. ePTFE-covered stents maintained lower portosystemic pressure gradient than bare stents (9.5 + or - 2.9 versus 13.2 + or - 1.5 mmHg, p < 0.05). ePTFE-covered stents resulted in higher patency rates and better hemodynamics than bare stents. Routine US surveillance may not be necessary in patients with ePTFE-covered TIPS stent.

Comparison of outcomes among secondary covered metallic, uncovered metallic, and plastic biliary stents in treating occluded primary metallic stents in malignant distal biliary obstruction

The self-expandable metallic stent (SEMS) has been widely used for unresectable malignant biliary obstruction but eventually becomes occluded by tumor ingrowth/overgrowth and sludge. Therefore, we aimed to determine the therapeutic effectiveness of secondary stents and to find differences according to various combinations of the first and second stents for the management of occluded SEMSs in patients with malignant distal biliary obstruction. Between 1999 and November 2008, 77 patients with malignant biliary obstruction underwent secondary biliary stent placement as "stent-in-stent" at three university hospitals in Korea (40 covered, 26 uncovered, and 11 plastic stents). The membrane of the covered SEMS was regarded as the barrier against tumor ingrowth. We categorized the patients into three groups based on whether the covered SEMS was either the first or the second stent: membrane-SEMS (18 covered-covered; 9 covered-uncovered; 22 uncovered-covered SEMS), bare-SEMS (17 uncovered-uncovered SEMS), and plastic stent (3 covered-plastic; 8 uncovered-plastic). The median patency of second stents was 138, 109, and 88 days (covered, uncovered, and plastic stents). The second covered SEMSs had a significantly longer patency than plastic stents (p=0.047). In a multivariate analysis including membrane-SEMS, bare-SEMS, and plastic stent groups, the bare-SEMS had a worse cumulative stent patency (HR=2.04, CI=1.08-3.86) and survival time (HR=2.37, CI=1.25-4.49) than the membrane-SEMS. Patients with ampulla of Vater cancer had better stent patency (HR=0.27, CI=0.08-0.98) and survival (HR=0.17, CI=0.04-0.77) than those with other pancreatobiliary malignancies. In addition, antitumor treatment prolonged survival time (HR=0.50, CI=0.26-0.99). The placement of additional biliary stents using the "stent-in-stent" method is an effective treatment for an occluded metallic primary stent. In addition, double biliary SEMS placement using at least one covered SEMS (in the primary and/or secondary procedure) might provide longer cumulative stent patency and survival than using uncovered SEMSs in both procedures.

E-006 Urgent recanalization using stents for acute internal carotid artery occlusion in progressive stroke patients

BackgroundRe-establishing cerebral blood flow in a timely fashion during an acute stroke has been shown to be efficacious in improving patient outcomes. Complete occlusion of the internal carotid artery (ICA)...

Endovascular Treatment of Profunda Femoris Artery Obstructive Disease: Nonsense or Useful Tool in Selected Cases?

Background: To evaluate the therapeutic value of endovascular techniques for the treatment of profunda femoris artery obstructive disease (PFAOD) in critical limb ischaemia (CLI) patients, with technically demanding open profunda repair. Design: Retrospective study of prospectively collected data of 15 consecutive CLI patients with technically demanding surgical treatment of PFAOD, that were treated by endovascular means in two European Centers of Vascular Surgery. Materials: All patients had critical limb ischaemia with a history of at least two previous vascular reconstructions in the ipsilateral groin and severe co-morbid conditions. All patients had good common femoral artery flow, long occlusion of the superficial femoral and popliteal arteries and impairment of crural arteries. Methods: Twelve patients underwent balloon angioplasty alone and, in the other three cases, an additional stent placement was necessary, due to flow-limiting dissection. The follow-up (mean 29.2 ± 10 months) included a surveillance protocol with the best medical treatment and duplex scanning at 1, 3, 6, 12 months and yearly thereafter. Results: The endovascular approach was technically successful in all cases and the procedure-related morbidity and mortality rates were 0% for the entire follow-up period. The 3-year primary and secondary patency rates of the treated segment were 80% and 86.7%, respectively. The limb salvage rate was 93.3%. Conclusions: The outcome of our series underscores the therapeutic value of balloon angioplasty in cases of severe PFAOD, as bailout treatment in critical limb ischaemia patients with technically demanding open profunda repair. This procedure can be repeated easily if significant restenosis occurs and provides a useful tool in selected cases.

Results of Intravascular Stent Placement for Fibrosing Mediastinitis

Fibrosing mediastinitis is a rare disorder characterized by an excessive fibrotic reaction in the mediastinum which can result in compromise of mediastinal structures. We sought to evaluate short- and midterm results of intravascular thoracic vessel stent placement for patients with fibrosing mediastinitis. We reviewed all records of fibrosing mediastinitis patients who were referred for stent placement to treat mediastinal vascular compression over a 7-year period. Catheterization reports and digital angiography were assessed to determine vessel dimension and stent characteristics. Thirteen catheterizations were performed in six patients (five females, mean age 39 years, range 23-63) with a range of 1-4 per patient. Four patients were treated with intravascular stents placed percutaneously. One patient underwent surgical intravascular stent placement, and one patient declined surgical therapy. The right pulmonary artery was treated in three patients, the superior vena cava was treated in one patient, and three pulmonary veins were treated in one patient. Pertinent vessel and hemodynamics including immediate short-, and mid-term results were assessed. Procedural complications, midterm follow-up (up to 7 years), and overall survival were determined. Each intervention resulted in hemodynamic improvement with subsequent clinical improvement. Reintervention was required within 12 months in two of four percutaneously treated patients. One death occurred 4 days after cutting balloon angioplasty in a preexisting pulmonary vein stent. Percutaneous therapy for vessel compression secondary to fibrosing mediastinitis is an option that is effective in improving short-term vascular patency. In-stent stenosis was a frequent complication in patients with fibrosing mediastinitis, particularly when pulmonary veins were involved. Short- and midterm success can be achieved, but progressive fibrosing mediastinitis remains a difficult clinical problem with repeat dilation of stents and/or additional stent placement necessary to maintain optimal stent patency and improvement in clinical symptomatology.

Palliative Self-expanding Metal Stents in the Treatment of Malignant Colorectal Obstruction

Background/Aims: This study was designed to evaluate the outcomes of self-expanding metal stents (SEMS) as palliative treatment for malignant obstruction of the colon and rectum. Methods: From January 2003 to September 2009, 28 patients (12 men and 16 women) with malignant colorectal obstruction received placement of uncovered or covered stents for palliative purposes under endoscopic or fluoroscopic guidance. The rates of technical success, clinical success, and the complications associated with stent insertion, patient survival, and long-term stent patency were evaluated. Results: The technical and clinical success rates were 100% (28/28) and 89.3% (25/28), respectively. Among the 25 patients with technical and clinical success, seven patients (28%) experienced complications: A case of perforation (n=1) was managed by surgical intervention, cases of tumor ingrowth (n=4), tumor ingrowth and overgrowth (n=1), and tumor overgrowth (n=1) were managed successfully with an additional stent. The median survival duration was 128.0±54.8 days. The median stent patency duration was 93.0±29.1 days, and the patency rates at 30, 90, and 180 days were 92%, 52%, and 25%, respectively. Conclusions: The placement of a self-expanding metal stent was safe and effective palliative treatment for malignant colorectal obstruction. Stent-associated complications can be managed with the placement of additional stents in the majority of the patients and long-term stent patency is favorable. (Intest Res 2010;8:135-141) 󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏󰠏

Endovascular Treatment of Profunda Femoris Artery Obstructive Disease: Nonsense or Useful Tool in Selected Cases?

Background To evaluate the therapeutic value of endovascular techniques for the treatment of profunda femoris artery obstructive disease (PFAOD) in critical limb ischaemia (CLI) patients, with technically demanding open profunda repair. Design Retrospective study of prospectively collected data of 15 consecutive CLI patients with technically demanding surgical treatment of PFAOD, that were treated by endovascular means in two European Centers of Vascular Surgery. Materials All patients had critical limb ischaemia with a history of at least two previous vascular reconstructions in the ipsilateral groin and severe co-morbid conditions. All patients had good common femoral artery flow, long occlusion of the superficial femoral and popliteal arteries and impairment of crural arteries. Methods Twelve patients underwent balloon angioplasty alone and, in the other three cases, an additional stent placement was necessary, due to flow-limiting dissection. The follow-up (mean 29.2 ± 10 months) included a surveillance protocol with the best medical treatment and duplex scanning at 1, 3, 6, 12 months and yearly thereafter. Results The endovascular approach was technically successful in all cases and the procedure-related morbidity and mortality rates were 0% for the entire follow-up period. The 3-year primary and secondary patency rates of the treated segment were 80% and 86.7%, respectively. The limb salvage rate was 93.3%. Conclusions The outcome of our series underscores the therapeutic value of balloon angioplasty in cases of severe PFAOD, as bailout treatment in critical limb ischaemia patients with technically demanding open profunda repair. This procedure can be repeated easily if significant restenosis occurs and provides a useful tool in selected cases.

The Role of Covered Self-expanding Metal Stents (cSEMS) in the Management of Bariatric Surgery Complications

Purpose: Bariatric surgery is associated with various complications including fistulas, leaks, perforations and strictures which can be managed by endoscopic stenting versus surgical procedures. The aim of our study was to assess the results of those 14 patients with complications after bariatric surgery who had been treated by endoscopic stenting. The adverse effects, length of hospitalization and success rates were analyzed to assess the feasibility of this approach. Methods: Prospectively collected data of 14 consecutive patients who underwent endoscopic insertion of cSEMS was analyzed. Indication for stent placement was bariatric surgery associated complications only. All cSEMS were placed endoscopically and reassessed 3 weeks after placement when the stent was removed. Any additional stents if required were deployed during the same endoscopy. Complications were noted. Results: 14 patients underwent cSEMS placement for bariatric surgery associated complications. 79% were female and 21% were male patients. 5 patients had Roux-en-Y gastric bypass, 8 had gastric sleeve resections and 1 had a Molina band converted to a duodenal switch. Indications for stent placements were strictures, leaks, an endoscopic perforation and a gastrogastric fistula. 8 of the 14 patients required a single cSEMS while 6 patients required two or more stent placement. Ultraflex was used in 10, Wallflex in 3 and Alimaxx in one patient. The success rate of the stent placement and healing was 93% with only one patient requiring surgical referral for a non healing gastrogastric fistula. The length of stay was considerably less for endoscopic stenting with a few cases even managed as an outpatient. Complications most commonly encountered were stent migration requiring additional stent placement, difficult removal, nausea and pain. Conclusion: cSEMS although not yet FDA approved for removal, nevertheless represent an important technique in non surgical management of bariatric surgical complications and are associated with decrease length of hospitalization, fewer adverse effects, earlier return to oral diet and positive results.

Endovascular treatment of internal iliac artery obstructive disease

This study evaluated the therapeutic value of endovascular techniques in patients with buttock claudication caused by stenosis or occlusion of the internal iliac artery. The records of patients with buttock claudication who had undergone endovascular treatment for internal iliac artery stenosis or occlusion were analyzed retrospectively, and any associated arterial lesions, morbidity, restenosis, or recurrent buttock claudication was noted. Outcomes were compared with published reports. Iliac artery duplex scans and aortoiliac angiography were performed to detect and confirm the internal iliac artery obstructive disease. The iliac duplex scanning surveillance protocol was set at 3, 6, and 12 months and yearly thereafter to detect eventual restenosis or occlusion. Between September 2006 and September 2008, 21 consecutive patients (19 men; mean age, 67 years) with 22 cases of buttock claudication (1 bilateral localization) underwent percutaneous transluminal angioplasty alone (14 cases) or additional stent placement in case of elastic recoil (8 cases). Buttock claudication was associated with impotence, thigh claudication, or calf claudication in seven patients. The endovascular approach was successful in all patients, without morbidity or mortality. During a mean follow-up of 14.7 +/- 5.7 months, 50% restenosis occurred in one 80-year-old patient. The patient had a pain-free walking distance of 110 meters and was treated conservatively. To our knowledge, the present study is the largest published report concerning endoluminal treatment of buttock claudication due to internal iliac artery obstructive disease. The midterm results are very encouraging and underscore the value of stent-supported angioplasty as first-line treatment. The procedure can be repeated should significant restenosis occur and does not compromise the option of surgical repair of the lesions.