Multiple Stents Research Articles

Reconstructive Treatment of Ruptured Intracranial Spontaneous Vertebral Artery Dissection Aneurysms: Long-Term Results and Predictors of Unfavorable Outcomes

IntroductionFew studies focused on predictors of unfavorable outcomes (modified Rankin Scale, 2–6) after reconstructive treatment of the ruptured intracranial spontaneous vertebral artery dissection aneurysms (ris-VADAs), which was evaluated based on 57 reconstructed lesions in this study.MethodsResults of 57 consecutive patients (M:F = 29∶28; median age, 48 years; range, 27 to 69 years) harboring 57 ris-VADAs, which were treated with coils combined with single stent(n = 32), double overlapping stents (n = 16), and triple overlapping stents (n = 9) between October 2000 to March 2011, were retrospectively reviewed and analyzed.ResultsThe available (n = 54) mean durations of angiographic and clinical follow-ups were 27 months (range, 12 to 78) and 62 months (range, 12 to 132), respectively. The involvement of PICA (p = 0.004), size of lesions (p = 0.000), quantity of stent (p = 0.001), and coil type (p = 0.002) affected the immediate obliteration grade, which was only risk factor for angiographic recurrences (p = 0.031). Although the post-treatment outcomes did not differ between single stent and multiple stents (p = 0.434), 5 angiographic recurrences, 1 rebleeding and 1 suspected rebleeding, all occurred in partial obliteration after single-stent-assisted coiling. Progressive thrombosis and in-stent obliteration were not detected on follow-up angiograms. Older age (odds ratio [OR] = 1.090; 95% confidence interval [CI], 1.004–1.184; p = 0.040) and unfavorable Hunt-Hess scale (OR = 4.289; 95%CI, 1.232–14.933; p = 0.022) were independent predictors of unfavorable outcomes in the reconstructed ris-VADAs.ConclusionsImmediate obliteration grade was only risk factor for angiographic recurrence after reconstructive treatment. Unfavorable Hunt-Hess grade and older age were independent predictors of unfavorable outcomes in ris-VADAs.

Neuroform Intracranial Stenting for Aneurysms Using Simple and Multi-stent Technique Is Associated With Low Risk of Magnetic Resonance Diffusion-Weighted Imaging Lesions

Detection of procedural thromboembolism by diffusion-weighted magnetic resonance imaging (MR-DWI+) can help identify and mitigate endovascular risk factors. Data remain scant on procedural MR-DWI+ following the use of the Neuroform open-cell design stent in aneurysm embolization. We sought to evaluate the incidence of MR-DWI+ in Neuroform simple and multi-stent construct stenting for intracranial aneurysms in an attempt to delineate baseline risk and identify possible associated procedural factors. Seventy-six patients receiving 97 Neuroform stents in the treatment of intracranial aneurysm were identified from a prospective database and eligible for inclusion in the study. Diffusion-weighted magnetic resonance imaging (MR-DWI) was obtained in all patients within 48 hours of the procedure and reviewed for the presence of MR-DWI+ with patient records reviewed for analysis of factors predisposing to these lesions. Patients were treated with single-stent Neuroform constructs in 57 cases (73%) and multi-stent Neuroform constructs in 21 cases (27%). Y-stent technique was used in 16 cases. MR-DWI+ was identified in 7 of 78 cases (9.0%), with MR-DWI+ in 0 of 10 subarachnoid hemorrhage cases. No MR-DWI lesions led to a permanent neurological deficit at discharge. There was no MR-DWI+ in patients treated with Y-stenting or multi-stent Neuroform constructs. The only factor associated with ipsilateral MR-DWI+ was target aneurysm location on an arterial sidewall over bifurcation (P = .01). The Neuroform stent carries a very low risk of MR-DWI+ compared with its closed-cell design counterpart. Subarachnoid hemorrhage and deployment of multiple stents in the same anatomical region in configurations such as the Y-stent construct did not increase the risk of acute procedural thromboembolism.

Paradigm Has Already Shifted to Ischemia-Guided Functional Approach

The anatomic Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) score is a stratification score illustrating the complexity of angiographic stenosis. It was considered a surrogate for poor prognosis after percutaneous coronary intervention (PCI).1 Accordingly, in patients with a high baseline SYNTAX score (bSS) requiring coronary revascularization, coronary artery bypass graft surgery was chosen over PCI in the current guidelines.2,3 The mechanism by which bSS is a good surrogate for long-term prognosis is evident. Patients with a high bSS compared with those with a low bSS have more complex comorbidities such as old age, diabetes mellitus, multiple stenoses, and low left ventricular function. Subsequently, they receive more complex procedures using multiple stents and devices. Since the SYNTAX score II was revised by taking into consideration clinical risk factors, the function of the scoring model in choosing between PCI and coronary artery bypass graft surgery and prognosis prediction has improved.4 Article see p 141 The residual SYNTAX score (rSS), which is a variant of the SYNTAX score, was recently constructed to represent the extent of untreated coronary lesions after revascularization treatment. In the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) study, comprising patients with acute coronary syndrome, there was a stepwise increase in the rate of major adverse cardiac events, including death, myocardial infarction, and unplanned revascularization, in patients with an rSS of 0 (16.3%), >0 to 2 (18.0%), >2 to 8 (20.0%), and >8 (22.4%).5 In particular, for patients with …

Future developments in biliary stenting

Biliary stenting has evolved dramatically over the past 30 years. Advancements in stent design have led to prolonged patency and improved efficacy. However, biliary stenting is still affected by occlusion, migration, anatomical difficulties, and the need for repeat procedures. Multiple novel plastic biliary stent designs have recently been introduced with the primary goals of reduced migration and improved ease of placement. Self-expandable bioabsorbable stents are currently being investigated in animal models. Although not US Food and Drug Administration approved for benign disease, fully covered self-expandable metal stents are increasingly being used in a variety of benign biliary conditions. In malignant disease, developments are being made to improve ease of placement and stent patency for both hilar and distal biliary strictures. The purpose of this review is to describe recent developments and future directions of biliary stenting.

Self Expandable Metal Stents for Anastomotic Stricture Following Liver Transplant

Endoscopic treatment for biliary strictures with plastic stent placement has been used widely. The use of covered self-expandable metal stents (CSEMS) has been reported in anastomotic strictures post liver transplant. The aim of this study was to evaluate the efficacy of different CSEMS in these subjects. A total of 55 patients with anastomotic stricture received CSEMS, which were removed after 3-4 months. There were 19 patients in group A (partially covered SEMS), 21 patients in group B (fully covered SEMS with fins) and 15 patients in group C (fully covered SEMS with flared ends). Technical success, stricture resolution, follows up, and complications were documented. CSEMS were successfully deployed in all 55 cases. There was no evidence of significant difference with regards to stricture resolution (14 [74%] vs. 15 [71%] vs. 9 [60%] p=0.6630, df=2) or complications between groups. Stent-related complications were as follows: three in group A (2 migration, 1 occlusion), five in group B (4 occlusions, 1 migration), and one proximal migration in group C (p=0.3894, df=2). Three cases required surgery (hepatico-jejunostomy) due to refractory strictures. The observed clinical success rate of CSEMS (70.4%) proved to be below the reported one for multiple plastic stents, while no significant differences between CSEMS types were observed.

HEART's Original [症例] 薬剤抵抗性のびまん性右冠動脈冠攣縮性狭心症に対し複数個のステント留置が有効であった1例

HEART's Original [症例] 薬剤抵抗性のびまん性右冠動脈冠攣縮性狭心症に対し複数個のステント留置が有効であった1例

Effectiveness and Safety of Endoscopic Treatment of Benign Biliary Strictures Using a New Fully Covered Self Expandable Metal Stent

Background. In patients with benign biliary strictures, the use of fully covered self-expandable metal stents (SEMS) has been proposed as an alternative to plastic stenting, but high quality prospective data are sparse. This study was performed to evaluate the long-term effectiveness and safety of a new fully covered SEMS for benign biliary strictures. Methods. All consecutive patients with benign biliary strictures were treated with placement of a fully covered SEMS (WallFlex) for 6 months. Short- and long-term stricture resolution, adverse events, and ease of stent removal were recorded. Results. 23 patients were enrolled. Stricture etiology was chronic pancreatitis (14), postorthotopic liver transplant (4), idiopathic (4), and biliary stones (1). All ERCPs were technically successful. All stents were successfully removed. Short-term stricture resolution was seen in 22/23 (96%) patients. Long-term success was 15/18 (83.3%). All 3 failures were patients with biliary strictures in the setting of chronic calcific pancreatitis. Conclusions. The use of the new SEMS for the treatment of benign biliary strictures led to short-term stricture resolution in the vast majority of patients. Over a long-term followup the success rate appears favorable compared to historical results achieved with multiple plastic stenting, particularly in patients with chronic pancreatitis. The study was registered with ClinicalTrials.gov (NCT01238900).

Perioperative aortic dissection rupture after endovascular stent graft placement for treatment of type B dissection

Background The perioperative aortic dissection (AD) rupture is a severe event after endovascular stent graft placement for treatment of type B AD. However, this life-threatening complication has not undergone systematic investigation. The aim of the study is to discuss the reasons of AD rupture after the procedure. Methods The medical record data of 563 Stanford type B AD patients who received thoracic endovascular repair from 2004 to December 2011 at our institution were collected and analyzed. Double entry and consistency checking were performed with Epidata software. Results Twelve patients died during the perioperation after thoracic endovascular repair, with an incidence of 2.1%, 66.6% were caused by aortic rupture and half of the aortic rupture deaths were caused by retrograde type A AD. In our study, 74% of the non-rupture surviving patients had the free-flow bare spring proximal stent implanted, compared with 100% of the aortic rupture patients (74% vs. 100%, P=0.213). The aortic rupture patients are more likely to have ascending aortic diameters ≥4 cm (62.5% vs. 9.0%, P=0.032), involvement the aortic arch concavity (62% vs. 27%, P=0.041) and have had multiple stents placed (P=0.039). Conclusions Thoracic AD endovascular repair is a safe and effective treatment option for AD with relative low in-hospital mortality. AD rupture may be more common in arch stent-graft patients with an ascending aortic diameter ≥4 cm and with severe dissection that needs multi-stent placement. Attention should be paid to a proximal bare spring stent that has a higher probability of inducing an AD rupture. Post balloon dilation should be performed with serious caution, particularly for the migration during dilation.

Covered self-expanding metal stents (CSEMS) may offer improved clinical success compared to multiple plastic stents (PS) in strictures secondary to chronic pancreatitis: A systematic review and meta-analysis

Covered self-expanding metal stents (CSEMS) may offer improved clinical success compared to multiple plastic stents (PS) in strictures secondary to chronic pancreatitis: A systematic review and meta-analysis

Indirect diagnosis of pancreatic exocrine insufficiency (PEI) in chronic pancreatitis (CP) by endoscopic ultrasound (EUS)-guided elastographic quantification of pancreatic fibrosis: A prospective observational study

s / Pancreatology 13 (2013) S2–S98 S75 b)When comparedwith abstainers, heavy drinker intake is a risk factor to develope CP (p1⁄40,038; O.R1⁄42,583) c) Pancreas divisum is a risk factor to develope ARP (p1⁄40,000; O.R1⁄410,533) but not CP. d) Moderate alcohol intake is not statistically significant in both ARP and CP. Conclusion: Heavy alcohol consumption and smoking inhabits are independent risks for CP. Pancreas divisum is a risk factor to develope ARP. PII-75 Abstract id: 197. Covered self-expanding metal stents (CSEMS) may offer improved clinical success compared to multiple plastic stents (PS) in strictures secondary to chronic pancreatitis: A systematic review and metaanalysis Antti Siiki , Mika Helminen , Juhani Sand , Johanna Laukkarinen . Dept. of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland 2 Science Center, Pirkanmaa Hospital District and School of Health Sciences, University of Tampere, Tampere, Finland Introduction: CSEMS are being increasingly used in the endoscopic treatment of benign biliary strictures (BBS). Despite promising results, there is not yet solid evidence to support their routine use. Aims: To evaluate feasibility of CSEMS compared to PS in BBS in terms of clinical success and complications. Materials & methods: A systematic search of Medline, Scopus and Embase database for studies published 2000-2012 combined to handsearch of reference lists resulted 4977 articles. Out of 99 potentially relevant studies selected for full-text review, 12 CSEMS (376 patients) and 13 PS studies (570 patients) met the final inclusion criteria. A systematic review was made using proportion meta-analysis. Results: A tendency to successful use of CSEMS in strictures related to chronic pancreatitis (CP) was shown: clinical success of 77% and 33% (95% CI 61-94% vs. 4-63%, p1⁄40.06) was achieved with CSEMS and PS at 12 months follow-up, respectively. There were no differences in the success rates of other etiologies except CP or in the early complications. In CSEMS, incidence of late adverse events was lower in CP related strictures (3% vs. 67%, 95%CI 0-13% vs. 17-99%, p1⁄40.02). The median number of ERCPs was lower with CSEMSs (1.5 vs. 3.9, p1⁄40.002). Conclusion: Improved clinical success with fewer endoscopic sessions and corresponding complication rate may be achieved with CSEMS compared to PS in BBS secondary to chronic pancreatitis. PII-76 Abstract id: 182. Indirect diagnosis of pancreatic exocrine insufficiency (PEI) in chronic pancreatitis (CP) by endoscopic ultrasound (EUS)-guided elastographic quantification of pancreatic fibrosis: A prospective observational study J. Enrique Dominguez-Mu~ noz , Margarita Casti~ neira-Alvari~ no , Maria Luaces-Regueira , Jos e Lari~ no-Noia , Laura Nieto-Garcia , Julio IglesiasGarcia . University Hospital of Santiago. Foundation for Research in Digestive Diseases, Spain 2 Foundation for Research in Digestive Diseases, Spain Introduction: Diagnosis of PEI is hindered by methodological difficulties of pancreatic function tests. The probability of PEI increases as fibrosis develops. Pancreatic fibrosis in CP can be quantified by EUS-guided elastography. Aims:We aimed at evaluating if pancreatic elastography can be used to predict PEI in patients with CP. Materials & methods: Prospective observational study including patients consecutively diagnosed with CP based on EUS ( 5 criteria) and/or s-MRCP findings. PEI was diagnosed by 13C-mixed triglyceride breath test and defined as a 13C-cumulative recovery rate 5.5). Conclusion: The degree of pancreatic fibrosis as measured by EUSguided elastography allows quantifying the probability of PEI, and thus the need for oral pancreatic enzyme therapy, in patients with CP PII-77 Abstract id: 296. Morphological features of pancreatic cystic lesions in endoscopic ultrasonography (EUS) examination – A single-center experience Malgorzata Degowska, Marek Stobinski, Janusz Milewski, Grazyna

Su1422 Phase III Randomized Controlled Trial of Fully Covered Metal Stent Versus Multiple Plastic Stents in Anastomotic Biliary Strictures Following Orthotopic Liver Transplantation: Midterm Evaluation

Biliary anastomotic stricture occurs in 15-20% of patients following orthotopic liver transplantation (OLT). They are usually endoscopically managed with plastic stenting. There is available data on treating benign biliary stenosis with fully covered self-expandable metal stent (cSEMS). The aim of this study is to compare the efficacy and safety of cSEMS versus multiple plastic stenting (MPS) in biliary anastomotic stricture (BAS) after OLT.

Su1425 Fully Covered Metal Stents for Treatment of Post Liver Transplantation Anastomotic Strictures - Results in 43 Patients From 2 Multi-Center Prospective Studies

Use of fully-covered self-expanding metal stents (FCSEMS) for treatment of anastomotic biliary strictures post orthotopic liver transplantation (OLT) has been described, but is not approved in the US. The use of multiple plastic stents remains the endoscopic standard of care, but often requires several stent exchanges to achieve acceptable stricture resolution.

Su1577 Endoscopic Ultrasound-Guided Pancreatic Pseudocyst With Metal Stent Appears to Be Effective and Safe Procedure

Currently, endoscopic ultrasound (EUS) is used not only for observation but also therapeutic procedure. Many endoscopists reported that EUS-guided drainage for the pancreatic pseudocyst (PC) was useful and safe. Although single or multiple plastic stents are placed in this procedure, recently several endoscopists performed to place the biliary metal stent or dedicated metal stent for PC. Herein, we'll describe the results of EUS-guided pancreatic pseudocysts drainages (EUS-PCDs) with metallic stents (MS) in our hospital.

Su1429 A Fully Covered Self-Expandable Metal Stent, Niti-S, for Benign Biliary Strictures: a Prospective Multi-Center Follow-up Study

Treatment of benign biliary stricture (BBS) generally consists of sequential placement of multiple plastic stents. A major drawback of this approach is the need for frequent stent exchange. Self-expandable metal stents (SEMS) are increasingly being used as an alternative because of their larger diameter. The use of fully covered SEMS enables easy stent removal; however, there is a risk of stent migration due to a lower anchoring capacity. The Niti-S is a fully covered SEMS with flared ends to prevent migration.

Endoscopic bilateral deployment of multiple metallic stents for malignant hilar biliary strictures

Jaundice and cholangitis are associated with morbidity and mortality for patients with malignant hilar biliary strictures. Endoscopic biliary drainage is considered a useful procedure for palliation of unresectable malignant hilar biliary strictures. However, even today, the devices and methods to effectively achieve the drainage of these strictures are under debate. Endoscopic bilateral deployment of multiple metallic stents for malignant hilar biliary strictures is a feasible and useful procedure, providing long-term patency and the preservation of functional liver volume. We report the cases of two patients who underwent endoscopic bilateral deployment of multiple metallic stents using the partial stent-in-stent method. Both of the patients had malignant hilar biliary stricture due to biliary tract cancer. The cancers were unresectable and the patients decided to receive chemotherapy. Before the chemotherapy, bilateral deployment of metallic stents was carried out and each patient has been receiving chemotherapy without occlusion of the metallic stents for several months.

Newly designed plastic stent for endoscopic placement above the sphincter of Oddi in patients with malignant hilar biliary obstruction

Plastic stent (PS) occlusion occurs as a result of bacterial adherence to the stent's inner wall. To retain the bacteriological barrier, placing a PS above the sphincter of Oddi ('inside stent') has been investigated. We designed a new PS (inside stent with thread [IT] stent) with attachable nylon thread for use as an inside stent and for easy retrieval. The present study evaluated the IT stent's technical feasibility and efficacy for malignant hilar biliary obstruction. A total of 26 consecutive patients with unresectable malignant hilar biliary obstruction underwent placement of IT stents from August 2007 to February 2011. IT stents were placed across the strictures without sphincterotomy to achieve bilateral drainage. The overall technical success rate of the IT stent was 100% for one session. Multiple IT stents were inserted in 25 cases(two stents in 15 patients, three stents in 10 patients). No stent-related early complications occurred. The functional success rate was 92% (24/26). The rate of reintervention because of stent malfunction was 50% (13/26). In all 16 patients who underwent stent removal, IT stents were easily retrieved using the nylon thread. According to Kaplan-Meier analysis, the median stent patency period was 136 days. IT stents for endoscopic placement above the sphincter of Oddi can be used safely and effectively for malignant hilar biliary obstruction.

New devices and techniques for management of pancreatic fluid collections

New devices and techniques for management of pancreatic fluid collections

Spot Stenting is Preferable in Long Diffuse Coronary Lesions: Possible Incremental Value of Physiologic and Intracoronary Imaging Modalities

The treatment of long and diffuse coronary lesions with percutaneous coronary intervention (PCI) has been problematic since the era of plain balloon angioplasty. With the advent of bare-metal stents (BMS), long and multiple stents were used to completely cover the diseased segments in order to improve outcomes. Lesion length has been proven to be a factor related to higher rates of restenosis and target lesion revascularization (TLR) and the risk was further increased by the multiplicity of implanted stents. Covering the lesion with the least number of non-overlapping stents might reduce the risk of restenosis. This strategy, called spot stenting , was initially tested in the BMS era to treat discrete high-grade disease within moderately diseased vessel segments and has been shown to significantly reduce restenosis rates. Drug-eluting stents (DES) have been consistently shown to reduce restenosis and the need for TLR and thus provide improved clinical efficacy compared with BMS. However, even with DES, diffuse disease and long lesions are still associated with an increased risk of restenosis, need for TLR and major adverse cardiac events (MACE). A major long-term concern regarding DES is the potential for stent thrombosis which is increased after complex procedures with implantation of longer, multiple and overlapping stents. Data are limited but recent reports suggest that even when DES are used, selective stenting of only the severely narrowed areas of long lesions reduces the risk of MACE compared to full lesion coverage. The data supporting the spot stenting approach along with some considerations regarding the technique are presented herein.

Patency of Multiple stents/Overlapping Stents in Single Artery Territory in Bangladeshi Patient: An Updated Single Center Experiences

Background: Coronary artery disease (CAD) in Bangladeshi population is diffuse in nature with small caliber arteries. Now a day, these are treated, by PCI with stent deployment, often multiple in a single coronary artery. However, long term data on In-stent re-stenosis (ISR) in multiple or overlapping stent in single coronary artery in these patients is not yet available. Therefore, the aim of our present study was to assess long-term outcome of stent patency or the development of ISR of varieties stent in single vessel territory. Methods: Patients were prospectively selected from, who underwent coronary angiogram at our hospital for further evaluation of their previous PTCA in the 3-36 months preceding the study for the quantifying period of 2007-2011. Total 51 patients (male: 42, Female: 9) who had multiple stents in one coronary artery were included in this study. Average age was Male: 57; Female:61. Average study period was 3.1 ± 2.4yrs. Results: Our results show that, among the total studied population 82.4% (42) were male and 17.6% (9) were female. Total 114 stent were deployed in 54 vessels of 51 patients. Territory wise distribution of deployed stent was LAD 52(45.6%), RCA 42 (36.8%) and LCX 20(17.5%). Stent used were BMS 45(39.5%), DES 69(60.5%). Re-look Coronary Angiogram (CAG) revealed that Significant ISR (ISR>60%) developed in BMS 8(17.8%) and DES 8(11.5%). Among the different DES the development of significant ISR were in Sirolimus 1(3.2%), Paclitaxel 4(16%), Everolimus 3 (30%). Conclusion: Our study has shown that deployment of multiple stents in a single artery territory (either separately or as overlapping) is safe and has reasonably lower degree of ISR, even when BMS was used. As a whole BMS shows higher degree of ISR than to DES for an average period of follow up of 3.1 yrs. DOI: http://dx.doi.org/10.3329/cardio.v5i2.14319 Cardiovasc. j. 2013; 5(2): 154-159

Two iatrogenic dissections during single percutaneous coronary intervention

Cardiologia CROATICA 80-year old female patient, presenting with unstable angina, was transferred to our hospital from the regional hospital. Coronary angiography revealed separate ostia of the left anterior descending artery (LAD) and the circumflex artery (Cx). Borderline stenosis of the ostium of the LAD with tight stenosis of its middle segment as well as distal tortuosity was observed. Cx and right coronary artery (RCA) were without significant lesions. We decided to proceed with an ad hoc percutaneous coronary intervention in the middle segment of the LAD. During advancement of the guidewire (Terumo Runtrough NS Intermediate) dissection, in the region of the lesion, developed with a complete lumen closure. Patient became hypotensive with ST-segment elevation. Subsequent attempts to cross the dissection resulted in multiple disengagements of the guiding catheter (XB LAD, 6Fr) together with its prolapse to the proximal Cx. Eventually this resulted in the dissection with a partial lumen obstruction of the proximal part of the Cx. Because of it, the proximal part of Cx was directly stented and the guiding catheter was exchanged (JL 4,0, 6Fr). After that, we were able to cross the dissection of the LAD with a support of an OTW balloon (Terumo Ryujin Plus) and a hydrophilic guidewire with a tapered tip (Asahi Fielder XT). Appropriate positioning of the OTW balloon in the true lumen was confirmed by the injection of the contrast through its lumen. Through the OTW balloon, whose extraction was found rather difficult using the 6 Fr system, standard guidewire (Terumo Runtrough NS Floppy) was introduced. After multiple balloon dilatations stent was successfully deployed in the middle segment of the LAD. Postprocedurally a rise in cardiac enzymes was observed, without electrocardiographic changes or angina. At follow-up, patient is well without any chest pain during daily activities.