Stent Position Research Articles

Endovascular management of aortic aneurysm with severe neck angulation and/or iliac artery tortuosity using multiple stiff wire technique: a case series

Background: Suitable aortic neck is one of the essential components for thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR). Advanced techniques were developed to adjust and compromise the aneurysm neck angulation but with adding additional devices and complexity to the procedure. We proposed a simple technique to modify severe neck angulation and/or iliac artery tortuosity by using the multiple stiff wire (MSW) technique. Method: Two femoral accesses were required for the MSW technique. A guidewire with a support catheter was inserted through the right and left femoral arteries and positioned in the abdominal or thoracic aorta. Wire exchanges were done with extra stiff wire in both femoral accesses. It can be considered to add multiple stiff wires to align the torturous neck / iliac artery. Delivery of the stent graft main body can be done via one of the accesses. Result: Six patients with different aortic pathology were admitted to our hospital. Four patients undergo EVAR procedure and two patients undergo TEVAR procedure. All patients had aortic neck angulation problems with one patient having iliac artery tortuosity. MSW technique was performed on the patients with good results. Follow-up CTA after 3 months revealed a good stent position without stent migration and no endoleak was found in all but one patient. Conclusion: MSW technique is a simple and effective technique to modify aortic neck/artery angulation in TEVAR or EVAR procedure.

Prognostic Impact of Drug-Coated Balloons in Patients With Diabetes Mellitus: A Propensity-Matched Study

Patients with diabetes mellitus (DM) are at higher risk of restenosis and stent thrombosis after percutaneous coronary intervention (PCI) and drug-eluting stent (DES) positioning. Whether drug-coated balloons (DCB) can offer any benefit in this subset of patients has been seldom cleared out and was the aim of the present propensity-matched cohort study, that compared the prognostic impact of DCB versus DES in patients with DM who underwent PCI. Patients with DM enrolled in the NOvara-BIella-TREnto (NOBITRE) Registry were identified and matched according to propensity score, to a control population of patients with DM treated with DES. The primary study end point was the occurrence of major adverse cardiovascular events (MACEs). A total of 150 patients were identified in the DCB group and matched with 150 DES-treated patients. Patients treated with DCB displayed more often a previous cardiovascular history and received a more complete pharmacological therapy. Target vessel diameter and the percentage of stenosis were lower in patients with DCB, whereas binary in-stent restenosis was more common (p<0.001, p=0.003, and p<0.001, respectively). Paclitaxel-eluting balloon represented the most common strategy in the DCB group, whereas Zotarolimus-eluting stents were used in half of the DES population. At a median follow-up of 545.5days, MACE occurred in 54 (19.4%) of patients, with no difference according to the PCI strategy (21.6% vs 17.3%, adjusted hazard ratio [95% confidence interval]1.51 [0.46 to 4.93], p=0.50). Major ischemic end points were slightly increased in patients treated with DCB, whereas overall death was significantly reduced (3.6% vs 10.9%; adjusted hazard ratio [95% confidence interval]0.27 [0.08 to 0.91], p=0.03). In conclusion, the present propensity-matched study shows that, in patients with DM who underwent PCI for in-stent restenosis or de novo lesions, the use of DCB is associated with a similar rate of MACE and a modest increase in target lesion failure, but a significantly improved survival as compared with DES.

Efficacy of a novel integrated biliary stent and nasobiliary catheter system for accidental tube deviation in biliary drainage.

Background and study aims Endoscopic nasobiliary drainage is accompanied by a risk of accidental removal of the nasobiliary drainage (NBD) tube, especially through self-removal in elderly patients. We studied the usefulness of an integrated biliary stent and nasobiliary catheter system (UMIDAS NB stent) for biliary drainage in case of accidental NBD tube removal. Patients and methods From April to November 2022, we placed a UMIDAS NB stent in 30 patients with acute cholangitis or obstructive jaundice. We evaluated the plastic stent (PS) position at the time of accidental stent removal and before the planned endoscopic procedure. In addition, we studied the ratio of successful biliary drainage and complications based on the usage of UMIDAS. Results All 11 patients with accidental stent removal exhibited correct PS position in X-ray fluoroscopy. Of the 19 patients with planned NBD tube removal, three had complete PS migration into the common bile duct and three had incomplete migration (the duodenal side flap entered the bile duct). In summary, 80% (24/30) of PS were in the correct position, and all patients had successful biliary drainage and no complications. Conclusions The UMIDAS NB stent might be useful for biliary drainage in patients with a high risk of NBD tube self-removal.

Mishaps with EUS–guided lumen-apposing metal stents in therapeutic pancreatic EUS: Management and prevention

Abstract EUS–guided interventions have become widely accepted therapeutic management options for drainage of peripancreatic fluid collections. Apart from endosonographic skills, EUS interventions require knowledge of the endoscopic stenting techniques and familiarity with the available stents and deployment systems. Although generally safe and effective, technical failure of correct stent positioning or serious adverse events can occur, even in experts' hands. In this article, we address common and rare adverse events in transmural EUS-guided stenting, ways to prevent them, and management options when they occur. Knowing the risks of what can go wrong combined with clinical expertise, high levels of technical skills, and adequate training allows for the safe performance of EUS-guided drainage procedures. Discussing the procedural risks and their likelihood with the patient is a fundamental part of the consenting process.

Lower urinary tract effects of ureteral stent length and intravesical position.

Ureteral stents can cause lower urinary tract problems such as stent-related irritative symptoms and urinary tract infections. This study aimed to determine the lower urinary tract effects of ureteral stent length and intravesical position in children. Patients who underwent double-J stenting after urological procedures between January 2017 and January 2022 were included in the study. The patients were assessed in terms of age, irritative symptoms, urinary tract infections, and stent length. The intravesical position of the ureteral stents was grouped as cross-trigonal and ipsilateral. The distribution of irritative symptoms, frequency of urinary tract infections and stent length were analyzed according to intravesical location. A total of 47 patients were included in the study. The median age was 5years (range: 1-16). Cross-trigonal stent position was significantly associated with symptoms of urgency (p = 0.046), suprapubic pain (p = 0.002), and lower mean age (p = 0.004). Urinary tract infections were more frequent in patients whose placed stents were longer than recommended (p < 0.001) or were in cross-trigonal position (p = 0.043). Our results suggest that stent-related irritative symptoms and urinary tract infections can be reduced in pediatric patients using a suitably sized ureteral stent and considering its intravesical position.

Safety and feasibility of intravascular ultrasound-guided robotic percutaneous coronary intervention.

Previous studies have demonstrated the benefit of intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) for preventing longitudinal geographic miss (LGM). However, it is yet unclear whether IVUS guidance is useful for robotic-PCI (robotic-assisted perctaneous coronary intervention [R-PCI]). A total of 58 consecutive patients with stable angina who underwent IVUS-guided R-PCI were enrolled. The stent landing position was angiographically marked using a balloon marker before stenting, followed by measurements of the expected stent length using balloon pullback. Subsequently, prestenting IVUS was performed to determine stent landing. All pre-PCI IVUS images were assessed for lesion length and percent plaque volume (%PV) using both IVUS and angiographic marking. LGM was defined as a residual %PV >50% at either the distal or proximal stent edge, any stent edge dissection, or additional stent deployment immediately after stenting. The included patients had an average age of 67.1 ± 10.1 years. IVUS guidance had significantly longer lesion lengths compared with angiographic marking. Based on IVUS-guided stent deployment, nine cases exhibited LGM immediately after stenting. IVUS-marked landing points had a significantly smaller %PV and significantly larger lumen area compared with those for angiography. IVUS-guided R-PCI was well-tolerated and may be better at preventing LGM compared with angiography-guided R-PCI.

Comparison between a dedicated stent positioning system and conventional stenting of aorto-ostial lesions: a prospective, multi-center, randomized controlled study.

The accurate placement of stents for treatment of coronary aorto-ostial lesions (AOLs) is technically challenging. The purpose of this study was to evaluate the efficacy and safety of a stent positioning system with a dedicated nitinol device and compare them with those of the conventional approach for stenting of coronary AOLs. In this prospective, multi-center, open-label, randomized study, conducted from November 2015 to April 2019, patients with coronary AOLs that underwent percutaneous coronary intervention (PCI) were randomly allocated (allocation ratio 1:1) using block randomization method to either a stent positioning system group or a conventional technique group. The primary endpoint was the range of stent slippage when positioning. The following secondary endpoints were applied: (I) the extent of swing of the guiding catheters during stent positioning; (II) the rate of accurate stent placement; (III) the procedure time; and (IV) the incidence of major adverse cardiovascular events (MACEs) including cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis. During the study period, 139 patients with aorto-ostial coronary artery stenosis were included at 5 centers. A total of 69 patients were allocated to the stent positioning system group and 70 patients to the conventional technique group. Angiographic and clinical success were achieved in 100% of the patients included in both groups. The range of stent slippage was significantly shorter in the stent positioning system group than it was in the conventional technique group [0.64 (0.22; 1.35) vs. 1.11 (0.48; 1.72) mm, P=0.01]. The rate of accurate placement of stents was higher in the stent positioning system group than it was in the conventional technique group (74.6% vs. 57.1%, P=0.03). The extent of guiding catheter swing during the stent positioning [0.24 (0.19; 0.53) vs. 0.23 (0.19; 0.53) mm; P=0.95] and the MACEs rates (1.4% vs. 2.9%, P>0.99) were similar between the 2 groups. The procedural time of the stent positioning system was longer than that of the conventional approach [1.00 (0.50; 1.50) vs. 0.80 (0.50; 1.50) min, P=0.09]. The dedicated stent positioning system was is safer and provides more accurate placement of stents for coronary AOLs than the conventional approach, and the associated prolongation of procedure time is insignificant. Chinese Clinical Trial Registry (ChiCTR), Unique identifier: ChiCTR2100053869. URL: https://www.chictr.org.cn/showproj.html?proj=133280.

A multi-device robotic-assisted PCI system: a proof-of concept study for left main bifurcation stenting with culotte technique in a porcine model

Background and purpose: Robotic-assisted percutaneous coronary intervention (PCI) has been increasingly used for simple lesion. For complex lesions, extensive manual intervention is still required. This study aims to verify the stability and safety of this robot system in complex lesion under fifth-generation (5G) network before clinical trial. Methods: We developed a robotic system that allows simultaneous remote control of multiple devices using a 5G wireless network. The key feature of the system is a bionic thumb along with two-bionic forefingers. The system was tested in eight pigs (six over 18.3 km and two over 1,100 km). Two stents were placed in the left main bifurcation using the culotte technique. All procedures, barring device loading onto the robot system, including manipulation of the guiding catheter, wire adjustments, stent or balloon positioning, and notably the final kissing step, were conducted remotely. Results: The rate of procedure success was 100%, with no device-related complications. In comparison to short-distance remote control, the delay with long-distance remote control was minimal (90.9 ± 1.5 vs. 81.5 ± 2.7 ms for command data transmission; 163.2 ± 1.3 vs. 161.0 ± 1.4 ms for image transmission). The procedure time was shorter when using two pairs versus a single pair of bionic fingers (104.3 ± 10.2 vs. 126.0 ± 3.9 min), primarily due to less time needed for device loading and exchange (33.1 ± 4.2 vs. 56.1 ± 4.0 min). Conclusions: With the 5G network, long distance was not a significant barrier for robotic-assisted PCI for chronic total occlusion. A design of the independent bionic finger module enabled final kissing balloon inflation with reduced requirement for manual intervention. Whether the system could be used beyond left main bifurcation lesions requires further investigation.

Effect of ureteral stent length and implantation position on migration after implantation.

Ureteral obstruction is a urinary system disease that causes urinary retention, renal injury, renal colic, and infection. Ureteral stents are often used for conservative treatment in clinics, and their migration usually results in ureteral stent failure. The migrations include proximal migration to the kidney side and distal migration to the bladder side, but the biomechanism of stent migration is still unknown. Finite element models of stents with lengths from 6-30cm were developed. The stents were implanted into the middle of the ureter to analyze the effect of stent length on its migration, and the effect of stent implantation position on 6-cm-long stent migration was also observed. The stents' maximum axial displacement was used to assess the ease of stent migration. A time-varying pressure was applied to the ureter outer wall to simulate peristalsis. The stent and ureter adopted friction contact conditions. The two ends of the ureter were fixed. The radial displacement of the ureter was used to evaluate the effect of the stent on peristalsis. The maximum migration occurs in the positive direction for a 6-cm-long stent implanted at the proximal ureter (CD and DE), but in the negative direction at the distal ureter (FG and GH). The 6-cm-long stent demonstrated almost no effect on ureteral peristalsis. The 12-cm-long stent diminished the radial displacement of the ureter from 3-5s. The 18-cm stent diminished the radial displacement of the ureter from 0-8s, and the radial displacement within 2-6s was weaker than other time. The 24-cm stent diminished the radial displacement of the ureter from 0-8s, and the radial displacement within 1-7s was weaker than other time. The biomechanism of stent migration and ureteral peristalsis weakening after stent implantation was explored. Shorter stents were more likely to migrate. The implantation position had less influence on ureteral peristalsis compared with the stent length, which provided a reference for stent design aimed at reducing stent migration. Stent length was the main factor affecting ureteral peristalsis. This study provides a reference for the study of ureteral peristalsis.

P315 GENETIC RESISTENCE TO CLOPIDOGREL AND COMPLEX PCI: A CASE REPORT

Abstract A 35–year–old man presents to the attention of the cardiology department for anterior STEMI. On history he reports hypertension, atrial fibrillation with CHA2DS2–VASc 2 on Rivaroxaban therapy, a previous PCI in the anterior interventricular artery, and a known genetic resistance to Clopidogrel (CYP2C19*2 mutation in heterozygosity) that emerged during diagnostic investigations for marked hyperhomocysteinemia (MTHFR A1298C variant in heterozygosity). Coronary angiography showed endoluminal thrombosis at the ostium of the anterior descending artery and an intrastent thrombosis. IVUS analysis, moreover, shows underexpansion and a concomitant protrusion of the stent at the ostium of the coronary. Thus, angioplasty with positioning of a drug eluting stent was performed. Antithrombotic therapy in these patients is usually triple therapy with ASA, clopidogrel and an anticoagulant. In this case the management of therapy was guided by the patient‘s genetic. Therefore, considering the low hemorrhagic risk and the high thrombotic risk, it was decided to undertake combination therapy with Dabigatran 150mg and Ticagrelor 90 BID in accordance with the Re–Dual PCI treatment trial. Thromboembolic events affect high mortality and morbidity, especially in the 30 days following the angioplastiy procedure. There is a part of the population that may have a poor response to the drugs used and most frequently to Clopidogrel. Genetic polymorphisms present in the coding regions for cytochrome CYP2C19 are involved in the altered metabolism and activation of the drug. The "genetic guided DAPT" used in the POPular Genetics study, was not inferior to Ticagrelor/Prasugrel therapy with regard to thrombotic events but showed a significant reduction in minor bleeding. Since long–term mortality post PCI is predominantly related to the occurrence of hemorrhagic rather than thrombotic events, the reduction of bleeding is very valuable in clinical practice. This case emphasizes the importance for the possible interindividual genetic variability and the most personalized approach possible in treatment choices. The feasibility in terms of cost and events saved of introducing "genetic–guided" DAPT into everyday clinical practice remains to be defined.

P201 DRUG–COATED BALLOON AND DIABETES MELLITUS: A MATTER OF SURVIVAL

Abstract Background Patients with diabetes mellitus (DM) are at higher risk of restenosis and stent thrombosis after percutaneous coronary intervention and drug eluting stent (DES) positioning. Limited although interesting data are available on prognosis after revascularization with drug–coated balloon (DCB) in this group of patients. The aim of this study is to evaluate the prognostic impact of DCB use in patients affected by DM. Methods Patients with DM enrolled in a retrospective multicenter registry were identified and matched to a control population of diabetic patients treated with DES enrolled in another retrospective registry, according to a propensity score calculated on the independent predictors of main adverse cardiac events (MACE). The primary study endpoint was the occurrence of MACE, a composite of death, myocardial infarction, and target vessel revascularization. Secondary endpoints were the independent components of the primary endpoint, or target lesion failure (TLF). Results 150 patients were identified in the DCB group and matched with 150 DES–treated patients. However, patients treated with DCB displayed more often a previous cardiovascular history and received a more complete pharmacological therapy. Target vessel diameter and the percentage of stenosis were lower in DCB patients, whereas binary in–stent restenosis was more common. At a median follow–up of 545.5 days, MACE occurred in 54 (19.4%) of the patients, with no difference according to the PCI strategy. Although a trend toward higher TLF was found (p=0.06), overall death was significantly reduced in diabetic patients (3.6% vs 10.9%; adjusted HR[95%CI]= 0.27[0.08–0.91], p=0.03). Conclusion Although limited by some differences among the groups, the present propensity–matched study shows that, among patients with DM undergoing PCI for in–stent restenosis or de novo lesions, the use of DCB is associated to a similar rate of MACE and a possible increase in TLF, but a significantly improved survival as compared to use of DES.

Coronary Revascularization in Patients With Cancer.

The treatment of coronary artery disease (CAD) in cancer patients is an evolving landscape. Recent data emphasizes the importance of aggressive management of cardiovascular risk factors and diseases in improving cardiovascular health in this unique group of patients regardless of cancer type or stage. Novel cancer therapeutics such as immune therapies and proteasome inhibitors have been associated with CAD. Recent stent technologies may safely allow for shorter duration (< 6months) of dual antiplatelet therapy post-percutaneous coronary interventions. Intracoronary imaging may be useful in the decision making process in terms of stent positioning and healing. Large registry studies have partially filled a gap left by the lack of randomized controlled trials in the treatment of CAD in cancer patients. Cardio-oncology is gaining traction as a major sub-specialty in the cardiology field given the release of the first European Society of Cardiology - Cardio-oncology guidelines in 2022.

Efficacy Analysis of Suprapapillary versus Transpapillary Self-Expandable Metal Stents According to the Level of Obstruction in Malignant Extrahepatic Biliary Obstruction.

The use of a self-expandable metal stent (SEMS) is recommended for unresectable malignant biliary obstruction (MBO). Stent-related adverse events might differ according to the position of the stent through the ampulla of Vater (AOV). We retrospectively evaluated SEMS patency and adverse events according to the position of the SEMS. In total, 280 patients who underwent endoscopic SEMS placement due to malignant distal biliary obstruction were analyzed retrospectively. Suprapapillary and transpapillary SEMS insertions were performed on 51 patients and 229 patients, respectively. Between the suprapapillary group (SPG) and transpapillary group (TPG), the stent patency period was not significantly different (median [95% confidence interval]: 107 days [82.3 to 131.7] vs 120 days [99.3 to 140.7], p=0.559). There was also no significant difference in the rate of adverse events. In subgroup analysis, the stent patency for an MBO located within 2 cm from the AOV was found to be significantly shorter than that for an MBO located more than 2 cm from the AOV in the SPG (64 days [0 to 160.4] vs 127 days [82.0 to 171.9], p<0.001) and TPG (87 days [52.5 to 121.5] vs 130 [97.0 to 162.9], p<0.001). Patients with an MBO located within 2 cm from the AOV in both groups had a higher percentage of duodenal invasion (SPG: 40.0% vs 4.9%, p=0.002; TPG: 28.6% vs 2.9%, p<0.001) than patients with an MBO located more than 2 cm from the AOV. The SPG and TPG showed similar results in terms of stent patency and rate of adverse events. However, patients with an MBO located within 2 cm from the AOV had a higher percentage of duodenal invasion with shorter stent patency than those with an MBO located more than 2 cm from the AOV, regardless of stent position.

MP35-15 PAIN CATASTROPHIZING IS ASSOCIATED WITH STENT-RELATED PAIN AFTER URETEROSCOPIC LASER LITHOTRIPSY

You have accessJournal of UrologyCME1 Apr 2023MP35-15 PAIN CATASTROPHIZING IS ASSOCIATED WITH STENT-RELATED PAIN AFTER URETEROSCOPIC LASER LITHOTRIPSY Alan J. Yaghoubian, Sarah Mozafarpour, Roman Shimonov, Raymond Khargi, Blair Gallante, Dara Lundon, Johnathan A. Khusid, William M. Atallah, and Mantu Gupta Alan J. YaghoubianAlan J. Yaghoubian More articles by this author , Sarah MozafarpourSarah Mozafarpour More articles by this author , Roman ShimonovRoman Shimonov More articles by this author , Raymond KhargiRaymond Khargi More articles by this author , Blair GallanteBlair Gallante More articles by this author , Dara LundonDara Lundon More articles by this author , Johnathan A. KhusidJohnathan A. Khusid More articles by this author , William M. AtallahWilliam M. Atallah More articles by this author , and Mantu GuptaMantu Gupta More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Ureteral stent-related pain varies in intensity for different patients. While stent-specific factors (e.g. stent position) may influence symptoms, patient-specific factors remain elusive. The pain catastrophizing scale (PCS) is a validated questionnaire quantifying the degree to which an individual may catastrophize painful stimuli. We aim to determine whether PCS score is associated with stent symptoms after ureteroscopic laser lithotripsy (URSLL). METHODS: This is an ongoing prospective study of patients undergoing URSLL. All patients completed the PCS prior to undergoing URSLL with stent placement and were labeled as catastrophizers (top third), non-catastrophizers (bottom third), or semi-catastrophizers (middle third). The ureteral stent symptom questionnaire (USSQ) was completed at 2 time points: post-op day (POD)#1 and POD#10. Prescriptions for phenazopyridine, ibuprofen, and oxybutynin were given. Outcomes included USSQ scores, total analgesic pills taken, pain-related office phone calls, and need for narcotic prescriptions. RESULTS: In sum 41 patients have been enrolled. Median USSQ pain scores on POD#10 were significantly higher among catastrophizers as compared to non-catastrophizers (24.5 vs. 14.0, p=0.036). There were no differences between all 3 groups in other USSQ domains. Catastrophizers took more tablets of phenazopyridine (11.0 vs. 5.5, p=0.027) and total prescribed tablets (26.5 vs. 15.5, p=0.023) compared to non-catastrophizers. Differences between number of pain-related calls between catastrophizers and non-catastrophizers approached significance (46.2% vs. 0%, p=0.057). Semi-catastrophizers had no significantly different outcomes from the other two groups. CONCLUSIONS: Pain catastrophizers have higher post-URSLL pain index scores, use more pain medications, and likely call the office more frequently. The PCS may ultimately become a practical tool to personalize patient care by identifying those at highest risk for severe stent pain. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e475 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alan J. Yaghoubian More articles by this author Sarah Mozafarpour More articles by this author Roman Shimonov More articles by this author Raymond Khargi More articles by this author Blair Gallante More articles by this author Dara Lundon More articles by this author Johnathan A. Khusid More articles by this author William M. Atallah More articles by this author Mantu Gupta More articles by this author Expand All Advertisement PDF downloadLoading ...

MP23-19 LESSONS LEARNT FROM A MULTICENTER SERIES OF 400 CASES ON THE UTILITY OF PRE-STENTING FOR PEDIATRIC RETROGRADE INTRA RENAL SURGERY (RIRS)

You have accessJournal of UrologyCME1 Apr 2023MP23-19 LESSONS LEARNT FROM A MULTICENTER SERIES OF 400 CASES ON THE UTILITY OF PRE-STENTING FOR PEDIATRIC RETROGRADE INTRA RENAL SURGERY (RIRS) Ee Jean Lim, Stefania Ferreti, Anna Bujons, Olivier Traxer, Danielle Castellani, Yesica Quiroz, Deepak Ragoori, Tanuj Paul Bhatia, Chandra Mohan Vaddi, Claudia Gatti, Khi Yung Fong, Yiloren Tanidir, Bhaskar Kumar Somani, Anil Shrestha, and Vineet Gauhar Ee Jean LimEe Jean Lim More articles by this author , Stefania FerretiStefania Ferreti More articles by this author , Anna BujonsAnna Bujons More articles by this author , Olivier TraxerOlivier Traxer More articles by this author , Danielle CastellaniDanielle Castellani More articles by this author , Yesica QuirozYesica Quiroz More articles by this author , Deepak RagooriDeepak Ragoori More articles by this author , Tanuj Paul BhatiaTanuj Paul Bhatia More articles by this author , Chandra Mohan VaddiChandra Mohan Vaddi More articles by this author , Claudia GattiClaudia Gatti More articles by this author , Khi Yung FongKhi Yung Fong More articles by this author , Yiloren TanidirYiloren Tanidir More articles by this author , Bhaskar Kumar SomaniBhaskar Kumar Somani More articles by this author , Anil ShresthaAnil Shrestha More articles by this author , and Vineet GauharVineet Gauhar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003248.19AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retrograde intrarenal surgery (RIRS) is an option for pediatric kidney stone upto 1 cm in EAU guidelines and many urologist do RIRS for >1 cm stones as well if they have sufficient experience. We aim to assess the outcomes of pre-stenting versus non-pre-stenting in a pediatric population undergoing RIRS for intrarenal stones in different age groups and locations. METHODS: Data collected on Children/adolescents with kidney stones undergoing RIRS in 9 centers between 2015-2020 were retrospectively reviewed. Exclusion criteria: ureteral lithotripsy, bilateral procedures. Stone-free status was evaluated at 3-month and deemed as a single residual fragment (RF) ≤2 mm/absence of multiple fragments. Patients were divided into two groups (Group 1 no pre-stenting , Group 2 pre-stented). Student’s, Chi-square and Fisher’s exact test was used to assess difference between groups. Univariable and multivariable logistic regression analysis were performed to predict RF. Statistical signicance: p-value <0.05. RESULTS: 389 children/adolescents were included (192 patients in Group 1). Pre-stented patients were younger compared with non-presented (mean age 8.30±4.93 vs 10.43±4.30 years, p<0.001). There were no differences in stone characteristics (number, size, locations). Lasing and total surgical time were similar. Urinary tract infections (Clavien grade 2) were more prevalent in Group 2 (10.7%) compared to Group 1 (3.7%, p=0.016). Sepsis (Clavien grade 4) occurred in 2.1% of patients in Group 2 and no patient in Group 1 (p=0.146). 30.7% patients in Group 1 and 26.4% in Group 2 had RF (p=0.322). Multivariate logistic regression analysis showed that stone size was associated with RF (OR 1.20 95% CI 1.08-1.36, p=0.001). CONCLUSIONS: RIRS showed similar stone-free rate in pre and non-pre-stented children/adolescents, In this multicenter study, we found that preoperative positioning of ureteral stent had no effect in clearing stones but a higher incidence of postoperative infections. Whilst routine pre-stenting cannot be recommended it becomes imperative that the child's guardian is counseled appropriately about pros and cons of prestenting including need for additional anaesthesia. Source of Funding: NIL © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e314 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ee Jean Lim More articles by this author Stefania Ferreti More articles by this author Anna Bujons More articles by this author Olivier Traxer More articles by this author Danielle Castellani More articles by this author Yesica Quiroz More articles by this author Deepak Ragoori More articles by this author Tanuj Paul Bhatia More articles by this author Chandra Mohan Vaddi More articles by this author Claudia Gatti More articles by this author Khi Yung Fong More articles by this author Yiloren Tanidir More articles by this author Bhaskar Kumar Somani More articles by this author Anil Shrestha More articles by this author Vineet Gauhar More articles by this author Expand All Advertisement PDF downloadLoading ...

Over-the-scope Technique for Partially Covered Self-expandable Metal Stent Placement to Treat Duodenal Perforation during EUS

Although endoscopic ultrasound (EUS) is generally safe, duodenal perforation may occur during the procedure. When the iatrogenic break is wide, endoscopic positioning of a covered self- expandable metal stent is indicated to avoid a more invasive surgical approach. We evaluated the efficacy of the 'over-the-scope stenting' (OTSS) technique to treat iatrogenic duodenal perforations occurred during EUS. Data of patients with large iatrogenic duodenal perforations treated with OTSS procedure were collected in 5 centers. Technical success was defined as a correct stent placement on the perforation site, and clinical success as complete healing of the duodenal leak at stent removal 3 weeks later. A total of 15 (7 males; median age: 78 years, range 47-91) patients were included in this series. A correct stent positioning was achieved in all cases (technical success: 100%), and the perforation was healed in all, apart from one patient at stent removal (clinical success: 93%). This patient was successfully treated with a novel stent placement. No immediate post-procedural adverse events occurred, and no need for emergency surgery was recorded. In one (6.7%) patient, stent migration occurred 10 days after positioning, and it was spontaneously expulsed with stool movement without complications two days later. Our data showed that the OTTS technique for partially covered self-expandable metal stent placement is feasible, safe and effective to tread large iatrogenic duodenal perforation occuring during EUS.

Redo-transcatheter aortic valve implantation in a patient at high risk of coronary obstruction due to sinus sequestration

LCA, left coronary artery; RCA, right coronary artery; VTC, virtual valve-to-coronary ostium distance; VTSTJ, virtual valve-to-sinotubular junction distance. An 80-year-old female presented with structural valve deterioration of a 26 mm CoreValve (aortic valve area = 0.5 cm2 and mean pressure gradient = 45 mmHg) and gastric cancer 9 years following transcatheter aortic valve implantation (TAVI). She underwent coronary artery bypass graft then stenting of proximal left anterior descending artery and ostial right coronary artery (RCA) for occlusion of vein grafts before TAVI. Redo-TAVI was considered at high risk of coronary obstruction due to sinus sequestration (Panel A): (i) ostia of both coronaries below pinned leaflet height of CoreValve; (ii) effaced sinuses of Valsalva [valve-to-sinotubular junction distance of 0.2 mm for left coronary artery (LCA) and 0.5 mm for RCA]; and (iii) ultranarrow valve-to-coronary distance (2.4 mm for LCA and 1.0 mm for RCA). Furthermore, commissural alignment of CoreValve and both coronaries was unfavourable (Panel B). Considering the patient’s high surgical risk (the Society of Thoracic Surgeons score 9.98%), massive gastrointerstinal bleeding, and the complexity of a surgical explant of CoreValve, redo-TAVI was performed. To prevent coronary obstruction, positioning of stents through CoreValve frames into both coronaries was facilitated by GuideLiner catheters (Panel C). Immediately after deploying a 23-mm MyValve with its outflow aiming at node 4 of CoreValve (Panel D), we implanted stents from coronaries into CoreValve frames with minimal protrusion (Panel E). Then the stent balloons were pulled back from the distal edge, inflating to higher pressures for flaring the proximal stents to improve re-access (see Supplementary data online, Video S1). Postprocedural CT demonstrated stents through the frames of CoreValve without deformation (Panel F).

Nasolacrimal Duct Coronary Stent Recanalization (NCR): First Cadaver Experience and Its Potential as an Alternative to DCR.

To investigate the feasibility of implanting a drug-eluting cobalt-chromium alloy coronary stent in the nasolacrimal ducts (NLDs) of human cadavers. The pilot study was carried out in 5 NLDs of 4 adult human cadavers. Sirolimus-eluting coronary stents of 2 mm in width and lengths of 8 and 12 mm, which were mounted on balloon catheters, were used. Following dilatation of the NLDs, the balloon catheters were introduced into the NLDs under direct endoscopy guidance. The stents were delivered following dilatation of the balloon to 12 ATMs and secured in a locked (spring out) position. The balloon is then deflated and securely extubated. The dacryoendoscopy confirmed the stent position. The lacrimal system was then dissected to assess several key parameters like the uniformity of the NLD expansion, anatomical interactions of the NLD mucosa with the stent rings and struts, integrity of the soft and bony NLD, stent movement on mechanical push and pull, and ease of manual removal. The cobalt-chromium alloy coronary stents could be delivered with ease and secured in the cadaveric NLDs. Its position was confirmed by a dacryoendoscopy and later by the direct NLD dissection. The NLD was uniformly dilated 360° with a wide and uniform lumen. NLD mucosa was noted to be uniformly distributed in spaces between the stent rings without influencing the expanded lumen. Following the lacrimal sac's dissection, the NLD stent showed significant resistance to downward movement but could be easily retrieved with forceps. The 12-mm stents could reach the near total length of the NLD with good luminal expansion. The integrity of the bony and soft-tissue NLD was maintained. The learning curve is shallow if the surgeon is adept with the techniques of balloon dacryoplasty. Drug-eluting cobalt-chromium alloy coronary stents can be precisely deployed and secured within the human NLDs. The study is the first of its kind to demonstrate the technique of NLD coronary stent recanalization in human cadavers. It is a step forward in the journey to evaluate their use in patients with primary acquired NLD obstructions and other NLD disorders.

Endoscopy management of sleeve gastrectomy stenosis: what we learned from 202 consecutive patients.

Gastric sleeve stenosis (GSS) is described in 1%-4% of patients. To evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach according to the characteristic of stenosis. Retrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center. We enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach wasused. We found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%. GSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of thestenosis should guide the most suitable endoscopic approach.

Assessment of the flow-diverter efficacy for intracranial aneurysm treatment considering pre- and post-interventional hemodynamics

Endovascular treatment of intracranial aneurysms with flow diverters (FD) has become one of the most promising interventions. Due to its woven high-density structure they are particularly applicable for challenging lesions. Although several studies have already conducted realistic hemodynamic quantification of the FD efficacy, a comparison with morphologic post-interventional data is still missing. This study analyses the hemodynamics of ten intracranial aneurysm patients treated with a novel FD device. Based on pre- and post-interventional 3D digital subtraction angiography image data, patient-specific 3D models of both treatment states are generated applying open source threshold-based segmentation methods. Using a fast virtual stenting approach, the real stent positions available in the post-interventional data are virtually replicated and both treatment scenarios were characterized using image-based blood flow simulations. The results show FD-induced flow reductions at the ostium by a decrease in mean neck flow rate (51%), inflow concentration index (56%) and mean inflow velocity (53%). Intraluminal reductions in flow activity for time-averaged wall shear stress (47%) and kinetic energy (71%) are present as well. However, an intra-aneurysmal increase in flow pulsatility (16%) for the post-interventional cases can be observed. Patient-specific FD simulations demonstrate the desired flow redirection and activity reduction inside the aneurysm beneficial for thrombosis formation. Differences in the magnitude of hemodynamic reduction exist over the cardiac cycle which may be addressed in a clinical setting by anti-hypertensive treatment in selected cases.