Bare Stents Research Articles

Comparison of bare and nonbare stent grafts during thoracic endovascular aneurysm repair of the aortic arch

ObjectiveWe compared the outcomes of patients treated with nonbare stents (NBS) and proximal bare stents (PBS) endografts with a proximal landing zone in the aortic arch during thoracic endovascular aortic repair (TEVAR). MethodsWe conducted a retrospective cohort, observational, multicenter study that included 361 consecutive TEVAR procedures undertaken between November 2005 and December 2021. TEVAR patients with both BS and NBS Relay stent graft configurations with proximal landing in zones 1, 2, or 3 were enrolled. Preoperative anamnestic and morphological data, clinical outcomes, and aortic modifications 30 days after surgery and at the latest follow-up available were collected. The primary outcome was freedom from proximal endoleak (type IA) comparing the two configurations. Total and detailed endoleak rates, clinical and technical success, intraoperative additional maneuvers, major adverse events, and reinterventions were secondary outcomes. ResultsThe median follow-up was 4.9 (interquartile range, 2.0-8.1) years. No statistically significant difference between NBS and PBS patients concerning 30-day major adverse events, retrograde aortic dissection, disabling stroke, or late type IA endoleak (10.8% vs 7.8%; P = .597). Aneurysmal disease (P = .026), PLZ diameter of >34 mm (P = .026), aortic tortuosity index of >1.4 (P = .008), type III aortic arch (P = .068), and PLZ thrombus (P = .014) identified as risk factors by univariate Cox regression analysis. PLZ thrombus was the only type IA endoleak risk factor at multivariate Cox regression (P = .016). ConclusionsWe found no statistically significant difference in freedom from type IA endoleak, retrograde dissection, or disabling stroke observed between the NBS and the BS configuration of the Relay endograft. Proximal landing zone thrombotic apposition was a prominent risk factor for type IA endoleak after TEVAR.

Randomized clinical trial to compare the efficacy of self-expanding bare metal nitinol stent and balloon angioplasty alone for below-the-knee lesions following successful balloon angioplasty: 1-year clinical outcomes.

This prospective, multicenter, randomized study aimed to compare the 1-year clinical outcomes after primary stenting with self-expanding bare metal nitinol stent (SENS) and plain old balloon angioplasty (POBA) in patients with critical limb ischemia (CLI) and below-the-knee (BTK) lesions. Overall, 119 patients with CLI and BTK lesions were randomized to POBA alone (POBA group, 61 patients) or primary stenting with SENS (stenting group, 58 patients) after achieving acceptable POBA results in target BTK lesions. Clinical outcomes including amputation and revascularization rates were prospectively compared for 1 year. After 1 year, similar incidence rates of individual clinical endpoints, including cardiac death (6.5% vs. 5.1%, p > 0.999), myocardial infarction (1.6% vs. 0.0%, p > 0.999), repeat revascularization (19.6% vs. 18.9%, p = 0.922), target lesion revascularization (13.1% vs. 17.2%, p = 0.530), and amputation (4.9% vs. 0.0%, p = 0.244), were observed. POBA appeared to have acceptable treatment outcomes compared with primary stenting with SENS after 1 year in CLI patients with BTK lesions undergoing percutaneous transluminal angioplasty (PTA).

Endovascular treatment of systematic isolated mesenteric artery dissection with a patent false lumen: Bare stents alone versus stent-assisted coiling.

Bare stent treatment and bare stent-assisted coiling treatment have not been directly compared in symptomatic isolated superior mesenteric artery dissection with a patent false lumen. Thus, we compared the early and mid-term outcomes of bare stent treatment and bare stent-assisted coiling treatment to determine the most effective remedy for patients with this condition. Consecutive patients diagnosed with systematic isolated superior mesenteric artery dissection with a patent false lumen admitted to the study hospital between January 2016 and December 2021 were enrolled in this retrospective study. Their demographic data, clinical findings, treatment options, early outcomes, and follow-up results were analyzed. A total of 85 patients (83 men) were included. 34.1% (n = 29) adopted bare stent treatment and 65.9% (n = 56) underwent bare stent-assisted coiling treatment. The symptoms were relieved in all patients (100%) with bare stent treatment and bare stent-assisted coiling treatment. There was no significant difference in the length of hospital stay between the two endovascular treatments (p = 0.354). The cumulative complete remodeling rate was 100% in bare stent-assisted coiling treatment vs. 70.4% in bare stent treatment (p < 0.0001). The prevalence of adverse events for abdominal pain recurrence (none in BST or bare stent-assisted coiling treatment), and formation of the aneurysm (two in bare stent treatment, and none in bare stent-assisted coiling treatment) showed no significant difference at follow-up. Both bare stent treatment and bare stent-assisted coiling treatment for symptomatic isolated superior mesenteric artery dissection with a patent false lumen have the same satisfying early outcome. In the midterm follow-up, bare stent-assisted coiling treatment has the higher cumulative complete remodeling rate which could be prioritized to treat this condition.

The efficacy of thin struct bare stents for the treatment of spontaneous isolated dissection of the superior mesenteric artery

Objective: To examine the safety and effectiveness of thin struct bare stents for the treatment of spontaneous isolated dissection of the superior mesenteric artery (SIDSMA). Methods: The data of 32 patients admitted to First Hospital of Jiaxing (20 cases) and Jinling Hospital (12 cases) with SIDSMA from January 2016 to January 2021 were retrospectively analyzed. There were 27 males and 5 females, aging (54.8±9.4) years (range: 36 to 75 years). All patients were treated with thin struct bare stents. Controllable spring coils were used to fulfill the false lumen in 2 cases. Symptoms, vascular remodeling pattern at the SIDSMA lesion, and patency of the stents were observed during follow-up. Results: The surgical success rate was 100%. According to the length of the lesions and stents, the number of stents implanted was 1 in 17 cases, 2 in 11 cases and 3 in 4 cases. The angiography showed that blood flow in the stent was smooth and that the false lumen disappeared or weakened. The numerical rating scale for abdominal pain decreased from 6.1±1.5 (range: 4 to 10) preoperatively to 1.0 (1.0) (range: 0 to 3) 1 hour postoperatively (W=528, P<0.01). The compression rate of the true lumen of the superior mesenteric artery decreased from (92.3±6.7)% (range: 25% to 94%) preoperatively to 0.8 (1.2)% (range: 0 to 3.2%) 1 month postoperatively (W=528, P<0.01). The primary patency rate of CT angiography at 1 month postoperatively was 100%. The vascular remodeling rate was (92.3±6.7)% (range: 80% to 100%). All patients were followed for (46.3±17.0) months (range: 24 to 76 months). The cumulative patency rates in 1, 2 and 5 years were all 100%. Conclusion: The use of thin struct bare stents for SIDSMA is safety and efficacy.

A case of stent-assisted balloon-induced intimal disruption and relamination of distal remaining aortic dissection after the ascending aorta and aortic arch replacement for acute aortic dissection

BackgroundThe early survival rate of patients with acute type A aortic dissection (TAAD) has improved remarkably over the past two decades. However, a false lumen may remain after proximal aortic repair and is a potential risk factor for aortic diameter enlargement, aortic rupture, and death in the chronic phase. In the stent-assisted balloon-induced intimal disruption and relamination of aortic dissection (STABILISE) technique, a stent graft is implanted at the proximal part of the aortic dissection, followed by bare-metal aortic stent placement over the distal aortic dissection. Next, an aortic balloon catheter is dilated inside the stent graft and the bare stent to disrupt the intima and collapse the false lumen, immediately restoring uniluminal thoracoabdominal aortic flow. This report describes our experience with the STABILISE technique for a residual aortic dissection after an ascending aorta, and partial aortic arch replacement for acute TAAD resulted in complications.Case presentationA 60-year-old man presented to our hospital with chest pain, paresthesia, and left lower-limb paralysis. He was diagnosed with acute type A aortic dissection (TAAD) and malperfusion of the left lower limb by computed tomography (CT), and an emergent ascending aorta and partial aortic arch replacement were performed. Immediately after surgery, the left femoral arterial pulse improved, and left lower limb revascularization was deferred. The postoperative course was good; however, back pain and intermittent claudication recurred on the 9th day after surgery. A CT examination revealed persistent antegrade false lumen flow in the descending thoracic aorta through the left subclavian artery dissection and retrograde false lumen flow from the thoracoabdominal segment, resulting in aortic diameter enlargement and narrowing of the true lumen. The symptoms did not improve, and the STABILISE technique was performed on the 12th day after the initial aortic surgery. The patient’s subsequent course was good; the back pain and intermittent claudication resolved. The patient was discharged on the 8th day after the STABILISE technique.ConclusionsThe STABILISE technique can obliterate the false lumen and resolve symptoms associated with a residual false lumen after proximal aortic repair for acute TAAD.

Covered stent graft for treatment of carotid artery stenosis with post-stenotic aneurysm

Several bare metals, self-expanding stents have been approved by the Food and Drug Administration (FDA) to treat carotid stenosis, but no covered stents have been particularly examined or approved for carotid or cerebrovascular applications. Nonetheless, there are a number of potentially useful applications for covered stents in the brachiocephalic, carotid, and even intracranial arteries. As with currently accepted applications for bare metal carotid stents, the use of covered stents in carotid arteries has been reserved for patients who are at high risk for complications with open surgical management of their specific problem. The present case report emphasizes the safety and efficacy of covered stent in complex carotid artery reconstruction entailing stenosis and aneurysmal dilatation and through light on its impact on minimizing the risk of ischemic complications associated with endovascular or surgical carotid sacrifice.

Successful Wallstent exclusion of iliofemoral venous aneurysms—a new treatment paradigm

Treatment of venous aneurysms involving the iliac and femoral veins has generally been an open surgical approach, with a few case reports noting use of an endovascular approach. We report three cases: (1) a patient with an iliocaval occlusion involving an occluded TrapEase filter who presented with a large left external iliac vein aneurysm; (2) a patient with a left common femoral vein aneurysm; and (3) a patient with left profunda femoris vein aneurysms with associated pulmonary embolism. All three patients were successfully managed with the use of appropriately sized bare metal woven stents (Wallstents; Boston Scientific). Their clinical presentation, technical considerations, and outcomes are reviewed.

Fucoidan-based coating on magnesium alloy improves the hemocompatibility and pro-endothelialization potential for vascular stent application

Biodegradable magnesium alloy stents have great application potential in the treatment of cardiovascular diseases. However, bare magnesium alloy stents are still limited by some problems such as too fast degradation, poor hemocompatibility, and inability to regulate the behaviors of vascular cells in clinical applications. Surface modifications are highly requested to improve the corrosion resistance and biocompatibility of magnesium alloy stents. Herein, a fucoidan-based coating consisting of MgF2 layer, polydopamine (PDA) and fucoidan was constructed on Mg-Zn-Y-Nd (ZE21B) alloy to improve its corrosion resistance, hemocompatibility and rapid endothelialization for vascular stent application. Compared to bare ZE21B alloy, the modified ZE21B alloy exhibited better corrosion resistance and hemocompatibility. More importantly, the endothelial cells (ECs) and smooth muscle cells (SMCs) exhibited a distinct dose-dependent behaviors towards the fucoidan grafting density. The relatively low fucoidan grafting density promoted the proliferation, spreading and migration of ECs, but suppressed these behaviors of SMCs. The results of in vivo implantation experiments indicated that the fucoidan-based coating modified ZE21B alloy can inhibit intimal hyperplasia, relieve tissue inflammation, and promote the rapid endothelialization. Thus, the fucoidan-based coating provides a simple and effective strategy to develop novel magnesium alloy stents with improved corrosion resistance, good hemocompatibility and pro-endothelialization potential.

Expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents for transjugular intrahepatic portosystemic shunt in people with liver cirrhosis.

Expanded polytetrafluoroethylene (ePTFE)-covered stents versus bare stents for transjugular intrahepatic portosystemic shunt in people with liver cirrhosis.

Simultaneous Transcatheter Closure of Coexistent Superior Sinus Venosus Defects and Oval Fossa Defects.

Device closure has become the preferred procedure for treating oval fossa defects in the last two decades. More recently, transcatheter sinus venosus defect (SVD) closure has emerged as an alternative to surgery. Transcatheter stenting aims to overcome potential late surgical complications such as stenosis of the superior vena cava (SVC) and right upper pulmonary vein (RUPV), as well as sinus node dysfunction. Balloon interrogation of the cavoatrial junction is able to identify patients who are suitable candidates for nonsurgical closure. Successful closure is possible when the balloon seals the SVD and redirects the RUPV towards the left atrium. Oval fossa (secundum) defects can coexist in approximately 9-16% of patients with SVD. Among a group of 80 patients who underwent transcatheter closure of SVD, five adult patients aged between 22 and 52years also required device closure of an associated oval fossa defect. The procedure involved simultaneous balloon interrogation of both the SVD and oval fossa defect, with continuous monitoring of the RUPV using bilateral femoral venous sheaths. Covered stent exclusion of the SVD was performed with concurrent device closure of the oval fossa defect using 12-36mm atrial septal occluders. During the procedure, two patients required protective balloon inflation in the RUPV while expanding the covered stent. In one patient, a higher small accessory RUPV was intentionally left to drain into the SVC through the struts of a bare stent anchoring the covered stent in the upper SVC. In another patient, a second overlapping covered stent was used to address residual flows from a fabric tear that became apparent after balloon deflation. There were no vascular complications and only one patient exhibited an insignificant 6mm residual flow from the caudal edge of the SVD during a follow-up of 5 to 72months. In conclusion, the closure of both SVD and associated oval fossa defects can be successfully performed in a single procedure, with comparable procedural times and favourable mid-term outcomes.

Outcomes of covered stents versus bare-metal stents for subclavian artery occlusive disease.

To compare the clinical efficacy of covered stents and bare-metal stents in the endovascular treatment of subclavian artery occlusive disease. Between January 2014 and December 2020, 161 patients (112 males) underwent stenting of left subclavian arteries; CSs were implanted in 55 patients (34.2%) and BMSs in 106 (65.8%). Thirty-day outcomes, mid-term patency, and follow-up results were analyzed with Kaplan-Meier curves. Relevant clinical, anatomical, and procedural factors were evaluated for their association with patency in the two groups using Cox proportional hazards regression. Mean follow-up was 45 ± 18 months. The primary patency was 93.8% (95% CI, 81.9%-98.0%) in the covered stent group and 73.7% (95% CI, 63.2%-81.6%; P = 0.010) in the bare-metal stent group. The primary patency in the total occlusion subcategory was significant in favor of CS (93.3%, 95% CI, 61.26%-99.0%) compared with BMS (42.3%, 95% CI, 22.9%-60.5%; P = 0.005). Cox proportional hazards regression indicated that the use of BMSs [hazard ratio (HR), 4.90; 95% CI, 1.47-16.31; P = 0.010] and total occlusive lesions (HR, 7.03; 95% CI, 3.02-16.34; P < 0.001) were negative predictors of patency, and the vessel diameter (HR, 3.17; 95% CI, 1.04-9.71; P = 0.043)) was a positive predictor of patency. Compared with bare stents, covered stents have a higher midterm primary patency in the treatment of subclavian artery occlusive disease.

Preceding Aortic Bare Stenting for Visceral and Limb Malperfusion before Proximal Surgical Repair of Stanford Type A Aortic Dissection.

Mesenteric malperfusion is a fatal complication of acute aortic dissection, which should rapidly be repaired. However, the optimal treatment strategy remains controversial in patients with type A aortic dissection. We report on a case with aortic bare stenting for visceral and lower limb malperfusion prior to the proximal repair. The visceral and limb reperfusion was obtained after aortic bare stenting and proximal repair was successfully performed. This technique can be an alternative option for visceral malperfusion due to type A aortic dissection. However, careful patient selection is required considering the risk of new dissection and rupture.

IVUS Improves Outcomes With SUPERA Stents for the Treatment of Superficial Femoral-Popliteal Artery Disease.

Nitinol interwoven bare metal stents represent an advancement in stent technology; however, nominal deployment remains an area of focus. Intravascular ultrasound (IVUS) has been shown to improve outcomes in both the coronary and peripheral vasculature by providing the operator with greater vessel detail; however, the use of adjunctive IVUS with nitinol bare metal stents has not been widely studied. This studies aims to determine the effect of IVUS when used adjunctively with nitinol interwoven bare metal stents in the management of femoropopliteal lesions. Retrospective study. This study included a cohort of 200 consecutive patients with peripheral artery disease. All patients were treated with ≥1 Supera bare metal stent, and 91 received adjunctive IVUS imaging prior to stent deployment. Deployment conditions of nominal, compressed, and elongated were measured, and the primary clinical outcomes included target lesion reintervention, amputation, and mortality. This study also showed that 8.3 number needed to treat (NNT) patients must be treated with IVUS to avoid an additional revascularization event. The patients who received IVUS had a significantly greater number of nominally deployed stents (p<0.001). Patients who had IVUS imaging also had significantly lower reintervention rates compared with those who did not receive IVUS imaging (p=0.047). The IVUS and angiography decreases clinically-driven target lesion reintervention and increases nominal deployment compared with angiography alone in femoropopliteal lesions treated with interwoven bare metal nitinol stents. Endovascular surgones may conisder the adjuctive use of IVUS when using the Supera stent for the treatment of infra inguinal superficial femoral artery lesions. The adjunct use of IVUS may lead to improved sizing, vessel prep, deployment, and ultiamtely reduction in CD-TLR.

The false lumen problem.

The false lumen problem.

In Vitro Radiological Evaluation of Different Types of Chimney Stents Using a Silicon Flow Model with Adjustable Physiological Simulating Conditions

To evaluate invitro the performance of invivo published covered or bare metal chimney stents (ChSs) in combination with the Endurant II abdominal endograft (Medtronic) as the only CE approved main graft (MG) in the treatment of juxtarenal abdominal aortic aneurysms with the chimney endovascular aneurysm repair (chEVAR) technique. Bench top experimental study. A silicon flow model with adjustable physiological simulating conditions and patient based anatomy was used to test nine different MG-ChS combinations: Advanta V12 (Getinge); BeGraft+ (Bentley); VBX (Gore & Associates Inc.); LifeStream (Bard Medical); Dynamic (Biotronik); Absolute Pro (Abbott); double Absolute Pro; Viabahn (Gore) lined with Dynamic; and Viabahn lined with EverFlex (Medtronic). Angiotomography was performed after each implantation. DICOM data were analysed blindly twice per observer by three independent experienced observers. Each blinded evaluation was performed at one month intervals. The main analysed parameters were the area of gutters, MG and ChS maximum compression, and the presence of infolding. Bland-Altman analysis confirmed adequate results correlation (p < .05). Each employed ChS showed significantly different performance favouring the balloon expandable covered stent (BECS). The smallest gutter area was seen in the combination with Advanta V12 (0.26 cm2). MG infolding was observed in all tests. The lowest ChS compression was observed in the combination with BeGraft+ (compression 4.91%, D ratio 0.95). In our model, BECSs showed higher angulations than bare metal stents (BMSs) (p < .001). This invitro study shows the variability of performance with each theoretically possible ChS and explains the divergent ChS outcomes in the published literature. BECS in combination with the Endurant abdominal device confirms their superiority vs. BMS. The presence of MG infolding in each test underlines the need for prolonged kissing ballooning. Angulation evaluation and comparison with other invitro and invivo publications demands the need for further investigation in transversely or upwardly oriented target vessels.

Midterm Results of the Conservative, Bare Stent, and Bare Stent-Assisted Coiling Treatments for Symptomatic Isolated Superior Mesenteric Artery Dissection

We compared the early and mid-term (31, 3-63 months) outcomes of conservative treatment, bare stent treatment (BST) and bare stent-assisted coiling treatment (BSACT) to determine the most effective treatment for patients with symptomatic isolated superior mesenteric artery dissection (SISMAD). Consecutive patients with SISMAD admitted to the study hospital between January 2016 and December 2021 were included in this retrospective study. Their demographic data, clinical findings, treatment options, early outcomes and follow-up results were analyzed. A total of 121 patients were included in the study (23 with conservative treatment, 42 with BST, 56 with BSACT). Symptoms were relieved in 91.3% of conservative patients, whereas all patients (100%) with BST or BSACT had symptom relief, p= .035. There was no significant difference in the length of hospital stay between the two endovascular treatments (EVT) (p=0.9051), but hospital stay was significantly shorter compared to conservative treatment (p<0.0001). The cumulative rate of complete remodeling was 100% for BSACT vs. 46.3% for BST (p < .0001) vs. 42.9% for conservative patients (p < .0001). There were no significant differences between the last two groups (p = .3925). The prevalence of adverse events for abdominal pain recurrence and aneurysm formation was also significantly lower in the BSACT group at follow-up. BSACT for SISMAD has a preferable early outcome. The cumulative complete remodeling rate and the event-free survival rate are satisfactory at mid-term follow-up. BSACT is an effective approach for SISMAD.

Bare Stent Fracture After TEVAR With the Modified Restrictive Bare Stent (RBS) Technique in Type B Aortic Dissections.

The aim was to assess the mid-term aortic remodeling and bare-metal stent (BMS) integrity of the restricted bare stent (RBS) technique reconstruction in aortic dissections. This retrospective cohort study included prospectively collected patients treated with the modified RBS technique between 2017 and 2020. The preoperative, postoperative, and last follow-up computed tomographic (CT) scans were analyzed in the centerline at the mid-descending, celiac trunk (CeT), and the mid-abdominal levels for false lumen (FL) patency, aortic diameter, and true lumen (TL) diameter changes. Bare-metal stent integrity was assessed in the 3-dimensional multiplanar reformats. The median follow-up of the cohort (n=17) was 26 (11, 45) months. The procedure was mainly performed with the Relay NBS endograft (15/17; 88%) + E-XL BMS (17/17; 100%). Postoperative mortality, paraplegia, stroke, renovisceral vessel loss, and type I and III endoleaks were not observed. BMS fractured in 6 patients (6/17; 36%), damaged the dissection flap in 4/17 (24%), and led to the reperfusion of the FL and re-interventions with TEVAR (4/17; 24%). Two patients without FL reperfusion showed stable CT follow-ups 13 and 17 months after the fracture diagnosis. The TL expansion was seen at all landmarks and peaked in the thoracic aorta (+10; 6, 15; p<0.001). The FL thrombosis after modified RBS was only relevant in the thoracic aorta (p<0.001) and at CeT (p=0.003). The aortic diameter was stable in the thoracic aorta and increased at distal landmarks (CeT [+5; 1, 10; p=0.001]; mid-abdominal [+3; 1, 5; p=0.004]). The modified RBS technique could not stop aortic growth below the diaphragm and prevent new membrane rupture due to the fractures of the BMS and consecutive flap damage with the reperfusion of the FL. The treatment of complicated type B aortic dissections with TEVAR has become a standard. Particularly, patients with true lumen collapse and malperfusion may benefit from a more aggressive treatment strategy including proximal TEVAR and distal bare-metal stent implantation to re-open the true lumen and to prevent distal stent-induced new entry. However, this study reports the challenges of this approach with a high rate of bare-metal stent fractures during the follow-up. The fractures that occurred at the site of vertical nitinol bridges led to the dissection membrane ruptures and the reperfusion of the false lumen with consecutive dilatation. A close follow-up is mandatory to detect this complication and to treat the patients with TEVAR extension.

A systematic review and meta-analysis of retrograde type A aortic dissection after thoracic endovascular aortic repair in patients with type B aortic dissection.

Retrograde type A dissection (RTAD) is a devastating complication of thoracic endovascular repair (TEVAR) with low incidence but high mortality. The objective of this study is to report the incidence, mortality, potential risk factors, clinical manifestation and diagnostic modalities, and medical and surgical treatments. A systematic review and single-arm and two-arm meta-analyses evaluated all published reports of RTAD post-TEVAR through January 2021. All study types were included, except study protocols and animal studies, without time restrictions. Outcomes of interest were procedural data (implanted stent-grafts type, and proximal stent-graft oversizing), the incidence of RTAD, associated mortality rate, clinical manifestations, diagnostic workouts and therapeutic management. RTAD occurred in 285 out of 10,600 patients: an estimated RTAD incidence of 2.3% (95% CI: 1.9-2.8); incidence of early RTAD was approximately 1.8 times higher than late. Wilcoxon signed-rank testing showed that the proportion of RTAD patients with acute type B aortic dissection (TBAD) was significantly higher than those with chronic TBAD (P = .008). Pooled meta-analysis showed that the incidence of RTAD with proximal bare stent TEVAR was 2.1-fold higher than with non-bare stents: risk ratio was 1.55 (95% CI: 0.87-2.75; P = .13). Single arm meta-analysis estimated a mortality rate of 42.2% (95% CI: 32.5-51.8), with an I2 heterogeneity of 70.11% (P < .001). RTAD is rare after TEVAR but with high mortality, especially in the first month post-TEVAR with acute TBAD patients at greater risk as well as those treated with proximal bare stent endografts.

Application of "Fabulous" stent system to improve aortic remodeling after TEVAR for type B aortic dissection.

Application of "Fabulous" stent system to improve aortic remodeling after TEVAR for type B aortic dissection.

Abstract Number ‐ 147: Rescue bailout repair of a direct carotid‐cavernous fistula using drug eluding coronary stent

Introduction Direct carotid‐cavernous fistula (DCCF) during neurosurgical procedures or trauma are repaired with flow diverters via trans‐arterial approach and/or transvenous embolization of the cavernous sinus. There are reports of using balloon mounted bare platinum coronary stent in the treatment of DCCF prior to the era flow diverters. There are limited data on the use of drug eluding stent in the repair of DCCF. We are presenting an unusual case of DCCF developed during Neurointerventiona in an acute ischemic stroke patient with severe intracranial atherosclerotic disease that was emergently repaired using a Medtronic resolute prelude drug eluding. Additionally, cause of DCCF and rational of balloon drug eluding stent was expalined. Methods case report Results 54 years old women with multiple cerebrovascular risk factors including prior stroke presented with right middle cerebral artery (MCA) stroke which improved to NIHSS 2. CT head demonstrated old strokes in the right MCA distributions and CT angiogram was consistent with severe intracranial atherosclerotic disease (ICAD) with 90% stenosis of right supraclynoid internal carotid artery (SICA). Patient was loaded with brilinta and aspirin. Cerebral angiogram confirmed focal ICAD and presence of ahteresclorotic pouches (AP) at the Pero‐cavernous junction with poor perfusion. Parent artery diameter was 2.2 mm and stenotic section 0.5 mm. Planned was to do balloon angioplasty and a possible stent. Endovascular strategies: 6 French guiding sheath was placed to RICA and CAT5 to protect ICA pouches, and be placed beyond the ophthalmic artery for navigation of balloon delivery system. Baseline activated coagulation time (ACT) was 168 and received 4000 units of heparin with 5 mg of intraarterial integrilin. During advancement of 2×20 mm maverick balloon, the CAT5 prolapsed back below the petrous ICA. Attempts were made to reposition the CAT5 over the wire without microcatheter resulting in injury to the AP with CAT5 forming DCCF. Immediately, balloon was navigated without manipulation of CAT5 and angioplasty of SICA with reduction of stenosis from 90% to less than 50%. Repeat angiogram demonstrated high‐flow DCCF. Because of ICAD and small ICA diameter, a flow‐diverter was not considered. A Medtronic resolute drug eluding 2×34 mm stent was advanced emergently through CAT5 and placed the injured area by withdrawing CAT5 and deployment of resulting in good apposition. Subsequent angiographies revealed gradual decrease of DCCF to complete obliteration. Repeat ACT was above 400 which was not reversed. Neurological examination remained unchanged without ophthalmic sign of DCCF. Patient was sent home in 48 hours with NIHSS 0 on brilinta and aspirin. Conclusions A flexible Medtronic resolute drug eluding could be used emergently to repair traumatic DCCF which is delivered over CAT5. An intermediate guiding catheter CAT5 or others must be advanced over a microcatheter alone with microwire carefully to prevent vessel injury especially, if there are existing disease in the wall of the artery. Brilinta load may potentially increase the baseline ACT, therefore a small bolus of heparin may be considered first if the baseline ACT is high to prevent supratherapeutic ACT. Further studies are required