Indications For Stent Placement Research Articles

Safety and efficacy of ultrasound-assisted bedside ureteric stent placement A prospective, single-institution study.

Previous studies have demonstrated the feasibility of bedside placement of ureteric stents; however, they have traditionally required two skilled operators and were associated with some stent malposition especially for proximal ureteric obstruction. We sought to investigate the efficacy and safety of a modified technique for ultrasound-assisted bedside ureteric stent insertion without the presence of a skilled assist. A single institution prospective study was performed from April-August 2023. Indications for stenting included infection, renal insufficiency, or intractable colic. Exclusion criteria included age <18 years, hemodynamic instability, and patients with history of chronic pain. Point-of-care ultrasound (POCUS) was used to confirm wire placement in the kidney and presence of a hydronephrotic drip from a 5 French ureteric catheter was used to confirm placement beyond the level of obstruction. Of 28 patients, all patients underwent successful bedside ureteric stent placement. Mean age was 64.9 years and mean body mass index (BMI) was 33.2. Proximal ureter obstruction was present in 52% of patients and mid/distal obstruction in 48%. In cases with obstructing stones, the mean stone size was 8.1 mm with a range of 4-15 mm. Infection was the indication for stent placement in most patients (71%), followed by pain (4%) and acute kidney injury (AKI) (4%). All patients who underwent successful stent placement had presence of hydronephrotic drip from the ureteric catheter. Ultrasound-assisted bedside ureteric stent insertion without a skilled assist is a safe and feasible option for management of acute ureteral obstruction. Presence of hydronephrotic drip can indicate successful access beyond the level of obstruction as an alternative to POCUS.

INDIVIDUALIZED APPROACH TO UPPER URINARY TRACT DRAINAGE AFTER RETROPERITONEOSCOPIC URETEROLITHOTOMY

Aim. To clarify the indications for the use of ureteral stents during retroperitoneoscopic ureterolithotomy (RULT). Materials and methods. We analyzed the results of treatment of 53 patients who underwent RULT for ureteral stone. In 18 (34%) patients, a stent was not placed after the operation (group 1), and in 35 (66.0%) patients, a stent was placed (group 2). Indications for stent placement were determined during surgery. Results. When performing RULT for the treatment of patients with ureteral stones, postoperative complications were not severe, resolved on their own or required a slight increase in therapy in the postoperative period. These complications did not significantly affect the duration of treatment or its results. There were no significant differences in the main clinical and laboratory parameters in both groups 2 weeks after surgery. The incidence of complications was low and did not differ significantly in both groups. Conclusions. No significant differences were found in terms of the immediate results of treatment of patients with ureterolithiasis after RULT, depending on whether a stent was used to drain the ureteral lumen in the patient or not, when a stent was used according to indications. Complications after RULT are infrequent, transient, and require only minimal therapeutic correction. Stenting of the ureter is expected to lead to a significant increase in the duration of surgery. Drainage of the ureter by placing a stent is an absolutely justified procedure in the presence of severe changes in the ureteral wall, manifested by edema of all layers, the presence of mucosal ulcers, as well as perifocal inflammation in the surrounding tissues surrounding the ureter. On the other hand, stenting of the ureter after RPU is not a routine procedure, and in the absence of the above changes, it can be abandoned without any complications.

Use of Polyurethane-Covered Stents for Exclusion of Pulmonary Arteriovenous Malformations.

To evaluate the safety, technical success and short-term effectiveness of polyurethane-covered stent (PK Papyrus, BioTronik, Berlin) in the treatment of pulmonary arteriovenous malformations (PAVMs) that are not amenable to embolotherapy. In this IRB-approved, retrospective study, data from patients who received polyurethane-covered stents for exclusion of PAVMs were analyzed. The study included 5 patients (all women) with a median age of 40years (range 25-60). Patients presented with hypoxemia, TIAs, and/or epistaxis; 4 were confirmed to have HHT. All had multiple PAVMs diagnosed on chest CT and underwent embolization with other devices in addition to the polyurethane-covered stent. The indication for stent placement in all cases was a short and/or tortuous feeding artery. Safety was assessed by immediate or short-term complications, e.g., migration, stent thrombosis, and fracture. Technical success was defined as the ability to accurately place the stent at the intended location. Effectiveness was defined as successful exclusion of PAVM with no perfusion across the AVM. Technical success of stent placement was 100%. AVM exclusion rate was 80% after single stent deployment; in the case of incomplete exclusion, success was achieved using an overlapping stent to completely cover a second feeding artery. During the median follow-up period of 5months (range 2-10), all stents remained patent, and AVMs were excluded without other complications. Exclusion of PAVMs with polyurethane-covered stents is technically feasible, safe, and shows short-term effectiveness for PAVMs with a short/tortuous feeding artery when traditional embolization techniques are not possible.

Variation in Carotid Artery Stenosis Measurements Among Facilities Seeking Carotid Stenting Facility Accreditation.

Based on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of extracranial carotid atherosclerotic disease. However, the rigor and consistency with which stenosis is measured outside of clinical trials are unclear. In an agreement study using a cross-sectional sample, we compared the percent stenosis as measured by real-world physician operators to that measured by independent expert reviewers. As part of the carotid stenting facility accreditation review, images were obtained from 68 cases of patients who underwent carotid stent placement. Data collected included demographics, stroke severity measures, and the documented degree of stenosis, termed operator-reported stenosis (ORS), by 34 operators from 14 clinical sites. The ORS was compared with reviewer-measured stenosis (RMS) as assessed by 5 clinicians experienced in treating carotid artery disease. The median ORS was 90.0% (interquartile range, 80.0%-90.0%) versus a median RMS of 61.1% (interquartile range, 49.8%-73.6%), with a median difference of 21.8% (interquartile range, 13.7%-34.4%), P<0.001. The median difference in ORS and RMS for asymptomatic versus symptomatic patients was not statistically different (24.6% versus 19.6%; P=0.406). The median difference between ORS and RMS for facilities granted initial accreditation was smaller compared with facilities whose accreditation was delayed (17.9% versus 25.5%, P=0.035). The intraclass correlation between ORS and RMS was 0.16, indicating poor agreement. If RMS measurements were used, 72% of symptomatic patients and 10% of asymptomatic patients in the population examined would meet the Centers for Medicare and Medicaid Services criteria for stent placement. Real-world operators tend to overestimate carotid artery stenosis compared with external expert reviewers. Measurements from facilities granted initial accreditation were closer to expert measurements than those from facilities whose accreditation was delayed. Since decisions regarding carotid revascularization are often based on percent stenosis, such measuring discrepancies likely lead to increased procedural utilization.

Abstract 133: Over Estimation Of Percent Stenosis By Physician Operators May Lead To Carotid Stent Over Utilization

Introduction: Based largely on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of carotid atherosclerotic disease. However, the rigor and consistency with which such stenosis is measured outside of clinical trials is unclear. We compared the percent stenosis as measured by real world physician operators to that measured by independent expert reviewers. Hypothesis: We hypothesized that the documented degree of stenosis, termed operator-reported stenosis (ORS), from real world facilities performing carotid stent placement would be larger than the reviewer-measured stenosis (RMS) as assessed by clinicians experienced in treating carotid artery disease. Methods: Images were selected from patient cases used for carotid stenting facility accreditation. Data collected included demographics, National Institutes of Health Stroke Scale, modified Rankin Score, and the documented degree of stenosis (ORS). The ORS was compared to the RMS, derived from a panel of expert clinicians. Results: A total of 68 angiograms were reviewed from 39 symptomatic and 29 asymptomatic patients. The RMS values demonstrated excellent agreement with an intra-class correlation of 0.80. The median ORS was 90.0% (IQR 80.0, 90.0) versus a median RMS of 61.1% (IQR 49.8, 73.6), with a median difference of 21.8% (IQR 13.7, 34.4), p &lt; 0.001. This discrepancy persisted within several subpopulations and was larger among asymptomatic patients and those treated at facilities granted delayed accreditation. Based on RMS values, 72% of symptomatic patients and only 10% of asymptomatic patients would meet the Centers for Medicare and Medicaid Services criteria for carotid stent placement. Conclusions: Real world operators tend to overestimate cervical carotid artery stenosis compared to external expert reviewers. Since decisions regarding carotid revascularization are often based at least partially on percent stenosis, such measuring discrepancies inevitably lead to a higher volume of procedures, which may in turn represent a degree of procedural over utilization.

Airway Stent in Lung Cancer: A Narrative Literature Review

Lung cancer complications are the leading cause of death in lung cancer patients. This study aimed to describe the prevalence of stent placement, indications for stent placement, success and complication rates, and prognosis of airway stent placement in patients with lung cancer. Malignant central airway obstruction (MCAO) is one of the significant complications. Insertion of airway stent can restore airway patency in more than 90% of patients with MCAO. Airway stent placement is indicated in patients with extrinsic lesions, obstruction of ≥ 50%, have patent airway below the obstruction, and are not in the terminal state. The technical success was reported to be very high and consistent with the range of 95-100%. Early complications were relatively rare; however, up to 87% of long-term complications were reported. Stent placement is a risk factor for lower respiratory tract infection, an adverse prognostic factor in lung cancer survival. Airway stents should be indicated and used with caution and discretion. With the advancement and development of technology, various materials and types of airway stents are being developed to minimize adverse outcomes.

Self-expanding metal stent in esophageal perforations and anastomotic leaks.

Placement of self-expanding metal stents (SEMS) has emerged as a minimally invasive treatment option for esophageal perforation and leaks. The aim of our study was to assess the role of SEMS for the management of benign esophageal diseases such as perforations and anastomotic leaks. All patients (n = 26) who underwent SEMS placement for esophageal perforation and anastomotic leaks between May 2012 and February 2019 were included. Data wereanalyzed in relation to theindications, type of stent used, complications, and outcomes. Indications for stent placement included anastomotic leaks 65% (n = 17) and perforations 35% (n = 9). Fully covered SEMS (FCSEMS) was placed in 25 patients, and in 1, partially covered SEMS (PCSEMS) was placed. Stent placement was successful in all thepatients (n = 26). Four patients did not report for follow-up after stenting. Among the patients on follow-up, 91% (20/22) had healing of the mucosal defect. Stent-related complications were seen in 5 (23%) patients and included stent migration [3], reactive hyperplasia [1] and stricture [1]. Covered stent placement for a duration of 8weeks is technically safe and clinically effective as a first-line procedure for bridging and healing benign esophageal perforation and leaks.

DOZ047.56: Esophageal stent placement for the treatment of severe stricture after the operation for esophageal atresia—preliminary report

Abstract Introduction Anastomotic stricture is the most common complication after the treatment of esophageal atresia. It occurs in 20%–80% of operated patients. The stricture can be usually effectively managed by repeated bougie or balloon dilations. Stent placement therapy is reserved for severe strictures. Material and Methods Between 2006 and 2018, 73 patients with esophageal atresia were admitted to the clinic. The esophagus was anastomosed in 63 of those patients. Clinical history of three patients with severe stricture treated with stent placement was analyzed retrospectively. Results Two patients were treated for esophageal atresia with lower tracheoesophageal fistula and one without the fistula (type ‘A’). In two patients, the undertension primary anastomosis was possible. The third patient underwent esophageal reconstruction with the large curvature of the stomach after upper esophagus elongation (Collis procedure). Anastomotic leakage and severe anastomotic stricture occurred in all three patients. Severe stricture was the indication for stent placement in two cases and a perforation during the dilation procedure in one. All stents were removed after the period of one week. The removal was accelerated by the aggravation of tracheomalacia symptoms in one case and by the onset of pulmonary tract infection due to gastroesophageal reflux in another. The third stent migrated to the stomach and had to be removed during endoscopy. One patient, qualified for stent therapy due to the perforation, did not require any other dilations after stent removal. In one patient with severe stricture, the stent therapy accelerated the healing—the narrowing never got tighter than the stent diameter and he required only three more dilations. In the third patient, no positive impact of the stent therapy was observed. Conclusions Stent placement for severe esophageal stricture after anastomosis was the definite therapy in one patient and substantially reduced the number of required dilations in one. Complications of the stent placement appeared in two out of three patients.

Su1149 COMPLICATIONS RELATED TO ESOPHAGEAL STENT (BOSTON SCIENTIFIC [WALLFLEX] VS MERIT MEDICAL ENDOTEK) USE IN BENIGN AND MALIGNANT CONDITION- A SINGLE CENTER RETROSPECTIVE REVIEW

Esophageal stents can be used to treat benign esophageal disorders such as esophageal leaks, fistulas, refractory strictures and malignant conditions like locally unresectable or advanced metastatic cancer of the esophagus, those with poor functional status who can’t tolerate surgery or chemo radiotherapy, or those in whom previous treatment failed or those with locally recurrent disease. There are various complications post stent placement like chest pain, bleeding and stent migration. These complications depend on a number of factors like indication of stent placement, diameter/length and design of the stent. This study focused on assessing Boston Scientific (WallFlex) VS Merit Medical Endotek complication rates in benign and malignant conditions. In this retrospective study, patients who underwent esophageal stent placement for benign and malignant esophageal conditions between January 1, 2006 and December 12, 2016 were selected. Charts were reviewed to capture gender, indication of stent placement, stent length/diameter, age of the patient at the time of stent placement, length of hospital stay, physician performing a procedure and complications within 90 days of stent placement. Descriptive statistics including means were reported with the standard deviation for the continuous variables along with frequencies and percentages for all categorical variables. 67 patients (71.6% male) underwent stent placement (WallFlex 49.3% and Merit 50.8%) for malignant (68.7%) mainly esophageal obstruction by primary esophageal cancer (89.1%) and benign causes (31.3%) mainly esophageal leak (66.7%). Merit and WallFlex used in malignant conditions were 82.4% and 54.6%, respectively, and in benign conditions were 17.7% and 45.5%, respectively. Mean age at which endoscopy was performed 63.0 ± 11.8 years. Most common diameter used was 23mm (74.2%) and length used was 120mm (38.8%). Complications post Merit and WallFlex placement were 79.4% and 60.6%, respectively, with chest pain (67.7% and 48.5%) being the most common complaint followed by stent migration (14.7% and 12.1%) and bleeding (29.4% and 18.2%). Complications with malignant and benign conditions were 73.9% and 61.9%, respectively (specific complication data in Figure 1). Complications with 19, 18 and 23mm diameters were 75.0%, 66.7% and 69.4%, respectively. Complications with 120, 150, 100, 15, 12, 10mm stent lengths were 84.6%, 58.3%, 58.8%, 80.0%, 75.0% and 33.3%, respectively. Our study showed that Merit stent was mainly used and major indication of stent placement was a malignant condition. Major complications were seen when the reason for stent placement was a malignant condition, diameter was 19mm, length was 120mm and use of Merit stent.

Sa1293 LARGEST U.S. EXPERIENCE WITH PARTIALLY COVERED SELF EXPANDABLE METAL STENTS (SEMS) FOR MALIGNANT BILIARY OBSTRUCTION: SIZE DOES NOT MATTER

Self-expandable metal stents (SEMS) can be used for treatment of malignant biliary obstruction. Previously published literature has either reported on limited numbers of partially covered SEMS (PCSEMS) or groups their outcomes with fully covered SEMS (FCSEMS) in comparison to uncovered SEMS (UCSEMS). There is limited data focusing on outcomes and adverse events related specifically to PCSEMS. Furthermore, there is currently no consensus data on the optimum SEMS diameter to use. Our study aims to examine the clinical success, patency, and complications with regard to stent coating and stent diameter. All patients receiving a PCSEMS or an UCSEMS between 2009-2017 at a single academic center were retrospectively analyzed. Comparative analyses between different stent coatings (PCSEMS vs UCSEMS) and stent diameters (8 vs 10mm) were carried out. Factors compared included clinical success rates, patency durations and adverse events that occurred early (<30 days) or late (>30 days) from the date of SEMS placement. Adverse events included pancreatitis, cholecystitis, perforation, bleeding, cholangitis, stent occlusion and migration. There were 282 patients who had either PCSEMS or UCSEMS placement for malignant biliary obstruction identified. Baseline characteristics (gender, age) were similar between stent groups regardless of coating or diameter. Indications for stent placement were jaundice 225(80%) and cholangitis 57(20%) in the setting of pancreatic cancer 180(64%), cholangiocarcinoma 58(21%), and other malignancies 44(15%). Distribution of stent coating groups was: 214 PCSEMS (76%) and UCSEMS 68 (24%). Clinical success rates and patency duration were not statistically significant between PCSEMS and UCSEMS (96% vs 98%, P=0.34 and 264 vs 300 days, P=0.59). Adverse event rates were similar between both stent types with regard to early (9.4% PCSEMS vs 7.4% UCSEMS, P=0.59) and late (9% vs 10%, P=0.74) groups. Stent diameter groups examined included 174 (62%) 8mm stents and 106 (38%) 10mm stents; two 6mm stents were excluded. Stent diameter did not have an impact on overall clinical success (96% vs 99%, P=0.11), patency duration (142 days vs 181 days, P=0.54), or adverse event rates (16% vs 18%, P=0.96). Our data suggest PCSEMS have similar clinical success, patency duration and adverse event rates compared to UCSEMS in the treatment of malignant biliary strictures. Furthermore, despite the larger diameter, 10mm stents do not have a higher clinical success, patency duration, or complication rate then the 8mm stent diameter.

Self-Expanding Biodegradable Stents for Postoperative Upper Gastrointestinal Issues.

Background and Objectives:Endoscopic stenting is a minimally invasive treatment modality for patients with various gastrointestinal conditions. We evaluated the safety and efficacy of uncovered biodegradable stents for postoperative leaks and strictures in the upper gastrointestinal tract.Methods:This was a retrospective study of patients treated endoscopically with biodegradable stents from January 2010 through November 2017.Results:Thirteen patients were enrolled, 7 of whom were men. Their mean age was 46 (range, 21–82) years. The indications for stent placement were postoperative leakage and stricture in 9 and 4 patients, respectively. The primary diagnoses were obesity in 7 patients, gastric cancer in 5, and peptic ulcer in 1. The average time to stent placement after surgery was 35 (range, 17–125) and 166 (range, 153–185) days for patients with postoperative leakage and stricture, respectively. Stent insertion was successful at the first attempt in all patients. Complete resolution of the leak and stricture was achieved after stent application in 11 patients, for a clinical success rate of 85%. The mean follow-up duration was 50 (range, 24–76) months. There were no major complications.Conclusions:Compared to self-expanding metal and plastic stents, the main advantages of uncovered biodegradable stents are that they do not have to be removed and have a low migration rate. Our results suggest that these stents have promise for management of postoperative gastrointestinal complications. Further randomized trials with larger sample sizes are necessary to determine the role of biodegradable stents in the treatment algorithm.

Airway stent complications: the role of follow-up bronchoscopy as a surveillance method.

Airway stenting has become an integral part of the therapeutic endoscopic management of obstructive benign and malignant central airway diseases. Despite increased use of airway stents and frequent stent-associated complications, no clear guidelines for surveillance and maintenance exist. This study aim is to elucidate predictive factors associated with development of stent complications, as well as an optimal surveillance period for follow-up bronchoscopy for early detection and possible prevention of stent-associated complications. Retrospective cohort study of all patients who underwent airway stent placements at our institution from April 2010 to December 2013 for benign and malignant airway diseases. Metallic, silicone (straight, Y stent, T-tube) and hybrid stents were included in the study. Stent complications were analyzed at the time of follow-up bronchoscopy performed four to six weeks after initial stent placement or earlier if patients became symptomatic. The study included 134 patients of which 147 stents were placed. Follow-up bronchoscopy was performed in 94 patients. Symptomatic status at the time of follow-up bronchoscopy was not associated with stent complications [odds ratio (OR) =1.88; 95% CI: 0.79-4.45; P=0.15]. Patient age, sex, indication for stent placement, and stent location, were not associated with development of complications (all P>0.05). Compared to all other stents, hybrid stents were more likely to migrate (OR =6.60; 95% CI: 2.16-20.2; P=0.001) or obstruct by secretions (OR =2.53; 95% CI: 1.10-5.84; P=0.03). There were no complications associated with surveillance bronchoscopy. Surveillance bronchoscopy within 4 to 6 weeks of stent placement may be useful for early detection of complications and their subsequent management, regardless of symptomatic status and indication for stent placement. Prospective multicenter studies are needed to compare optimal surveillance methods and the impact on patient mortality, morbidity and healthcare costs.

Stenting as a bail-out option after failed percutaneous transluminal angioplasty in infrainguinal vein bypass grafts.

To study the safety and efficacy of bare and covered stents in infrainguinal vein grafts after failure of PTA for treating graft stenoses. An analysis of a prospective database of all patients who underwent stenting of infrainguinal vein bypass grafts at this institution between 1 January 2008 and 31 December 2012 was carried out. The main outcome considered was primary patency, which was reported at 1, 6 and 12 months. A total of 18 patients with a mean age of 73 years (range: 56 to 86) were included. The indications for stent placement were significant recoil (7, 39%), graft rupture (6, 33%), residual vein cusps (3, 17%) and aneurysmal degeneration (2, 11%). There was a high overall technical success rate of 94% (17/18) and arrest of haemorrhage was achieved in all cases of graft rupture. The primary patency at 1, 6 and 12 months was 89%, 71% and 59%, respectively. The use of bare and covered stents in infrainguinal vein grafts appears safe and effective. They are an excellent bail-out option for the treatment of graft rupture and give acceptable short-term results.

A143 - Endoscopic Stent Management of Postoperative Anastomotic Leaks and Strictures After Foregut Surgery

Introduction: Anastomotic complications after foregut surgery are a morbid technical complication and include leaks, fistulas, and late strictures. The management of these complications can be challenging, and when possible, it may be desirable to avoid complicated reoperation. Methods: We performed a retrospective review of a prospectively managed database in order to identify patients who had undergone endoscopic stent placement after foregut surgery. Data was collected on patient demographics, preoperative workup, intraoperative findings, and postoperative outcomes. Results: From October of 2009 to November of 2014, 49 patients (mean age 51.5; 37 women and 12 men) underwent endoscopic stent placement for anastomotic complication following upper gastrointestinal (UGI) surgery. The mean time from index operation to endoscopic stent placement was 317 days (range 1-5280 days). 41 (83.7%) of index surgeries were bariatric operations, and the remaining 8 included cancer surgery and peroral endoscopic myotomy (POEM). A total of 56 stents were deployed, and of these the majority were partially covered self-expanding metal stents (81.6%) and the remainder were fully covered self-expanding metal stents (20.4%). Indications for stent placement were leak (n 1⁄4 27), stricture (n 1⁄4 15), fistula (including gastrogastric and enterocutaneous, n 1⁄4 4), anastomotic perforation (n 1⁄4 1), and bleeding (n 1⁄4 1). Symptomatic improvement occurred in 73.5% of patients (n 1⁄4 36) and early oral intake was initiated in 51% of patients (n 1⁄4 25). 17 patients required subsequent stent exchange for continued symptomatology. No patients required reoperation. Stent migration occurred in 3 patients which was addressed endoscopically. There were no deaths in our series. The average duration of stent placement was 21.2 days (range 1-53 days). The average followup was 352.6 days (range 13-1912 days). Conclusion: We propose that in the appropriate setting, endoscopic stent management of anastomotic complications following upper gastrointestinal surgery is an effective and less invasive therapeutic approach. Advantages include expediting early enteral nutrition and decreased morbidity compared to reoperation.

Fully covered self-expandable metal stent in the treatment of postsurgical colorectal diseases: outcome in 29 patients

Self-expandable metal stent (SEMS) placement is a minimally invasive treatment for palliation of malignant colorectal strictures and as a bridge to surgery. However, the use of SEMS for benign colorectal diseases is controversial. The purpose of this retrospective study is to evaluate the efficacy and safety of fully covered SEMS (FCSEMS) placement in postsurgical colorectal diseases. From 2008 to 2014, 29 patients with 32 FCSEMS deployment procedures were evaluated. The indications for stent placement were: 17 anastomotic strictures (3/17 presented complete closure of the anastomosis); four anastomotic leaks; seven strictures associated with anastomotic leak; and one rectum-vagina fistula. Clinical success was achieved in 18 out of 29 patients (62.1%) being symptom-free at an average of 19 months. In the remaining 11 patients (37.9%), a different treatment was needed: four patients required multiple endoscopic dilations, 4 patients colostomy confection, one patient definitive ileostomy and three patients revisional surgery. The FCSEMS were kept in place for a mean period of 34 (range: 6-65) days. Major complications occurred in 12 out of 29 patients (41.4%) and consisted of stent migration. Minor complications included two cases of transient fever, eight cases of abdominal or rectal pain, and one case of tenesmus. FCSEMS are considered a possible therapeutic option for treatment of postsurgical strictures and leaks. However, their efficacy in guaranteeing long-term anastomotic patency and leak closure is moderate. A major complication is migration. The use of FCSEMS for colonic postsurgical pathologies should be carefully evaluated for each patient.

Mo1560 Validity of Endoscopic Submucosal Dissection for Early Gastric Cancer in Super-Elderly Patients With Concomitant Diseases

group performance status (ECOG-PS) was 0 in 3 patients, 1 in 11 patients, 2 in 11 patients and 3 in 3 patients. The main indications for stent placement were pancreatic adenocarcinoma with duodenal infiltration in 13 (46.4%) patients, gastric adenocarcinoma in 7 (25%), cholangiocarcinoma in 3 (10.7%), duodenal adenocarcinoma in 3 (10.7%) and 1 (3.6%) in each of small bowel adenocarcinoma and gall bladder adenocarcinoma. Technical success rate for stent deployment was 100% and oral intake was possible in all (100%) of the stented patients with 93% of patients being capable of eating at least a mechanical soft diet. There were no sedation related adverse events and procedure related complications including perforation and haemorrhage. Among late complications there were 3 (10.7%) stent obstructions related to tumour ingrowth requiring re-insertion of stents and 1 (3.5%) biliary obstruction requiring biliary stent insertion. The mean survival from stent placement to death was 111 days (range 9-438). Three patients (11%) were still alive after an average of 250 days post stent deployment. 30 days mortality was 6 (21%) but this was related to advance malignant disease rather related to endoscopic stent placement. Conclusion: In our experience enteral stenting is a safe palliative procedure and it improves quality of life by relieving gastrointestinal obstruction and restoration of enteral tract for nutrition in all successfully stented cases. Enteral stenting contributed towards an average survival of around four months and hence must be considered in this high risk group of patients.

Durability and Efficacy of Tibial Arterial Stent Placement for Critical Limb Ischemia

PurposeTo analyze the efficacy and durability of long-term tibioperoneal arterial stent placement for selected cases of symptomatic chronic limb ischemia (CLI). Materials and MethodsFrom January 2005 to June 2012, 168 limbs (155 patients) were treated with percutaneous transluminal angioplasty (PTA)/stent placement for de novo tibial stenosis or occlusion in at least one tibial artery. Most patients (92.9%) were classified with severe disease (Rutherford category 5/6). Concomitant interventions were performed in 58%. Bare metal (84%) and drug-eluting (16%) stents were used. Indications for stent placement were residual stenosis after PTA (> 30%), elastic recoiling, and dissection. Primary endpoints were freedom from symptomatic intrastent restenosis, target lesion revascularization (TLR), major amputation, and overall survival (OS). ResultsTechnical success rate was 99%. Within 30 days, five deaths (3.2%) occurred, and a 1.8% (95% confidence interval [CI], 0.1%–27.2%) major adverse cardiac event rate, 3.6% (95% CI, 0.1%–22.1%) major adverse limb event rate, and 1.8% (95% CI, 0%–27.5%) amputation rate were recorded. Mean follow-up was 33 months (range, 1–96 mo). Symptomatic intrastent restenosis occurred in 20 limbs (12%) at a mean of 10.3 months ± 11.27; this was identified as a prognostic factor for limb loss (P = .045). TLR was necessary in 10.8% of limbs, for a limb salvage rate of 89.2%. OS was influenced by age (> 75 y; P < .001), diabetes (P = .048), and renal insufficiency and/or dialysis (P < .001). Estimated survival rate was 63% at 36 months (hazard ratio, 1.63; 95% CI, 54%–70%). ConclusionsStent placement offers promising short- to long-term restenosis and patency rates, even in cases of multilevel symptomatic disease. Rigorous follow-up is vital.

Endoscopic treatment of nonstricture-related benign biliary diseases using covered self-expandable metal stents.

Nonstricture benign biliary diseases (BBDs) such as leaks, perforations, and bleeding, have been traditionally managed by placement of one or more plastic stents. Emerging data support the use of covered, self-expandable, metal stents (CSEMSs). The aim of this study was to assess the outcomes of endoscopic temporary placement of CSEMS in patients with nonstricture BBD. This was a retrospective study of CSEMS placement for BBD between May 2005 and August 2013 at two tertiary care centers. The main outcome measures were resolution of perforation, bleeding, leak, and adverse events related to CSEMS treatment. A total of 87 patients were included (median age 62 years [range 18 - 86]). Indications for stent placement were bile leaks (n = 35, 40 %), bleeding (n = 27, 31 %), perforation (n = 18, 21 %), and other conditions (n = 7, 8 %). Fully and partially covered 8 - 10-mm diameter CSEMS were placed and subsequently removed in all 87 patients (100 %). Resolution of the underlying problem was achieved for 33 bile leaks (94 %), 25 bleedings (93 %), 18 perforations (100 %), and for 3 cases with other indications (43 %). The median duration of stenting was 9 weeks in patients with biliary leaks, 3 weeks for bleeding, and 9.5 weeks for perforations. Median follow-up was 82 weeks after stent removal. Seven adverse events occurred, including cholangitis in six patients (7 %), and tissue hyperplasia leading to difficulty in the removal of a partially covered SEMS in one patient. Nonstricture BBD can be effectively and safely treated with the short term placement of CSEMS. .

Optimal management of renal artery fibromuscular dysplasia.

Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory angiopathy of unknown cause affecting medium-sized (most commonly renal) arteries and causing renovascular hypertension. The most common medial multifocal type of FMD (with the “string of beads” appearance) is more than four times more prevalent in females than in males. FMD accounts for up to 10% of cases of renovascular hypertension. Compared with patients with atherosclerotic renal artery stenosis, patients with FMD are younger, have fewer risk factors for atherosclerosis, and a lower occurrence of atherosclerosis in other vessels. The etiology is multifactorial, including vessel wall ischemia and smoking, as well as hormonal and genetic factors. Intra-arterial digital subtraction angiography is still the gold standard for exclusion or confirmation of renal artery stenosis caused by FMD, at least in young patients, who more often have lesions in branches of the renal artery. For FMD patients with atherosclerosis and those who are older (>50–55 years), significant renal artery stenosis may be confirmed or excluded with ultrasonography. The FMD lesion is typically truncal or distal, whereas atherosclerotic lesions are more often proximal or ostial. Treatment options are medical, endovascular (percutaneous transluminal renal angioplasty [PTRA]), and surgical. Invasive treatment should be considered when hypertension cannot be controlled with antihypertensive drugs and in patients with impaired renal function or ischemic nephropathy. PTRA has become the treatment of choice and normally yields good results, especially in unifocal disease and young patients. Pressure gradients are normally completely abolished, and there is no indication for stent placement. Surgical revascularization is indicated after PTRA complications; thrombosis, perforation, progressive dissection, repeated PTRA failure or restenosis. Centralization of handling is recommended.

Endovascular Stent Placement of Juxtaanastomotic Stenosis in Native Arteriovenous Fistula After Unsuccessful Balloon Angioplasty

BackgroundIn hemodialysis patients, the most common problem in arteriovenous fistulas, as the best functional vascular access, is the juxtaanastomotic located lesions. Percutaneous transluminal angioplasty is accepted as the treatment method for juxtanastomotic lesions.ObjectivesTo assess juxtaanastomotic stent placement after insufficient balloon angioplasty in the treatment of autogenous radiocephalic or brachiocephalic fistula dysfunction.Patients and MethodsBetween July 2003 and June 2010, 20 hemodialysis patients with autogenous radiocephalic or brachiocephalic fistula dysfunction underwent stent placement for the lesion located at the juxtaanastomotic region. Indications for stent placement were insufficient balloon dilatation, early recurring stenosis, chronic organizing thrombus and vessel rupture. The Kaplan-Meier method was used to calculate the stent patency rates. All patients who had fistula dysfunction (thrombosis of hemodialysis access, difficult access cannulation, extremity pain due to thrombosis or decreased arterial access blood flow) were evaluated by color Doppler ultrasound. The stenoses were initially dilated with standard noncompliant balloons (3 to 10-mm in diameter). Dilatation was followed by high pressure (Blue Max, Boston Scientific) or cutting balloons (Boston Scientific), if the standard balloon failed to dilate the stenotic segment.ResultsTwenty-one stents were applied. The anatomical and clinical success rate was 100%. Seventeen additional interventions were done for 11 (55%) patients due to stent thrombosis or stenosis during follow-up. Our 1- and 2-year secondary patency rates were 76.2% and 65.5%, respectively and were comparable to those after balloon angioplasty and surgical shunt revision.ConclusionMetallic stent placement is a safe and effective procedure for salvage of native hemodialysis fistula after unsuccessful balloon angioplasty.