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Vascular Access
Published in James Michael Forsyth, How to Be a Safe Consultant Vascular Surgeon from Day One, 2023
Stent grafting? Why not consider a bare metal stent?“No. Bare metal stents have not demonstrated an advantage in long term patency over balloon angioplasty.”
Complications of hemodialysis access
Published in Sachinder Singh Hans, Mark F. Conrad, Vascular and Endovascular Complications, 2021
Mia Miller, Prakash Jayanthi, William Oppat
Stenting is an attractive option for this disease, but caution must be maintained. The KDOQI recommends it in the setting of failed or recurrent CVS with angioplasty.67 In Figures 29.7 and 29.8, we illustrate a brachiocephalic vein stenosis treated with angioplasty and stenting. It is inadvisable to stent the thoracic outlet, where it will be exposed to the compressive forces of the clavicle and first rib and may result in extrinsic compression and stent fracture.35,67 Stent grafts have shown improved outcomes over bare metal stents, with improved primary and assisted patency rates. This may allow for immediate salvage for accesses in difficult cases.66 A covered stent may unintentionally occlude important collaterals of other central veins, posing complications for the future.67 Post-procedural monitoring should also consider the possibility of edge stent stenosis. In the setting of pacers, it may be easier to place a contralateral access, due to the refractory nature of stenotic lesions from pacer wires.67 However, if relocating the wires is not deemed possible, the pacer wires should be removed and the pacer moved to a different site, to allow for intraluminal stenting without crushing of the wire. Angioplasty alone is possible but has the added risk of injury to the wires.
Perioperative issues
Published in Neeraj Sethi, R. James A. England, Neil de Zoysa, Head, Neck and Thyroid Surgery, 2020
Gordon A. G. McKenzie, David J. H. Shipway
The deployment of stents in the coronary vasculature requires antiplatelet cover to reduce the risk of stent thrombosis and myocardial infarction (MI) until the stent has undergone successful endothelialisation. The type of previous percutaneous coronary intervention (PCI) and stenting determines the minimum recommended duration of dual antiplatelet therapy (DAPT), and therefore may affect the timing of elective surgery. Cessation of DAPT prior to these timeframes represents an increased risk of perioperative in-stent thrombosis and acute MI, which is associated with greatly increased cardiovascular mortality: Bare metal stent (30 days)Drug-eluting stent (3–6 months, depending on product used; upper limit preferred)Balloon angioplasty (2 weeks or more) [11]
Contemporary review of management techniques for cephalic arch stenosis in hemodialysis
Published in Renal Failure, 2023
Gift Echefu, Shivangi Shivangi, Ramanath Dukkipati, Jon Schellack, Damodar Kumbala
Due to poor angioplasty outcomes, in part due to the need for recurrent interventions and poor primary patency, alternative management options for CAS are being investigated. Stent graft placement improves angioplasty outcomes and is becoming more employed in the primary management of CAS (Figure 4). Bare metal stents (BMS) are falling out of favor due to high in-stent restenosis and low patency rates making stent grafts a better alternative. Bare metal stents appear relatively superior to angioplasty alone [39]. Dukkipati et al. compared outcomes following angioplasty alone to BMS in their study of 45 patients. The authors reported a median patency of 152 days among BMSs patients versus 91.5 days in those who underwent only angioplasty [40]. Shemesh et al. conducted a randomized control trial comparing the patency rates of bare metal stents and stent graft among 25 patients undergoing management for failed angioplasty for the management of recurrent CAS. They reported primary patency at 6 months for BMS at 39% compared to stent grafts at 82%. Primary patency at 1 year was 32% in the stent graft group versus 0% in the bare stent group. Rate of restenosis was 70% (10) in the BMS group and 18% (11) in the stent graft group [41]. Jones et al. described a group of 39 patients who underwent stent graft placement for management of CAS. They reported primary patency of 85%, 67%, and 4%, at 3, 6, and 12 months respectively. Primary assisted patency was 95% at 12 months [42].
Long-term improvement of symptoms of angina pectoris after successful revascularization of coronary artery chronic total occlusions
Published in Scandinavian Cardiovascular Journal, 2023
Hirokazu Miyashita, Lauri Mansikkaniemi, Juha Sinisalo, Juhani Stewart, Petri Laine
A CTO was defined as a 100% stenosis in a coronary artery stenosis with TIMI 0 antegrade flow, and an assumed duration of over three months [10]. Procedural success was defined as a less than 20% residual angiographic stenosis with a TIMI flow grade 3, and without periprocedural MACE. All patients were on acetylsalicylic acid (ASA) treatment before the CTO PCI intervention, with dual antiplatelet therapy (DAPT) initiated using ADP receptor blockers (P2Y12 inhibitors, including clopidogrel, prasugrel, or ticagrelor) in all patients not receiving anticoagulant therapy. After successful CTO PCI, DAPT was recommended for at least 12 months for drug eluting stents. None of the patients were treated with a bare metal stent. After successful CTO PCI in anticoagulated patients DAPT and oral anticoagulation were continued for at least one month, after which the continuation of DAPT was according to the discretion of the treating cardiologist. The patients with a failed CTO PCI attempt received guideline-based OMT, without additional DAPT.
Interventions in Congenital Heart Disease:A Review of Recent Developments: Part I
Published in Structural Heart, 2021
Despite important advances in the understanding of this disease, management of PVS remains challenging, with neither surgical nor transcatheter interventions yielding satisfactory long-term results. The introduction of “sutureless” surgical techniques has been useful in treating proximal disease, but results remain disappointing in cases of distal disease.70 In this regard, transcatheter intervention has become a component of various treatment strategies. Conventional balloon angioplasty and cutting balloon angioplasty (BA) are of comparable efficacy in providing acute hemodynamic and angiographic relief. However, restenosis is the norm with no difference in reintervention rates (freedom from reintervention at 1 year 4% for cutting balloon and 23% for conventional BA).71 There are no data comparing outcomes of stent versus balloon angioplasty. The largest published experience of bare metal stents (BMS) in primary pediatric and postoperative PVS reported freedom from reintervention of only 42 ± 7% at 1 year, despite excellent acute gradient relief. A stent implant with larger diameter, ≥7 mm, was associated with longer freedom to reintervention.72 Hybrid pulmonary vein stenting has been proposed as a useful adjunct at the time of surgical intervention for recurrent and malignant PVS.73