Short Stent Research Articles

Endoscopic Management of Postlaparoscopic Sleeve Gastrectomy Leaks: A Single-Center Experience

Abstract Introduction Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Sleeve leak is the most important complication, with an incidence of 1.9 to 2.4%. Various endoscopic approaches to LSG have been used, including self-expanding metal stents (SEMSs), glue injection, and clipping along with percutaneous drainage. This study was aimed to study the role of endotherapy in the management of post-LSG leaks. Methods This study included patients referred for endotherapy for post-LSG leak between January 2016 and December 2018. We maintained data prospectively, which included the location and type of leak, type of endotherapy, adverse events, and time for leak closure. Primary endotherapy included mega SEMS placement; if it failed, then secondary endoscopic therapy was performed. Results Seven patients (four females, with a mean age of 45.2 years) with a preoperative body mass index of mean 38.5 kg/m2 underwent endotherapy for post-LSG leaks. Two were acute, four were early, and the remaining one was late leak. Five were located proximally near gastroesophageal junction and two at the midsleeve level. In four (57.1%) patients, the leak was resolved by primary therapy. Three patients underwent secondary therapy that included overlapping SEMS placement (in one patient), SEMS replacement (in one patient), and short plastic biliary stent placement with Argon plasma coagulation (APC) to create a raw surface and induce granulation tissue. The median duration for leak closure was 12 weeks (range: 8–24 weeks). One patient who had partial distal migration underwent overlapping SEMS placement. Three patients had nonbleeding ulcers at the distal end of SEMS at removal. Conclusion Endotherapy is effective and safe for the management of post-LSG leaks. Additional endotherapy can be used if primary therapy is not successful for resolution of the leak.

Troubleshooting for severe acute cholangitis caused by proximally migrated metal stent into the intrahepatic bile duct: Stent shortening via a balloon catheter.

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Long-term outcomes of a long, partially covered metal stent for EUS-guided hepaticogastrostomy in patients with malignant biliary obstruction (with video)

We previously reported safety and effectiveness of EUS-guided hepaticogastrostomy (EUS-HGS) using a long, partially covered metal stent (LP-CMS) for malignant biliary obstruction (MBO). In this study, we aimed to evaluate long-term outcomes of EUS-HGS in an expanded cohort. One hundred ten patients undergoing EUS-HGS using an LP-CMS in 2 centers were retrospectively studied. Technical and functional success, adverse events, recurrent biliary obstruction (RBO), and reinterventions were evaluated. The cause of MBO was pancreatic cancer in 50%, and the location of MBO was distal in 68%. The stent length was 8 cm in 2%, 10 cm in 84%, and 12 cm in 15%, with a median intragastric stent length of 54mm. Technical and functional success rates were 100% and 94%, respectively. The adverse event rate was 25% (mild 15%, moderate 7%, severe 3%), but about one-half of adverse events were mild transient fever and abdominal pain. RBO developed in 33%, with a median cumulative time to RBO of 6.3 months. The major cause of RBO was hyperplasia at an uncovered portion. The presence of prior biliary drainage and short intragastric stent length were significantly associated with RBO. Reintervention for RBO was successfully achieved through the EUS-HGS route in 92%. The remaining reintervention procedures were 1 EUS-HGS and 2 percutaneous transhepatic biliary drainage all in cases with hilar MBO. EUS-HGS using an LP-CMS for unresectable MBO was safe and effective. RBO was not uncommon, butreintervention through the EUS-HGS route was technically possible in most cases.

Right ventricular outflow tract prestenting with AndraStent XXL before percutaneous pulmonary valve implantation

The indications for percutaneous pulmonary valve implantation (PPVI) have been extended to include large dysfunctional right ventricular outflow tracts (RVOTs). Prestenting of the RVOT is commonly performed before PPVI in order to ensure a stable landing zone. The AndraStent XXL (AndraMed GmbH, Reutlingen, Germany), a cobalt-chromium stent with semi-open cell design, has unique mechanical properties in this indication but is no longer available in France. To assess the efficiency of AndraStent XXL before PPVI. In this retrospective multicentre cohort study, 86 AndraStents XXL were implanted in 77 patients in 6 centres. PPVI was indicated mainly for pulmonary regurgitation (75.3%) in native or patched RVOT (88.3%). The stents were manually mounted on balloon catheters and delivered through sheaths using a conventional femoral approach. PPVI was performed successfully in 97.4% of patients after successful prestenting, generally during the same procedure (77.9%). There were no deaths associated with stent implantation, and four patients experienced five complications, mainly stent embolization, including one requiring surgery. Neither stent fracture nor dysfunction were observed in any patient during a mean follow-up of 19.2±8.7months. Stent analysis showed an excellent maximal stent expansion (97.1%) regardless of balloon size. A 22.3%±3.4 stent shortening with a 30mm balloon was observed. Implantation of large cobalt-chromium AndraStent XXL stents is efficient for prestenting before PPVI.

IS IT NECESSARY TO INSERT A SILICONE TUBE AFTER ENDOSCOPIC ENDONASAL DACRYOCYSTORHINOSTOMY? AND FOR HOW LONG? A COMPARATIVE PROSPECTIVE STUDY

This study aimed to evaluate the necessity for silicone tube insertion following endonasal endoscopic dacryocystorhinostomy (DCR), and the optimal time for its removal. A prospective study was done at Al-sadr Teaching and Al-Shafaa General Hospitals in Basrah, Iraq on seventy two patients with nasolacrimal duct obstruction diagnosed and referred from ophthalmologist to ENT clinic. Preoperative assessment with investigations were done and all patients were subjected to endoscopic endonasal DCR. The patients were divided into three groups; the first group included those with long period stenting (silicone tube removed three months or more), the second group included those patients with short period stenting (tube removed 2-3 weeks after surgery), and the last group included those with no silicone tube stenting. The success rate and complications after surgery were studied in each group for more than one year. The 72 patients were; 63 females (87.5%) who affected more than males (9, 12.5%). the most common age group was 21-45 years. Left side of disease 41(56.9%) is more than right side 31(43.1%). Sixty eight operations (94.4%) out of 72 were primary surgery while four (5.6%) were revision surgery. Ancillary procedures were done also; 13 (18%) septal surgery and 3(4.1%) endoscopic sinus surgery. Success rate was more among short period stenting group 22 out of 24 (91.6%), then without stenting group 19 (82.6%) and those with long period stenting was only 20 from 25 (80%). In conclusion, no statistical significant difference (benefit) about the usage or not of the silicone tube and also about how long keeping the tube, but it is preferable to use silicone tube (for 2-3 weeks only) to improve success rate. Keywords: Silicone tube, Insertion, Endonasal, Endoscopic, Surgery

Prognostic Factors for Acute Transjugular Intrahepatic Portosystemic Shunt Occlusion Using Expanded Polytetrafluoroethylene-Covered Stent.

The expanded polytetrafluoroethylene (ePTFE)-covered stent has been widely used in the transjugular intrahepatic portosystemic shunt (TIPS) procedure. However, the epidemiologic data of acute TIPS occlusion (ATO) and the underlying mechanisms are scarce. The purpose of this study was to evaluate the incidence and prognostic factors for ATO within 1week in TIPS recipients using ePTFE-covered stents. We identified 222 patients who underwent ePTFE-covered TIPS creation for complications of portal hypertension between June 2015 and June 2017 at a large tertiary center. Medical records and TIPS procedure data were retrospectively reviewed, and the influence of these variables on ATO was assessed by multivariate logistic regression analysis. TIPS technical success was achieved in 219 patients (98.6%). Two patients were excluded due to missing data, leaving 217 patients for final analysis. ATO occurred in nine patients (4.1%). Blood flow was restored by balloon angioplasty (n = 4), additional stent insertion (n = 4), and parallel TIPS (n = 1). In multivariable logistic regression, intrastent stenosis (HR 43.871; 95% CI 3.816, 504.373; P = 0.002), previous splenectomy (HR 26.843; 95% CI 2.106, 342.124; P = 0.011), and stent shortening in the hepatic vein (HR 11.54; 95% CI 1.021, 130.416; P = 0.048) were demonstrated as independent significant risk factors for ATO. These findings suggest that the intrastent stenosis, previous splenectomy, and stent shortening in the hepatic vein are vital prognostic factors for ATO in TIPS recipients. Individualized post-TIPS management strategy was required.

International multicenter expert survey on endoscopic treatment of upper gastrointestinal anastomotic leaks.

Background and study aims A variety of endoscopic techniques are currently available for treatment of upper gastrointestinal (UGI) anastomotic leaks; however, no definite consensus exists on the most appropriate therapeutic approach. Our aim was to explore current management of UGI anastomotic leaks. Methods A survey questionnaire was distributed among international expert therapeutic endoscopists regarding management of UGI anastomotic leaks. Results A total of 44 % of 163 surveys were returned; 69 % were from gastroenterologists and 56 % had > 10 years of experience. A third of respondents treat between 10 and 19 patients annually. Fifty-six percent use fully-covered self-expandable metal stents as their usual first option; 80% use techniques to minimize migration; 4 weeks was the most common reported stent dwell time. Sixty percent perform epithelial ablation prior to over-the-scope-clip placement or suturing. Regarding endoscopic vacuum therapy (EVT), 56 % perform balloon dilation and intracavitary EVT in patients with large cavities but small leak defects. Regarding endoscopic septotomy, 56 % consider a minimal interval of 4 weeks from surgery and 90 % consider the need to perform further sessions. Regarding endoscopic internal drainage (EID), placement of two stents and shorter stents is preferred. Persistent inflammation with clinical sepsis was the definition most commonly reported for endoscopic failure. EVT/stent placement and EVT/EID were the therapeutic options most often chosen in patients with previous oncologic surgery and previous bariatric surgery, respectively. Conclusions There is a wide variation in the management of patients with UGI anastomotic leaks. Future prospective studies are needed to move from an expert- to evidence- and personalization-based care.

The use of a low-profile stent graft with a polymer ring sealing technology combined with bare renal stent (vent technique) in patients with juxtarenal aneurysm not eligible for open surgery and fenestrated endograft

ObjectiveIn cases of juxtarenal abdominal aortic aneurysm (jAAA), endovascular aneurysm repair (EVAR) involves the use of custom-made fenestrated stent grafts, which usually need large-diameter access vessels, superior costs, and a certain time between graft planning and delivery. We report our preliminary experience using the bare renal stent technique (called vent) in combination with the ultralow-profile stent graft Ovation (Endologix, Irvine, Calif) to seal jAAAs in patients evaluated to be unfit for open surgery and not suitable for fenestrated endograft. MethodsA single-center retrospective review of jAAAs treated by Ovation vent technique from January 2015 to December 2018 was conduced. The vent procedure consisted of a modified, off-label deployment of the sealing ring of the ultralow-profile Ovation stent graft close to renal orifices in combination with short bare-metal stents. The exclusion criterion was a diameter >31 mm at the level of the lowest renal artery. Early technical and clinical results, estimated midterm survival, renal artery patency, freedom from type IA endoleak, freedom from reintervention, and freedom from neck enlargement (>2 mm) were reported. ResultsOverall, 38 patients had jAAA and were considered unfit for open repair and not eligible for fenestrated EVAR. The proximal neck was <5 mm in all cases (mean, 3.3 ± 1.2 mm). Vent renal stents were implanted bilaterally in 16 patients. Primary technical success was 94.7% (36/38), with satisfactory cannulation of all renal arteries and sealing of the aneurysm in all but two cases because of type IA endoleaks that were treated immediately with success. Primary clinical success at 1 month was 100%. During a median follow-up period of 22.4 ± 3.6 months (range, 1-46 months), no abdominal aortic aneurysm-related deaths occurred, and no patient was lost to follow-up. The survival curve at 1 year and 2 years was, respectively, 96.4% and 91.6% (standard error, 0.57%). There were no cases of neck dilation or endograft migration. Freedom from reintervention at 12 months and 24 months was 100% and 89.5%, respectively (standard error, 0.7%); freedom from type IA endoleak was 100% and patency of the renal artery was 100% at 2 years. ConclusionsThe described technique includes the use of a low-profile stent graft with a polymer ring sealing technology combined with bare renal stents that are not competing for the same room. This early experience shows that the vent technique is safe and feasible and increases the range of treatment of those patients with jAAA who are unfit for open repair and for fenestrated EVAR because of several anatomic constraints.

2195 Expanding Therapeutic Options for Ileocecal Valve and Rectal Strictures With Lumen-Apposing Fully Covered Metal Stents

INTRODUCTION: Radiation-induced and Crohn’s-related colonic strictures are debilitating conditions requiring intensive serial endoscopic dilations or surgery. Use of colonic stents in benign strictures are limited by migration risk, lack of removability, and technical difficulties in placement. This is especially true of ileocecal valve (ICV) strictures given the anatomically challenging location and short stents are preferred. We report the cases of an ICV and distal rectal stricture, refractory to endoscopic dilation, that underwent successful lumen apposing fully covered metal stent (LAMS) placement. CASE DESCRIPTION/METHODS: A 32-year-old African American male with a history of Crohn’s disease complicated by ICV stenosis causing recurrent partial small bowel obstruction, was admitted with worsening nausea, vomiting, and abdominal pain. An abdominal CT showed dilated distal ileum to 4 cm with associated fecalization consistent with partial small bowel obstruction. A colonoscopy with balloon occlusion enterography confirmed a short &lt;1 cm severe ICV stricture with non-inflamed colonic mucosa. He opted for an endoscopic dilation to 10 mm with good clinical response but this only lasted for 2 weeks. A stent placement was then performed using a 15 mm × 10 mm LAMS (Figure 1). His abdominal pain markedly improved with radiologic resolution of the small bowel obstruction. A 55-year-old African American female with a history of pelvic radiation for cervical cancer presented with tenesmus and alternating constipation and diarrhea. Barium enema and flexible sigmoidoscopy showed a focal rectal stricture at 10 cm proximal to the anal verge. She underwent serial endoscopic dilations up to 12-mm over a span of 6 months with no significant clinical response and the stricture kept recurring despite 2-3 week intervals between dilations. Ultimately, a 15 mm × 10 mm LAMS was placed (Figure 2). At 8-weeks, her tenesmus and post-constipation diarrhea were completely resolved. DISCUSSION: Our cases demonstrate the feasibility and efficacy of LAMS placement for refractory high-grade strictures even at anatomically challenging locations. LAMS was preferred here due to its removability and short length that could optimally fit in the ICV and distal rectum with an aim to minimize risk of stent migration due to its dumbbell configuration. However, the stricture site has to be reachable by a therapeutic gastroscope. Optimal duration for stent indwelling and risk of restenosis after stent removal remain unclear and warrant further study.

2136 The Migrating and Perforating Biliary Stent

INTRODUCTION: Although there are high success rates with biliary endoprostheses, there is also accumulating evidence of short and long term complications including: sepsis, migration, perforation, fistula formation and bowel obstruction. This case report presents successful nonsurgical intervention of a rare but grave complication following biliary stent placement. CASE DESCRIPTION/METHODS: A 78 year old male with choledocholithiasis underwent an ERCP with incomplete stone removal, necessitating a 10Fr x 5 cm double-pigtail stent. Repeat ERCP at 6 weeks and an abdominal x-ray suggested distal migration of the stent. Despite multiple laxatives, a followup CT scan confirmed stent retention localized to the IC valve. Although he remained asymptomatic, colonoscopy was pursued and unexpectedly revealed one end of the stent penetrating terminal ileum mucosa, with the other end transecting the serosal surface and perforating through the cecum. The stent was removed with a snare and hemostatic clips were placed to close the defect. At 6 months, he continues to do well without any complications. DISCUSSION: Stent migration occurs in up to 10% of cases, with less than 1% risk of perforation. Short stents tend to travel proximally while longer stents tend to travel distally causing abdominal pain or bowel obstruction. Stent length (&gt;7 cm), benign strictures, sphincter of Oddi dysfunction, post-sphincterotomy and papillary stenosis have all been associated with higher rates of distal migration. Most stents will pass uneventfully into excreta. Rarely, bowel perforation can occur. The duodenum is the most reported site of perforation due to its fixed setting. However, there have been close to a dozen cases of colonic perforation. Both stent design and patient’s anatomy can be obvious risk factors. Straight plastic stents have been associated with higher risk as compared to metal or pigtail stents. Anatomic aberrancies such as abdominal hernias, extensive adhesions and colonic diverticulae are associated with higher risk. Our case highlights bizarre stent migration/perforation with a theoretically lower risk stent, in an asymptomatic patient without known risk factors. Despite this precarious scenario, endoscopic intervention without surgery was sufficient. The collection of case reports in the literature, including our own, suggests the need for guidelines outlining appropriate measures (e.g. followup intervals for repeat imaging) and guidelines outlining management of biliary endoprostheses complications.

Delaying surgery after preoperative biliary drainage does not increase surgical morbidity after pancreaticoduodenectomy

BackgroundThe effects of the time interval from preoperative biliary drainage to pancreaticoduodenectomy on morbidity and mortality have not been established, but a recent multicenter study found that an interval greater than 4 weeks resulted in fewer major complications. We investigated whether delaying pancreaticoduodenectomy after preoperative biliary drainage led to improved postoperative morbidity and mortality. MethodsPatients who underwent elective open pancreaticoduodenectomy between January 2009 and December 2016 were retrospectively analyzed. They were divided into a short duration group (time interval to surgery <4 weeks) and a delaying surgery group (time interval to surgery ≥4 weeks). An unstented control group (no stent group) was added. Perioperative characteristics and surgical outcomes were compared. ResultsOf 603 patients who underwent pancreaticoduodenectomy, 183 (30.3%) had preoperative biliary drainage, 110 patients (18.2%) in the short duration group and 73 (12.1%) in the delaying surgery group. The median interval between preoperative biliary drainage and pancreaticoduodenectomy was 3 weeks (interquartile range, 2–3) for the former group and 6 weeks (interquartile range, 5–7) for the latter. With the exception of wound infection, which was significantly higher in the short duration group than in the controls (8.2% vs 1.7%, P = .002) but not significantly increased compared with the delaying surgery group (8.2% vs 4.1%, P = .368), other complications were comparable among the 3 groups. Subgroup analyses in the intermediate- and high-risk cohort based on either original or alternative Fistula Risk Score showed similar outcomes. Univariate and multivariate analyses showed that short stent duration and female sex were independent factors associated with wound infection. ConclusionA time interval between preoperative biliary drainage and resection greater than 4 weeks does not have a negative impact on short-term surgical outcomes. This finding indicates the relative safety of postponing surgery, if necessary, for preoperative treatment, optimization, or preparation.

Radiopaque Short Pancreatic Stents Reliably Migrate in Nearly All Patients When Inserted for Prevention of Pancreatitis

Placement of a pancreatic duct (PD) stent for prevention of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP)1-3 often necessitates a second procedure for stent removal, generally within 2-4 weeks to avoid stent occlusion or injury to the duct.4 These procedures are associated with increased costs and may result in procedure-related complications. Stents without internal anchoring flaps were developed to allow spontaneous migration into the duodenum,5 thus obviating the need for a repeat procedure. However, radiographic confirmation of a migrated stent can be challenging.6.

Surgical Techniques and Long-Term Outcomes of Flexible Neuroendoscopic Aqueductoplasty and Stenting in Infants with Obstructive Hydrocephalus: A Single-Center Study

To technically review and explore long-term follow-up results of aqueductoplasty and stenting under flexible neuroendoscopy in infantile obstructive hydrocephalus. The clinical data, surgical techniques, and long-term effects in 14 infants with obstructive hydrocephalus treated by flexible neuroendoscopic aqueductoplasty and stenting between 2008 and 2010 were analyzed retrospectively. The 14 infants had a mean age of 5.71 ± 3.10 months (range, 2-11 months) and a mean duration of follow-up of 62.64 ± 34.52 months (range, 9-121 months). Subdural effusion was observed in 4 infants (28.6%) after surgery. There were no deaths or serious complications related to intracranial stent placement. Three infants (21.4%) failed, 2 due to proximal aqueduct occlusion from a short stent length and 1 due to intraluminal ependymal adhesion obstruction. One case was abandoned when a second surgical adjustment stent was unsuccessful, and the other 2 cases went to shunt surgery. Aqueductoplasty with stenting is a feasible and safe surgical procedure for treating infants with midbrain aqueduct stenosis or occlusion. However, the optimal stent material and definitive outcomes after this procedure require additional long-term follow-up studies in large numbers of infants.

Stent-Assisted Coil Embolization of MCA Bifurcation Aneurysms at a Hypoplastic M1 Branch by Use of Hook Technique

We describe the Hook technique enabling coil embolization in unfavorable M1 bifurcation aneurysms and analyze the morphologic variations in M1 bifurcation to evaluate how often such aneurysms can be seen. Among 42 MCA aneurysms treated by stent-assisted coil embolization, aneurysms arising at the acute-angled hypoplastic M1 branch (n= 14) were treated by the Hook technique, in which a short stent was deployed only to protect the aneurysm neck after microcatheter selection of the hypoplastic M2, followed by subsequent coiling of the aneurysm. Outcome was evaluated, including Raymond classification, coil packing density, final modified Rankin Scale (mRS), and recurrence. Separately, 100 middle cerebral artery (MCA) bifurcation aneurysms were analyzed to assess the proportion of such unfavorable aneurysms. Procedural success of the Hook technique was obtained in 13 of 14 patients (93%). A mean packing density of 30% was achieved. Magnetic resonance angiographic follow-up at a median 4 months (range, 1-26 months) showed complete occlusion in 11 patients and residual neck filling in 3 patients. There was no clinical event (mRS= 0) over a median 17 months (range, 2-26 months) of clinical follow-up. One patient had a thrombotic occlusion during the procedure, which was resolved after tirofiban infusion, without evidence of an infarct or deficit. Of the 100 MCA bifurcation aneurysms, aneurysm arising in asymmetric hypoplastic M2 division was the most common type (48%). The Hook technique enabled stent-assisted coiling of M1 bifurcation aneurysm with extension along the asymmetric hypoplastic M2 division and also securing the M2 branch.

Endoscopic management of biliary leaks: a systematic review with meta-analysis

The first-line approach to the treatment of biliary leaks is endoscopic retrograde cholangiopancreatography. A variety of techniques can be used, including sphincterotomy, stenting, a combination of both techniques, or nasobiliary drainage. We performed a systematic review with meta-analysis to define the optimal strategy. We searched MEDLINE/PubMed, EMBASE, CENTRAL, Scopus, Google Scholar, and Web of Science until January 2018 for randomized clinical trials, case-control studies, and prospective cohort studies. Data on procedure, success, and complication rate were extracted. Risk of bias was assessed. A network meta-analysis was performed to compare sphincterotomy alone vs. stenting alone vs. combination treatment. Stenting was further stratified into leak-bridging and short stenting. 11 studies out of 5085 references were included. Compared with sphincterotomy alone, the combination of sphincterotomy with leak-bridging stenting had the highest success rate (risk ratio [RR] 1.15, 95 % confidence interval [CI] 0.97 - 1.50), followed by leak-bridging stenting alone (RR 1.10, 95 %CI 0.84 - 1.44). For nonbridgeable leaks, stenting alone had a higher success rate than sphincterotomy alone (RR 1.07, 95 %CI 0.72 - 1.40). The combination of short stents with sphincterotomy had no added benefit (RR 0.94, 95 %CI 0.49 - 1.29). Overall quality of the included studies was considered to be moderate. We recommend sphincterotomy with stenting if the biliary leak can be bridged. If not, stenting alone with a short stent may be preferred in order to avoid sphincterotomy-related complications. More and larger studies are needed to confirm these findings.

False Lumen Occlusion in Chronic Aortic Dissection: The New Generation Candy-Plug II

To introduce the new generation Candy-Plug II with a self-closing channel construction inside the plug. The technique of the Candy-Plug II was demonstrated in a 50-year-old patient with residual chronic aortic dissection and thoracic false lumen aneurysm with false lumen backflow after open surgical repair of the ascending aorta for acute type A aortic dissection. The Candy-Plug Technique was applied in addition to a branched arch procedure using a new generation Candy-Plug II for false lumen occlusion. The Candy-Plug II is a short tubular stent graft with a small open channel inside the graft to accommodate the central cannula and allow retrieval of the dilator tip, which closes itself as soon as the dilator tip is removed. The channel inside the graft is unsupported and will collapse and thereby close. This new design obviates additional placement of a plug to occlude the midsection of the first-generation Candy-Plug. After deployment of the Candy-Plug, distal false lumen occlusion was confirmed on final angiogram and postoperative computed tomography scans without any leakage through the Candy-Plug. The new generation Candy-Plug II is a useful refinement of the previously available model. It reduces the procedural steps and provides a longer sealing segment.

Multiple Stent Delivery System "Multi-LOC": Focal self-expanding nitinol stenting of complex femoropopliteal lesions-A monocenter feasibility pilot study.

AimsThe Multiple Stent Delivery System (VascuFlex® Multi-LOC) is a novel stent delivery system with six short stents (13 mm long each) mounted on one wire-guided catheter, designed for the treatment of femoropopliteal arteries. The aim of the present study is to evaluate the safety and the feasibility of the VascuFlex® “Multi-LOC” stent delivery system, which enables spot stenting without changing the delivery system.Methods and resultsAfter proof of concept in a porcine model and after European Conformity marking, first clinical experiences were gathered in 20 patients with severe intermittent claudication or critical limb ischemia. First-in-human data are presented. The study included 20 limbs that underwent femoropopliteal revascularization for claudication (n = 14) or critical limb ischemia (n = 6). “Multi-LOC” provisional spot stenting resulted in acute technical success in all lesions with resolution of flow-limiting dissection and elastic recoil after balloon dilatation of the femoropopliteal artery. There were no device-related complications. Follow-up examinations after 30 to 40 days revealed no major adverse events, and six months’ results were encouraging.ConclusionsFirst clinical use of the novel Multiple Stent Delivery System (Multi-LOC) after balloon dilatation of the femoropopliteal artery was safe and feasible in this early study.

EUS-specific stents: Available designs and probable lacunae.

Interventional EUS has seen exponential growth in its indications and applications in the last decade.[1,2,3] Dedicated endoscopic devices for EUS-guided interventions are still limited. Up until recently, the tools used have been borrowed from other procedures such as ERCP. In interventional EUS, the linear-array echoendoscope allows a needle to be advanced under EUS-guidance from the upper gastrointestinal lumen to the biliary, pancreatic, or another adjacent intestinal lumen. Real-time puncture can be performed and provide the possibility of EUS-guided transluminal drainage (EUS-TLD). Plastic stents and conventional self-expandable metallic stents (SEMSs) were initially used but present several limitations due to their design.[1,4,5] They lack lumen-to-lumen anchorage and present migratory risks in the absence of stricture to hold them in place. Plastic stents are associated with potential pneumoperitoneum and bile peritonitis, whereas fully-covered SEMS (FCSEMS), despite preventing bile leak, will not maintain secure apposition between two nonadherent organs. Furthermore, their length often exceeds the anatomical requirement of a shorter transluminal anastomosis and predisposes them to obstruction as well as difficult positioning. With the rise in new EUS-guided interventional techniques, new tools, in particular, new stent designs have evolved to facilitate the various applications. A few EUS-specific stents have now become available for EUS-TLD.[4,5] We hereby review the stent designs and discuss lacunae to be addressed to improve the efficacy, safety, and ease of procedures.

EUS-guided antegrade procedures.

Endoscopic transpapillary procedure, so-called ERCP-related procedure, should be considered as the first-line treatment method for biliary disorders such as acute cholangitis, obstructive jaundice, or choledocholithiasis because of its less invasiveness and lower risk of adverse events than other techniques despite the risk of post-ERCP pancreatitis.[1,2,3,4,5] However, ERCP-related procedure is not always successfully accomplished, even when performed by skilled endoscopists, in cases of inability of selective biliary cannulation because of the presence of intradiverticular papillae, a long narrow distal segment of the distal bile duct, or inaccessible papilla because of gastric outlet obstruction or surgically altered anatomy (SAA) even using balloon enteroscope.[6,7] Recently, in such cases, EUS-guided biliary drainage (EUS-BD) approach has been developed and reported as a novel useful alternative technique when standard ERCP-related procedure has failed.[8,9,10,11,12,13,14] As regards EUS-BD for obstructive jaundice due to malignant biliary stricture, EUS-BD is divided into several techniques depending on the approach route.[15] At present, there is no universal consensus on the optimal strategy for which the EUS-BD technique should be selected. Thus far, the selection of the EUS-BD approach depends on the patient's condition, which may involve the presence of gastric outlet obstruction, the site of biliary obstruction, the anastomosis after surgical intervention, or the preference of the endoscopist.[16] In several EUS-BD techniques, EUS-guided choledochoduodenostomy (EUS-CDS) and EUS-guided hepaticogastrostomy (EUS-HGS) are common mostly in patients with malignant diseases at the end stage of disease because these techniques are simple. However, bile flow in EUS-CDS or EUS-HGS is not physiological, resulting in short stent patency rather than retrograde biliary metal stent placement across the stricture site by ERCP. Furthermore, as there are as yet no commercially available dedicated metal stents for EUS-CDS or EUS-HGS around the world, a braided-type covered metal stent is conventionally used on EUS-CDS or EUS-HGS, which has some concern about stent misplacement or migration due to its high shortening rate.[17] Therefore, EUS-guided antegrade stenting (EUS-AGS) has been developed and reported as a useful option of EUS-BD because of the theoretical physiological bile flow in patients with inaccessible ampulla.[18] Moreover, EUS-antegrade intervention (EUS-AI) for benign biliary diseases in patients with surgically altered anatomy that is an antegrade treatment via the approach route created by EUS-HGS has been developed by application of EUS-AGS.[19] Herein, we describe technical details regarding such EUS-guided antegrade procedure for malignant and benign biliary diseases.

Preoperative Biliary Stenting and Major Morbidity After Pancreatoduodenectomy: Does Elapsed Time Matter?

To analyze possible associations between the duration of stent placement before surgery and the occurrence and severity of postoperative complications after pancreatoduodenectomy (PD). The effect of preoperative stent duration on postoperative outcomes after PD has not been investigated. From 2013 to 2016, patients who underwent PD for any reasons after biliary stent placement at 5 European academic centers were analyzed from prospectively maintained databases. The primary aim was to investigate the association between the duration of preoperative biliary stenting and postoperative morbidity. Patients were stratified by stent duration into 3 groups: short (<4 weeks), intermediate (4-8 weeks), and long (≥8 weeks). In all, 312 patients were analyzed. The median time from stent placement to surgery was 37 days (2-559 days), and most operations were performed for pancreatic cancer (67.6%). Morbidity and mortality rates were 56.0% and 2.6%, respectively. Patients in the short group (n = 106) experienced a higher rate of major morbidity (43.4% vs 20.0% vs 24.2%; P < 0.001), biliary fistulae (13.2% vs 4.3% vs 5.5%; P = 0.031), and length of hospital stay [16 (10-52) days vs 12 (8-35) days vs 12 (8-43) days; P = 0.025]. A multivariate adjusted model identified the short stent duration as an independent risk factor for major complications (odds ratio 2.64, 95% confidence interval 1.23-5.67, P = 0.013). When jaundice treatment cannot be avoided, delaying surgery up to 1 month after biliary stenting may reduce major morbidity, procedure-related complications, and length of hospital stay.