Primary Stent Placement Research Articles

Abstract No. 215: Long-term outcome of primary stent placement for the complex iliac artery occlusive disease

Abstract No. 215: Long-term outcome of primary stent placement for the complex iliac artery occlusive disease

Endovascular Revascularization of Diseased Native Arteries following Failed Aortoiliac and Femoropoliteal Grafts: Report of Two Cases

Arterial reconstructions for lower-extremity ischemia, comprising aortoiliac, aortofemoral, and femoropopoliteal bypasses, and other procedures, have an intrinsic tendency to fail as time elapses. Surgical approaches to arteries in patients who have failed bypass grafts are often rendered more difficult, or even impossible to use, by surgical scarring or infection. The authors report two cases in which the diseased native arteries treated with failed aortoiliac and femoropopliteal bypass grafts were successfully recanalized with primary stent placement. Our cases show that stent placement of the diseased native arteries can represent a possible option for the treatment of failed bypass grafts.

Endovascular reconstruction of the aortic bifurcation in patients with Leriche syndrome

The Leriche syndrome with contiguous total occlusions of the infrarenal aorta and the iliac arteries is a variant of Trans-Atlantic Inter-Society Consensus (TASC) type D aortoiliac disease, for which surgery is the recommended treatment of choice. We sought to prospectively assess the feasibility and safety of an endovascular therapeutic approach. Eleven consecutive patients with Leriche syndrome (eight men; 64 +/- 12 years) constituted the study cohort. The treatment strategy consisted of recanalization by transbrachial access of the occluded segments and subsequent transfemoral angioplasty with selective stent placement in the distal aorta and primary nitinol stent placement in the iliac arteries. Bilateral endovascular success was achieved in eight patients (73%), unilateral success in the other three patients. Seven patients received aortic stents; the total stented segment length in 19 iliac arteries successfully recanalized amounted to a median of 18 cm (range 12-26 cm). There was one periprocedural complication, an acute thrombotic aortoiliac occlusion managed by thrombolysis. One patient with unilateral endovascular success had to undergo femorofemoral crossover bypass grafting. At a median of 14 months, significant hemodynamic improvement was observed in successfully revascularized legs (ankle-brachial index, 0.79 +/- 0.20 vs. 0.48 +/- 0.08 at baseline; P = 0.0004); walking capacity as well as Rutherford category of peripheral arterial disease had improved in all patients. In this small series of patients with Leriche syndrome, the reconstruction of the totally occluded aortoiliac bifurcation by endoluminal means was shown to be feasible and safe and associated with excellent mid-term clinical outcomes.

Stent implantation in chronic mesenteric ischemia

Chronic mesenteric ischemia (CMI) is a life-threatening disorder, which is usually associated with stenosis or occlusion of celiac or mesenteric arteries. To review our experience and to assess short-term results of stent placement in stenotic mesenteric arteries. Primary stent placement was performed in 15 patients who had nausea, vomiting, postprandial pain, and weight loss due to steno-occlusive diseases of mesenteric arteries. After stenting, the patients were followed clinically and with Doppler ultrasound at 1, 6, and 12 months. Symptomatic patients with restenosis were examined with digital subtraction angiography and were referred for retreatment with balloon dilatation. Twenty-three stenoses and 11 occlusions were detected in 15 patients, and 18 stenoses were treated with primary stenting. Single-vessel endovascular treatment was performed in 12 patients. In three patients, two arteries were stented in the same session. Technical success rate was 18/18 (100%). Clinical success was achieved in 13/15 (86.6%) patients. First-month mortality was 13%. During the mean 16.1-month follow-up period, restenoses developed in three patients. One of them was successfully treated with balloon angioplasty. Primary patency was 9/11 (81%) and primary assisted patency was 81% at 12 months. The complication rate was 1/15 patients (0.06%). Our experience suggests that stent placement has a potential role in chronic mesenteric ischemia with low incidence of complications and high technical and clinical success rates.

Covered Wallstents for palliation of malignant biliary obstruction: primary stent placement versus reintervention

Covered self-expandable metallic stents (SEMSs) are designed to prevent tumor ingrowth and can be removed if necessary. Only limited comparative data are available on the performance of covered SEMSs after primary placement versus reintervention. To assess the effectiveness and safety of covered SEMS placement either as primary treatment or reintervention in patients requiring palliation of malignant biliary obstruction. Retrospective clinical cohort study. Tertiary referral center. This study involved 104 patients with unresectable malignant biliary strictures. Covered biliary SEMS placement. Stent patency, technical success, and patient survival. Covered SEMSs were placed as primary treatment in 48 patients (46%), and reintervention was performed in 56 patients (54%). At 3, 6, and 12 months thereafter, the Kaplan-Meier estimated fractions of all patients with patent stents were 94%, 84%, and 58%, respectively. Covered SEMSs remained patent until the patient's death in 75 of 89 nonsurvivors (84%). Although patency rates 3, 6, and 12 months after primary placement (100%, 93%, and 82%, respectively) were higher than those after reintervention (90%, 78%, and 48%, respectively), the differences were not statistically significant (P = .057). Overall, the most frequent adverse events were cholangitis (7%) and stent migration (4%). The distribution of stricture locations differed among the groups, and survival data suggested the presence of more extensive disease in the primary treatment group at baseline. The clinical utility and safety of primary covered SEMS placement were confirmed. This study provides the most extensive evidence to date that reintervention with a covered SEMS can provide a useful palliative option.

Primary Stenting for Recurrent Stenosis Following Carotid Endarterectomy

Carotid angioplasty and stenting is an accepted alternative treatment for severe restenosis following carotid endarterectomy. Balloons may not be required to effectively treat these lesions, given their altered histopathology compared to primary atherosclerotic plaque and tendency to be less calcified. Primary stenting using self-expanding stents alone may, therefore, be a safe and effective treatment for restenosis post-carotid endarterectomy. We review our experience in the treatment of 12 patients with symptomatic severe restenosis following carotid endarterectomy with primary stent placement alone. Self-expanding stent placement alone reduced the mean internal carotid artery stenosis from 85% to 29%. Average peak systolic velocity determined at the time of ultrasonography decreased from 480 cm/s at initial presentation to 154 cm/s post-stent deployment and further decreased to 104 cm/s at one year follow-up. The stented arteries remained widely patent with no evidence of restenosis. A single peri-procedural ipsilateral transient ischemic event occurred. There were no cerebral or cardiac ischemic events recorded at one year of follow-up. In this series, primary stent placement without use of angioplasty balloons was a safe and effective treatment for symptomatic restenosis following carotid endarterectomy.

Hemodynamic instability during carotid artery stenting: the relative contribution of stent deployment versus balloon dilation

Hemodynamic instability may complicate carotid angioplasty and stenting in up to 40% of patients. The authors have previously demonstrated that primary self-expanding stent placement alone can gradually dilate severely stenosed carotid arteries without the use of balloons. The authors hypothesized that eliminating the balloon would reduce carotid baroreceptor stimulation, thereby decreasing the incidence of hemodynamic instability. Ninety-seven high surgical risk patients with symptomatic, severely stenosed carotid arteries were treated with the intention of using a self-expanding stent alone. Seventy-seven arteries (79%) were treated with stenting alone, and 20 required angioplasty (21%). Intraprocedural bradycardia (heart rate < 60 bpm) developed in 29 patients (38%) and hypotension (systolic blood pressure < 90 mm Hg) occurred in 1 patient (1%) treated with stenting alone. Fourteen patients (70%) who underwent angioplasty and stenting had bradycardia, and hypotension developed in 4 (20%). Atropine, glycopyrrolate, or vasopressors were required in 8% of patients who received stenting alone, compared to 30% of patients who underwent angioplasty. In the first 24 hours after treatment, hypotension or bradycardia developed in 25 patients (32%) who had undergone stent placement alone, and in 15 patients (75%) after stent placement and balloon angioplasty. There was no difference in the occurrence of intra- or postprocedural hypertension (systolic blood pressure > 160 mm Hg) between patients treated with stenting alone or stenting and balloons. Factors independently associated with hemodynamic depression included baseline heart rate and balloon use. Hemodynamic instability during and after carotid artery stenting was observed more frequently when balloon angioplasty was required than when stent placement was performed without concurrent balloon angioplasty.

Primary stent placement for late complete occlusion after aortoiliac reconstructive surgery: Report of a case

We report a case that was successfully treated by primary stent placement without thrombolysis or thrombectomy for graft thrombosis after aortoiliac reconstructive surgery. A 79-year-old man presented with a 2-month history of severe intermittent claudication of the right leg. He had undergone a surgical repair of abdominal aortic aneurysm with a bifurcated polyester graft 3 years before presentation. Digital subtraction angiography revealed total occlusion of the right limb of the graft. He underwent primary stent placement on the lesion, and completion angiography showed revascularization of the right limb. Primary stent placement can be performed to decrease the risks of surgery and increase the salvage of a graft with chronic total occlusion.

Treatment of atherosclerotic intracranial arterial stenosis.

David Pelz MD L. Nelson Hopkins MD Elad Levy MD Section Editors: Atherosclerotic stenosis of the major intracranial arteries (intracranial internal carotid artery, middle cerebral artery, vertebral artery, basilar artery) is probably the most common cause of stroke worldwide.1 Intracranial atherosclerosis causes 30% to 50% of strokes in Asia2 and 8% to 10% of strokes in North America.3 This review focuses on the medical and endovascular treatment of atherosclerotic intracranial arterial stenosis. Initially, a retrospective study suggested that warfarin was superior to aspirin for stroke prevention in patients with symptomatic intracranial arterial stenosis.4 This retrospective data combined with a proposed pathophysiological rationale for anticoagulation5 made warfarin a common treatment choice for symptomatic intracranial stenosis.6 However, the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial showed that aspirin was safer and as effective as warfarin for stroke prevention in patients with symptomatic intracranial stenosis. WASID was stopped early after a mean follow-up of 1.8 years because of higher rates of death and major hemorrhage in the warfarin arm. The primary end point of ischemic stroke, brain hemorrhage or vascular death, occurred in 22.1% of patients assigned aspirin and 21.8% of those in the warfarin group.7 The rates of myocardial infarction or sudden death were also higher in the warfarin arm. Certain high-risk subgroups of patients with intracranial stenosis were previously thought to benefit from anticoagulation, such as those with severe stenosis,4 vertebrobasilar disease,4 and those who have failed antithrombotic therapy.8 In WASID, however, patients with severe stenosis9 or those previously on antithrombotic therapy9,10 did not benefit from warfarin. Patients with basilar artery stenosis in WASID did appear to have a lower rate of the primary end point on warfarin, but there was no difference in the rate of stroke in the …

Outcome of Covered Esophageal Stents for the Palliation of Malignant Dysphagia: Long-Term Results from the Ludwigshafen Esophageal Cancer Register

Background: High-grade dysphagia is the predominant late symptom of local advanced esophagogastric cancer. Different types of covered metal stents are currently available for palliation of patients with malignant dysphagia. Data of their advantages and disadvantages are based on results from previously published prospective trials. Aim/Methods: To evaluate efficacy and outcome of 4 different types of covered metal/plastic stents in malignant dysphagia. Prospective trial of 269 consecutive patients (pts.) with malignant dysphagia due to esophagogastric cancer. We used 4 types of covered esophageal stents (group A: Gianturco Z stent n=61 pts.; group B: Ultraflex stent n=103 pts.; group C: Flamingo Wallstent n=68 pts.; group D Polyflex stent n=37 pts.). There were 66 female and 203 male with a median age of 64.6 (range 43-94) years. Pre- and post-stent dysphagia symptoms were graded on a scale from 0 to 4 (0=normal swallowing to 4=cannot swallow own saliva). The 4 stent groups were compared for improvement of dysphagia score, survival, recurrent dysphagia, Karnofsky-performance-score (KPS), and complications. Results: Primary stent placement was successful in 56/61 (92%) pts. of group A, 99/103 (96%) of group B, 65/68 (95%) of group C and 32/37 (86%) pts of group D. Median hospital stay after implantation was 4.1 days (group A), 3.2 days (group B), 3.5 days (group C) and 5.2 days (group D) (p=0.23). At 2 to 4 weeks after stenting, median dysphagia score improved in group A (from 2.77 to 0.99), group B (from 2.68 to 0.72), group C (from 2.62 to 0.81) and group D (2.99 to 0.92). There was no significant difference between the groups (p=0.37). Median survival after insertion of the stents was 96 days (group A), 118 days (group B), 108 days (group C) and 102 days (group D) (p=0.18). Major complications were seen in 21/61 (34%) pts. of group A, 17/103 (16%) pts. of group B, 11/68 (17%) pts. of group C and 14/37 (37%) pts. of group D (p=0.04). Migration occurred significantly more often in group D (24%). Conclusion: All 4 types of covered stents evaluated in the study offer the same degree of palliation of patients with malignant dysphagia. However, insertion of Gianturco-Z stents and Polyflex stents seems to be associated with more major complications as compared with Ultraflex stents and Flamingo Wallstents. Overall, the “perfect” esophageal stent for palliation of malignant dysphagia has not been found until today.

Assessment of Microvascular Obstruction and Prediction of Short-term Remodeling after Acute Myocardial Infarction: Cardiac MR Imaging Study

To evaluate which cardiac magnetic resonance (MR) imaging technique for detection of microvascular obstruction (MVO) best predicts left ventricular (LV) remodeling after acute myocardial infarction (MI). This study had local ethics committee approval; all patients gave written informed consent. Sixty-three patients with first acute MI, treated with primary stent placement and optimal medical therapy, underwent cine MR imaging at 4-7 days and at 4 months after MI. Presence of MVO was qualitatively evaluated at baseline by using three techniques: (a) a single-shot saturation-recovery gradient-echo first-pass perfusion sequence (early hypoenhancement), mean time, 1.09 minutes +/- 0.07 (standard deviation) after contrast material administration; (b) a three-dimensional segmented saturation-recovery gradient-echo sequence (intermediate hypoenhancement), mean time, 2.17 minutes +/- 0.26; and (c) a two-dimensional segmented inversion-recovery gradient-echo late gadolinium enhancement sequence (late hypoenhancement), mean time, 13.32 minutes +/- 1.26. Contrast-to-noise ratios (CNRs) were calculated from the signal-to-noise ratios of the infarcted myocardium and MVO areas. Univariable linear regression analysis was used to identify the predictive value of each MR imaging technique. Early hypoenhancement was detected in 44 (70%) of 63 patients; intermediate hypoenhancement, in 39 (62%); and late hypoenhancement, in 37 (59%). Late hypoenhancement was the strongest predictor of change in LV end-diastolic and end-systolic volumes over time (beta = 14.3, r = 0.40, P = .001 and beta = 11.3, r = 0.44, P < .001, respectively), whereas intermediate and late hypoenhancement had comparable predictive values of change in LV ejection fraction (beta = -3.1, r = -0.29, P = .02 and beta = -2.8, r = -0.27, P = .04, respectively). CNR corrected for spatial resolution was significantly superior for late enhancement compared with the other sequences (P < .001). By using cardiac MR imaging, late hypoenhancement is the best prognostic marker of LV remodeling, with highest CNR between the infarcted myocardium and MVO regions.

Early prediction of infarct size by quantitative myocardial blush grade in patients with acute non-st-elevation and ST-elevation myocardial infarction treated with primary angioplasty and stent placement

Early prediction of infarct size by quantitative myocardial blush grade in patients with acute non-st-elevation and ST-elevation myocardial infarction treated with primary angioplasty and stent placement

Primary Stent Placement of an Acute Occlusion in the Iliac Arteries of Patients with Acute Limb Ischemia

Purpose: To assess the efficacy of stent-assisted recanalization for the management of acute limb ischemia (ALI) after a failed surgical revascularization in patients with acute iliac arterial occlusion and considered unfit for a thrombolysis. Materials and Methods: The data on 6 patients with acute limb ischemia due to iliac arterial occlusion, and treated with stent implantation between November 2005 and March 2008, was analyzed retrospectively. The reasons for ALI in the patients analyzed included acute thrombosis related to a traumatic injury (n=3), acute in-situ thrombosis with pre-existing atherosclerotic stenosis (n=2), and cardiogenic embolism (n=1). A preprocedural CT angiography and conventional angiography revealed an occlusion at the iliac artery. This study examined the clinical data, technical and clinical outcome of the procedure, and complications related to the procedure or follow-up period for each patient. Results: Primary stenting was technically successful in all patients, thus resulting in the reduction or elimination of clinical symptoms in the 5 patients observed. One patient expired due to multi-organ failure related to a reperfusion injury. The other five patients showed good clinical results without symptom recurrence and normal duplex USG or CT angiographic findings during the 3-15 month follow-up period. Conclusion: A stent-assisted recanalization is an effective treatment for patients with ALI, which are considered unfit for thrombolysis and surgical recanalization.

Atualização sobre endopróteses vasculares (stents): dos estudos experimentais à prática clínica

Atualmente, o tratamento das doenças vasculares periféricas é uma das áreas da medicina de maior expansão. O número de intervenções vasculares aumenta e os resultados das novas técnicas endovasculares estão muito próximos aos das tradicionais cirurgias vasculares. Embora a angioplastia ofereça bons resultados em curto prazo, o implante de stents procura melhorar o sucesso do procedimento e estender o seu uso a um número maior de pacientes com doença vascular periférica. Entretanto, a sua utilização ainda é controversa. O implante de stents no sistema aorto-ilíaco tem bons resultados; porém, a sua indicação para as lesões femoro-poplíteas ainda é discutida. Além disso, o rápido desenvolvimento de stents e sua escolha para uso no sistema vascular periférico têm sido uma difícil tarefa para o cirurgião endovascular. Muitos fatores influenciam a escolha do stent, e um amplo conhecimento desse material é essencial. Tal escolha depende da avaliação pré-operatória, da localização e das características da lesão e também do uso do stent primário ou seletivo. Nesse trabalho, são realizadas revisão do histórico do desenvolvimento dos stents, desde os estudos experimentais até os ensaios clínicos e também discussão sobre a sua aplicação no tratamento das doenças vasculares periféricas.

Combined Prognostic Utility of White Blood Cell Count, Plasma Glucose, and Glomerular Filtration Rate in Patients Undergoing Primary Stent Placement for Acute Myocardial Infarction

Although high white blood cell (WBC) count and plasma glucose (PG) and low glomerular filtration rate (GFR) on admission have been associated with poor outcomes after acute myocardial infarction (AMI), the combined prognostic utility of these 3 variables was unclear. The association of WBC count, PG, and GFR on admission to in-hospital outcomes was examined in 2,633 patients who underwent primary stent placement for ST-segment elevation AMI within 48 hours after symptom onset. In-hospital mortality progressively increased as the number of the variables of high WBC count (> or =11,120/microl; upper tertile), high PG (> or =10.4 mmol/L; upper tertile), and low GFR (< or =60 ml/min/1.73 m(2); lower tertile) increased. Patients with all 3 variables had a strikingly higher in-hospital mortality rate (25.9%). After adjusting for baseline characteristics, multivariate analysis showed that compared with patients who had none of these variables, odds ratios for in-hospital mortality were 1.63 (95% confidence interval [CI] 0.88 to 3.03, p = 0.12) in patients with only 1 variable, 2.33 (95% CI 1.28 to 3.96, p = 0.047) in those with 2 variables, and 6.16 (95% CI 2.98 to 12.6, p <0.001) in those with all 3 variables. In conclusion, combined evaluation of WBC count, PG, and GFR on admission was a simple and useful method for the early prediction of risk of in-hospital death in patients undergoing primary stent placement for ST-segment elevation AMI.

Evaluation of myocardial perfusion and deformation in patients with acute myocardial infarction treated with primary angioplasty and stent placement

To prospectively compare the usefulness of myocardial perfusion and deformation imaging for the prediction of functional recovery and left ventricular (LV) remodeling in patients with ST-elevation myocardial infarction (STEMI). We prospectively examined 36 patients with reperfused STEMI, 12+ or -9 h after primary angioplasty and stent placement. LV function was reevaluated at 4-6 months of follow-up, to assess relative improvement of LV-ejection fraction (DeltaEF%) and increase in end-diastolic volume (DeltaEDV). During the follow-up period, 19 of 36 patients showed LV function improvement (DeltaEF%> or =10%), whereas 10 patients had LV remodeling (DeltaEDV> or =20%). Peak negative strain (epislon (peak)), peak negative strain rate (SRpeak), and myocardial blood flow (Axbeta) correlated with DeltaEF% (r=-0.55, -0.57, and 0.46, respectively, P<0.01 for all), and allowed for prediction of LV remodeling on an individual level (area under the curve of 0.85 for strain rate, 0.95 for strain, and 0.90 for regional blood flow, P<0.001 for all). The combined assessment of myocardial perfusion and deformation correctly predicted LV remodeling in four additional patients, compared with each technique separately. Contrast echocardiography, strain Doppler imaging, and possibly the combination of both are useful for the prediction of adverse LV remodeling and for the early risk stratification of patients with STEMI.

Early posttransplant hepatic venous outflow obstruction: Long-term efficacy of primary stent placement

Although balloon angioplasty has been accepted as the safe and effective initial treatment to manage hepatic venous outflow abnormalities, it may induce rupture of the fresh anastomosis but also may be ineffective to eliminate various etiologies of venous outflow abnormalities in the early post-transplant period. Therefore, we performed primary stent placement in 108 patients to treat early-onset (</=4 weeks) post-transplant hepatic venous outflow abnormality. The following parameters were documented retrospectively: technical success and complications: clinical success; recurrence; and patency of stent-inserted hepatic veins.Technical success was achieved in 166 (97.6%) of 170 anastomoses (107 patients). Major complications occurred in 5 (4.6%) patients: partial stent migration (n = 2) and stent malposition (n = 3). Clinical success was achieved in 83 (82.2%) of 101 patients who had abnormal liver enzymes or clinical symptoms. Seven patients without initial clinical symptoms have remained healthy. Restenosis or occlusion of the stent-inserted hepatic veins was documented in 22 patients at a mean of 9.6 +/- 8.6 months after stent placement. Four of them underwent stent replacement or retransplantation due to liver function deterioration. Overall 1-, 3-, and 5-year primary patency rates were 82.3 +/- 0.3%, 75.0 +/- 0.4%, and 72.4 +/- 0.5%, respectively. Multivariate Cox regression analysis showed that diameter of stents was an independent factor associated with patency of stents (p = 0.001).Primary stent placement seems to be an effective treatment modality with an acceptable long-term patency to treat early post-transplant hepatic venous outflow obstruction.

Comparison of Primary Angioplasty With Stent Placement for Treating Symptomatic Intracranial Atherosclerotic Diseases

We sought to compare the clinical outcomes between primary angioplasty and stent placement for symptomatic intracranial atherosclerosis. We retrospectively analyzed the clinical and angiographic data of 190 patients treated with 95 primary angioplasty procedures and 98 intracranial stent placements (total of 193 procedures) in 3 tertiary care centers. Stroke and combined stroke and/or death were identified as primary clinical end points during the periprocedural and follow-up period of 5 years. The rates of significant postoperative residual stenosis (>/=50% of greater stenosis immediately after the procedure) and binary restenosis (>/=50% stenosis at follow-up angiography within 3 years) were also compared. The comparative analysis was performed after adjusting for age, sex, and center. Fourteen procedures in the angioplasty-treated group (15%) and 4 in the stent-treated group (4.1%) had significant postoperative residual stenosis (relative risk [RR]=2.8, 95% CI, 0.85 to 9.5, P=0.09, for the adjusted model). There were 3 periprocedural deaths (1.5%), 1 in the angioplasty group (1.1%) and 2 in the stent-treated group (2.0%) and 14 periprocedural strokes (7.3%), 7 periprocedural strokes in each group (7.4% and 7.1%, respectively; hazard ratio=1.1; 95% CI, 0.57 to 1.9, P=0.85). Angiographic follow-up was available for 134 procedures (66 angioplasty-treated and 68 stent-treated cases). Forty-eight procedures (36.1%) had evidence of binary restenosis (25 of 66 angioplasties, 23 of 68 stents, P=0.85). Binary restenosis-free survival at 12 months was 68% for the angioplasty-treated group and 64% for the stent-treated group. There was no difference in follow-up survival (stroke, or stroke and/or death) between the angioplasty-treated and the stent-treated groups (hazard ratio=0.54; 95% CI, 0.11 to 2.5, P=0.44 and hazard ratio=0.50; 95%, CI 0.17 to 1.5, P=0.22, respectively, after adjusting for age, sex, and center). The stroke- and/or death-free survival at 2 years for the angioplasty-treated group and the stent-treated group was 92+/-4% and 89+/-5%, respectively. Stent treatment for intracranial atherosclerosis may lower the rate of significant postoperative residual stenosis compared with primary angioplasty alone. No benefit of stent placement over primary angioplasty in reducing stroke or stroke and/or death could be identified in this study.

Catheter‐based treatment of the subclavian and innominate arteries

We report outcomes in patients undergoing catheter-based intervention for symptomatic subclavian and innominate artery (S/IA) atherosclerosis. Symptomatic S/IA obstructive lesions have traditionally been treated with open surgical revascularization. Catheter-based endovascular therapies reduce the morbidity and mortality associated with surgery in many vascular beds. Between December 1993 and May 2006, 170 patients underwent primary stent placement in 177 S/IA arteries. Indications for revascularization included arm ischemia (57%), subclavian steal syndrome (37%), coronary-subclavian steal syndrome (21%), and planned coronary bypass surgery with the involved internal mammary artery (8%). Technical success was achieved in 98.3% (174/177) arteries, including 99.4% for stenotic lesions (155/156) and 90.5% for occlusions (19/21). There were no procedure-related deaths and one stroke (0.6%, 1/170). Follow-up was obtained in 151 (89%) patients at 35.2 +/- 30.8 months, with a target vessel revascularization rate of 14.6% (23/157). At last follow-up, 82% (124/151) of all treated patients remained asymptomatic with a primary patency of 83% and a secondary patency of 96%. Catheter-based revascularization with stents for symptomatic S/IA lesions is safe and effective with excellent patency rates and sustained symptom resolution in the majority (>80%) of patients over 3 years of follow-up. Percutaneous primary stent therapy is the preferred method of revascularization in patients with suitable anatomy.

CONCURRENT COMPARISON OF OUTCOMES OF PRIMARY ANGIOPLASTY AND OF STENT PLACEMENT IN HIGH-RISK PATIENTS WITH SYMPTOMATIC INTRACRANIAL STENOSIS

To compare the long-term outcomes of treatment of symptomatic intracranial stenosis using primary angioplasty or stent placement. Both primary angioplasty and stent placement have been proposed as treatment modalities, but long-term outcome comparisons are not available. We determined rates of technical success and rates of major stroke, second procedure, or death in patients with symptomatic intracranial stenosis (>or=70% in severity and/or medication failure). Pre- and posttreatment angiographic stenosis was measured by independent reviewers. Angioplasty was used preferentially in patients with more technically challenging lesions. Kaplan-Meier analysis was used to determine the rate of major stroke-free survival and major stroke- or repeat procedure-free survival between the two treatment modalities over periods of 12 and 24 months. Cox proportional hazards analysis was used to determine the differential risk of major stroke or death after either angioplasty or stent placement. Twenty-two patients (mean age, 62 +/- 13 yr) were treated with primary angioplasty and 22 patients (mean age, 58 +/-14 yr) with stent placement. The mean stenosis (+/-standard deviation) decreased from 76 +/- 13% to 28 +/- 18% in the primary angioplasty-treated and from 68 +/- 9% to 17 +/- 13% in the stent-treated group. There was no difference in time to major stroke or death (log-rank statistic, 0.44; P = 0.5), and time to major stroke, repeat procedure, or death (log-rank statistic, 0.78; P = 0.4) between the two treatment groups. At 12 months, major stroke-free survival was 95% (+/- standard error of 4%) for the stent-treated patients and 93% (+/- standard error of 7%) for the angioplasty-treated patients. There was no significant difference in the risk of major stroke or death between angioplasty and stent placement (P = 0.996) using Cox proportional hazards analysis after adjusting for age, gender, race/ethnicity, presence of hyperlipidemia, qualifying event, preprocedure stenosis, and target vessel. The results of primary angioplasty and primary stent placement were comparable at intermediate follow-up examination after the procedure. The results highlight the need for carefully designed, randomized clinical trials to determine the precise value of stent placement in the intracranial circulation.