Stent Failure Research Articles

Comparison of Biomechanical Properties of the iCover and VBX Stent Grafts When Used as Bridge Stents in Fenestrated Endografts: An In Vitro Study.

The objective of this study was to compare in vitro the different biomechanical properties of 2 balloon-expandable covered stents, VBX (Viabahn VBX, W.L. Gore & Associates, Flagstaff, AZ) and iCover (iVascular, Barcelona, Spain), as bridging stents in fenestrated aortic endoprostheses. Three biomechanical tests were performed to evaluate a total of 12 stents (6 VBX 6 × 59 mm and 6 iCover 6 × 57m). First, a 3-point bending test was performed with a calibrated dynamometer to evaluate the bending strength of the 40% and 150% deformation of the system in its crimped state and the force necessary to deform the expanded stent by 40% with respect to its initial diameter. Then the stents were expanded to their nominal diameter inside a 6-mm-diameter handmade fenestration and flared up to 8 and 10 mm. The whole set was fixed in the dynamometer to carry out the pullout-force (perpendicular dislocation) and shear-stress-force (axial dislocation) tests. The resulting forces were recorded via the force transducer. Load, deformation, and displacement data were recorded in newtons. The results of each stent test were examined under the microscope, and both stent types were compared. Higher forces were required to bend the crimped VBX (16.24 N [IQR, 13.87-17.47 N] for the iCover and 19.01 N [IQR, 16.01-19.50 N] for VBX; P < 0.001), but lower forces were necessary for the expanded VBX compared with the iCover (0.36 N [IQR, 0.1-0.49 N] and 1.01 N [IQR, 0.97-1.09 N], respectively; p = 0.004). Pullout forces were 3.56 N (IQR, 3-4.1 N) and 7.07 N (IQR, 6.86-7.28 N) for the 8-mm flare and 7.29 N (IQR, 6.13-8.45 N) and 14 N (IQR, 12.05-15.95 N) for the 10-mm flare for the iCover and VBX, respectively (P = 0.333 for both comparisons). The shear-stress forces needed to dislocate the 6-mm iCover and VBX axially with a 10-mm flare to 50%, 100%, and 200% were 0.88, 1.61, and 3.55 N for the iCover and 0.71, 1.43, and 2.51 N for the VBX (P = 0.343, P = 0.486, and P = 0.486, respectively). After evaluating the stents under in vitro conditions, the VBX and iCover stents showed similar results in terms of biomechanical properties, which demonstrates their competence in in vitro conditions. Further in vitro comparisons with other stent grafts are required. The BECS used in FEVAR / BEVAR must ensure some properties to avoid the most frequent complications derived from the failure of these bridging stents (stenosis, thrombosis, stent integrity, dislodgement or endoleaks) that represent the most common cause for reintervention. This paper adds to the limited data available, information to the clinician after comparing some properties of two BECS used in these techniques that demonstrate their competence in in-vitro conditions.

Failure signal of high orientation Poly(L-lactic acid) monofilament for self-expanding stent during lifetime: Disappeared amorphous connections

The premature failure of bioresorbable self-expanding stents for peripheral arterial disease could lead to form thrombosis and threaten patients′ lives. Predicting the time and cause of mechanical and structural failure is crucial to prevent premature failure of implanted stents. Herein, we report a situ accelerated hydrolysis to investigate the degradation properties of self-expanding stents braided by high-performance Poly(L-lactic acid) (PLLA) monofilaments in an accelerated term over a formal long one. Degradation, microstructure, and mechanical properties were comprehensively evaluated to identify key factors of the failure during lifetime. The results show that the upper temperature limit for accelerated hydrolysis is 50 °C. The mechanical properties undergo multiple stages of functional holding, decreasing, and eventual failure. It is attributed to uneven degradation and distribution of crystalline and amorphous regions. Specifically, the disappearance of amorphous chains between fibrils at 6 months leads to mechanical failure. Further disappearance of amorphous chains within fibrils at 18 months results in structural disintegration. Additionally, the degradation behavior of the stents and potential effects of degradation products on vascular tissues are validated for predictive accuracy. These insights provide valuable experimental references for optimizing design and clinical application of PLLA-based self-expanding stents.

A decade's experience of robotic buccal ureteroplasty for post ureteroscopic laser lithotripsy induced strictures—Should this be the new standard?

ObjectiveTo present the surgical technique of robotic buccal ureteroplasty for strictures after laser lithotripsy and its outcomes. MethodsThis was a retrospective study conducted at the Department of Urology at Apollo Hospitals, Chennai, India from October 2012 to October 2022. Indications for surgery included worsening hydronephrosis, declining renal function, and recurrent urinary tract infections with obstruction. Apart from liberal exposure of the stricture, we stress upon the use of indocyanine green to assess vascularity and quilting of the graft to bare area of psoas muscle to increase the graft vascularity. ResultsAmong the 15 patients, ureteropelvic junction strictures were observed in eight (53.3 %), while five (33.3 %) had proximal stricture, and two (13.3 %) had mid-ureteral stricture. Notably, eight of the 15 (53.3 %) patients had previous unsuccessful double-J stenting. The median stricture length was 3.5 cm (range: 2–5 cm), with a mean operative time of 167 min (range: 126–214 min) and estimated blood loss of 140 mL (range: 40–200 mL). After a median follow-up of 12 months (range: 4–32 months), 13 out of 15 (86.7 %) patients showed significant improvement in their follow-up functional scans. ConclusionRobotic buccal ureteroplasty is a very effective technique for the management of laser-induced ureteral strictures with good long-term results and minimum morbidity. The results are comparable irrespective of previous failed stenting.

Combination Tools for Calcium Modification from RASER to Orbitalshock.

Coronary artery calcification is frequently encountered during percutaneous coronary intervention and its presence is associated with a higher risk of stent under-expansion which has been associated with long-term risk of stent failure. There are several different calcium modification strategies available, whether they be balloon-based devices (cutting/scoring and intravascular lithotripsy) or atherectomy devices (orbital atherectomy, rotational atherectomy, excimer laser coronary atherectomy) that are established for the modification of coronary calcification. Each strategy applies a different mechanism of action for calcium modulation and consequently the potential to combine modifying tools may offer synergistic advantages over device monotherapy. This article will focus on reviewing the evidence for the use of multiple calcium modification techniques and examine whether there really is any such synergistic effect of combining these tools.

The role of intra-vascular imaging in patients undergoing intravascular lithotripsy: Insights from the COIL registry.

The role of intra-coronary imaging in patients with stent failure undergoing intravascular lithotripsy (IVL) is unclear. We aimed to assess clinical outcomes in patients undergoing IVL treatment for stent failure stratified according to the use of intra-coronary imaging and lesion complexity. This is a pre-specified subgroup analysis of patients who were included in the coronary intravascular lithotripsy in patients with stent failure (COIL) registry (international multi-centre study assessing IVL treatment for stent failure in 6 European centres). A complex lesion was defined if IVL treatment was used in the left main, true bifurcation, long lesion, or coupled with athero-ablative therapy. The primary endpoint was the composite of cardiac death, spontaneous myocardial infarction, or target vessel revascularization (TVR) at 12 months. There were 102 patients analyzed, of whom 27 (26%) patients had complex anatomy. The use of intra-coronary imaging following IVL in stent failure was more frequent in patients with complex versus Noncomplex anatomy (56% vs. 31%, p = 0.022). IVL treatment was effective in both groups, however, patients with complex anatomy had worse clinical outcomes (30% vs. 11%, p = 0.02), driven by a higher rate of TVR (26% vs. 8%, p = 0.017). In the complex group, patients who underwent intracoronary imaging post intervention had lower event rate compared to those without imaging (13% vs. 50%, p = 0.038). In patients undergoing IVL treatment for stent failure with complex coronary anatomy, the use of intra-coronary imaging was associated with fewer adverse events compared to angiography guided intervention.

Long-term effect of biodegradable vs durable polymer everolimus-eluting stents on neoatherosclerosis in ST-segment elevation myocardial infarction: the CONNECT trial.

Neoatherosclerosis is a leading cause of late (>1 year) stent failure following drug-eluting stent implantation. The role of biodegradable (BP) versus durable polymer (DP) drug-eluting stents on long-term occurrence of neoatherosclerosis remains unclear. Superiority of biodegradable against durable polymer current generation thin-strut everolimus-eluting stent (EES) was tested by assessing the frequency of neoatherosclerosis 3 years after primary percutaneous coronary intervention (pPCI) among patients with ST-segment elevation myocardial infarction (STEMI). The randomized controlled, multicentre (Japan and Switzerland) CONNECT trial (NCT03440801) randomly (1:1) assigned 239 STEMI patients to pPCI with BP-EES or DP-EES. The primary endpoint was the frequency of neoatherosclerosis assessed by optical coherence tomography (OCT) at 3 years. Neoatherosclerosis was defined as fibroatheroma or fibrocalcific plaque or macrophage accumulation within the neointima. Among 239 STEMI patients randomized, 236 received pPCI with stent implantation (119 BP-EES; 117 DP-EES). A total of 178 patients (75%; 88 in the BP-EES group and 90 in the DP-EES group) underwent OCT assessment at 3 years. Neoatherosclerosis did not differ between the BP-EES (11.4%) and DP-EES (13.3%; odds ratio 0.83, 95% confidence interval 0.33-2.04, p=0.69). There were no differences in the frequency of fibroatheroma (BP-EES 9.1% vs DP-EES 11.1%, p=0.66) or macrophage accumulation (BP-EES 4.5% vs DP-EES 3.3%, p=0.68), and no fibrocalcific neoatherosclerosis was observed. Rates of target lesion failure did not differ between groups (BP-EES 5.9% vs DP-EES 6.0%, p=0.97). Use of BP-EES for primary PCI in patients presenting with STEMI was not superior to DP-EES regarding frequency of neoatherosclerosis at 3 years.

Ureteral stenting in patients with locally advanced cervical cancer: Predictors of low success rate

ObjectiveCervical cancer is the leading gynecologic malignancy in Ethiopia. The diagnosis is often delayed and many patients present with locally advanced disease. Involvement of the ureters with or without the development of hydroureteronephrosis is a common finding. Ureteral stent placement is a modality utilized to relieve an established obstruction (therapeutic) or to prevent its early occurrence (prophylactic). However, the procedure may not be successful in all patients. The objective of this study is to assess the factors associated with low success rate of ureteral stenting in these patients with locally advanced disease. MethodsThis is a hospital based cross-sectional study of patients diagnosed with locally advanced cervical cancer for whom a retrograde ureteral stent placement is attempted from January 2019 to March 2020. Data of 175 patients were retrieved by a retrospective chart review and analyzed for factors associated with low procedural success. ResultsSocio-demographic data were similar between patients regardless of procedural success. The overall success rate of stenting was 54.2 %. In the prophylactic group (with no hydronephrosis and normal creatinine) success rate was 94 % and in the therapeutic group 42.6 %. Logistic regression analysis showed that bilateral hydronephrosis and increased serum creatinine were indicators of significant ureteral obstruction and were predictors of stent placement failure. ConclusionIncreased serum creatinine and presence of hydronephrosis are risk factors for failed ureteral stenting. For these patients, other options of urinary diversion such as percutaneous nephrostomy should be considered from the outset.

Predictor of left main coronary artery size: an intravascular ultrasound study in Southeast Asia population.

Left main (LM) percutaneous coronary intervention (PCI) has expanded rapidly in the past decade, with up to fourfold increase annually. Recent trials found that intravascular imaging (IVI)-guided LM PCI resulted in lower risks of cardiac death and stent failure due to suboptimal PCI compared to angiography-guided PCI. IVI usage has increased in recent years; however, its utilization remains variable across regions and is still incredibly low in developing countries. Furthermore, to date, there is no data about LM size in the Southeast Asian population. This study aims to determine the mean external elastic membrane (EEM) diameter, cross-sectional area (CSA) of LM, and its predictor. This is a cross-sectional observational study on 100 patients with coronary artery disease (CAD) who underwent IVUS-guided PCI with a pullback to LM in Dr. Hasan Sadikin General Hospital Bandung, Indonesia, from January 2020 until December 2022. Linear regression was used to determine the predictors of LM size. There were 100 segments of LM. LM's mean EEM diameter and CSA were 5.02 ± 0.43mm and 19.93 ± 3.48mm2. Body surface area (BSA) is an independent predictor of EEM diameter and CSA with a positive linear relationship (p 0.001 and p 0.0001). Hypertension is an independent predictor of EEM diameter with a positive linear relationship (p 0.034). The linear equation to predict EEM diameter and CSA were (2.741 + 1.272BSA(m2) + 0.165 hypertension (yes)) and (2.745 + 9.601BSA(m2)), respectively. The LM coronary artery size of the Southeast Asian population was comparable with the previous studies. BSA and hypertension are independent predictors of EEM diameter, with BSA being stronger than hypertension. Neither sex nor other cardiovascular risk factors affect the LM size. The knowledge of coronary artery size will help the clinician have a reference for intervention, especially when no intravascular imaging is available.

Coronary artery size based on intravascular ultrasound in Southeast Asia population

BackgroundOne of the downsides of percutaneous coronary intervention (PCI) is stent failure which could be related to stent underexpansion. Hence, PCI based on an accurate coronary artery size obtained from intracoronary imaging is tremendously important. Until now, there is no data about all coronary artery dimensions in the Southeast Asian population performed by intravascular ultrasound (IVUS). The coronary artery size of 153 patients with chronic coronary syndrome (CCS) in acute or chronic settings who underwent percutaneous coronary intervention (PCI) with IVUS was examined. The mean artery size and its predictors were analyzed.ResultsThere were 153 patients with 633 coronary artery segments: the mean left main (LM) external elastic membrane (EEM) diameter and cross-sectional area (CSA) were 5.02 ± 0.43 mm and 19.93 ± 3.48 mm2, proximal left anterior descending artery (LAD) 4.25 ± 0.42 mm and 14.34 ± 2.85 mm2, the mid-LAD 3.86 ± 0.39 mm and 11.70 ± 2.24 mm2, the distal LAD 3.32 (2.83–4.30) mm and 8.77(6.23–14.99) mm2, the proximal left circumflex artery (LCX) 3.91 ± 0.42 mm and 12.07 ± 2.53 mm2, the distal LCX 3.51 ± 0.47 mm and 9.90 (5.09–14.20) mm2, the proximal right coronary artery (RCA) 4.50 ± 0.48 mm and 16.14 ± 3.43 mm2, the mid-RCA 4.16 ± 0.420 mm and 13.74 ± 2.72 mm2, the distal RCA 3.81 ± 0.41 mm and 11.59 ± 2.46 mm2, respectively. Body surface area (BSA) is an independent predictor for the majority of epicardial coronary arteries with a positive linear relationship.ConclusionsThe mean artery size of the Indonesian population was comparable with previous studies. The knowledge of coronary artery size will help the clinician to have a reference for intervention, especially when no intravascular imaging is available.

Mechanism of Stent Failure in Patients With Eruptive Calcified Nodule Treated With Rotational Atherectomy

BackgroundPercutaneous coronary intervention (PCI) for lesions with eruptive calcified nodules (CNs) is associated with worse outcomes compared with that for other calcified lesions. We aimed to clarify the relationship between eruptive CNs at index PCI, optical coherence tomography (OCT) findings at the 8-month follow-up, and clinical outcomes using serial OCT. MethodsThis retrospective observational study used data from a prospective, single-centre registry. We conducted consecutive PCI for calcified lesions requiring rotational atherectomy (RA) with OCT guidance. We categorized 51 patients (54 lesions) into those with (16 patients [16 lesions]) and without eruptive CNs (35 patients [38 lesions]). ResultsPost-PCI, stent expansion was comparable between the 2 groups, and CN-like protrusion was found in 75% of lesions with eruptive CNs. Follow-up OCT at 8 months revealed in-stent CNs in 54% of treated eruptive CN lesions, whereas lesions without eruptive CNs lacked in-stent CNs. Multivariate linear regression analysis demonstrated that eruptive CN was associated with maximum neointimal tissue (NIT) thickness (regression coefficient 0.303; 95% confidence interval, 0.057-0.549; P = 0.02). Consequently, patients with eruptive CNs exhibited a higher clinically driven target lesion revascularization (TLR) rate than did those without at 1 year (31.3% vs 2.9%, P = 0.009) and 5 years (43.8% vs 11.4%, P = 0.02). TLR primarily occurred in lesions with maximum eruptive CN arc angles > 180°. ConclusionsFollowing RA treatment with acceptable stent expansion, eruptive CNs before PCI correlated with greater NIT formation with in-stent CNs, resulting in a higher TLR rate, particularly in lesions with maximum eruptive CN arc angles exceeding 180°.

Distinct Challenges of Eruptive and Non-Eruptive Calcified Nodules in Percutaneous Coronary Intervention.

To provide a summary of prevalence, pathogenesis, and treatment of coronary calcified nodules (CNs). CNs are most frequently detected at the sites of hinge motion of severely calcified lesions such as in the middle segment of right coronary artery and left main coronary bifurcation. On histopathology, CNs exhibit two distinctive morphologies: eruptive and non-eruptive. Eruptive CNs, which have a disrupted fibrous cap with adherent thrombi, are biologically active. Non-eruptive CNs, which have an intact fibrous cap without thrombi, are biologically inactive, representing either healed eruptive CNs or protrusion of calcium due to plaque progression. Recent studies using optical coherence tomography (OCT) have shown a difference in the mechanism of stent failure in the two subtypes, demonstrating early reappearance of eruptive CNs in the stent (at ~ 6months) as a unique mechanism of stent failure that does not seem to be preventable by simply achieving adequate stent expansion. The cause of CN reappearance in stent is not known and could be due to acute or subacute intrusion or continued growth of the CN. Whether modification of CN is needed, the most effective calcium modification modality and effectiveness of stent implantation in eruptive CNs has not been elucidated. In this review, we discuss pathogenesis of CNs and how intravascular imaging can help diagnose and manage patients with CNs. We also discuss medical and transcatheter therapies beyond conventional stent implantation for effective treatment of eruptive CNs that warrant testing in prospective studies.

Clinical study of 57 cases of endovascular treatment for total subclavian artery occlusion.

To investigate the safety and efficacy of endovascular treatment for totally occlusive lesions of the subclavian artery (SCA). A retrospective study was performed on 57 patients treated with angioplasty and stenting, including 42 males and 15 females, with an average age of 61.8years (range: 49 to 81years). Efficacy, safety, and complications were evaluated. Procedural success was achieved for 47/57 patients and symptoms were relieved. Rat-tail occlusion is the most common type, and all cases were successfully recanalized. Plain type occlusion is less common with a recanalization rate of 55.6%. Hilly and plain occlusions are the main types of stent implantation failure. Through univariate analysis and trend matching analysis, the type of SCA occlusion and surgical approach had statistical significance on the success rate of surgery. The mean follow-up time was 34.6 ± 16.2months. The cumulative stent patency rates at 1, 3, and 5years were 95.5%, 86.4%, and 77.3% in the calcified plaque group and 92.0%, 76.0%, and 68.0% in the non-calcified plaque group, respectively. The 3-year and 5-year patency rates in the calcified plaque group were higher than those in the non-calcified plaque group (p < .05). Different occlusion types and surgical approaches can affect the surgical success rate. The combined femoral and brachial approach can improve the rate of recanalization of SCA occlusions. The patency rates at 3 and 5years in the calcified plaque group were higher than those in the non-calcified plaque group.

Glycemic Control and Coronary Stent Failure in Patients With Type 2 Diabetes Mellitus

BackgroundThe impact of glycemic control in the risk of stent failure in subjects with type 2 diabetes (T2D) is currently unknown. ObjectivesThis study sought to study whether poor glycemic control is associated with a higher risk of stent failure in subjects with T2D. MethodsThis observational study included all patients in Sweden with T2D who underwent implantation of second-generation drug-eluting stents (DES) during 2010 to 2020. The exposure variable was the updated mean of glycated hemoglobin (HbA1c). Individuals were stratified by glycemic control, with HbA1c 6.1% to 7.0% (43-53 mmol/mol) as the reference group. The primary endpoint was the occurrence of stent failure (in-stent restenosis and stent thrombosis). The main result was analyzed in a complete cases model. Sensitivity analyses were performed for missing data and a model with death as a competing risk. ResultsThe study population consisted of 52,457 individuals (70,453 DES). The number of complete cases was 24,411 (29,029 DES). The median follow-up was 6.4 years. The fully adjusted HR was 1.10 (95% CI: 0.80-1.52) for HbA1c of ≤5.5% (≤37 mmol/mol), 1.02 (95% CI: 0.85-1.23) for HbA1c of 5.6% to 6.0% (38-42 mmol/mol), 1.25 (95% CI: 1.11-1.41) for HbA1c of 7.1% to 8.0% (54-64 mmol/mol), 1.30 (95% CI: 1.13-1.51) for HbA1c of 8.1% to 9.0% (65-75 mmol/mol), 1.46 (95% CI: 1.21-1.76) for HbA1c of 9.1% to 10.0% (76-86 mmol/mol), and 1.33 (95% CI: 1.06-1.66) for HbA1c of ≥10.1% (≥87 mmol/mol). Sensitivity analyses did not change the main result. ConclusionsWe found a significant association between poor glycemic control and a higher risk of stent failure driven by in-stent restenosis.

Outpatient PCI - early discharge PCI, single center experience

Abstract Funding Acknowledgements None. Background Percutaneous coronary intervention (PCI) has undergone rapid evolution over the last years and is currently a widely generalized therapeutic option. In the past, it was associated with a significant rate of complications, yet, with the improvement of new generation drug eluting stents, and the radial access (RA) development, PCI has become safer and simpler, with a minimum rate of complications. This allows patient’s faster discharge. Besides the pressure from the limited number of beds in wards, the improvement of PCI has given the confidence to urge outpatient PCI programs. However, there are still centers where there is no ambulatory PCI. Purpose This study aims to describe our center experience of ambulatory PCI program, in terms of safety and efficacy. Methods We analyzed our center’s retrospective cohort of 723 PCI, in 2022. Ambulatory PCI was defined as PCI with same day hospital discharge. Our inclusion criteria were patients submitted to PCI. We excluded patients with acute coronary syndromes and patients needing hospital admission for other non-coronary reasons. Results 467 (65%), of the 723 PCI were performed in ambulatory setting. Patients mean age was 67,8±11 years and 23% (n=107) were female. In 12% (n=55) of the cases, the coronary anatomy was previously known, from a differed procedure. 63% (n=298) had a normal left ventricle ejection fraction (LVEF), 6% (n=26) had a moderate depression of LVEF and 3% (n=13) had LVEF severe depression. RA was possible in 82% of the cases (n=384), and 18% (n=83) of PCI was done by femoral access (FA). The access size was 6 Fr in 77% (n=359) of the cases, 7Fr in 22% (n=105) and 8Fr in 1% (n=2). The RA hemostasis was by compression (either manually or by external device) and FA hemostasis was first intended by closing device, however in 17% of the transfemoral PCI (n=14) had to be compressed, due to device hemostasis failure. PCI was successful in 97% of the cases (n=449), with revascularization of the goal lesion. The unsuccessful PCI (3% n=18) were because uncrossable lesion in 2% (n=14), and no reflow after PCI in 1% (n=4). 6 patients had to be admitted, after planned outpatient PCI, 5 due to peripheral access complication with hemorrhage of FA (after closing device and manual compression failure) and 1 due to PCI complication, with small coronary perforation. There was a higher probability of admission in patients submitted to transfemoral PCI (p&amp;lt;0,05), and there was no statistically significant relation between unplanned admission and patient’s LVEF. There were no episodes of death, MACE, non-planned hospital readmission and stent failure in the ambulatory PCI population. PCI has become a predictable and reliable technique, capable to treat outpatients. Patients undergoing successful non-complex PCI, without events, can safely be discharged on the same day. Outpatient PCI helps with the functioning of inpatient care, allowing beds to be freed up for other situations.

Bioresorbable vascular scaffolds - a single center experience

Abstract Funding Acknowledgements None. Background/Introduction Bioresorbable vascular scaffolds (BVS) were considered promising alternatives to drug-eluting stents in percutaneous coronary interventions (PCI). They would restore the normal vasomotor tone and allow positive remodeling, reducing the trigger for inflammation and facilitating further interventions. Although randomized trials showed beneficial outcomes up to 1 year of follow-up, longer-term results have been disappointing, with increased rates of events, leading to its discontinuation. Purpose This study aims to evaluate our center’s 5-year follow-up of the BVS implantations, in terms of safety and efficacy. Methods Retrospective cohort of 46 patients submitted to PCI with a BVS was evaluated. The outcomes assessed were composite endpoint of death, myocardial infarction (MI), and revascularization (DMR), target vessel failure (TVF) and cardiovascular death, and each endpoint individually. Data analysis was done with SPSS software. Results The cohort was a total of 46 patients, with a mean age 69,5±1,5 years, and 23,9% women (n=11). The mean follow-up time was 5,6±0,2 years. BVS were implanted 74% (n=34) of the times in acute coronary syndromes, and 68% (n=31) were PCI on previous stent failure. Total of 24% (n=11) had an episode in the follow-up. Regarding each individual outcome, there was 9% (n=4) of MI, 0% (n=0) of cardiovascular deaths and 15,2% (n=7) of BVS re-stenosis requiring revascularization. Only 4% (n=2) of patients had complete BVS resorption on reassessment coronary angiography. Conclusions In the 5-year follow-up, there was a high rate of events, with 24% (n=11) of events, of which the most common was BVS re-stenosis, with 15,2% cases (n=7), and MI in 9% (n=4). Despite theoretical benefits with the resorption of BVS, it was only verified in 4% of the cases (n=2). According to the recent data, from the longer-term follow-up, BVS have been associated with a higher number of events, with the intended benefit not being verified.

Routine Functional Testing or Standard Care in High-Risk Patients after Percutaneous Coronary Intervention.

This review aimed to collate the available evidence on outcomes following routine functional stress testing vs standard of care (i.e. symptom-guided stress testing) in high-risk patients following percutaneous coronary intervention (PCI). The most recent pragmatic POST-PCI trial provided randomized evidence showing that routine functional stress testing post-PCI did not lead to a reduction in 2-year ischemic cardiovascular events or all-cause mortality, as compared to a symptom-guided standard-of-care approach. This was also true for sub-analyses including multivessel or left main disease, diabetics, as well as following imaging or physiology guided PCI. In the absence of a change in their clinical or functional status suggestive of stent failure, post-PCI routine periodic stress testing in stable patients on guideline-directed medical therapy is currently not recommended by American clinical practice guidelines. While evidence on the cost-effectiveness of routine stress testing strategy is scarce, physician, payer, and policy-level interventions to reduce inappropriate use of routine functional testing need to be addressed.

Classification of Stent Failure and Risk Factors for Further Reintervention in Patients Treated for Deep Venous Obstruction

Classification of Stent Failure and Risk Factors for Further Reintervention in Patients Treated for Deep Venous Obstruction

Clinical application of the retrograde track method in reopening dysfunctional biliary stents.

Biliary stent dysfunction is challenging to treat in clinic. The retrograde track method (RTM) has a promising clinical application in the reopening of dysfunctional biliary stents. This study aimed to evaluate the clinical value of the RTM in reopening dysfunctional biliary stents. From February 2013 to January 2020, 151 patients underwent percutaneous transhepatic biliary interventional procedures for reopening dysfunctional biliary stents at the First Affiliated Hospital of Zhengzhou University, and 25 patients (12 females, 13 males; mean age 63.12 years old) underwent the RTM after anterograde reopening dysfunction biliary stent failure. Technical success, clinical success, irradiation dose, procedure time, complications, and overall survival (OS) were recorded, and levels of total bilirubin (TBIL), direct bilirubin (DB), alanine aminotransferase (ALT), albumin (ALB), and carbohydrate antigen-199 (CA-199) were compared before treatment and 1 month after treatment. The technical and clinical success rates were 100% and 96%, respectively, and the irradiation dose and procedure times were 774.07±330.80 mGy and 45.16±9.48 min, respectively. Two patients (8%) experienced major complications. The median OS was 10.73 months [95% confidence interval (CI): 9.37-12.09]. Compared with pretreatment values, the mean levels at 1 month after RTM administration for TBIL (189.47±59.20 vs. 44.65±16.12 µmol/L), DB (144.21±55.83 vs. 27.95±13.86 µmol/L), ALT (89.62±30.85 vs. 49.44±14.25 U/L), and CA-199 (584.59±269.82 vs. 176.76±100.68 U/mL) showed significant decreases, while that of ALB (36.32±2.05 vs. 40.22±1.95 g/L) showed a significant increase (all P values <0.05). RTM is an effective alternative treatment method when anterograde reopening of a dysfunctional biliary stent occurs.

Comparative outcomes of open mesenteric bypass after a failed endovascular or open mesenteric revascularization for chronic mesenteric ischemia

IntroductionClinical practice guidelines have recommended an endovascular-first approach (ENDO) for the management of patients with chronic mesenteric ischemia (CMI), whereas an open mesenteric bypass (OMB) is proposed for subjects deemed to be poor ENDO candidates. However, the impact of a previous failed endovascular or open mesenteric reconstruction on a subsequent OMB is unknown. Accordingly, this study was designed to examine the results of a remedial OMB (R-OMB) after a failed ENDO or a primary OMB (P-OMB) for patients with recurrent CMI. MethodsAll patients who underwent an OMB from 2002 to 2022 at the University of Florida were reviewed. Outcomes after an R-OMB (ie, history of a failed ENDO or P-OMB) and P-OMB were compared. The primary end point was 30-day mortality, whereas secondary outcomes included complications, reintervention, and survival. The Kaplan-Meier methodology was used to estimate freedom from reintervention and all-cause mortality, whereas multivariable Cox proportional hazards modeling identified predictors of death. ResultsA total of 145 OMB procedures (R-OMB, n = 48 [33%]; P-OMB, n = 97 [67%]) were analyzed. A majority of R-OMB operations were performed for a failed stent (prior ENDO, n = 39 [81%]; prior OMB, n = 9 [19%]). R-OMB patients were generally younger (66 ± 9 years vs P-OMB, 69 ± 11 years; P = .09) and had lower incidence of smoking exposure (29% vs P-OMB, 48%; P = .07); however, there were no other differences in demographics or comorbidities. R-OMB was associated with less intraoperative transfusion (0.6 units vs P-OMB, 1.4 units; P = .01), but there were no differences in conduit choice or bypass configuration.The overall 30-day mortality and complication rates were 7% (n = 10/145) and 53% (n = 77/145), respectively, with no difference between the groups. Notably, R-OMB had decreased cardiac (6% vs P-OMB, 21%; P < .01) and bleeding complication rates (2% vs P-OMB, 15%; P = .01). The freedom from reintervention (1 and 5 years: R-OMB: 95% ± 4%, 83% ± 9% vs P-OMB: 97% ± 2%, 93% ± 5%, respectively; log-rank P = .21) and survival (1 and 5 years: R-OMB: 82% ± 6%, 68% ± 9% vs P-OMB: 84% ± 4%, 66% ± 7%; P = .91) were similar. Independent predictors of all-cause mortality included new postoperative hemodialysis requirement (hazard ratio [HR], 7.4, 95% confidence interval [CI], 3.1-17.3; P < .001), pulmonary (HR, 2.7, 95% CI, 1.4-5.3; P = .004) and cardiac (HR, 2.4, 95% CI, 1.1-5.1; P = .04) complications, and female sex (HR, 2.1, 95% CI, 1.03-4.8; P = .04). Notably, R-OMB was not a predictor of death. ConclusionsThe perioperative and longer-term outcomes for a remedial OMB after a failed intraluminal stent or previous open bypass appear to be comparable to a P-OMB. These findings support the recently updated clinical practice guideline recommendations for an endovascular-first approach to treating recurrent CMI due to the significant perioperative complication risk of OMB. However, among the subset of patients deemed ineligible for endoluminal reconstruction after failed mesenteric revascularization, R-OMB results appear to be acceptable and highlight the utility of this strategy in selected patients.

A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure

Video 1A novel method of bilateral biliary decompression by EUS-guided hepaticogastrostomy with bridging stenting using the partial stent-in-stent method for reintervention of multiple metal stent failure.We report a case in which anterior and posterior drainage was performed using the partial stent-in-stent method via the transpapillary approach. The patient had a bismuth type IV biliary obstruction, but only the right hepatic lobe was drained due to obstruction of the left portal vein. For the recurrent stent dysfunction, the patient underwent placement of a plastic stent within an uncovered self-expanding metal stent to correct stent dysfunction. A 7F plastic stent inside a metal stent is shown.The patient later experienced stent failure and jaundice due to tumor progression and was admitted for plastic stent replacement. Neither imaging results nor symptoms suggested duodenal stenosis. The transpapillary approach was attempted first but was unsuccessful. Duodenoscopy was challenging to perform because of duodenal stenosis. Fluoroscopy confirmed the duodenal stenosis. The plastic stent was extracted using an upper endoscope. Multiple uncovered metal stents are shown (1 stent in the anterior bile duct and 2 stents in the posterior bile duct). Jaundice did not resolve despite plastic stent removal.The patient refused to undergo percutaneous biliary drainage, so a decision was made to perform an EUS-guided hepaticogastrostomy (HGS) instead. The left bile duct was observed in the stomach. The left bile duct was punctured with a 19-gauge FNA needle. A 0.025-inch hydrophilic guidewire was directed into the left bile duct. Enhancement of the bile duct showing malignant hilar biliary obstruction (bismuth IV) is seen. Insertion of the guide wire into the posterior bile duct is shown.The stent mesh was then dilated using a balloon dilator. However, there was difficulty inserting the catheter. Additional dilation was performed using a spiral dilator. This instrument is a tapered tip dilator that fits into 0.025-inch guidewires and is expandable to 7F. Insertion of a second guidewire with a larger caliber was done to straighten the bile duct and help stabilize stent insertion. A 0.035-inch hydrophilic guidewire into the posterior bile duct using a double-lumen cannula and insertion of a 0.025-inch hydrophilic guidewire into the anterior bile duct are shown.The stent mesh was then dilated using a spiral dilator. A metal stent was placed through the anterior bile duct at a steep angle. Insertion and deployment of the first uncovered self-expanding metal stent (8× 60mm) from the anterior bile duct into the left bile duct is shown. Multiple metal stents were implanted into the hilar area, and the new stent was placed using the partial stent-in-stent method to prevent overexpansion. Guidewire seeking the posterior bile duct from inside the deployed stent through the stent mesh is shown.The stent mesh was then dilated using a balloon dilator. Insertion and deployment of an uncovered self-expanding metal stent (8× 60mm) from the posterior bile duct to the left bile duct using the partial stent-in-stent method is shown. Enhancement of the bile duct shows drainage from the right bile duct. The fistula of the HGS was only dilated with the spiral dilator. The risk of bile leakage was low, so we decided to implant a plastic stent. A 7F× 15-cm plastic stent was placed from the posterior bile duct into the stomach. Anterior and posterior segment drainage by EUS-HGS with bridging stenting using the partial stent-in-stent method is shown, with left segment drainage by EUS-HGS with the plastic stent.We performed EUS-HGS on a patient with multiple metal stents in place. There were no adverse events, and total bilirubin levels were reduced by more than half within 2 weeks. Six months have passed without stent dysfunction.