New bifurcation stenting technique: shunt stenting.

The optimal treatment of bifurcation lesions remains controversial. We describe a new technique we term shunt stenting. This technique incorporates both the new technology of drug-eluting stents and a novel procedure for optimizing the ostial side branch stent positioning. To date, early angiographic and clinical follow-up have been encouraging.     

Carotid stenting

From my point of view, carotid artery stenting, in 2005, is clearly here to stay. "Houston, the Eagle has landed." The rest is up to you and me as we encourage our surgical colleagues and our various medical Societies to embrace this safe, effective, and durable technology and make it available to the patients who will really benefit from it.     

冠状动脉造影后即刻支架术与择期支架术的临床研究

目的比较冠状动脉造影后即刻支架术与择期支架术的成功率和并发症发生率，从而探讨即刻支架术的临床应用价值。方法对2005年1—12月在我科行冠状动脉造影后即刻支架术（即刻组，n=115例）和择期支架术（择期组，n=172例）患者的资料进行分析。结果A型和B型病变的成功率和并发症率两组间差异无统计学意义（P〉0．05），而C型病变的成功率即刻组低于择期组（P〈0．01），而并发症率高于择期组（P=0．05）。结论A型和B型病变冠状动脉造影后即刻支架术是临床可行的，而C型病变不宜冠状动脉造影后即刻支架术。因此，冠状动脉造影后即刻支架术有一定的临床应用价值。     

Technique of colonic stenting

Colonic stents have been used for more than 20 years for preoperative and palliative relief of malignant colonic obstruction. Self-expandable metal stent (SEMS) placement is more technically challenging than luminal stent placement in other locations. SEMS placement is performed most commonly with fluoroscopic guidance using through-the-scope devices. Accessories used for performing pancreaticobiliary procedures facilitate colonic SEMS placement.     

Direct stenting.

Stents have ameliorated the outcome of percutaneous coronary interventions. Improved design, profile and flexibility of the currently available stents now permit to deliver the stent without pre-dilatation. In western European countries, stent implantation now occurs in up to 80% of all percutaneous revascularization procedures. In selected cases the safety and feasibility of direct stenting over conventional balloon-predilatation stenting has been demonstrated, in association with slightly superior outcome. This likely results from reduced vessel wall damage-dissections are sealed at the moment they are created-and distal embolization is reduced. In addition, a significant reduction in terms of costs and duration of procedures was demonstrated, while restenosis rate is not reduced with direct stenting.     

Carotid stenting.

Coding personnel should be aware of the new CPT guidelines for reporting carotid and vertebral stent placement. Payors' billing requirements for these procedures vary, and it is important to determine before billing whether the payor will accept the applicable CPT category I or III code or whether an unlisted code must be reported. Coding guidancefor these procedures will likely continue to evolve in thenear future.     

Carotid artery stenting

From the earliest experiences with carotid artery stenting (CAS) presumptive high risk features have included thrombus‐containing lesions, heavily calcified lesions, very tortuous vessels, and near occlusions. In addition patients have been routinely excluded from CAS trials if they have contra‐indications to dual antiplatelet therapy (aspirin and thienopyridines), a history of bleeding complications and severe peripheral arterial disease (PAD) making femoral artery vascular access difficult. Variables that increase the risk of CAS complications can be attributed to patient characteristics, anatomic or lesion features, and procedural factors. Clinical features such as older age (≥80 years), decreased cerebral reserve (dementia, multiple prior strokes, or intracranial microangiopathy) and angiographic characteristics such as excessive tortuosity (more than two 90° bends within 5 cm of the target lesion) and heavy calcification (concentric calcification ≥ 3 mm in width) have been associated with increased CAS complications. Other high risk CAS features include those that prolong catheter or guide wire manipulation in the aortic arch, make crossing a carotid stenosis more difficult, decrease the likelihood of successful deployment or retrieval of an embolic protection device (EPD), or make stent delivery or placement more difficult. Procedure volume for the operator and the catheterization laboratory team are critical elements in reducing the risk of the procedure. In this article, we help CAS operators better understand procedure risk to allow more intelligent case selection, further improving the outcomes of this emerging procedure.© 2013 Wiley Periodicals, Inc.     

Noncoronary vascular stenting

The aim of this report is to review the current state of the art with respect to noncoronary vascular stenting. A review of the literature was performed, examining the historical aspects of stent design and usage, as well as the currently available designs and their respective functions. When appropriate, we note our personal experience with stent placement in each anatomic site. Currently available stents take many forms: balloon-expandable, self-expanding, and shape-memory alloy. Varied design modifications have been made to maximize the open area, to limit the surface area of the prosthesis, to increase (or decrease) flexibility, and to increase (or decrease) stent plasticity and elasticity. Modifications to minimize thrombogenicity are also underway. The clinical uses of the currently available stents in multiple anatomic locations will be discussed. Intravascular stents are an addition to the arsenal available for prolonging blood vessel patency.     

Provisional bifurcation stenting

Obstructive coronary lesions involving a branch origin or extending into the branch itself, remain one of the main challenges in the rapidly developing world of interventional cardiology. Acutely, these lesions are prone to the complications resulting residual stenosis or loss of one of the branches. Long-term follow up has also been disappointing with a high incidence of restenosis. Numerous techniques have been developed, aimed at optimizing the in significant acute and long-term results by adapting standard angioplasty hardware, with limited success, particularly in the long term. This article describes a fully dedi cated system for bifurcation lesions with stenting of the main vessel to the main branch, yet ensuring side branch patency, with limited risk of branch origin stenosis or stent jailing, allowing for provisional stenting of the branch as dictated by the angiographic outcome.     

Bifurcational stenting.

Treatment of bifurcation lesions is a complex issue, and there is no single panacea to the variety of lesions that form this cohort. The contribution of side-branch compromise to the adverse clinical events occurring after stent implantation need not be stressed and requires an aggressive approach including balloon dilatation before and after stent deployment. Various new techniques of kissing stent placement, such as the 'T', 'V', 'Y', and the culottes technique, have been proposed in recent years to treat different anatomical situations. The angle formed by the side-branches, the severity of involvement of the ostia and the vessel size are the main factors which influence selection of the strategy. Newer generations of stents, such as the bifurcate stents, tailor-made for bifurcation lesions, are evolving, and are expected to make a positive impact on the procedural outcomes and long-term results after bifurcation stenting. The development of new strategies and stent designs has greatly improved safety and immediate outcome of bifurcational stenting, but the procedural success still needs to be matched by an equal improvement in long-term patency.     

Direct stenting versus predilatation and stenting technique when using paclitaxel-eluting stents

Direct stenting without predilatation is a well-defined, feasible method with bare metal stents. Direct stenting has also been shown to be safe and feasible with drug-eluting stents, however, there is much less evidence with this type of device when compared with bare metal stents. Three hundred and sixty-four coronary lesions in 257 consecutive patients (mean age, 57.4 +/- 9.8 years; 63 women) who had undergone elective stenting either with or without predilatation via a paclitaxel-eluting stent between March 2003 and March 2006 were retrospectively analyzed. Quantitative coronary angiography analysis was compared between the two groups of procedures; stenting with predilatation and direct stenting. All procedures were uneventful. No deaths occurred during the follow-up period. Direct stenting when compared with the predilatation technique, significantly decreased both procedure time (32.1 +/- 17.9 minute versus 41.2 +/- 18.6 minute, P < 0.0001) and fluoroscopy time (10.6 +/- 7.8 minute versus 15.5 +/- 7.6 minute, P < 0.0001). There was no difference in quantitative analysis parameters of coronary angiography during follow-up or the rates of stent thrombosis and restenosis. Direct stenting seems to be as feasible and safe as conventional predilatation and stenting in selected cases. Direct stenting seems to decrease procedural time and radiation exposure without any negative effect on quantitative analysis parameters of coronary angiography with approximately a one-year follow-up period.