Repeat Stenting Research Articles

Fibrin Sheath Angioplasty: A Technique to Prevent Superior Vena Cava Stenosis Secondary to Dialysis Catheters

Fibrin sheaths are a heterogeneous matrix of cells and debris that form around catheters and are a known cause of central venous stenosis and catheter failure. A total of 50 cases of central venous catheter fibrin sheath angioplasty (FSA) after catheter removal or exchange are presented. A retrospective review of an outpatient office database identified 70 eligible patients over a 19-month period. After informed consent was obtained, the dialysis catheter exiting the skin was clamped, amputated, and a wire was inserted. The catheter was then removed and a 9-French sheath was inserted into the superior vena cava, a venogram was performed. If a fibrin sheath was present, angioplasty was performed using an 8 × 4 or 10 × 4 balloon along the entire length of the fibrin sheath. A completion venogram was performed to document obliteration of the sheath. During the study, 50 patients were diagnosed with a fibrin sheath, and 43 had no pre-existing central venous stenosis. After FSA, 39 of the 43 patient's (91%) central systems remained patent without the need for subsequent interventions; 3 patients (7%) developed subclavian stenoses requiring repeat angioplasty and stenting; 1 patent (2.3%) developed an occlusion requiring a reintervention. Seven patients with prior central stenosis required multiple angioplasties; five required stenting of their central lesions. Every patient had follow-up fistulograms to document long-term patency. We propose that FSA is a prudent and safe procedure that may help reduce the risk of central venous stenosis from fibrin sheaths due to central venous catheters.

P-043 Stenting for pseudotumor: angiographic and hemodynamic follow-up and patterns of hemodynamic failure

Introduction/purposeStenting of a dural sinus for idiopathic intracranial hypertension (IIH) (pseudotumor cerebri), is becoming recognized as a potential cure for the subgroup of patients who have venous outflow obstruction. The...

Safety and 1-year revascularization outcome of SilverHawk atherectomy in treating in-stent restenosis of femoropopliteal arteries: A retrospective review from a single center

Treatment of in-stent restenosis of the femoropopliteal arteries with balloon angioplasty carries a high rate of recurrence and requires frequent repeat stenting. In the "Instructions for Use," SilverHawk atherectomy (SA) is contraindicated for in-stent restenosis at a peripheral site. SA, however, has a theoretical advantage of reducing the volume of restenotic tissue and potentially delaying the need for frequent repeat revascularization and additional stenting. We present a retrospective analysis from our center on the safety and outcomes of SA in the treatment of in-stent restenosis of the femoropopliteal arteries. Demographic, clinical, angiographic, and procedural data were collected on all patients who underwent SA for in-stent restenosis from February 2005 to April 2010 at a single medical center. Major adverse events and 1-year target lesion revascularization (TLR) and target vessel revascularization (TVR) were obtained by review of medical records and phone calls. Descriptive analysis was performed on all variables. Kaplan-Meier survival curves for TVR were plotted. A total of 41 consecutive patients (mean age 70.9±9.2 years, 56% males) were included and followed for a mean of 331.63 days. The following variables were noted: mean ankle brachial index (ABI) of treated leg 0.66±0.2; chronic renal failure (creatinine >2.0 at baseline) 14.6%; diabetes 61%; history of smoking 85.4%; number of vessel runoffs of treated limb 1.9±0.9; hypertension 90.2%; lesion length 126.2±79.3mm; lesion severity 90.7±8.2%; vessel diameter 5.8±0.7 mm. All patients received bivalirudin during the procedure and were on aspirin. Ninety-five percent of patients were placed on clopidogrel. Adjunctive balloon angioplasty was performed in 97.6% at a mean pressure of 11.9±3.3atm. Embolic filter protection (EFP) was used in 56.1% of patients. Bailout stenting was 24.4%. Acute procedural success (<30% angiographic residual narrowing) occurred in 100% of patients. Compared to baseline, ABI at 1 month significantly improved to 0.91±0.19 (P<0.05) but was not statistically different at 1 year (0.61±0.28). Debris was noted in 81.9% of filters used; 36.4% were macrodebris. The following adverse events were reported: distal embolization (DE) requiring treatment 7.3%; stent thrombosis 4.9%; planned minor amputation in the nonindex limb 2.4%. No device-related complications occurred. There was no death or amputation. TLR and TVR occurred in 31.7% and 34.1%, respectively. SA has favorable acute results in treating in-stent restenosis of the femoropopliteal arteries. At 1 year, TLR and TVR remain high but compare favorably to published data. DE also occurs significantly with SA and EFP appears to be effective in capturing the debris.

Twelve-month clinical outcomes after coronary stenting with the Genous Bio-engineered R Stent in patients with a bifurcation lesion

The e-Healthy Endothelial Accelerated Lining Inhibits Neointimal Growth (e-HEALING) registry was designed to capture clinical data on the use of the endothelial progenitor cell capture stent (ECS) in routine clinical practice. In this analysis, we investigated the 12-month clinical outcomes in patients treated with an ECS for a bifurcation lesion. The worldwide, prospective, nonrandomized e-HEALING registry aimed to enroll 5000 patients treated for coronary artery disease with one or more ECS between October 2005 and October 2007. Clinical follow-up was obtained at 1, 6, and 12 months. The primary endpoint was target vessel failure (TVF), defined as the composite of cardiac death, myocardial infarction, and target vessel revascularization at 12 months. A total of 573 patients were treated for at least one bifurcation lesion and were assessed in the current analysis. Baseline characteristics showed a median age of 65 years; 21% were diabetic patients and 36% had unstable angina. A total of 63% of the bifurcation lesions were located in the left artery descending and the mean stent length was 20.7±12.6 mm. At 12 months, TVF was 12.7% and target lesion revascularization was 7.5%. Definite or probable stent thrombosis occurred in 1.7% of the patients. Moreover, one or more stents per lesion [hazard ratio (HR): 2.79, 95% confidence interval (CI): 1.60-4.86, P<0.001], predilatation (HR: 0.39, 95% CI: 0.17-0.87, P=0.023), and lesions located in the right coronary artery (HR: 4.56, 95% CI: 1.07-19.5, P=0.041) were independent predictors of TVF. In the e-HEALING registry, coronary bifurcation stenting with the ECS results in favorable clinical outcomes and low incidences of repeat revascularization and stent thrombosis.

Repeat percutaneous coronary revascularization: Indications and outcomes in a “Real World” cohort

To investigate rates of and reasons for second and subsequent stent procedures in an unselected, "real-world" population. Repeat stenting is the primary difference reported in clinical trials of alternative revascularization strategies. The incidence, indication, and outcome for repeat stenting in contemporary practice outside the more selective populations of trials and registries has not been described. All patients undergoing a first percutaneous coronary intervention (PCI) procedure with stenting from January 2001 to August 2009 (10,509) from a large UK tertiary referral and district general hospital were identified. Mortality and the incidence, timing, and indication for repeat revascularization in this population were investigated from patient records. Of 10,509 patients undergoing a first PCI and stent implant 23.5% underwent repeat angiography of which 11.2% required repeat PCI and 2% coronary artery bypass grafting (median follow-up of 3.8 years). A total of 1.3% went on to a third PCI. The commonest indication for repeat stenting was disease progression remote from the original stent (46%) and planned staged PCI (23%); 21% had a stent-related indication. Functional assessment before repeat stenting was used in one-third of stable patients. Mortality was 2.5% per annum. In contemporary practice, patients undergoing a first stenting procedure have a low subsequent mortality, and the substantial majority (86.4%) requires no further revascularization over a median 3.8 year follow-up. For those who do require repeat stenting, this is most commonly at a site remote from the first stent.

Repeat Procedures Within 30 days in Patients Stented for Malignant Distal Biliary Strictures: Experience of 508 Patients at a Tertiary Referral Center.

BackgroundStent related occlusion and migration remains a problem despite attempts to improve stent design over this time period. Flanged polyethylene plastic stents (FPS) remains the stent of choice in most centers. Early failure of stents placed for malignant extrahepatic biliary strictures (MEBS) has not previously been studied in detail. We set out to determine the incidence and reasons for biliary stent change within 30 days of the index procedure in a large tertiary center population during a period where (FPS) was the sole plastic stent used.MethodsRetrospective analysis of endoscopic retrograde cholangiography (ERCP) was undertaken in patients who were stented for presumed or known MEBS between 1993 and 2001. Patients who required repeat stenting within 30 days were identified.ResultsAll 508 patients were stented for MEBS. 5.7% of patients had a total of 34 repeat stenting procedures within 30 days of the index procedure; 27of 29 index stents were plastic, 2 were self-expandable metal stents (SEMS), 20 (3.9%) patients had stent failure as the reason for a stent exchange (plastic stent occlusion n = 15, mean time to stent change 14 ± 8.3 days; metal stent occlusion n = 2, mean time to stent change 24.5 ± 7.8 days; plastic stent migration n = 3, mean time to stent change 25 ± 5.3 days). There was a statistically significant difference in the time to stent change between the occluded plastic stent and migrated plastic stent cases (P = 0.045, 95% CI -21.7 to -0.29). 6 patients spent at least 2 additional days in hospital as a result of stent failure.ConclusionsEarly stent failure is an uncommon problem, especially in patients with SEMS. Early plastic stent failure appears to occur sooner with stent occlusion than with stent migration. Early stent failure is associated with significant morbidity and bears an economic impact in additional procedures and hospital stay.

Endoscopic Stenting for Treatment of Leaks Following Sleeve Gastrectomy

Background: Sleeve gastrectomy has become a valuable and effective option in the treatment of morbid obesity. Although a safe procedure overall, the operation does have a significant potential complication in the form of staple line leak. One of the strategies described to treat this complication is the placement of esophageal stents. We describe our experience with the placement of covered esophageal stents as a first -line treatment of staple line leakage after sleeve gastrectomy.Methods: A retrospective review of all patients undergoing sleeve gastrectomy at our institution from 28th June 2004 to 31st Oct 2011 was performed. Patients presenting with staple line leak were identified. Also included were patients transferred from outside institutions with this diagnosis. In all cases, the leak was treated with esophageal stent placement. Outcomes of interest included rate of resolution, body mass index (BMI) and time at presentation.Results: Four patients were identified with a diagnosis of staple line leak after laparoscopic sleeve gastrectomy. Time at presentation was 35 ± 47.7 weeks postoperatively. BMI was 45 ± 2.25. In all cases, the leak was successfully managed with endoscopic placement of covered esophageal stent. In two cases, the patients required multiple stent placements.Conclusion: Staple line leaks after sleeve gastrectomy can be successfully and safely managed with endoscopic placement of covered metal stents. Stenting should be considered as first-line treatment of these complications. Optimal duration of stent therapy is 6 to 8 weeks although repeat stent placement may be required.

Dural sinus stent placement for idiopathic intracranial hypertension

The use of unilateral dural sinus stent placement in patients with idiopathic intracranial hypertension (IIH) has been described by multiple investigators. To date there is a paucity of information on the angiographic and hemodynamic outcome of these procedures. The object of this study was to define the clinical, angiographic, and hemodynamic outcome of placement of unilateral dural sinus stents to treat intracranial venous hypertension in a subgroup of patients meeting the diagnostic criteria for IIH. Eighteen consecutive patients with a clinical diagnosis of IIH were treated with unilateral stent placement in the transverse-sigmoid junction region. All patients had papilledema. All 12 female patients had headaches; 1 of 6 males had headaches previously that disappeared after weight loss. Seventeen patients had elevated opening pressures at lumbar puncture. Twelve patients had opening pressures of 33-55 cm H(2)O. All patients underwent diagnostic cerebral arteriography that showed venous outflow compromise by filling defects in the transverse-sigmoid junction region. All patients underwent intracranial selective venous pressure measurements across the filling defects. Follow-up arteriography was performed in 16 patients and follow-up venography/venous pressure measurements were performed in 15 patients. Initial pressure gradients across the filling defects ranged from 10.5 to 39 mm Hg. Nineteen stent procedures were performed in 18 patients. One patient underwent repeat stent placement for hemodynamic failure. Pressure gradients were reduced in every instance and ranged from 0 to 7 mm Hg after stenting. Fifteen of 16 patients in whom ophthalmological follow-up was performed experienced disappearance of papilledema. Follow-up arteriography in 16 patients at 5-99 months (mean 25.3 months, median 18.5 months) showed patency of all stents without in-stent restenosis. Two patients had filling defects immediately above the stent. Four other patients developed transverse sinus narrowing above the stent without filling defects. One of these patients underwent repeat stent placement because of hemodynamic deterioration. Two of the other 3 patients had hemodynamic deterioration with recurrent pressure gradients of 10.5 and 18 mm Hg. All stents remained patent without restenosis. Stent placement is durable and successfully eliminates papilledema in appropriately selected patients. Continuing hemodynamic success in this series was 80%, and was 87% with repeat stent placement in 1 patient.

An Unusual Case of Stent Migration After Celiac Trunk Endovascular Revascularization

A 61-year-old woman underwent celiac trunk stenting to treat abdominal angina. Three months later, she was readmitted for recurrent symptoms. Computed tomography control revealed the migration of the stent into the splenic artery. No sign of vessel injury or end-organ ischemia was detected. Repeat stenting of the celiac trunk was performed; the postoperative course was uneventful. 12 months later, the patient was asymptomatic with the second stent in its correct position, and she was asymptomatic for mesenteric ischemia.

Extensive distortion and dysfunction of an Edwards Valeo lifestent placed for stenosis of the superior vena cava

We present a case of multiple interventions to treat symptomatic stenosis of the superior vena cava in a child, with end-stage renal disease and a history of long-term hemodialysis, who had required indwelling central venous catheters for several years. The stenosis was successfully treated with an Edwards Valeo Lifestent, but recurrent symptomatic superior vena caval stenosis developed within 5 months, requiring repeat catheterization and stent placement.

Elevated stricture rate following the use of fully covered self-expandable metal biliary stents for biliary leaks following liver transplantation

Biliary leaks and strictures are common complications after liver transplantation and can be managed surgically or endoscopically. Endoscopic management using fully covered self-expandable metal stents (FCSEMS) might provide some advantages over the commonly used plastic stents in the management of bile leaks after liver transplantation. Between December 2006 and January 2009, 17 liver transplant recipients underwent placement of a FCSEMS for treatment of biliary leaks. FCSEMS were deployed at median of 18 days (range: 6 - 160) after liver transplantation and left in place for a median of 102 days (range: 35 - 427), with a median follow-up after FCSEMS removal of 407 days (range: 27 - 972). Long-term leak control was obtained in all but one patient. Complications included 6 clinically significant biliary strictures (35 %), which were treated with repeat stent placement, and two clinically insignificant strictures (12 %) which required no intervention. Additionally, three patients (18 %) had biliary ulcerations after stent removal, confirmed by choledochoscopy, and were managed conservatively. Two patients required repeat liver transplantation due to hepatic artery thrombosis, and one patient died from sepsis unrelated to FCSEMS stenting. FCSEMS treat biliary leaks effectively, but carry a relatively high stricture risk in patients who have received liver transplants. FCSEMS cannot be recommended for management of biliary leaks following liver transplantation at this point.

Treatment of renal artery bifurcation stenosis due to fibromuscular dysplasia by kissing balloon technique and intrarenal stent deployment: A case report

Renal artery stenosis due to fibromuscular dysplasia is well treated by PTA, but in some cases repeat PTA or stent placement may be necessary. In this paper, we report a case of distal renal arterial lesion affecting both branches of the renal artery and complicated with a bifurcation aneurysm which was treated by kissing PTA and intrarenal stent placement in a hypertensive patient. Satisfactory angiographic result was achieved and the patient remained normotensive on no medication for nine months follow up period. In rare ocasions, renal artery stent placement even into intrarenal branches can be used safely and effectively.

A multicenter analysis of safety and outcome of removal of a fully covered self-expandable metal stent during ERCP

Fully covered self-expandable metal stents (FCSEMSs) have been used for palliation of both malignant and benign biliary strictures. Limited data are available about safety and outcome of endoscopic removal of these stents. To evaluate safety and efficacy of endoscopic removal of FCSEMSs. Retrospective review of patients who underwent endoscopic removal of Viabil FCSEMSs. Four centers with experience in using FCSEMSs. Thirty-seven patients who had stents endoscopically removed. ERCP with endoscopic removal of FCSEMSs. Feasibility, safety, and complications associated with endoscopic removal of FCSEMS. All 37 stent removal attempts were successful and were achieved without difficulty. Indwelling stent-related complications occurred in 4 of 37 patients, including secondary strictures in 3 and minor bile leak in 1. Two of 3 secondary strictures occurred at the distal stent margin of oversized intraductal stents, and another stricture occurred at a proximal stent margin of an oversized transpapillary stent. One case of minor confined intratumoral bile leak also occurred in a patient with metastatic urothelial cancer of the bile duct. All of these cases were successfully treated with repeat stenting and resolved without sequelae. No free perforations or significant bleeding occurred. Retrospective study. Endoscopic removal of Viabil FCSEMSs placed for benign or malignant conditions is feasible and easily accomplished. Secondary strictures may be found at the time of stent removal or with a delayed presentation in patients with oversized stents who may require repeat stent placement.

Postprocedural Peak Systolic Blood Flow Measurements Correlate with the Need for Stent Reintervention at 12 Months

Purpose Duplex surveillance of arterial stents has focused on detecting in-stent restenosis. Although velocity is commonly reported, that differs from blood flow, and patency of arterial prostheses is flow-dependent. Preliminary evaluation was performed to determine if postprocedure peak systolic blood flow (PSF) through stents correlates with rate of repeat intervention at 12 months. Materials and Methods Retrospective review of consecutive patients undergoing arterial stent placement was performed. Demographics, comorbidities, stent size, postprocedure duplex information, and repeat intervention rates were recorded. PSF was calculated by using peak systolic velocity (PSV) and stent dimensions. Results Consecutive stents ( N = 35) were placed in 27 patients (mean age, 72.6 y ± 14). Twenty stents were free from repeat intervention (FR) and 15 required repeat intervention (RR) at 12 months. There was a significant difference between FR and RR groups with respect to initial in-stent PSV and PSF (92.5 cm/s for FR vs 43.7 cm/s for RR [ P < .002]; 1,918 mL/min for FR vs 722 mL/min for RR [ P < .0001]). PSF showed sensitivity, specificity, and accuracy rates of 92%, 82%, and 86.2%, respectively, for predicting repeat intervention, versus 83%, 71%, and 76% for PSV. Receiver operating characteristic curve analysis showed a greater area under the curve for PSF versus PSV (0.965 vs 0.859). Conclusions PSF from an initial postprocedure duplex study accurately correlates with need for repeat stent intervention at 12 months. PSV had a lower sensitivity, specificity, and accuracy. This preliminary finding must be confirmed by prospective studies in individual vascular beds and larger patient populations. A new approach to stent surveillance is suggested.

Current status of the Xience V® everolimus-eluting coronary stent system

The introduction of drug-eluting stents has led to a marked reduction of restenosis, which is a major limitation of percutaneous coronary intervention for coronary artery disease. The next-generation Xience V® (Abbott Vascular, CA, USA) everolimus-eluting stent was designed to address the limitations of first-generation drug-eluting stents. The cobalt–chromium stent platform with an open-cell design offers excellent deliverability. Moreover, the combination of a thin fluoropolymer eluting the antirestenotic drug everolimus provides both an effective suppression of neointimal tissue and rapid re-endothelialization above and between stent struts in preclinical studies. Large randomized clinical trials comparing the everolimus-eluting stent with the Taxus Express® and Liberté® (Boston Scientific, MA, USA) paclitaxel-eluting stents have shown reduced rates of repeat revascularization, myocardial infarction and stent thrombosis at 1-year follow-up with the everolimus-eluting stent. However, we will have to await long-term (5-year) data from these randomized clinical trials with the everolimus-eluting stent to determine whether the observed benefit is robust. Furthermore, data are currently limited the clinical performance of the everolimus-eluting stent relative to drug-eluting stents other than the Taxus Express and Liberté paclitaxel-eluting stents, although a large number of trials are now being conducted to address these questions. In this article, we provide a comprehensive overview of (pre)clinical studies with the everolimus-eluting stent.

The Traction that Broke the Anti-reflux Stentʼs Back - A Rare but Important Complication

Purpose: The Cook Dua Esophageal Stent with Anti-Reflux Valve was developed to reduce reflux of stomach contents in patients with cancers of the esophagus. We report a case of a spontaneously torn anti-reflux flap previously noted to be in working order. Methods: The patient was a 55-year-old male with metastatic distal esophageal adenocarcinoma with progressive dysphagia. Previous placement of a partially covered esophageal Wallflex stent had allowed oral intake, but resulted in significant reflux symptoms secondary to the stent traversing the gastroesophageal junction. Decision to attempt placement of a Dua Anti Reflux Stent within the previously placed stent in order to curb the reflux of gastric contents. A gastroscope was advanced to the stomach traversing the previously placed Wallstent, retroflexion revealed the stent to be well situated beneath the lower esopohageal sphincter. A 12 cm Cook esophageal Z-stent with Dua anti-reflux valve was then passed over a Savory guide-wire with the distal most radio-opaue marker positioned over the distal margin of the previous stent. The stent was deployed into excellent position under fluroscopic guidance. The gastroscope was then advanced with no resistance and verification of positioning of both stents was confirmed. Post placement x-ray showed no evidence of perforation or migration and the patient was discharged with symptomatic improvement in reflux related discomfort. Results: Two weeks post placement, the patient returned with unbearable chest pain secondary to progressive reflux symptoms. The patient had severe dysphagia to both liquids and solids and had no chest wall tenderness and crepitis. Repeat Esophagogastroduodenoscopy (EGD) with fluroscopy revealed the two stents to be in good position. The scope was passed through the center of the stents into the stomach. The anti-reflux flaps of the Dua stent appeared to be partially torn along the distal edge of the stent with prolapse into the esophagus. A rat tooth forceps was used to grasp the proximal edge of the Z- stent and under fluroscopic guidance the stent was removed. The endoscope was passed again through the previous Wallflex stent which remained in good position without migration and tissue in-growth. The patient was medically managed for reflux and will be considered for repeat stent placement. Conclusion: Previous reports have noted overstrain or defective materials as the reason for the rupture. We believe the etiology of the tear of the anti-reflux valve in this instance to be from direct contact injury from the distal edge of the previously placed Wallflex esophageal stent. We recommend that post-placement tear with consequent dysphagia and recurrent reflux symptoms be cited as a potential complication.

Reconstruction of late‐onset transplant ureteral stricture disease

• To describe our experience with surgical management of transplant ureteral strictures over a 6-year period. • The present study identified patients who underwent open reconstruction for transplant ureteral strictures between March 2002 and May 2008 after kidney or kidney-pancreas transplantation. • Baseline clinical characteristics were documented, including age at transplantation and reconstruction, serum creatinine levels, immunosuppressive drug regimen, and comorbidities. • Postoperative complications were noted, including urinary tract infections, stricture recurrence and graft failure. • Successful reconstructions were defined as stable allograft function with unobstructed outflow not requiring repeat dilation, ureterotomy or stent placement. • Median age at the time of reconstruction was 51 years and the mean time from transplantation was 62 months. • Seven of the 13 patients had failed previous balloon dilation. • The patients were followed for a median of 41 months and a successful repair was achieved in 10 of 13 patients. • Ureteral strictures recurred in two patients who received ureteroneocystostomies, which were subsequently managed with chronic stent exchanges. • Another recurrence involved a 1.5-cm anastomotic stricture 6 months postoperatively, which was balloon-dilated and has remained recurrence-free for 16 months. • Patients who present > 6 months after renal transplantation with ureteral strictures that are recalcitrant to endoscopic management can safely undergo open surgical ureteral reconstruction without subsequent renal or graft failure. • Further investigation involving a larger patient cohort is required to confirm these initial results.

130 Repeat percutaneous revascularisation after coronary stenting: a single centre 9 year experience

Introduction Repeat revascularisation after coronary angioplasty and stenting is well recognised, a feature of most prospective trials of percutaneous intervention (PCI) and is a major difference reported in trials comparing surgical to percutaneous revascularisation strategies. We investigated outcomes and repeat procedures in some 25 000 consecutive patients over 9 years from a UK teaching hospital. Methods Between January 2001 and August 2009, 24 521 patients presented to the John Radcliffe Hospital Oxford for coronary angiography. Revascularisation procedures in the follow-up period were analysed using the procedural database, stored angiographic images and from casenote review. Results 10 697 (43.6%) underwent PCI with stenting, 832 (3.4%) PCI alone, 4589 (18.7%) coronary artery bypass surgery (CABG) and 8133 (33.2%) medical treatment. Two thousand four hundred and seventy-seven of the 10 697 stented patients (23.2%) returned for a second angiogram and 1314 (12.3%) underwent further stenting and 211 (2.0%) CABG over a median follow-up of 4.25 years (IQR 2.13–6.13 years). Three hundred and eighty-four patients (29.2%) of those requiring a second stenting procedure underwent a third angiogram during the follow-up period and 161 (12.3%) underwent further stenting and 33 (2.5%) CABG. Rates of stenting for the fourth, fifth and sixth procedures were respectively 21%, 24% and 38% representing 0.3%, 0.1% and 0.02% of the initial stented cohort (Abstract 130 Figure 1). 59.9% of repeat PCI stenting procedures were elective, 38.1% urgent and 1.5% primary. Clinical indications for repeat stenting are shown in Abstract 130 Figure 2. A minority of patients (15.7%) required restenting for in-stent restenosis with most patients returning either with disease progression in an unstented area (45.2%) or for staged PCI (25.2%). Stent thrombosis as an indication for repeat stenting was rare (3.3%). Of those requiring restenting, 37.2% patients received drug eluting stents (DES) in their first stenting procedure and 62.8% received bare metal stents (BMS) alone. 5.4% of patients had both DES and BMS in the same procedure. This did not differ significantly from the ratio of DES/BMS in those patients undergoing stenting who did not require further revascularisation in the follow-up period (39% DES, 61% BMS, 14.8% both DES and BMS). 19.3% people requiring a second stenting procedure had multi vessel stenting at first PCI. Conclusion and Implications This study shows that in a large unselected ‘real world’ cohort of patients undergoing stenting, a substantial minority of patients undergoing a first stenting procedure will require repeat assessment (23%) and/or repeat stenting (12%). However the driving force behind repeat stenting procedures is progression of disease distant from the site of the first stent (45%) and staged PCI (25%) rather than isolated stent-related restenosis which accounts for under 16% of second stenting procedures and thus a minority of restenting cases.

Repeat Angioplasty and Stenting for Femoropopliteal Occlusive Disease: Factors Affecting Outcomes of the Second-Time Endovascular Intervention

Introduction: Repeat percutaneous interventions for femoropopliteal occlusive disease are common, but the outcomes are poorly understood. We sought to determine the results of second-time femoropopliteal percutaneous transluminal angioplasty/stenting (SPTAS) and identify factors associated with outcome. Methods: A retrospective review of patients undergoing multiple percutaneous lower extremity procedures at a single institution from 2002 and 2007 identified 73 SPTAS in 73 limbs. Patient comorbidities, anatomic, and procedural characteristics were analyzed with respect to outcomes with descriptive statistics, life-table analysis, and Cox proportional hazards modeling. Patency rates were determined from the time of SPTAS. Results: Patients included 39 men (64%) and 22 women (36%) at a mean age of 70 ± 10 years. Indications included claudication in 56 limbs (77%) and critical limb ischemia in 17 (23%). Median time from the initial endoluminal intervention to SPTAS was 322 days. Twenty limbs (27%) had TransAtlantic Inter-Society Consensus II (TASCII) category D lesions; the rest were treated for TASCII A, B, and C disease. Technical success was achieved in 72 patients (99%) and initial clinical improvement in 64 (89%). During a mean follow-up of 15.3 months, 2-year primary patency, assisted primary patency, secondary patency, limb salvage, and survival were, respectively, 66% ± 8%, 86% ± 4%, 86% ± 4%, 97%, and 89%. Cox proportional hazard modeling showed that SPTAS ≤180 days of the initial endovascular intervention was the only significant predictor of failure of SPTAS primary patency (hazard ratio, 3.5; 95% confidence interval, 1.1-11). TASCII D classification was associated with failure of assisted primary and secondary patency. Conclusions: Second-time femoropopliteal angioplasty/stenting has excellent initial success but limited midterm primary patency. The need for early SPTAS is highly associated with failure of primary patency and the need for additional interventions. With vigilance, good midterm assisted primary and secondary patency in those with limited extent of disease as well as excellent limb salvage can be achieved.

Post-Transcatheter Aortic Valve Implantation (TAVI) Heart Block in the Self-Expandable and Balloon Expandable Valves

longer-termoutcomes inpatients treatedwithPAMIusing BMS and DES. Methods: Consecutive patients with STEMI undergoing PAMI from August 2006 to 2009 were included in this retrospective study. PAMI was defined as the primary reperfusion modality for STEMI presenting within 12h of symptoms.Outcomes assessed includeddeath,MI, repeat coronary angiogram, re-intervention and stent thrombosis. Results: A total of 205 patients (62± 11 yrs, 77% male) were included. 171 patients had BMS, 25 had DES and 9 had mixed stents (excluded). The mean follow-up was 15± 10 months for BMS and 9± 8 months for DES.