Lumen-apposing metal stents provide early and late clinical benefits for the management of benign gastrointestinal strictures: Is there a role for definitive therapy?

Objectives: This study aimed to characterize the clinical outcomes, safety, and efficacy of lumen-apposing metal stents (LAMS) in treating benign gastrointestinal strictures. Methods: A single-center retrospective review of all patients who underwent LAMS placement for benign strictures from June 2017 to July 2023. Primary outcomes were technical success, early clinical success, late clinical success (LCS), and sustained post-LAMS clinical success (SPLCS). Secondary outcomes included stent dwell time, stenosis changes, adverse events, reintervention rates, and symptomatology evaluation. Results: Thirty-five patients underwent placement of 42 LAMS (74% female, mean age: 54.2 ± 11.7 years). Anastomotic strictures accounted for 64% of cases (N = 27, 45% at the gastrojejunal anastomosis). The median STD was 91.0 days (interquartile range [IQR]: 55.0-132.0). Technical success was obtained in all cases. Early clinical successand LCS were achieved in 80% of cases overall. SPLCS was achieved in 45% (n = 15) of cases. The overall reintervention rate was 63%, with a median time to reintervention being 50.5 days (IQR: 24-105). adverse events occurred in 28% (n = 12) overall, with a 24% migration rate (n = 10). Follow-up was completed in 83% of cases with a median duration of 629 days (range: 192.0-1297.0). Overall symptom improvement occurred in 79% (n = 27) during indwelling LAMS versus 58% and 56% at 30- and 60-days post-removal, respectively. Conclusions: LAMS for benign gastrointestinal strictures are associated with high technical and early clinical success/LCS rates, positive quality-of-life metrics, and a tolerable adverse event rate. Overall, recurrence of symptoms and high reintervention rates post-LAMS removal reinforce the difficulty in managing benign gastrointestinal strictures but also argue for LAMS as a definitive therapy in select cases.

Unloading and successful treatment with bioresorbable stents during percutaneous coronary intervention: A case report.

BACKGROUND: With the development of percutaneous coronary intervention (PCI), the number of interventional procedures without implantation, such as bioresorbable stents (BRS) and drug-coated balloons, has increased annually. Metal drug-eluting stent unloading is one of the most common clinical complications. Comparatively, BRS detachment is more concealed and harmful, but has yet to be reported in clinical research. In this study, we report a case of BRS unloading and successful rescue. CASE SUMMARY: This is a case of a 59-year-old male with the following medical history: "Type 2 diabetes mellitus" for 2 years, maintained with metformin extended-release tablets, 1 g PO BID; "hypertension" for 20 years, with long-term use of metoprolol sustained-release tablets, 47.5 mg PO QD; "hyperlipidemia" for 20 years, without regular medication. He was admitted to the emergency department of our hospital due to intermittent chest pain lasting 18 hours, on February 20, 2022 at 15: 35. Electrocardiogram results showed sinus rhythm, ST-segment elevation in leads I and avL, and poor R-wave progression in leads V1-3. High-sensitivity troponin I level was 4.59 ng/mL, indicating an acute high lateral wall myocardial infarction. The patient's family requested treatment with BRS, without implantation. During PCI, the BRS became unloaded but was successfully rescued. The patient was followed up for 2 years; he had no episodes of angina pectoris and was in generally good condition. CONCLUSION: We describe a case of a 59-year-old male experienced BRS unloading and successful rescue. By analyzing images, the causes of BRS unloading and the treatment plan are discussed to provide insights for BRS release operations. We discuss preventive measures for BRS unloading.

Polish Society of Biomechanics Morecki&Fidelus Award Winner: Comparison of two polymers PDO and PLLA/PCL in application of urological stent for the treatment of male urethral stenosis.

Purpose: The primary objective of the conducted research was to develop an urological stent design for the treatment of male ure-thral stenosis. Given the variable loading conditions inside the urethra, the proposed stent should maintain normal tissue kinetics and obstruct the narrowed lumen. The suitable selection for the stent material significantly influences the regeneration and proper remodeling of the urethral tissues. Methods: In this work, the mechanical characteristics of some polymer materials were studied, including: polydi-oxanone (PDO) and poly(L-lactide) (PLLA)/polycaprolactone (PCL) composite. The obtained mechanical properties for static tensile testing of the materials, allowed the determination of such parameters as Young's modulus (E), tensile strength (R m) and yield strength (R e). Subsequently, the design of a urological stent was developed, for which a numerical analysis was carried out to check the behaviour of the stent during varying loads prevailing in the urethra. Result: The research indicated that PDO has better mechanical properties than the proposed PLLA/PCL composite. The numerical analysis results suggested that the developed stent design can be successfully used in the treatment of male urethral stenosis. The obtained stress and strain distributions in the numerical analysis confirm that the PDO material can be used as a material for an urological stent. Conclusions: The biodegradable polymers can be successfully used in urology. Their advantages over solid materials are their physicochemical properties, the ability to manipulate the rate and time of degradation and the easy availability of materials and manufacturing technology.

Impact of Drug Elution on Infectious Outcomes after Ductal Stenting in Newborns.

Ductal stenting (DS) is an interesting palliation for neonates with duct-dependent pulmonary circulation. With the introduction of drug-eluting stents (DES), which have a lower rate of restenosis and longer patency, these stents have replaced bare metal stents (BMS) in the global market. DES release Rapamycin group drugs, which have anti-proliferative and immunosuppressive effects. While the released drug amount is negligible in adult patients, it can lead to high blood levels in neonates, potentially increasing their risk of infections. We conducted a retrospective observational study on infants (under 2 months of age) with duct-dependent pulmonary circulation who underwent successful DS procedures between September 2013 and September 2023. Infants who received at least one DES were categorized into the DES group, while those receiving only BMS were categorized into the BMS group. We compared the prevalence of sepsis (both clinical and proven) and mortality between the two groups. We identified 53 infants (58.4% males), comprising 30 (56.6%) in the DES group and 23 (43.4%) in the BMS group. In the DES group, there were 11 cases (36.7%) of sepsis, including 8 clinical and 3 culture-positive cases. In contrast, the BMS group had 4 cases (13%) of sepsis, all of which were clinical (p = 0.053). Three patients (5.6%) died due to sepsis: two from the DES group and one from the BMS group. Six patients were suspected of having immunodeficiency (22q11.2 deletion or asplenia), with three in each group. Among these, only one patient in the DES group developed clinical sepsis. Our findings indicate that drug elution did not significantly increase the risk of infection following DS in newborns.

Electrospun bioresorbable polymer membranes for coronary artery stents.

Percutaneous coronary intervention, a common treatment for atherosclerotic coronary artery lesions, occasionally results in perforations associated with increased mortality rates. Stents coated with a bioresorbable polymer membrane may offer an effective solution for sealing coronary artery perforations. Additionally, such coatings could be effective in mitigating neointimal hyperplasia within the vascular lumen and correcting symptomatic aneurysms. This study examines polymer membranes fabricated by electrospinning of polycaprolactone, polydioxanone, polylactide-co-caprolactone, and polylactide-co-glycolide. In uniaxial tensile tests, all the materials appear to surpass theoretically derived elongation thresholds necessary for stent deployment, albeit polydioxanone membranes are found to disintegrate during the experimental balloon expansion. As revealed by in vitro hemocompatibility testing, polylactide-co-caprolactone membranes exhibit higher thrombogenicity compared to other evaluated polymers, while polylactide-co-glycolide samples fail within the first day post-implantation into the abdominal aorta in rats. The PCL membrane exhibited significant water leakage in the permeability test. Comprehensive evaluation of mechanical testing, bio- and hemocompatibility, as well as biodegradation dynamics shows the advantage of membranes based on and the mixture of polylactide-co-caprolactone and polydioxanone over other polymer groups. These findings lay a foundational framework for conducting preclinical studies on stent configurations in large laboratory animals, emphasizing that further investigations under conditions closely mimicking clinical use are imperative for making definitive conclusions.

3D-Printed Stents Loaded with Panax notoginseng Saponin for Promoting Re-endothelialization and Reducing Local Inflammation in the Carotid Artery of Rabbits.

Endovascular treatment (EVT) using stents has become the primary option for severe cerebrovascular stenosis. However, considerable challenges remain to be addressed, such as in-stent restenosis (ISR) and late thrombosis. Many modified stents have been developed to inhibit the hyperproliferation of vascular smooth muscle cells (SMCs) and protect vascular endothelial cells (VECs), thereby reducing such complications. Some modified stents, such as those infused with rapamycin, have improved in preventing acute thrombosis. However, ISR and late thrombosis, which are long-term complications, remain unavoidable. Panax notoginseng saponin (PNS), a traditional Chinese medicine consisting of various compounds, is beneficial in promoting the proliferation and migration of VECs and inhibiting the proliferation of SMCs. Herein, a 3D-printed polycaprolactone (PCL) stent loaded with PNS (PNS-PCL stent) was developed based on a previous study. In vitro studies confirmed that PNS promotes the migration and proliferation of VECs, which were damaged, by increasing the expression levels of microRNA-126, p-AKT, and endothelial nitric oxide synthase. In vivo, the PNS-PCL stents maintained the patency of the carotid artery in rabbits for up to three months, outperforming the PCL stents. The PNS-PCL stents may present a new solution for the EVT of cerebrovascular atherosclerotic stenosis in the future.

Long-Term Results of Bioresorbable Vascular Scaffolds in Patients With In-Stent Restenosis: The RIBS VI Study.

BACKGROUND: In patients with in-stent restenosis (ISR) bioresorbable vascular scaffolds (BVS) provide similar results to drug-coated balloons (DCBs) but are inferior to drug-eluting stents (DES) at 1 year. However, the long-term efficacy of BVS in these patients remains unknown. OBJECTIVES: This study sought to assess the long-term safety and efficacy of BVS in patients with ISR. METHODS: RIBS VI (Restenosis Intrastent: Bioresorbable Vascular Scaffolds Treatment; NCT02672878) and RIBS VI Scoring (Restenosis Intrastent: Bioresorbable Vascular Scaffolds Treatment With Scoring Balloon; NTC03069066) are prospective multicenter studies designed to evaluate the results of BVS in patients with ISR (N = 220). The inclusion and exclusion criteria were identical to those used in the RIBS IV (ISR of DES) (Restenosis Intra-stent of Drug-eluting Stents: Drug-eluting Balloon vs Everolimus-eluting Stent; NCT01239940) and RIBS V (ISR of bare-metal stents) (Restenosis Intra-stent of Bare Metal Stents: Paclitaxel-eluting Balloon vs Everolimus-eluting Stent; NCT01239953) randomized trials (including 249 ISR patients treated with DCBs and 249 ISR patients treated with DES). A prespecified comparison of the long-term results obtained with these treatment modalities (ie, DES, DCBs, and BVS) was performed. RESULTS: Clinical follow-up at 3 years was obtained in all (100%) 718 patients. The 3-year target lesion revascularization rate after BVS was 14.1% (vs 12.9% after DCBs [not significant], and 5.2% after DES [HR: 2.80; 95% CI: 1.47-5.36; P = 0.001]). In a landmark analysis (>1 year), the target lesion revascularization rate after BVS was higher than after DES (adjusted HR: 3.41; 95% CI: 1.15-10.08) and DCBs (adjusted HR: 3.33; 95% CI: 1.14-9.70). Very late vessel thrombosis was also more frequent with BVS (BVS: 1.8%, DCBs: 0.4%, DES: 0%; P = 0.03). CONCLUSIONS: In patients with ISR, late clinical results of DES are superior to those obtained with DCBs and BVS. Beyond the first year, DCBs are safer and more effective than BVS.

Rescue Stenting of Isolated Middle Cerebral Artery (MCA) Dissections (MCAD) with Antithrombogenic Coated Stents and Mono-Antiplatelet Therapy (MAPT).

Objective: Acute ischemic stroke (AIS) is a leading cause of death, but isolated middle cerebral artery dissection (MCAD) is rarely reported. The aim of this article is to sum up the current information on this pathology and to explore the technical aspects of its endovascular treatment with emphasis on novel coated, antithrombogenic stents and antiplatelet management. Another part of this article offers our experience with the problematics represented by a small sample group of patients with an MCAD diagnosis who were treated in our center. Methods: We conducted literature research and a retrospective review of patients treated for anterior circulation AIS at our comprehensive stroke center from January 2022 to March 2024. The cohort included 16 patients diagnosed with isolated MCAD, 9 received antithrombogenic coated stents, while 7 received bare metal stents. Pharmacological management of coated stents involved the use of Cangrelor for acute antiplatelet therapy, transitioning to oral Ticagrelor. Results: Among the 16 patients treated, those with antithrombogenic coated stents showed no major complications and had a lower incidence of intracranial hemorrhage compared to the bare metal stent group. The average National Institutes of Health Stroke Scale (NIHSS) score at discharge improved in both groups. Functional outcomes and mortality rates were slightly better in the coated stent group, but no statistical significance was proven. Conclusions: Antithrombogenic coated stents, in conjunction with MAPT, demonstrated a safe and effective option for treating isolated MCAD. These stents offer promising potential for improved outcomes and reduced complications compared to traditional treatments. Further multicentric studies with larger cohorts are recommended to validate these findings.

Endoscopic techniques for management of large colorectal polyps, strictures and leaks.

The implementation of screening colonoscopy with polyp removal has significantly decreased mortality rates associated with colorectal cancer (CRC), although it remains a major cause of cancer-related deaths globally. CRC typically originates from adenomatous polyps, and increased removal of these growths has led to reduced CRC incidence and mortality. Endoscopic polypectomy techniques, including hot and cold snare polypectomy, play a pivotal role in this process. While both methods are effective for small polyps (<10 mm), recent evidence favors cold snare polypectomy due to its superior safety profile and comparable complete resection rates. Large polyps (>10 mm), particularly those with advanced features, pose increased cancer risks and often require meticulous assessment and advanced endoscopic techniques, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for resection. This chapter also provides a practical overview of endoscopic techniques for managing colonic obstructions and pericolonic fluid collections, detailing their indications, advantages, disadvantages, and complications. The goal is to improve understanding and application in clinical practice. Additionally, we provide a summary of endoscopic closure techniques that have revolutionized the management of perforations and fistulas, offering safe and effective alternatives to surgery.

Drug-Coated Balloon Angioplasty in Patients Undergoing Complex Percutaneous Coronary Intervention.

Background: There are limited clinical data on drug-coated balloon (DCB)-based percutaneous coronary intervention (PCI) compared with drug-eluting stent (DES)-only PCI in patients with complex coronary artery lesions. Objectives: The goal of the current study was to investigate the efficacy of DCB in patients undergoing PCI for complex coronary artery lesions. Methods: From an institutional registry of patients with de novo complex coronary artery lesions, 126 patients treated with DCB-based PCI were compared with 234 propensity score-matched patients treated with DES-only PCI. Complex coronary artery lesions were defined as the presence of at least 1 of the following: bifurcation, chronic total occlusion, unprotected left main disease, long lesion ≥38 mm, multivessel disease, lesion requiring ≥3 devices, or severe calcification. The primary endpoint was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel-related myocardial infarction, and target vessel revascularization. Results: Baseline characteristics were comparable between the 2 groups. DCB-based PCI showed a comparable risk of TVF vs DES-based PCI (7.6% vs 8.1%; HR: 0.81; 95% CI: 0.33-1.99; P = 0.638). The risks of cardiac death (5.0% vs 5.7%; HR: 0.78; 95% CI: 0.24-2.49), target vessel-related myocardial infarction (0.9% vs 1.3%; HR: 2.65; 95% CI: 0.26-27.06), and target vessel revascularization (3.5% vs 2.0%; HR: 1.30; 95% CI: 0.30-5.67) were also comparable between the 2 groups. Conclusions: DCB-based PCI showed comparable risks of TVF vs those of DES-only PCI in patients with complex coronary artery lesions. DCB might be considered as a suitable alternative device to DES in patients undergoing complex PCI. (Long-term Outcomes and Prognostic Factors in Patient Undergoing CABG or PCI; NCT03870815).

Serial Vascular Responses of Balloon-Expandable Stent With Biodegradable Film-Type Graft in a Rabbit Iliac Artery Dissection Model (BioGard Study).

BACKGROUND AND OBJECTIVES: Arterial dissection during endovascular therapy rarely occurs but can be lethal. A fabric-based covered graft stents yield poor clinical outcomes. A novel balloon-expandable stent with biodegradable film graft for overcoming these issues was evaluated in a rabbit iliac artery model. METHOD: Eighteen rabbits with iliac artery dissections were induced by balloon over-inflation on angiography (Ellis type 2 or 3) and treated using the test device (3.0×24 mm). Subsequently, survived twelve animals underwent histologic examinations and micro-computed tomography (CT) at 0, 2, 4, and 8 weeks and 3, 6, 9, and 12 months and angiography at one-year. RESULTS: There were no adverse cardiovascular events during the one-year. Early-stage histologic examination revealed complete sealing of disrupted vessels by the device, exhibiting mural hematoma, peri-stent red thrombi, and dense infiltration of inflammatory cells. Mid- and long-term histologic examination showed patent stents with neointimal hyperplasia over the stents (% area stenosis: 11.8 at 2 weeks, 26.1 at 1 month, 29.7 at 3 months, 49.2 at 9 months, and 51.0 at 1 year), along with mild peri-strut inflammatory response (Grade: 1-2 at mid-term and 0-1 at long-term). The graft film became scarcely visible after six months. Both CT and angiography revealed no instances of thrombotic occlusion or in-stent restenosis (% diameter stenosis: 5.7 at 2 weeks, 12.3 at 1 month, 14.2 at 3 months, 25.1 at 9 months, and 26.6 at 1 year). CONCLUSIONS: The novel balloon-expandable stent with a biodegradable film graft demonstrates feasibility in managing severe artery dissection and preventing lethal vascular events in animal model.

Myocardial ischemia caused by the synergistic effect of myocardial bridge and moderate stenosis: case report.

BACKGROUND: Clinical events such as angina pectoris, acute coronary syndrome, and sudden death caused by myocardial bridge (MB) have attracted increasing attention. It is still a challenge to diagnose whether MB can cause the symptoms of patients with MB. For most MB patients, medication remains the primary treatment. CASE PRESENTATION: This article reports a case of chest pain in a patient with MB in the middle segment of the left anterior descending artery (LADm) with moderate stenosis in the proximal segment (LADp). Through functional assessment, we found that neither MB nor fixed stenosis had sufficient effect on coronary blood flow to cause myocardial ischemia, but their synergistic effect resulted in myocardial ischemia. Finally, a stent was implanted in LADp and good clinical results were achieved. CONCLUSIONS: For symptomatic patients with MB combined with fixed stenosis, functional evaluation may be necessary, which has significant guiding significance for treatment strategy selection. For asymptomatic patients, early detection of myocardial ischemia may also improve the prognosis of patients.

Colonic stenting: is the bridge to surgery worth its cost? A cost-effectiveness analysis at a single Asian institution.

Purpose: In patients with acute left-sided colonic obstruction, stenting can convert an emergency operation into a semi-elective procedure. However, its use continues to be debated. We performed a cost-effective analysis using our institution's experiences. Methods: Endoscopic, surgical, and financial details were prospectively collected for patients who presented with acute colonic obstruction and underwent stenting between 2019 and 2022. Outcomes were defined as technical/clinical success and successful surgical resection. The financial cost of stenting was compared with the expected cost without stenting. Results: Forty patients were included, with 29 undergoing definitive resection. The most common pathology was primary colon cancer (27 patients, 93%). Endoscopic stenting had high technical (90%) and clinical (83%) success rates, with low rates of complications such as perforation (2 patients, 7%) and migration (0 patients, 0%). As a bridge to surgery, the median procedure time was 226 minutes and the surgical outcomes also showed a low rate of complications (3 patients, 11%), such as anastomotic leakage (0 patients, 0%), intraabdominal abscesses (2 patients, 7%), and 30-day postoperative mortality (0 patients, 0%). The cumulative costs with colonic stenting were $32,900, while the expected costs with emergency surgery, including stoma reversal, were $40,700 (healthcare cost-savings of $7,800 per person). The difference was mainly due to the avoidance of upfront emergency surgery. The incremental cost-effectiveness ratio was 0.81, favoring colonic stenting over upfront emergency surgery. Conclusion: Colonic stenting as a bridge to surgery is safe and cost-effective for treating left-sided colonic obstruction with high success rates and low complication rates.

Complex intestinal fistula treated with colon­indwelling drainage stent under prostate resection endoscopy instrumentation guidance: A case report.

The treatment of complex intestinal fistulas has been a challenge in general surgery. A complex fistula is defined as a fistula with more than one abnormal connection between the gastrointestinal tract and skin, or a fistula with multiple bowel loops. The present case report describes the minimally invasive treatment of a complex intestinal fistula. Briefly, a 51-year-old man presented with an intestinal fistula. Following adequate anti-infective drainage of the abdominal abscess, transurethral prostate resection instrumentation was used to flush and drain the intestinal drainage tubes. On reduction of leakage, a drainage tube was inserted into the intestinal tract to serve as an internal stent. Imaging confirmed the successful cessation of intestinal leakage and a satisfactory recovery. The drainage tube was removed under colonoscopy, restoring normal small intestine function. To summarize, after sufficient drainage, the leakage gradually decreased, promoting healing; the patient achieved full recovery upon removal of the internal stent via colonoscopy and the establishment of a small intestinal stoma. In conclusion, transurethral prostate resection instrumentation enables safe and minimally invasive placement of intestinal stents, ensuring effective drainage for managing intestinal fistulas.

Outcomes Following Carotid Revascularization in Patients with Prior Ipsilateral Carotid Artery Stenting in the Vascular Quality Initiative.

OBJECTIVES: The outcomes of carotid revascularization in patients with prior carotid artery stenting remain understudied. Prior research has not reported the outcomes after Transcarotid artery revascularization (TCAR) in patients with previous carotid artery stenting. In this study, we compared the peri-operative outcomes of TCAR, tfCAS and CEA in patients with prior ipsilateral CAS using the VQI. METHODS: Using the Vascular Quality Initiative data from 2016 to 2023, we identified patients who underwent TCAR, tfCAS, or CEA following prior ipsilateral carotid artery stenting. We included covariates such as age, race, sex, BMI, comorbidities (hypertension, diabetes, prior CAD, prior CABG/PCI, CHF, renal dysfunction, smoking, COPD, anemia), symptom status, urgency, ipsilateral stenosis, and contralateral occlusion into a regression model to compute propensity scores for treatment assignment. We then used the propensity scores for inverse probability-weighting and weighted logistic regression to compare in-hospital stroke, in-hospital death, stroke/death, postoperative myocardial infarction (MI), stroke/death/MI, 30-day mortality and cranial nerve injury (CNI) following TCAR, tfCAS, and CEA. We also analyzed trends in the proportions of patients undergoing the three revascularization procedures over time using Cochrane-Armitage trend testing. RESULTS: We identified 2,137 patients undergoing revascularization following prior ipsilateral carotid stenting: 668 TCAR patients (31%), 1128 tfCAS patients (53%) and 341 CEA patients (16%). In asymptomatic patients, TCAR was associated with a lower yet not statistically significant in-hospital stroke/death than tfCAS (TCAR vs tfCAS: 0.7% vs 2.0%,aOR:0.33[0.11-1.05]; p=0.06), and similar odds of stroke/death with CEA (TCAR vs CEA: 0.7% vs 0.9%,aOR:0.80[0.16-3.98]; p=0.8). Compared with CEA, TCAR was associated with lower odds of post-operative MI (0.1% vs 14%,aOR:0.02[0.00-0.10]; p<0.001), stroke/death/MI (0.8% vs 15%,aOR:0.05[0.01-0.25]; p<0.001), and CNI (0.1% vs 3.8%,aOR:0.04[0.00-0.30]; p=0.002) in this patient population. In symptomatic patients, TCAR had an unacceptably elevated in-hospital stroke/death rate of 5.1% with lower rates of CNI than CEA. We also found an increasing trend in the proportion of patients undergoing TCAR following prior ipsilateral carotid stenting (2016 to 2023: 14% to 41%), with a relative decrease in proportions of tfCAS (61% to 45%) and CEA (25% to 14%) (p<.001). CONCLUSIONS: In asymptomatic patients with prior ipsilateral carotid artery stenting, TCAR was associated with lower odds of in-hospital stroke/death compared with tfCAS, with comparable stroke/death but lower postoperative MI and CNI rates compared with CEA. In symptomatic patients, TCAR was associated with unacceptably elevated in-hospital stroke/death rates. In line with the post-procedure outcomes, there has been a steady increase in the proportion of patients with prior ipsilateral stenting undergoing TCAR over time.

Evaluating no fixation, endoscopic suture fixation, and an over-the-scope clip for anchoring fully covered self-expanding metal stents in benign upper gastrointestinal conditions: a comparative multicenter international study (with video).

BACKGROUND AND AIMS: Fully covered self-expandable metal stents (FCSEMSs) are widely used in benign upper gastrointestinal (GI) conditions, but stent migration remains a limitation. An over-the-scope clip (OTSC) device (Ovesco Endoscopy) for stent anchoring has been recently developed. The aim of this study was to evaluate the effect of OTSC fixation on SEMS migration rate. METHODS: A retrospective review of consecutive patients who underwent FCSEMS placement for benign upper GI conditions between 1/2011 and 10/2022 at 16 centers. The primary outcome was rate of stent migration. The secondary outcomes were clinical success and adverse events. RESULTS: A total of 311 (no fixation 122, OTSC 94, endoscopic suturing 95) patients underwent 316 stenting procedures. Compared to the no fixation (NF) group (n=49, 39%), the rate of stent migration was significantly lower in the OTSC (SF) (n=16, 17%, p=0.001) and endoscopic suturing (ES) group (n=23, 24%, p=0.01). The rate of stent migration was not different between the SF and ES groups (p=0.2). On multivariate analysis, SF (OR 0.34, CI 0.17-0.70, p<0.01) and ES (OR 0.46, CI 0.23-0.91, p=0.02) were independently associated with decreased risk of stent migration. Compared to the NF group (n=64, 52%), there was a higher rate of clinical success in the SF (n=64, 68%; p=0.03) and ES group (n=66, 69%; p = 0.02). There was no significant difference in the rate of adverse events between the three groups. CONCLUSION: Stent fixation using OTSC is safe and effective at preventing stent migration and may also result in improved clinical response.

Optimising the indications for biliary stent placement during endoscopic retrograde cholangiopancreatography: a quality improvement initiative to enhance patient care and reduce healthcare resource utilisation.

BACKGROUND: A retrospective chart audit was performed to review biliary stent utilisation from January 2020 to January 2021. Non-guideline-based stent insertion was identified in 16% of patients with common bile duct (CBD) stones presenting for endoscopic retrograde cholangiopancreatography (ERCP). To improve this knowledge-practice gap, a quality improvement (QI) intervention was devised and trialled. AIM: To synchronise clinical indications for biliary stent insertion in patients with CBD stones in accordance with published guidelines. METHODS: Using a QI pre-post study design, chart audits were completed and shared with the ERCP team (n=6). Indication for biliary stent insertion was compared to published guidelines assessed by two reviewers independently (kappa statistic calculated). The QI intervention included an education session and quarterly practice audits. An interrupted time series with segmented regression was completed. RESULTS: A total of 661 patients (337 F), mean age 59±19 years (range 12-98 years), underwent 885 ERCPs during this postintervention period. Of 661 patients, 384 (58%) were referred for CBD stones. A total of 192 biliary stents (105 plastic, 85 metal) were placed during the first ERCP (192/661, 29%), as compared with the preintervention year (223/598, 37%, p=0.2). Furthermore, 13/192 stents (7%) were placed not in accordance with published guidelines (kappa=0.53), compared with 63/223 (28%) in the preintervention year (p<0.0001). A 75% reduction in overall avoidable stent placement was achieved with a direct cost avoidance of $C97 500. For the CBD stone subgroup, there was an 88% reduction in avoidable biliary stent placement compared with the preintervention year (8/384, 2% vs 61/375, 16%, p<0.0001). CONCLUSIONS: Education with audit and feedback supported the closing of a knowledge-to-practice gap for biliary stent insertion during ERCP, especially in patients with CBD stones. This has resulted in a notable reduction of avoidable stent placements and additional follow-up ERCPs and an overall saving of healthcare resources.

The effects of fibroblast growth factor-23 on diagnosis of cerebral infarction and vertebral basilar artery stenosis☆.

OBJECTIVES: This study aimed to explore the correlation between Fibroblast Growth Factor-23 (FGF23) levels and Cerebral Infarction (CI), and to determine whether there is a significant relationship between FGF23 and the occurrence and severity of CI. METHODS: The study categorized Cerebral Infarction (CI) patients into severe and mild stenosis groups based on vertebrobasilar artery stenosis, using Digital Subtraction Angiography (DSA) and Magnetic Resonance Imaging (MRI). The study compared the levels of Fibroblast Growth Factor-23 (FGF23) in the serum of CI patients and healthy controls using a t-test and evaluated the diagnostic effectiveness of serum FGF23 using a Receiver Operating Characteristic (ROC) curve. Additionally, the study analyzed the correlation between FGF23 levels and CI severity after treatment using the National Institute of Health Stroke Scale score. RESULTS: The study found a significant increase in serum Fibroblast Growth Factor-23 (FGF23) levels in patients with Cerebral Infarction (CI) compared to healthy volunteers, (p < 0.001). A higher serum FGF23 level was observed in the severe stenosis group than in the mild stenosis group (p < 0.001). Furthermore, the study showed that a high FGF23 level at admission was significantly related to more severe symptoms of CI as indicated by the National Institute of Health Stroke Scale (NIHSS) score on the 7th day after treatment (p < 0.001). CONCLUSIONS: This study discovered a correlation between Fibroblast Growth Factor-23 (FGF23) levels, vertebrobasilar artery stenosis, and short-term prognosis in patients who had recently experienced acute Cerebral Infarction (CI).

Management of cephalic arch stenosis in hemodialysis access: Updated systematic review and meta-analysis.

INTRODUCTION: Cephalic arch stenosis (CAS) is often recurrent, resistant to treatment and the intervention outcome is not well validated so far. We purposed to assess the clinical outcomes of CAS treatment in patients with hemodialysis access. METHODS: Electronic bibliographic sources were searched up to December 4 2023 to identify studies reported outcome after treating CAS. Direct and indirect evidence was combined to compare odds ratios (OR) and surfaces under the cumulative ranking curves across the different treatment modalities through meta-analysis and network meta-analyses (NMA). This systematic review was conducted in accordance with the PRISMA-P. The review is registered in PROSPERO (CRD42022296513). RESULTS: Four randomized controlled trials (RCTs) and 15 non-RCTs were included in the analysis. The study population differed in fistula type, restenosis or thrombosis, and significant heterogeneity was observed among the publications. The risk of bias was low to serious. Meta-analysis found no significant difference between DCB and PTA in primary patency at 6 and 12 months (OR 1.16 and 0.60, respectively; low certainty of evidence). Favorable result with STG compared to stent or PTA at 3, 6, and 12 month was observed (OR 4.28, 5.13, and 13.12, and 4.28, 5.13, 13.12, respectively; low certainty of evidence). Regarding primary patency, the treatment rankings, from highest to lowest, were STG (92.7%), transposition (76.0%), stent (67.5%), DCB (46.3%), and PTA (64.5%) at 12 months. CONCLUSION: Despite data limitations, the low-quality evidence suggests that STG may merit consideration as a primary treatment option when all alternatives are applicable, given their potential for better primary patency and higher treatment ranking.