Successful Endovascular Stenting Research Articles

Endovascular revascularization of chronically occluded common carotid artery for symptomatic cerebral hypoperfusion.

Endovascular recanalization is increasingly being utilized in symptomatic patients with chronically occluded carotid arteries.1 In carefully selected patients, endovascular recanalization has shown to lower the risk of ischemic events when compared to medical management alone.1 However, successful endovascular revascularization is technically challenging and not without risk.1, 2 In this video, we demonstrate a case of a 64-year-old woman who presented with recurrent transient ischemic attacks. On imaging she was found to have a chronic total occlusion of the common carotid artery from the arch. After obtaining informed consent, the patient underwent a successful endovascular recanalization and stenting of a chronically occluded left common carotid artery with aid from an intravascular guided re-entry catheter. Post operatively the patient developed a neck hematoma which improved and she returned to her neurological baseline. She reported no further symptoms on her three month follow up.

혈관내 스텐트를 이용하여 경정맥구 게실에 의한 박동성 이명을 치료한 증례보고

Pulsatile tinnitus is a rare otologic symptom that presents a diagnostic and management dilemma for experienced otolaryngologists. Treatment options range from conservative management to surgery, but patients may not be able to tolerate symptoms with the former and the latter procedure may be associated with significant morbidity We describe the case of using a stent-assisted coil approach to treating a patient with jugular bulb diverticulum (JBD) and severe pulsatile tinnitus. We describe a 41-year-old woman who presented with disabling pulsatile tinnitus due to right JBD. Both surgical or endovascular approaches were possible, but we decided to treat the diverticulum with coil emboli-zation and stenting of the jugular bulb. Following the procedure, tinnitus presence and severity were self-reported or assessed using the tinnitus handicap inventory (THI) and tinnitus magnitude index (TMI). The total score of both THI and TMI improved in 6 months after surgery, and there was no complication. Therefore, we report this experience, which was resolved through successful endovas-cular coiling and stent procedure for severe pulsatile tinnitus with no complication.

Ureteroiliac artery fistula caused by full-length metallic ureteral stenting in a malignant ureteral obstruction: a case report

BackgroundThe metallic stent is a new device for relieving the urinary tract in patients with malignant ureteral obstruction with short life expectancy and has been used frequently worldwide for its efficacy and safety. A ureteroarterial fistula with indwelling ureteral stent is rare but highly fatal, and there are several reports of ureteroarterial fistula treated by conventional polymer stents, although there are no reports on metallic stents. To our knowledge, this paper describes the first case of a ureteroiliac artery fistula caused by a full-length metallic ureteral stent in malignant ureteral obstruction.Case presentationOur patient was a 57-year-old Asian woman with a history of locally advanced cervical cancer who underwent abdominal total hysterectomy and chemoradiotherapy. She was diagnosed with right hydronephrosis and hydroureter secondary to upper ureteral obstruction because of retroperitoneal lymph node metastasis. A urinary tract obstruction after placement of 12 months of polymer stent followed by 18 months of metallic stent was relieved, consequently resulting in intermittent gross hematuria with bladder tamponade and anemia. Contrast-enhanced computed tomography could not reveal a ureteroarterial fistula; however, retrograde pyelography emphasized the existence of a ureteroiliac artery fistula. The patient underwent successful endovascular heparin-bonded stent graft placement, and her gross hematuria disappeared thereafter.ConclusionThe metallic stent is a useful device for patients with malignant ureteral obstruction with a short life expectancy, although it may impose a higher pressure on the extraureteral tissue than conventional polymer stents due to its properties and may cause a ureteroarterial fistula. The narrowing of the external iliac artery diameter visualized by computed tomography may be helpful for predicting ureteroarterial fistulas.

First Experience of Endovascular Recanalization and Stenting of the Chronic Post-Thrombotic Occlusion of the Inferior Vena Cava and Both Common Iliac Veins in Krasnodar Krai

Aim. To present the first experience of a successful endovascular recanalisation and stenting of chronic post-thrombotic occlusion of the inferior vena cava and both common iliac veins in Krasnodar Krai.Methods and materials. A man, 72 years old, was admitted with the complaints of intermittent claudication, pronounced edema of both lower limbs, compaction and hyperpigmentation of the skin of the lower legs. Using ultrasound and computed tomography angiography, chronic post-thrombotic occlusion of the inferior vena cava and common iliac veins was established. The severe course of post-thrombotic syndrome (15 points on the Villalta scale) and the failure of conservative treatment were regarded as indications for performing endovascular surgery. Through puncture accesses in both common femoral veins and in the right internal jugular vein, guides were introduced through the occlusion zone, and balloon angioplasty was performed, followed by stenting of the common iliac veins and the inferior vena cava.Results. In-hospital and 4-month treatment results were analysed. The postoperative period was uneventful. The patient noted a decrease in the feeling of heaviness and edema in the lower extremities, as well as an increase in walking distance. A follow-up examination was performed following 4 months. The functional status significantly improved. The Villalta score was 4 points (absence or mild post-thrombotic syndrome). Ultrasound examination and computed tomography angiography established the patency of the stents in the inferior vena cava and in the common iliac veins.Conclusion. Endovascular recanalisation and stenting of the inferior vena cava and common iliac veins is an effective treatment for severe post-thrombotic syndrome.

Factors Associated with Failed Conservative Management in Symptomatic Isolated Mesenteric Artery Dissection

The aim of this study was to assess factors associated with conservative management failure in patients with symptomatic isolated mesenteric artery dissection. Patients with symptomatic isolated mesenteric artery dissection who underwent conservative therapy as first line treatment between February 2010 and May 2018 were included in this retrospective study. Conservative management failure was defined as the persistence or aggravation of symptoms and signs, increasing aneurysmal dilation, or new appearance of a dissecting aneurysm after conservative management. Univariable and multivariable analyses were performed to identify risk factors for failure of conservative management. A total of 123 patients (115 men, 8 women, mean age, 53.7±6.1 years) were included in this study. Conservative management was successful in 89 (72.4%) patients but failed in the remaining 34 (27.6%) patients. Of the 89 for whom conservative management was successful, all of the symptoms were eliminated (n=81) or relieved (n=8) within 3.8±0.7 days after conservative management. All of the 34 patients in whom conservative management failed underwent successful endovascular stenting. Failure of conservative management was associated with type II IMADs as defined by the Sakamoto classification (meaning that there is an entry tear, but no re-entry, and still no thrombosis of false lumen, odds ratio: 33.76; 95% confidence interval 8.65-131.85; p<.001) and with ≥90% luminal stenosis (odds ratio 40.70; 95% confidence interval: 3.76-440.07; p<.01). Conservative management can be used successfully in most patients with symptomatic isolated mesenteric artery dissection. Risk factors for failed conservative treatment were type II IMADs and degree of luminal stenosis ≥90%.

Antiplatelet Therapy is Associated with Stent Patency After Iliocaval Venous Stenting.

To examine the effectiveness of antithrombotic medications to prevent venous stent malfunction for iliocaval occlusive disease. A retrospective analysis was performed on 62 patients who underwent technically successful endovascular iliocaval stent placement between May 2008 and April 2017. Clinical records were reviewed for demographic information, procedure details, post-stenting antithrombotic prophylaxis and stent patency on follow-up. Stent malfunction was defined as > 50% stenosis or occlusion at follow-up. Risk factors for stent malfunction were assessed with univariable and multiple Cox proportional hazard models. The median follow-up period was 11.6months (range 0.1-76.4). Overall primary and secondary cumulative patency rates at 12months were 70.0% and 92.4%, respectively. After stent placement, 97% of patients received anticoagulation with warfarin, enoxaparin or a factor Xa inhibitor. In addition, 61% received antiplatelet prophylaxis with aspirin, clopidogrel or a combination. In multiple Cox regression analysis, post-stenting antiplatelet use remained significantly associated with primary stent patency (HR = 0.28, P = 0.022). After iliocaval venous stenting, stent patency was best predicted by concomitant antiplatelet and anticoagulation therapy rather than anticoagulation alone. This novel finding warrants further research underlying mechanisms leading to venous stent thrombosis, and has implications for optimal medical management after venous stenting.

Случай успешного эндоваскулярного стентирования протяженного сужения перешейка аорты стентом с покрытием из ePTFE у больного с рекоарктацией аорты после баллонной ангиопластики и репротезирования митрального клапана

Случай успешного эндоваскулярного стентирования протяженного сужения перешейка аорты стентом с покрытием из ePTFE у больного с рекоарктацией аорты после баллонной ангиопластики и репротезирования митрального клапана

Successful Endovascular Repair of Mycotic Aortic Pseudoaneurysm Followed by Aortoesophageal Fistula

Mycotic aneurysm of the aorta is a rare, but life-threatening pathology. In recent years, endovascular stent graft placement has been introduced as an effective alternative for treating infected aortic aneurysms. A 64-year-old woman with a history of paraplegia due to spinal cord injury was referred to our institute with fever and blood-tinged sputum. Computed tomography (CT) scan showed an 11-cm pseudoaneurysm arising from the proximal descending aorta, which was normal 1 month ago at the previous CT scan. The patient underwent thoracic endovascular aortic repair for the pseudoaneurysm, deployed with a transiliac access approach, and received antibacterial medical therapy. On postoperative day 11, she developed signs of infection, caused by an aortoesophageal fistula. The infection was treated conservatively with parenteral nutrition and antibiotic administration. The patient had an uneventful recovery and was discharged on postoperative day 113. At 2-year follow-up, she had a normal physical examination and CT angiography showed a marked reduction of the pseudoaneurysm sac. We report a successful endovascular stent grafting and subsequent medical treatment in a patient with a mycotic thoracic aortic pseudoaneurysm followed by a postoperative aortoesophageal fistula.

Successful Endovascular Stenting of Aortoesophageal Fistula

Introduction Aortoesophageal fistula (AEF) is rare and caries high mortality. Esophageal cancer, foreign body ingestion, esophageal stent, thoracic aortic aneurysm are among common causes. Treatment is challenging, and early recognition is the key. We present a case of successful endovascular stent treatment of AEF presented with massive upper gastrointestinal bleeding. Case Presentation A 69 year-old man with history of GERD, Barrett's esophagus, who was found to have a high-grade signet ring adenocarcinoma on a surveillance endoscopy. Soon thereafter, he had dysphagia and significant weight loss. An endoscopic metal stent was placed. He had persistent symptoms and inability to swallow. A jejunal tube was placed for nutrition. He presented to the ER with sudden onset of hematemesis and drop in hemoglobin from 13 to 6.9 in 12 hours. CT scan of the chest was performed which showed suspicion for AEF (Figure 1). He immediately had an angiogram, which confirmed AEF. (Figure 2,3) An endovascular stent graft was placed above the celiac axis. The angiogram showed good apposition of the graft without any continued bleeding. Discussion AEF is rare case that carries high incidence of morbidity and mortality. Commonly presented with hematemesis, dysphagia and/or chest pain. Early diagnosis and intervention is a key for treatment. The goals for therapy in AEF include - Prevention of immediate exsanguination, treatment of the primary fistula and prevention of complications. Treatment options include endoscopic, surgical and interventional radiology. Endovascular stent placement is a quick procedure where a covered stent is used to block the vascular defect. Primary open surgical closure has a high mortality rate. There is an approximate 15 % risk of re bleed and graft infection after endovascular repair alone. Therefore, additional surgical repair of the fistula, which may include debridement of the thoracic cavity, may be required. Antibiotics are one of the strongest factors shown to lower the mortality in a multivariate analysis. Antibiotic duration has not been studied prospectively, however a 4-8 week duration has been suggested to prevent immediate mortality in retrospective analysis. Conclusion AEF is a rare and fatal complication of esophageal disorders. Early recognition is important. High index of suspicion need to be maintained in the right patient cohort. Immediate vascular stenting is key to prevention of exsanguinating and severe bleeding.Figure 1Figure 2Figure 3

Acute Type B Aortic Dissection Present as Innominate Vein Compression Syndrome: A Rare Presentation

Summary The term “innominate (brachiocephalic) vein compression syndrome” was first coined by Wurtz et al in 1989 to describe a patient who presented with “unilateral superior vena cava syndrome.” Here we report a 70-year-old male with comorbidities including hypertension, end-stage renal disease with a left arm arteriovenous fistula for hemodialysis, who presented with left brachiocephalic (innominate) vein compression by a Stanford Type B aortic dissection presenting with left arm edema. The diagnosis was confirmed by venography and computed tomography scan, and he underwent successful endovascular stent grafting.

Persistent Intraluminal Pressure After Endovascular Stent Grafting for Type B Aortic Dissection

Despite technically successful thoracic endovascular stent graft repair (TEVAR) in patients with Stanford Type B aortic dissection (TBAD), long-term follow up studies have shown that the false lumen may continue to dilate. The aim of this study was to analyze the possible mechanisms leading to such changes from a hemodynamic perspective. Twenty-eight exvivo fresh porcine TBAD models (Mo A: 10; Model B: 12; Model C: 6) were established to simulate three clinical situations: Model A with patent false lumen (pre-TEVAR); Model B with distal re-entry only (post-TEVAR), and Model C with thrombus filling in the false lumen and a distal re-entry (chronic stage of post-TEVAR). Synchronous pressure waveforms were taken from both the true and the false lumen. True lumen and false lumen pressure differences were calculated for each model as four indices: systolic index (SI), diastolic index (DI), mean pressure index (MPI) and area under curve index (AUCI). These indices were compared between the three models. False lumen pressure and corresponding pressure-accumulating effects were significantly higher in Model A than in Model C: SI (99.9% vs. 189.4%; p<.001); MPI and AUCI (99.5% vs. 128.2%; 99.5% vs. 128%; p<.001). The SI, MPI, and AUCI were significantly higher in Model B compared with Model C. The differences between the four indices were not significant between Model A and B. The false lumen area under curve (AUC) in Model C was merely lowered by 20% compared with its true lumen (67.5mmHg vs. 85.2mmHg). The false lumen pressure remained unchanged in the non-thrombosed segment with patent blood flow after the primary entry tear sealed. Intraluminal pressure reduction in the thrombosed false lumen was significant. However, nearly 80% of the pressure remained in the thrombosed false lumen. If this high intra-thrombus pressure persists, it may contribute to delayed aneurysmal formation after endovascular treatment.

Initial and Middle-Term Outcome of Treatment for Spontaneous Isolated Dissection of Superior Mesenteric Artery.

Symptomatic isolated dissection of the superior mesenteric artery (SIDSMA) represents an extremely rare condition. Although various treatments including conservative treatment, endovascular stenting (ES), and surgical repair are currently available, consensus treatment guideline is absent due to scarce of SIDSMA cases. Thus, we present our experience in the treatment of SIDSMA at our single center.Fourteen cases of SIDSMA were treated with conservative treatment, catheter-directed thrombolysis (CDT), endovascular stenting (ES), or surgical repair at our center between January 2008 and January 2014. Demographics, clinical manifestations, coexisting medical conditions, imaging feature, treatments, and follow-up outcome of these patients were retrospectively collected and analyzed.For 13 patients without peritonitis, conservative treatment was given for 4 to 6 days initially. After the first observation cycle, symptoms and signs were alleviated in 8 patients, and conservative treatments were continued. The remaining 5 patients received technically and clinically successful ES (in 4) or CDT (in 1) due to worsening symptoms and signs during conservative treatment. One patient with peritonitis underwent emergency surgery, with the necrotic small intestine resected. However, the abdominal pain was not alleviated 17 days postoperatively, ES was thus performed and symptoms relieved immediately. Two weeks after ES, a new aneurysm and partial thrombosis in the distal part of the stent were found by computed tomography angiography in this patient. No intestinal infarction or mortality developed during hospitalization. Follow-up was accomplished in 11 cases, ranging from 4 to 74 months (23.5 ± 21.3). Except that one complained with mild abdominal pain, the other 10 achieved complete remission. All patients were free from new aneurysmal formation of SMA and all stents remained patent.For SIDSMA without peritonitis, conservative treatment can be provided with reasonable success rate, while ES may serve as an effective alternative once conservative treatment fails. For SIDSMA with peritonitis, open surgery remains the treatment of choice by resection of necrotic intestine and revasculization.

Use of subclavian steal in treating chronic total subclavian artery occlusion

Endovascular treatment is a well-established option for subclavian artery stenosis. However, total occlusion of the proximal subclavian artery remains a challenge, posing difficulties of nonvisualization of distal vessels, access site issues, and deployment of vertebral embolism protection devices. A 65-year-old man with chronic total occlusion of the ostial left subclavian artery, underwent successful endovascular stenting in which the subclavian steal phenomenon was utilized as a roadmap to cross the occlusion.

Absent right common carotid artery with stenting of symptomatic internal carotid artery stenosis

Absent common carotid artery with independent origin of internal and external carotid arteries from the subclavian artery is a rare but recognized phenomenon. We describe one such case with an associated symptomatic proximal high-grade stenosis of the right internal carotid artery. The abnormal carotid anatomy was not initially well appreciated, resulting in a failed surgical exploration and subsequent successful endovascular carotid stenting. To our knowledge, this is the first reported case of carotid stent in a right internal carotid artery originating from the subclavian artery.

Endovascular stenting for nutcracker syndrome

Nutcracker syndrome (NCS) is a rare pathology manifested by pain or hematuria in males and females alike. It can be easily overlooked, and should be considered in young men or women with symptoms of extended duration. We present a case of a 54-year-old female with chronic lower abdominal pain radiating to the left thigh of 4 years in duration. Computed tomography (CT) eventually revealed engorged left renal, gonadal, and uterine veins due to compression between the superior mesenteric artery (SMA) and the abdominal aorta, consistent with NCS. After a successful endovascular stenting and a 6-month period of antiplatelet and anticoagulant therapy, the patient returned to stable health. NCS, while rare, should be suspected in patients of both sexes with persistent pain or hematuria.

Repair of Traumatic Aortoinnominate Disruption Using CorMatrix

Blunt traumatic injuries to the innominate artery are rare but potentially devastating injuries. Patients with an innominate injury who survive typically have an isolated intimal tear with an intact adventitia. There are multiple case reports and series describing off-pump repair of innominate injuries using synthetic grafts, and even reports of successful endovascular stenting. We report the first successful case of innominate artery disruption and repair using CorMatrix (CorMatrix Alpharetta, GA) extracellular matrix.

Endovascular Management of Stanford Type A (Ascending) Aortic Dissection

With advances in endovascular technology and stent graft improvement over the past decade, it might be only a matter of time before pure endovascular management of ascending aortic dissection becomes a viable option. Successful endovascular stent graft repair of thoracic aortic dissection involving the ascending aorta and aortic arch requires a sufficient proximal landing zone with a portion of healthy aorta for the stent graft to fix and seal, while preserving aortic valvular competence, coronary and supra-aortic perfusion.

Effective Endovascular Stenting of Malignant Portal Vein Obstruction in Pancreatic Cancer

We report herein the case of a patient successfully treated by transhepatic portal venous stent placement for malignant portal vein obstruction with associated gastric and small bowel varices and repeated gastrointestinal bleeding. CT angiography and portography showed severe portal vein obstruction from recurrent pancreatic cancer 15 months following pancreaticoduodenectomy with tumor encasement and dilated collateral veins throughout the gastric and proximal small bowel wall as the suspected cause of the GI bleeding. Successful transhepatic endovascular stent placement of the splenic vein at the portal vein confluence followed by balloon dilation was performed with immediate decompression of the gastric and small bowel varices and relief of GI hemorrhage in this patient until his death four months later. The treatment for patients with this dilemma can prove to be difficult, but as we have shown endovascular stenting of the portal system is an effective treatment option.

Successful Endovascular Stenting of Total Juxtarenal Aortic Occlusion Performed through Brachial and Femoral Access

Successful Endovascular Stenting of Total Juxtarenal Aortic Occlusion Performed through Brachial and Femoral Access

Endovascular Stenting of Peripheral Infected Aneurysms: A Temporary Measure or a Definitive Solution in High-Risk Patients

The purpose of this study was to demonstrate the use of endovascular technology in the management of peripheral infected aneurysms in high-risk patients as a temporary measure or definitive solution. Five cases underwent successful endovascular stenting of infected aneurysms of the subclavian, femoral, and carotid arteries. All these patients were at high risk for open surgery. Covered stents were placed by percutaneous approach under local anesthesia in all patients. Postoperatively, antibiotics were continued for 3 months. A literature review using the Medline database was also undertaken, and all the relevant papers on endovascular management of peripheral infected aneurysms were taken into account. Stent deployment was successful in all patients. One patient died of mediastinal sepsis and another from type A aortic dissection 5 weeks later. Two patients required drainage of the infected hematoma. Three patients did well at a median follow-up of 1 year, with no evidence of sepsis. A review of the literature shows promising early and midterm results. Most early reports were of single cases, reflecting the low incidence of peripheral infected aneurysms. We conclude that further development of endoluminal techniques and long-term follow-up to establish the durability of stenting could potentially lead to a decrease in the high morbidity and mortality rates associated with infected aneurysmal disease in this high-risk group of patients.