Manuel Maynar

Gianturco self-expanding stents: Clinical experience in the vena cava and large veins

Twenty-five patients with stenosis of the vena cava (21) and other large veins (4) have been treated with self-expanding Gianturco metallic stents. Eighteen patients had superior vena cava syndrome. In 17, the stricture was due to malignant superior vena cava compression recurrent after maximum tolerance radiotherapy and/or chemotherapy. In 16 of these patients there was early symptomatic relief. In 1 patient with a benign posttraumatic superior vena cava stricture, the stenosis was not relieved, and occlusion occurred after 1 month. Stenoses associated with dialysis shunts were relieved in 2 other patients. Two malignant and one benign inferior vena cava stenoses were relieved either until death, or in the benign case, for 30 months. One malignant subclavian vein obstruction occluded after 24 h due to stent misplacement and another with extrinsic mediastinal compression remained patent until death, extensive thrombus having been lysed prior to stent placement. The results of this short series suggest that the Gianturco self-expanding stent in the vena cava and large veins is easy and safe to place, and in most cases produces almost immediate palliation of the distressing effects of venous obstruction, often in a preterminal and inoperable patient.

Use of gianturco self-expandable stents in the tracheobronchial tree

Gianturco self-expandable stents were used successfully in the management of 5 patients with tracheobronchial pathology. Placement was performed under endoscopic and fluoroscopic guidance. None of the patients has experienced complications secondary to the stent placement, and in all of them the clinical problems resolved satisfactorily. Longer follow-up is required to determine the place of tracheobronchial stenting in patients with respiratory compromise.

Comparison of thrombolytic therapy of lower-extremity acute, subacute, and chronic arterial occlusions

Our purpose was to study the effectiveness of thrombolytic therapy in treating acute, subacute, and chronic arterial occlusions in a multicenter retrospective study. Intraarterial urokinase infusion was performed in 235 patients for occluded native arteries. There were 70 (30%) with acute and 26 (5%) with subacute occlusions, and 141 (59%) with chronic symptoms for longer than 3 mo. Complete thrombolysis was achieved in 60 (86%) of the acute, 20 (77%) of the subacute, and 106 (75%) of the chronic occlusions. Adjunctive interventional procedures were performed as needed. Long-term follow-up revealed a primary patency of 87%, 85%, and 76% for the acute, subacute, and chronic occlusion groups, respectively. We conclude that the rate of complete thrombolysis of chronic occlusions proved slightly more efficient for acute and virtually the same for subacute occlusions. Long-term follow-up demonstrated a higher failure rate with chronic than with acute occlusions, probably due to worsened peripheral vascular runoff.

Treatment of Chronic Iliac Artery Occlusions with Guide Wire Recanalization and Primary Stent Placement

PURPOSE To evaluate the results of primary stent placement without initial thrombolysis in the treatment of iliac occlusions. MATERIALS AND METHODS During a 3-year period, 61 iliac artery occlusions were treated in 59 patients. The mean length of the occluded segment was 10 cm (range, 4-25 cm). The occluded arteries were treated with primary placement of self-expandable metallic stents. RESULTS Successful recanalization with primary stent placement was possible in 56 of 61 occlusions (92% technical success rate). Mean Doppler ankle/brachial index increased from 0.51 to 0.90 immediately after treatment and was 0.91 on the last follow-up (P < .05). Primary patency rate at 24 months was 73%, and secondary patency rate was 88%. Procedural complications included distal embolization (n = 4) and an episode of massive intra-abdominal bleeding. Three patients developed a hematoma at the puncture site that did not require additional therapy. Late complications included stent occlusion (n = 9) and significant stenosis related to intimal hyperplasia (n = 1). Mean follow-up period was 29 months (range, 7-55 months). CONCLUSION Primary stent placement is an effective therapeutic option for iliac artery occlusions.

Cragg Endopro System I: Early Experience. I. Femoral Arteries

PURPOSE This work describes the early experience with the Cragg Endopro System I. The safety and efficacy of this device in the treatment of atherosclerotic lesions of the femoral arteries are evaluated. MATERIALS AND METHODS Eleven patients with complex femoral artery lesions were treated. Ten patients presented with femoral artery occlusion and one had a 90% stenosis. All patients had life-style limiting claudication. Associated comorbid states included smoking (n = 10), hypertension (n = 4), hyperlipidemia (n = 5), coronary artery disease (n = 3), and diabetes (n = 1). The stents were dilated to the size of the native artery in the first three patients. The protocol was modified and stents were overdilated by 1 mm in the remaining eight patients. An anticoagulation regimen was used in the first three patients and modified per protocol requirements in the remaining eight. Prophylactics antibiotics were given before the procedure. Follow-up studies included Doppler ultrasound and intravenous and intraarterial digital subtraction angiography. RESULTS An antegrade femoral approach was used. Stent placement was successful in all patients. The mean lesion length was 9.9 cm (4-18 cm). Mean ankle/brachial index before treatment was 0.65 and increased to 0.87 after treatment. Mean follow-up was 17.2 months, and one patients was lost to follow-up. Complications included sepsis (n = 1), fever (n = 2), severe pain (n = 4), thrombosis (n = 5), and hematoma (n = 2). Stent patency was improved after protocol modifications. Overall primary patency rate was 45% and secondary patency was 56%. CONCLUSION This early experience with the Cragg Endopro System I shows that recanalization of long femoral occlusions and stent-graft placement is feasible. The primary and secondary patency rates are low and the complication rate is high. Improved patency rates are expected with a more aggressive anticoagulation regimen and stent overdilation.

Clinical follow‐up in endovascular treatment for TASC C‐D lesions in femoro‐popliteal segment

To demonstrate the technical success and clinical follow‐up after endovascular treatment of femoropopliteal segment TASC II C and D lesions.

Transjugular liver biopsy : A review of 77 biopsies using a spring-propelled cutting needle (biopsy gun)

Seventy-seven transjugular liver biopsies were performed with a coaxial, spring-loaded, 18-gauge cutting needle, the Biopty gun (Bard Biopsy System, Covington, GA, USA) on consecutive patients between July 1993 and February 1995. Fifty men and 27 women were included in the study; the mean age was 45 years (range 15–69 years). The average number of punctures per patient was 5.2, with a range of 2–9, yielding an average of 4.8 samples per patient (range 1–7). The length of the samples varied from 10 to 22 mm with a constant diameter of 1 mm. The mean time required to complete the procedure was 48 min (43–52 min). Histological diagnoses were obtained in 74 of 77 patients (96%), with non-diagnostic specimens attributed to excessive fragmentation (3 cases). Complications occurred in 10 patients (puncture site hematoma, carotid artery puncture, abdominal pain, vasovagal reaction, hepatic capsule perforation, and hemobilia). The latter two complications were self-limited. In our experience this transjugular hepatic biopsy method is promising for performing biopsies in patients with chronic liver disease, due to its high success rate and low morbidity rate.

Carotid stenting without use of balloon angioplasty and distal protection devices: preliminary experience in 100 cases.

BACKGROUND AND PURPOSE: A major concern during carotid artery stent placement is the potential for cerebral embolism. Diminishing the number of device manipulations across the lesion might reduce procedural stroke risk. For this purpose, we report our initial experience with carotid stent placement without the use of either balloon angioplasty or distal protection devices. MATERIALS AND METHODS: Eighty-seven consecutive patients with 100 carotid stenoses compose this series. Ninety four of the 100 hundred stented carotid arteries were either symptomatic (58 [58%]) or had a greater than 70% stenosis (36 [36%]). Six percent of them were asymptomatic and had stenosis between 50% and 70%. Patients underwent neurologic evaluation before the procedure and during follow-up at 1, 3, 6, and 12 months and annually thereafter. Carotid sonography and plain films of the neck were performed immediately after the procedure and then at the same time intervals. RESULTS: Primary stent placement was successful in 98 of 100 case subjects. In 2 case subjects, predilation was necessary before stent deployment. Neurologic periprocedural complications included 1 nondisabling and 1 disabling stroke and 5 transient ischemic attacks. The mean duration of follow-up was 23 months (range: 10–36 months). During the follow-up period, there were 5 deaths, all unrelated to the carotid disease, and no major stroke. The degree of stenosis decreased from a mean of 78.85% before the procedure to a mean of 21.23% immediately after. CONCLUSIONS: In this series, carotid stent placement without the use of either balloon angioplasty or distal protection devices was safe and effective with a low incidence of periprocedural complications.

Treatment of Complete and Partial Obstruction of the Nasolacrimal System with Polyurethane Stents: Initial Experience

AbstractPurpose: To present our experience in the treatment of nasolacrimal occlusion by means of polyurethane stents. Methods: Forty polyurethane stents were placed under fluoroscopic guidance in 35 consecutive patients with epiphora due to total or partial obstruction of the nasolacrimal system. The set designed by Song was used in all patients. The procedure was performed by introducing a guidewire through the superior punctum into the canaliculus and advancing it across the obstruction into the inferior meatus of the nasal cavity. After pulling out the guidewire, the stent was advanced in retrograde fashion and released into the sac and the nasolacrimal duct. Results: The technical success rate was 100%. The average time for the procedure was 25 min (range 10–60 min). Immediate complications were: mild pain (n= 5), severe pain (n= 1), minimal epistaxis (n= 7), and moderate epistaxis (n= 1). No major complications occurred. The last clinical control revealed complete resolution of epiphora in 35 eyes and partial resolution in four; one patient did not improve. Conclusion: This technique for treatment of obstruction of the nasolacrimal system is simple and safe, and may obviate the use of more invasive procedures.

Percutaneous Transluminal Angioplasty versus Turbostatic Carbon–coated Stents in Infrapopliteal Arteries: InPeria II Trial

PURPOSE To determine the clinical outcome and the success of stent application for high-grade lesions of the infrapopliteal arteries compared with treatment with percutaneous transluminal angioplasty (PTA) in critical limb ischemia (CLI). MATERIALS AND METHODS In this ethics board-approved randomized prospective study, PTA or stent application was performed on 131 lesions in 88 patients with CLI. The primary end points were clinical improvement after endovascular treatment and limb salvage rate. Secondary end points were defined by the minimal lumen diameter (MLD) before and after the revascularization procedure, percentage of residual diameter stenosis (DS), binary restenosis rate (>50% DS and >70% DS), and incidence of target lesion revascularization at 9-month follow-up. RESULTS At 3 months, the clinical status in the PTA group was less improved than that in the stent group (P = .008). At 9 months, there had been five minor and two major amputations in the PTA group and five major and five minor amputations in the stent group. MLD was significantly larger and the percentage of DS was significantly less in the stent group at completion angiography. At 9 months, the angiographic control showed better trends for the stent group in comparison to the PTA group despite that no significant differences were detected (MLD, 1.19 mm ± 0.92 vs 1.02 mm ± 1.02; DS, 38.68% ± 25.47 vs 43.31% ± 28.37). CONCLUSION Infrapopliteal stent application is an effective treatment modality in CLI. The PTA and stent groups were essentially equal at 3 and 9 months except for the difference in clinical improvement in the stent group at 3 months.