Stent-supported Angioplasty Research Articles

Factors Influencing the Need for Target Vessel Revascularization After Renal Artery Stenting

To provide additional insight into factors that may be associated with the need for target vessel revascularization (TVR) following de novo renal artery stenting during long-term follow-up. A retrospective chart and database review was conducted to analyze the progress of all patients with de novo symptomatic renal artery stenosis who underwent stent-supported angioplasty under the auspices of the Single Operator, Single Center, Renal Stent Retrospective Study (SOCRATES). The records review identified 782 patients who were enrolled in the study between 1993 and 2004; after excluding 34 (4.5%) patients (lost to follow-up or inadequate data), 748 consecutive patients (412 women; mean age 70.7+/-9.7 years, range 37-92) were suitable for longitudinal analysis. The need for TVR was based on strict clinical criteria (> or =20% rise in serum creatinine, worsening hypertension, and/or recurrent flash pulmonary edema), and all patients underwent multidisciplinary evaluation before stenting and during follow-up. Follow-up spanned a mean 45.8+/-26.5 months. TVR was needed in 88 (10.03%) of 877 arteries and was best predicted by patient age < or =67 years (OR 2.91, p=0.0001), stent diameter < or =5.0 mm (OR 2.31, p=0.001), solitary functioning kidney (OR 2.01, p=0.048), history of lower extremity peripheral artery disease (OR 1.87, p=0.008), and antecedent history of stroke (OR 1.73, p=0.026). Renal artery stenting appears to be durable, with only 10% of stented arteries requiring TVR during clinically-based long-term follow-up. Arteries with a final stent diameter < or =5.0 mm were more than twice as likely to need TVR, as were patients with a solitary kidney. The authors acknowledge that clinical recurrence is not a surrogate for ultrasound surveillance after renal artery stenting, so prospective controlled trials will be needed to determine risk factors for restenosis.

Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy

A prospective analysis of renal artery stent revascularization with distal embolic protection in a high-risk patient population with ischemic nephropathy is presented. A total of 63 patients (median age 70.2 years, range 54-86 years) had significant atherosclerotic stenosis of 83 renal arteries documented on pre-procedural imaging. All patients had baseline chronic renal insufficiency with a documented deterioration in renal function in the 6 months before revascularization. The endovascular technique used in all patients involved primary passage of an embolic filter into the distal main renal artery followed by primary stent deployment with a balloon expandable stainless steel stent. The filter baskets were recaptured and contents submitted for pathological analysis. At 6 months post-intervention, 97% of patients demonstrated stabilization or improvement in renal function. Only 3% of patients had an inexorable decline in renal function, unchanged by the intervention. After a mean follow up of 16.0 months (6-27), 94% of patients demonstrated stabilization or improvement in renal function. One patient suffered an acute post-procedural deterioration in renal function. In total, 60% of the filter baskets contained embolic material. This study confirms the technical feasibility of renal artery stent deployment with adjuvant embolic protection. The excellent results for renal preservation at 6 months post-intervention also suggest that a distal embolic protection device may improve the impact of percutaneous renal revascularization on progressive deterioration in renal function. The postulated mechanism is through the prevention of atheromatous embolization and the embolic yield from the distal filters supports this hypothesis. Patients most likely to receive the greatest benefit are those with mild baseline chronic renal insufficiency and a recent decline in renal function.

Carotid Stent‐Supported Angioplasty via Radiobrachial Route

Endovascular stent-supported angioplasty is a treatment option for atherosclerotic disease of the cervical internal carotid artery in high-risk patients. The traditional transfemoral approach is not suitable for patients who suffer from common femoral artery or abdominal aorta atheropathy. We report a case of carotid stent deployment using the radial route in a 68-year-old man with type B aortic dissection, having severe right internal carotid artery origin stenosis, presenting with ipsilateral retinal ischemic events. Technical aspects of carotid stenting via the radial approach are described and the related literature is discussed.

Image‐guided and ‐monitored renal artery stenting using only MRI

To demonstrate the ability of a unique interventional MR system to be used safely and effectively as the only imaging modality for all phases of MR-guided stent-supported angioplasty. An experimental disease model of renal stenosis was created in six pigs. An interventional MR system, which employed previously reported tools for real-time catheter tracking with automated scan-plane positioning, adaptive image parameters, and radial true-FISP imaging with steady-state precession (True-FISP) imaging coupled with a high-speed reconstruction technique, was then used to guide all phases of the intervention, including: guidewire and catheter insertion, stent deployment, and confirmation of therapeutic success. Pre- and postprocedural X-ray imaging was used as a gold standard to validate the experimental results. All of the stent-supported angioplasty interventions were a technical success and were performed without complications. The average postoperative residual stenosis was 14.9%. The image guidance enabled the stents to be deployed with an accuracy of 0.98 +/- 0.69 mm. Additionally, using this interventional MRI system to guide renal artery stenting significantly reduces the procedure time, as compared to using X-ray fluoroscopy. This study has clearly demonstrated the first successful treatment of renal artery stenting in an experimental animal model solely under MRI guidance and monitoring.

Stent-Supported Angioplasty for Acute Stroke Caused by Carotid Dissection

Carotid dissection is a less common but important cause of acute ischemic stroke, which has specific treatment implications. We describe the case of a patient with acute, fluctuating neurological symptoms found to be caused by carotid dissection who underwent endovascular stent-supported angioplasty of this lesion with good outcome. Pros and cons of the various treatment options encountered in this case including intravenous thrombolysis, angioplasty and stenting, and antithrombotic therapy are discussed. Endovascular treatment of carotid dissection in acute stroke can be performed safely. Treatment must ultimately be individualized to each specific case.

Stent-supported angioplasty versus endarterectomy for carotid artery stenosis

Carotid artery stenting (CAS) for carotid artery stenoses is evolving as an alternative to carotid endarterectomy (CEA). However, the value of CAS is still a matter of debate. Therefore, we performed a metaanalysis of the randomized controlled clinical trials (RCT) on this issue. RCTs were identified through searching MEDLINE, textbooks and by personal communication. Six finished RCTs on this issue could be identified, including 1263 patients, 628 randomized to CAS and 635 to CEA. The 30-day death or stroke rate was 8.0% (50/628) in patients treated with CAS compared to 6.1% (39/635) in CEA patients (OR=1.36, 95% CI: 0.88-2.11; p=0.17; p for heterogeneity=0.009). The rate of cranial nerve palsy was 7.1% in the CEA compared to 0% in the CAS group (p<0.0001). The rate of myocardial infarctions was reduced from 3.1 to 1% (OR=0.32, 95% CI: 0.12- 0.81; p=0.02; p for heterogeneity=0.49). The death or stroke rate during follow-up was 12.1% in patients treated with CAS compared to 12.2% in CEA patients (OR=0.99, 95% CI: 0.70-1.42; p=0.98; p for heterogeneity=0.02). The available RCT data on CAS vs. CEA suggest that both methods seem to be equally effective concerning short- and medium-term results, while CAS is associated with lower minor complications than CEA. However, because of the significant heterogeneity between the study outcomes, the results of the large RCTs underway should be awaited before it can be advised to use CAS in a broader perspective.

Surgical management of acute carotid thrombosis after carotid stenting: A report of three cases

We report three cases of symptomatic acute carotid thrombosis occurring after carotid artery stenting (CAS). CASE 1: A patient presented with crescendo transient ischemic attacks on the second day after CAS. Ultrasound images demonstrated incomplete in-stent thrombosis due to plaque protrusion. The urgent surgical procedure consisted of stent removal and carotid thromboendarterectomy. CASE 2: A case of complete thrombosis of a carotid stent occurred 4 days after implantation in a patient with essential thrombocythemia diagnosed by chance. The surgical strategy included stent removal and carotid thromboendarterectomy. CASE 3: Cardiac multiple embolisms in a patient with chronic atrial fibrillation caused concomitant leg ischemia and acute carotid stent occlusion 2 hours after CAS. Cerebral reperfusion was established by embolectomy, without removing the stent. At the same time, the right leg ischemia was resolved by a thromboembolectomy with a Fogarty catheter. These three cases demonstrate that acute thrombosis after carotid stenting can be managed successfully with emergent surgical intervention. Thromboendarterectomy with stent removal or in selected cases, simple thromboembolectomy, can minimize neurologic sequelae in patients suffering from acute post-stenting carotid thrombosis.

Stent-supported angioplasty of a residual coronary artery dissection following replacement of the ascending aorta for acute type A aortic dissection

The patient was a 54-year-old male who suddenly noted severe back pain while eating. A diagnosis of acute type A aortic dissection was made on contrast enhanced CT. As a result, emergency surgical repair was performed on the same day. Through median sternotomy, graft replacement of the ascending aorta, including removal of the site of the intimal tear, was carried out under deep hypothermia and retrograde cerebral perfusion. Although the postoperative course was satisfactory, the patient complained of severe chest pain with ECG change on the 23rd postoperative day. Emergency coronary angiography revealed the presence of wide coronary artery dissection from an entry of the left anterior descending aorta (LAD) to a reentry of the left circumflex artery (LCX). Multiple stents were implanted in the LAD and LCX. After stenting, chest symptoms were relieved, and ECG change disappeared. He was discharged from our hospital on the 42nd postoperative day.

A 70-Year-Old Woman With Poor Grade Subarachnoid Hemorrhage Complicated by Carotid Stenosis, Cerebral Vasospasm, and Cerebral Rebleed

Subarachnoid hemorrhage is one of the most common entities encountered in neurocritical care units. Knowledge of disease sequelae and their management is paramount for all neurointensivists. This study relates the case of a 70-year-old woman with poor grade subarachnoid hemorrhage who underwent endovascular detachable coil embolization of a right internal carotid artery aneurysm. Her hospital course was subsequently complicated by symptomatic carotid stenosis and cerebral vasospasm requiring intervention. The discussants present their views regarding five main questions pertaining to management of the patient regarding the choice of endovascular versus surgical aneurysm occlusion, stent-supported angioplasty in a patient with a recent subarachnoid hemorrhage, and treatment options for vasospasm.

Carotid Stent Placement, Stroke Prevention, and Training

Carotid Stent Placement, Stroke Prevention, and Training

Primary stent-supported angioplasty for treatment of below-knee critical limb ischemia and severe claudication: Early and one-year outcomes

The objective of this study was an investigation of the safety and efficacy of primary below-knee stent-supported angioplasty (BKSSA) for restoring straight inline arterial flow in patients with critical limb ischemia (CLI) or lifestyle-limiting claudication (LLC). Surgical tibial bypass for CLI and severe LLC is associated with significant morbidity, mortality, and graft failure, whereas percutaneous angioplasty is suboptimal. Below-knee stent-supported angioplasty was attempted in 82 patients (92 limbs) with either CLI (68%) or severe LLC (32%). Patients received daily aspirin, thienopyridine, and glycoprotein IIb/IIIa agents during the procedure. One-month major adverse events (MAEs) were defined as death, myocardial infarction, major unplanned amputation, need for surgical revascularization, or major bleeding. Clinical success was defined as improved resting ankle brachial index by > or =0.10, relief of resting pain, healing of ulceration or amputation, and improvement of claudication. Mean age of patients was 74 +/- 17 years. In 86 limbs, straight inline flow was restored to at least one tibial vessel. Technical success was 94% for de novo lesions and there were no MAEs. Ankle brachial indexes increased for all groups (CLI = 0.32 +/- 0.13 to 0.9 +/- 0.14 and LLC = 0.65 +/- 0.09 to 0.95 +/- 0.12; p < or = 0.0001, pre vs. post). Relief of rest pain and healing of ulcerations and amputations were seen in 96% (47 of 49) of patients with CLI who underwent successful intervention. Below-knee stent-supported angioplasty for CLI and LLC improves ankle brachial indexes comparable to tibial bypass, heals amputations and ulcerations, relieves rest pain, and improves ambulation. Because BKSSA is associated with minimal MAE, it may hold promise as an alternative therapy for patients with CLI and LLC.

Extracranial Revascularization Therapy: Angioplasty and Stenting.

Beginning with simple balloon angioplasty, minimally invasive revascularization techniques have progressed to the use of metallic stents for improved immediate and long-term results. Stent-supported angioplasty now offers a therapeutic option for those individuals ineligible for surgical revascularization of stenotic atherosclerotic lesions and who have failed maximal medical therapy. However, the clinical equivalence, or possibly even superiority, of angioplasty of the extracranial carotid and vertebral arteries in atheromatous occlusive disease over surgical revascularization has yet to be determined in ongoing randomized controlled trials. Additionally, endovascular techniques offer treatment for a variety of nonatherosclerotic disease affecting the extracranial arteries, such as inflammatory, radiation-induced, and postsurgical strictures; acute intimal dissection; traumatic and spontaneous arteriovenous fistulas; and aneurysms or pseudoaneurysms. For certain disease entities at high risk for surgical complications, endovascular procedures have gained preference as the therapeutic modality of choice, yet lacking controlled trials providing evidence for noninferiority against surgical approach. Continued innovation and refinement of endovascular technology and techniques will further improve technical success, reduce procedure-related morbidity, and broaden the endovascular therapeutic spectrum for extracranial and intracranial cerebrovascular disease.

Stent-supported angioplasty of severe atherosclerotic renal artery stenosis preserves renal function and improves blood pressure control: long-term results from a prospective registry of 456 lesions.

To report a prospective study evaluating the long-term impact of stent-supported angioplasty on renal function and blood pressure control. In a 6-year period, 456 hemodynamically significant de novo renal artery stenoses > or =70% were treated in 340 consecutive hypertensive patients (223 men; mean age 66+/-10 years, range 44-84) with or without impaired renal function. Baseline data on serum creatinine (sCr), intrarenal resistance index, ambulatory 24-hour blood pressure monitoring, and documentation of the number and dose of antihypertensive drugs were compared to values obtained during follow-up. The primary endpoint was a 10% decrease in sCr; the glomerular filtration rate and changes in blood pressure control were additional outcome measures. During a mean follow-up of 34+/-20 months, sCr decreased significantly from 1.45+/-0.87 to 1.39+/-0.73 mg/dL (p=0.048). In 34% of the patients, sCr decreased >10%, 39% were unchanged, and 27% had an increase >10%. Glomerular filtration rate increased from 59+/-26 to 62+/-26 mL/min/1.73 m(2) (p=0.6). Systolic, diastolic, and mean blood pressure measurements significantly improved immediately after the intervention (132/72/93 versus 144/79/102 mmHg at baseline, p<0.0001) and remained improved during follow-up (p<0.0001). Blood pressure control was improved in 46%, unchanged in 43%, and deteriorated in 11%. Baseline sCr, bilateral intervention, percent diameter stenosis, and 3-vessel coronary disease were independent predictors of improved renal function during follow-up; the number of antihypertensive drugs taken before the intervention predicted improved blood pressure control. Stent-supported angioplasty of renal artery stenoses preserves renal function and improves blood pressure control in a broader spectrum of patients than previously thought.

Response: Combined testing of cardiac and carotid artery stenosis?

Response: Combined testing of cardiac and carotid artery stenosis?

Predictors of improved renal function after percutaneous stent-supported angioplasty of severe atherosclerotic ostial renal artery stenosis

BACKGROUND CONTEXT: After cervical corpectomy, the use of tricortical autologous bone to fill the large defect is biomechanically and structurally inadequate and may lead to excessive donor site pain and morbidity. The major alternative, fibular strut allograft, has inherent problems that lead to lower rates of solid arthrodesis and graft migration. Majd et al. reported on 34 cases with a 97% solid fusion rate using titanium mesh cages and local bone graft to fill the cervical corpectomy defect.PURPOSE: With long-term results, to confirm the results previously reported by Majd et al.STUDY DESIGN/SETTING: Retrospective chart and radiological review.PATIENT SAMPLE: The first 26 patients in the senior author's practice eligible for a minimum 2-year follow-up, having had cervical corpectomy reconstructed with titanium mesh cages, local bone graft and anterior plating.OUTCOME MEASURES: Odom's criteria were used to assess clinical outcome. Anteroposterior, lateral and lateral flexion and extension radiographs were used to assess fusion.METHODS: Twenty-six patients with multilevel cervical pathology underwent successful corpectomy, decompression and fusion with titanium mesh cages filled with local bone graft. Rigid anterior plating was applied across the corpectomy defect. Preoperative, operative and postoperative chart data were collected retrospectively. Radiographic assessment included a minimum 2-year follow-up.RESULTS: Follow-up ranged from 24 to 64 months. Clinically, 21 of 26 (80.7%) had an excellent or good clinical outcome. No radiolucencies or motion were detected on radiographic analysis, yielding a fusion rate of 100% (26 of 26). Broken or pulled out screws were identified in two patients, one of whom had plate revision. All cages remained intact with no evidence of cage settling or collapse.CONCLUSIONS: The use of titanium mesh cages in conjunction with local bone graft, and rigid anterior plating is effective for cervical reconstruction after corpectomy and a viable alternative to the use of fibular strut allograft. These results confirm those previously reported by Majd et al.

Renal-Artery Stenting Improves Renal Function and BP

Percutaneous transluminal renal angioplasty is performed often, even though previous studies of it have been small, have predated routine stenting, or have not documented clear improvement of renal function. In this single-center, prospective study from Germany, 215 patients (99% with hypertension; 41% with diabetes) underwent stent-supported angioplasty for ostial renal-artery stenosis (diameter, ≥70%); 23% …

Subclavian artery stenting: factors influencing long-term outcome.

This study provides extended follow-up of a nonrandomized series of symptomatic patients who underwent subclavian stent-supported angioplasty (SSA) with emphasis on preprocedure factors that may have influenced outcome. The endpoints of mortality and restenosis were analyzed using backward stepwise logistic regression with the following clinical variables: coronary artery disease, hypertension, hyperlipidemia, smoking, diabetes mellitus, chronic obstructive pulmonary disease, chronic renal insufficiency/failure, and hypothyroidism. Restenosis is reported based on prospective serial noninvasive studies and/or angiography. Mortality was evaluated by retrospective database review and inquiry to the State Department of Health and Human Services' statistical registry in patients who were lost to follow-up. Over a 9-year period (mean follow-up, 36.1 +/- 30.4 months; maximum observation, 109.5 months), 101 stents were placed in 91 consecutive patients (37 male, 54 female). The mean age at intervention was 62.03 +/- 9.3. The procedure was technically successful in 89 patients 97% (mean pre- and postoperative stenosis and pressure gradients were 90.2% +/- 9.4% vs. 3.7% +/- 6.6%, P < 0.001, and 59.9 +/- 35.2 vs. 0 mm Hg, P < 0.001, respectively), with 13 minor complications and no immediate major complications. One patient died of unrelated causes within 30 days. Per Kaplan-Meier method, for years 1 through 5, the rates of overall patency were 96%, 91%, 86%, 77%, and 72%; likewise, overall patient survival was 93%, 88%, 8%4, 81%, and 76%. No clear predictors for restenosis were discovered, although a trend toward higher recurrence was noted in women (18.5% in female vs. and 8.6% in male; P > 0.05), but the same were less likely to die during follow-up (P > 0.001). Also, the presence of hypothyroidism (P = 0.004) and increasing age (P = 0.068) were positively correlated with all-cause mortality. This study suggests that SSA is predictable, safe, and durable. The diagnosis of symptomatic subclavian disease is of prognostic importance, with age and male gender representing important predictors of all-cause long-term mortality. The strong association of increased mortality with hypothyroidism is difficult to discard and raises the question of a yet to be described thyroid steal phenomena.

Endovascular intervention of aortoiliac occlusive disease in high-risk patients using the kissing stents technique: long-term results.

Endovascular intervention deploying a kissing stents (KS) technique has been used as an alternative to surgical intervention in treating symptomatic aortoiliac occlusive disease. However, the long-term results on high-risk patients are unknown. We retrospectively analyzed data on high-risk patients who underwent endovascular intervention using the KS technique at our institution. Fifty high-risk patients aged 62 +/- 6.4 years with severe aortoiliac stenosis underwent stent-supported angioplasty using the KS technique. Thirty percent of the patients had total occlusion of the distal aorta and/or the iliac arteries. Twelve patients received thrombolytics prior to stenting. The procedure was successful in all 50 patients. There was a 4% acute complication rate (distal embolization). However, there were no vascular complications, myocardial infarction, or perioperative death. Primary patency during follow-up of 20 +/- 12.3 months was 92%, while secondary patency rate was 100%. Amputation-free survival was 100%. Ninety-two percent remained free of lifestyle-limiting claudication.

3584 Stent-supported angioplasty of severe atherosclerotic renal artery stenosis: long-term results of a prospective registry with 456 lesions

3584 Stent-supported angioplasty of severe atherosclerotic renal artery stenosis: long-term results of a prospective registry with 456 lesions

How to best counteract the enemies? By ensuring adequate oxygen delivery

Shortage of oxygen supply due to inadequate perfusion induces depressed contractile function in viable myocardium (hibernation) or myocardial cell death (myocardial infarction). The present review addresses the role of revascularization in the prevention of myocardial infarction in acute coronary syndromes, optimization of myocardial salvage once myocardial infarction has occurred, and treatment of hibernating myocardium. In acute coronary syndromes, the risk for death and myocardial infarction can be reduced by systematic revascularization in combination with modern antithrombotic treatment (early invasive strategy). In acute myocardial infarction, myocardial salvage can be maximized by stent-supported angioplasty in combination with glycoprotein IIb/IIIa receptor blockade. If hibernating myocardium is identified by dobutamine echocardiography, nuclear imaging techniques or magnet resonance imaging, then revascularization will improve contractile function and long-term outcome in most patients.