Colonic Migration of a Nephroureteral Stent Through a Colovesical Fistula.

Description We describe a case of a patient with a two-year history of prostate cancer who underwent placement of nephroureteral stents. He subsequently presented to the hospital with complications from prolonged retention of the stents, which ultimately lead to a secondary diagnosis of adenocarcinoma of the rectum. A colonoscopy performed approximately two weeks after a bilateral nephroureteral tube exchange demonstrated what was believed to be locoregional metastatic disease and a fistulous connection with the distal nephroureteral stents. Radiographic features of this complication are discussed together with proper management and possible complications of distal nephroureteral stents. Both nephroureteral stents were explanted, and nephrostomy catheters were sequentially replaced to allow for healing of the fistula.

Dislodged Coronary Artery Stent Retrieved With an Endovascular Snare.

Advances in stent design and technology have made stent loss during percutaneous coronary intervention rare. When stent loss occurs, the risk of life-threatening procedural complications is high. We describe the use of an endovascular snare system to retrieve a dislodged stent from the proximal right coronary artery of a 54-year-old man during percutaneous coronary intervention after other conventional retrieval techniques had failed.

Results of a national survey on the use of stents for the treatment of colonic obstruction. / Resultados de una encuesta nacional sobre el uso de stent para el tratamiento de la obstrucción de colon.

INTRODUCTION: We distributed a survey in order to determine the current indications for the use of colonic stents to treat colonic obstruction in Spain and its compliance with international guidelines. METHODS: Descriptive study of a survey distributed by the Spanish Association of Surgeons (Asociación Española de Cirujanos), the Catalan Society of Surgery (Societat Catalana de Cirurgia) and the Spanish Society of Digestive Endoscopy (Sociedad Española de Endoscopia Digestiva). RESULTS: 340 valid responses were received: 25% from gastrointestinal specialists, and 75% from general surgeons. During the last year, 44.4% of respondents assessed between 10 and 20 COC. Of these, 52.2% indicated less than 5 stents/year, 75% of which were indicated as a prior step to preferential surgery and only 25% were performed with palliative intent. 55.3% of the participants reported knowing the official guidelines, and 64% of respondents would use the stent as a step prior to surgery in elderly patients with localized disease. 75.9% would place stents as palliative therapy in young patients with carcinomatosis, and 61.8% would use them in stage IV malignancies under treatment with chemotherapy. Only 18.1% knew of the risk of colon perforation after stent placement in patients undergoing treatment with antiangiogenics. CONCLUSIONS: In Spain, the indication for colonic stents is reserved for selected cases and varies according to the specialty and the years of experience of the respondent. The compliance with international guidelines of most respondents is moderate. It is important to insist on the high risk of perforation after angiogenics, which is unknown to most surgeons.

Longitudinal Deformation of Distal Edge in a New-Generation Stent Caused by Guidewire Entrapment.

Longitudinal stent deformation, described in some older stent geometries, prompted design modifications such as reinforcing struts on the proximal end. However, distal edges of stents-also subject to longitudinal force-have not been reinforced. We report a case of guidewire entrapment that deformed the distal edge of a new-generation stent during percutaneous coronary intervention, and we describe our efforts to restore the stent to its initial length. This case highlights the risk of manipulating equipment beyond the position of a newly deployed stent, the ongoing potential for deformation of distal edges in newer stent platforms, and the advisability of treating distal lesions before proximal ones.

Stent-graft relining in a patient with acute aortic aneurysm and a completely migrated endograft

Abstract Stent-graft migration and type I endoleaks are associated with a higher rate of reintervention and increased mortality and morbidity. This article describes a patient presented with an infrarenal aortic stent-graft which had migrated into the aortic sac with loss of all aortic neck attachment. The acutely expanding abdominal aortic aneurysm was treated by placing a second modular endograft within and above the migrated stentgraft. The patient returned 36 months later, with features of an acute myocardial infarction, severe bilateral lower limb ischemia, and renal failure. He was too ill for intervention and demised within 48 hours.

Drug-Coated Balloon Treatment of Very Late Stent Thrombosis Due to Complicated Neoatherosclerosis / Tratamento por Balão Farmacológico de Trombose de Stent Muito Tardia Causada por Neoaterosclerose Complicada

Abstract We describe the treatment of a patient presenting with very-late stent thrombosis with the use of a drug-coated balloon. In this patient, optical coherence tomography disclosed that ruptured and complicated neoatherosclerosis was the underlying substrate responsible for the episode of very-late stent thrombosis. The potential use of drug-coated balloons in this unique scenario is discussed.

Resumo Descrevemos o tratamento de um paciente apresentando trombose de stent muito tardia com a utilização de um balão farmacológico. Nesse paciente, a tomografia de coerência ótica revelou que a neoaterosclerose apresentava-se complicada e com ruptura, sendo portanto o substrato subjacente responsável pelo episódio de trombose de stent muito tardia. O uso potencial de balões farmacológicos nesse cenário especial é discutido.

Implantable Cardioverter-Defibrillator Shock after Stenting Across the Device Leads.

A 45-year-old man with nonischemic cardiomyopathy and end-stage renal disease had lived uneventfully with a cardiac resynchronization therapy defibrillator (CRT-D) for 5 years. Less than a month before presenting at our institution, he had undergone stenting of his partially occluded subclavian vein, to relieve stenosis of the ipsilateral arteriovenous fistula that was used for his hemodialysis. The CRT-D subsequently discharged. Device interrogation revealed that electrical noise originating from leads damaged by the stent had caused the inappropriate shock and intermittent electrical discharges thereafter. The patient was highly traumatized by these events and insisted upon device removal, which deprived him of a potentially life-saving intervention. He later had a cardiac arrest that resulted in sustained profound hypoxic ischemic encephalopathy with minimal neurologic recovery: his family placed him in a long-term care facility on ventilator support, with a tracheostomy and feeding tube. This situation might have been avoided through collaboration between the interventional radiologist and the electrophysiologist. To our knowledge, this is the first report of a patient with nonischemic cardiomyopathy and end-stage renal disease who presented with inappropriate defibrillator discharge caused by lead damage secondary to stenting across the leads.

Successful Prasugrel Therapy for Recurrent Left Main Stent Thrombosis in a Clopidogrel Hyporesponder.

Stent thrombosis is a life-threatening sequela of drug-eluting stent implantation. Dual antiplatelet therapy with aspirin and thienopyridine is typically used to prevent this catastrophic event. In terms of stent thrombosis, the major concern is the variable response of patients to clopidogrel, and this has raised interest in new antiplatelet agents. We present the case of a 64-year-old woman whom we successfully treated with prasugrel after she had repeated episodes of stent thrombosis caused by a poor response to clopidogrel. This case highlights the potential role of new antiplatelet agents for patients who are undergoing drug-eluting stent implantation.

Very Late Stent Thrombosis 11 Years after Implantation of a Drug-Eluting Stent.

Very late stent thrombosis is an infrequent yet potentially fatal complication associated with drug-eluting stents. We report the case of an 88-year-old man who sustained an ST-segment-elevation myocardial infarction 11 years after initial sirolimus-eluting stent implantation. Optical coherence tomograms of the lesion showed that the focal incomplete endothelialization of the stent struts was the likely cause; neointimal formation, neoatherosclerosis, and late stent malapposition might also have contributed. To our knowledge, this is the longest reported intervening period between stent insertion and the development of an acute coronary event secondary to very late stent thrombosis. The associated prognostic and therapeutic implications are considerable, because they illuminate the uncertainties surrounding the optimal duration of antiplatelet therapy in patients who have drug-eluting stents. Clinicians face challenges in treating these patients, particularly when competing medical demands necessitate the discontinuation of antiplatelet therapy. In addition to the patient's case, we discuss factors that can contribute to very late stent thrombosis.

Acute promyelocytic leukemia as a cause of intracoronary drug-eluting-stent thrombosis.

Stent thrombosis is a potentially lethal complication of percutaneous coronary intervention. We describe the case of a 51-year-old man who presented with acute anterior ST-segment-elevation myocardial infarction and underwent successful percutaneous transluminal coronary angioplasty and placement of 3 drug-eluting stents in the left anterior descending coronary artery. Despite receiving dual antiplatelet therapy, the patient presented a week later with a non-ST-segment-elevation myocardial infarction and was found to have nonocclusive thrombosis of the left anterior descending coronary artery stents and his ostial left main and left circumflex coronary arteries. Subsequently, bone marrow biopsy analysis indicated that the patient had acute myelogenous leukemia, which we believe was the underlying cause of his prothrombotic state and stent thrombosis.

Coronary stent infections: a case report and literature review.

Although rare, coronary artery stent infections are associated with a high mortality rate. Since the introduction of coronary stents in 1987, only 16 cases of infection have been reported. We report a new case in a 66-year-old woman who had undergone a difficult percutaneous coronary intervention procedure, during which 3 overlapping stents were implanted in the mid portion of the right coronary artery. Twenty-two days after the procedure, the patient died. Autopsy revealed the cause of death to be pericardial tamponade due to rupture of the right ventricular myocardium. The stented portion of the right coronary artery was enveloped by an abscess, and purulent material completely occluded the stents. Cultures of the myocardium were positive for methicillin-resistant Staphylococcus aureus. We conducted a review of the literature on coronary artery stent infections. Data suggest that early-onset infections (<10 days after stent implantation) are potentially amenable to medical therapy alone, but late-onset infections (≥10 days after implantation) or major complications necessitate combined surgical and medical therapy. Medical therapy consists of broad-spectrum antibiotics. Surgical intervention includes stent removal if possible, and abscess drainage or perforation repair when indicated.

Percutaneous coronary intervention with optimal medical therapy vs. optimal medical therapy alone for patients with stable angina pectoris.

SCIENTIFIC BACKGROUND: Stable Angina Pectoris (AP) is a main syndrome of chronic coronary artery disease (CAD), a disease with enormous epidemiological and health economic relevance. Medical therapy and percutaneous coronary interventions (PCI) are the most important methods used in the treatment of chronic CAD. RESEARCH QUESTIONS: The evaluation addresses questions on medical efficacy, incremental cost-effectiveness as well as ethic, social and legal aspects in the use of PCI in CAD patients in comparison to optimal medical therapy alone. METHODS: A systematic literature search was conducted in June 2010 in the electronic databases (MEDLINE, EMBASE etc.) and was completed by a hand search. The medical analysis was initially based on systematic reviews of randomized controlled trials (RCT) and was followed by the evaluation of RCT with use of current optimal medical therapy. The results of the RCT were combined using meta-analysis. The strength and the applicability of the determined evidence were appraised. The health economic analysis was initially focused on the published studies. Additionally, a health economic modelling was performed with clinical assumptions derived from the conducted meta-analysis and economic assumptions derived from the German Diagnosis Related Groups 2011. RESULTS: Seven systematic reviews (applicability of the evidence low) and three RCT with use of optimal medical therapy (applicability of the evidence for the endpoints AP and revascularisations moderate, for further endpoints high) were included in the medical analysis. The results from RCT are used as a base of the evaluation. The routine use of the PCI reduces the proportion of patients with AP attacks in the follow-up after one and after three years in comparison with optimal medical therapy alone (evidence strength moderate); however, this effect was not demonstrated in the follow-up after five years (evidence strength low). The difference in effect in the follow-up after four to five years was not found for the further investigated clinical endpoints: death, cardiac death, myocardial infarction and stroke (evidence strength high) as well as for severe heart failure (evidence strength moderate). Two studies were included in the health economic analysis. The costs estimations from these studies are not directly transferable to the corresponding costs in Germany. The average difference in the total costs for PCI in comparison with optimal medical therapy alone, which was calculated in the modelling, was found to be 4,217 Euro per patient. The incremental cost-effectiveness ratio per life-year of a patient with avoided AP attacks was estimated to be 24,805 Euro (evidence strength moderate). No publication was identified concerning ethical, social or legal aspects. DISCUSSION: Important methodical problems of the studies are a lack of blinding of the patients and incomplete data for several endpoints in the follow-up. The determined incremental cost-effectiveness ratio per life-year of a patient with avoided AP attacks was appraised not to be cost-effective. CONCLUSIONS: From a medical point of view the routine use of PCI in addition to the optimal medicinal therapy in patients with stable AP can be recommended for the reduction of the proportion of patients with AP attacks after one year and after three years (recommendation degree weak). Otherwise, PCI is to be performed in patients with refractory or progressing AP despite of optimal medical therapy use; in this case PCI is expected to be applied in 27% to 30% of patients in five years. From the health economic view the routine use of PCI in addition to an optimal medical therapy in patients with stable AP cannot be recommended. No special considerations can be made concerning special ethical, social or legal aspects in the routine use of PCI in addition to optimal medical therapy in patients with stable AP.

Paclitaxel induces thrombomodulin downregulation in human aortic endothelial cells.

Patients with paclitaxel-eluting stents are at risk of developing stent thrombosis upon premature discontinuation of dual antiplatelet therapy. In this study, we set out to clarify whether paclitaxel can modulate thrombomodulin expression in human aortic endothelial cells. Human aortic endothelial cells were stimulated with paclitaxel. Methoxyphenyl tetrazolium inner salt cell viability assay, Western blot analysis, real-time polymerase chain reaction, and immunohistochemical assay were performed. In human aortic endothelial cells, paclitaxel (10(-5) to 10(-9) mol/L) treatment for 13 hours caused significant cytotoxicity at drug concentrations greater than 10(-7) mol/L. Paclitaxel (10(-5) to 10(-9) mol/L) treatment for 5 hours downregulated thrombomodulin expression dose-dependently, persisting even at 13 hours. Cotreatment with thrombin and paclitaxel did not alter the effect of paclitaxel on thrombomodulin downregulation. Paclitaxel caused a 0.63-fold decrease in thrombomodulin messenger RNA expression, and thrombin cotreatment did not alter this decrease. In vivo studies confirmed that paclitaxel (10 mg/kg) caused endothelial thrombomodulin downregulation in mice. In summary, paclitaxel downregulates thrombomodulin expression regardless of thrombin stimulation, which is an important factor for patients receiving paclitaxel-eluting stents. Therefore, further designs of drug-eluting stents should consider the influence of the eluted drugs on endothelial thrombogenicity.

Efficacy and safety of drug-eluting stents in patients with acute ST-segment-elevation myocardial infarction: a meta-analysis of randomized controlled trials.

We compared the efficacy and safety of drug-eluting stents with that of bare-metal stents in patients who experienced acute ST-segment-elevation myocardial infarction (STEMI) and underwent primary percutaneous coronary intervention. To do this, we performed a meta-analysis of 13 randomized controlled trials in which drug-eluting stents were compared with bare-metal stents in STEMI patients. The trials involved 6,769 patients (4,246 received drug-eluting stents and 2,523 received bare-metal stents) and follow-up periods of 6 to 48 months. In comparison with bare-metal stents, drug-eluting stents significantly reduced the incidence of major adverse cardiac events, with a risk ratio (RR) of 0.59 (95% confidence interval [CI], 0.47-0.73; P < 0.00001). Drug-eluting stents were not associated with a significant reduction in overall death (RR = 0.94; 95% CI, 0.74-1.20; P = 0.64), but were associated with significant reductions in recurrent myocardial infarction (RR = 0.76; 95% CI, 0.58-0.98; P = 0.03), target-vessel revascularization (RR = 0.47; 95% CI, 0.39-0.56; P <0.00001), and in-stent restenosis (RR = 0.32; 95% CI, 0.25-0.39; P < 0.00001). Moreover, no significant difference was found in the comparative risk of stent thrombosis (RR = 0.85; 95% CI, 0.63-1.14; P = 0.27).On the basis of risk ratio, we conclude that using drug-eluting stents in STEMI patients who undergo primary percutaneous coronary intervention is safe with regard to stent thrombosis within 48 months, and that drug-eluting stents improve clinical outcomes by reducing the risks of major adverse cardiac events, recurrent myocardial infarction, reintervention, and in-stent restenosis, compared with bare-metal stents. However, in order to investigate possible very late stent thrombosis, follow-up of these trials beyond 48 months is warranted.

Covered-stent treatment of coronary aneurysm after drug-eluting stent placement: case report and literature review.

Most commonly, coronary artery aneurysms are secondary to atherosclerosis, but cases have been reported in patients who have vasculitis or tissue disorders, and in patients who have undergone interventional procedures. However, over the past few years, an increasing number of cases of coronary artery aneurysms after drug-eluting stent implantation have been reported. The exact mechanism is unknown. Experimental animal studies have shown that both the active drug and the polymer coating, under certain circumstances, might cause progressive luminal dilation, positive vascular remodeling, and aneurysmal formation. Complications like rupture, thrombosis, embolization, myocardial infarction, and even sudden death have been reported. Treatment options vary from aggressive surgical ligation of the aneurysm, in union with distal bypass surgery, to percutaneous implantation of a covered stent or conservative medical management with continued antiplatelet therapy. Currently, there is no consensus on an ideal approach to treating coronary artery aneurysm after drug-eluting stent implantation. Polytetrafluoroethylene-covered stents, easy and rapid to deploy, have emerged as a newer option. We report a case of coronary artery aneurysm at the site of a previous drug-eluting stent. The lesion was successfully treated with a polytetrafluoroethylene-covered stent.

Drug-eluting stent thrombosis 1,659 days after stent deployment: case report and literature review.

Drug-eluting stents are considered to be superior to bare-metal stents in reducing restenosis rates at 6 months. However, drug-eluting stents appear to be subject to stent thrombosis, a concern that has been reported more frequently in recent times. In November 2003, a 64-year-old man with a medical history of hypertension, type 2 diabetes mellitus, and coronary artery disease underwent percutaneous coronary intervention for the deployment of a sirolimus-eluting stent in the left anterior descending coronary artery. He experienced no complications. More than 4 years later, at age 69, he underwent neurosurgical treatment for a subdural hematoma that resulted from a fall, and he was advised to stop taking aspirin and clopidogrel. Thirty-three days later--1,659 days after stent deployment--he presented with a clinical event that was associated with very late stent thrombosis. After undergoing emergent coronary angiography and the placement of 2 bare-metal stents, he resumed antiplatelet therapy, recovered uneventfully, and was discharged from the hospital in stable condition. To the best of our knowledge, 1,659 days is the longest reported interval between the deployment of a drug-eluting stent and the occurrence of a clinical event that was associated with very late stent thrombosis. Herein, we discuss the case of our patient, review the pertinent medical literature, reinforce the importance of continuous and uninterrupted antiplatelet therapy in drug-eluting stent recipients, and offer considerations regarding the use of drug-eluting stents.

Impact of C-reactive protein on in-stent restenosis: a meta-analysis.

We sought to evaluate the impact of C-reactive protein (CRP) levels on in-stent restenosis after percutaneous coronary intervention.The plasma level of CRP is considered a risk predictor for cardiovascular diseases. However, the relationship between CRP and in-stent restenosis has been a matter of controversy. Meta-analysis reduces variability and better evaluates the correlation.We performed a systemic search for literature published in March 2008 and earlier, using MEDLINE(R), the Cochrane clinical trials database, and EMBASE(R). We also scanned relevant reference lists and hand-searched all review articles or abstracts from conference reports on this topic. Of the 245 studies that we initially searched, we chose 9 prospective observational studies (1,062 patients).Overall, CRP concentration was higher in patients who experienced in-stent restenosis. The weighted mean difference in CRP levels between the patients with in-stent restenosis and those without was 1.67, and the Z-score for overall effect was 2.12 (P=0.03). Our subgroup analysis that compared patients with stable and unstable angina showed a weighted mean difference in the CRP levels of 2.22 between the patients with and without in-stent restenosis, and the Z-score for overall effect was 2.23 (P=0.03) in 5 studies of unstable-angina patients. There was no significance in 4 studies of stable-angina patients.In spite of significant heterogeneity across the studies, our meta-analysis suggests that preprocedurally elevated levels of CRP are associated with greater in-stent restenosis after stenting and that this impact appears more prominent in unstable-angina patients.

Late stent thrombosis associated with heavy exercise.

Bare-metal stents are commonly used in the treatment of coronary artery disease. Stent thrombosis usually occurs within the first 48 hours after stent deployment. After a week, the incidence of thrombosis is low. Late stent thrombosis (after 30 days) is rarely seen; however, its clinical outcomes are severe 30-day mortality rates of 20% to 48% and myocardial infarction rates of 60% to 70%. Herein, we present the case and discuss the treatment of a patient who, after heavy exercise, experienced acute myocardial infarction due to late thrombosis in a bare-metal stent.A 54-year-old man presented with unstable angina pectoris. Coronary angiography revealed critical occlusion of the middle right coronary artery. A bare-metal stent was implanted, and he was discharged from the hospital on a medical regimen. Eleven months later, he presented with acute myocardial infarction, which had developed after heavy exercise. Coronary angiography revealed occlusion of the stent in the right coronary artery. After the occlusion was crossed with a guidewire, balloon angioplasty was applied, and Thrombosis-in-Myocardial-Infarction (TIMI)-3 flow was restored. The patient was asymptomatic during his 5-day hospitalization and was discharged on dual antiplatelet therapy.In addition to presenting this patient's case, we discuss mechanisms that may contribute to late stent thrombosis, implications of the condition, and preventive therapy.

Fracture of zotarolimus-eluting stent after implantation.

Drug-eluting stents were developed and approved for the reduction of in-stent restenosis. However, restenosis still occurs, and stent fracture is suggested as a cause of restenosis after implantation. Although sirolimus-eluting stents are considered to carry a high risk of fracture, the risk is also present with other drug-eluting stents. Herein, we report the case of a 78-year-old woman who received a zotarolimus-eluting stent for a bifurcation lesion of the left anterior descending coronary artery. Ten months later, she underwent coronary angiography due to angina. The angiogram revealed in-stent restenosis, with a grade IV stent fracture. After percutaneous coronary angioplasty, the patient's clinical symptoms improved.