Primary Self-Expandable Nitinol Stent Placement in Focal Lesions of Infrarenal Abdominal Aorta: Long Term Results

Purpose To evaluate the technical and clinical success, safety and long term results of percutaneous transluminal angioplasty/self-expandable nitinol stent placement of infrarenal abdominal aorta focal lesions. Materials and Methods Eighteen patients underwent PTA of focal atherosclerotic occlusive disease of distal abdominal aorta. Two symptomatic occlusions and 16 stenoses in 10 male and 8 female patients (mean age 68.2 years) were treated with primary self-expandable nitinol stent placement. Results Primary self-expandable nitinol stent placement was technically successful in all 18 procedures; clinical success was achieved in 100% of patients. No complications associated with the procedure occurred. During the 49.4 months of mean follow up (range 3–96, 4 months) all treated aortic segments remained patent. Conclusions Endovascular treatment (primary self-expandable nitinol stent placement) of focal atherosclerotic lesions of distal abdominal aorta is a safe method with excellent primary technical and clinical success rates and favourable Long term results.     

Primary Stenting of Focal Atherosclerotic Infrarenal Aortic Stenoses: Long-Term Results in 13 Patients and a Literature Review

We conducted this study to investigate the value of primary stent implantation for the endovascular treatment of focal atherosclerotic stenoses of the infrarenal abdominal aorta. The data of 13 patients with a localized complex infrarenal aortic stenosis who underwent primary stenting was retrospectively evaluated. The patients (6 females, 7 males) had a mean age of 57.3 ± 9.1 years (mean ± SD). In all patients, the aortic diameter was measured on CT sections, and a self-expanding endoprosthesis was primarily implanted followed by dilatation with single or double balloons. In 3 patients, additional distal stenoses were also endovascularly treated. The procedure was technically successful in all patients. No complications occurred except for 2 minor groin hematomas. During the 43 ± 23 months (mean ± SD) follow-up (range: 12–96 months), all stented aortic segments remained patent. Clinical patency was lost in 4 patients, which was due to atherosclerosis or restenosis distal to the aorta. In view of the excellent early and long-term results, we believe that primary stenting should be considered the first line treatment in properly selected patients with focal atherosclerotic infrarenal stenoses of the abdominal aorta.     

Metallic endoprostheses for malignant tracheobronchial obstruction: Initial experience

Purpose To assess the efficacy of the Wallstent endoprosthesis in malignant tracheobronchial obstruction. Methods Seven patients with irresectable carcinoma of the bronchus were treated with nine Wallstent endoprostheses. The procedures were performed under endoscopic and fluoroscopic guidance. Wallstent endoprostheses ranging from 8–16 mm in diameter and 26–49 mm in length were deployed after balloon dilatation of the strictures. Results All stents were successfully deployed in the desired positions. There was one procedural complication and one procedure-related death. Three patients showed significant improvement in respiratory status after stenting. At a mean follow-up of 5.1 months, there has been no stent migration, fracture, or collapse. One patient had proximal tumor overgrowth that was treated with additional stent insertion. One patient died after a bout of massive hemoptysis 3 months poststenting and it was difficult to tell whether this was related to the endoprosthesis. Conclusion The use of the Wallstent endoprosthesis in malignant tracheobronchial obstruction is technically feasible.     

Aortic bifurcation reconstruction: Use of the memotherm self-expanding nitinol stent for stenoses and occlusions

PURPOSE: To assess the technical success, initial clinical outcome, and intermediate follow-up of the Memotherm nitinol self-expanding stent in aortic bifurcation reconstruction. METHODS: Thirty-three patients (13 male, 20 female), mean age 64 years, were treated, who had symptoms classified by the Surgical Vascular Society/International Society of Cardiovascular Surgery (SVS/ICVS) classification as grade 2 in 11 (33%), grade 3 in 19 (58%) and grade 4 in 3 (9%) patients. Lesions were classified according to severity and type. Indications for placement of a Memotherm nitinol self-expanding stent were failed angioplasty in 14 (42%), chronic occlusions in 12 (37%), and complex stenoses in seven (21%) patients. RESULTS: Sixty-seven stents were technically successfully placed in 66 aorto-iliac segments in 33 patients, with one major complication. Initial clinical outcome was improvement in 25 (81%), no change in four (13%), and a worsening in two (6%) patients by Rutherford criteria. Mean early ankle/brachial pressure index (ABI) gain was 0. 27 for occlusions and 0.05 for stenoses. Clinical follow-up was obtained in all patients, with retrospective angiographic follow-up in 28 (85%) at a mean of 16 months (range 12-26 months). The decrease in ABI and the decrease in angiographic luminal diameter at follow-up was determined as the "late loss." The mean ABI late losses were -0.06, 0.00, and 0.09, and the mean angiographic late losses were 6.7%, 10% and 14% for occlusions, stenoses, and normal segments respectively. Primary clinical patency was 96%, primary angiographic patency was 89%, and secondary angiographic patency was 93%. CONCLUSION: The high technical success of stent placement, the low complication rates for aortic bifurcation reconstruction using the Memotherm self-expanding stent, and high clinical and angiographic patency maintained at intermediate follow-up support their use in aortic bifurcation reconstruction.     

Percutaneous transluminal aortic angioplasty: Early and late results

Percutaneous transluminal angioplasty of the infrarenal abdominal aorta (13 patients) and its bifurcation (15 patients) was performed in 28 patients with a total of 32 dilatation procedures. The group consisted of 16 female and 12 male patients and initial successful dilatation was achieved in all Recurrence within 1 month requiring bypass surgery occurred in 1 patient. Three patients were lost to follow-up. Long-term follow-up in the remaining 24 patients ranged from 1 to 9 years with a mean of 4.5 years. During the follow-up period, repeat angioplasty of the original stenosis was performed in 3 patients and another patient underwent dilatation of a new lesion which developed in the aorta. According to clinical and noninvasive studies, these 4 patients, as well as the other 20, have maintained patency of the treated lesions and are symptom free. No immediate complications requiring surgery occurred. We conclude that angioplasty is the initial treatment of choice in focal lesions of the distal abdominal aorta and its bifurcation.     

Primary stenting in infrarenal aortic occlusive disease

Purpose: To evaluate the results of primary stenting in aortic occlusive disease. Methods: Thirty patients underwent primary stenting of focal concentric (n = 2) and complex aortic stenoses (n = 19), and aortic or aorto-iliac occlusions (n = 9). Sixteen patients underwent endovascular outflow procedures, three of whom also had distal open surgical reconstructions. Median follow-up was 16 months (range 1–60 months). Results: Guidewire crossing of two aorto-biiliac occlusions failed, resulting in a 93% (28/30) technical success. Major complications included one access hematoma, one myocardial infarction, one death (recurrent thromboembolism) in a patient with widespread malignancy, and one fatal hemorrhage during thrombolysis of distal emboli from a recanalized occluded iliac artery. One patient did not improve his symptoms, resulting in a 1-month clinical success of 83% (25/30). Following restenting the 26 stented survivors changed their clinical limb status to +3 (n = 17) and +2 (n = 9). During follow-up one symptomatic aortic restenosis occurred and was successfully restented. Conclusions: Primary stenting of complex aortic stenoses and short occlusions is an attractive alternative to conventional surgery. Larger studies with longer follow-up and stratification of lesion morphology are warranted to define its role relative to balloon angioplasty. Stenting of aorto-biiliac occlusions is feasible but its role relative to bypass grafting remains to be defined.     

Pancreatitis-Induced Extrahepatic Portal Vein Stenosis Treated by Percutaneous Transhepatic Stent Placement: a Case Report

One month after onset of an acute biliary pancreatitis, a 75-year-old man developed refractory ascites. Duplex ultrasound and CT scan revealed a focal stenosis of the extrahepatic portal vein as confirmed by transhepatic direct portography. In the same session, this stenosis, responsible for symptomatic prehepatic portal hypertension, was successfully dilated and stented and afterwards a residual pressure gradient of 1 mmHg over the stented segment was measured. One week after the stenting procedure the patient was free of ascites and control physical and biochemical examination one year later is completely normal.     

Percutaneous fenestration of aortic dissection: Salvage of an ischemic solitary left kidney

The false channel of a type III aortic dissection caused acute renal ischemia by compression of the origin of the left renal artery in a patient with status post-right nephrectomy. To relieve the ischemia and restore renal function, percutaneous balloon fenestration was performed successfully.     

Transluminal angioplasty of failing infrainguinal arterial by-pass grafts: Initial and long-term results in 13 patients

Thirteen stenotic infrainguinal arterial bypasses (12 venous, 1 Gore-tex graft) were treated by transluminal angioplasty, either percutaneously (10 patients) or surgically (3 patients). Eleven procedures were immediately successful (two at the proximal portions of femoropopliteal grafts, six near the distal anastomoses, and three at the distal parts of femoroinfrapopliteal grafts) and dilated stenoses are still patent with a mean duration of 24 months in all patients except 2 who died during the follow-up period. The calculated cumulative patency rate is 85% at 36 months. Two procedures were followed by immediate disruption near the distal end of anin situ saphenous bypass graft where balloon inflation was performed. These required immediate surgical repair. Dilatation of the distal ends ofin situ saphenous femoropopliteal bypasses may not be as safe as in other locations.     

Percutaneous hepatic venous reanastomosis in a patient with Budd-Chaiari syndrome

A 33-year-old woman with Budd-Chiari syndrome for 9 years presented with worsening right upper quadrant pain and progressive liver dysfunction. Hepatic venography demonstrated hepatic vein occlusions, without significant IVC obstruction. Attempts at stenting a stenotic middle hepatic vein were unsuccessful. Transjugular access, however, allowed puncture from the stump of the right hepatic vein into the engorged right intrahepatic vein that had been demonstrated by retrograde hepatic venography. Two Palmaz stents were used to form the veno-venous reanastomosis. Initial success was documented angiographically and by pressure measurements before and after shunting. Followup at 7 and 16 months confirmed patency of the anastomosis without intimai hyperplasia. The patient noted near-complete resolution of her pain, and her liver function stabilized.     

A Newly Designed Nitinol Stent: Early Clinical Experience in the Treatment of Iliac Artery Stenoses and Occlusions

Objective

To investigate the effectiveness of the newly designed Niti-S stent in the management of iliac arterial stenoses and occlusions.

Materials and Methods

Stenoses (n=25) or occlusions (n=5) in the iliac arteries of 25 patients (30 limbs) were treated. The site of the lesions was the common (n=15) or external (n=11) iliac artery, or both (n=4). Eight limbs were treated for diffuse disease, six for highly eccentric lesion, five for occlusive lesion, and 11 for failed angioplasty.

Results

In all patients, technical success was achieved without major complications. One death, not procedure-related, occurred within 30 days. Ankle-brachial indexes improved from 0.63±0.30 to 0.99±0.21, and ischemic symptoms showed improvement in 22 patients (88%). Fontaine classifications before stenting, namely IIa(n=3), IIb(n=16), III(n=2), and IV(n=4) improved to I(n=17), IIa(n=5), and IV(n=3). Follow-up over a 27 (mean, 19.8±8)-month period showed that cumulative patency rates were 95.8% at 1 year and 86.2% at 2 and 3 years. No significant decrease in the mean ankle-brachial index was observed.

Conclusion

The Niti-S stent appears to be a safe and effective device for the treatment of iliac stenoses and occlusions. These preliminary results require confirmation with a larger series.     

Interventional therapeutic techniques in Budd-Chiari syndrome

Purpose To analyze the results obtained with percutaneous therapeutic procedures in patients with Budd-Chiari syndrome (BCHS). Methods Between August 1991 and April 1993, seven patients with BCHS were treated in our hospital. Three presented with a congenital web; in another three cases the hepatic veins and/or the inferior vena cava (IVC) were compromised after major hepatic surgery; one patient presented with a severe stenosis of the intrahepatic IVC due to hepatomegaly. Results One of the patients with congenital web has required several new dilatations due to restenosis; one patient required a transjugular intrahepatic portosystemic shunt procedure while awaiting a liver transplantation. The two postsurgical patients with stenosed hepatic veins did not require any new procedure after the placement of metallic endoprostheses. However, the patient with liver transplantation presented IVC restenosis after balloon angioplasty that required the deployment of metallic endoprostheses. In the patient with hepatomegaly a self-expandable prosthesis was placed in the intrahepatic portion of the IVC before (4 months) a liver transplantation. Conclusion Interventional therapeutic techniques offer a wide variety of possibilities for the treatment of patients with BCHS. For IVC stenoses, the results obtained with balloon angioplasty are at least as good as those obtained with surgery.     

Use of through-and-through guidewire for delivering large stent-grafts into the distal aortic arch

The availability of large diameter stent-grafts is now allowing the endovascular treatment of thoracic aortic aneurysms. Most aneurysms are closely related to the distal arch and it is thus necessary to pass the delivery systems into the arch to effectively cover the proximal neck. Even with extra-stiff guidewires in position, it may still be difficult to achieve this, as a result of tortuosity at the iliac arteries and the aorta. We detail a technique where a stiff guidewire is passed from a brachial entry point through the aorta and out at the femoral arteriotomy site. This allows extra-support and may enable the delivery system to be passed further into the aortic arch than it could with just the regular guidewire position.     

Acute Duodenal Obstruction After Percutaneous Placement of Metallic Biliary Stents: Peroral Treatment with Enteral Stents

Three patients with malignant biliary obstruction were treated with placement of metallic biliary stents. Two patients had known partial duodenal stenosis but had no symptoms of gastrointestinal obstruction. The patients developed symptomatic duodenal obstruction early after biliary metallic stent placement. The symptomatic duodenal obstructions were successfully treated with peroral placement of duodenal stents, which obviated the need for surgical intervention.     

Stenosis of the inferior vena cava after liver transplantation: Treatment with gianturco expandable metallic stents

Purpose: Evaluate the efficacy of double Gianturco expandable metallic stents for stenosis of the inferior vena cava (IVC) after orthotopic liver transplantation (OLT). Methods: Three patients developed severe Budd-Chiari syndrome secondary to suprahepatic caval stenosis after OLT. Percutaneous angioplasty (PTA) of the stenoses was unsuccessful. Therefore double Gianturco expandable metallic stents, connected in tandem, were deployed at the site of the stenoses. Results: One double stent was successfully and definitively deployed in patient 1. Partial dislocation of the upper and lower stents comprising the double stent occurred in patient 2. The double stent initially implanted across the stenosis became displaced in patient 3. The Budd-Chiari syndrome resolved in all three patients who remained asymptomatic during follow-up from 3 to 32 months. Conclusions: Double Gianturco stent deployment is a viable option in patients with anastomotic stenosis of the IVC secondary to OLT when initial treatment with PTA fails. Certain modifications of the stents employed are suggested for the purpose of avoiding technical complications.     

Chronic aortic dissection: Stenting of aortic true lumen obliteration with late dynamic variations of both lumens

Percutaneous endovascular techniques were used to treat an arteriovenous fistula (AVF) associated with pancreatic transplantation. A pancreatic transplant superior mesenteric artery-to-superior mesenteric-vein AVF was successfully embolized while flow to the pancreas transplant was preserved. The embolization was aided by the use of Guglielmi detachable coils and a detachable balloon. No complications were encountered. At 23 months follow-up, the patient is doing well with no recurrence.     

Use of endoluminal stent-grafts in acute aortic rupture

Purpose: To report our experience with stent-graft treatment of acute aortic injuries. Materials and methods: Emergent stent-graft placement was considered in patients with acute aortic rupture or injury who were deemed to be high-risk candidates for surgery. After medical stabilization, patients were evaluated for suitability for endovascular interventions. Anatomic criteria for stent-grafting included: (1) contained ruptures of the thoracic aorta located distal to the left subclavian artery and above the celiac axis, and (2) a proximal and distal neck of ≥ 15 mm in length and ≤ 40 mm in diameter. Stent-grafts consisted of a modified Z-stent endoskeleton covered with woven polyester vascular graft material. All devices were placed under general endotracheal anesthesia. A transfemoral approach was utilized if the iliofemoral artery diameter was ≥ 8 mm. For iliofemoral diameters < 8 mm, the catheters were inserted directly into the infrarenal aorta after a retroperitoneal exposure. Patient follow-up consisted of angiography and spiral CT scan prior to discharge from the hospital. Subsequent spiral CT studies were performed at 6 and 12 months, and at 1-year intervals thereafter. Results: Thirteen patients (11 men and 2 women) with a mean age of 60 years (range 34–81 years) underwent emergent placement of thoracic stent-grafts for acute aneurysmal rupture (n = 8), traumatic transection (n = 3), or tumor and abscess erosions (n = 2). The stent-grafts were deployed successfully in all cases and there were no cases of embolization, paraplegia, or stent-graft migration. No patient required surgical conversion. The average stent-graft dimension was 34 mm in diameter (range 24–38 mm) by 15.8 cm in length (range 5.0–17.5 cm). No patient with traumatic aortic injury was excluded on the basis of anatomic criteria. Two patients died within 1 month of the procedure, one of ventricular rupture and the other of cardiac arrest on day 28 after an uneventful hospital course for a ruptured aneurysm. Conclusion: The preliminary experience from our series demonstrates that aortic stent-grafting for traumatic aortic injury is technically feasible and can be used to treat thoracic aortic rupture in patients at high risk for standard operative therapy.     

Effort Thrombosis: Effective treatment with vascular stent after unrelieved venous stenosis following a surgical release procedure

Acute symptomatic effort thrombosis in a 33-year-old male necessitated an aggressive approach consisting of thrombolysis, angioplasty, and surgical thoracic outlet release. The patient required postoperative placement of a Wallstent and was placed on anticoagulation. He has remained symptom free for the past 10 months, both clinically and sonographically.     

Outcome of Endovascular Treatment in Symptomatic Intracranial Vascular Stenosis

Objective

The outcome evaluation for the revascularization of intracranial vascular stenoses has not been fully described due to the highly technical nature of the procedure. We report here on the early and late clinical outcomes of angioplasty and/or stenting of symptomatic severe intracranial vascular stenoses at a single institute.

Materials and Methods

Since 1995, we have treated 35 patients with symptomatic intracranial vascular stenosis (more than 70% stenosis, mean stenosis: 78.6% ± 6.2%). Angioplasty (n = 19) was performed for the horizontal segment of the middle cerebral artery (M1) (n = 16) and the basilar artery (BA) (n = 1), the intradural vertebral artery (VA) (n = 1), and the cavernous internal carotid artery (ICA) (n = 1). Stenting (n = 16) was performed for the cavernous or petrous ICAs (n = 9), the intradural VA (n = 3), BA (n = 2), and M1 (n = 2) artery. We assessed the angiographic success (defined as residual stenosis < 50%) rate, the periprocedural complications during the 30-day periprocedural period, the symptomatic recurrence and restenosis during a mean 22-month follow-up (FU) period. The Kaplan-Meier estimate of the cumulative event-free rate of the major cerebrovascular events, i.e. death, stroke or restenosis, was also done.

Results

Angiographic success was achieved in 97% of our patients (34/35). There were four procedure-related complications (11%) including a death and a minor stroke. During the mean 22-month FU, the asymptomatic restenosis rate was 9% and the symptomatic restenosis rate was 6% in the target lesion and 9% in all the vascular territories. The Kaplan-Meier estimate was 70.6% (95% confidence interval = 46.5-94.7) after 33 months of FU.

Conclusion

In addition to a high angiographic success rate and an acceptable periprocedural complication rate, intracranial angioplasty and/or stenting revealed a relatively low symptomatic recurrence rate. Hemorrhage is a rare, but the physician must aware that potentially fatal periprocedural complications can occur.