Giant stentolith: A rare complication of long-dwelling biliary endoprosthesis

Endoscopic biliary stenting is performed for various indications in routine clinical practice. Plastic stents are indicated primarily for short-term biliary decompression and require removal or exchange after 12–16 weeks. However, patients who become asymptomatic after the procedure may not return for scheduled stent removal and subsequently present with severe complications. We herein present the case of a 57-year-old female who underwent biliary stenting after the endoscopic clearance of bile duct stones. Her symptoms resolved after the intervention, but she was lost to follow-up with the stent remaining in situ. Four years later, she presented with pain in the right hypochondrium and experienced recurrent episodes of cholangitis. Magnetic resonance cholangiopancreatography revealed a retained plastic stent in the proximal bile duct with a large stone cast around the stent—a stentolith. Owing to the large stone size and proximal migration of the retained biliary stent, the patient required open surgical exploration for stentolith removal. Patients with forgotten biliary stents presenting with serious complications are not uncommon in India. Unaware of the complications of long-dwelling biliary stents, patients ignore the advice for the timely removal of biliary stents. Detailed patient counselling, education and documentation are essential to avoid this condition.     

Difficult removal of fully covered Self Expandable Metal Stents (SEMS) for benign biliary strictures: The “SEMS in SEMS” technique

BackgroundRemoval of biliary Fully Covered Self Expandable Metal Stents can fail due to stent migration and/or hyperplastic ingrowth/overgrowth.MethodsA case series of 5 patients with benign biliary strictures (2 post-cholecystectomy, 2 following liver transplantation and 1 related to chronic pancreatitis) is reported. The biliary stricture was treated by temporary insertion of Fully Covered Self Expandable Metal Stents. Stent removal failed due to proximal stent migration and/or overgrowth. Metal stent removal was attempted a few weeks after the insertion of another Fully Covered Metal Stent into the first one.ResultsThe inner Fully Covered Self Expandable Metal Stent compressed the hyperplastic tissue, leading to the extraction of both the stents in all cases. Two complications were reported as a result of the attempt to stents removal (mild pancreatitis and self-limited haemobilia).ConclusionIn the present series, the “SEMS in SEMS” technique revealed to be effective when difficulties are encountered during Fully Covered Self Expandable Metal Stents removal.     

腹主动脉瘤支架置入术后处理

目的探讨腹主动脉瘤支架植入术后的处理方法,提高治疗效果,减少并发症的发生。方法收集我院自2011年4月至2014年2月收治的腹主动脉瘤患者38例,分为对照组和观察组,各19例。均采用支架置入术,术后对照组给予常规的护理治疗方式,观察组在常规护理治疗的基础上给予科学的康复干预处理。1个月后观察比较两组的疗效。结果对照组14例患者术后康复良好,康复率73.7%,4例患者出现较重并发症,1例患者病情加重死亡;观察组18例患者康复良好,康复率94.7%,1例出现较重并发症,无死亡病例。结论观察组患者康复率94.7%明显高于对照组康复率73.7%,并发症少于对照组,得出腹主动脉瘤支架置入术后,给予科学的康复干预处理,可以有效的提高患者康复率,减短康复时间,并发症少,值得临床推广和应用。     

冠状动脉支架置入术1年随访LDL-C控制及他汀使用情况:与新指南的距离

目的分析冠状动脉支架置入术后1年随访时低密度脂蛋白胆固醇(LDL-C)控制及他汀使用情况,并与新指南对照。方法入选2010年9月至2012年12月在解放军第三〇六医院心血管内科行冠状动脉支架置入术患者539例,随访1年,收集复查资料,包括LDL-C水平及生化指标以及他汀类药物使用情况。结果治疗1年后,按2004年ACC/AHA血脂指南LDL-C水平,达标373例(69.2%),未达标166例(30.8%)。按2013年ACC/AHA新指南评价,LDL-C水平达标195例(36.1%),未达标344例(63.9%)。两种标准评价是否一致Kappa值为-0.047,P=0.178,两种标准比较存在明显统计学差异。他汀类药物治疗以阿托伐他汀(n=247,10 mg~80 mg)和瑞舒伐他汀(n=147,5 mg~20 mg)为主,其他还包括辛伐他汀(n=139,25.7%,10 mg~40 mg),氟伐他汀(n=2,40 mg),普伐他汀(n=4,40mg)。根据新指南中他汀类药物治疗强度,本研究中低强度降脂治疗21例(4.0%),中等强度512例(94.9%),高强度6例(1.1%),43例联合普罗布考治疗。结论按2013年新指南,冠状动脉支架置入术后他汀治疗1年,随访时多数患者LDL-C不达标,新指南是否适合中国人群需要进一步研究。     

Occurrence of longitudinal stent compression before stent deployment: Two case studies

Several recent reports have described the occurrence of longitudinal stent deformation(LSD, defined as the distortion or shortening of a stent along the longitudinal axis), following its successful deployment. However, few reports have described LSD prior to any stent deployment. This previously unrecognized complication is the result of modifications to stent design. It has been noted that the new-generation stent platforms have a reduced number of connectors, which in turn causes a reduction in longitudinal stent strength. To corroborate previous findings by our lab and others(Vijayvergiya et al, 2013), we describe here two cases of LSD prior to stent deployment that occurred due to crushing of the proximal stent edge by the guide catheter while attempting to withdraw the crimped stent. In addition, we discuss the associated risk factors, such as the length of the stent, and specific management strategies, including technical guidelines and use of fluoroscopic guidance for maneuvering the stent during the procedure.     

Allium覆膜金属输尿管支架长期留置治疗输尿管-回肠吻合口狭窄的初期临床经验及随访结果

目的: 总结长期留置Allium覆膜金属输尿管支架治疗根治性膀胱切除术后输尿管-回肠吻合口狭窄的初期临床经验及随访结果。方法: 2018年9月至2019年9月在北京大学人民医院及北京市大兴区人民医院收治的8例(10侧)根治性膀胱切除术后输尿管-回肠吻合口狭窄患者,均采用Allium覆膜金属输尿管支架长期留置的方式进行输尿管狭窄的治疗。收集患者术前肾脏B超下肾盂宽度评估肾积水、手术前后肌酐及尿素氮、围手术期是否出现全身感染等手术相关和支架管相关并发症。出院后第1、3、6、12个月和之后每年复查血肌酐、尿素氮、超声下肾盂宽度,并通过尿路造影及泌尿系腹部X线检查观察支架位置和形态有无变化。回顾患者的围手术期资料和随访资料,观察统计患者的支架长期通畅率、并发症发生率、肾功能变化和肾积水情况。使用t检验或者秩和检验比较术前-末次随访的配对样本计量资料。结果: 8例患者中有6例(7侧)输尿管-回肠流出道吻合口狭窄,2例(3侧)输尿管-回肠原位新膀胱吻合口狭窄。5例患者术前长期留置输尿管单J管,平均留置时间为(20.6±8.8)个月,平均更换频率为(3.6±1.3)个月/次。术前肾脏超声检查平均肾盂宽度为(26.5±9.1) mm。6例患者采用逆行置入方式成功留置Allium输尿管支架,2例患者采用双镜联合、顺逆行结合的方式成功置入支架;围手术期未出现手术相关并发症。患者平均随访9.8个月,所有患者在末次随访时均保持Allium支架和输尿管通畅,未进行过更换或移除;与术前相比,末次随访的平均肾盂宽度和平均尿素氮均显著降低[(26.5±9.1) mm vs. (13.4±2.5) mm,P=0.008;(11.6±2.3) mmol/L vs. (10.2±2.2) mmol/L,P=0.017)],而平均血肌酐和血红蛋白均无明显差异(P>0.05);未见输尿管再梗阻、支架管移位等支架管相关并发症。结论: Allium覆膜金属输尿管支架长期留置可用于治疗输尿管-回肠吻合口狭窄,可以保持相对长期的通畅率,有助于保护肾功能,提高患者生活质量。     

Combining Antiplatelet and Antithrombotic Therapy (Triple Therapy): What Are the Risks and Benefits?

Most patients with mechanical heart valves and many patients with atrial fibrillation will require long-term anticoagulation therapy. For patients with mechanical prosthetic valves, only warfarin is indicated. However, for patients with nonvalvular atrial fibrillation who are at increased risk for embolic stroke, one of the newer antithrombotic medications, such as rivaroxaban, dabigatran, and apixaban, also can be used. Patients with indications for antithrombotic therapy often will have coexisting vascular disease, such as coronary artery disease, requiring concomitant antiplatelet therapy with aspirin alone or more commonly with a dual antiplatelet regimen, aspirin and clopidogrel, or prasugrel or ticagrelor. The risks and benefits of this approach are still not well defined, and current guidelines have included recommendations based primarily on expert opinion.     

Role of prophylactic filter placement in the endovascular treatment of symptomatic thrombosis in the central veins

Objectives

To evaluate the role of filter implantation in reducing the incidence of fatal pulmonary embolism during the endovascular treatment of thrombosis in the major tributary of the superior vena cava (SVC).

Methods

From October 2004 to October 2008, we conducted a cohort study of 40 patients with thrombosis of the central veins who were preparing for endovascular interventions and received or did not receive filter. The symptom scores were measured, the incidence of pulmonary embolism (PE) was observed, and patient follow-up studies were conducted for three years.

Results

One week after therapy, the symptom score improved in both groups compared with before therapy (P < 0.001), but no significant difference was found between the scores of the two groups (P > 0.05). Four patients in the control group died from PEs after therapy, but no patients in the filter group presented evidence of PE. The survival rates at 1, 2, and 3 years (72.9%, 50%, and 27.1%, respectively) for the filter group were higher than those for the control group (47.6%, 19.0% and 14.3%, respectively; P = 0.015). The survival time of patients in the filter group with bronchogenic carcinoma (18 ± 2 months) was longer than that of the patients in the control group (12 ± 2 months) after the endovascular treatment (P < 0.001).

Conclusions

Prophylactic filter placement could be a safe and effective method for preventing PE in pre- or post-endovascular-treated patients with thrombi in their central veins.