Subsequent Stent Placement Research Articles

Application of Self-Expandable Metal Stents for Ureteroileal Anastomotic Strictures: Long-Term Results

We report our long-term experience with the management of benign ureteroileal anastomotic strictures using self-expandable metal stents. A total of 16 male and 2 female patients with a mean+/-SD age of 72+/-7 years (range 66 to 78) with benign fibrotic strictures at the site of ureteroileal anastomosis underwent implantation of self-expandable metal stents with a nominal diameter of 6 to 8 mm. A total of 24 ureteroileal conduits were treated. The external nephrostomy tubes were removed after fluoroscopic validation of ureteral patency. Patients were followed with blood biochemistry, ultrasonography, urography and/or virtual endoscopy. Retrograde external-internal catheter insertion through the cutaneous stoma was performed in cases of recalcitrant stricture. The technical success rate of ureteroileal stricture crossing and stenting was 100% (24 of 24 cases). Mean followup was 21 months (range 7 to 50). The clinical success rate during the immediate post-stenting period was 70.8% (17 of 24 cases). The 1 and 4-year primary patency rates were 37.8% and 22.7%, respectively. Secondary interventions included repeat balloon dilation in 15 ureters, of which 8 also underwent subsequent coaxial stent placement. The 1 and 4-year secondary patency rates were 64.8% and 56.7%, respectively. Except in 2 patients who died external-internal Double-J catheters continued to be inserted retrograde in 6 ureteroileal conduits. They are periodically exchanged to prevent mucous inspissation and stent encrustation. Metal stents served as the definitive treatment for stricture in more than half of the cases, whereas in the remainder the stents allowed the uncomplicated and regular exchange of Double-J catheters in retrograde fashion. This combined, less invasive treatment for ureteroileal anastomotic strictures may help patients avoid surgical revision and preserve quality of life.

Imaging and intervention of retroperitoneal fibrosis

Retroperitoneal fibrosis is a rare condition characterized by the development of fibrous plaques in the retroperitoneal space. The fibrous plaques characteristically arise distal to the bifurcation of the abdominal aorta and progress to encase the iliac vessels distally and are defined by the associated encasement of one or both ureters. Imaging plays an important role in not only establishing the diagnosis, but also in monitoring disease progression. Historically, the radiological diagnosis was made predominantly by intravenous urography and retrograde pyelography. More recently, advances in cross-sectional imaging with ultrasound and contrast-enhanced CT have allowed for a more precise diagnosis as well as helping to accurately define the extent of the disease. At our institution, we have found ultra-fast MRI to also play a useful role in establishing the diagnosis. In particular, magnetic resonance urography using HASTE (half Fourier-acquired single shot turbo spin-echo) sequences allow a safe alternative to intravenous urography, particularly in patients with poor renal function. The purpose of this article is to describe the role of the various imaging methods available to the radiologist and to emphasize the important role that the interventional radiologist now plays, not only in obtaining tissue for diagnosis, but also in providing treatment of the disease by percutaneous nephrostomy drainage and subsequent stent placement in select cases.

Primary Endovascular Stent Placement for Focal Infrarenal Aortic Stenosis: Long-term Results

The objectives of this retrospective study were to determine the technical success, safety, and long-term results of primary stent implantation in infrarenal aortic stenosis. A total of eight atherosclerotic stenoses and one occlusion of the infrarenal aorta (ie, midaortic syndrome) were treated with endoluminal stent placement after balloon angioplasty. Aortoiliac lesions were excluded. Technical success and patency were assessed. Primary technical success in percutaneous transluminal angioplasty and subsequent stent placement was achieved in all patients. No complications occurred, and no morbidity was encountered. Primary clinical patency rates were 100% on all follow-up examinations. Long-term results with a mean follow-up of 110 months (range, 99-117 months) were recorded in seven patients; one patient had died and one was lost to follow-up. In view of the excellent initial results and promising long-term follow-up data in a small series, stent placement after predilation in properly selected patients with isolated infrarenal aortic stenosis appears to be a promising, durable treatment. It should be considered as a primary method of treatment.

Measurement Accuracy of a Novel Stent-Sizing Device in the Porcine Airway

Background: Accurate measurement of stenosis length and lumen diameter for subsequent stent placement can be challenging. Substantial experience is required to accomplish accurate and consistent sizing. Inaccuracy can result in stent migration, damage to the device used, or tissue granulation. The purpose of this study is to assess the design, function, and performance of a novel luminal measuring device, the Alveolus stent-sizing device (SSD; Alveolus Inc., Charlotte, NC). Methods: Three dissected porcine bronchial trees were used for the purposes of this experiment. Distal trachea (within 3.5 cm of the carina), right and left main stem bronchi, and the right bronchus intermedius measurements were conducted in 3 separate sessions using 1) a bronchoscope, 2) the Alveolus SSD, and 3) a caliper. Data collected using each method was sequestered after each session. In addition, ratings were collected to quantify user appraisal of features and functions of the SSD. Results: Methods of measurement were comparable within 1 to 3 mm of each other in the 4 sites. The rankings for function and design of the SSD indicate that the device is satisfactory for the needs of the end user. Highest ratings were for device performance characteristics and design output qualifications, including actuation, durability, and visualization. Conclusion: The novel stent sizing device, the Alveolus SSD, met end user expectation as a confirmatory tool in lumen sizing. The device was comparable to the other methods tested and rated well in the areas of design and performance.

Sphincter of Oddi Dysfunction Is Associated with Pancreatic Duct Anomalies

Purpose: Sphincter of Oddi dysfunction is known to be associated with pancreas divisum but other types of pancreatic ductal anomalies (PDA) have not been well studied. Duct toruosity and tight angulation can make deep guidewire cannulation difficult or impossible. Recognition of ductal anomalies is important in patients with suspected SOD because of the need for deep pancreatic cannulation and stent placement for prophylaxis of post-ERCP pancreatitis. Methods: Data form 1428 consecutive ERCP procedures performed on 1032 patients between 1999 and 2005 were collected prospectively. Two subsets of patients were then extracted from the database: those diagnosed with sphincter of Oddi dysfunction (SOD) and patients with PDA. Each PDA was independently reviewed and classified by a radiologist trained in reading ERCP studies. PDAs were classified as looping above main duct (upper ansa), looping below main duct (lower ansa), tightly angulated (switchback), dorsal dominant, or mixed PDA. Results: Of the 1032 patients included in our study, 270 (26%) were identified as having SOD of which 27 (10%) had PDAs. There were 762 without SOD of which 7 (0.9%) had PDAs. Thus PDAs occurred more frequently in patients with SOD than without SOD (p<0.0001). Of the 34 total patients with PDAs, there were 9 (26%) upper ansa loops, 10 (29%) lower ansa loops, 10 (29%) switchback loops, 1 (3%) dorsal dominant, and 4 (12%) mixed PDAs. Conclusions: PDAs occur much more frequently in patients with SOD compared to patients without SOD. Recognition of PDAs is important in patients with suspected SOD because the potential difficulty to achieve deep guidewire cannulation and subsequent pancreatic stent placement. An association between SOD and PDA may imply a congenital etiology for SOD.Table: Correlation of PDAs with SOD

Vascular Complications After Liver Transplantation in Pediatric Patients

Vascular complications are the major cause of morbidity and mortality after liver transplantation, particularly in pediatric patients, owing to their smaller vascular diameters. Between September 2001 and June 2004, among 21 (16 boys and 5 girls) pediatric liver transplantations of mean age 8.3 ± 5.1 years, hepatic arterial thrombosis (HAT) was diagnosed in 2 (9.5%) patients, and hepatic arterial stenosis (HAS) in 4 (19.4%). Vascular patency was evaluated with Doppler ultrasonography every 12 hours in the first postoperative week and daily in the second postoperative week. When occlusion was suspected, conventional angiography was performed. Thrombectomy was performed in one patient, and thrombectomy and reanastomosis were performed in another patient with HAT. Two patients with HAS were treated with balloon angioplasty. A third patient was treated with balloon angioplasty and endoluminal stent placement at the same time. The last patient with HAS had an intimae dissection, which occurred 24 hours after balloon angioplasty, that was treated with subsequent endoluminal stent placement. Mean follow-up for the patients with vascular complications was 9.5 ± 5.7 months (range, 4 to 18 months). The overall mortality rate was 14.1% (3/21); however, no deaths were caused by vascular complication. Routine Doppler ultrasonographic evaluation is an effective choice for diagnosing vascular complications seen after liver transplantation. Immediate surgical intervention is required for acute vascular complications, whereas late complications may be treated with balloon angioplasty and/or endoluminal stent placement.

Long-term outcomes and predictors of iliac angioplasty with selective stenting

To review our 11-year experience of iliac angioplasty with selective stenting and to evaluate the safety, short- and long-term patency, clinical success rates, and predictive risk factors in patients with iliac artery occlusive disease. From August 1993 to November 2004, 151 iliac lesions (149 stenoses, 2 occlusions) in 104 patients were treated by percutaneous transluminal angioplasty (PTA). The patients had chronic limb ischemia described as disabling claudication (the Society for Vascular Surgery clinical category 2 or 3) in 76 (50%), rest pain (category 4) in 38 (25%), and ulcer/gangrene (category 5) in 37 (25%). Forty-six limbs (30%) were treated with concomitant infrainguinal endovascular (36, 24%) or open procedures (10, 6%). Thirty-four limbs (23%) had one or more stents placed for primary PTA failure, including residual stenosis (> or =30%), mean pressure gradient (> or =5 mm Hg), or dissection (stent group); whereas, 117 limbs (77%) underwent PTA alone (PTA group). The affected arteries treated were 28 (19%) common iliac, 31 (20%) external iliac, and 92 (61%) both arteries. According to TransAtlantic Inter-Society Consensus (TASC) classification, 39 limbs (26%) were in type A, 71 (47%) in type B, 36 (24%) in type C, and 5 (3%) in type D. Reporting standards of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery were followed. There was no perioperative death. Total complication rate was 0.7% (one groin hematoma). The mean follow-up was 21 months (median, 10; range, 1 to 94 months). Only 9 (8%) of 117 of the PTA group had subsequent stent placement for recurrent stenosis. The iliac lesions were more severe and extensive in the stent group than those in the PTA group according to TASC classification (Mann-Whitney U test [M-W], P < .0001) and anatomic location (M-W, P = .0019). The technical success rate was 99%, and the initial clinical success rate was 99%. Overall, the cumulative primary patency rates at 1, 3, and 5 years were 76%, 59%, and 49% (Kaplan-Meier [K-M]). The cumulative assisted primary and secondary patency rates at 7 years were 98% and 99% (K-M). The mean number of subsequent iliac endovascular procedures was 1.4 per limb in patients with primary failure of iliac angioplasty/stenting. The continued clinical improvement rates at 1, 3, and 5 years were 81%, 67%, and 53% (K-M). The limb salvage rates at 7 year were 93% (K-M). Of 15 predictor variables studied in 151 iliac lesions, the significant independent predictors for adverse outcomes were smoking history (P = .0074), TASC type C/type D lesions (P = .0001), and stenotic ipsilateral superficial femoral artery (P = .0002) for the primary patency rates; chronic renal failure with hemodialysis (P = .014), ulcer/gangrene as an indication for PTA (P < .0001), and stenotic ipsilateral superficial femoral artery (P = .034) for the continued clinical improvement (K-M, log-rank test and Cox regression model). Although the primary patency rates were not high, the assisted primary and secondary patency rates were excellent without primary stenting. Overall, >70% of iliac lesions were treated successfully with PTA alone. The results of this study show that selective stenting offers satisfactory assisted primary and secondary long-term patency after iliac angioplasty. Patients with TASC type C/type D iliac lesions, a stenotic ipsilateral superficial femoral artery, ulcer/gangrene, smoking history, and chronic renal failure with hemodialysis should be followed carefully after endovascular iliac revascularization. These risk factors could be considered indications for primary stenting, although further studies are needed to confirm this.

Assessment and treatment of acute heart failure-Case Study: Wet and warm profile with concomitant anuric renal failure

An 86-year-old man arrived by ambulance at the emergency department (ED) at 7:15 P.M. with shortness of breath, wheezing, and sweating. The history obtained of his present illness was brief due to the patient’s extreme dyspnea. He had missed his dialysis appointment the previous day, and he complained of worsening shortness of breath that morning. En route he received nebulized albuterol and was on 100% O2 by nonrebreather mask. The patient had suffered a myocardial infarction approximately 7 years previously. He had also undergone two cardiac catheterizations documenting extensive coronary artery disease (CAD), resulting in angioplasty with subsequent stent placement. In addition, he had a history of congestive heart failure (CHF) and hypertension that precipitated end-stage renal failure requiring hemodialysis. He also had chronic obstructive pulmonary disease (COPD) and was on home O2 at 2 l/min. His medications were as follows: enalapril 40 mg/day, clonidine 0.1 mg t.i.d., isosorbide dinatrate 25 mg/day, atenolol 25 mg/day, salmeterol 2 puffs b.i.d., fluticasone 2 puffs b.i.d., albuterol p.r.n., lansoprazole 15 mg/day, calcium acetate 665 mg t.i.d., and Nephrocaps 1/day.

Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting

The use of percutaneous angioplasty with subsequent intravascular metallic stent placement has gained increasing acceptance over the past decade. Infections of these stents appear to be uncommon; however, the rarity of this complication may in part be the result of a lack of availability of long-term follow-up data. A number of examples of infected cardiac and peripheral vascular stents have been reported, often with fatal consequences. Herein, we report a 74-year-old woman who underwent subclavian and brachiocephalic artery angioplasty and stent placement for symptomatic stenoses. Six months after the initial intervention, the patient returned with restenosis of the stents and underwent repeat angioplasty to restore full patency. Two weeks later, the patient was readmitted with generalized malaise and multiple erythematous, macular lesions on the right forearm and hand. Blood cultures grew Staphylococcus aureus, and a computed tomographic scan of the chest showed a large brachiocephalic artery pseudoaneurysm with surrounding hematoma. Despite prompt surgical intervention, this complication proved ultimately fatal. Infections of metallic endovascular stents are potentially life-threatening complications and must be addressed urgently, including possible surgical intervention. (J Vasc Surg 2002;36:625-8.)

Diagnosis and Treatment of Concomitant Venous Obstruction in Patients with Secondary Lymphedema

It has been proposed that concomitant iatrogenic venous obstruction substantially contributes to the appearance and severity of the secondary lymphedema that follows cancer surgery, radiation, and other traumas. The purpose of this study was to investigate the frequency of venous obstruction in the clinical presentation of patients with secondary lymphedema and to analyze the efficacy of interventional therapy in this patient population. The experience of the university center for lymphatic and venous disorders with combined lymphaticovenous edema was retrospectively examined. The records and clinical course were reviewed for all patients referred to a university lymphedema center for evaluation between January 1996 and March 1999. During this interval, in 365 patients with lymphedema, 35 radiocontrast venograms were obtained to evaluate the suspected presence of mixed lymphaticovenous edema. Venographic evidence of venous stenosis (>50%) or occlusion was analyzed, as were the technical success of the intervention, determined by ability to cross the affected segment of the vein and perform venoplasty and place the stent, and the clinical success of the intervention assessed by relief of clinical symptoms (edema, pain) within 24 hours. The diagnosis of venous obstruction was confirmed in 17 patients (4.6% of all patients with lymphedema; 49% of patients studied with venography). Venography disclosed clinically relevant venous stenosis in five of seven patients with edema of the upper extremity and in six of 10 patients with leg lymphedema. Venous occlusion was found in two of seven patients with upper extremity edema and in four of 10 patients with leg lymphedema. Percutaneous endovascular venoplasty was attempted in all 17 patients and was successful in 16. Subsequent venous stent placement was performed in three patients with upper extremity edema and in all patients with lower extremity lymphedema. Clinical amelioration of edema was observed in 15 of these 17 patients. Amelioration was assessed by relief of symptoms, improvement in function, and reduction in limb girth. This study supports the clinical importance of concomitant venous obstruction in some patients with chronic secondary lymphedema. Edema can often be ameliorated through percutaneous catheter-based interventions.

Radiological Stenting Provides Effective Palliation in Malignant Central Venous Obstruction

Malignant superior vena caval obstruction (SVCO) due to lung cancer carries a poor prognosis and response to palliative radiotherapy is variable. Eighteen patients presenting with the appearance of malignant SVCO (thirteen due to primary bronchial tumours) in a four year period from June 1995 to July 1999 underwent venography with a view to placement of an expanding metal stent under radiological control. Fourteen patients were male and four female with a mean age at presentation of 65 years (range 44–84 years). At venography only three patients had isolated SVC stenosis, five also had brachiocephalic, internal jugular or subclavian vein stenoses and one had an isolated right brachiocephalic stenosis. Venography demonstrated thrombus in eight of the remaining patients, seven in association with stenosis. In one patient stenosis of the SVC was thought to be due to radiation fibrosis as no mass was visible. All underwent Seldinger catheterization of the great veins via a right femoral puncture with deployment of the stent over a guide wire. Balloon angioplasty was performed prior to stent placement in eight patients. The eight patients with thrombus underwent thrombolysis using rt-PA (recombinant tissue-type plasminogen activator) with subsequent stent placement in seven. Radiological relief of obstruction with abolition of collateral flow was observed in all cases. One patient required further stenting for recurrent obstruction after 160 days of palliation. The median duration of palliation after stenting was 87 days. No procedure-related morbidity was observed. Thrombolysis was of value in patients with occlusive thrombus, either in isolation or complicating a malignant stricture, where radiotherapy may not have been effective. Radiological stenting is a safe technique which offers rapid palliation of SVCO. Copyright 2002 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.

Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction.

Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. Magnetic resonance cholangiopancreatography (MRCP) offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient's risk of developing postprocedure bacterial cholangitis. We used decision analysis techniques to quantitate the cost-effectiveness of MRCP before stent placement versus routine placement of bilateral biliary stents in the setting of inoperable malignant hilar obstruction. In addition to determining which strategy was most economical, we used sensitivity analysis to identify the critical factors defining relative costs. A decision analysis model was designed comparing MRCP with subsequent unilateral biliary stent placement and double biliary stent placement approaches for palliation of jaundice in a patient with inoperable malignant hilar obstruction, as viewed from the societal perspective. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively. MRCP with subsequent directed unilateral stent placement was the least costly approach ($3806) compared with bilateral stent placement ($4275), provided the bilateral biliary stent complication rate was >3%. Bilateral stent placement needed to confer a survival advantage of at least 7 days over unilateral stent placement to become the more cost-effective approach. The use of MRCP to guide biliary stent placement in a patient with inoperable hilar obstruction reduces the overall cost of treatment. The uncertainty of any survival advantage that bilateral biliary stent placement confers over unilateral stent placement makes cost-effectiveness difficult to assess.

Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction

OBJECTIVE: Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. Magnetic resonance cholangiopancreatography (MRCP) offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient’s risk of developing postprocedure bacterial cholangitis. We used decision analysis techniques to quantitate the cost-effectiveness of MRCP before stent placement versus routine placement of bilateral biliary stents in the setting of inoperable malignant hilar obstruction. In addition to determining which strategy was most economical, we used sensitivity analysis to identify the critical factors defining relative costs. METHODS: A decision analysis model was designed comparing MRCP with subsequent unilateral biliary stent placement and double biliary stent placement approaches for palliation of jaundice in a patient with inoperable malignant hilar obstruction, as viewed from the societal perspective. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively. RESULTS: MRCP with subsequent directed unilateral stent placement was the least costly approach ($3806) compared with bilateral stent placement ($4275), provided the bilateral biliary stent complication rate was >3%. Bilateral stent placement needed to confer a survival advantage of at least 7 days over unilateral stent placement to become the more cost-effective approach. CONCLUSIONS: The use of MRCP to guide biliary stent placement in a patient with inoperable hilar obstruction reduces the overall cost of treatment. The uncertainty of any survival advantage that bilateral biliary stent placement confers over unilateral stent placement makes cost-effectiveness difficult to assess.

Definitive treatment of pancreatic abscess by endoscopic transmural drainage

Background: Experience with endoscopic transmural drainage of pancreatic pseudocysts prompted the use of a similar technique for the primary treatment of pancreatic abscess. The aim of this study was to assess the feasibility, safety, and effectiveness of endoscopic transmural drainage for the treatment of pancreatic abscesses compressing the gut lumen. Methods: In 9 patients, a total of 11 pancreatic abscesses compressing the stomach, duodenum, or both organs were drained endoscopically by means of endoscopic fistulization followed by saline solution irrigation and subsequent stent(s) placement. Complete resolution of the pancreatic abscess was defined as the absence of symptoms and no residual collection on follow-up CT. Observations: Endoscopic transmural drainage was technically successful in all cases. Ten abscess cavities (91%) resolved completely after stent placement for a mean duration of 32 days. In 2 patients, insertion of a nasopancreatic catheter was required to irrigate thick pus or necrotic debris. Bleeding occurred in 1 case (11%) but there was no mortality. The relapse rate was 13% over a mean follow-up of 18 months. Conclusion: Endoscopic transmural drainage is an effective therapy with minimal morbidity for pancreatic abscess compressing the gut lumen and is a valuable alternative to surgical drainage.

Dilation of high-grade pancreatic and biliary ductal strictures with small-caliber angioplasty balloons

Background: Pancreatic and bile duct strictures may be too stenotic to allow passage of conventional endoscopic dilators. Methods: Four patients with strictures (3 pancreatic, 1 biliary) that could not be traversed with conventional endoscopic dilating devices, or in 1 case by a Soehendra stent extractor, underwent stricture dilation with a 3.3F peripheral angioplasty balloon to a maximum diameter of 6 mm. Observations: All strictures in the 4 patients were successfully traversed and dilated and stents were placed with resolution of the presenting clinical problem. Conclusions: Small-caliber angioplasty balloons are useful for dilation with subsequent stent placement of pancreatic and biliary strictures that are refractory to standard endoscopic approaches.

Magnetic resonance cholangiopancreatography-guided unilateral endoscopic stent placement for Klatskin tumors

Background: Advanced and incurable Klatskin tumors of Bismuth-type III and IV cause obstructive jaundice. Palliation of patients with Klatskin tumors is usually carried out by bilateral endoscopic stent placement. Endoscopic retrograde cholangiography (ERC) in such patients is associated with a comparatively high morbidity and mortality mainly due to postprocedure bacterial cholangitis. To reduce ERC-related complications the outcome of replacing ERC with magnetic resonance cholangiopancreatography (MRCP) was investigated. Subsequently, unilateral contrast injection and stent placement were performed, thus avoiding bilateral contrast injection and stent insertion. Methods: Patients thought to have a Klatskin tumor underwent clinical evaluation, laboratory, and noninvasive imaging studies before ERC. Patients were enrolled in this feasibility study if investigators agreed with the clinical diagnosis of an advanced and incurable Klatskin tumor. MRCP images were used to determine the predominate ductal drainage for the liver segments thus directing stent placement. Based on these findings, unilateral ERC and subsequent unilateral stent placement were performed. Antibiotics were not given before ERC. Amsterdam-type stents (10F) were placed and replaced routinely at 2 months. In cases of earlier occlusion, the stents were replaced immediately. Results: Thirty-five patients underwent MRCP, ERC, and unilateral stent deployment. Two further patients enrolled after MRCP were withdrawn because ERC could not be carried out. In 35 patients with unilateral stents bilirubin levels decreased (18.9 ± 6.3 mg/dL to 3.2 ± 2.3 mg/dL) and jaundice resolved in 86%. After first stent deployment, post-ERC bacterial cholangitis occurred in 6% (2 of 35) of patients. Conclusions: This new method of MRCP-guided endoscopic unilateral stent placement could reduce ERC-related complications caused by initial stent deployment.The results of this study justify a randomized prospective comparative trial. (Gastrointest Endosc 2001;53:40-6.)

3396 Endoscopic drainage of pancreatic abscess with endoscopic fistulization and transgastro-duodenal stenting.

Background: Recently, pancreatic endotherapy is increasingly used even for the treatment of infectious complication of acute pancreatitis and successful endoscopic drainage of infected organized pancreatic nectrosis has been reported (Monkemuller et al, Gastrointest Endosc 1999). Although endoscopic internal drainage of pancreatic abscess has been successfully employed (Messmann, Endoscopy 1995), experience is limited and role of endoscopic drainage in the treatment of pancreatic abscess complicating acute pancreatitis is less well defined. Aim: To determine feasibility, effectiveness and safety of endoscopic drainage for the treatment of pacreatic abscess. Methods: In 6 patients (3M, 3F, mean age 56.1, range 49-67), 8 pancreatic abscesses compressing gut lumen (duodenal compression in 3 cases, stomach compression in 1 case, both duodenum and stomach compressing in 2 cases, mean size 5.3×6.8 cm) were drained endoscopically by means of endoscopic fistulization and subsequent stent(s) placement. Endoscopic fistulization was performed through the gastroduodenal wall using needle-knife (HPC-2, Wilson-Cook Medical Co, NC). Single, 7-10 Fr, biliary stent (pigtail in 6, straight in 2) was placed into the abscess cavity after an aspirate was taken for bacterial culture and irrigation with sterile saline through the evacuated needle-knife sheath or cannulation cathter. In one patient with largest abscess with thick pus, a 7 Fr nasobiliary catheter was placed concurrently with the 10 Fr stent to improve drainage after dilation of fistulous tract using a 10 Fr biliary dilation catheter. Follow-up was done by contrast enhanced CT. Results: Endoscopic drainage with endoscopic fistulization and placement of stent across the gastro-duodenal wall into the abscess cavity was successful in all cases. The mean duration of stent placement was 32.3 days (range 14-42). Complete drainge was achieved in 7 of 8 abscess cavities (87.5%). The complication was 1 case of bleeding (12.5%) requiring surgery which occurred during the repeated attempt of endoscopic transgastric drainage due to incomplete drainage. There was no mortality. Conclusion: These results suggest that endoscopic drainage with endoscopic fistulization followed by transgastro-duodenal stenting is a feasible, effective, and relatively safe non-surgical therapy in selective patients with pancreatic abscess compressing gastro-duodenal lumen. Background: Recently, pancreatic endotherapy is increasingly used even for the treatment of infectious complication of acute pancreatitis and successful endoscopic drainage of infected organized pancreatic nectrosis has been reported (Monkemuller et al, Gastrointest Endosc 1999). Although endoscopic internal drainage of pancreatic abscess has been successfully employed (Messmann, Endoscopy 1995), experience is limited and role of endoscopic drainage in the treatment of pancreatic abscess complicating acute pancreatitis is less well defined. Aim: To determine feasibility, effectiveness and safety of endoscopic drainage for the treatment of pacreatic abscess. Methods: In 6 patients (3M, 3F, mean age 56.1, range 49-67), 8 pancreatic abscesses compressing gut lumen (duodenal compression in 3 cases, stomach compression in 1 case, both duodenum and stomach compressing in 2 cases, mean size 5.3×6.8 cm) were drained endoscopically by means of endoscopic fistulization and subsequent stent(s) placement. Endoscopic fistulization was performed through the gastroduodenal wall using needle-knife (HPC-2, Wilson-Cook Medical Co, NC). Single, 7-10 Fr, biliary stent (pigtail in 6, straight in 2) was placed into the abscess cavity after an aspirate was taken for bacterial culture and irrigation with sterile saline through the evacuated needle-knife sheath or cannulation cathter. In one patient with largest abscess with thick pus, a 7 Fr nasobiliary catheter was placed concurrently with the 10 Fr stent to improve drainage after dilation of fistulous tract using a 10 Fr biliary dilation catheter. Follow-up was done by contrast enhanced CT. Results: Endoscopic drainage with endoscopic fistulization and placement of stent across the gastro-duodenal wall into the abscess cavity was successful in all cases. The mean duration of stent placement was 32.3 days (range 14-42). Complete drainge was achieved in 7 of 8 abscess cavities (87.5%). The complication was 1 case of bleeding (12.5%) requiring surgery which occurred during the repeated attempt of endoscopic transgastric drainage due to incomplete drainage. There was no mortality. Conclusion: These results suggest that endoscopic drainage with endoscopic fistulization followed by transgastro-duodenal stenting is a feasible, effective, and relatively safe non-surgical therapy in selective patients with pancreatic abscess compressing gastro-duodenal lumen.

Recurrent Hypertension After Migration of a Renal Artery Stent

The use of angioplasty and intravascular stenting has been applied to a variety of arterial lesions including atherosclerotic renal artery stenosis (RAS). The authors describe a patient with renovascular hypertension who underwent angioplasty and subsequent right renal artery stent placement for proximal RAS. Recurrent hypertension 4 months after the procedure led to arteriography that documented distal migration of the stent into the renal hilum and restenosis of the proximal vessel. Operative stent removal and revascularization was required to correct the problem.

Randomised comparison of primary stent placement versus primary angioplasty followed by selective stent placement in patients with iliac-artery occlusive disease

Percutaneous transluminal angioplasty (PTA) is a safe, simple, and successful treatment for intermittent claudication caused by iliac-artery occlusive disease. Primary stent placement has been proposed as more effective than PTA. We compared the technical results and clinical outcomes of two treatment strategies-primary placement of a stent across the stenotic segment of the iliac artery, or primary PTA followed by selective stent placement when haemodynamic results were inadequate. We randomly assigned 279 patients with intermittent claudication, recruited from departments of vascular surgery, either to direct stent placement (group I, n=143) or primary angioplasty (group II, n=136), with subsequent stent placement in case of a residual mean pressure gradient greater than 10 mm Hg across the treated site. The main inclusion criterion was intermittent claudication on the basis of iliac-artery stenosis of more than 50%, proven by angiography. All patients had a clinical assessment before intervention and at 3, 12, and 24 months. Clinical success was defined as improvement of at least one clinical category. Secondary endpoints were initial technical results, procedural complications, cumulative patency as assessed by duplex ultrasonography, and quality of life. In group II, selective stent placement was done in 59 (43%) of the 136 patients. The mean follow-up was 9.3 months (range 3-24). Initial haemodynamic success and complication rates were 119 (81%) of 149 limbs and 6 (4%) of 143 limbs (group I) versus 103 (82%) of 126 limbs and 10 (7%) of 136 limbs (group II), respectively. Clinical success rates at 2 years were 29 (78%) of 37 patients and 26 (77%) of 34 patients in groups I and II, respectively (p=0.6); however, 43% and 35% of the patients, respectively, still had symptoms. Quality of life improved significantly after intervention (p<0.05) but we found no difference between the groups during follow-up. 2-year cumulative patency rates were similar at 71% versus 70% (p=0.2), respectively, as were reintervention rates at 7% versus 4%, respectively (95% CI -2% to 9%). There were no substantial differences in technical results and clinical outcomes of the two treatment strategies both at short-term and long-term follow-up. Since angioplasty followed by selective stent placement is less expensive than direct placement of a stent, the former seems to be the treatment of choice for lifestyle-limiting intermittent claudication caused by iliac artery occlusive disease.

Endoscopic therapy in children with pancreas divisium presenting with acute pancreatitis or chronic abdominal pain

Pancreas divisum is the most common congenital anomaly of the pancreas, potentially resulting in a relative outflow obstruction across a stenotic minor papilla. As a result of this drainage deficiency, patients are predisposed to acute pancreatitis or chronic pancreatic-type pain. Endoscopic stent placement or sphincterotomy of the minor papilla has been shown to be beneficial in reducing abdominal pain as well as episodes of pancreatitis in a subset of adult patients with pancreas divisum and acute recurrent pancreatitis (ARP). The significance of pancreas divisum in children presenting with ARP or chronic abdominal pain is unknown. AIM: To determine the efficacy of endoscopic sphincterotomy or stent therapy of the minor papilla in children with pancreas divisum associated with ARP or chronic abdominal pain. METHODS: 16 patients (5M, llF, age range 13-17, mean 15.6 yrs), presented With pancreas divisum and ARP (10), chronic pain (3), or chronic pancreatitis (3). Treatment consisted of pancreatic stent across the minor papilla, 3 exchanges over a 9 month period (13) or minor papilla sphincterotomy (3). Patients were evaluated for recurrent episodes of pancreatitis and/or presence of abdominal pain at each retum visit and at the end of the study by interview. RESULTS: All patients underwent successful pancreatography with subsequent therapy, stent placement (7 French) or sphincterotomy. Endoscopic therapy was successful in 8 of 10 patients (80%) presenting with ARP whereas only 33% of patients with chronic pain only or chronic pancreatitis (CP) had successful treatment outcome.