Late Stent Occlusion Research Articles

Endovascular Stenting for Malignant Obstruction of Superior Vena Cava: A Single-Center Experience Using the Body Floss Technique

Abstract Purpose Endovascular stenting is the treatment of choice for malignant obstruction of the superior vena cava (SVC) when rapid symptomatic relief is desired. Body floss technique is not routinely used during SVC stenting but has few advantages over single-access technique. We report our experience with stenting for malignant obstruction of the SVC using the body floss technique. Materials and Methods Between March 2015 and March 2020, 25 patients (20 men, 5 women; median age, 65 years) with malignant SVC obstruction underwent endovascular stenting of the SVC. We retrospectively evaluated these patients for clinical and technical success rates, complications, recurrence-free survival, and overall survival. Results Stent placement was successful in 24/25 patients (technical success: 96%). Clinical success was achieved in 23/25 (92%) patients. A mortality rate of 4% (1/25) was noted due to SVC rupture. Partial stent migration was noted in two patients (8%) and was treated by placing an additional overlapping stent. Incidental early stent thrombosis was seen in two patients within 8 hours of stent placement, but these patients showed symptom relief with anticoagulation. Follow-up imaging confirmed stent patency in all patients. Late stent occlusion due to tumor progression was seen in one patient. The primary patency rate was 88% (22/25). Overall median survival of 133 days was observed (range: 1–847 days). Conclusion Endovascular stenting of the SVC for malignant obstruction using the body floss technique is associated with high technical and clinical success, and low rate of complications.

Covered versus uncovered self-expandable metal stent for palliation of primary malignant extrahepatic biliary strictures: a randomized multicenter study

Self-expandable metal stents (SEMSs) are used to relieve malignant biliary obstructions. We aimed to compare stent patency, the adverse events rate, and overall survival of covered versus uncovered self-conformable metal stents in patients with primary malignant extrahepatic biliary strictures, not eligible for surgery. This is a multicenter randomized trial analyzing 158 patients with inoperable distal malignant biliary obstruction conducted in 5 Italian referral centers between December 2014 and October 2016. Seventy-eight patients were randomized to receive a fully covered SEMS (FCSEMS), and 80 patients received uncovered SEMSs (USEMSs). Data from 148 (72 FCSEMSs and 76 USEMSs) of 158 patients were analyzed. Median time of stent patency was lower for FCSEMSs (240 days vs 541 days for USEMSs; P= .031). Adverse events occurred with 19 FCSEMSs (26.4%) and 10 USEMSs (13.2%); P= .061. The main causes of FCSEMS dysfunction were migration (7% vs 0% in the USEMS group) and early occlusion mainly because of sludge or overgrowth; late stent occlusion because of tumor ingrowth occurred in 13.2% of patients in the USEMS group. There were no significant differences either in levels of conjugated bilirubin improvement or in overall survival between the FCSEMS and USEMS groups. Median survival was 134 days in the FCSEMS group and 112 days in the USEMS group (P= .23). The number of stent-related adverse events was higher, although not significantly, among patients in the FCSEMS group. FCSEMSs had a significantly higher rate of migration than USEMSs, and stent occlusion occurred earlier. A significant difference in the patency rate was observed in favor of the USEMS group. (Clinical trial registration number: NCT02102984.).

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients

To evaluate outcomes after endovascular treatment of patients with aneurysmal or occlusive vasculopathy in HIV-infected patients. Retrospective analysis of a prospective database of treatment outcomes in patients with HIV related vasculopathies between April 2005 and September 2015. Sixty HIV patients presented with post-traumatic pseudoaneurysm formation (n=7), aneurysmal disease (n=24) or occlusive disease (n=29 (48%)). The majority were male (42/60 (70%)), with a mean age of 43.9 years (SD±12.6). All seven patients with a post-traumatic pseudoaneurysm were treated by insertion of a covered stent (n=6) or coiling (n=1). All were successfully treated at 30 days, but only one patient returned for late surveillance. 23/24 patients who underwent insertion of a stent graft/covered stent for aneurysmal disease returned for 30 day review (one asymptomatic stent graft occlusion). Only 11 patients attended for late surveillance; 9/11 were asymptomatic with patent stent grafts. Late stent occlusion occurred in two (no further action (n=1), major limb amputation (n=1). In the 29 patients who underwent endovascular treatment for occlusive disease, 9 (31%) had immediate treatment failure (including 8 amputations (28%)). Of the sixteen who returned for serial review, 8 (50%) suffered further complications including 4 amputations. Overall, 12/29 treated patients (41%) ultimately underwent amputation. In the immediate short term, an 'endovascular first' strategy was associated with good outcomes in HIV patients with aneurysmal disease. By contrast, outcomes were poor in HIV patients with occlusive disease. Whether this relates to the underlying natural history of HIV occlusive vasculopathies remains unclear. One major problem in trying to formulate meaningful management strategies is a generalised reluctance for HIV patients to return for surveillance.

Loss of bifurcation patency after cross-over stenting of ostial lesions in superficial femoral artery: possible causes, prevention and reintervention

Crossover stenting across the origin of the profunda femoral artery (PFA) and occasionally into the common femoral artery (CFA) is commonly used after suboptimal balloon angioplasty of ostial occlusive lesions of the superficial femoral artery (SFA) involving the bifurcation. Late stent occlusion at the bifurcation is not rare and results in severe lower extremity ischemia. Therefore, we tried to assess its possible causes, prevention and reintervention. Using a prospectively maintained single-center database, 12-month femoral bifurcation patency was retrospectively compared and lesion and procedural predictors of stent occlusion were determined among 63 patients (64 lesions) who between July 2011 and February 2013 underwent crossover (36 non-jailed and 15 jailed SFA, and 12 distal and 1 complete CFA) stenting of de novo ostial SFA lesions. Twelve-month overall patency rate at the femoral bifurcation was 88%, with no significant difference between jailed-ostial SFA (80%) and distal CFA (67%) stenting (P = 0.731), and significant differences between either and non-jailed ostial stenting (100%, P = 0.035 and 0.002). When PFA ostium was jailed by the stent, patients with preexisting CFA or PFA lesions had a 12-month bifurcation patency rate of 20%, significantly lower than those with simple ostial SFA lesions (83%, P = 0.015). Stent induced intimal hyperplasia caused bifurcation occlusion in 6 surgical reintervention cases. In crossover stenting of ostial lesions in SFA, bifurcation patency loss was significantly higher in distal CFA and jailed ostial SFA stenting than non-jailed ostial SFA stenting. Preexisting CFA or PFA lesion is a significant risk factor for bifurcation patency loss when PFA ostium is jailed by crossover stenting.

Comparison of endosonography-guided vs. percutaneous biliary stenting when papilla is inaccessible for ERCP.

Endoscopic retrograde cholangiopancreatography (ERCP) and biliary stenting fails in 5-10% patients of malignant biliary obstruction because papilla is inaccessible. Percutaneous transhepatic biliary drainage (PTBD) is an accepted alternative. Endosonography-guided biliary drainage (EUS-BD) has been described recently. To compare success rates and complications of EUS-BD and PTBD internal stenting. This retrospective study included failed ERCP in inoperable malignant biliary obstruction due to inaccessible papilla undergoing PTBD or EUS-BD. Percutaneous transhepatic cholangiography guided/EUS-guided rendezvous procedures were excluded. When PTBD internal stenting failed, external drainage was performed. EUS-BD was performed using either intra- or extrahepatic approach, and stents were placed by transmural (choledocho-duodenostomy or hepatico-gastrostomy) or antegrade approach. Self-expandable metallic stents or plastic stents were placed in both groups. Success of internal stenting and complications were compared using t-test and chi-squared test. Retrospective review of 6 years of records (2005-2011) revealed 50 patients meeting the required criteria. EUS-BD was attempted in 25 and PTBD in 26 patients (one crossover from EUS-BD to PTBD). Internal stenting was technically and clinically successful in 23/25 (92%) EUS-BD vs. 12/26 (46%) PTBD (p < 0.05). External catheter drainage was performed in remaining 14 PTBD patients. Complications occurred in 5/25 (20%) EUS-BD (one major, four minor) and in 12/26 (46%) PTBD (four major, eight minor; p < 0.05). Late stent occlusion occurred in one EUS-BD and three PTBD. In this retrospective study comparing success and complications of EUS-BD and PTBD in patients with inoperable malignant biliary obstruction and inaccessible papilla, EUS-BD was found superior to PTBD for both comparators.

Late and very late coronary stent thrombosis: Intravascular ultrasound findings and associations with antiplatelet therapy

Late and very-late stent occlusion remains a serious complication of coronary stenting. Despite their high anti-restenotic efficacy, drug-eluting stents (DES) have been associated to more late-thrombosis as compared to bare-metal stents (BMS). The aim of this study is to analyze the clinical presentation, angiographic, and intravascular ultrasound (IVUS) findings in patients with late or very late stent thrombosis and the relationship with the antiplatelet regimen. Between January 2007 and December 2011, 34 consecutive patients with clinical syndromes compatible with late or very-late stent occlusion were studied with IVUS during emergency catheterization; 25 had DES and 9 had BMS. Thrombotic total occlusion was more common in DES (16 = 64%) than BMS patients (2 = 22%; P = 0.02) and ST-segment elevation myocardial infarction was the predominant clinical presentation in the former group (60% compared to 22%; P = 0.05). The time elapsed between implantation and failure was much longer in DES patients: 33 ± 22 versus 17 ± 14 months for BMS; P = 0.05. IVUS analysis showed a higher incidence of incomplete stent apposition (ISA) in the DES group compared to the BMS group (56% vs. 11%; P = 0.005) and in-stent plaque rupture was the most common finding in the BMS group (78%). In DES group, ISA was found more frequently in patients still under dual antiplatelet therapy (71%). Very late DES failure often causes ST-elevation myocardial infarction; these very late events may not correlate with the interruption of antiplatelet therapy. Severe, late acquired ISA belongs to DES and is frequently observed in patients with very late DES thrombosis.

ROLE OF ENDOSCOPIC STENTING FOR BILIARY STRICTURES IN CHRONIC PANCREATITIS

To review the published work concerning the role of biliary stenting for chronic pancreatitis-related strictures. A case study in which multiple plastic stents are used to manage a chronic pancreatitis biliary stricture is presented, and the published work reviewed. There has been a gradual evolution in the endoscopic management of distal biliary strictures secondary to chronic pancreatitis. Most early series used single (usually 10 F) plastic stents for varying time periods. Long-term stricture resolution occurred in only approximately 25% of patients and stent-related complications were high if stent exchanges were not performed routinely every 3-4 months. Recent studies using multiple (≥ 3) 10 F stents placed sequentially every few months for approximately 12 months have resulted in resolution of biliary strictures in up to 90% of patients. In general, the use of both uncovered and partially covered self-expandable metal stents for biliary strictures due to chronic pancreatitis have been disappointing due to problems with epithelial hyperplasia involving the uncovered portions of the self-expandable metal stents resulting in late stent occlusion and other problems. Similarly, early published data does not at this stage support the routine use of fully covered self-expandable metal stents because of unacceptable stent-related complications. Chronic pancreatitis-related biliary strictures should be managed initially with sequentially-placed multiple 10 F plastic stents for approximately 12 months.

Comparison of a Newly Designed Double-Layered Combination Covered Stent and D-Weave Uncovered Stent for Decompression of Obstructive Colorectal Cancer: A Prospective Multicenter Study

Stent reocclusion and migration are the most important complications after stent insertion. To overcome both problems, a double-layered combination covered stent was developed. Our purpose was to compare the efficacy and safety of the newly designed double-layered combination covered stent (Niti-S enteral colonic stent, Comvi type) and the double-wire woven uncovered stent (Niti-S enteral colonic stent, D-type) in the treatment of malignant colorectal obstructions. Sixty-eight patients with obstructive colorectal cancer underwent stent placement for preoperative decompression (n = 30) or palliative purpose (n = 38) at 6 medical centers. Combination covered stents were used in 31 patients and uncovered stents were used in 37 patients. There were no significant differences between both stents in terms of technical and clinical success rates. Regarding complications after stent insertion, there was no significant difference in early stent occlusion and migration rate between the combination covered stents and the uncovered stents. Despite a trend toward lower rates of late stent occlusion in the combination covered stent group, there was no significant difference in the rate of late stent occlusion by tumor ingrowth between the 2 groups (0% vs 20%, respectively; P = .107), and late stent migration occurred significantly more often with the combination covered stent (22.2% vs 0%, respectively; P = .041). However, we observed no significant difference in the overall late-complication rates and stent patency duration between the 2 groups. In our study, we could not prove that the newly designed double-layered combination covered stents have preventive advantages in stent migration compared with the uncovered stent.

Initial performance profile of a new 6F self-expanding metal stent for palliation of malignant hilar biliary obstruction

A 6F endoscopic biliary self-expanding metal stent (SEMS) has been newly introduced for intended simultaneous side-by-side bilateral deployment in hilar malignant obstruction. To report our initial experience with the Zilver 635 biliary SEMS. Retrospective chart review. Tertiary referral medical center. Sixteen consecutive malignant hilar biliary obstruction patients. Endoscopic palliative treatment of malignant biliary obstruction with the Zilver 635 SEMS from December 2008 to January 2010. Technical/functional success rates, early complications (within 30 days of stent placement), early/late stent occlusion, and biliary reintervention rates. A total of 49 Zilver SEMSs were placed in 16 patients (mean age 61 years, 6 men) for Bismuth type II (n = 4), III (n = 5), and IV (n = 7) lesions. Twelve had cholangiocarcinoma, 2 had metastatic colon cancer, 1 had lung cancer, and 1 had pancreatic cancer. The technical success rate was 100%. Side-by-side simultaneous bilateral stent deployment was required and was achieved successfully in 10 cases. Additional transpapillary stents were placed for potential future biliary access. The 30-day mortality rate was 0%. There were 1 early (6%) and 3 late (19%) stent occlusions. Successful overall biliary drainage was 75%. Small sample size, uncontrolled retrospective study. Malignant hilar biliary obstruction endoscopic palliation with the Zilver 635 SEMS offers acceptable initial feasibility, safety, and efficacy profiles. The current design facilitates smaller bile duct negotiation and more precise intrahepatic placement. Expanding available lengths would allow transpapillary bridged bilateral SEMS placement for future reobstructed biliary access. Further long-term studies are required for comparative outcomes with other current SEMS technology.

Expandable metal stents for endoscopic bilateral stent-within-stent placement for malignant hilar biliary obstruction

Placement of biliary stents is effective for palliation of unresectable hilar malignant biliary obstruction. However, when bilateral self-expandable metal stents (SEMSs) are used, placement can be technically challenging. In many studies, side-by-side placement is performed, although it is unclear whether this is the most anatomical and functional approach. We sought to assess the technical feasibility and effectiveness of deploying bilateral SEMSs with a stent-within-stent approach using commercially available stents with a large cell width. Retrospective study. Tertiary care medical center. Patients with malignant biliary hilar obstruction referred for endoscopic palliation of obstructive jaundice. Technical success, ie, successful bilateral SEMS placement across the stricture; functional success, ie, decrease in pretreatment bilirubin level; early and late complications; and stent patency. Bilateral biliary drainage was attempted and successfully established in 21 patients with malignant hilar obstruction (15 men, 6 women; mean age 63.7 [standard deviation 13.9] years), resulting in clinical improvement of obstructive symptoms. Median follow-up was 6.14 months (interquartile range 3.5-9.5 months). There were 1 (5%) early and 7 (33%) late stent occlusions that required endoscopic reintervention. The 30-day mortality rate was 10% (2 deaths). Retrospective study of a series of cases treated at a tertiary care center by expert endoscopists. This simple technique was performed by using an open-cell expandable metal stent is technically feasible and easy and allows bilateral placement of SEMSs in patients with unresectable hilar malignancy.

The Influence of Routine Duplex Scanning Surveillance on Outcome after Percutaneous Iliac Angioplasty and Stenting

Purpose We sought to determine the utility of noninvasive color-flow duplex imaging (CDI) in the detection of iliac artery stenoses or occlusions and correlate the findings of long-term color flow duplex surveillance (CFDS) to clinical outcome after percutaneous iliac interventions. Methods All patients undergoing percutaneous iliac angioplasty and stenting are prospectively entered in a surveillance protocol with CFDS and ankle-brachial indices (ABIs) performed within 6 weeks, 6 months, 12 months, and every year thereafter. Preprocedural ABI and peak systolic velocity (PSV) values were compared with postprocedural values with the Student t-test. Kaplan-Meier life-table analysis was used to estimate the patency rates. Results During the last 4 years, 80 patients with 112 treated iliac systems fulfilled the study criteria. A total of 68 patients (84%) had claudication, 8 (10%) had pain at rest, and 5 (6%) had a nonhealing ulcer or gangrene. The procedural success rate was 96.4%. Comparison of ABIs and PSV values before and after iliac intervention was statistically significant ( p &lt; 0.0001). Duplex scan allowed the detection and/or monitoring of abnormal velocities in 14 treated iliac arteries. Four cases (3.5%) required reintervention on previously treated iliac arteries for symptomatic restenosis and/or disease progression. Late stent occlusions were correctly identified in two cases. Primary patency, assisted primary patency, and secondary patency rates were 77%, 94%, and 96% at 4 years, respectively. Conclusion CFDS allows the detection of iliac artery stenoses and is a useful tool to identify restenosis after intervention. Because of the overall excellent patency rates observed with iliac angioplasty and stenting, CFDS surveillance in the absence of symptoms may not always be necessary and its long-term use should be individualized.

Angioplasty for the late stent thrombosis, the new technical challenge: A single centre experience

Late Angiographic Stent Thrombosis (LAST) following drug-eluting stent is quite a well recognised entity today with most reported cases having occurred following antiplatelet therapy withdrawal late after stent implantation. Angioplasty of these late thrombotic stent occlusions poses a new technical challenge quite different from usual native vessel thrombotic occlusions, an issue that has not been addressed at length primarily due to the limited numbers and stray nature of the reports. We herein report our experience with percutaneous intervention in five such cases of late stent thrombosis > 2 years following drug-eluting stent implantation from a single centre.

Intracranial Stenting in the Treatment of Wide-Necked Aneurysms

We positioned the following self-expanding stents certified for intracranial application: 16 Neuroform (Boston Scientific), three INX (Medtronic), one Leo (Balt). 6F calibre femoral introducers and guiding catheters were used for stent placement changing to 5F calibre introducers and guiding catheters (Envoy, Cordis) for the Neuroform 2 and 3 stents. All procedures were carried out under general anaesthesia and heparinization. Our pharmacological protocol consisted of adjunctive treatment with anti-aggregants during the interventional procedure and for the following six months, without premedication. From November 2000 to August 2006 we treated 28 patients (27 F/1M) with giant wide-necked aneurysms and one dissecting basilar artery aneurysm requiring the placement of 29 stents. We successfully positioned 20 stents: 11 stents combined with coils (8 immediate; 3 late) with complete exclusion of the aneurysm from the circulation in seven cases and subtotal exclusion in four; nine stents not followed by embolization with complete exclusion of the aneurysm from the circulation in six cases and subtotal exclusion in three. Stenting was not possible in nine cases due to extreme vessel tortuosity and the poor flexibility of release systems for the first stents. No late stent occlusion or subarachnoid haemorrhage were encountered after treatment.

The role of ERCP in patients with pancreatico-biliary problems in the setting of hematopoietic stem cell transplant

Patients undergoing hematopoietic stem cell transplant may develop pancreatico-biliary complications that may require ERCP. Due to their immunocompromised state, these patients may be at higher risk of procedure-related complications. To determine the role of ERCP in the diagnosis and treatment of patients who have undergone hematopoietic stem cell transplant and the patients' clinical outcomes. Retrospective analysis of patients with hematopoietic stem cell transplant who underwent ERCP from 1997 to 2004 evaluating ERCP indications, diagnosis, therapeutic interventions, and complications. Tertiary referral center. Of the 16 patients identified, 9 were female, 15 had had allogeneic hematopoietic stem cell transplant, and 1 had an autologous hematopoietic stem cell transplant. Twenty-six ERCP procedures were performed in the 16 patients. Index ERCP findings included: extra hepatic bile duct obstruction in 12 patients, of which 7 had biliary lithiasis. Ampullary obstruction due to infiltration from graft versus host disease was seen in 3 of 12 patients, benign bile duct stricture in 1 of 12, and ampullary obstruction in the setting of a peri-ampullary diverticulum in 1 of 12. Index ERCP findings in the remaining 4 patients included: intrahepatic bile duct compression due to metastatic disease in 1 of 16 patients, bile duct leak in 1 of 16, pancreatic duct stone in 1 of 16, and normal ERCP in 1 of 16. Complications occurred in 4 patients: mild pancreatitis (1), mild bleeding (1), cholangitis due to late stent occlusion (1), and intermittent bradycardia (1). There were no ERCP-related deaths. Single-center study. In patients with hematopoietic stem cell transplant, bile duct lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to graft versus host disease. ERCP yielded clinically relevant information in this particular group of patients.

Mechanisms of Biliary Stent Clogging: Confocal Laser Scanning and Scanning Electron Microscopy

Endoscopic insertion of plastic biliary endoprostheses is a well-established treatment for obstructive jaundice. The major limitation of this technique is late stent occlusion. In order to compare events involved in biliary stent clogging and identify the distribution of bacteria in unblocked stents, confocal laser scanning (CLS) and scanning electron microscopy (SEM) were carried out on two different stent materials - polyethylene (PE) and hydrophilic polymer-coated polyurethane (HCPC). Ten consecutive patients with postoperative benign biliary strictures were included in the study. Two 10-Fr stents 9 cm in length, one made of PE and the other of HCPC, were inserted. The stents were electively exchanged after 3 months and examined using CLS and SEM. No differences were seen between the two types of stent. The inner stent surface was covered with a uniform amorphous layer. On top of this layer, a biofilm of living and dead bacteria was found, which in most cases was unstructured. The lumen was filled with free-floating colonies of bacteria and crystals, surrounded by mobile laminar structures of mucus. An open network of large dietary fibers was seen in all of the stents. The same clogging events occurred in both PE and HCPC stents. The most remarkable observation was the identification of networks of large dietary fibers, resulting from duodenal reflux, acting as a filter. The build-up of this intraluminal framework of dietary fibers appears to be a major factor contributing to the multifactorial process of stent clogging.

Efficacy and complications of covered Wallstents in malignant distal biliary obstruction

This study evaluated the efficacy and the complications associated with the use of the covered Wallstent in the setting of unresectable malignant biliary obstruction. Between March 2001 and January 2003, all patients with distal malignant biliary obstruction that required drainage were treated with a covered Wallstent. Every 2 months, the patients were evaluated clinically and biochemical tests of liver function were obtained. Data were recorded for the following variables: early complications (within 30 days of stent placement), early and late stent occlusion, duration of stent patency, need for subsequent biliary intervention, and patient survival. A total of 88 covered Wallstents were inserted in 80 patients. Stent patency rates at 3, 6, and 12 months were 90%, 82%, and 78%, respectively. Complications included stent migration (5), stent occlusion (12), episodes of cholecystitis (3), and episodes of post-ERCP pancreatitis (5). Biliary intervention was required in 9 patients subsequent to placement of the initial covered Wallstent. Deployment of a covered Wallstent is safe and relatively easy. It achieves biliary drainage with an acceptable risk to benefit ratio in the majority of patients with distal malignant biliary obstruction.

Role of ERCP in Patients with Pancreatico-Biliary (PB) Disease in the Setting of Hematopoietic Stem Cell Transplant (HSCT)

Background: Patients (pts) undergoing HSCT may develop PB complications that may need to be evaluated by ERCP. These pts are immunocompromised and may be at higher risk of procedure related complication than average risk pts. Surprisingly, few data have been published regarding ERCP findings/benefits/risks in this population. Aim: To determine the role of ERCP in the diagnosis, treatment, and outcome ERCP in the setting of HSCT. Materials &Methods: Retrospective analysis of HSCT pts who underwent ERCP from 1997-2004. We examined ERCP indications, diagnosis, therapeutic interventions, and complication rates. Results: Of the pts who received HSCT, 16 pts (7M/9F) were identified who had undergone ERCP; 15/16 had allogeneic HSCT & 1/16 had autologous HSCT. Indications for HSCT were: AML (6),CML (3), ALL (1), NHL (2), myeloma (1), met breast ca (2). 26 ERCP procedures were performed in these 16 pts. 10/16 pts were >100days post HSCT. 8/26 had a platelet count< 50x103/L. ERCP indications: obstructive jaundice (4); possible ascending cholangitis (7); post cholecystectomy bile leak (1); relapsing pancreatitis (4).ERCP Findings were: BD lithiasis (7), Ampullary infiltration from GVHD (3), BD stricture(1), BD leak (1),cholangitis (1), Mirrizzi (1), PD stone (1), normal (1). ERCP interventions were: BD sphincterotomy (8), BD lithiasis removal (11), BD stents (13), NB tube(4), PD stent for drainage(1), prophylactic temporary PD mini stents (6), Transpapillary endoscopic GB drain (2). Complications occurred in 3 pts: bleed (1), cholangitis due to late stent occlusion (1), mild pancreatits (1). No deaths. Conclusion: In patients with HSCT, BD lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to GVHD. ERCP was safe and successful in this population. Background: Patients (pts) undergoing HSCT may develop PB complications that may need to be evaluated by ERCP. These pts are immunocompromised and may be at higher risk of procedure related complication than average risk pts. Surprisingly, few data have been published regarding ERCP findings/benefits/risks in this population. Aim: To determine the role of ERCP in the diagnosis, treatment, and outcome ERCP in the setting of HSCT. Materials &Methods: Retrospective analysis of HSCT pts who underwent ERCP from 1997-2004. We examined ERCP indications, diagnosis, therapeutic interventions, and complication rates. Results: Of the pts who received HSCT, 16 pts (7M/9F) were identified who had undergone ERCP; 15/16 had allogeneic HSCT & 1/16 had autologous HSCT. Indications for HSCT were: AML (6),CML (3), ALL (1), NHL (2), myeloma (1), met breast ca (2). 26 ERCP procedures were performed in these 16 pts. 10/16 pts were >100days post HSCT. 8/26 had a platelet count< 50x103/L. ERCP indications: obstructive jaundice (4); possible ascending cholangitis (7); post cholecystectomy bile leak (1); relapsing pancreatitis (4).ERCP Findings were: BD lithiasis (7), Ampullary infiltration from GVHD (3), BD stricture(1), BD leak (1),cholangitis (1), Mirrizzi (1), PD stone (1), normal (1). ERCP interventions were: BD sphincterotomy (8), BD lithiasis removal (11), BD stents (13), NB tube(4), PD stent for drainage(1), prophylactic temporary PD mini stents (6), Transpapillary endoscopic GB drain (2). Complications occurred in 3 pts: bleed (1), cholangitis due to late stent occlusion (1), mild pancreatits (1). No deaths. Conclusion: In patients with HSCT, BD lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to GVHD. ERCP was safe and successful in this population.

Utilization of EUS for Endoscopic Drainage of Pancreatic Pseudocysts: Results of a National and an International Survey

Utilization of EUS for Endoscopic Drainage of Pancreatic Pseudocysts: Results of a National and an International Survey Tony E. Yusuf, Todd H. Baron Introduction: Pancreatic pseudocysts are a type of pancreatic fluid collection that can complicate acute and chronic pancreatitis. Pancreatic pseudocysts can be drained endoscopically via the transpapillary or the transmural (transgastric or transduodenal) routes. Aim: The aim of this study was to assess the endoscopic approach and techniques of pancreatic pseudocyst drainage as performed by endoscopists in the United States and internationally. Methods: A web-based survey was designed to assess the type of practice and the endoscopic techniques used in drainage of pancreatic pseudocysts. Questions that addressed imaging modalities used prior to or during drainage were included. An initial electronic message with a link to the web survey followed by a reminder message was sent to endoscopists in the United States and internationally. E-mail addressees were obtained from the ASGE membership directory. Results: The survey was sent to 3,054 endoscopists of whom 266 (8.7%) replied. Of the responders, 198 performed endoscopic drainage of pancreatic pseudocysts. Each endoscopist performed a mean of 69 cases (range, 1-364 cases). The transgastric route was the most commonly used drainage route (98%) versus transduodenal (72%). Transmural entry was performed using a needle knife in 53% of the non EUS-guided transmural drainage. The number of stents placed was 1-4 stents for a period of 2-24 weeks. Imaging studies to guide drainage included CT scan alone (60%) or in combination with other radiographic imaging (35%). EUS imaging was used prior to drainage by 72 of 103 (70%) endoscopists in the US compared to 56 of 95 (59%) international endoscopists (pZ0.1). EUSguided drainage was used by 56% of endoscopists in the US compared to 43% international endoscopists (pZ0.06). Conclusions: The transgastric route is the most common route for transmural endoscopic drainage of pancreatic pseudocysts. Computed tomography is the most commonly used pre-drainage imaging modality. The majority of endoscopists in both the US and abroad utilize EUS prior to and during transmural drainage of pancreatic pseudocysts. The practice of EUS prior to drainage is not significantly different among endoscopist in the United States and internationally. T1226 Role of ERCP in Patients with Pancreatico-Biliary (PB) Disease in the Setting of Hematopoietic Stem Cell Transplant (HSCT) Majed Al Nusair, Margarida C. de Magalhaes-Silverman, William B. Silverman Background: Patients (pts) undergoing HSCT may develop PB complications that may need to be evaluated by ERCP. These pts are immunocompromised and may be at higher risk of procedure related complication than average risk pts. Surprisingly, few data have been published regarding ERCP findings/benefits/risks in this population. Aim: To determine the role of ERCP in the diagnosis, treatment, and outcome ERCP in the setting of HSCT. Materials M 15/ 16 had allogeneic HSCT & 1/16 had autologous HSCT. Indications for HSCTwere: AML (6),CML (3), ALL (1), NHL (2), myeloma (1), met breast ca (2). 26 ERCP procedures were performed in these 16 pts. 10/16 pts were O100days post HSCT. 8/26 had a platelet count! 50x103/L. ERCP indications: obstructive jaundice (4); possible ascending cholangitis (7); post cholecystectomy bile leak (1); relapsing pancreatitis (4).ERCP Findings were: BD lithiasis (7), Ampullary infiltration from GVHD (3), BD stricture(1), BD leak (1),cholangitis (1), Mirrizzi (1), PD stone (1), normal (1). ERCP interventions were: BD sphincterotomy (8), BD lithiasis removal (11), BD stents (13), NB tube(4), PD stent for drainage(1), prophylactic temporary PD mini stents (6), Transpapillary endoscopic GB drain (2). Complications occurred in 3 pts: bleed (1), cholangitis due to late stent occlusion (1), mild pancreatits (1). No deaths. Conclusion: In patients with HSCT, BD lithiasis was the most common finding at ERCP, followed by obstructive ampullary tissue infiltration due to GVHD. ERCP was safe and successful in this population.

Optimal Duration of Antiplatelet Therapy in Recipients of Coronary Drug-Eluting Stents

Four weeks' therapy with clopidogrel, in addition to aspirin (acetylsalicylic acid), is currently standard care after percutaneous coronary intervention (PCI) with stent implantation. The recent availability of drug-eluting stents (DES), which dramatically reduce restenosis at the site of PCI, has again raised the issue of stent thrombosis. In clinical trials, the risk of stent thrombosis appeared unrelated to the presence of the drug eluting from the stent and was documented within the usual range of < or =1% at 9 months after DES implantation. However, these devices feature delayed strut endothelialisation and there are reports describing late DES thrombosis up to 18 months after PCI, in most cases after clopidogrel has been discontinued. Although infrequent after bare-metal stenting (0.4-2.8%), stent thrombosis is a catastrophic event. Before DES availability, adjunctive intravascular brachytherapy significantly reduced in-stent neointimal proliferation, at the price of a higher-than-expected rate of late stent occlusion (6-8%). In such setting, a 12-month aspirin plus clopidogrel regimen showed a beneficial effect on long-term adverse events. An additional consideration is that, among patients undergoing bare-metal stent PCI, combined antithrombotic therapy with aspirin and clopidogrel has been recently associated with favourable effects on cardiovascular outcome beyond stent thrombosis in two large-scale clinical trials. Therefore, we propose that prolonged combination therapy with aspirin and clopidogrel be mandatory up to 1 year after PCI in all patients receiving DES.

Unilateral placement of metallic stents for malignant hilar obstruction: A prospective study

Background: Palliation of patients with malignant hilar stenoses, especially advanced lesions, by stent insertion poses particular difficulties. This study assessed the efficacy of endoscopically inserted unilateral metallic stents for complex malignant hilar obstruction. Methods: A prospective, uncontrolled, single-center study was conducted by using a cohort of 61 patients with malignant hilar obstruction. A single, unilateral metallic stent was inserted across the stricture into the duct that technically was easiest to access. Patients were evaluated 1 month after stent placement and, thereafter, every 3 months. Results: Successful stent insertion was achieved in 59 of 61 (96.7%) patients. In 3 of 61 (4.9%) cases, stent malfunction occurred. Successful drainage was achieved in 59 of 61 (96.7%) patients and complete resolution of jaundice in 86% of cases. Early complications included cholangitis in 3 of 61 (4.9%) patients and stent occlusion in 2 of 61 (3.2%). Late stent occlusion occurred in 14 of 61 (22.9%) patients, including 10 (16.3%) cases of cholangitis and one of liver abscess. Median stent patency was 169 days. Median patient survival was 140 days. Conclusions: Unilateral metallic stent insertion is safe, feasible, and achieves adequate drainage in the great majority of patients with nonresectable hilar cholangiocarcinoma. (Gastrointest Endosc 2003;58:50-3.)