Wallstent Placement Research Articles

Carotid Artery Stenting Using a Closed-Cell Stent-in-Stent Technique for Unstable Plaque

Purpose: To examine whether carotid artery stenting (CAS) of stenoses with unstable plaque using a closed-cell stent-in-stent technique prevents plaque protrusion. Materials and Methods: Between December 2014 and August 2018, 35 consecutive patients (mean age 75.8 years; 29 men) with carotid artery stenosis (20 symptomatic) and unstable plaque diagnosed by magnetic resonance imaging were prospectively analyzed. Mean diameter stenosis was 83.5%. All CAS procedures were performed with stent-in-stent placement of Carotid Wallstents using an embolic protection device and conservative postdilation. The technical success rate, incidence of plaque protrusion, ischemic stroke rate within 30 days, and new ipsilateral ischemic lesions on diffusion-weighted imaging (DWI) within 48 hours after CAS were prospectively assessed. Follow-up outcomes included the incidences of ipsilateral stroke and restenosis. Results: The technical success rate was 100%. No plaque protrusion or stroke occurred in any patient. New ischemic lesions were observed on DWI in 10 (29%) patients. During the mean 11.6-month follow-up, no ipsilateral strokes occurred. Two (6%) patients developed asymptomatic restenosis recorded as 53% lumen narrowing and occlusion, respectively. Conclusion: CAS using a closed-cell stent-in-stent technique for unstable plaque may be useful for preventing plaque protrusion and ischemic complications.

Deep Venous Thrombosis Associated With Caval Extension of Iliac Stent

It is generally difficult to place an iliac vein stent “precisely” at the iliac caval junction with venographic control or even with IVUS guidance. This is because the anatomic junction is not circular but a tilted oval and the lesion whether primary or post-thrombotic may variably encroach on the vena cava. We have advocated extending the stent 3 to 5 cm into the cava to prevent the lesion squeezing the stent distally or compressing the end into a cone. This suggestion has met with resistance due to concerns of jailing contralateral iliac flow and subsequent deep venous thrombosis (DVT). We analyzed DVT incidence following placement of Wallstent with caval extension as well as a modification where a Z stent on top of the Wallstent stack was used for the extension. With widely spaced struts, contralateral jailing was less likely to occur in addition to other technical benefits. A total of 755 limbs with consecutive Wallstent caval extensions (2007 to 2011) and 982 limbs with Z stent extensions (2011 to 2015) were analyzed for DVT incidence. Fisher exact test was used for statistical comparison. Patient demographics were similar for both groups. The mean age was 58 years old; 68% female and 32% male; 61% of patients left side, and 39% right side. Patient pathology: 52% PTS only, 35% MTS only, 13% had both MTS and PTS. DVT incidence is shown in the Table. Left sided DVT was more common overall and in either group (P < .003). DVT incidence overall, ipsilateral DVT, and contralateral DVT were all significantly lower with the Z stent modification. (P < .0001). In addition, the Z stent modification provides greater radial strength at the iliac-caval choke point and enormously simplifies simultaneous or sequential bilateral stenting.TableComparison of DVT incidence among Wall-stent and Z-stent patientsContralateral DVT (<30 days)Contralateral DVT (≥30 days)Total Contralateral DVTsIpsilateral DVT (<30 days)Ipsilateral DVT (≥30 days)Total Ipsilateral DVTsTotal DVTsWall-stent (n = 755)5141926123857Z-stent (n = 982)21***3***6***3**9***12***NS (>0.05), * (<0.05), ** (<0.01), *** (<0.001). Open table in a new tab

Venogram Versus Intravascular Ultrasound for Diagnosing and Treating Iliofemoral Vein Obstruction (VIDIO): Report From a Multicenter, Prospective Study of Iliofemoral Vein Interventions

Venogram Versus Intravascular Ultrasound for Diagnosing and Treating Iliofemoral Vein Obstruction (VIDIO): Report From a Multicenter, Prospective Study of Iliofemoral Vein Interventions

Carotid Wallstent placement difficulties encountered in carotid artery stenting

PurposeThe present study aimed to identify the types of curved lesions that are difficult to place Carotid Wallstent (CWS).Materials and methodsThe study targeted 31 consecutive carotid artery (CA) stenosis underwent carotid artery stenting using CWS. CWS placement success rate, stenosis location, lesion tortuosity, and relationship with stent placement failures were investigated. Lesion tortuosity was defined as the angle formed by 2 tangential lines between internal CA and common CA from the inflection point (IP) was defined as the center of lesion curvature. Stenosed lesions were classified into type A or B. Type A was defined as if the distal end of the stenosis was located proximal to the IP at a distance ≥0.5 of a vertebral body based on the posterior height of the 3rd vertebral body, otherwise was type B.ResultsThe stent placement success rate was 93.5% (29/31). The 2 unsuccessfully stented lesions, both lesions were significantly different from other lesions by having a lesion tortuosity less than 90° and by belonging to type B.ConclusionSince CWS placement is difficult in patients with CA stenosis located close to the IP at a lesion tortuosity ≤90°, open-cell stents should be considered as an alternative.

Long-Term Results of Metallic Stents for Malignant Ureteral Obstruction in Advanced Cervical Carcinoma

We present our experience with the use of metallic stents (Wallstents®) in the management of malignant ureteral obstruction to maintain renal function, thereby permitting the use of chemotherapeutic agents to treat the underlying malignancy. We retrospectively reviewed the records of 24 patients with ureteral obstruction secondary to advanced cervical carcinoma, stage T3b (n=10) and T4 (n=14), that was relieved by Wallstents. Nineteen patients needed bilateral and 5 needed unilateral Wallstents to relieve the obstruction. Fifty-six additional endourologic interventions were necessary to assure continued patency. Holmium laser ablation was used 14 times to manage tumor proliferation and ingrowth at the distal end of the stent. Thirty-two endostents, 4 extension, and 6 replacement stents were used to maintain patency of the ureter. Nineteen of our 24 patients received between one and five chemotherapeutic cycles over 18 to 140 months. In five patients, placement of Wallstents did not achieve adequate decrease of the creatinine levels to allow treatment with chemotherapy. Thirteen of 24 Wallstents remained patent over 18 months, yielding a primary patency rate of 54%. Technical success rate of Wallstent placement was 100%. The overall mean primary and secondary patency rates of the stent were 16.5 and 52 months, respectively. For T3b and T4 patients, the mean primary patency rates were 20.6 and 13.6 months, respectively. Secondary patency for T3b patients was 73.9 months vs 36.4 months for T4 patients. There were no serious complications associated with Wallstent placement. Wallstents offer a salutary solution to the problem of maintaining prolonged patency of ureters compromised by encasing neoplasms.

Endovascular uncovered Wallstent placement for life-threatening isolated iliac vein injury caused by blunt pelvic trauma

Isolated iliac vein injury caused by blunt pelvic trauma is a rare condition that is difficult to diagnose and often fatal. We report a case of a 52-year-old female who presented with life-threatening isolated iliac vein injury caused by blunt pelvic trauma that was successfully managed with endovascular uncovered stent placement. Although further studies are warranted to clarify the hemostatic mechanism, uncovered stent placement can be considered as an alternative treatment option to covered stent placement for life-threatening iliac vein injury when a covered stent is not rapidly available.

Laparoscopic-Assisted Recipient Nephrectomy and Recipient Kidney Procurement during Orthotopic Living-Related Kidney Transplantation

Advanced atherosclerosis or thrombosis of iliac vessels can constitute an absolute contraindication for heterotopic kidney transplantation. We report the case of a 42-year-old women with end-stage renal disease due to lupus nephritis and a history of bilateral thrombosis of iliac arteries caused by antiphospholipid antibodies. Occlusion had been treated by the bilateral placement of wall stents which precluded vascular anastomosis. The patient was transplanted with a right kidney procured by laparoscopic nephrectomy from her HLA semi-identical sister. The recipient had left nephrectomy after laparoscopical transperitoneal dissection. The donor kidney was orthotopically transplanted with end-to-end anastomosis of graft vessels to native renal vessels and of the graft and native ureter. Although, the patient received full anticoagulation because of a cardiac valve and antiphospholipid antibodies, she had no postoperative complication in spite of a short period of delayed graft function. Serum creatinine levels three months after transplantation were at 1.0 mg/dl. Our case documents that orthotopical transplantation of laparoscopically procured living donor kidneys at the site of recipient nephrectomy is a feasible procedure in patients with surgical contraindication of standard heterotopic kidney transplantation.

NEW METHOD OF COVERED WALLSTENTS FOR DISTAL MALIGNANT BILIARY OBSTRUCTION TO REDUCE EARLY STENT‐RELATED COMPLICATIONS BASED ON CHARACTERISTICS

We previously reported a low occlusion rate with covered Wallstents for malignant biliary obstruction, but stent-related complications other than occlusion posed a problem. A modified covered Wallstent insertion method based on stent characteristics was evaluated to reduce stent-related complications. A total of 138 patients with distal malignant biliary obstruction received covered Wallstent placement. From October 2001 to October 2003, 69 patients received covered Wallstent placement (Group 1). Thereafter, we modified our stent insertion method and 69 patients received stent placement using this modified method from November 2003 to January 2007 (Group 2). The modified insertion method consists of endoscopic sphincterotomy carried out in patients without pancreatic duct invasion and longer stent placement with the center of the stent located in the center of the biliary stricture to prevent pancreatitis, kinking of the bile duct, and stent dislocation. A comparative analysis was carried out using prospectively collected data in these two cohorts. Tumor ingrowth was not observed, and stent occlusion rate was 18.8% in Group 1 and 23.2% in Group 2. The overall rates of stent-related complications did not differ (39.1% in Group 1 and 30.4% in Group 2), but stent-related complications within 3months decreased from 22 episodes in Group 1 to 13 episodes in Group 2. Median event-free survival was prolonged by modified stent insertion method (125days in Group 1 and 268days in Group 2, P=0.020), although cumulative survival and stent patency were not significantly different. Our modified method of covered Wallstent placement showed improved event-free survival.

Outcome Analysis of Urethral Wall Stent Insertion With Artificial Urinary Sphincter Placement for Severe Recurrent Bladder Neck Contracture Following Radical Prostatectomy

We present outcome and quality of life analyses for the treatment of post-radical prostatectomy bladder neck contracture with urethral wall stent insertion and subsequent artificial urinary sphincter placement. A retrospective analysis from June 2001 to September 2007 identified 25 consecutive men who underwent urethral wall stent placement for severe, recurrent bladder neck contracture despite aggressive transurethral resection after radical prostatectomy. Assessment of symptoms and quality of life impact from urinary incontinence was conducted with a self-administered, standardized questionnaire. Nonparametric testing was used for comparing covariates among groups. Univariate Cox proportional hazards modeling was used to assess predictors of treatment failure. P values are double-sided and are considered statistically significant if </=0.05. Etiology of recurrent bladder neck contracture was radical prostatectomy in all patients. Concurrent severe stress incontinence before treatment of bladder neck contracture was noted in 23 of 25 patients (92%). Before urethral wall stent insertion a median of 3 (IQR 2 to 5) failed endoscopic treatments were performed. Bladder neck contracture stabilization with insertion of 1 urethral wall stent was noted in 13 of 25 (52%) patients with a median followup of 2.9 years from last urethral wall stent insertion. Multiple urethral wall stent insertions (range 2 to 4) salvaged an additional 6 of 25 (24%) patients and failure to obtain patency was observed in 6 of 25 (24%). All patients responded to the questionnaire and quality of life improvement was noted in 23 of 25 patients (92%). Urethral wall stent and delayed artificial urinary sphincter placement for treatment of severe, recurrent bladder neck contracture and incontinence after radical prostatectomy is associated with improvement in quality of life. Long-term followup is required to further delineate the efficacy of this treatment approach.

A Case of Merkel Cell Carcinoma Metastasis to the Head and the Body of the Pancreas

Merkel cell carcinoma (MCC) is a rare, cutaneous, malignant tumor of neuroendocrine cells. It has a high propensity for local recurrence and regional lymph node metastasis. Thus far, only two cases of MCC with metastasis to the pancreas have been reported in the scientific literature. Here we present the case of a 65-year-old male who presented with abdominal pain of gradually increasing severity over the past two weeks accompanied by jaundice, lower back pain and non-bloody vomiting. He had been diagnosed with MCC of the right gluteal mass 10 months prior with subsequent excision, radiation and chemotherapy. On current admission, computed tomography revealed two masses on the pancreas. After dual sphinctetomies of the bile duct and pancreatic duct, and covered wall stent placement, presenting symptoms resolved and continued radiation and chemotherapy prescribed. This case illustrates the possibility of metastisis of MCC to the pancreas even with excision, ration therapy, and chemotherapy of the primary site.

Malignant Gastroduodenal Obstruction: Treatment with Self-Expanding Uncovered Wallstent

To retrospectively evaluate the clinical effectiveness of a self-expanding uncovered Wallstent in patients with malignant gastroduodenal obstruction. Under combined endoscopic and fluoroscopic guidance, 29 patients with a malignant gastroduodenal stenosis were treated with a self-expanding uncovered metallic Wallstent. A dysphagia score was assessed before and after the intervention to measure the success of this palliative therapy. The dysphagia score ranged between grade 0 to grade 4: grade 0 = able to tolerate solid food, grade 1 = able to tolerate soft food, grade 2 = able to tolerate thick liquids, grade 3 = able to tolerate water or clear fluids, and grade 4 = unable to tolerate anything perorally. Stent patency and patients survival rates were calculated. The insertion of the gastroduodenal stent was technically successful in 28 patients (96.5%). After stenting, 25 patients (86.2%) showed clinical improvement by at least one score point. During follow-up, 22 (78.5%) of 28 patients showed no stent occlusion until death and did not have to undergo any further intervention. In six patients (20.6%), all of whom were treated with secondary stent insertions, occlusion with tumor ingrowth and/or overgrowth was observed after the intervention. The median period of primary stent patency in our study was 240 days. Placement of an uncovered Wallstent is clinically effective in patients with malignant gastroduodenal obstruction. Stent placement is associated with high technical success, good palliation effect, and high durability of stent function.

Treatment of gastric outlet and duodenal obstructions with uncovered expandable metal stents

To investigate and evaluate the technical feasibility and clinical effectiveness of fluoroscopically guided peroral uncovered expandable metal stent placement to treat gastric outlet and duodenal obstructions. Fifteen consecutive patients underwent peroral placement of Wallstent(TM) Enteral Endoprosthesis to treat gastric outlet and duodenal obstructions (14 malignant, 1 benign). All procedures were completed under fluoroscopic guidance without endoscopic assistance. Follow-up was completed until the patients died or were lost, and the clinical outcomes were analyzed. The technique success rate was 100%, and the oral intake was maintained in 12 of 14 patients varying from 7 d to 270 d. Two patients remained unable to resume oral intake, although their stents were proven to be patent with the barium study. One patient with acute necrotizing pancreatitis underwent enteral stenting to treat intestinal obstruction, and nausea and vomiting disappeared. Ten patients died during the follow-up period, and their mean oral intake time was 50 d. No procedure-related complications occurred. Stent migration to the gastric antrum occurred in one patient 1 year after the procedure, a tumor grew at the proximal end of the stent in another patient 38 d post-stent insertion. Fluoroscopically guided peroral metal stent implantation is a safe and effective method to treat malignant gastrointestinal obstructions, and complications can be ignored based on our short-term study. Indications for this procedure should be discreetly considered because a few patients may not benefit from gastrointestinal insertion, but some benign gastrointestinal obstructions can be treated using this procedure.

Carotid Artery Stenting with Distal Protection Using the Carotid Wallstent and Filterwire Neuroprotection: Single-Center Experience of 380 Cases with Midterm Outcomes

Emerging data have supported the clinical efficacy of carotid artery stenting (CAS) in stroke prevention in high-risk surgical patients. This study was performed to evaluate the midterm clinical outcome of CAS using the Carotid Wallstent and FilterWire distal protection (both Boston Scientific, Natick, MA) at an academic institution. Risk factors for in-stent restenosis (ISR) were also analyzed. Clinical variables and treatment outcome of high-risk patients who underwent Carotid Wallstent placement with FilterWire EX/EZ neuroprotection were analyzed during a recent 54-month period. Three hundred eighty CAS procedures were performed in 354 patients. Technical success was achieved in 372 cases (98%), and symptomatic lesions existed in 85 (24%) patients. No patient experienced periprocedural mortality or neuroprotective device-related complication. The 30-day stroke and death rate was 2.7%, and the overall complication rate was 6.9%. The overall major or fatal stroke rates in symptomatic and asymptomatic patients were 4.6% and 1.3%, respectively (not significant). The overall stroke and death rates between the symptomatic and asymptomatic groups were 5.8% and 2.4%, respectively (not significant). The median follow-up period was 29 months (range 1-53 months). With Kaplan-Meier analysis, the rates of freedom from 60% or greater ISR after CAS procedures at 12, 24, 36, and 48 months were 97%, 94%, 92%, and 90%, respectively. The rates of freedom from all fatal and nonfatal strokes at 12, 24, 36, and 48 months were 97%, 91%, 89%, and 85%, respectively. Multivariable analysis of significant univariate predictors identified that postendarterectomy stenosis (odds ratio [OR] 3.98, p = .02) and multiple stent placement (OR 3.68, p = .03) were independent predictors of ISR. Our study yielded favorable short-term and midterm clinical results using Carotid Wallstent with FilterWire neuroprotection. Late follow-up results showed low rates of fatal and nonfatal stroke and favorable ISR rates compared with other carotid stent trials. Postendarterectomy and multiple stent placement were associated with subsequent ISR.

Use of an Ultrathin Gastroscope to Allow Endoscopic Insertion of Enteral Wallstents Without Fluoroscopic Monitoring

Self-expanding metallic stents are useful in relieving tumoral obstruction in the gastrointestinal tract. Endoscopic insertion is usually made through the working channel of a therapeutic endoscope. Fluoroscopy during insertion is thought to be mandatory in most cases. Endoscopists sometimes encounter problems in using or accessing fluoroscopy facilities. This study describes a method to insert, under certain circumstances, enteral Wallstents using only endoscopic control. An ultrathin gastroscope is used to pass severe tumoral strictures and place a guide wire beyond the stenosis. The ultrathin gastroscope is removed leaving the guide wire in place, which is then inserted in a retrograde fashion into a therapeutic colonoscope, allowing insertion of through-the-scope stents. Successful insertion was achieved in 5 malignant gastric outlet obstructions and in 6 rectosigmoid tumoral obstructions. In conclusion, in some cases using an ultrathin endoscope to place a guide wire beyond the stricture can be useful for endoscopic placement of Wallstents without fluoroscopy.

Ureteropelvic junction obstruction: an innovative approach combining metallic stenting and virtual endoscopy.

We report our experience with auto-expandable metallic stents for treating ureteropelvic junction obstruction. We treated 4 patients with a mean age of 45 years who had ureteropelvic junction obstruction with placement of a self-expandable intraureteral metallic stent (Wallstent, Schneider, Zurich, Switzerland). All patients presented with recurrent ureteropelvic junction obstruction after open pyeloplasty. Excretory urography and 3-dimensional reconstruction computerized tomography were performed 1 and 6 months after stent insertion. Virtual endoscopy images were obtained at followup due to the need to define ureteral patency. Mean followup was 16 months (range 9 to 24). Wallstent placement was successful and immediate patency was achieved in all cases. During followup 3 patients required no further intervention and the stented ureteropelvic junction remained patent. In the remaining patient stricture recurred 2 months after initial stent insertion due to the ingrowth of scar tissue through the prosthesis. Additional intervention was deemed necessary after placing a longer 6 cm., completely coaxial overlapping metal stent. Virtual endoscopy and excretory urography findings concurred. Virtual endoscopy allows visualization of the stented ureteropelvic junction lumen cephalad and caudal to the prosthesis. It also enables easy navigation within the stent at different angles of view. The concept of applying metallic stents for ureteropelvic junction obstruction and adjacent adynamic ureteral segments combined with virtual endoscopy is strengthened by the results of this study.

Cerebral microembolization after protected carotid artery stenting in surgical high-risk patients: Results of a 2-year prospective study

This was a prospective single-center study to assess and analyze cerebral embolization resulting from carotid artery stenting with neuroprotective filter devices in patients considered as poor surgical candidates for surgical carotid endarterectomy. Fifty-three consecutive patients with an internal carotid artery stenosis were treated by placement of carotid Wallstents with two different types of temporary distal filter protection devices: the Spider filter and the FilterWire. Diffusion-weighted magnetic resonance imaging (DWI) of the brain was obtained 24 hours before the procedure and within 5 to 30 hours after the procedure to detect ischemic brain lesions resulting from the procedure. Inclusion criteria were symptomatic (> or =70%) or asymptomatic (> or =80%) stenoses in surgical high-risk patients. Two (4%) regressive minor strokes occurred. Postprocedural DWI detected new focal ischemic lesions in 21 patients (40%). The average number of lesions was 5.9 per patient, and the mean lesion volume was 1 mL or less in 19 patients (90%). Small differences were found in the lesion distribution: homolateral anterior circulation in eight cases (15.1%), other vascular territories in seven cases (13.2%), and homolateral anterior circulation plus other vascular territories in six cases (11.3%). The microembolization risk seemed nonpredictable on the basis of clinical parameters and internal carotid artery lesion characteristics. An increased risk in the rate of ipsilateral hemispheric embolization has been observed in difficult carotid arch implantations (P = .04). The incidence of new focal ischemic lesions detected by DWI is higher than expected on the basis of previous reports. Embolization from the aortic arch or common carotid arteries could account for most of those events in patients considered as surgical high-risk patients. Although 90% of the events were clinically silent, this high rate of microembolization raises questions about the possible consequences on cerebral cognitive functions.

Efficacy and safety of the covered Wallstent in patients with distal malignant biliary obstruction

The aim of this study was to evaluate the efficacy and the safety of the covered Wallstent, a commercially available silicone-covered, self-expandable metallic stent (covered Wallstent), for the treatment of distal malignant biliary obstruction. Sixty-nine consecutive patients with unresectable distal malignant biliary obstruction who underwent covered Wallstent placement between October 2001 and October 2003 were studied at 4 affiliated hospitals. Mean stent patency and mean survival were 139.1 days and 200.9 days, respectively. Stent occlusion occurred in 7 cases (10.1%), but tumor ingrowth was not observed. Seventeen complications, including 5 cholangitis (7.2%), 4 stent migration (5.8%), 4 cholecystitis (5.8%), and 4 pancreatitis (5.8%) were observed in 16 patients (23.2%). Stent misplacement was observed in 7 patients (10.1%). Covered Wallstent is effective in preventing tumor ingrowth for the treatment of distal malignant biliary obstruction. However, the overall complication rate may be higher than uncovered self-expanding metal stents and covered self-expanding metal stents of different design.

Stent Migration Complicating Treatment of Inferior Vena Cava Stenosis after Orthotopic Liver Transplantation

A case of inferior vena cava (IVC) stenosis after orthotopic liver transplantation was treated with balloon angioplasty and Wallstent placement. There was stent migration into the right atrium (RA), and percutaneous removal of the stent was attempted without success. Open cardiac surgery was required for stent removal and repair of aortic/RA fistula. Months later, recurrent IVC stenosis was successfully treated with placement of large Z stents after additional failed surgical repair. At 2 years follow-up, the patient is asymptomatic and Doppler ultrasonography demonstrated the stent to be patent and well-positioned.

Prospective Evaluation of On-Site FNA Cytology Analysis vs Final Cytology Analysis in EUS Cases

OBJECTIVES: On-site cytopathologic interpretation of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has been shown to improve the adequacy of tissue obtained. The preliminary diagnosis made within the endoscopy suite can guide therapeutic interventions such as celiac plexus block or biliary wall stent placement in the setting of pancreatic adenocarcinoma. No study to date has evaluated the reliability of a preliminary cytologic diagnosis. Our goal was to compare the on-site and final diagnoses of individual EUS-FNA samples. METHODS: Consecutive patients who underwent EUS- FNA were prospectively evaluated. All samples were prepared by a cytotechnologist using the Diff-Quick staining technique and a preliminary diagnosis, made by a cytopathologist, was recorded. Cytologic diagnoses were classified as unsatisfactory, negative, atypical, suspicious, or positive for malignancy. A final diagnosis was made after complete evaluation of all tissue obtained. Minor discrepancies were defined as a one step change in diagnosis (i.e. atypical to suspicious) while major discrepancies were defined as a two step change in diagnosis (i.e. atypical to positive). RESULTS: EUS-FNA of 29 lesions in 20 patients was performed without complications. This included 16 lymph nodes, 10 pancreatic lesions, 2 adrenal lesions, and 1 submucosal rectal lesion. Overall agreement of on-site diagnoses vs. final diagnoses was 55% (16/29). Agreement of lymph node diagnoses was 62.5% (10/16). 4 lymph nodes originally classified as unsatisfactory were changed to either negative or positive for malignancy after review of the cell block from the needle rinse. Agreement of pancreatic lesion diagnoses was 40% (4/10). Three patients overall had major discrepancies between the on-site and final diagnoses. CONCLUSION: In this pilot study, the on-site diagnosis often differed from the final diagnosis. While most were minor discrepancies, there were a few significant differences. This would suggest that the decision to perform irreversible endoscopic therapy should be based on the final diagnosis.

Ultraflex stents for the management of airway complications in lung transplant recipients

Respirology 2003;8:59–64. Chhajed PN, Malouf MA, Tamm M, Glanville AR. Comments: In this study, Chhajed and coworkers report their experience with the use of an uncovered Ultraflex (nitinol) stent in the management of airway stenosis in 9 lung transplant recipients. The indications for stent placement were stenosis of the large airway in 4 patients, combined stenosis and bronchomalacia in 3 patients, and tracheomalacia and bronchomalacia in 1 patient each. A total of 11 stents were deployed in 9 patients. Stents were placed using a flexible bronchoscope with fluoroscopy guidance under conscious sedation. Proximal release stents were used in 6 patients and distal release stents in 3 patients. The mean ± standard deviation increase in forced expiratory volume in 1 second (FEV1) after insertion of the procedure was 522 ± 391 mL (range, 120–1150 mL). Successful stent deployment led to improvement in dyspnea in all patients. In 2 patients, initial placement of the stent was unsatisfactory as a result of proximal displacement of the stent delivery device. This problem occurred with the proximal release stent delivery device in both cases. Stricture resulting from excessive growth of granulation tissue formed in 1 patient, and it was treated with balloon dilatation and laser resection. Stent migrated in 1 patient from its original position, and it had to be removed. No patient developed stenosis at the stent extremities or mucus plugging during the follow-up period of 263 ± 278 days after the procedure. Airway complications are common after lung transplantation. Common complications include anastomotic stenosis, bronchomalacia, or a combination of stenosis and malacia, granulation tissue, and anastomosis dehiscence. The majority of patients with symptomatic airway stenosis after lung transplantation require interventional bronchoscopic treatment (Chest 2001;120:1894–9). The choice of treatment depends on endoscopic findings. For stenosis, balloon dilatation is the first-line treatment. However, despite its high initial success, the majority of patients eventually require airway stent as a result of recurrence of stenosis or as a result of development of bronchomalacia. There is no single ideal stent for this purpose. Recent reports indicate successful deployment of self-expandable metal stents in these patients. Uncovered wall stents have been considered more suitable than prior designs of metallic stents (such as Gianturco and Palmaz stents) for this purpose. However, in a prior study, Chhajed and coworkers reported granulation tissue and mucus plugging in 27% patients each after placement of uncovered wall stents in lung transplant recipients (Chest 2001;120:1894–9). The present study by Chhajed and coworkers suggests that the Ultraflex stent could be better than uncovered wall stents for managing airway stenosis after lung transplantation as a result of the very low risk of secretion accumulation, mucus plugging, and development of granulation tissue at the ends of the stent. Although the sample size was small, the results indicate that the Ultraflex stent is presently the most useful metal stent for management of airway stenosis in lung transplant recipients.