Stent Fracture Research Articles

Mid-term outcomes after percutaneous pulmonary valve implantation in complex right ventricular outflow tracts using the “folded” Melody® valve technique

Percutaneous pulmonary valve implantation (PPVI) using Melody®valve has been validated as a valuable therapeutic option for the management of right ventricular outflow tract (RVOT) dysfunction but remains challenging. The “Folded” modification of the Melody®valve has been reported as a safe and feasible technique in complex RVOT . We sought to evaluate mid-term outcomes in a multicentre cohort who underwent PPVI using the “folded” Melody® valve technique. Patients who underwent PPVI using a Foled Melody®between April 2012 and November 2018 in 6 European tertiary Centerswere retrospectively included. “Folded” Melody® valve technique was successfully performed in 28 patients (mean age = 17.7 ± 10 years old). Indications were: short RVOT and early bifurcation of pulmonary arteries in 12 (42.8%) ( Fig. 1 ) , bioprosthetic valves in 10 (35.7%), coronary arteries proximity in 4 (14.3%) and prevention of retrosternal compression in 2 (7.2%). No complication occurred during procedures. All patients had excellent hemodynamic results. Mean transvalvular peak velocity decreased from 3.8 ± 0.86 m/s before PPVI to 2.4 ± 0.55 m/s in the immediate post-PPVI period. Only 5 patients had trivial pulmonary regurgitation (PR) at discharge. After a median follow up (FU) of 27 ± 17.9 months, all patients were alive, and all, but 3 patients, were free from reintervention: 1 patient (3.5%) developed Melody® valve infective endocarditis 3 months after PPVI and underwent RVOT surgical replacement; Two underwent pulmonary artery stenting 2 and 4 years after of PPVI, but the lesions were not related to the Folded valve. At last FU mean transvalvular peak velocity was 2.6 ± 0.66 m/s and only 5 (17.8%) patients had mild or less PR. No stent fractures were observed. The “folded valve technique” is a safe and feasible modification of the Melody® valve which provides favourable mid-term results without increased rate of valve related complications.

Efficacy and Safety of a Newly Developed Self-Expanding Open-Cell Type Nitinol Stent for Peripheral Arteries: A Preclinical Study in Minipigs

목적얇고 새로운 구조로 개발된 말초동맥용 자가팽창성 개방형 니티놀 스텐트의 유효성 및 안전성을 기존에 사용하는 스텐트와 비교 평가하였다.대상과 방법미니피그 14마리를 대상으로 실험군과 대조군 스텐트를 무작위배정 후 각 개체의 장골동맥에 대칭적으로 삽입하여 1개월(n = 5) 및 6개월(n = 9) 추적관찰하였다. 혈관조영술로 혈관 직경, 후기 내강 손실 및 협착 정도를 평가하고 조직계측학적으로 내탄력층 면적, 내강 면적, 신생 내막 면적 및 협착 정도를 분석하였다. 추적기간 중 모든 실험 개체에 대하여 매일 임상적 평가 및 식이 정도를 추적관찰하였다.결과모든 개체는 추적관찰 기간 중 생존하였으며 중대한 유해 반응을 보이지 않았다. 혈관조영술상 6개월 추적관찰군에서 실험군의 내강 직경이 유의하게 컸으며(p = 0.014), 후기 내강 손실이 적었고(p = 0.019), 협착 정도가 낮았다(p = 0.014). 조직학적으로 1개월 추적관찰군에서 실험군이 신생 내막 면적 및 면적 협착이 유의하게 낮았다(각, p = 0.008, p = 0.016). 6개월 추적관찰군에서는 실험군이 대조군에 비하여 내강 면적이 유의하게 넓었으며(p = 0.040), 내탄력층 면적, 신생 내막 면적 및 면적 협착이 통계적으로 유의하게 낮았다(각, p = 0.004, p = 0.008, p = 0.014).결론새로 개발된 말초혈관용 자가팽창성 개방형 니티놀 스텐트는 기존에 사용하는 스텐트와 비교하여 안전하며 신생 내막 증식의 정도가 적었다.

Ultrathin (60 μm), ultralong (≥40 mm) sirolimus-eluting stent: study of clinical and safety profiles among real-world patients.

Although thin-strut drug-eluting stents (DES) with a more flexible design are easily obtainable, data regarding using ultralong DES (≥40 mm) for long coronary lesions are limited in the literature. Therefore, the current study assessed the safety and efficacy of an ultralong (≥40 mm) and ultrathin (60 μm) biodegradable polymer-coated sirolimus-eluting stent (SES), Supralimus Grace, with a unique Long Dual Z-link (LDZ-link) design (Sahajanand Medical Technologies Pvt. Ltd., Surat, India) in real-world patients with long coronary lesions. The assigned stents were implanted in 684 patients. The primary endpoint was target lesion failure (TLF), which is a composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularization (TLR), whereas periprocedural secondary endpoints included device failure (failure of stent delivery, change of stent, and stent fracture) and patient-oriented composite endpoint (POCE), which is a composite of all deaths, any MI, and any revascularization, and stent thrombosis (ST). These outcomes were analyzed at one-year follow-up and during the procedure. The patients' mean age was 52.7±15.9 years; 537 (78.5%) were males. 626 (91.5%) patients suffered from acute coronary syndrome and 58 (8.5%) patients from chronic coronary syndrome (CSS). 989 lesions were removed. The mean numbers of lesions and stents implanted per patient were 1.3±0.2 mm and 1.4±0.3 mm, respectively. TLF occurred in 42 (6.1%) as a result of cardiac death, target vessel MI, and TLR in 9 (1.3%), 20 (2.9%), and 13 (1.9%) patients, respectively. POCE was observed in 131 patients (19.1%) at one-year follow-up, mainly in 63 (9.2%) patients because of any revascularization. Stent failure was seen in 21 patients (3.1%) as a result of delivery failure (2.2%), edge dissection (0.8%), and fracture (0.1%). Definite and probable ST were observed in 8 (1.1%) and 9 (1.3%) patients, respectively. Ultralong (≥40 mm), ultrathin (60 μm) Supralimus Grace stent can be safely implanted in vessels having long and multiple lesions.

Coronary Stent Fracture in a Patient with an Atrial Septal Defect and Severe Pulmonary Hypertension

Coronary Stent Fracture in a Patient with an Atrial Septal Defect and Severe Pulmonary Hypertension

Lesion Revascularisation Subsequent to Femoropopliteal Spot Stenting Using the Multi-LOC Stent Delivery System.

Restenosis and stent fractures are well-characterised treatment failures following femoropopliteal (FP) stent-based interventions. We aimed to determine patterns of restenosis and fracture rates following focal stenting of FP arteries. This retrospective study investigated angiographic patterns of restenosis and the occurrence of stent fractures following focal FP stenting with the multiple stent delivery system VascuFlex® Multi-LOC. We identified 10 patients with 10 (of 129) FP lesions (mean length 11.7±4.6 cm) and a total of 51 (of 646) Multi-LOC stents that underwent clinically driven target lesion revascularizations (TLR) after 11.5±9.2 months, due to symptomatic recurrence of stenosis. None of the Multi-LOC stents had fractured. No isolated in-stent restenosis (>50%) was observed. Median diameter lumen loss was significantly more pronounced at the inter-stent segments (27.0%) compared to in-stent segments (7.8%, p=0.023). No evidence of fracture or susceptibility to stent-related restenosis using Multi-LOC stents was observed. Focal FP stenting may be more effective when combined with strategies known to reduce restenosis in non-stented artery segments.

Long-term outcome of endoscopic ultrasound-guided pancreatic duct drainage using a fully covered self-expandable metal stent for pancreaticojejunal anastomosis stricture.

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has been proposed for pancreatic duct obstruction after failure of endoscopic retrograde pancreatography. We evaluate the long-term outcomes of EUS-PD using a fully covered self-expandable metal stent (FCSEMS) for pancreaticojejunal anastomosis (PJA) strictures following Whipple procedures. Twenty-three patients with PJA strictures underwent EUS-PD according to the findings of EUS-guided pancreatogram and the passage of the guidewire through PJA stricture (complete vs partial stricture) after failure of endoscopic retrograde pancreatography. Technical and clinical success, adverse events (AEs), and long-term outcomes were assessed. Technical and clinical success was achieved in all patients. The complete and partial strictures were 11 and 12, respectively. The direct transanastomotic and transmural plastic stenting in partial PJA stricture was successful in only three patients (13%). Therefore, 20 patients underwent EUS-guided transmural FCSEMS placement during the initial attempt. Early AEs, including abdominal pain (n=3) and peripancreatic fluid collection (n=1), occurred in four patients (17.4%). During the follow-up periods (median, 27.2months; interquartile range [IQR], 18.7-40.6), five patients (21.7%) developed late AEs, including asymptomatic stent fracture at the gastric end (n=3), asymptomatic stent migration (n=1), and stent occlusion (n=1). The total duration of stent placement was 27.2months (IQR, 18.7-40.6), and the median number of stent revision was 2 (IQR, 1-2). In terms of safety and efficacy, EUS-PD with an FCSEMS showed favorable success and acceptable AEs rate and durable long-term outcomes.

Prevalence of Subclavian Artery Stent Fractures and their Impact on Restenosis Development

Introduction - Stenting is the preferred, minimally invasive treatment for subclavian artery (SA) steno-occlusive disease. Stent fractures in the SA have not been assessed in large cohorts. Our aim was to determine the prevalence of SA stent fractures, identify predisposing factors, and analyse their impact on restenosis development. Methods - 120 patients (71 women; mean age: 59.4+/-9.0 years) with symptomatic significant SA stenosis who underwent stenting between 2002 and 2014 at our Department were included in the study. In 2016, patients were asked to return for a fluoroscopic examination of the implanted stents. Stent fractures were defined as type I: single-strut fracture, type II: > 2 strut fractures without deformation, type III: > 2 strut fractures with deformation, type IV: multiple strut fractures with acquired transection but without gap, and type V: multiple strut fractures with acquired transection with gap in the stent body. Colour duplex scan was used to monitor stent patency. In case of continuous variables t or Mann-Whitney U tests, while in case of categorical variables chi-square or Fisher exact tests were performed. Results - 122 stents were deployed (balloon-expandable, n = 94; self-expandable, n = 28). The median follow-up time was 81.4 (41.1-113.7) months. 43 (35.2%) stent fractures were detected (type I-II, n = 28; type III-V, n = 15). The difference between the fractured (n = 43) and non-fractured (n = 79) groups was non-significant regarding the atherosclerotic risk factors (age > 70 years, female sex, smoking, hypertension, hyperlipidemia, diabetes mellitus, obesity, chronic kidney disease), underlying pathology (atherosclerosis, restenosis, radiation-induced arteriopathy, vasculitis), lesion location, and stenosis grade. Calcifications, long lesions (> 20 mm), and long balloon-expandable stents (> 20 mm) were more common in the fractured than in the non-fractured groups (86.0% versus 43.0%, P < 0.001; 51.2% versus 20.3%, P < 0.001; 62.8% versus 40.5%, P = 0.036, respectively). The restenosis and reintervention rates were significantly higher in patients with type III-V fractures compared to those with type I-II fractures (60.0% versus 3.6%, P < 0.001; 46.7% versus 3.6%, P < 0.001, respectively). Conclusion - Fractures frequently occur. Lesion and stent characteristics have an influence on fracture rate. Complex fractures increase the risk of restenosis.

Why do Human Femoral Stents Fail? First In-man Pathology and Multimodality Imaging of Acute and Chronic Femoral Stenting in Human

Introduction: Lower extremity peripheral arterial disease (PAD) is a major cause of morbidity. Endovascular therapy remains the gold standard to treat PAD1. While pathology of coronary stenting has been well studied2, pathology of lower extremity femoral stenting remains poorly understood. The objective was to comprehensively evaluate the pathology of acute and chronic femoral stenting in symptomatic atherosclerotic patients and to understand the causes of stent failures (SF) using multi-modality imaging including micro-computed tomography (microCT). Methods: Twelve stents were obtained from 10 patients with history of PAD (mean age 74 ± 9.3; 7 male and three female); all the stented arteries underwent radiography, microCT and histologic assessment. Dissected arteries were embedded in Spurr and sawed at 3-5 mm intervals and Exact slides were prepared at 60 to 100 mm and a total of 78 sections examined following co-registration with microCT. Results are reported as median and interquartile (25 to 75th percentile, IQR). Results: Duration was 150 days (30 - 365, IQR), diameter was 5.90 mm (5.44 - 7.16, IQR) and stented length was 39.5 mm (27 - 107.5, IQR). Two of 12 stents were drug-eluting stents, 10 of 12 were bare-metal stents. Half of them were overlapping stents. Indications for stenting were intermittent claudication (40%), chronic limb ischemia (50%), and acute limb ischemia (10%). Morphometric analysis of the histologic sections showed stent success [(defined as < 75% cross sectional area narrowing and absence a thrombus (>30% narrowing from thrombus)] in 4 of 12 stents with 31.0% stenosis (22.16 - 35.0, IQR). The causes of SF in the remaining 8 were: stent-thrombosis (Figure 1), 3; in-stent restenosis, 2; and chronic total occlusions, 3, with 91.5% stenosis (78.3 - 100, IQR). Histologic malapposition3 occurred in 8 of the 12 stented lesions. Underlying nodular calcification (NC) was observed in half of the lesions, medial calcifications observed in 67% of cases with the median arch of calcification of 63° (0-283, IQR). Intimal calcification was observed in 11/12 cases, degree of calcification was 126° (38 - 248, IQR). The duration of implantation was divided into short-term (≤90 days) and long-term (>90 days) stenting. The extent of medial calcification was significantly different in short-term vs. long-term stenting [126° (18.0 - 195.8) vs 0 (0 - 2.25) respectively, p=0.003]. Malapposition (Figure 2) was observed more frequently in the short-term vs. long-term groups [50.0% (25.0 - 87.5) vs 0% (0-11.9) respectively, p=0.02]. Stent fractures were observed in 3 stents (3/11, 27.7%) and all of them were associated with SF. Also, SF had a higher medial injury score4: 2 (1 - 3, IQR) vs 1 (1 - 2, IQR), p=0.04. Conclusion: This descriptive histologic study is the first series of explanted human femoral stents, removed at surgery (n=10) and autopsy (n=2). Medial calcification and malapposition play an important role in long-term stent patency. Excessive injury and stent fracture also contributes to SF. Use of microCT in this study illustrates the advantages of high-resolution CT to detect SF, especially stent fractures. This study also enlightens the necessity to evaluate any explanted material in the future5.Figure 2Multi-modality imaging showing stent malapposition.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Disclosure: Sho Torii receives research grants from SUNRISE lab. Renu Virmani and Aloke V. Finn have received institutional research support from Abbott Vascular, Boston Scientific, Cook Medical, Cardiovascular Systems, Inc., Medtronic, and Terumo Corporation; Renu Virmani is a consultant for 480 Biomedical, Abbott Vascular, Medtronic, and W.L. Gore. Other authors report no conflicts of interest.

Type IIIB Endoleak Associated to an Iliac Branch Device Bridging Stent.

Introduction: Frequently during aortoiliac endovascular exclusion (EVAR), distal fixation at the external iliac artery is needed. Iliac branch devices allow preservation of antegrade flow to the hypogastric artery. These are more complex procedures compared to standard aorto-iliac aneurysm repairs since involve additional arteries, materials, manoeuvers and longer procedural time. In most cases, the procedure is safe and mid-term complications are rare. We report a rare case of an endoleak associated with an iliac branched device during EVAR. Methods: A 75-year-old man with a history of hypertension, dyslipidemia, and former smoker, was intervened by an endovascular exclusion of aorto-iliac aneurysms twenty months earlier. The abdominal aortic aneurysm size was 72 mm and right iliac aneurysm size was 30 mm. A suprarenal aortic stent graft (Zenith LP) and a right iliac branched device (ZBIS) were implanted. A balloon-expandable covered stent of 8x37 mm was used as a bridging stent. During the follow-up, computed tomography angiography (CTA) at 22 months showed a growth of the aneurysmal sac. Catheter angiography was performed, which demonstrated a type III endoleak secondary to stent rupture. Through an open axillary access, endovascular treatment was performed, implanting an overlapping 8x58 mm balloon expandable stent and 8x40 mm self-expanding stent.The completion angiography showed a technical success with a permeability of the endoprosthetic branch and absence of endoleaks. Results: During follow-up, a three-month ultrasound scan and a plain x-ray showed internal iliac branch patency, no stent fracture, and absence of endoleaks. Conclusion: Material related endoleaks associated to the exclusion of an abdominal aortic aneurysm are rare and in branched hypogastric devices, no case has been described. The occurrence of these late complications reinforces the need for post-operatory surveillance of these patients as well as the need to constantly improve the new materials being employed. In most cases, endovascular techniques allow their treatment through a minimally invasive approach with low morbidity.

Carotid Stent Failure as a Predictor for Periprocedural Stroke or Death After Carotid Artery Stenting: A Substudy of the International Carotid Stenting Study (ICSS)

Introduction - Compared to carotid endarterectomy (CEA), carotid artery stenting (CAS) has been associated with a higher 30-day stroke rate and increased rate of new postprocedural ischemic brain lesions on magnetic resonance-diffusion weighted imaging (MR-DWI). We assessed whether this periprocedural risk after CAS was related to stent failure within the randomised International Carotid Stenting Study (ICSS). Methods - Patients with recently symptomatic carotid artery stenosis enrolled in ICSS were randomly assigned in a 1:1 ratio to receive CAS or CEA. CAS patients were eligible for the present analysis if a postprocedural computed tomography angiography (CTA) of the treated carotid was available. Two observers independently scored stent failure, defined as presence of any of the following parameters: in-stent lesions (hypo- or hyperattenuating), residual stenosis (>30%, according to NASCET criteria) and stent fracture (by visual assessment). In addition, residual stenosis was scored on completion angiography. The primary outcome measure was the occurrence of any stroke or death within 30 days of treatment. The secondary outcome was the presence of any new ischemic brain lesion on postprocedural MR-DWI. This is a substudy of a registered trial, ISRCTN 25337470. Results - [PRELIMINARY] A total of 92 CAS patients were included. Postprocedural CTA was performed after median 33 (interquartile range 29-35) days. The primary outcome measure occurred in eight patients. No stent fractures occurred. Stent failure was scored as in-stent lesion in 19 [21%] patients, with an occlusion in two. Stent failure was noted in 3 [38%] patients with a stroke, and in 16 [19%] of patients without a stroke (odds ratio [OR] 2.55, 95% confidence interval [CI] 0.55-11.79). One of the stent occlusions resulted in a stroke, the other remained asymptomatic. In-stent lesions were found in two of 11 [18%] patients with a new postprocedural MR-DWI lesion and in six of 37 [16%] patients without a new lesion (OR 1.15, 95% CI 0.20-6.70). Data on residual stenosis on completion angiography will be ready at the time of the ESVS conference. Conclusion - These preliminary data show that stent failure occurred in about one of every five CAS patients. In-stent lesions occurred twice as often in patients who had experienced a 30-day stroke compared to stroke-free patients, although no significance was shown. To allow for definite conclusions, these findings need to be validated in a larger cohort.

One Year Results in the Endovascular Treatment of the Femoro-Popliteal Segment with the Tigris® Stent in Patients with Critical Limb Ischemia

Introduction: The endovascular treatment with stenting in the femoro-popliteal arterial segment is particularly challenging due to certain anatomical features and biomechanical forces to which it may be exposed. The purpose of this study is to report our 1-year results in term of efficacy of the dual stent (TIGRIS®) in the femoro-popliteal region in patients with critical limb ischemia (CLI). Methods: We included patients classified as Rutherford grade ≥4 that required Tigris stent implantation in the femoro-popliteal region from January 2012 to January 2018 in one center. Two groups were analyzed: Group A, patients receiving Tigris stent in the superficial femoral artery [SFA] (n=24) and Group B, in the popliteal artery (n=21). The stenting indication in group A was primary stenting in 14 cases and angioplasty (ATP) failure in 10 cases. All cases included in group B were due to primary ATP failure (residual stenosis >50%, dissection or recoil). Technical success, primary patency, secondary patency and limb salvage are described for the entire cohort and both groups. The follow-up visits consisted of clinical examination and color-doppler ultrasound at 3, 6,12 months. Kaplan-Meyer analysis was used to estimate outcomes measures at 3,6 and 12 months. The groups were compared using the log-rank text. Results: Sixty-one Tigris® stent were implanted in 45 patients with mean age 74,67± 1,6 years. More than 40% were classified as Rutherford V. Occlusion rate was 57,8%. The median follow-up was 12,02 months (range 3-72 months). For the entire series, technical success was 100%. Primary patency at 3 and 6 months was 91,1% and 84,4% at 12 months. Secondary patency at 3,6 and 12 months was, 95,6%, 93,3% and 86,7%, respectively. Limb salvage was 86,7% at 12-month analysis. The 2 groups were comparable for preoperative comorbidities. Patients in Group A had longer lesions (15,8mm vs 7,9mm, p=0,044) requiring longer and more stents (124,2mm vs 82,9mm, p=0,001). No difference in primary or secondary patency and limb salvage between both groups was found during follow-up. No stent fractures were reported. Conclusion: The Tigris® stent in the femoro-popliteal region has demonstrated high primary patency and limb salvage rate during the first year follow-up in complex cases such as those with CLI. No difference in patency rates regarding sector location of the stent was found. It is necessary to validate these results in the long term.

Endovascular Treatment of Superficial Femoral and Proximal Popliteal Arteries Lesions

Abstract Mechanical stress due to flexion-extension in the femoropopliteal space may cause stent failure via stent fracture and thrombosis. Wire-Interwoven self-expanding Nitinol Stents design partially mimics the reticular structure of native vessels, emphasizing radial strength, flexibility and kink resistance; these stent features can offer more chances for short and long term patency. We have evaluated 5 patients with peripheral artery disease with significant superficial femoral artery or proximal popliteal artery lesions. All patients underwent endovascular therapy with Wire-Interwoven self-expanding Nitinol Stents, with primary focus on stent patency at follow-up visits (1, 6, 12 months). The endovascular initial success was achieved in all 5 patients. Stent patency at 1-year follow-up was achieved in 3 patients (60%). 2 patients (40%) had stent thrombosis within 30 days after procedure secondary to arterial dissection at distal stent extremity and self-withdrawal dual antiplatelet therapy; subsequently target lesion revascularization with endovascular therapy and ilio-femoral bypass was performed.

Endovascular Stent Graft Repair of Traumatic Popliteal Artery Injuries

Introduction: Popliteal artery injury is a potentially-limb threatening complication of traumatic knee dislocation. The purpose of this study was to evaluate the feasibility and effectiveness of endovascular repair of traumatic popliteal a3.102rterial injuries. Methods: A retrospective analysis of 11 patients with clinical suspicion of popliteal arterial injuries that were confirmed by arteriography was performed from September 2015 to June 2017. Clinical data included demographics, mechanism of injury, type of injury, location of injury, concomitant injuries, time of endovascular procedures, time interval from trauma to blood flow restoration, and follow-up. All patients were male (mean age of 32.7 ± 8.5 years) and suffered traumatic knee dislocation along with significant ligament and neurovascular injuries. The type of lesion involved dissection (n = 3), partial transection (n = 5), complete transection (n = 2), arteriovenous fistula (n = 1). All patients underwent endovascular repair with Viabahnâ stent graft for popliteal arterial injuries. Results: Technical success rate was 100%. No perioperative death and procedure-related complication occurred. The length of the stent graft ranged between 5 and 10 cm; the diameter of the stents was 6 mm. The average follow-up was 22.4 ± 5.6 months (range 16–25 months). One patient who underwent knee arthroplasty with tourniquet treated with catheter directed thrombolysis due to stent thrombosis at 19 months after the procedure. All limbs were salvaged. Stent graft migration, deformation, or fracture was not found during the follow-up. Conclusion: Traumatic knee dislocations are rare injuries that may be associated with potentially devastating vascular complications. A prompt diagnosis and timely arterial repair is of paramount importance if limb salvage is to be achieved. In complicated traumatic popliteal artery injuries, an endovascular stent graft implantation as a backup or bail-out technique might be a valid option in some selected cases. Further studies are required to evaluate the long-term efficacy of endovascular stent graft repair.

Classification of Factors Associated with Stenosis, Re-Occlusion and Subsequent Re-intervention, Following Deep Venous Stenting for Acute Iliofemoral Deep Venous Thrombosis

Introduction: Post thrombotic syndrome (PTS) is devastating sequela of acute iliofemoral deep venous thrombosis (DVT). Thrombolysis and deep venous stenting aims to restore vessel outflow and reduce PTS in accordance with the open vessel hypothesis. For a proportion of patients, despite initial interventional success, re-occlusion or stenosis will necessitate further treatment. This study aimed to determine and classify the causes of re-occlusion and stenosis following deep venous interventions for acute iliofemoral DVT, with identification of preventable factors to improve future treatment. Methods: A retrospective single centre cohort study of patients successfully lysed for treatment of iliofemoral DVT between November 2013 and 2017 was carried out. Patient records and imaging were examined for: baseline demographics, risk factors, extent of DVT, extent of vessel clearance, stents inserted, quality of in-flow, time to and success of re-intervention, anticoagulation compliance, and secondary vessel patency. Failure was classified as either technical, haematological, flow related or mixed. Technical causes were further subdivided into lack of stenting, failure to address inflow or outflow and device related failure. Results: 143 limbs were identified: 95 without further intervention (66%), and 48 limbs (34%) requiring re-intervention. 45% of cases occurred in the first 6 weeks, with a median time to re-intervention of 45 days. Re-intervention was successful in 31 cases (67%). This was achieved in all cases managed prior to complete vessel occlusion compared to 8/25 (32%) of those presenting with complete occlusion (p=0.001). Need for re-intervention was associated with a younger median age (44 vs. 31, p=0.002), IVC involvement (13% vs. 35%, p=0.002) and presence of a stent across the inguinal ligament (15% vs. 38%, p=0.002). Non-compliance with anticoagulation post-procedurally was found to be strongly associated with re-occlusion: relative risk 3.17 (95%CI 0.29-0.91, p=0.0001). Haematological issues were observed in 33% of re-intervention cases, flow-related issues in 44%% of re-intervention cases, and technical problems were observed in 54% of re-intervention cases. Four cases due to stent fracture or compression were observed. Identified problems were multifactorial in 27% of cases. Overall vessel salvage was achieved in 71% of cases with a single causative factor compared to 54% of cases classified as multifactorial. This did not translate into a statistically significant difference in secondary patency. Conclusion: Re-intervention occurred due to potentially preventable factors in a substantial proportion of patients. Re-intervention following complete vessel re-occlusion carries a lower likelihood of success. This study emphasises the need for precision in stenting technique, for post-procedural surveillance, and for adherence to anticoagulation in order to optimise patient outcome. Disclosure: Cook, BSCI, Optimed, Bard, Medtronic, Vesper, Veniti, Philips-Volcano, BTG

An application of RASER technique in the treatment of chronic total occlusion accompanied with stent fracture in right coronary artery: a case report

BackgroundThe interventional treatment of chronic total occlusion (CTO) with stent fracture as well as severe calcification was extremely difficult and no effective technique has been reported.Case presentationA 50-year-old woman was hospitalized for angina, angiography revealed triple vessel disease, CTO accompanied with stent fracture in right coronary artery (RCA). Treatment using conventional coronary intervention was expected to be difficult. Therefore, we performed RASER technique, which was a combination of excimer laser coronary atherectomy (ELCA) with rotational atherectomy (RA), followed by the deployment of drug-eluting stents. Intravascular ultrasound (IVUS) revealed well attachment of the stents, the patient was discharged 3 days after the procedure and no recurrent chest discomfort was reported in a follow-up time of 10 months.ConclusionThis case report provided a first report of RASER technique in the treatment of CTO with stent fracture and severe calcification.

Late Stent Thrombosis Concurrent With Stent Fracture at Calcified Nodule Lesion in Saphenous Vein Graft

A 72-year-old woman presented with intermittent chest oppression. She had undergone coronary artery bypass surgery with saphenous vein graft to the left anterior descending artery 36 years ago. Emergent coronary angiography showed a radiolucent area with hinge motion in the proximal saphenous vein

Midterm Follow-up of Fenestrated and Scalloped Physician-Modified Endovascular Grafts for Zone 2 TEVAR

Purpose: To investigate the midterm outcomes of scalloped or fenestrated physician-modified endovascular grafts (PMEGs) for zone 2 thoracic endovascular aortic repairs (TEVAR). Materials and Methods: Between November 2013 and May 2019, 54 consecutive patients (mean age 63 years; 41 men) were treated with thoracic PMEGs modified with 7 scallops or 47 fenestrations for the left subclavian artery (LSA). Indications for aortic repair were acute complicated type B aortic dissection (17, 31%), degenerative aneurysm (13, 24%), acute traumatic rupture of the aortic isthmus (9, 16%), post chronic dissection aneurysmal evolution (8, 15%), penetrating aortic ulcer (3, 6%), intramural hematoma (2, 4%), and floating thrombus (2, 4%). Results: Technical success was 94%; 3 (6%) LSAs were unintentionally covered. An intraoperative type Ia endoleak was treated during the index procedure. One (2%) patient suffered spinal cord ischemia, with irreversible bilateral paraplegia. Three (6%) patients experience postoperative minor strokes with full neurological recovery. Four (7%) patients died in the perioperative period; 2 (2%) were due to aneurysm rupture. Mean follow-up was 26±16 months; 15 (28%) patients had at least 3 years of follow-up. Two (4%) type II endoleaks were identified and successfully treated (4% reintervention rate); no other endoleaks were identified. All the LSAs remained clinically and radiologically patent. There were no conversions to open repair, ruptures, retrograde dissection, stent fracture, migrations, or other aortic complications. Conclusion: Scalloped or single-fenestrated PMEGs for the LSA appear to be durable and safe in the midterm. Combined with low periprocedural morbidity and mortality, these results suggest that this approach can be considered as an off-label alternative to extend proximal seal to zone 2 for TEVAR. Further studies with a larger number of patients and long-term outcomes are needed to fully validate this approach.

AAA 5. Bridging Stent Grafts in Fenestrated Aortic Repair: Performance of Different Covered Stents for This Indication in an In Vitro Model

The objective of this report was to study the performance of different covered stents as bridging stent grafts in a plain fenestrated model. Four different balloon-expandable covered stent grafts (Advanta V12 [Getinge AB, Gothenburg, Sweden], BeGraft [Bentley Innomed GmbH, Hechingen, Germany], BeGraft Plus [Bentley Innomed GmbH], and VBX [Gore Medical, Flagstaff, Ariz], each in 6 mm, 10 of each) were placed in a flat fenestrated model and flared by a 10-mm balloon. After this, the polytetrafluoroethylene (PTFE) fabric was analyzed by a micro camera (Keyence, Milton Keynes, United Kingdom). The stent structure was investigated by radiography. Pullout force was measured by recording force vs displacement to analyze the strength of the connection between the bridging stent graft and the fenestration. Tangential force vs displacement was measured to assess the shear stability of the different stents and to analyze the ability of the stents to resist migration and misalignment of a fenestrated endograft (Fig 1). No damage or rupture of the PTFE fabric was observed in all types of covered stents. Moreover, no stent fractures in any of the covered stents was seen by radiography. Maximal pullout force for 6-mm stents was 16.9 ± 1.9 N for the Advanta V12, 23.0 ± 4.3 N for the VBX, 17.6 ± 1.3 N for the BeGraft, and 28.1 ± 4.2 N for the BeGraft Plus. The slope of the measured pullout force of these stents in the first part was 2.83 N/mm for the Advanta V12, 1.9 N/mm for the VBX, 1.87 N/mm for the BeGraft, and 2.12 N/mm for the BeGraft Plus. Maximal shear strength was 29.6 ± 3.2 N for the Advanta V12, 20.4 ± 3.1 N for the VBX, 18.9 ± 1.9 N for the BeGraft, and 28.8 ± 2.0 N for the BeGraft Plus. Shear force at 6-mm displacement was 7.2 ± 1.4 N for the Advanta V12, 8.7 ± 1.9 N for the VBX, 6.7 ± 0.8 N for the BeGraft, and 9.6 ± 1.5 N for the BeGraft Plus (Fig 2). The material of all tested covered stents has withstood the flaring forces without damage of the PTFE fabric or stent fracture. Pullout force was highest in the BeGraft Plus, followed by VBX, BeGraft, and Advanta V12, but the slope of the pullout force at the first part was highest in the Advanta V12 stent, followed by BeGraft Plus, VBX, and BeGraft. The ability to withstand crushing forces was highest in Advanta and BeGraft Plus, followed by VBX and BeGraft. These findings together with the special features of the tested stents should have an important implication for clinical practice. Fatigue tests for these stents in this special indication are mandatory to ave a dedicated bridging stent graft for fenestrated aortic repair in the future.Fig 2Shear strength 6-mm bridging stent graft.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

P2741Predictors of subtle left ventricular systolic dysfunction after treatment of coarctation of the aorta

Abstract Background With the advent of the term “Heart Failure with Preserved Ejection Fraction - HFpEF”, more and more evidence has emerged supporting the importance of Speckle Tracking Echocardiography in measurement of Left ventricular (LV) Strain to assess subtle myocardial systolic dysfunction in such patients. Aim: To assess Global Longitudinal stain (GLS) of the LV in patients with Coarctation of the Aorta (CoA) after surgical or percutaneous treatment and predict the variables affecting the occurrence of subtle myocardial dysfunction in these patients. Patients and methods This was a cross sectional observational study that included 77 patients who presented to Ain Shams University hospital for follow up post treatment of Coarctation of the Aorta. All of these patients underwent intervention (surgical or catheter based) in the period between January 2005 and December 2017 and aged between 15 and 40 years at the time of the study. The patients underwent a detailed transthoracic echocardiogram, including Speckle Tracking using Phillips Q Lab version 7.1 software. All patients had normal systolic functions as measured by LV ejection fraction using Modified Simpsons' method. Correlations between variables were studied using “Independent paired T test and Chi square test”. Results The mean follow up duration was 13.19±3 years. The least accepted GLS value using the Phillips Q Lab version 7.1 software was −16.4%. Accordingly, the study group was divided into two groups (Normal GLS and Abnormal GLS). Nineteen patients had a low GLS, representing 24% of the study population. There was no age nor sex predilection between the two groups. Age at first intervention correlated positively with GLS (p=0.01), meaning that earlier intervention lead to better LV strain as the GLS is a negative value. Patients with Bicuspid Aortic Valve and those having Left ventricular Hypertrophy had significantly lower GLS (p=0.001). Patients with continuous abdominal Aortic flow had significantly lower GLS as compared to patients with pulsatile flow (p=0.005) (see figure). The occurrence of complications, e.g. stent fracture or recoarctation caused a significant reduction in GLS (p=0.012). Type of intervention, Order of interventions and age at second and third interventions did not significantly affect the GLS. CoA dimensions by MSCT and presence of Hypertension both before and after treatment did not affect the GLS. Effect of Aortic flow on GLS Conclusions Although most patients post CoA repair have normal LV ejection fraction, a good proportion of them have impaired LV global longitudinal strain and are thus prone to HFpEF. Earlier age at intervention, absence of complications and LV hypertrophy, as well as presence of pulsatile Abdominal Aortic flow lead to better LV performance as measured by GLS. LV strain derived from Speckle Tracking Echocardiography should be an integral part of follow up of CoA patients after repair. Acknowledgement/Funding None

Suivi clinique après implantation d’un stent couvert dans l’artère fémorale commune au décours immédiat d’une complication vasculaire per-TAVI

BackgroundVascular complications are frequent in the context of transcatheter aortic valve replacement and may require the implantation of a covered stent graft in the common femforal artery. However, common femoral artery is considered to be at high risk of stent fracture or occlusion due to high mobility of the hip joint. Patients and methodsWe analyzed medical records of patients with transcatheter aortic valve replacement related vascular complications between 2015 and 2018, treated with commom femoral artery transluminal angioplasty or surgery. Vascular complications or suspect symptoms were followed up by phone calls. ResultsAmong 552 patients, 43 patients were included. Twelve (11.6 %) were managed by prolonged balloon inflation, 5 (11.6 %) by first line surgery and 26 (60.4 %) by the implantation of a covered stent graft. Among the latter group, the covered stent graft was efficient in 24 patients (92.3 %). The median follow-up was 430 days [3–1499]. The first-line surgery group had a higher risk of red blood cell transfusion and all causes mortality. At follow-up, no patient had suspicious symptoms of vascular covered stent complication. Four patients (9.3 %) had US-doppler or CT vascular imaging at follow-up, showing no evidence of stent fracture or occlusion. ConclusionIn our study, the implantation of a covered stent graft in the common femoral artery was an efficient and safe strategy for the management of transcatheter aortic valve replacement related vascular complications.