Treatment of peripheral arterial diseases may be distinguished into conservative and interventional management; the latter is divided into surgical and endovascular procedures. Management of peripheral artery stenosis and occlusion with vascular stents is associated with the risk of late complications such as restenosis, stent fracture or dislocation.
A 62-year-old woman with generalized atherosclerosis, particularly extensive in lower limb arteries, was admitted to the Department of Angiology 11 months after having an endovascular procedure performed due to critical ischemia of left lower limb. Because of stent occlusion, a decision to perform angiographic examination of lower limb arteries was made. Examination revealed occlusion of the superficial femoral artery along its entire length, including previously implanted stents. Distal stent was fractured with slight dislocation of the proximal segment. A decision was made to perform mechanical thrombectomy using a Rotarex system followed by a stent-in-stent placement procedure. Follow-up angiography and ultrasound scan performed 24 hours after the procedure revealed a patent vessel with satisfactory blood flow.
Nowadays, imaging diagnostics of peripheral artery stenosis involves non-invasive examinations such as ultrasound, minimally invasive examinations such as angio-MRI and MDCT, or invasive examinations such as DSA and IVUS. DSA examinations are used to confirm significant stenosis or occlusion of a vessel, particularly when qualifying a patient for endovascular treatment. Due to their anatomic location, the superficial femoral artery and the popliteal artery are subject to various forces e.g. those exerted by the working muscles. Mechanical thrombectomy and atherectomy are efficient methods of arterial recanalization used in the treatment of acute, subacute or even chronic occlusions or stenosis of peripheral vessels.
Frequency of angioplasty and vascular stent implantation procedures is increased in patients with peripheral arterial disease, thus increasing the incidence of reported early and late complications such as acute stent thrombosis, restenosis and stent fractures. The Rotarex transcutaneous mechanical thrombectomy system is an efficient method of treating occlusions in arterial stents. It is also safe when performed by experienced operators.
stent fracture; mechanical thrombectomy; femoral artery occlusion
In this study, we retrospectively reviewed 36 cases that required surgical treatment in the femoropopliteal regions (46 regions) because of the development of obstructions after stent placement in these patients. Of the 46, stents were placed in 37 involved regions (80.4%) that included the common femoral and popliteal arteries; such as the common femoral, entire length of superficial femoral, or popliteal arteries, and the anastomosis site created during femoropopliteal (prosthetic graft) bypass surgeries (Group A). In contrast, 9 involved regions (19.6%) did not include the common femoral or popliteal arteries; the stents were primarily localized in the superficial femoral artery (Group B). Symptoms of stent occlusion were more severe in the former group of patients, who subsequently required peripheral artery bypass surgery. These results indicate that placement of stents in the common femoral artery and popliteal arteries should be avoided. (*English translation of J Jpn Coll Angiol 2012; 52: 19-23)
peripheral arterial disease; stent occlusion; stent fracture; endovascular treatment; femoropopliteal artery
A 55-year-old male patient presented with an acute myocardial infarction. A sirolimus-eluting stent (SES) was implanted in the proximal left anterior descending artery (LAD). Eight months later, there was a newly developed distal LAD lesion. An additional SES was implanted. Twenty-eight months after the index procedure of primary coronary intervention, the electrocardiogram showed ST elevation in the precordial leads and an emergency coronary angiogram showed diffuse stent thrombosis (ST) in the proximal LAD. Thirty-four months after the index procedure, coronary angiography showed a large peri-stent coronary aneurysm in the proximal LAD and focal in-stent restenosis (ISR) at the proximal edge of the distal LAD stent. On fluoroscopy, a fracture was noted in the middle part of the distal SES. A zotarolimus- eluting stent (ZES) was deployed and overlapped the restenosis and fracture sites. Forty months after the index procedure, there were no changes in the size of the aneurysm or in the other stent complications including the fracture and restenosis. At present, the patient has remained asymptomatic for eight months.
Percutaneous transluminal coronary augioplasty; Drug-eluting stents
Neointimal hyperplasia is a major complication of endovascular stent placement with consequent in-stent restenosis or occlusion. Improvements in the biocompatibility of stent designs could reduce stent-associated thrombosis and in-stent restenosis. We hypothesised that the use of a diamond-like carbon (DLC)-coated nitinol stent or a polyethylene glycol (PEG)-DLC-coated nitinol stent could reduce the formation of neointimal hyperplasia, thereby improving stent patency with improved biocompatibility.
A total of 24 stents were implanted, under general anaesthesia, into the iliac arteries of six dogs (four stents in each dog) using the carotid artery approach. The experimental study dogs were divided into three groups: the uncoated nitinol stent group (n = 8), the DLC-nitinol stent group (n = 8) and the PEG-DLC-nitinol stent group (n = 8).
The mean percentage of neointimal hyperplasia was significantly less in the DLC-nitinol stent group (26.7±7.6%) than in the nitinol stent group (40.0±20.3%) (p = 0.021). However, the mean percentage of neointimal hyperplasia was significantly greater in the PEG-DLC-nitinol stent group (58.7±24.7%) than in the nitinol stent group (40.0±20.3%) (p = 0.01).
Our findings indicate that DLC-coated nitinol stents might induce less neointimal hyperplasia than conventional nitinol stents following implantation in a canine iliac artery model; however, the DLC-coated nitinol stent surface when reformed with PEG induces more neointimal hyperplasia than either a conventional or DLC-coated nitinol stent.
A bare-metal stent fracture as a cause of acute coronary thrombosis and consequently of acute coronary syndrome is a rare clinical event that, to the best of our knowledge, has previously not been reported. A stent fracture is a rare complication arising from percutaneous coronary intervention.
We present, to the best of our knowledge, the first documented case of ST-segment elevation myocardial infarction in a patient following a late bare-metal stent fracture and thrombosis in a native coronary artery. The patient, a 51-year-old Caucasian man, was treated successfully with primary percutaneous coronary intervention and a new stent implantation.
A coronary stent fracture is a rare complication that has been described in venous bypass grafts deploying either a drug-eluting stent or a bare-metal stent. Stent fractures rarely occur in coronary arteries. In light of the non-specific presentation of stent fracture, it is also an easily missed complication. Patients may present with a non-specific symptom of angina. The angina could either be stable or unstable as a result of restenosis or in-stent thrombosis, or both. Our case demonstrates the most severe consequences of a bare-metal stent fracture (sudden coronary thrombosis and subsequent myocardial infarction) in a native coronary artery. It was diagnosed angiographically and treated early and effectively.
We present a case in which endovascular stenting was used for recurrent proximal para-anastomotic stenosis 11 years after aorto-bi-iliac bypass grafting for severe aortoiliac occlusive disease. A 55-year-old woman presented with worsening bilateral hip and buttock claudication. At presentation, her resting ankle-brachial indices were 0.87 bilaterally and decreased to 0.39 on the right and 0.40 on the left with exercise. Aortography demonstrated a proximal para-anastomotic aortic graft stenosis without distal outflow obstruction, patent superficial femoral arteries, and good triple-vessel runoff bilaterally.
The stenosis was dilated with a 9- × 4-cm OPTA balloon angioplasty catheter. A Palmaz stent (P424, Cordis) was mounted on a 10- × 4-cm OPTA balloon catheter and deployed across the proximal stenosis. Completion arteriography confirmed adequate placement and reduction in the degree of stenosis. There was no pressure gradient across the proximal anastomosis. At our patient's 1-week follow-up visit, her resting ankle-brachial indices were both greater than 1.0 and her exercise ankle-brachial indices were 1.0 bilaterally. She remained asymptomatic at 13 months.
Most late sequelae of aortic graft surgery involve the distal anastomosis and are resolved surgically without complicated techniques. However, revision at the proximal anastomosis involves the aorta directly and therefore requires open abdominal dissection and aortic cross-clamping. Percutaneous aortic stenting for primary aortoiliac disease has been shown to reduce operative time, cost, and hospital stays, to improve patency, and to be durable. Our clinical experience with aortic stenting for primary disease led us to consider this procedure for recurrent proximal stenosis. (Tex Heart Inst J 2002;29:45–7)
Angioplasty, balloon; aorta, abdominal; aortic diseases/therapy; arteriosclerosis/therapy; case report; female; graft occlusion, vascular/therapy; middle age; stents; vascular patency
Coronary stent fractures have been suggested as a potential new mechanism of restenosis. The mechanical properties of stents were designed not only to prevent vessel recoil, but also to resist the mechanical stress of vessel movement over millions of cardiac cycles. We present a case in which mechanical stress may have contributed to the fracture of a stent implanted in a saphenous vein graft (SVG) to the left coronary artery. The patient was admitted due to chest pain 2 years after receiving a coronary artery bypass graft. A coronary angiography revealed the culprit vessel to be the SVG to the left coronary artery. The graft was stenosed and was stented with a sirolimus-eluting stent. A 6-month follow-up coronary angiography revealed 80% in-stent restenosis with stent fracture. We re-intervened by balloon angioplasty. This is the first report of sirolimus-eluting stent fracture combined with restenosis of SVG in Korea.
Drug-eluting stents; Coronary artery bypass grafting
A stent fracture is an emerging complication of the coronary stents. There are numerous risk factors for stent fractures; which include forceful exaggerated motion in the atrioventricular groove seen in right coronary artery, long stent, an ostial lesion at the point of maximum curvature in a tortuous vessel, stent over-expansion, stent overlapping with different size stents, complex lesion after stenting of a totally occluded vessel, Cypher stent and a highly mobile segment causing high mechanical stress. Furthermore, chronic stretch at specific vessel sites as bends may lead to late occurrence of fracture.
Here we report a case of 40-year-old male who had two overlapping Cypher stents (3.0 × 13 mm and 2.75 × 18 mm) deployed at mid left anterior descending artery 2 years earlier presented with progressive chest pain.
Stent fracture; Coronary artery disease; Drug eluting stent; Sirolimus-eluting stent
The antiphospholipid syndrome (APS) is a common cause of both arterial and venous thrombosis. While studies exist demonstrating the role of APS in coronary artery bypass graft failure, its role in stent thrombosis is less clearly documented. Also, a literature search of PubMed did not reveal any articles regarding the coexistence of clopidogrel resistance and APS despite increasing awareness of resistance to clopidogrel treatment. We present a case of a 59-year-old male having recurrent myocardial infarction after subacute restenosis of multiple drug-eluting stents despite anticoagulant therapy. The patient had in-stent thrombosis of seven drug-eluting stents in a course of eight days. He was subsequently found to have mild elevation of IgG anticardiolipin (aCL) antibody titers and resistance to clopidogrel. Long-term anticoagulation with a combination of low-molecular-weight heparin, clopidogrel, and aspirin has been effective. While the patient's aCL titer level was not elevated above the level required by the current diagnostic criteria for APS, we believe that this patient suffers from the antiphospholipid syndrome. We will discuss some of the controversies surrounding the diagnosis of APS as well as appropriate treatment and recognition of the coexistence of APS and clopidogrel resistance in patients with stent thrombosis.
Drug-eluting stents were developed and approved for the reduction of in-stent restenosis. However, restenosis still occurs, and stent fracture is suggested as a cause of restenosis after implantation. Although sirolimus-eluting stents are considered to carry a high risk of fracture, the risk is also present with other drug-eluting stents. Herein, we report the case of a 78-year-old woman who received a zotarolimus-eluting stent for a bifurcation lesion of the left anterior descending coronary artery. Ten months later, she underwent coronary angiography due to angina. The angiogram revealed in-stent restenosis, with a grade IV stent fracture. After percutaneous coronary angioplasty, the patient's clinical symptoms improved.
Blood vessel prosthesis implantation/instrumentation; coronary restenosis/diagnosis/etiology/prevention & control; drug-eluting stents; drug implants/adverse effects; prosthesis failure; retreatment; stents/adverse effects
The combination of Trans-Atlantic Intersociety Consensus (TASC) D aortoiliac occlusive disease as well as a symptomatic abdominal aortic aneurysm (AAA) is not a common occurrence. Extensive calcified atherosclerotic disease, occlusions, and small iliofemoral segmental arteries make transfemoral access difficult, if not impossible, for endovascular aneurysm repair (EVAR) in these patients. We present a case in which “controlled rupture” of the external iliac artery with a covered stent allowed transfemoral delivery of an aortouni-iliac stent graft with a completion femoral-to-femoral bypass. The patient is a 60-year-old male with a 5.3 cm symptomatic infrarenal AAA and a history of one block right leg claudication. Preoperative computed tomography angiography revealed the patient to have occlusion of the right common iliac artery, extensive calcified stenoses of his aortoiliac segments, and a prohibitively small left external iliac artery, which measured 4.5 mm at its narrowest diameter. The patient, despite discussions concerning the suitability of his iliac arteries as conduits for the delivery of the stent graft, insisted on an endovascular approach to lessen his chances of postoperative sexual dysfunction as well as minimize his length of stay. Access was obtained through bilateral femoral artery cutdowns, and attempts at dilating the left external iliac artery using 16-French dilators were performed without success. An 8 mm × 5 cm covered self-expanding stent was deployed in the diseased 4.5 mm left external iliac artery, followed by angioplasty performed with an 8 mm noncompliant balloon to disrupt the vessel. This endoconduit now allowed accommodation of our 18-French introducer for the aortouni-iliac stent graft. The operation was completed with a femoral—femoral bypass. Flow to both hypogastric arteries was preserved. We believe use of such techniques will ultimately expand the number of patients eligible for EVAR and avoid devastating access-related complications.
Circumferential stent fracture is extremely uncommon, and in rare cases, it can cause stent thrombosis. Recognizing stent fracture can be difficult on conventional fluoroscopy because of poor stent radiopacity. We found that StentBoost image acquisition yields improved visibility of stent struts, enabling the identification of stent fracture and the precise positioning of new stents over previously stented segments.
We report the case of a 50-year-old man who presented with acute myocardial infarction and subacute stent thrombosis a week after percutaneous transluminal coronary angioplasty and placement of a bare-metal stent. The new lesion was crossed with a guidewire, but multiple attempts to advance a balloon catheter were unsuccessful. Live StentBoost image acquisition revealed circumferential stent fracture into 2 separate sections, with abnormal angulation between the proximal and distal portions of the stent. With StentBoost guidance, the wire and balloon catheter were both easily manipulated to cross the lesion, and angioplasty and restenting were completed with good results.
StentBoost can be a useful adjunctive tool for the cardiac interventionist during complex percutaneous transluminal coronary angioplasty, and it was invaluable in this challenging situation. We discuss stent fracture and the benefits of using StentBoost in such situations.
Angioplasty, balloon, coronary/instrumentation; blood vessel prosthesis implantation; coronary restenosis/etiology/radiography; prosthesis failure; radiographic image enhancement/methods; radiographic image interpretation, computer-assisted/methods; stents; ultrasonography, interventional
The purpose of this study was to assess the preventive effect of cilostazol on in-stent restenosis in patients after superficial femoral artery (SFA) stent placement.
Materials and methods
Of 28 patients with peripheral arterial disease, who had successfully undergone stent implantation, 15 received cilostazol and 13 received ticlopidine. Primary patency rates were retrospectively analyzed by means of Kaplan–Meier survival curves, with differences between the two medication groups compared by log-rank test. A multivariate Cox proportional hazards model was applied to assess the effect of cilostazol versus ticlopidine on primary patency.
The cilostazol group had significantly better primary patency rates than the ticlopidine group. Cumulative primary patency rates at 12 and 24 months after stent placement were, respectively, 100% and 75% in the cilostazol group versus 39% and 30% in the ticlopidine group (P = 0.0073, log-rank test). In a multivariate Cox proportional hazards model with adjustment for potentially confounding factors, including history of diabetes, cumulative stent length, and poor runoff, patients receiving cilostazol had significantly reduced risk of restenosis (hazard ratio 5.4; P = 0.042).
This retrospective study showed that cilostazol significantly reduces in-stent stenosis after SFA stent placement compared with ticlopidine.
cilostazol; ticlopidine; stent; primary patency rate; peripheral arterial disease; superficial femoral artery
The use of endovascular stents has become widely established in maintaining both arterial and venous patency in congenital heart disease. Stent implantation is now applied to pulmonary arterial stenoses, coarctation, pulmonary and systemic venous obstruction, and obstructed homografts and conduits, in both the pediatric and adult populations. The purpose of this report is to describe 3 new applications of stent technology: 1) double pulmonary artery stent implantation with simultaneous balloon dilation of a previously placed stent; 2) a new technique for traversing tight pulmonary arterial corners for stent delivery using the “sheath-within-sheath” method; and 3) a new technique for recannulation and stent implantation in unilateral femoral venous occlusion.
Balloon dilatation; femoral vein; heart defects, congenital; pulmonary artery; stents
Percutaneous transluminal angioplasty +/− stent (PTA/S) and surgical bypass are both accepted treatments for claudication due to superficial femoral artery (SFA) occlusive disease. However, long-term results comparing these modalities for primary intervention in patients who have had no prior intervention has not been reported. We report our results with three year follow-up.
We reviewed all lower extremity bypass procedures at Beth Israel Deaconess Medical Center from 2001–2009 and all PTA/S performed from 2005 through 2009 for claudication. We excluded all limb salvage procedures and included only those that were undergoing their first intervention for claudication due to SFA disease. We recorded patient demographics, comorbidities, perioperative medications, TASC classification, and runoff. Outcomes included complications, restenosis, symptom recurrence, reinterventions, major amputation, and mortality.
We identified 113 bypass grafts and 105 PTA/S of femoral-popliteal lesions without prior interventions. Bypasses were above the knee in 62% (45% vein) and below the knee in 38% (100% vein). Mean age was 63 (bypass) vs. 69 (PTA/S) (P<.01). Mean length of stay (LOS) was 3.9 vs. 1.2 days (P<.01). Bypass grafts were used less for TASC A (17% vs. 40%, P<.01), and more for TASC C (36% vs. 11%, P<.01) and TASC D (13% vs. 3%, P<.01) lesions. There were no differences in perioperative (2% vs. 0%, NS) or 3 year mortality (9 vs. 8%, NS). Wound infection was higher with bypass (16% vs. 0%, P<.01). None involved grafts. Bypass showed improved freedom from restenosis (73% vs. 42% - 3 years, HR 0.4, 95% CI 0.23–0.71), symptom recurrence (70% and 36% at 3 years, HR 0.37, 95% CI 0.2–0.56), and freedom from symptoms at last follow-up (83% vs. 49%, (HR 0.18, 95% CI 0.08–0.40). There was no difference in freedom from reintervention (77% vs. 66% at 3 years, NS). Multivariable analysis of all patients showed that restenosis was predicted by PTA/S (HR 2.5, 95% CI 1.4–4.4) and TASC D (HR 3.7, 95% CI 3.5–9) lesions. Recurrence of symptoms was similarly predicted by PTA/S (HR 3.0, 95% CI 1.8–5) and TASC D lesions (HR 3.1, 95% CI 1.4–7). Statin use postoperatively was predictive of patency (HR 0.6 95% CI 0.35–0.97) and freedom from recurrent symptoms (HR 0.6 95% CI 0.36–0.93).
Surgical bypass for the primary treatment of claudication showed improved freedom from restenosis and symptom relief despite treatment of more extensive disease, but was associated with increased LOS and wound infection. Statins improved freedom from restenosis and symptom recurrence overall.
We report a case of acute limb ischaemia due to unusual upstream stent migration into the aorta 2 years after successful kissing stenting. Angiography showed a misplacement of both common iliac stent into the aorta, upstream migration with a fracture on the left external iliac stent into the iliac common artery, occlusion of the left iliac and femoral artery, dilatation of aortic bifurcation and stent separation on the right side. The patient underwent a successful axillo-bifemoral bypass graft. Vessel wall remodelling due to overestimation of stent size, aortic turbulence and rebound effect may explain this complication.
Stent migration; Stent obstruction; Kissing stenting complication
A 41-year-old African American woman presented with chest pain and was found to have non-ST segment elevation myocardial infarction with a peak cardiac troponin I of 28.5. Elective cardiac catheterization revealed a 70% ostial left anterior descending (LAD) artery stenosis. The patient underwent percutaneous coronary intervention and a sirolimus-eluting stent (Cypher, Miami, FL, 3.5 × 8 mm) was successfully deployed. Three years after stent implantation, the patient presented with recurrent angina. Repeat coronary angiography revealed a large aneurysm involving the proximal portion of the stent with a total occlusion at the mid to distal portion of the stent with collaterals to LAD from left circumflex artery. The patient underwent coronary artery bypass surgery with left internal mammary artery graft to LAD and ligation of LAD at its origin proximal to the aneurysm.
coronary artery aneurysm; coronary artery bypass; sirolimus-eluting stent; percutaneous coronary intervention
Background—The value of angioplasty in occluded coronary arteries is limited by a restenosis/reocclusion rate of 50-70%. In patients with subtotal occlusion, stent implantation has been shown to reduce clinical and angiographic restenosis. Retrospective observational studies have suggested that stenting could reduce restenosis in total occlusions. The value of sustained coronary patency on global and regional left ventricular function in this clinical setting has not been defined clearly.
Objectives—To assess the medium term effect of elective intracoronary stent deployment after successful percutaneous transluminal coronary angioplasty (PTCA) of an occluded coronary artery.
Methods—Sixty patients with a total coronary occlusion successfully treated by PTCA were randomised to receive an intracoronary stent or no stent. Patients underwent clinical and angiographic follow up at six months.
Results—Thirty patients received a stent (group A) and 30 were treated by angioplasty alone (group B), all with initial success. One patient in group B required repeat angioplasty with stenting at 24 hours and one patient died after 10 days. Angiographic follow up was available for 57 patients. This showed a significantly reduced reocclusion rate in group A compared with group B (7% v 29%, p < 0.01) and a tendency to a reduced restenosis rate (22% v 40%, p = 0.105) in patients with no reocclusion. Left ventricular function, both global and regional, improved in group A. Only the regional left ventricular function in the area supplied by the target coronary artery improved in group B. Recurrence of symptoms and clinical events such as repeat angioplasty, coronary artery bypass grafting, death or myocardial infarction tended to be reduced in group A (4 (13%) v 9 (30%)).
Conclusions—Intracoronary stent insertion is effective in reducing the rate of reocclusion and shows a trend towards reduced restenosis after opening of a total coronary occlusion by balloon angioplasty. Sustained patency of the target coronary artery is associated with improvement in global and regional left ventricular function.
Keywords: intracoronary stenting; total coronary occlusion; left ventricular function
We wanted to evaluate the status of self-expandable nitinol stents implanted in the P2 and P3 segments of the popliteal artery in Korean patients.
Materials and Methods
We retrospectively analyzed 189 consecutive patients who underwent endovascular treatment for stenoocclusive lesions in the femoropopliteal artery from July 2003 to March 2009, and 18 patients who underwent stent placement in popliteal arterial P2 and P3 segments were finally enrolled. Lesion patency was evaluated by ultrasound or CT angiography, and stent fracture was assessed by plain X-rays at 1, 3, 6 and 12 months and annually thereafter.
At the 1-month follow-up, stent fracture (Type 2) was seen in one limb (up to P3, 1 of 18, 6%) and it was identified in seven limbs at the 3-month follow-up (Type 2, Type 3, Type 4) (n = 1: up to P2; n = 6: P3). At the 6-month follow-up, one more fracture (Type 1) (up to P3) was noted. At the 1-year follow-up, there were no additional stent fractures. Just four limbs (up to P2) at the 2-year follow-up did not have stent fracture. The primary patency was 94%, 61% and 44% at 1, 3 and 6 months, respectively, and the group with stent implantation up to P3 had a higher fracture rate than that of the group that underwent stenting up to P2 (p < 0.05).
We suggest that stent placement up to the popliteal arterial P3 segment and over P2 in an Asian population can worsen the stent patency owing to stent fracture. It may be necessary to develop a stent design and structure for the Asian population that can resist the bending force in the knee joint.
Artery; Stent; Intervention; Fluoroscopy; Fracture; Angioplasty
We report the results of 26 patients who underwent stent deployment for chronic total occlusion of proximal subclavian artery. From January 1998 to October 2005, 26 patients (18 male; mean age, 62.7 years, range 22 to 83 years), 28 lesions, underwent 29 procedures of stenting for chronic total occlusion of the proximal subclavian artery. Twenty-three patients had symptoms of claudication in their arm, no patients had subclavian steal syndrome. A brachial approach was used in 2' procedures, a femoral approach was used in five procedures, and combined femoral-brachial approach was required in three procedures. Primary stent deployment was success in 24 lesions (85.7%), and secondary procedure was success in one patient, totally 25 lesions (89.3%) were successfully treated by stenting. Procedure related complication occurred in four cases, including stent migration without symptoms in two procedures, hemianopsia on next day in a case, and TIA on unclear reason in one case. Permanent morbidity rate is 3.4% in procedure. Target lesion re-treatment required in three lesions, caused by subacute thrombosis, in-stent-restenosis, and dissection of the vessel by stent edge. The cases of subacute thrombosis and in-stent-restenosis were treated by re-PTA, and the case of dissection was treated by additional stenting. Secondary patency was 100%.
We conclude that stenting for chronic total occlusion of subclavian arteries appears feasible and safe.
subclavian artery, chronic total occlusion, percutaneous transluminal angioplasty, stent
It is common to see patients with atherosclerotic coronary disease and peripheral arterial disease in routine clinical practice. One needs to have a comprehensive and integrated multi-speciality approach and panvascular revascularization in such patients. We report a 54-year-old diabetic hypertensive male with extensive atherosclerotic coronary and peripheral arterial disease, who presented with congestive heart failure, claudication of both lower limbs and mesenteric ischemia. He underwent successful percutaneous panvascular revascularization of coronary, renal, mesenteric, aorto-iliac and superficial femoral arteries. Long-term patency of all the stents was also documented.
Atherosclerosis; Aorto-iliac bifurcation; Coronary artery disease; Chronic mesenteric ischemia; Contrast induced nephropathy; C-reactive protein; Inferior mesenteric artery; Peripheral arterial disease; Stents
We report the results of stenting in 17 patients who underwent treatment for total occlusions in the subclavian arteries between July 1991 and December 1995. Fourteen of the lesions were located in the left side; 15 patients had a subclavian steal syndrome. The indications for treatment were vertebrobasilar insufficiency (n = 7); arm claudication (n = 5); vertebrobasilar insufficiency and upper-limb ischemia (n = 3); protection of a left internal mammary artery coronary bypass (n = 1); and an isolated subclavian steal syndrome (n = 1). A total of 23 stents were implanted in 17 patients; in 1 patient, 2 stents migrated during deployment, resulting in a 94% procedural success rate. One case of axillary thrombosis was successfully treated with local thrombolysis and balloon angioplasty. There were no postprocedural neurologic complications or deaths. Follow-up over a mean duration of 19.4 months (range, 4 to 56 months) revealed 1 asymptomatic restenosis at 5 months in a patient with 3 stents. Life-table analysis showed an 81% cumulative patency rate at 6 months. We conclude that stenting for occlusion of the subclavian arteries appears feasible and safe; however, further evaluation in a larger group of patients is needed to confirm these results.
OBJECTIVE--To assess the early and follow up results of implantation of a self expanding stent in aorto-ostial stenoses of vein grafts. DESIGN--Prospective, non-randomised, observational study. SETTING--Tertiary referral centre for cardiac diseases. PATIENTS--Nineteen patients with ostial stenoses of saphenous vein grafts. MAIN OUTCOME MEASURES AND RESULTS--Stents were successfully deployed in all 19 patients with satisfactory angiographic results. In one patient this required two attempts. There were no deaths and no major procedural complications related to ostial stenting. Before discharge two (11%) patients had thrombosis of the ostial stent; one patient had a Q wave myocardial infarction. Femoral artery bleeding occurred in three (16%) patients. Angiographic follow up was performed in 18 patients at a mean of seven months. Restenosis within the ostial stent was detected in three (16%) patients. Twelve (63%) patients had an improved functional status at a mean follow up of nine months. One patient died suddenly at three months. Three (16%) patients required additional revascularisation procedures because of symptoms caused by restenosis within the ostial stent during follow up. CONCLUSIONS--Intracoronary stenting is an attractive treatment for the management of patients with vein graft ostial stenoses.
Bare-metal stents are commonly used in the treatment of coronary artery disease. Stent thrombosis usually occurs within the first 48 hours after stent deployment. After a week, the incidence of thrombosis is low. Late stent thrombosis (after 30 days) is rarely seen; however, its clinical outcomes are severe 30-day mortality rates of 20% to 48% and myocardial infarction rates of 60% to 70%. Herein, we present the case and discuss the treatment of a patient who, after heavy exercise, experienced acute myocardial infarction due to late thrombosis in a bare-metal stent.
A 54-year-old man presented with unstable angina pectoris. Coronary angiography revealed critical occlusion of the middle right coronary artery. A bare-metal stent was implanted, and he was discharged from the hospital on a medical regimen. Eleven months later, he presented with acute myocardial infarction, which had developed after heavy exercise. Coronary angiography revealed occlusion of the stent in the right coronary artery. After the occlusion was crossed with a guidewire, balloon angioplasty was applied, and Thrombosis-in-Myocardial-Infarction (TIMI)-3 flow was restored. The patient was asymptomatic during his 5-day hospitalization and was discharged on dual antiplatelet therapy.
In addition to presenting this patient's case, we discuss mechanisms that may contribute to late stent thrombosis, implications of the condition, and preventive therapy.
Aspirin/administration & dosage/therapeutic use; blood vessel prosthesis implantation/adverse effects; coronary disease/therapy; coronary restenosis/etiology/pathology/prevention & control/therapy; coronary thrombosis/etiology/therapy; exercise/physiology; myocardial revascularization; platelet aggregation inhibitors/administration & dosage; postoperative complications/etiology; stents/adverse effects; treatment outcome
In-stent re-stenosis is a frequent complication of endovascular stents, especially in the superficial femoral artery (SFA). Endovascular re-intervention of in- or peri-stent occlusive disease consists of recanilization through the occluded stent. In our case report, we describe the endovascular treatment of a previously placed stent in the SFA. We unintentionally passed the affected stent subintimally, in a double barrel fashion next to the first stent. The procedure was without any complications and with a successfull angiographic result. At one year follow-up the patient still has no complaints and the stent is still patent.
Interventional radiology; Superficial femoral artery; Endovascular stenting; Reocclusion; PIER