Temporary metallic stent placement in the treatment of refractory benign esophageal strictures: results and factors associated with outcome in 55 patients

The purpose of this study was to evaluate the effectiveness of temporary metallic stenting in 55 patients with treatment-resistant benign esophageal strictures and to identify factors associated with clinical outcomes. Under fluoroscopic guidance, covered retrievable stents were placed in 55 patients with benign esophageal strictures and were removed with retrieval hook 1 week to 6 months after placement. Stent placement was successful in all patients, and the mean dysphagia score was reduced from 2.8 to 1.3 (p < 0.001). The most common complications were tissue hyperproliferation (31%), severe pain (24%), and stent migration (25%). During follow-up (mean: 38 months), recurrence of the stricture necessitating balloon dilation was seen in 38 (69%) of 55 patients. Maintained patency rates after temporary stenting at 1, 3, and 6 months and 1, 2, and 4 years were 58%, 43%, 38%, 33%, 26%, and 21%, respectively. In multivariate analysis, length (p = 0.003) of the stricture was the only significant factor associated with maintained patency after temporary stenting. In conclusion, temporary metallic stenting for refractory benign esophageal strictures may be effective during the period of stent placement, but is disadvantaged by the high recurrence rates after stent removal, particularly in patients with a long length of stricture (>7 cm).     

Covered metallic stent placement in the management of cervical esophageal strictures

PURPOSE: To describe the authors' experience with self-expandable covered metallic stents in 16 patients with malignant and benign cervical esophageal strictures. MATERIALS AND METHODS: Sixteen expandable covered metallic stents were placed with fluoroscopic guidance in 16 patients (14 men, two women; mean age, 60 years; age range, 26-75 years) with malignant and benign strictures of the cervical esophagus. The causes of strictures were ingestion of corrosive agents (n = 3), biopsy-proved squamous cell carcinoma (n = 12), and postsurgical scarring (n = 1). The mean dysphagia scores at presentation were compared with those after stent placement by using the Wilcoxon signed rank test. RESULTS: Stent placement was technically successful in all patients. The reduction in the mean dysphagia score after stent placement was statistically significant (P = .0327). All patients complained of mild to severe foreign body sensation, with four reporting severe pain necessitating immediate stent removal. With the exception of one patient with limited follow-up, complications requiring intervention occurred in all patients, including migration in nine patients and tissue hyperproliferation in two. Of the 12 patients with a malignant stricture of the esophagus, four patients eventually underwent gastrostomy for the placement of a feeding tube and one patient underwent surgery. All four patients with a benign cervical stricture failed to achieve long-lasting improvement with temporary stent placement. CONCLUSIONS: Although the placement of covered metallic stents in the cervical esophagus provides adequate initial palliation, it is associated with poor patient tolerance and a high complication rate.     

Expandable metallic stent treatment for malignant colorectal strictures

Four patients were treated by placement of an expandable metallic stent (two Gianturco Z-stents, two Ultraflex stents) for malignant colorectal strictures. All four patients were able to defecate after stent placement. Stent migration was recognized in one patient. Two patients suffered from tenesmus after stent placement.     

金属内支架植入姑息性治疗食管恶性狭窄

目的 评价金属内支架在食管恶性狭窄治疗中的作用。方法 ２５例病人（男２１例、女４例,年龄４６～４８岁）行进口食管自膨式金属内支架植入术,其中单纯恶性狭窄２２例、食管气管漏２例、食管隔漏１例,共植入支架２７枚。结果 植入术后狭窄明显改善,症状明显减轻,疗效满意;随访２～１８个月,支架保持开放、食管保持通畅。结论 金属内支架植入术是治疗食管恶性狭窄的有效的姑息性疗法。     

Carotid arterial stent placement: results and follow-up in 53 patients

PURPOSE: To describe the results, complications, and follow-up data after stent placement for occlusive internal carotid arterial disease and to compare the results with those in the literature. MATERIALS AND METHODS: Carotid arterial stent placement was attempted in 57 arteries in 53 patients. Thirty-six (68%) of 53 patients were symptomatic. Forty-two (79%) of 53 patients had one to three clinically important comorbidities and were considered at high risk. All patients underwent pre- and postprocedural independent neurologic examinations. Follow-up consisted of serial duplex ultrasonography and clinical assessment. RESULTS: The immediate technical success rate of stent deployment was 97%. Periprocedurally, three (three [5%] of 57 interventions) transient ischemic attacks and three (three [5%] of 57 interventions) minor strokes occurred. Two deaths occurred in the first 30 days (one myocardial infarction, one renal failure). One ipsilateral major stroke occurred 3 weeks after the procedure. The 30-day ipsilateral major stroke and death rate was 5% (three of 57 interventions). At 30 days, one of three patients with minor stroke had mild residual dysphasia. Treatment remained clinically successful in 48 (96%) of 50 patients. The restenosis rate was 4% (two patients). CONCLUSION: Carotid arterial stent placement in a high-risk population has morbidity and mortality rates comparable to those of carotid endarterectomy in a lower risk population. Carotid arterial stent placement can be performed with a low restenosis rate.     

Femoropopliteal stent placement: long-term results.

Twenty-one patients who underwent percutaneous transluminal angioplasty (PTA) followed by attempted insertion of a self-expandable vascular endoprosthesis for femoropopliteal lesions were prospectively followed up for an average of 17.6 months with angiographic, Doppler ultrasound, and clinical examinations. Stents were placed bilaterally in one patient. Of the 22 lesions, 18 were total occlusions and four, stenoses. Stent placement was successful in 21 of 22 lesions. Nine occlusions occurred: four in the first 30 days and five 1-5 months after PTA. Three patients developed intrastent intimal hyperplasia that necessitated an additional percutaneous procedure. At 12 months, the patency rate without other interventions (the primary patency rate) was 49%. In patients who underwent secondary intervention (fibrinolysis, atherectomy, or PTA), the secondary patency rate was 67%, which fell to 56% after 18 months. At the end of the study, the overall rate of reocclusion was 43%. It is concluded that use of the self-expandable vascular endoprosthesis in the femoropopliteal region likely does not decrease the reocclusion rate after PTA alone. Its use is indicated for treatment of acute closures after femoropopliteal PTA.     

Antegrade transluminal dilatation of benign ureteral strictures: long-term results

The long-term results (follow-up of 15 months or longer) of antegrade transluminal dilatation of 127 benign ureteral strictures are assessed and analyzed. The overall success rate is 50%. When lesions were classified according to age of the stricture, status of vascular supply, and other etiologic factors contributing to formation, the following findings were evident: transluminal dilatation was successful in 30 (91%) of 33 patients with fresh strictures in whom there was no evidence of compromised vascular supply; in 23 (53%) of 43 similar strictures older than 3 months; in 3 (25%) of 12 with fresh strictures with evidence of vascular compromise; and in 7 (18%) of 39 with similar older strictures. Regardless of age of stricture and other etiologic factors, transluminal dilatation was successful in 53 (70%) of 76 patients with strictures without evidence of ischemic compromise but was successful in only 10 (20%) of 51 with strictures with evidence of devitalization. These findings emphasize the importance of considering both the age and vascular supply of a stricture and adjacent ureter when making the decision about treatment by antegrade transluminal dilatation.     

内支架置入对食管良恶性狭窄姑息性治疗的临床应用

目的 采用内支架置入的方法对食管良恶性狭窄和食管瘘患者进行姑息性治疗,观察并比较进口支架和国产支架的临床应用情况。方法 20例食管癌所致食管狭窄患者中,手术后吻合口狭窄3例,合并食管－气管瘘4例,食管－纵 隔瘘1例。置入进口支架10个;国产支架10个。对4例食管造影显示完全梗阻和7例严重狭窄的患者,先行球囊扩张,后置入支架。9例直接置入。结果 15例单纯食管狭窄患者置入支架后,进食情况明显改善,5例合并瘘者置入带膜支架后,瘘口消失。分别随访2个月至2年。1例20d后死于消化道大出血。3例6个月后再次出现狭窄,1例行放射治疗,2例第2次置入支架。其余患者均未出现明显的进食障碍。结论 食管内支架置入术简单、安全、近期疗效明显,无严重并发症,是食管癌性狭窄和食管瘘的一种良好的姑息性治疗方法。国产支架与进出口支架疗效相仿,值得临床推广应用。     

Dutch iliac stent trial: long-term results in patients randomized for primary or selective stent placement

PURPOSE: To determine long-term results of the prospective Dutch Iliac Stent Trial. MATERIALS AND METHODS: The study protocol was approved by local institutional review boards. All patients gave written informed consent. Two hundred seventy-nine patients (201 men, 78 women; mean age, 58 years) with iliac artery disease were randomly assigned to undergo primary stent placement (143 patients) or percutaneous transluminal angioplasty (PTA) with selective stent placement in cases in which the residual mean pressure gradient was greater than 10 mm Hg across the treated site (136 patients). Before and at 3, 12, and 24 months and 5-8 years after treatment, all patients underwent assessment, which included duplex ultrasonography (US), ankle-brachial index (ABI) measurement, Fontaine classification of symptoms, and completion of the Rand 36-Item Health survey for quality-of-life assessment. Treatment was considered successful for symptoms if symptoms increased at least one Fontaine grade, for ABI if ABI increased more than 0.10, for patency if peak systolic velocity ratio at duplex US was less than 2.5, and for quality of life if the RAND 36-Item Health Survey score increased more than 15 points. Effects of both treatments on symptoms, quality of life, patency, and ABI were compared by using survival analyses. RESULTS: Patients who underwent PTA and selective stent placement had better improvement of symptoms (hazard ratio [HR], 0.8; 95% confidence limits [CLs]: 0.6, 1.0) than did patients treated with primary stent placement, whereas ABI (HR, 0.9; 95% CLs: 0.7, 1.3), iliac patency (HR, 1.3; 95% CLs: 0.8, 2.1), and score for quality of life for nine survey dimensions did not support a difference between treatment groups. CONCLUSION: Patients treated with PTA and selective stent placement in the iliac artery had a better outcome for symptomatic success compared with patients treated with primary stent placement, whereas data about iliac patency, ABI, and quality of life did not support a difference between groups.     

Treatment of nasolacrimal duct obstruction with polyurethane stent placement: long-term results

OBJECTIVE: The purpose of this study was to evaluate the long-term efficacy of polyurethane stent placement in adults with nasolacrimal duct obstruction. SUBJECTS AND METHODS: Polyurethane stents were placed under fluoroscopic guidance in 52 eyes of 49 patients (mean age, 43 years) with severe epiphora due to idiopathic nasolacrimal duct obstruction. The obstruction was complete in 44 eyes and partial in eight. Clinical success was defined as complete resolution of or great improvement in the symptoms of epiphora and the patency of the lacrimal system to irrigation. Mean follow-up was 23 months (range, 14-44 months). RESULTS: Stent placement was technically successful in 50 eyes (96%). The mean fluoroscopy screening time was 2.2 min (range, 0.2-5.8 min). Two patients were lost to follow-up. Clinical success was obtained in 33 (69%) of 48 eyes. Lacrimal symptoms developed in 23 (70%) of these 33 eyes at least once during the follow-up, but these patients responded well to topical drug treatment and lacrimal irrigation. External dacryocystorhinostomy was performed in 13 eyes after failure of the stents. At surgery, lacrimal sacs were shrunken, hyperemic, and fragile in all eyes, making it difficult to anastomose with nasal mucosa. Histologic examination showed granulation tissue and chronic inflammation of the sac epithelium. CONCLUSION: The success rate of the nasolacrimal stent decreases as follow-up lengthens. After stent treatment, lacrimal symptoms frequently develop, even if the stent remains patent, and require multiple office visits and therapy. The polyurethane stent may induce a chronic inflammatory response in the lacrimal sac, which can interfere with subsequent dacryocystorhinostomy.     

Removal of a covered esophageal metallic stent 8 years after placement

A covered expandable esophageal metallic stent was placed to treat a corrosive esophageal stricture that was refractory to repeated balloon dilations. The stent was removed 8 years after placement due to severe dysphagia. The stented esophageal area has since maintained long-term patency for 2 years. These results suggest the feasibility of removal of a metallic stent after long-term stent placement.     

Nasolacrimal polyurethane stent placement for epiphora: technical long-term results

PURPOSE: To assess technical problems related to implantation of a polyurethane stent to treat obstructive epiphora, and to assess the long-term patency of the nasolacrimal system. MATERIALS AND METHODS: Fluoroscopically guided placement of a polyurethane nasolacrimal stent was performed in 70 obstructed lacrimal systems of 62 patients with grade 3-4 obstructive epiphora. Follow-up was conducted for 1-20 months (average, 11.3 months). The obstruction was at the lacrimal sac in six systems, at the junction between the lacrimal sac and the nasolacrimal duct in 60 systems, and at the nasolacrimal duct in four systems. The cause of the obstruction was idiopathic in all cases but was probably residual to dacryocystitis. RESULTS: Of these 70 procedures, stent placement was technically successful in 61 systems (87%). On long-term follow-up, 41 (67.2%) stents remained in place, with resolution or clinical improvement, and 18 (29.5%) stents were removed (because of occlusion in 17 systems), with stent malpositioning in the duct in six cases. There were seven cases of malpositioning in all. Statistical analysis was performed to evaluate patency, compare patency in properly positioned stents and malpositioned stents, and establish the relationship between malpositioning and the need for irrigation to maintain stent patency. Of the total 70 stents originally placed, 41 (58.6%) were still in place and functional at long-term follow-up. At 1 year, 73% of properly positioned stents remained patent versus 0% of improperly positioned stents. Median stent patency in the former group was 20 months and was 1 month in the latter group (P = .00002). Eleven percent of properly positioned stents required irrigation versus 57% of incorrectly positioned stents (P = .01). CONCLUSION: After follow-up for 1 year, recurrence of epiphora brought on by stent obstruction was 28%. Early stent blockage and the need for periodic irrigation may be indicative of malpositioning of the stent.