Stent-related Complications Research Articles

Endoscopic pancreaticobiliary drainage with overlength stents to prevent delayed perforation after endoscopic papillectomy: A pilot study.

BACKGROUNDEndoscopic papillectomy (EP) is rapidly replacing traditional surgical resection and is a less invasive procedure for the treatment of duodenal papillary tumors in selected patients. With the expansion of indications, concerns regarding EP include not only technical difficulties, but also the risk of complications, especially delayed duodenal perforation. Delayed perforation after EP is a rare but fatal complication. Exposure of the artificial ulcer to bile and pancreatic juice is considered to be one of the causes of delayed perforation after EP. Draining bile and pancreatic juice away from the wound may help to prevent delayed perforation.AIMTo evaluate the feasibility and safety of placing overlength biliary and pancreatic stents after EP.METHODSThis is a single-center, retrospective study. Five patients with exposure or injury of the muscularis propria after EP were included. A 7-Fr overlength biliary stent and a 7-Fr overlength pancreatic stent, modified by an endoscopic nasobiliary drainage tube, were placed in the common bile duct and pancreatic duct, respectively, and the bile and pancreatic juice were drained to the proximal jejunum.RESULTSEP and overlength stents placement were technically feasible in all five patients (63 ± 12 years), with an average operative time of 63.0 ± 5.6 min. Of the five lesions (median size 20 mm, range 15-35 mm), four achieved en bloc excision and curative resection. The final histopathological diagnoses of the endoscopic specimen were one tubular adenoma with high-grade dysplasia (HGD), one tubulovillous adenoma with low-grade dysplasia, one hamartomatous polyp with HGD, one poorly differentiated adenocarcinoma and one atypical juvenile polyposis with tubulovillous adenoma, HGD and field cancerization invading the muscularis mucosae and submucosa. There were no stent-related complications, but one papillectomy-related complication (mild acute pancreatitis) occurred without any episodes of bleeding, perforation, cholangitis or late-onset duct stenosis.CONCLUSIONFor patients with exposure or injury of the muscularis propria after EP, the placement of overlength biliary and pancreatic stents is a feasible and useful technique to prevent delayed perforation.

When Is It Safe to Proceed With Pancreaticoduodenectomy Without Biliary Decompression?

An absolute bilirubin level where preoperative biliary decompression (PBD) is indicated before pancreaticoduodenectomy has been elusive. Our goal was to identify a total bilirubin level whereby biliary decompression provides clear benefit, despite associated expenses and potential complications. We reviewed a prospectively collected database of patients undergoing pancreaticoduodenectomy at the Vidant Medical Center between 2007 and 2016. Patients were arbitrarily subdivided into 3 groups based on presenting bilirubin level (≤10mg/dL, 10.1-14.9mg/dL, and ≥15mg/dL) to determine the presence of overall complications, severe complications (Clavien-Dindo classification ≥3), prolonged length of stay (>1 SD), readmissions, or mortality. Common bile duct stenting independently predicted a higher incidence of complications in patients presenting with bilirubin ≤10mg/dL (P = .03) vs. those patients going directly to surgery. No differences were observed for patients with bilirubin between 10.1mg/dL and 14.9mg/dL. Biliary decompression in patients with bilirubin ≥15mg/dL independently predicted fewer overall (73.8% vs. 100%, P = .0082) and less severe complications (14.3% vs. 44.5%, P = .03) and lower readmission rates (15.8% vs. 55.6%, P = .03) vs. those going directly to surgery. Patients not undergoing biliary decompression underwent pancreaticoduodenectomy sooner than those decompressed (4.7days vs. 17.2days, P = .01). All patients presenting with bilirubin ≥15mg/dL should undergo PBD, while those with bilirubin ≤10mg/dL should forego stent placement to avoid stent-related complications. The decision to stent between 10.1 and 14.9mg/dL should be made on a case-by-case basis keeping in mind timeliness to definitive cancer treatment.

Self-assembled nanosheets on NiTi alloy facilitate endothelial cell function and manipulate macrophage immune response

Stenting has been widely adopted for the treatment of cardiovascular diseases, but the complications such as in-stent restenosis and late stent thrombosis cannot be completely avoided, which are closely related to endothelial dysfunction and inflammatory response. In the present work, oxide nanosheets were grown on the surface of nearly equiatomic NiTi alloy by alkaline corrosion (AC), aiming at yielding favorable endothelial functionality and immune microenvironment. The results show nanosheets mainly composed of TiO2, Ni(OH)2, and K2TiO3 can be grown on the alloy in KOH solution of 2.5–15 M at room temperature. The AC-treated samples significantly promote endothelial cell (EC) functionality such as proliferation, migration, NO production, VEGF secretion, and angiogenesis. In addition, the sample grown in KOH of 15 M can switch macrophages to an anti-inflammatory M2 phenotype and up-regulate the gene expression of VEGF to facilitate EC functionality. These results demonstrate that the nanosheets can directly and indirectly up-regulate EC functionality, possibly leading to rapid re-endothelialization of the stents thus addressing the stent-related complications.

Comparison of Clinical Outcomes After Stent-Assisted Coiling with 3 Types of Self-Expanding Laser-Cut Stents in Patients with Wide-Necked Intracranial Aneurysms

We report the clinical outcomes of stent-assisted coiling for wide-necked intracranial aneurysms using 3 low-profile laser-cut stents and compare the results according to stent type. All patients treated with stent-assisted coiling for their intracranial aneurysms at our hospital between July 2010 and September 2019 were reviewed. We selected patients with Enterprise, Neuroform EZ, or Neuroform Atlas stents who underwent imaging follow-up and investigated aneurysm and stent features, stent-related complications, recanalization, and retreatment rates. We compared the retreatment risk among the patients treated with the 3 stent types using Kaplan-Meier survival analysis and Cox regression analysis. We evaluated 364 consecutive cases (103 Enterprise, 105 Neuroform EZ, and 156 Neuroform Atlas stents). Neuroform Atlas was more frequently used in distal vessels: 8 (7.8%) Enterprise, 2 (1.9%) Neuroform EZ, and 41 (26.3%) Neuroform Atlas cases, respectively. The median follow-up durations were 6.49, 4.91, and 1.24 years for the Enterprise, Neuroform EZ, and Neuroform Atlas cases, respectively, and retreatment was performed in 11 (10.1%), 9 (8.6%), and 6 (3.8%) cases. In the first 2 years of follow-up, the estimated retreatment risk ratios for Neuroform EZ and Neuroform Atlas with Enterprise as reference were 0.63 (95% confidence interval, 0.24-1.65; P= 0.35) and 0.54 (95% confidence interval, 0.18-1.59; P= 0.26), respectively. Neuroform Atlas stents were more frequently deployed in small-caliber vessels compared with the other 2 types of stents. The complication rate and retreatment risk until at least 1 year after the aneurysm treatment appeared to be similar for the 3 stent types.

Using individualized three-dimensional printed airway models to guide airway stent implantation

Airway stents are used to manage central airway obstructions by restoring airway patency. Current manufactured stents are limited in shape and size, which pose issues in stent fenestrations needed to be manually created to allow collateral ventilation to airway branches. The precise location to place these fenestrations can be difficult to predict based on 2-dimensional computed tomography images. Inspiratory computed tomography scans were obtained from 3 patients and analysed using 3D-Slicer™, Blender™ and AutoDesk® Meshmixer™ programmes to obtain working 3D-airway models, which were 3D printed. Stent customizations were made based on 3D-model dimensions, and fenestrations into the stent were cut. The modified stents were then inserted as per usual technique. Two patients reported improved airway performance; however, stents were later removed due to symptoms related to in-stent sputum retention. In a third patient, the stent was removed a few weeks later due to the persistence of fistula leakage. The use of a 3D-printed personalized airway model allowed for more precise stent customization, optimizing stent fit and allowing for cross-ventilation of branching airways. We determine that an airway model is a beneficial tool for stent optimization but does not prevent the development of some stent-related complications such as airway secretions.

Trans-uretero-cystic external urethral stent for urinary diversion in pediatric laparoscopic pyeloplasty: A novel approach.

Purpose:We present a new approach for urine drainage in pediatric patients following laparoscopic pyeloplasty, the trans-uretero-cystic external urethral stent (TEUS).Methods:We retrospectively identified 85 children who underwent laparoscopic pyeloplasty from July 2015 to June 2017. The included children were assigned to group A (double-J stent) or group B (TEUS). In group A, the double-J stent was removed by a cystoscopy under anesthesia after 1 month, while in group B, the external stent was removed after 5 to 7 days. We examined the durations of operation, hospital stay and the frequency of stent-related complications including urinary leakage, stent dislocation, stent occlusion, and urinary tract infection.Results:The operation time was significantly longer for patients in group B than for those in group A. No significant difference was observed between the groups regarding stent-related complications. In group A, 4 patients need auxiliary stent re-insertion for the management of complications, 2 developed urinary tract infection, and 2 had stent occlusion. In group B, none needed auxiliary stent re-insertion for complications and avoided re-operation.Conclusions:In children, the outcome of external stent implantation was similar to that using double-J stent, and the use of the former approach may be beneficial for younger children.

Self-expanding metal stent in esophageal perforations and anastomotic leaks.

Placement of self-expanding metal stents (SEMS) has emerged as a minimally invasive treatment option for esophageal perforation and leaks. The aim of our study was to assess the role of SEMS for the management of benign esophageal diseases such as perforations and anastomotic leaks. All patients (n = 26) who underwent SEMS placement for esophageal perforation and anastomotic leaks between May 2012 and February 2019 were included. Data wereanalyzed in relation to theindications, type of stent used, complications, and outcomes. Indications for stent placement included anastomotic leaks 65% (n = 17) and perforations 35% (n = 9). Fully covered SEMS (FCSEMS) was placed in 25 patients, and in 1, partially covered SEMS (PCSEMS) was placed. Stent placement was successful in all thepatients (n = 26). Four patients did not report for follow-up after stenting. Among the patients on follow-up, 91% (20/22) had healing of the mucosal defect. Stent-related complications were seen in 5 (23%) patients and included stent migration [3], reactive hyperplasia [1] and stricture [1]. Covered stent placement for a duration of 8weeks is technically safe and clinically effective as a first-line procedure for bridging and healing benign esophageal perforation and leaks.

S2328 A Tale of Two Perfs: Successful Repair of Dual Iatrogenic Duodenal Perforations Through Endoscopic Stenting

INTRODUCTION: Duodenal perforations are rare but serious gastrointestinal injuries, which pose challenging management decisions dependent on their etiology.[1,2] We report the use of a fully-covered self-expanding metal stent (FC-SEMS) for the management of iatrogenic duodenal perforations, which resulted in successful healing of perforations albeit associated with delayed morbidity from stent migration. CASE DESCRIPTION/METHODS: A 33 year-old male was admitted following a major motor vehicle collision with severe intraabdominal injuries requiring multiple surgeries, leading to the development of intra-abdominal infection requiring percutaneous drainage of RUQ and midabdominal fluid collections. Eight weeks after drain placement, enteral feeds were initiated with upper GI series confirming an active duodenal leak (Figure 1A). Endoscopic intervention was pursued due to high operative risk and demonstrated evidence of lateral and medial duodenal perforations secondary to erosions from the percutaneous RUQ drain (Figures 2A and 2B). The duodenal perforations were successfully stented using a FC-SEMS (18 mm × 12 cm) and sutured in place with an over-the-scope suturing system (Figures 1B and 1C). Enteral feeds were reinitiated with a small but stable leak, and the patient was discharged 12 weeks later. Eight weeks after discharge, the patient was readmitted for soft tissue infection from a colocutaneous fistula from prior bowel surgery, however CT scan also showed stent migration into the jejunum (Figure 3A) with a stable duodenal leak. Single balloon enteroscopy was performed with removal of the stent facilitated by pulling the stent into the cap with rat tooth forceps and using the splinting tube as an overtube to minimize bowel injury during withdrawal. Final endoscopic visualization revealed complete healing of the peritoneal fistula and near-complete healing of the retroperitoneal fistula (Figures 2C and 2D). DISCUSSION: The use of SEMS for the management of duodenal perforations has previously been reported, although predominately in the treatment of malignant gastric outlet obstruction or biliary stent complications and with limited patient follow up data.[3–6] Our case illustrates the successful use of a FC-SEMS for healing of dual duodenal perforations in a patient whose level of illness precluded medical or surgical management. Our case also highlights the risk of stent related complications such as delayed stent migration which can be difficult to manage, in particular outside centers of expertise.Figure 1.: Figure 3A: Upper GI series showing medical (circle) and lateral contrast leakage (arrow) Figure 1B: Duodenal stent in place with contrast injection showing minimal leak Figure 1C: Stent sutured in place in the gastric antrum.Figure 2.: Figure 2A: Pigtail drain in duodenum (*) and peritoneal fistula (^) Figure 2B: Visible retroperitoneal drain (*) in retroperitoneal fistula after RUQ drain repositioned Figure 2C: Duodenal lumen 20 weeks following stent placement without evidence of peritoneal fistula Figure 2D: Healing retroperitoneal fistula, approximately 1-2 mm in diameter.Figure 3.: Figure 3A: Stent migration into the jejunum, 20 weeks after placement Figure 3B: Endoscopic view of jejunal stent including endoscopic sutures (*) Figure 3C: Stent following removal.

TCT CONNECT-386 Diabetes Mellitus Is Associated With Increased Risk of Early Stent-Related Complications in Patients Undergoing Drug-Eluting Stent Implantation: Insight From the Victorian Cardiac Outcomes Registry (VCOR)

TCT CONNECT-386 Diabetes Mellitus Is Associated With Increased Risk of Early Stent-Related Complications in Patients Undergoing Drug-Eluting Stent Implantation: Insight From the Victorian Cardiac Outcomes Registry (VCOR)

Long-Term Safety of Endoscopic Biliary Stents for Cholangitis Complicating Choledocholithiasis: A Multi-Center Study.

Background: Treatment of cholangitis complicating choledocholithiasis includes biliary sphincterotomy and stone extraction. In certain cases of elderly comorbid patients with high risk for definitive endoscopic treatment, biliary stenting is the only measure for relieving biliary obstruction. Aim: We aimed to report the safety of retained biliary stone. Methods: a multi-center, retrospective case-control study conducted at two Israeli medical centers from January 2013 to December 2018 including all patients 18 years of age or older who underwent ERCP and biliary stent insertion for the treatment of acute cholangitis due to choledocholithiasis. Results: Three-hundred and eight patients were identified. Eighty-three patients had retained long-term biliary stents of more than 6 months (group A) from insertion compared to 225 patients whose biliary stents were removed within a 6-month period (group B). The mean follow-up in group A was 66.1± 16.3 vs. 11.1 ± 2.7 weeks in group B. Overall complications during the follow-up were similar between groups A and B (6% vs. 4.9%, OR 1.24, Chi square 0.69). Similarly, the rate of each complication alone was not different when comparing group A to group B (3.6%, 1.2% and 1.2% vs. 2.7%, 0.44% and 1.8%) for cholangitis, stent related pancreatitis and biliary colic, respectively (Chi square 0.85). Even after 12 months, the rates of overall complications and each complication alone were not higher compared to less than 12 months (Chi square 0.72 and 0.8, respectively). Conclusion: endoscopic biliary stenting for cholangitis complicating choledocholithiasis is safe for the long-term period without increase in stent related complications.

Long-Term Follow-Up of Yearly Replaced Double Internal Stents for Extrinsic Malignant Ureteral Obstruction.

Introduction: To assess long-term outcomes of double internal stents (DIS) for the relief of external malignant ureteral obstruction (MUO). Materials and Methods: DIS (7F each; 12-month indwelling time) were inserted under general anesthesia in 62 consecutive patients (75 renal units) with MUO during 2007-2018. Surveillance was performed every 3 months, and stents were exchanged routinely every year. The need for permanent stent retrieval was considered stent failure. Maintenance of stent patency and disease-specific survival (DSS) were estimated (Kaplan-Meier). Risk factors were also assessed (univariate and multivariable Cox regression analyses). Results: The median follow-up was 27 months (interquartile range [IQR] 20-27). The most frequent tumors causing obstruction were colorectal and ovarian cancers. Six patients (10%) had stent failure caused by sepsis, creatinine elevation, or hematuria. The average time to failure was 15 months (range 1-27). A history of radiation and an estimated glomerular filtration rate (eGFR) ≤45 mL/(min/1.73 m2) were associated with stent failure (p = 0.038 and p = 0.001, respectively). Thirty-nine patients died with a median DSS of 21 months (IQR 8.6-not reached). Multivariate analysis identified eGFR ≤60 mL/(min/1.73 m2) (hazard ratio [HR] 2.1, 95% confidence interval [CI] 1.1-4.2, p = 0.02) and need for balloon dilation (HR 2.1, 95% CI 1.1-4.1, p = 0.02) as independent predictors for disease-related mortality. Twenty-six patients (42%) had stent-related complications, for example, irritative symptoms, hematuria, and infections, of whom only two failed. Conclusions: One-year indwelling DIS provide effective long-term relief of MUO and represent a simple and effective alternative to other methods of urinary diversion. They avoid the need for external tubes and contribute to improved patient satisfaction.

Short-term outcomes after self-expandable metal stent insertion for obstructing colon cancer: a retrospective cohort study.

ABSTRACTBACKGROUND: Self-expanding metal stents (SEMS) are used as a bridge to surgery for colon cancer patients as an alternative to emergency surgery. Currently, there is a paucity of literature from Saudi Arabia on the preoperative usage of SEMS.OBJECTIVE: Determine whether SEMS are associated with a higher rate of complications.DESIGN: Retrospective cohort studySETTINGS: Tertiary care hospital in Saudi Arabia.PATIENTS AND METHODS: In patients diagnosed with obstructing colon cancer, up-front surgical resection was compared with insertion of SEMS followed by surgical resection between the years 2009 and 2013.MAIN OUTCOME MEASURES: Rate of stent-related short-term complications. Secondary endpoint, postoperative complications.SAMPLE SIZE: 65.RESULTS: Twenty-four (36.9%) patients underwent SEMS placement; 41 (63.1%) underwent primary surgery. The median (interquartile range) hospital stay was significantly higher among the SEMS group (13 [8.5] days versus 7 [3] days in the primary surgery group, P<.001). Five patients (20.8%) in the SEMS group developed complications: 2 (8.3%) perforations, 2 (8.3%) obstructions, and 1 (4.2%) stent migrations.CONCLUSION: SEMS is associated with longer hospital stays and short-term serious complications. Further research should be conducted, preferably with a larger sample size.LIMITATIONS: Retrospective design, small sample size.CONFLICT OF INTEREST: None.

Heavy Encrustation and Stone Formation on Forgotten Double “J” Ureteral Stent: A Case Repot

Background: Placement of double “J” ureteral stent for various indications is common in urological surgery. The encrustation and stone formation on forgotten DJ stents can result in significant morbidity and its management remains a challenging task. Case Presentation: A 51 years male presented with history of right flank pain of over 6 months duration. He had undergone right pyelolithotomy for right renal stones 4 years ago at some other hospital. There was no medical record available and the patient did not present himself to the surgeon for follow-up. Clinical examination was unremarkable. His complete blood counts, random blood sugar, renal function tests were normal. Urinalysis revealed many pus cells/hpf. At ultrasonography, there were two renal stone with moderate hydronephrosis and a 2 cm vesical stone. An x-ray KUB, revealed a forgotten ureteric stent with stones at its both ends. The patient underwent cystoscopy and a large stone on ureteric stent was dealt with by litholapaxy. The stone on the proximal end of was managed by percutaneous lithotripsy and stent was removed. The postoperative recovery was uneventful. On stone analysis, it was made of calcium oxalate 30% and ammonium urate 70%. Conclusion: The management of encrusted stents is challenging, and each case has to be dealt with individually depending on stone site and burden, and patient related factors. Endourological management is the preferred option. Adequate patient counseling and proper stent documentation (stent placement, proposed duration and removal of stent) is necessary to minimize stent related complications.

Lessons Learned From Reinterventions After Vein Stent Placements

The goal of this study is to understand why venous iliocaval stents fail. We retrospectively reviewed 994 patients who underwent stenting for chronic iliocaval obstruction between January 9, 2013, and June 26, 2019, at a single institution. Females comprised 56.5% (n = 562) and mean age was 60 years (range, 19–95). Time from the first vein stenting procedure to the last visit ranged from 0 to 2368 days (mean, 529 days). Follow-up at 30 days was 91.4% and at 1 year or greater was 48.7%. The patients who needed reintervention were stratified based on intraoperative findings and symptom resolution. Within this venous stent population, 166 major reinterventions (all endovascular) were performed. Females comprised 56% (n = 93). Mean age was 62 ± 13 years (range, 19-91 years). Mean time from the first operation to the reintervention was 778 ± 532 days (range, 7-2737 days), and mean time to the last follow-up was 1375 ± 611 days (range, 42-3017 days). Major intraoperative findings during reinterventions included: stenosis in native vein proximal or distal to prior stent in 45% (n = 74), stent-related complications (stent stenosis, angulation, malposition) in 28% (n = 46), outflow obstruction from contralateral stent in 21% (n = 35), stenosis in contralateral native vein in 18% (n = 30), no major finding in 14% (n = 24), acute stent thrombosis in 5% (n = 8), and chronic stent thrombosis in 2% (n = 4). Interventions performed included stent(s) placement in 47% (n = 78), delayed iliac kissing stents in 22% (n = 37), no intervention 1 in 5% (n = 25), balloon angioplasty alone in 14% (n = 24), and catheter thrombolysis in 4% (n = 7). At 6 months after the reinterventions, outcomes were graded as worse than preoperatively in <1% (n = 1), no change in 9% (n = 15), minor improvement in 13% (n = 21), major improvement in 35% (n = 59), symptom resolution in 29% (n = 49), and no information in 14% (n = 23). The majority of vein stent failures were related to a technical aspect of the initial stenting procedure. There was no intrinsic biological process or stent structural issue that alone resulted in stent failure. Intimal hyperplasia was not observed in venous stents. Acute and chronic stent thrombosis were uncommon; review of each case demonstrated an underlying mechanical cause of the stent thrombosis in every case. The most common finding during reinterventions was a new or previously missed stenosis in a native iliac vein. Other common findings were related to technical failures such as inadequate stent expansion or malposition of the initial stent(s). Unilateral stents that extended into the inferior vena cava obstructed flow from the contralateral iliac vein over time in a small number of cases. Reinterventions identified distinct problems that could be corrected and mostly resulted in symptomatic improvement for the patient.

Preliminary Results of Gore Viabahn Balloon-Expandable Endoprosthesis in Visceral and Renal Arteries of Patients Treated With Branched or Fenestrated Endografts for Complex Aortic Aneurysmal Disease

The objective was to retrospectively evaluate perioperative and midterm results of Gore Viabahn balloon-expandable endoprosthesis (VBX; W. L. Gore & Associates, Flagstaff, Ariz) as a visceral bridging stent in fenestrated and branched procedures. From January 2007 to December 2019, 127 fenestrated and branched endovascular aneurysm repairs for complex aortic disease were performed and 460 visceral vessels were included in the repair (3.6 vessels per patient). Data concerning such interventions were prospectively recorded in a certified institutional registry. A retrospective analysis of the registry was performed, and 103 visceral vessels treated with Gore VBX in 28 patients between July 2018 and December 2019 were found. Perioperative results were analyzed in terms of technical success, VBX-related adjunctive procedures, 30-day patency, and reinterventions. The follow-up program consisted of a computed tomography angiography scan at 1 month and yearly thereafter and duplex ultrasound examination at 3 months and every 6 months thereafter. Follow-up results were analyzed in terms of bridging stent-related patency, complications, and reinterventions. The indication for intervention was a thoracoabdominal aneurysm in 18 cases, a juxtarenal dilation in 5 patients, a pararenal aneurysm in 3 patients, a proximal para-anastomotic aneurysm after open aortic reconstruction in 1 case, and a short-neck (<5 mm) aneurysm in another patient. All patients underwent an elective intervention. In 19 cases, a fenestrated graft was placed, and in 4, a branched graft; in the remaining 5 cases, a combination of both fenestrations and branches was the configuration of choice. Overall, 55 renal arteries, 25 superior mesenteric arteries, and 23 celiac trunks were treated with Gore VBX. Technical success was 100%. Additional stent placement into a target visceral vessel to extend the distal landing zone was required in five vessels (4.9%). The asymptomatic occlusion (1/103 [0.9%]) of the VBX for a celiac trunk affected by subocclusive stenosis preoperatively was recorded 20 days after the procedure and was left untreated. No perioperative reinterventions were performed. Median duration of follow-up was 4.4 months (range, 1-14 months); no occlusion was documented. Reintervention rate was 0.9% (1/103); a type IC endoleak from a celiac trunk was diagnosed 3 months after the procedure and was treated with distal placement of another VBX stent graft into the celiac trunk, with complete resolution of the endoleak. In our experience of 103 target visceral vessels, the Gore VBX stent graft guaranteed satisfying perioperative results, providing optimal delivery and adaptability into target vessels. Further investigation is needed to evaluate follow-up results, especially in terms of resistance to the continuous aortic remodeling and the pinching load related to vessel pulsatility.

On Yıldan Uzun Süre Üreteral J Stentle Yaşamanın Sonuçları

Amaç: Unutulmuş üreteral stentlerin infeksiyon, enkrustasyon, taşlaşma ve böbrek yetmezliği gibi majör komplikasyonları vardır. Bu komplikasyonlar stentin kalış süresi ile artar. Bu çalışmada 10 yıldan uzun süre üreteral stentle yaşayan hastaların tedavi yönetimi ve stentlerin hastalara verdiği zararlar tartışılmıştır.

Endoscopic management of walled-off pancreatic necrosis.

Walled-off pancreatic necrosis (WON) can develop in the late phase of necrotizing pancreatitis. When the WON is accompanied by an infection in the necrotic bed, it becomes a life-threatening complication. Open necrosectomy with drainage has been the standard treatment; however, it is associated with a significant morbidity and high mortality. Therefore, minimally invasive therapeutic alternatives are in demand. Recently, a new treatment algorithm for necrotizing pancreatitis, known as the step-up approach, has been proposed. The initial report on it consisted of percutaneous drainage followed by, if necessary, a minimally invasive retroperitoneal necrosectomy. However, the endoscopic step-up approach, which consists of EUS-guided transluminal drainage followed by, if necessary, endoscopic necrosectomy, was later introduced. Recent studies have suggested that an endoscopic step-up approach might be more advantageous than a minimally invasive surgical step-up approach. A lumen apposing metal stent (LAMS) with a cautery-enhanced delivery system is currently preferred over the conventional plastic stents for endoscopic interventions, because it decreases the technical difficulty of the procedure and may obviate the need for an adjunctive debridement procedure. However, some recent findings suggest that LAMS could be associated with a higher risk of stent-related complications than conventional plastic stents, especially in patients with long-term placement. Therefore, early removal of LAMS at 3weeks post-intervention is proposed if the WON is resolved on CT examination. Thus, endoscopic interventions have emerged as a key player in the management of WON. However, multidisciplinary treatment approaches should be considered because the endoscopic approach has limitations in treating complicated WON.

Predictors for Treatment Failure of Self-Expandable Metal Stents for Anastomotic Leak after Gastro-Esophageal Resection.

Self-expandable metal stents are used for the treatment of anastomotic leaks after gastro- esophageal surgery. Predictors for treatment failure and complications are unknown. In this observational retrospective study, we summarize our experience with self-expandable metal stents for the treatment of anastomotic leaks, in order to determine the predictors of treatment failure. Between 2009 and 2015, 34 patients with anastomotic leak after curative resection of gastro- esophageal cancer were treated with self-expandable metal stents. Gender, histology, comorbidity, body mass index, neoadjuvant therapy, previous surgery, leak size, and stent diameter were analyzed for their predictive value according to treatment success and complication rate. Leak closure rate was 76%. Risk factors for treatment failure were neoadjuvant chemo-radiotherapy, squamous cell histology, and esophageal tumor location. Gender, comorbidity, body mass index, neoadjuvant chemotherapy, and previous surgery were not correlated with outcome. Mortality rate was 20%, most often due to uncontrolled leak. Severe stent-related complications occurred in 15% of patients, most of them following insertion of a large-sized stent. Squamous cell histology, neoadjuvant chemo-radiotherapy, and esophageal tumor location are predictors for treatment failure. Severe stent-related complications seem to be preferentially associated with the use of large-sized stents.

Use of Continuous Infusions of Eptifibatide and Cangrelor in Large Vessel Occlusion Acute Ischemic Stroke After Emergent Carotid Artery Stenting

Placement of carotid stents in the setting of large vessel occlusion (LVO) is sometimes necessary in patients with steno-occlusive disease of the extracranial internal carotid artery (ICA) or ICA dissection. Use of antiplatelet agents is required to prevent in-stent thrombosis; however, after an LVO, a decompressive hemicraniectomy may be necessary. After placement of a carotid stent, a fine balance must be obtained between preventing stent-related thromboembolic complications while also maintaining the possibility of quickly and safely performing a decompressive hemicraniectomy, if indicated. In this case, we discuss the novel use of continuous eptifibatide and cangrelor infusions after carotid stent placement to maintain stent patency, while preserving the option of emergent hemicraniectomy. A 55-year-old man presented with left hemispheric ischemic symptoms due to flow failure from a left ICA dissection. He underwent emergent angiography with angioplasty and stenting of the petrous and ascending cervical segments of the left ICA. The procedure was complicated by an embolization of thrombus to a left middle cerebral artery (MCA) M2 division branch, resulting in an occlusion, which could not be opened. The patient was placed on short acting intravenous antiplatelet agents (eptifibatide infusion for 60 h and cangrelor infusion for 24 h) for prevention of in-stent thrombosis while under close observation for potential neurologic decline and need for decompressive hemicraniectomy. After 84 h of observation, the patient did not experience a decline and the antiplatelet infusions were discontinued after he received aspirin and a loading dose of clopidogrel. Intravenous eptifibatide or cangrelor infusions are short-acting antiplatelet options that can be used in patients with acute ischemic stroke from LVO in the setting of ICA stent placement when there exists a potential for decompressive hemicraniectomy. J Neurol Res. 2020;10(3):99-103 doi: https://doi.org/10.14740/jnr591

Experience with Ureteral Stent Removal Using Anselfextraction String in South Indian Patients – Single Institute Prospective Study

Background: The study aims to know the safety and effectiveness of a stent with a string attached after ureteroscopy (URS) for self-removal of the stent by the patient in our practice. Subjects and Methods: After Institutional Review Board approval, a chart review was performed concerning patients who underwent URS &amp; received an indwelling stent with or without a string attached to the stent (55 vs. 65, respectively). Statistical analyses included chi-square and Student’s t-tests. Results: The string group consisted of 55patients, in which 32.7% of the patients were male. In the no-string group, 33.8% of the 65 patients were males. No significant difference in complication rates between both groups (P-value = 0.317). Stent duration (Indwell time) was significantly more in no string group (13.32days) compared to the string group (6.28days). In the string group, stent dislodgement has significant (P-value = 0.0183), can be easily overcome by patient education. Post-procedural pain was significant in no string group (P-value = 0.0233). Conclusion: The use of a stent with an Extraction string after URS appears safe and effective and offers several advantages without increasing stent-related urinary symptoms, complications, or postoperative morbidity.