Longer Stent Research Articles

Timing of Iliofemoral Vein Stent Implantation after Mechanical Thrombectomy for Acute Iliofemoral Venous Thrombosis.

Comparison of the treatment effects of immediate stent implantation vs staged stent implantation after AngioJet mechanical thrombectomy in patients with acute iliofemoral venous thrombosis. A study included 80 patients with acute iliofemoral venous thrombosis formed between June 2021 and February 2023. They were divided into two groups: the direct implantation group (37 patients, 9 males) and the staged implantation group (43 patients, 10 males). Venous angiography and Villata scoring were used to assess patency rates and the occurrence of post-thrombotic syndrome (PTS). A one-year follow-up was conducted and a multiple-factor Cox regression model was used to analyze the clinical factors affecting patency rates. Surgery was successfully completed without serious complications or deaths during follow-up. The direct implantation group had significantly shorter hospital stays and surgical times compared to the staged implantation group (p < 0.001). Both groups showed a decrease in Villata scores (p < 0.001), and the direct group had higher scores than the staged group at 12 months post-surgery (p < 0.001). One year after the procedure, there was no significant difference in stent patency rates (p = 0.658), but postoperative scores at one month (p = 0.012) and stent length (p = 0.015) had a significant impact. For acute iliofemoral venous thrombosis, both direct stent implantation and staged implantation are effective. The direct implantation procedure has shorter hospital stays and surgical times, while staged implantation has a lower long-term risk of post-thrombotic syndrome (PTS). Villata scores at one month after surgery can predict the risk of vascular obstruction. Longer stents may reduce the risk of postoperative obstruction.

Changes of coronary blood flow before and after post-dilation following primary percutaneous coronary intervention in patients with STEMI.

This retrospective cohort study aimed to examine changes in coronary blood flow before and after post-dilation following primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI). 419 eligible patients who underwent PPCI due to STEMI between January 2019 and September 2023 were enrolled. The corrected thrombolysis in myocardial infarction frame count (CTFC), final quantitative coronary angiography, and the incidence of no-reflow and slow-flow during different procedure moments were assayed. The changes in coronary blood flow before and after post-dilation in the post-dilation group were analyzed. Among the 419 patients enrolled, 259 patients underwent post-dilation. The post-dilation procedure was more frequently performed in patients with calcium plaque present, longer stents, bigger-diameter stents, and overlapping stents. The incidence of final no-reflow and slow-flow in the post-dilation group was not significantly higher than that observed in the non-post-dilation group. In contrast post-dilation patients had significantly increased CTFC values by 3.54 ± 10.54 frames (P < .001) and the rate of no-reflow/slow-flow increased on average by 114% (P < .001) in comparison to patients not undergoing post-dilation. The receiver operating characteristic curve showed that if post-dilation was performed in patients when their after-stent CTFC was smaller than 23.25, no-reflow/slow-flow was less likely to occur (63.5% sensitivity, 88.8% specificity, [AUC]: 0.817, 95% CI: 0.749-0.886, P < .001). Post-dilation exacerbates the coronary blood flow and increases the incidence of no-reflow/slow-flow during PPCI for STEMI patients, except where after-stend CTFC values were <23.25.

Elucidating the hemodynamic impact of residual stenosis post-carotid artery stenting: A numerical study.

Residual stenosis (RS) and hemodynamics demonstrate a significant correlation with postoperative in-stent restenosis/thrombosis following carotid artery stenting (CAS). This study endeavors to elucidate the potential associations between RS and adverse postoperative hemodynamic factors. This study utilized 46 patient-specific carotid artery models post-stenting, which were categorized into two groups based on the presence of RS: the normal group (N, n=23) and the RS group (RS, n=23). A comparative analysis was conducted to evaluate the discrepancies in geometry and adverse hemodynamic parameters, alongside investigating the potential correlation between hemodynamic and geometric parameters. The results reveal that a higher reflux flow volume is discernible in the RS group during low-velocity phases of the cardiac cycle, concomitant with an augmented extent of areas exposed to oscillatory shear stress and extended particle residence time. Moreover, the adverse hemodynamic parameters exhibit a positive correlation with the degree of stent expansion, stent length in the common carotid artery (CCA), and the distal slope of the RS. The distal slope and tortuosity of RS significantly influence the development of adverse hemodynamic conditions post-stenting, exacerbating the hemodynamic environment near the stenosis. Interestingly, while an extended stent length in the internal carotid artery (ICA) region improves hemodynamics by reducing flow disturbance, a longer stent in the CCA significantly worsens these conditions. Hence, it is prudent to analyze the characteristics of the local lesion regions to optimize the strategy for stent implantation.

Abstract 12711: Stent Length as a Predictor of Target Vessel Revascularization in Patients Treated With Drug-Eluting Stents

Background: While several factors have been shown to increase the risk of stent thrombosis, most cases of target vessel revascularization (TVR) are due to in-stent restenosis (ISR) and have not been fully evaluated. Objectives: Our aims were to identify predictors of early and late TVR after drug-eluting stents (DES) implantation in a large prospective registry, focusing on stent length. Methods and Results: We analyzed rates of TVR according to stent length in a prospective registry of 14,447 all-comers treated with angioplasty and DES implantation in our institution. Patients were divided into quartiles according to stent length - mean 21mm - percentile 25 (Q1) 15mm, 50 (Q2) 18mm, 75 (Q3) 26mm and 100 (Q4) 32mm. At baseline patients had similar rates of diabetes mellitus, congestive heart failure and left ventricular ejection fraction. Patients in the first quartile tend to be older, more commonly of female gender, with higher rates of GFR&lt;60, anemia, and unprotected LM angioplasty. At 4 years follow-up, rates of TVR and MACE were higher in patients with longer stents; 8.5%, 9.8%, 10.4% and 16.1% (p&lt;0.001) and 25.3%, 26.6%, 27% and 28.4% (p=0.031); for TVR and MACE in Q1, Q2, Q3 and Q4 groups of patients; respectively. There were no significant differences in the rates of all-cause death amongst patients in different quartiles. Furthermore, at multivariate Cox-regression analysis length of stent was found to be a significant independent predictor for TVR (OR 1.25 95.0% CI 1.11 - 1.42; p&lt;0.001). Conclusion: From the analysis of a large cohort of all-comer angioplasty patients who were treated with DES, stent length emerged as an independent predictor of TVR and MACE.

Clinical and Procedural Outcomes of IVUS-Guided vs. Angiography-Guided CTO-PCI: A Systematic Review and Meta-Analysis.

Chronic total occlusions (CTO) in coronary angiographies present a significant challenge nowadays. Intravascular ultrasound (IVUS) is a valuable tool during CTO-PCI, aiding in planning and achieving procedural success. However, the impact of IVUS on clinical and procedural outcomes in CTO-PCI remains uncertain. This meta-analysis aimed to compare IVUS-guided and angiography-guided approaches in CTO-PCI. The study included five studies and 2320 patients with stable coronary artery disease (CAD) and CTO. The primary outcome of major adverse cardiac events (MACE) did not significantly differ between the groups (p = 0.40). Stent thrombosis was the only secondary clinical outcome that showed a significant difference, favoring the IVUS-guided approach (p = 0.01). Procedural outcomes revealed that IVUS-guided procedures had longer stents, larger diameters, and longer procedure and fluoroscopy times (p = 0.007, p < 0.001, p = 0.03, p = 0.002, respectively). Stent number and contrast volume did not significantly differ between the approaches (p = 0.88 and p = 0.33, respectively). In summary, routine IVUS use did not significantly improve clinical outcomes, except for reducing stent thrombosis. Decisions in CTO-PCI should be individualized based on patient characteristics and supported by a multi-parametric approach.

Removal of Duckbill-type laser-cut anti-reflux metal stents: Clinical evaluation and in vitro study.

Duckbill-type metal stent (DMS) was the first laser-cut biliary metal stent with an anti-reflux valve. Removal of DMS is believed to be difficult and relevant reports are scarce. This study aims to investigate the feasibility of DMS removal. We retrospectively analyzed patients who underwent DMS removal between June 2019 and March 2022 to evaluate success rates and factors affecting outcomes. In addition, six different methods of DMS removal were reproduced in vitro, varying removal devices, angle of applied force, and grasped location. Extraction resistance, the distance of forceps stroke, and stent length after removal were compared. Forty patients were enrolled, and DMS removal was successful in 31 cases (78%). No adverse events were observed. Tumor ingrowth was evident in 78% (7/9) of failed cases. Patients receiving biliary metal stents for the first time (naïve cases), long indwelling time, longer stent, and stent tearing during removal were associated with unsuccessful stent removal. In the in vitro study, a larger force was required to remove the stent at an extraction angle of 120° than at 0°. Among cases in which force was applied at 120°, the load tended to be lower when rat-tooth forceps were applied horizontally across the stent. Stent removal was possible in a majority of cases. Deployment of additional stents inside DMS may be preferable to forceful removal in the presence of factors associated with difficult stent removals, such as tumor ingrowth, naïve cases, longer stents, long indwelling time, and stent tearing during removal.

Long term clinical outcome after success re-attempt percutaneous coronary intervention of chronic total occlusion

BackgroundTo evaluate the long-term outcome after re-attempt CTO-PCI.MethodsThis is a retrospective cohort study that included 113 re-attempt CTO-PCI patients who were consecutively registered from January 2019 to December 2020 at Beijing Anzhen Hospital's Center of Coronary Artery Disease. All patients were divided into two groups based on procedural success or failure. The primary endpoint was major adverse cardiac events (MACE), a composite of all-cause mortality, myocardial infarction and target vessel revascularization (TVR). The secondary endpoint was angina after PCI.ResultsOverall, the successful re-attempt CTO-PCI was archived in 77 patients, the failed CTO-PCI was performed in 36 patients. After a median follow-up of 21.7 months (interquartile range: 10.9–26.0), the incidence of the primary outcome was significantly lower in the success group [14.2% vs. 38.9%, adjusted hazard ratio (HR) 0.351, 95% CI 0.134–0.917, P = 0.033], mainly driven by the reduction of TVR (9.1% vs. 30.6%, adjusted HR 0.238, 95% CI: 0.078–0.72, P = 0.011). Furthermore, patients who had successful re-attempt CTO-PCI had a lower risk of angina after PCI (27.3% vs.61.1%, adjusted HR 0.357, 95% CI 0.167–0.76, P = 0.008). The risk factors of TVR in the patients with successful re-attempt CTO-PCI were stent length > 100 mm (adjusted HR 21.805, 95% CI 1.765–269.368, P = 0.016) and J-CTO score > 3(adjusted HR: 9.733, 95% CI:1.533–61.797, P = 0.016).ConclusionsFor the patients with previous CTO-PCI failure, a successful re-attempt CTO-PCI was associated with significantly lower MACE, which was primarily driven by a lower TVR rate. More complex CTO lesions and longer stents were the independent predictors of TVR after successful CTO-PCI.

Real-world intravascular ultrasound (IVUS) use in percutaneous intervention-naïve patients is determined predominantly by operator, patient, and lesion characteristics

Intravascular Ultrasound (IVUS) has been shown to improve clinical outcomes in patients undergoing percutaneous intervention (PCI) in numerous trials. However, it is still underutilized outside of trial settings, and most trials include a significant proportion of patients with prior PCI. The aim of this study is to look at real-world use and outcomes in PCI-naïve patients who undergo IVUS-guided intervention. Prospectively collected data from 10,574 consecutive patients undergoing their index PCI was retrospectively analyzed. 455 (4.3%) patients underwent IVUS, with a median follow-up of 4.6 years. Patients undergoing IVUS had higher levels of comorbidities including diabetes (27.5% vs. 19.7%, p < 0.001), hypertension (58.0% vs. 47.9%, p < 0.001), hypercholesterolemia (51.6% vs. 39.2%, p < 0.001) and were generally older (65.9 ± 14.5 vs. 64.5 ± 13.4 years, p = 0.031) with higher mean baseline creatinine levels (95.4 ± 63.3 vs. 87.8 ± 46.1 μmol/L). The strongest predictor of IVUS use was the operating consultant graduating from medical school after the year 2000 [OR 14.5 (3.5-59.8), p < 0.001] and the presence of calcific lesions [OR 5.2 (3.4-8.0) p < 0.001]. There was no significant difference in MACE nor 1-year mortality between patients undergoing IVUS-guided or angiography-only PCI on unadjusted analysis [OR 1.04 (0.73-1.5), p = 0.81, OR 1.055 (0.65-1.71) p = 0.828] nor mortality throughout the study period (HR 0.93 (0.69-1.26), p = 0.638). This held true for stents longer than 28 mm. Propensity matched analysis of patients similarly showed no mortality difference between arms for all patients and those with longer stents (p = 0.564 and p = 0.919). The strongest predictors of IVUS use in PCI-naïve patients are the operator's year of graduation from medical school and proxy measures of calcific lesions. On both matched and adjusted analysis there was no evidence of improved mortality nor reduced MACE in this specific retrospective cohort, although this may well be explained by significant selection bias.

Suboptimal coronary flow after PCI in STEMI patients: clinical implications and predictors

Abstract Background Even in experienced angioplasty centers, percutaneous coronary intervention (PCI) in the acute setting of ST-elevation myocardial infarctions (STEMI) is associated with a low, but still significant rate of suboptimal coronary flow. Identification of its clinical impact and potential modifiable risk factors is important. Purpose To evaluate the clinical impact of suboptimal coronary flow after PCI in STEMI patients and to access potential predictors of suboptimal coronary flow. Methods We retrospectively evaluated 103 hospitalized patients with acute STEMI who were admitted to our center between 2018 and 2019 and underwent PCI. Coronary flow was accessed using the Thrombolysis in myocardial infarction (TIMI) Flow Grading System. Patients were divided into suboptimal patency of the culprit-vessel, defined as TIMI flow ≤2 (group 1, n=8 (7,8%)) and optimal patency of the culprit-vessel defined as TIMI flow 3 (group 2, n=95 (92,2%)). Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. Results Mean age 58,15±12,6 years and 85,4% were males. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes, 17 (15,5%) were obese and 4 (3,9%) had chronic kidney disease. The revascularization strategy was primary PCI in 55 (54,4%) patients and fibrinolytic therapy with facilitated PCI in 48 (46,6%) patients. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). Angiographic no-reflow after PCI was 3,0%. Intrahospital cardiovascular death occurred in 4 (3,9%) patients and was significantly associated with suboptimal flow (p=0,036) and there was no association with stent thrombosis. Predictors of suboptimal flow were higher blood urea nitrogen, creatinine and GFR at hospital admission (p=0,017 and p=0,012), peak creatinine (p=0,012) and stent length (p=0,038). Suboptimal flow was associated with higher Zwolle score (p=0,010) and ischemic Paris score (p=0,036). Conclusion Failure to achieve optimal culprit-vessel patency after PCI in STEMI patients, although infrequent, is associated with increased hospital cardiovascular death. Longer stents could be and important modified risk factor. Renal dysfunction is an important comorbidity that should be promptly identified and could be partially improved with medical treatment. Funding Acknowledgement Type of funding sources: None.

Stent fractures in the superficial femoral artery: predisposing factors and their implications.

BackgroundFractures in stents implanted in the superficial femoral artery (SFA) are recognized complications of endovascular management of this arterial territory.ObjectivesThe objective of this study was to determine the prevalence of fractures in stents implanted in the SFA and to identify predisposing factors for these fractures together with their impact on the patency of these devices.MethodsThe study included 39 patients (65.7±9.0 years) who previously underwent angioplasty for delivery of 56 stents into the SFA. During follow-up, which ranged from 7 to 46 months, variables were collected on the characteristics of the lesions treated and characteristics of the stents implanted. Two examiners independently analyzed digital radiographs for the presence of stent fractures and the patency of the devices.ResultsWe found a 10.7% prevalence of fracture of implanted stents. Implantation of multiple stents was identified as a significant predisposing factor for fractures. We observed a marked tendency for fractures in female patients and in lesions treated with longer stents (> 150 mm). Stenosis exceeding 50% and occlusions were significantly more frequent in fractured stents.ConclusionsThis study suggests that implants longer than 150 mm and multiple stents are associated with higher device fracture rates. In cases with stent fractures, stenoses exceeding 50% and occlusions were significantly more frequent.

Impact of Target Visceral Vessel Anatomical Configuration on Early Complications Following Endovascular Repair of Thoracoabdominal Aortic Aneurysms

Fenestrated and branched endovascular aortic repair (fEVAR-bEVAR) is a viable treatment option for thoracoabdominal aortic aneurysms but target visceral stent (TVS) endoleak and thrombosis remain a limiting factor. This study aims to evaluate TVS anatomy impact on 1-year risk of thrombosis and endoleak. Patients treated with fEVAR-bEVAR for thoracoabdominal aneurysms between 2008 and 2020 in our centre were enrolled. We recorded comorbidities, operative details, 1-month postoperative CT scan (anatomical reference), and TVS behaviour: thrombosis and endoleak at 1-year follow-up. For each TVS, different points were identified using a centre-lumen-line: (A) TVS origin, (B) end of branch/fenestration, (C) visceral vessel entry, (D) end of TVS, (E) 1-cm distally. We analyzed TVS tortuosity ((centre-lumen-line/straight distance)-1, in %), image vector analysis of each segment in 2D (antero-posterior, left-right) and 3D (craneo-caudal displacement), and centre-lumen-line analysis (bending in ABC and CDE). Three independent observers performed a blind analysis, and anatomical differences between bEVAR/fEVAR, and cases with/without 1-year thrombosis and TVS endoleak, were compared using Kaplan-Meier curves (Log-Rank test), and t-test/Wilcoxon signed-ranks test respectively. Fifty-four patients (72 ± 713 years mean age; 182 TVS: 50 branches, 132 fenestrations) met the inclusion criteria. bEVAR cases had longer stents, with more caudal 3D angulation, and greater ABC angulated segment. After excluding bEVAR cases (low case number), 97 fEVAR TVS were analyzed. Five thrombosis and 7 endoleaks were observed. While anatomical configuration showed no association to thrombosis, it was related to endoleak: these cases presented more tortuous stents (5.97% ± 0.10, 21.40% ± 0,22, P=0.011), with more angulated centre-lumen-line at ABC segment (5.69° ± 15.77°, 7.18° ± 7.77°, P=0.012), and more upward-pointing stents in the origin of the stent (AB: 89.07° ± 24.46°, 109.09° ± 16.56°, P=0.012; BC: 87.86° ± 21.10°, 113.11° ± 22.23°, P=0.026). Anatomical configuration of the TVS is associated with type III endoleak, but not thrombosis, at 1-year following fEVAR. Cases with endoleak presented more tortuous stents, with a more angulated exit from the endograft, and upward-pointing of the origin of the stent.

Clinical Impact of Intraprocedural Stent Thrombosis During Percutaneous Coronary Intervention in Patients Treated With Potent P2Y12 inhibitors - a VALIDATE-SWEDEHEART Substudy.

BackgroundThe clinical importance of intraprocedural stent thrombosis (IPST) during percutaneous coronary intervention in the contemporary era of potent oral P2Y12 inhibitors is not established. The aim of this study was to assess IPST and its association with clinical outcome in patients with myocardial infarction undergoing percutaneous coronary intervention with contemporary antithrombotic medications.Methods and ResultsThe VALIDATE‐SWEDEHEART study (Bivalirudin Versus Heparin in ST‐Segment and Non–ST‐Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies Registry Trial) included 6006 patients with myocardial infarction, treated with potent P2Y12 inhibitors during percutaneous coronary intervention. IPST, defined as a new or worsening thrombus related to a stent deployed during the procedure, was reported by the interventional cardiologist in 55 patients (0.9%) and was significantly associated with ST‐segment elevation myocardial infarction presentation, longer stents, bailout glycoprotein IIb/IIIa inhibitors, and final Thrombolysis in Myocardial Infarction flow <3. The primary composite end point included cardiovascular death, myocardial infarction, out‐of‐laboratory definite stent thrombosis and target vessel revascularization within 30 days. Secondary end points were major bleeding and the individual components of the primary composite end point. Patients with versus without IPST had significantly higher rates of the primary composite end point (20.0% versus 4.4%), including higher rates of cardiovascular death, target vessel revascularization, and definite stent thrombosis, but not myocardial infarction or major bleeding. By multivariable analysis, IPST was independently associated with the primary composite end point (hazard ratio, 3.82; 95% CI, 2.05–7.12; P<0.001).ConclusionsIPST is a rare but dangerous complication during percutaneous coronary intervention, independently associated with poor prognosis, even in the current era of potent antiplatelet agents. Future treatment studies are needed to reduce the rate of IPST and to improve the poor outcome among these patients.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT02311231.

Risk factors associated with intra-stent restenosis after percutaneous coronary intervention.

The present study aimed to explore the correlations between clinical, biological, imagistic and procedural factors with the risk of intra-stent restenosis (ISR) in coronary artery disease (CAD) patients after percutaneous coronary intervention (PCI). An observational cross-sectional study was conducted in a high-volume PCI center over a period of 2 years. A total of 235 consecutive patients diagnosed with angina or acute coronary syndrome treated by PCI were included in the study. Diagnosis of ISR was documented by coronary angiography in patients with suggestive coronary symptoms and ischemic changes in non-invasive or invasive paraclinical investigations. Thus, they were assigned to two groups: With or without ISR. All patients underwent clinical and laboratory examination, providing clinical and paraclinical variables that could be considered risk factors for ISR. Current smokers [risk ratio (RR)=1.63; 95% confidence interval (95% CI): 1.25-2.13], arterial hypertension (RR=1.86; 95% CI: 1.41-2.45), diabetes (RR=1.83; 95% CI: 1.42-2.36), high C-reactive protein (CRP) levels (RR=1.44; 95% CI: 0.93-2.24), chronic kidney disease (CKD) (RR=1.90; 95% CI: 1.53-2.36) and thrombolysis in myocardial infarction (TIMI) score were found to have a significant role in estimating the risk for ISR. Moreover, the ISR group (119 patients) presented with a lower stent inflation pressure when compared to the control group (116 patients) (14.47 vs. 16.14 mmHg, P=0.004). An increased mean stent diameter used for PCI was not associated with a high ISR incidence (P=0.810) as well as complex coronary treated lesions with longer stents (mean length of 24.98 mm in patients without ISR vs. 25.22 mm in patients with ISR; P=0.311). There was an estimated two times higher risk (RR=2.13; 95% CI: 1.17-3.88) concerning multi-stenting and restenosis degree >70%. To conclude, smoking, hypertension, diabetes mellitus, high CRP levels, CKD, TIMI score, stent type, low pressure for stent implantation and multi-stenting were found to be associated with ISR in patients following PCI. Therefore, a close follow-up should be targeted in such patients.

Device size selection can enhance Y-stentrieving efficacy and safety as a rescue strategy in stroke thrombectomy

BackgroundDespite advancements in stroke treatment, refractory clots are relatively common, prompting the exploration of alternative techniques. Bifurcation occlusions pose specific intraprocedural challenges, occasionally dealt with by two stentrievers deployed in...

Predictors of stent dysfunction in patients with bilateral metal stents for malignant hilar obstruction.

For unresectable hilar obstruction, restoring and maintaining biliary ductal patency are crucial for improved survival and quality of life. The endoscopic placement of stents is now a mainstay of its treatment, and bilateral stenting is effective for biliary decompression. This study aimed to determine the clinical outcomes of bilateral metal stent placement using large cell-type stents and the clinical predictors of stent dysfunction in patients with malignant hilar obstruction. We performed a retrospective analysis of patients who underwent bilateral metal stent placement using two large cell-type stents at two academic teaching hospitals between September 2017 and February 2019. The primary outcome was stent dysfunction. Secondary outcomes included predictors related to stent dysfunction and overall survival. The study included 87 patients who underwent bilateral metal stent placement for malignant hilar obstruction. Technical success and clinical success were achieved in 80 patients (92.0%) and 83 patients (95.4%), respectively. During the follow-up period (median: 201, range: 18-671 days), stent dysfunction occurred in 42 patients (48.3%), and the median stent patency was 199 days (95% confidence interval [CI]: 181-262). In univariate analysis, age, cholangitis before stent insertion, and subsequent chemotherapy were found to be associated with the cumulative risk of stent dysfunction. In multivariate analysis, cholangitis before stent insertion (hazards ratio [HR]: 2.26, 95% CI: 1.216-4.209, P = 0.010) and subsequent chemotherapy (HR: 0.250, 95% CI: 0.130-0.482, P<0.001) remained as statically significant factors associated with the cumulative risk of stent dysfunction. The median overall survival was 288 days (95% CI: 230-327). The bilateral placement of large cell-type stents for malignant hilar obstruction was effective with high technical and clinical success rates and acceptable patency. Cholangitis before stent insertion was associated with shorter patency, and subsequent chemotherapy was associated with longer stent patency.

Impact of Coronary Artery Curvature on the Longitudinal Stent Foreshortening: Real-World Observations

Longitudinal stent foreshortening is a known phenomenon, however, the impact of coronary artery curvature on longitudinal stent foreshortening remains unclear. The aim of this study is to determine the impact of coronary artery curvature on the longitudinal stent foreshortening in the real-world scenarios. A total of 86 consecutive patients underwent coronary stent implantation were included in the present study. The degree of coronary artery curvature was defined as the length of the coronary artery curvature divided by the straight length. Longitudinal stent foreshortening was defined as the stent length after implantation divided by the stent length before implantation. The mean longitudinal foreshortening rate of coronary stents was about 94% in curved coronary arteries. Longitudinal stent foreshortening rate was positively correlated with the degree of coronary artery curvature (r = –0.86, P < 0.01). Coronary artery curvature is associated with significant longitudinal foreshortening of coronary stents, thus longitudinal foreshortening should be considered on deciding the stent length in curved coronary artery and a longer stent is usually needed in curved coronary artery.

A rare complication of ERCP: duodenal perforation due to biliary stent migration.

Background and study aims Perforation of the duodenal wall opposing the major papilla due to a migrated pancreatobiliary stent rarely has been described in the literature as a complication of endoscopic retrograde cholangiopancreatography (ERCP). Factors associated with perforation from migrated stents from ERCP are unknown. Patients and methods This was a retrospective, observational study. Patients were identified from January 1, 1994 to May 31, 2019 in a prospectively maintained ERCP database. Results Eleven cases of duodenal perforation from migrated pancreatobiliary stents placed at ERCP were identified during the study period. All cases involved biliary stents, placed for biliary stricture management. The perforating stent was plastic in 10 cases (91 %). This complication occurred in one in 2,293 ERCP procedures in which a pancreatobiliary stent was placed. Conclusion This complication is more common with biliary stents compared to pancreatic stents. This may be related to the angle of exit of biliary stents being more perpendicular to the opposing duodenal wall and the near exclusive use of external pigtail plastic stents in the pancreatic duct. All perforating plastic stents were ≥ 9 cm in length. Longer stents may provide leverage for perforation with a migration event.

Adoption of same day discharge following elective left main stem percutaneous coronary intervention

BackgroundThis study sought to investigate the safety and feasibility of same day discharge (SDD) practice and compare clinical outcomes to patients admitted for overnight stay (ON) undergoing elective left main stem (LMS) percutaneous coronary intervention (PCI). ON observation is still widely practiced in highly complex PCI as the standard of care, with no previous data comparing clinical outcomes in patients undergoing LMS PCI. MethodsWe analysed 6452 patients undergoing elective LMS PCI between 2007 and 2014 in England and Wales. Multiple logistic regressions and the BCIS risk model were used to study association between SDD and 30 day mortality. ResultsSDD rates almost doubled from 19.9% in 2007 to 39.8% in 2014 for all LMS procedures and increased from 20.7% to 41.4% for unprotected LMS cases during the same study period. There was a significant increase in procedural complexity with higher use of rotational atherectomy, longer stents and multivessel PCI. SDD was not associated with increased 30 day mortality (OR 0.70 95%CI 0.30–1.65) in the overall LMS PCI cohort and the results were similar in unprotected LMS (OR 0.48 95%CI 0.17–1.41) and those requiring ON stay (OR 0.58 95%CI 0.25–1.34). ConclusionsWe did not find evidence that SDD is not safe or feasible in highly complex LMS PCI procedures despite increasing procedural complexity with no significant increase in 30 day mortality rates.

Geometric and hemodynamic analysis of fenestrated and multibranched aortic endografts

ObjectiveThe objective of this study was to determine the influence of hemodynamic force on the development of type III endoleak and branch thrombosis after complex endovascular thoracoabdominal aortic aneurysm repair. MethodsPatients with thoracoabdominal aortic aneurysm, within surgical range, treated with a fenestrated or branched endovascular aneurysm repair from 2014 to 2018 and with 3-month control computed tomography angiography were selected. Demographic variables, aneurysm anatomy, and endograft conformation were analyzed retrospectively from a prospective registry. The hemodynamic force was calculated using the mass and momentum conservation equations. ResultsTwenty-eight patients were included; the mean follow-up period was 24.7 ± 19.3 months. There were 102 abdominal vessels successfully catheterized (19 celiac arteries, 29 superior mesenteric arteries, 27 right renal arteries, 26 left renal arteries, and 1 polar renal artery). The rate of type III endoleak was 11.5% (n = 12); six cases were associated with branches that received two stents (P < .001). A higher rate of endoleak was observed with wider stents (8.50 ± 1.0 mm vs 7.17 ± 1.3 mm; P = .001) but not with longer stents (P = .530). All cases of type III endoleak affected visceral arteries (eight celiac arteries and four superior mesenteric arteries). The freedom from type III endoleak at 24 months was 86%. The rate of thrombosis was 5.9% (n = 6). A higher rate of thrombosis was observed in smaller vessels (5.00 ± 1.3 mm vs 7.16 ± 1.8 mm; P = .001), with higher stent oversizing (36.87% ± 23.6% vs 5.52% ± 15.0%; P < .001), and with a higher angle of curvature (124.33 ± 86.1 degrees vs 57.71 ± 27.9 degrees; P < .001). All cases of thrombosis were related to renal arteries (two left renal arteries, two right renal arteries, and two polar renal arteries). The freedom from thrombosis at 24 months was 92%. The area under the curve for the angle of curvature was 0.802 (95% confidence interval, 0.661-0.943; P = .013), and the cutoff point was established at 59.5 degrees (sensitivity, 100%; specificity, 60.4%). The receiver operating characteristic curve for the stent oversize showed an area under the curve of 0.903 (95% confidence interval, 0.821-0.984; P = .001), and the cutoff point was 14.5% (sensitivity, 100%; specificity, 77.1%). A higher hemodynamic force was associated with thrombosis (23.35 × 10−3 N ± 18.7 × 10−3 N vs 12.31 × 10−3 N ± 6.8 × 10−3 N; P = .001) but not with endoleak (P = .796). The freedom from endoleak and thrombosis at 24 months was 86% and 90%, respectively. ConclusionsLonger stents should be preferred to avoid type III endoleak. A higher angle of curvature leads to a higher hemodynamic force that results in a higher rate of thrombosis. Accordingly, we recommend maintaining the angle of curvature under 59.9 degrees. Small vessels and excessive stent oversizing entail a higher risk of thrombosis; as such, we advise a maximum stent oversize of 14.5%. Renal arteries are more susceptible to thrombosis, whereas visceral arteries are more prone to endoleak.

The Effect of Drug-Eluting Stents on Target Lesion Revascularization in Native Coronary Arteries: Results from the NORSTENT Randomized Study

Background: The NORSTENT trial randomized 9,013 patients to percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) or bare-metal stent (BMS) with 5-year follow-up. No difference was found in the composite primary outcome of death from any cause and nonfatal spontaneous myocardial infarction after a median of 5 years of follow-up. Secondary outcomes included repeat revascularizations, which were reduced by DES. We report the occurrence of target lesion revascularization (TLR) in time and across demographic and clinical subgroups in patients with lesions in native coronary arteries (n = 8,782). Results: Clinically driven TLR was performed on 488 (5.6%) of the 8,782 patients during 5 years of follow-up. Male gender, older age, visible thrombus in the lesion, and larger stent diameter were associated with less TLR; multivessel disease and longer stents were associated with a higher risk of TLR. There was a substantial and highly significant reduction of the risk of any TLR after 5 years in the DES group (hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.36–0.52], p < 0.001). The effect of DES on TLR was limited in time to the first 2 years in the study with no evidence of a later rebound effect. The reduction in TLR after DES insertion was consistent across subgroups defined by gender, age, diabetes status, renal function, and lesion and stent characteristics. The number needed to treat with DES (vs. BMS) to prevent 1 TLR ranged from 4 to 110 across clinically relevant subgroups. Conclusion: DES have a time-limited effect on the rate of TLR, but with a substantial and highly significant reduction in the first 2 years after the procedure. This effect was found to be consistent across all important clinical subgroups.