1. Θεματική ενότητα: Stenting
Μ. Ματσάγκας, MD, PhD, FEBVS
Σάββατο 1 Φεβρουαρίου 2014

2. Stenting Acute Complications of Stent Placement
Late Complications of Stent Placement

3. Acute Complications of Stent Placement
Arterial dissection
Arterial occlusion
Arterial rupture
Migration or embolization of the stent
Embolization of atherosclerotic material

4. Arterial dissection
If acute arterial dissection occurs in juxtaposition to a stent, an additional stent is placed in this location
The lead point for arterial dissection associated with stent placement is usually within a centimeter of the end of the stent
A stent is placed in this segment even if it is not clear exactly where the lead point of the dissection is located

5. Arterial dissection

6. Arterial occlusion
The stented site may occlude as a result of arterial dissection or as a result of placement of a stent that is not fully expanded
After stent placement, additional balloon dilatation is usually performed to ensure full expansion of the stent
If the problem is not resolved, check outflow thoroughly, consider the use of covered-stent

7. Arterial rupture
If the stent has been fully deployed, a balloon catheter is inserted and placed within the stent along the area where the rupture is thought to have occurred and the balloon is inflated
A covered stent is placed in the same location
Emergency operative repair is undertaken

8. Migration of the stent
Migration of the stent may occur during deployment, usually because the size of the stent that was required was underestimated
If the stent has migrated enough that the area of interest has not been adequately stented, another stent is placed in this location

9. Embolization of the stent
Use a long sheath and a loop snare to pull or push into a favorable location
to retrieve surgically (common femoral artery)
to abandon (internal iliac, deep femoral, or tibial arteries)

10. Embolization of atherosclerotic material
Distal embolization may occur as a result of instrumentation of a friable atherosclerotic lesion
It is unusual for further embolization to occur after the entire lesion has been covered with stents

11. Late Complications of Stent Placement
Intimal hyperplasia
Recurrent stenosis
Infection
Stent damage

12. Intimal hyperplasia Recurrent stenosis
Intimal hyperplasia can be treated with
repeat balloon dilatation
additional stents
directional atherectomy
surgery
If recurrent stenosis occurs in juxtaposition to a stent, an overlapping stent is placed

13. Infection
Infection of a stent is rare and is managed by excising the stent, usually along with the arterial segment
Balloon-expandable stent requires surgical removal: if the stent is fully deployed, the artery probably requires reconstruction. An artery cannot be occluded with a clamp at the location of a stent. The ends of the stent are sharp
Self-expanding stent requires surgical removal: the stent may be extracted by squeezing it, which narrows the whole stent

14. Stent damage Stents can be damaged by external forces
Chronic repetitive shoulder motion with compression of a stented subclavian artery against the first rib leads to stent fracture
Stents can also be crushed, especially the balloon- expandable stents, by:
arterial clamps
blood pressure cuffs
motion at joints
external blunt trauma

15. Bailout maneuvers for balloon-expandable stents
Balloon with stent will not pass through the sheath:
The sheath may have kinked
Consider pulling the kinked part of the sheath back into a straighter segment of the artery and try again to pass the balloon and stent
Pull out the balloon and stent with the sheath but leave the guidewire in place. Change the sheath and start again
Predilate the lesion; use a larger sheath and stiffer wire
Consider using a self-expanding stent for tortuous arteries

16. Bailout maneuvers for balloon-expandable stents
Balloon with stent will not pass through the sheath

17. Bailout maneuvers for balloon-expandable stents
Loose stent on the catheter shaft:
Pull the balloon back into the stent using the tip of the sheath to pin the stent
Pull the stent back into the sheath, if possible
Use a partially inflated balloon to pull the stent and remove the sheath
If the stent cannot be pulled back into the sheath, pin the back end of the stent with the tip of the sheath and deploy in a neutral location

18. Bailout maneuvers for balloon-expandable stents
Loose stent on the catheter shaft

19. Bailout maneuvers for balloon-expandable stents
Loose stent on the guidewire :
Advance small balloon into the stent to flare the end and stabilize
Deploy in a neutral location

20. Bailout maneuvers for balloon-expandable stents
Balloon ruptures during deployment:
Perform high-pressure, hand-powered balloon inflation with saline solution in an attempt to overwhelm the hole in the leaky balloon
Advance the sheath to pin the stent so that it is not withdrawn with the balloon
Rotate and remove the ruptured balloon
Cross the stent with another balloon, and inflate

21. Bailout maneuvers for balloon-expandable stents
Loose stent on the catheter shaft

22. Bailout maneuvers for balloon-expandable stents
Stent tilts:
Some balloon-expanding stents are too rigid for tortuous arteries.
Self-expanding stents are often a better choice
Place another stent to straighten the curve

23. Bailout maneuvers for balloon-expandable stents
Stent tilts

24. Bailout maneuvers for self-expanding stents
End of the stent is not fully expanded:
The hoop strength of the self-expanding stent may not be adequate to compress the lesion
Dilate the body of the stent to make sure it is properly seeded, and then dilate the ends

25. Bailout maneuvers for self-expanding stents
End of the stent is not fully expanded

26. Bailout maneuvers for self-expanding stents
Stent extends into undesired location:
Dilate the stent to foreshorten it. This works well with a Wallstent
Other types of self-expanding stents can sometimes be moved a very short distance by inflating a balloon and pulling gently on the catheter

27. Bailout maneuvers for self-expanding stents
Stent extends into undesired location

28. Bailout maneuvers for self-expanding stents
Stent location is inaccurate:
The only way to avoid this is to deploy the end of the stent first that has the greatest precision requirement

29. Bailout maneuvers for self-expanding stents
Stent location is inaccurate

30. Bailout maneuvers for self-expanding stents
The end of the stent extends into the introducer sheath:
The stent will not deploy
If the tip of the sheath does not have a radiopaque marker, it may be difficult to visualize
Pull the sheath back slightly while holding the stent delivery catheter in place to release the crimped stent

31. Bailout maneuvers for self-expanding stents
The end of the stent extends into the introducer sheath

32. Bailout maneuvers for self-expanding stents
Stent collapses in its midsection:
Repeat angioplasty
If that is unsuccessful, place a balloon-expandable stent inside the self-expanding stent

33. Bailout maneuvers for self-expanding stents
Stent collapses in its midsection