A surprising culprit for delayed gastrointestinal bleeding after endoscopic ultrasound-guided cholecystoduodenostomy: the double-pigtail stent.

Endoscopic ultrasound-guided gallbladder drainage using a lumen-apposing metal stent has emerged as an accepted option for the treatment of acute cholecystitis in patients unfit for surgery. While metal stents carry a risk of intra- and post-procedural bleeding, the coaxial placement of a double-pigtail stents through lumen-apposing metal stents has been proposed to lower the bleeding risk by preventing tissue abrasion against the stent flanges. We present a case of an 83 year-old male who had previously undergone uncomplicated endoscopic ultrasound-guided cholecystoduodenostomy with this technique. Six months later, he presented with upper gastrointestinal bleeding due to a duodenal pressure ulcer from the coaxial 10-Fr double-pigtail stent originally employed to prevent such bleeding. The 10-Fr stent was replaced with two 7-Fr stents whose increased flexibility and distribution of pressure across multiple points of contact with the duodenal wall was theorized to reduce the likelihood of erosion or perforation. Following the procedure, the patient's clinical course improved significantly with complete resolution of his symptoms of choledocholithiasis and cholecystitis. While 10-Fr double-pigtail stents are generally preferred for this indication due to their stiffness that reduces out-migration, use of more flexible 7-Fr stents may be advisable in thin-walled structures such as the duodenum.

A rabbit model of tracheal collapse for optimal self-expanding metal stents.

Investigating the characteristics of tracheas can help the understanding of diseases related to the trachea, particularly tracheal collapse (TC) in dogs. This study aimed to compare the mechanical properties of tracheas from New Zealand White (NZW) rabbits and dogs and to introduce a method for inducing a model of TC in the normal trachea. Tracheal samples were obtained from NZW rabbit cadavers (n=5) weighing 3.62-3.92 kg and from dog cadavers (n=5) weighing 2.97-3.28 kg. Three live NZW rabbits weighing 3.5-4.0 kg were used to establish the model. The radial forces of both sample sets were measured using a digital force gauge and statistically compared. Subsequently, TC was surgically induced in three female NZW rabbits by physically weakening their tracheal cartilage under general anesthesia. Their clinical signs were monitored for 3 months, and radiographic examinations were performed monthly for 3 months. The mean radial forces of the two sample sets were comparable (P>0.05). The clinical signs, radiographic examinations, and macroscopic examinations were all comparable to those of dogs with TC. The cadaveric study between the rabbits and dogs demonstrated that the surgically induced rabbit model of TC is an excellent candidate for the experimental study of dogs with TC. This study also provides a reference of tracheal radial force values to enable selection of appropriate mesh types and wire diameters of self-expanding metal stents.

Evaluation of short- and long-term results of Y-stent-assisted coiling with Leo stents in endovascular treatment of wide-necked intracranial bifurcation aneurysms.

PURPOSE: This study aimed to evaluate the feasibility, safety, and efficacy of Y-stent-assisted coiling (Y-SAC) using LEO Baby® stents in treating of bifurcation aneurysms. METHODS: Patients who underwent Y-SAC using a braided stent (LEO Baby®, Montmorency, France) for wide-necked intracranial aneurysms between 2009 and 2019 and whose radiological and clinical follow-up data for at least 6 months could be obtained were evaluated. Data were obtained from patient records and analyzed retrospectively. RESULTS: We evaluated 111 patients with a mean age of 56.0 ± 10.8 years (range, 25-88 years). Most of the aneurysms were detected incidentally. Three patients had ruptured aneurysms. LEO Baby deployment and coiling were successful in all patients. Immediate aneurysm occlusion rates were determined as modified Raymond-Roy classification (mRRC) I 95.5% (n = 106), mRRC II 3.6% (n = 4), mRRC IIIa 0.9% (n = 1). In the sixth month, aneurysm occlusion rates were found to be complete and nearly complete in all patients (mRRC I 94.6%, n = 105 and mRRC II 4.5%; n = 5, respectively). Follow-up data of 91 patients for > 2 years were obtained. Of these, 88 had MRRCI obstruction and 3 had MRRC II obstruction. The overall complication rate was 4.8%, and one patient died during the post-procedural follow-up. CONCLUSION: The long-term follow-up results of Y-stenting with LEO Baby revealed that it provides stable closure of the aneurysm sac while preserving the main arterial structures. Therefore, it is a safe, durable, and effective method for treating wide-necked and complex bifurcation aneurysms.

Safety and efficacy of flow diverter stents in the treatment of middle cerebral artery aneurysms: a single-center experience and follow-up data

PURPOSE: This study aims to evaluate the safety and efficacy of flow diverters (FDs) in the treatment of middle cerebral artery (MCA) aneurysms and share the follow-up (F/U) results. METHODS: The treatment and F/U results of 76 MCA aneurysms treated with the flow re-direction endoluminal device (FRED), FRED Jr., and pipeline embolization device (PED) FD stents were evaluated retrospectively. The aneurysm occlusion rates were compared between FDs, and the integrated and jailed branches were evaluated through follow-ups. The oversizing of the stent was compared between occluded/non-occluded aneurysms and integrated branches. RESULTS: The mean F/U duration was 32 ± 6.3 months, and the mean aneurysm diameter was 4.45 mm. A total of 61 (80.3%) aneurysms were wide-necked; 73 (96.1%) were saccular; 52 (68.4%) were located at the M1 segment; and 36 (45.6%) FREDs, 23 (29.1%) FRED Jr.s, and 19 (24.1%) PEDs were used for treatment. The overall occlusion rates for the 6-, 12-, 24-, 36-, and 60-month digital subtraction angiographies were 43.8%, 63.5%, 73.3%, 85.7%, and 87.5% respectively. The last F/U occlusion rates were 67.6% for FRED, 66.7% for PED, and 60.6% for FRED Jr. (P = 0.863). An integrated branch was covered with an FD during the treatment of 63 (82.8%) aneurysms. A total of six (10%) of the integrated branches were occluded without any symptoms at the last F/U appointment. The median oversizing was 0.45 (0-1.30) for occluded aneurysms, and 0.50 (0-1.40) for non-occluded aneurysms (P = 0.323). The median oversizing was 0.70 (0.45-1.10) in occluded integrated branches and 0.50 (0-1.40) in non-occluded branches (P = 0.131). In-stent stenosis was seen in 22 (30.1%) of the stents at the 6-month F/U and in only 2 (4.7%) at the 24-month F/U. Thus, none of the patients had any neurological deficits because of the in-stent stenosis. Severe in-stent stenosis was seen in two stents. CONCLUSION: MCA aneurysms tend to be complex, with integrated branches and potentially wide necks. FD stents are safe and effective in the treatment of MCA aneurysms, and the patency of the side and jailed branches is preserved in most cases. Higher occlusion and lower in-stent stenosis rates are seen with longer F/U durations.

In-stent restenosis and stented-territory infarction after carotid and vertebrobasilar artery stenting.

BACKGROUND: Prognosis after vertebrobasilar stenting (VBS) may differ from that after carotid artery stenting (CAS). Here, we directly compared the incidence and predictors of in-stent restenosis and stented-territory infarction after VBS and compared them with those of CAS. METHODS: We enrolled patients who underwent VBS or CAS. Clinical variables and procedure-related factors were obtained. During the 3 years of follow-up, in-stent restenosis and infarction were investigated in each group. In-stent restenosis was defined as reduction in the lumen diameter > 50% compared with that after stenting. Factors associated with the occurrence of in-stent restenosis and stented-territory infarction in VBS and CAS were compared. RESULTS: Among 417 stent insertions (93 VBS and 324 CAS), there was no statistical difference in in-stent restenosis between VBS and CAS (12.9% vs. 6.8%, P = 0.092). However, stented-territory infarction was more frequently observed in VBS than in CAS (22.6% vs. 10.8%; P = 0.006), especially a month after stent insertion. HbA1c level, clopidogrel resistance, and multiple stents in VBS and young age in CAS increased the risk of in-stent restenosis. Diabetes (3.82 [1.24-11.7]) and multiple stents (22.4 [2.4-206.4]) were associated with stented-territory infarction in VBS. However, in-stent restenosis (odds ratio: 15.1, 95% confidence interval: 3.17-72.2) was associated with stented-territory infarction in CAS. CONCLUSIONS: Stented-territory infarction occurred more frequently in VBS, especially after the periprocedural period. In-stent restenosis was associated with stented-territory infarction after CAS, but not in VBS. The mechanism of stented-territory infarction after VBS may be different from that after CAS.

Adjunctive techniques in endovascular repair of postcarotid endarterectomy pseudoaneurysm: Case report and literature review.

Pseudoaneurysm (PA) following carotid endarterectomy (CEA) is a rare and dangerous complication. In recent years endovascular approach has been preferred to open surgery as it is less invasive and reduces complications in an already operated neck, especially cranial nerve injuries. We report a case of large post-CEA PA causing dysphagia, successfully treated by deployment of two balloon-expandable covered stents and coil embolization of the external carotid artery. A literature review dealing with all cases of post-CEA PAs since 2000 treated by endovascular means is also reported. The research was conducted on Pubmed database using keywords "carotid pseudoaneurysm after carotid endarterectomy," "false aneurysm after carotid endarterectomy," "postcarotid endarterectomy pseudoaneurysm," and "carotid pseudoaneurysm."

Stage-1 Hybrid Palliation for High-Risk 2-Ventricle Patients with Ductal-Dependent Systemic Circulation in the Era of High Prenatal Detection.

OBJECTIVE: We reviewed our center's prenatal detection and surgical experience with high-risk, 2-ventricle patients, with complex congenital heart disease that underwent stage-1 hybrid palliation. METHODS: We retrospectively identified those born between March 2008 and March 2021 with 2-ventricle hearts, complex congenital cardiovascular malformations, and ductal-dependent systemic circulation that underwent stage-1 hybrid palliation consisting of surgical bilateral pulmonary artery banding and interventional catheterization placed ductus arteriosus stents. RESULTS: We identified 30 patients. Of the 30, 19 (63%) were male. For the 30, median gestational age was 35 weeks (29-39 weeks), and median birth weight was 2.2 kg (0.6-4.5 kg). Of the 30, 1 was transferred from an adjacent state, and 29 were born in Nevada. Of the 29 born in Nevada, overall statewide prenatal detection was 18 of 29 (62%); however, for 2008 to 2011 the prenatal detection rate was 3 of 10 (30%) and 15 of 19 (79%) for 2012 to 2021, P = .03. For the last 5 years, prenatal detection for Nevada-born patients was 8 of 8 (100%). Two full-term newborns, without a prenatal diagnosis, presented postnatally in extremis. For the 30 patients, there were 0 stage-1 hybrid palliation mortalities, 1 subsequent repair mortality, and 3 late nonsurgical deaths. CONCLUSIONS: Stage-1 hybrid palliation may result in excellent surgical outcomes for high-risk, 2-ventricle patients. Additionally, high rates of population-wide prenatal detection are possible for high-risk congenital heart disease, allowing prenatal planning and possibly reducing postnatal extremis presentations.

Real-life patency of plastic biliary stents in the pandemic era: is stent removal after 6 months safe and effective?

BACKGROUND: The SARS-CoV-2 pandemic conditioned the optimal timing of some endoscopic procedures. ESGE guidelines recommend replacement or removal of the plastic biliary stents within 3-6 months to reduce the risk of complications. Our aim was to analyse the outcomes of patients who had delayed plastic biliary stent removal following endoscopic retrograde cholangiopancreatography (ERCP) in the pandemic era. METHODS: Retrospective study including consecutive ERCPs with plastic biliary stent placement between January 2019 and December 2021. Delayed removal was defined as presence of biliary stent >6 months after ERCP. The evaluated outcomes were stent migration, stent dysfunction, obstructive jaundice, cholangitis, acute pancreatitis, hospitalization, and biliary pathology-related mortality. RESULTS: One-hundred and twenty ERCPs were included, 56.7% male patients, with a mean age of 69.4 ± 15.7 years. Indications for plastic biliary stent insertion were choledocholithiasis (72.5%), benign biliary stricture (20.0%), and post-cholecystectomy fistula (7.5%). Delayed stent removal occurred in 32.5% of the cases. The median time to stent removal was 3.5 ± 1.3 months for early removal and 8.6 ± 3.1 months for delayed removal. Patients who had delayed stent removal did not have a significantly higher frequency of stent migration (20.5 vs 11.1%, p = 0.17), stent dysfunction (17.9 vs 13.6%, p = 0.53), hospitalization (17.9 vs 14.8%, p = 0.66), obstructive jaundice (2.6 vs 0.0%, p = 0.33), cholangitis (10.3 vs 13.6%, p = 0.77), acute pancreatitis (0.0 vs 1.2%, p = 1.0), or biliary pathology-related mortality (2.6 vs 1.2%, p = 0.55). CONCLUSIONS: Delayed plastic biliary stent removal does not seem to have a negative impact on patients' outcomes. In the current pandemic situation, while scheduled endoscopic procedures may have to be postponed, elective removal of plastic biliary stents can be safely deferred.

Endovascular Bailout Repair After Intraprocedural Thrombosis of a Bifurcated Unimodular Stent-graft During Aorto-iliac Revascularization in a Patient with Sars CoV-2 Infection.

To describe a case of endovascular bailout strategy during stent-graft thrombotic complication in an endovascular procedure for complex TASC II D aortoiliac lesion. A 77-year-old patient was admitted at our institution with bilateral lower limb rest pain due to aortoiliac obstructive disease in a previous aortobifemoral bypass grafting with an asymptomatic Sars-CoV-2 infection. We planned an anatomic reconstruction of the aortoiliac segment with an unimodular bifurcated stent-graft. During the procedure, we observed a preocclusive thrombosis of the aortic portion requiring endovascular thrombectomy with vacuum assisted system followed by a successfully kissing-stent endolining. The post-operative period was uneventful and patient was discharged on the 14th post-operative day. Endovascular thrombectomy may be a helpful strategy during thrombotic complication of complex reconstructions of obstructive aortoiliac disease avoiding surgical conversion to laparotomy.

Biodegradable biliopancreatic stents could help conserve health care resources during the COVID-19 pandemic: An observational multicenter study.

BACKGROUND: Considering limited resources for follow-up due to COVID-19, we used biodegradable stents (BPBS) for a range of biliopancreatic diseases. AIMS: This observational multicenter study aimed to evaluate technical safety and give first insights into clinical utility. METHODS: Technical success, clinical success, and necessity of follow-up visits for BPBS placed at three Austrian tertiary care hospitals between April 2020 and January 2021 were retrospectively analyzed. RESULTS: 63 stents were deployed in 60 patients. Main indications were prophylaxis of post-ERCP pancreatitis (PEP; n = 30/63; 48%) and bridging of prolonged waiting times to cholecystectomy (n = 21/63; 33%). Median time to surgery was 47 days (range: 136 days). The technical success rate was 94% (n = 59/63; 95% CI [0.84, 0.98]). Technical difficulties primarily arose with dislocations. Clinical success was achieved in 90% (n = 57/63; 95% CI [0.80, 0.96]). Clinical failure despite successful deployment was caused by papillary bleeding (1 patient) and cholestasis (1 patient). Both required reinterventions. No follow-up visits were needed in 97% of cases (n = 57/59; 95% CI [0.88, 1.00]). CONCLUSION: Biodegradable stents could help conserve health care resources without compromising treatment standards for PEP prophylaxis, which is particularly valuable in times of restricted resources. First insights into feasibility as bridging to cholecystectomy indicate a favorable safety profile.

Covid-19 associated free hanging clots in acute symptomatic carotid stenosis.

BACKGROUND: Thrombotic complications including stroke were previously described following Covid-19. We aim to describe the clinical and radiological characteristics of Covid-19 related with acutely symptomatic carotid stenosis (aSCS). METHOD: All patients presenting with an aSCS were prospectively enrolled in an ongoing institutional database. Inclusion criteria for the Covid-19-aSCS group were a combination of both antigen test and a positive reverse-transcriptase (PCR) test for Covid-19 upon admission. Patients with additional potential etiologies for stroke including cardioembolism, carotid dissection or patients with stenosis of <50% on CTA were excluded. A cohort of non-Covid-19 related aSCS patients admitted to the same institution before the pandemic during 2019 served as controls. RESULTS: Compared to controls (n = 31), Covid-19-aSCS (n = 8), were younger (64.2 ± 10.7 vs 73.5 ± 10, p = 0.027), and less frequently had hypertension (50% vs 90%, p = 0.008) or hyperlipidemia (38% vs 77%, p = 0.029) before admission. Covid-19-aSCS patients had a higher admission NIHSS score (mean 9 ± 7 vs 3 ± 4, p = 0.004) and tended to present more often with stroke (88% vs 55%, p = 0.09) rather than a TIA. Covid-19-aSCS patients had higher rates of free-floating thrombus and clot burden on CTA (88% vs 6.5%, p = 0.002). Covid-19 patients also less often achieved excellent outcomes, with lower percentage of mRS score of 0 after 90-days (13% vs 58%, p = 0.022). CONCLUSION: Covid-19- aSCS may occur in a younger and healthier subpopulation. Covid-19- aSCS patients may have higher tendencies for developing complex clots and less often achieve excellent outcomes.

Spanish cardiac catheterization and coronary intervention registry. 31st official report of the Interventional Cardiology Association of the Spanish Society of Cardiology (1990-2021).

INTRODUCTION AND OBJECTIVES: The Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC) presents its annual activity report for 2021. METHODS: All Spanish centers with catheterization laboratories were invited to participate. Data were collected online and were analyzed by an external company, together with the members of the ACI-SEC. RESULTS: A total of 121 centers participated (83 public and 38 private). Compared to 2020, both diagnostic coronary angiograms and percutaneous coronary interventions (PCI) increased by 11,4% and 10,3%, respectively. The radial approach was the most used access (92,8%). Primary PCI also increased by 6.2% whereas rescue PCI (1,8%) and facilitated PCI (2,4%) were less frequently conducted. Transcatheter aortic valve implantation was one of the interventions with the most relevant increase. A total of 5720 transcatheter aortic valve implantation procedures were conducted with an increase of 34,9% compared to 2020 (120 per million in 2021 and 89,4 per million in 2020). Other structural interventions like transcatheter mitral or tricuspid repair, left atrial appendage occlusion and patent foramen oval closure also experienced a significant increase. CONCLUSIONS: The 2021 registry demonstrates a clear recovery of the activity both in coronary and structural interventions showing a relevant increase compared to 2020, the year of the COVID-19 pandemic.

Clinical and Endoscopic Consequences of Delay in Stent Exchange Procedures With ERCP During the Covid-19 Pandemic.

INTRODUCTION: During the COVID-19 pandemic, elective endoscopic retrograde cholangiopancreatography (ERCP) procedures have been postponed as recommended by international guidelines. In this study, the results of biliary and pancreatic ERCP procedures that had to be postponed during the pandemic process were investigated. MATERIALS AND METHODS: Forty-seven patients whose stent exchange procedures with ERCP were postponed between March 2020 and June 2020 due to the COVID-19 pandemic were included in the study. Patients were evaluated in 2 groups as delayed biliary procedures (n: 32) and delayed pancreatic procedures (n: 15). Clinical problems (biliary or pancreatic pain, itching, cholangitis, etc.) and technical problems encountered during the procedure (stent migration, abundant stone sludge in the bile ducts, etc.) were compared with 46 patients who could be treated without delay (39 interventions for the biliary system and seven interventions for the pancreas). FINDINGS: Considering the procedures for the biliary system, there was no difference in age and sex between the groups. Although clinical problems in biliary procedures were more common in the group with delay than in those without delay, this difference was not significant (34% vs. 20%; P : 0.14). The technical problems encountered during the procedures in the group with delay were significantly higher than those without delay (21% vs. 2.5%; P : 0.019), with stent migration being the most common problem (n: 5). Age and sex did not differ in the patients who had pancreatic interventions with and without delay. The clinical problems that developed in the patients did not differ between the groups with and without delay (26% vs. 28%; P : 0.8). Although technical problems were encountered in 1 out of 15 patients in the group with delay, no technical problem was experienced in the group without delay ( P : 0.68). CONCLUSION: Postponing elective ERCP procedures for the biliary system not for the pancreatic system during the COVID-19 pandemic brings technical problems.

Mesenteric Ischemia in a Patient with Essential Thrombocythemia: Does COVID-19 Play Any Role? A Case Report and Overview of the Literature.

INTRODUCTION: Chronic mesenteric ischemia is a rare entity with non-specific symptomatology; combined with rare etiologies, it could lead to unwarranted surgical indication. CASE REPORT: We report the case of an 85-year-old woman, with a history of hypertension, persistent thrombocytosis, atherosclerosis, and recent minor COVID-19 infection, presenting to the hospital with postprandial abdominal pain and nonspecific clinical examination findings; upon abdominal CT, superior mesenteric artery circumferential thrombosis was revealed. A bone marrow biopsy was performed due to suspected essential thrombocythemia, confirming the diagnosis. An endovascular approach was chosen as therapy option and a stent was placed in the occluded area. Dual antiplatelet and cytoreductive therapies were initiated after the intervention. Clinical course was excellent, with no residual stenosis 1 month after stenting. CONCLUSIONS: The therapeutic strategy in elderly patients with exacerbated chronic mesenteric ischemia requires an interdisciplinary approach in solving both the exacerbation and the underlying conditions in order to prevent further thrombotic events. Although the patient presented a thrombotic state, other specific risk factors such as COVID-19 related-coagulopathy and essential thrombocythemia should be considered.

Effect of alar nasal valve stent on nasal breathing.

PURPOSE: Lateral nasal wall insufficiency has previously been a surgical challenge. In 2018, the Alar Nasal Valve Stent (Medtronic) was taken into use at Helsinki University Hospital. The alar cartilages are repositioned and locked into position with the Alar Nasal Valve Stent on the mucosa. The stent gives support and widens the alar valve while cartilages scar into their new position presumably facilitating breathing after removal of the stent. The aim of this prospective, observational study was to investigate whether the Alar Nasal Valve Stent has an effect on nasal breathing in patients with lateral nasal wall insufficiency. MATERIALS AND METHODS: Symptom questionnaires (Sino-Nasal Outcome Test-22, Nasal Obstruction Symptom Evaluation, five-step symptom score) were analyzed preoperatively and at 3, 6, and 12 months postoperatively. Acoustic rhinometry, rhinomanometry, and peak nasal inspiratory flow were analyzed preoperatively and 3 months postoperatively. The patients performed a stress ergometry preoperatively and 3 months postoperatively, with their noses being photographed and filmed. RESULTS: In a series of 18 patients, a significant positive difference was seen in subjective symptom scores preoperatively versus postoperatively. The difference remained stable throughout the follow-up. No difference in objective symptom measurements was observed. CONCLUSIONS: Patients suffering from lateral nasal wall insufficiency experience a significant subjective improvement in nasal breathing after Alar Nasal Valve Stent surgery.

Appropriateness criteria for the use of cardiac computed tomography, SIC-SIRM part 2: acute chest pain evaluation; stent and coronary artery bypass graft patency evaluation; planning of coronary revascularization and transcatheter valve procedures; cardiomyopathies, electrophysiological applications, cardiac masses, cardio-oncology and pericardial diseases evaluation.

In the past 20 years, cardiac computed tomography (CCT) has become a pivotal technique for the noninvasive diagnostic workup of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Randomized clinical trials documented the value of CCT in increasing the cost-effectiveness of the management of patients with acute chest pain presenting in the emergency department, also during the pandemic. Beyond the evaluation of stents and surgical graft patency, the anatomical and functional coronary imaging have the potential to guide treatment decision-making and planning for complex left main and three-vessel coronary disease. Furthermore, there has been an increasing demand to use CCT for preinterventional planning in minimally invasive procedures, such as transcatheter valve implantation and mitral valve repair. Yet, the use of CCT as a roadmap for tailored electrophysiological procedures has gained increasing importance to assure maximum success. In the meantime, innovations and advanced postprocessing tools have generated new potential applications of CCT from the simple coronary anatomy to the complete assessment of structural, functional and pathophysiological biomarkers of cardiac disease. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), represents the second of two consensus documents collecting the expert opinion of cardiologists and radiologists about current appropriate use of CCT.