Step‐by‐step StentBoost‐guided small vessel stenting using the self‐expandable sparrow stent‐in‐wire

A 56 year‐old woman underwent percutaneous coronary intervention for a lesion in a small mid‐left anterior descending coronary artery (reference vessel diameter by quantitative coronary angiography: 2.11 mm) with a novel drug‐eluting stent specifically designed for small vessels, the CardioMind Sparrow stent delivery system. This is a self‐expandable sirolimus‐eluting nitinol stent directly mounted into a 0.014‐inch coronary guidewire. The stent has a very thin strut thickness (67 micron), limiting its radiopacity. A specific X‐ray stent‐enhancing visualization technique, “StentBoost”, allowed clear visualization and understanding of the steps needed for an appropriate release and deployment of the aforementioned stent. © 2008 Wiley‐Liss, Inc.     

A “Jail Escape Technique” (JET) for distal side branch wiring during provisional stenting: Feasibility and first‐in‐man study

Objective

To evaluate the feasibility of a novel technique for achieving distal SB access and improve strut apposition during provisional stenting.

Background

While distal rewiring and stent expansion toward the side branch (SB) are associated with better results during provisional stenting of coronary artery bifurcation lesions, these techniques are technically challenging and often leave unopposed struts near the carina.

Methods

The “Jail Escape Technique” (JET) is performed by passing the proximal tip of the SB wire between the main vessel (MV) stent struts and balloon before implantation, allowing the MV stent to push the SB wire against the distal part of the carina. The MV stent can then be deployed without jailing the SB wire. Distal SB access and strut distribution at the carina were tested in phantom and swine models. Stent distortion, dislodgement forces, and material damage were evaluated with tensile testing. Human feasibility was then tested on 32 patients.

Results

Preclinical testing demonstrated that the SB wire was located at the most distal part of the carina and no strut malapposition at the carina was present after balloon inflation. Stent distortion, dislodgement forces, or material damage were not affected. JET was successfully performed in 30 of 32 patients. No major adverse cardiovascular events occurred in any patient at 6‐month follow‐up.

Conclusion

The “JET” enables distal SB access and eliminates strut malapposition at the carina. Further studies with larger numbers of patients are needed to further investigate this technique.

     

Innovative use of self‐expanded polytetrafluoroethylene endoprosthesis for percutaneous endovascular interventions

VIABAHN® endoprosthesis (Gore & Associates, Flagstaff, AZ), a nitinol self‐expanding polytetrafluoroethylene (PTFE) lined stent, has demonstrated utility for percutaneous treatment of chronic occlusive disease involving the superficial femoral artery. In a case series communication we aimed to describe the feasibility of a PTFE‐lined stent for percutaneous treatment of conditions other than chronic occlusive disease. We report the successful use of PTFE‐endoprosthesis to percutaneously treat several vascular conditions, including arterio–venous fistula closure, reconstruction of a distal limb of an aorto–femoral endoprosthesis aneurysm, femoral artery perforation repair, and an exclusion of large saphenous vein graft aorto–coronary bypass aneurysm. This case series illustrates the feasibility of the “off‐label” use of self‐expanded PTFE endoprosthesis to percutaneously treat several conditions, which would otherwise require “open” surgical reconstructions. © 2011 Wiley Periodicals, Inc.     

Carotid stent fracture: Diagnosis and management

With increasing numbers of carotid stent implantations, stent fractures likely will be detected in this vessel region. The authors report two cases of stent fracture: one balloon expandable and one self expandable stent fractured and caused symptoms. CT angiography identified the stent fractures. One partial stent fracture in the internal carotid artery caused a significant restenosis. One complete stent fracture in the common carotid artery caused neurological symptoms, but no significant restenosis. Computerized tomographic angiography (CTA) findings were confirmed by conventional angiography and treated by repeated stent implantation. In a 12‐month follow‐up period, both patients remained further neurologically asymptomatic and there was no restenosis in duplex sonography or CTA. © 2009 Wiley‐Liss, Inc.     

The “double stingray technique” for recanalizing chronic total occlusions with bifurcation at the distal cap

Antegrade dissection re‐entry is often discouraged for chronic total occlusions (CTOs) with a bifurcation at the distal cap due to risk of side branch occlusion that can lead to periprocedural myocardial infarction and incomplete revascularization. Antegrade dissection re‐entry, however, is often needed, especially in complex cases. We present the novel “double Stingray technique” for CTOs involving bifurcations, in which the Stingray system is used twice for re‐entry into both vessel branches, followed by two‐stent bifurcation stenting to maintain the patency of both branches.     

A case of intracoronary protruded thrombus caused after bailout stenting for side branch occlusion

A 69-year-old woman underwent percutaneous coronary intervention for a severe stenotic lesion in the bifurcation of the mid-left anterior descending artery and first diagonal branch. A single stent was implanted into the left anterior descending artery. After the stent strut was dilated by balloon inflation in the diagonal branch, dissection occurred at the ostium of the diagonal branch and resulted in side branch occlusion due to hematoma. Bailout stenting was performed in the diagonal branch, but thrombus projection occurred in the left anterior descending artery. Aspiration, balloon inflation and thrombolytic therapy were performed, but distal embolism developed. This case illustrates that thrombus projection caused by stenting in a side branch may occur as a rare complication in percutaneous coronary intervention.     

A “Simplified” culotte technique using two dedicated bifurcation stents and additional angiographic stent enhancement to treat a complex bifurcation lesion in non‐ST segment elevation myocardial infarction with poor left ventricular function

We present a case of a bifurcation lesion treated with two dedicated sirolimus eluting bifurcation stents, BiOSS Lim in the setting of non‐ST elevation myocardial infarction and poor left ventricular function. We demonstrate the feasibility of a new technique, a “simplified” culotte technique. The key differences of this new technique compared with conventional culotte are: better sizing of the stent due to the specific design of the stent with a larger proximal diameter and smaller distal diameter, direct stenting of the second stent without predilatation of the stent struts of the first deployed stent, and possibility to perform post‐dilatation directly with properly sized balloons without additional predilatation. © 2015 Wiley Periodicals, Inc.     

First report on the use of a novel self‐expandable stent for treatment of ST elevation myocardial infarction

A 69‐year‐old female underwent primary percutaneous coronary intervention with a Stentys? self‐expandable stent. Potential benefits of this stent are less intimal proliferation, reduced need for predilatation, reduced risk of malapposition and distal embolization. After written informed consent, the occluded proximal left anterior descending artery was successfully treated with thrombosuction, followed by implantation of the self‐expandable stent. Intravascular ultrasound examination postprocedure and at 5 days showed good stent apposition and it appeared that the vessel diameter had increased probably due to self‐expanding properties of the stent and relief of coronary spasm. The patient was discharged event‐free. A larger patient cohort is needed to investigate safety and feasibility of this novel stent. © 2009 Wiley‐Liss, Inc.     

Balloon angioplasty versus stenting with nitinol stents in intermediate length superficial femoral artery lesions

Background : Recent randomized trials investigating stent implantation compared with balloon angioplasty for treatment of superficial femoral artery (SFA) disease have given divergent results in short (mean 5 cm) and intermediate (mean 10 cm) lesions. We reinvestigated whether primary nitinol stenting is associated with a morphologic and clinical benefit when compared with percutaneous transluminal angioplasty with optional stenting (PTA) in intermediate‐length lesions. Methods : We randomly assigned 73 patients with severe claudication or chronic limb ischemia and average 8 cm long (range 3–20 cm) SFA stenosis or occlusion to primary stent implantation (n = 34) or PTA (n = 39). Restenosis >50% and clinical outcome were assessed at 3, 6, and 12 months postintervention. Results : Average length of the treated segments was 98 ± 54 mm and 71 ± 43 mm in the stent and PTA groups (P = 0.011), respectively. In the PTA group, secondary stenting was performed in 10 of 39 patients (26%) due to a suboptimal result after balloon dilation. Restenosis rates in the stent and PTA groups were 21.9% versus 55.6% (P = 0.005) at 6 months by CT‐angiography, and 2.9% versus 18.9% (P = 0.033), 18.2% versus 50.0% (P = 0.006), and 34.4% versus 61.1% (P = 0.028) at 3, 6, and 12 months by sonography, respectively. Clinically, patients in the stent group reported a significantly higher maximum walking capacity compared with the PTA group at 6 and 12 months. Conclusion : In this randomized multicenter trial, primary stenting with a self‐expanding nitinol stent for treatment of intermediate length SFA disease resulted morphologically and clinically superior midterm results compared with balloon angioplasty with optional secondary stenting. © 2009 Wiley‐Liss, Inc.     

Combined Use of Uncovered Duodenal and Covered Biliary Metallic Stent for Carcinoma of the Papilla of Vater

We have reported successful implantation of self‐expandable metallic stents for palliative treatment in a case of an 87‐year‐old female patient with carcinoma of the papilla of Vater. She suffered from both duodenal and biliary stenoses, but refused surgical treatment. For the duodenal stenting, a self‐expandable knitted nitinol metallic stent, for esophageal use, was inserted endoscopically. For the biliary stenting, a self‐expandable metallic stent, partially polyurethane‐covered on the proximal part to prevent tumor ingrowth and overgrowth, was inserted via the percutaneous transhepatic biliary drainage route. No major complications occured during these procedures. After the two stents were inserted in an end‐to‐side fashion, she was able to eat a normal diet adequately and suffered from no abdominal symptoms and jaundice during the follow‐up period of 13 months. These stenting procedures might be less invasive and more useful than surgical treatment and provide long patency of biliary stenting and a good quality of life.     

Restenosis after stent implantation for superficial femoral artery disease in patients treated with cilostazol

Background : Restenosis after endovascular treatment for superficial femoral artery (SFA) disease remains a significant clinical issue. We assessed whether cilostazol reduce restenosis after SFA stenting with self‐expandable nitinol stent. Methods : The study was a multicenter, prospective maintained database, retrospective analysis. From April 2004 to December 2009, 861 consecutive patients (mean age 71 years, 71% male) who underwent successful stenting for de novo lesions were retrospectively identified. Of them, 492 received cilostazol (cilostazol(+)) and 369 did not receive cilostazol (cilostazol(?)) after procedure. Propensity‐score analyses matched 281 cilostazol(+) with 281 cilostazol (?) group. Primary endpoint was binary restenosis rate. Secondary endpoints were reocclusion, all‐cause mortality and limb salvage in patients with critical limb ischemia (CLI). Restenosis was defined as >2.4 of peak systolic velocity ratio by duplex. Results : Mean follow‐up period was 25 months. According to analysis of matched pairs, binary restenosis rates were significantly lower (31.2% vs. 42.9% at 5‐year, P = 0.02). In‐stent re‐occlusion rate tended to be lower in patients who received cilostazol (10.8% vs. 18.2% at 5‐year, P = 0.09) compared with control. No significant difference of all‐cause mortality (21.4% vs. 18.3% at 5‐year, P = 0.84) and limb salvage rate in patients with CLI (86.2% vs. 78.5% at 5‐year, P = 0.29) was found between both groups. After adjustment for prespecified risk factors, cilostazol was an independent negative predictor of restenosis. In subgroup analysis, male, age <75 years, claudicant patients, TASCII C/D, small vessels and poor runoff vessel was significantly lower in binary restenosis. Conclusions : Cilostazol reduced restenosis after SFA stenting with self‐expandable nitinol stent and it seems to be more effective in high‐risk patients for restenosis. © 2011 Wiley Periodicals, Inc.     

Novel application of the “CART” technique for endovascular treatment of external iliac artery occlusions

We report the novel application of the C ontrolled A ntegrade and R etrograde subintimal T racking technique for the endovascular treatment of occlusions of the external iliac artery (EIA). We hypothesized that this technique would limit the extent of subintimal dissection to the length of the EIA occlusion, thus preserving patency of the internal iliac artery proximally and the circumflex iliac artery distally and minimizing the length of stent required to treat the occlusion, including the length of stent placed in the common femoral artery. The technical execution and clinical experience with this technique is reported. © 2009 Wiley‐Liss, Inc.     

Repeat percutaneous coronary revascularization: Indications and outcomes in a “Real World” cohort

Objectives : To investigate rates of and reasons for second and subsequent stent procedures in an unselected, “real‐world” population. Background : Repeat stenting is the primary difference reported in clinical trials of alternative revascularization strategies. The incidence, indication, and outcome for repeat stenting in contemporary practice outside the more selective populations of trials and registries has not been described. Method : All patients undergoing a first percutaneous coronary intervention (PCI) procedure with stenting from January 2001 to August 2009 (10,509) from a large UK tertiary referral and district general hospital were identified. Mortality and the incidence, timing, and indication for repeat revascularization in this population were investigated from patient records. Results : Of 10,509 patients undergoing a first PCI and stent implant 23.5% underwent repeat angiography of which 11.2% required repeat PCI and 2% coronary artery bypass grafting (median follow‐up of 3.8 years). A total of 1.3% went on to a third PCI. The commonest indication for repeat stenting was disease progression remote from the original stent (46%) and planned staged PCI (23%); 21% had a stent‐related indication. Functional assessment before repeat stenting was used in one‐third of stable patients. Mortality was 2.5% per annum. Conclusions : In contemporary practice, patients undergoing a first stenting procedure have a low subsequent mortality, and the substantial majority (86.4%) requires no further revascularization over a median 3.8 year follow‐up. For those who do require repeat stenting, this is most commonly at a site remote from the first stent. © 2012 Wiley Periodicals, Inc.     

A word of caution using self‐expanding transcatheter aortic valve‐frame infolding

Transcatheter aortic valve replacement has become a mainstay alternative to surgical aortic valve replacement in patients with severe aortic stenosis at high and intermediate surgical risk. Two commercially approved valves are available in the United States: balloon‐expandable and self‐expanding. We report here a rare complication of a self‐expanding Evolut PRO (Medtronic, Minneapolis, Minnesota) valve failing to expand due to nitinol frame infolding. This results in a malopposed valve with a severe paravalvular leak, even though treated successfully with balloon valvuloplasty. It is important to recognize the characteristic angiographic signature of this complication—the “straight line” sign—and how to avoid this potentially serious complication by balloon valvuloplasty or by recapture and deployment of a new valve.     

NEW METHOD OF STENTING TREATMENT FOR MALIGNANT DUODENAL STENOSIS: USING DOUBLE‐BALLOON ENTEROSCOPY

Recently, a self‐expandable metallic stent has been recognized for treatment of malignant duodenal stenosis. But the complications by stenting are important problems even now. In the present study, we report our new method of duodenal stenting by using of double‐balloon enteroscopy considered safe and effective.     

Treatment of acute stent thrombosis with local urokinase therapy using catheter-based,drug delivery systems: A case report

Abrupt thrombotic stent closure remains a difficult problem to treat in the cardiac catheterization laboratory. A 63-yr-old white female initially underwent successful placement of a Palmaz-Schatz biliary stent in the proximal RCA following failed coronary angioplasty. One week later, the patient represented with an acute inferior infarction and thrombotic occlusion of the stent site in spite of adequate anticoagulation. A new, local drug infusion catheter (the Dispatch? catheter) was placed at the angioplasty site and 150,000 units of urokinase were locally infused, with immediate restoration of normal distal flow and a subsequent marked decrease in angiographic thrombus. A small, residual thrombotic filling defect was further treated with a urokinase-coated hydrogel balloon (Hydro Plus?). Following local urokinase delivery with the Dispatch catheter and hydrogel balloon, there was complete resolution of angiographic thrombus with TIMI 3 flow and no evidence of distal embolization or no-reflow. Local urokinase delivery directly to the site of thrombus with catheter-based drug delivery systems may be a useful technique for rapidly lysing intracoronary clot and re-establishing coronary flow in the setting of acute stent thrombosis.     

Novel self‐expanding stent system for enhanced provisional bifurcation stenting: Examination by StentBoost and intravascular ultrasound

A 62‐year‐old man underwent percutaneous coronary intervention of a bifurcation lesion (Medina type 010) involving the mid‐left anterior descending coronary artery and an important first diagonal branch with a novel stent specifically designed for bifurcations, the Stentys coronary bifurcation system. This is a self‐expanding nitinol stent, with Z‐shaped struts linked by interconnections that can be disconnected (in prespecified points every 1.5 mm all around the circumference and the length of the stent) at the level of the ostium of the side branch, simply by inflating an angioplasty balloon tracked to the ostium of the side branch, through the stent struts. The steps required for deployment of the stent and the final result obtained were evaluated by intravascular ultrasound examination and StentBoost Subtract, a specific X‐ray stent‐enhancing visualization technique. © 2009 Wiley‐Liss, Inc.     

Hairpin‐trap: A novel stent retrieval technique

We report a novel technique for retrieving lost stents or other equipment from the intravascular space. A hairpin is formed at the distal part of a 0.014 inch coronary guidewire, inserted through the Touhy valve, and used to “hook” the lost stent. The distal tip of the wire is then pulled back into the guiding catheter, where it is trapped by a balloon, forming a “hairpin‐trap.” The entire system is subsequently withdrawn. © 2010 Wiley‐Liss, Inc.     

First human implant of the Alterra Adaptive PrestentTM: A new self‐expanding device designed to remodel the right ventricular outflow tract

Current balloon expandable transcatheter valves have limited applicability to patients with “native” right ventricular outflow tracts (RVOT), meaning those who have had previous surgery and are left with large, compliant, irregular RVOT. The Alterra Adaptive Prestent^TM is a self‐expanding, partially covered stent that was designed to internally reconfigure these types of RVOT, making them suitable for implantation of a commercially available balloon expandable heart valve, the SAPIEN 3. Herein, we describe the first human implant of this device.     

Successful management of a distal vessel perforation through a single 8‐French guide catheter: Combining balloon inflation for bleeding control with coil embolization

Coronary perforation is an infrequent, but serious complication of percutaneous coronary intervention (PCI), and is more likely to occur with complex (such as chronic total occlusion) PCI and use of atheroablative devices. For main vessel perforations, the “dual catheter” technique is usually employed in which a balloon is delivered over the first guide catheter to stop bleeding, whereas the covered stent is delivered through a second guide catheter. This is required because the large profile of the currently commercially available covered stents precludes fitting within even an 8‐French guide together with a balloon. However, coil embolization for distal artery wire perforation and collateral vessel perforation can be achieved through a microcatheter that can fit along with a balloon within an 8‐French guide catheter, obviating the need for a second guide catheter. We describe a case in which a distal artery wire perforation was successfully treated using a single 8‐French guide catheter. © 2015 Wiley Periodicals, Inc.