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      Mechanical thrombectomy using Rotarex system and stent-in-stent placement for treatment of distal femoral artery occlusion secondary to stent fracture – a case report and literature review

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          Summary

          Background:

          Treatment of peripheral arterial diseases may be distinguished into conservative and interventional management; the latter is divided into surgical and endovascular procedures. Management of peripheral artery stenosis and occlusion with vascular stents is associated with the risk of late complications such as restenosis, stent fracture or dislocation.

          Case Report:

          A 62-year-old woman with generalized atherosclerosis, particularly extensive in lower limb arteries, was admitted to the Department of Angiology 11 months after having an endovascular procedure performed due to critical ischemia of left lower limb. Because of stent occlusion, a decision to perform angiographic examination of lower limb arteries was made. Examination revealed occlusion of the superficial femoral artery along its entire length, including previously implanted stents. Distal stent was fractured with slight dislocation of the proximal segment. A decision was made to perform mechanical thrombectomy using a Rotarex system followed by a stent-in-stent placement procedure. Follow-up angiography and ultrasound scan performed 24 hours after the procedure revealed a patent vessel with satisfactory blood flow.

          Discussion:

          Nowadays, imaging diagnostics of peripheral artery stenosis involves non-invasive examinations such as ultrasound, minimally invasive examinations such as angio-MRI and MDCT, or invasive examinations such as DSA and IVUS. DSA examinations are used to confirm significant stenosis or occlusion of a vessel, particularly when qualifying a patient for endovascular treatment. Due to their anatomic location, the superficial femoral artery and the popliteal artery are subject to various forces e.g. those exerted by the working muscles. Mechanical thrombectomy and atherectomy are efficient methods of arterial recanalization used in the treatment of acute, subacute or even chronic occlusions or stenosis of peripheral vessels.

          Conclusions:

          Frequency of angioplasty and vascular stent implantation procedures is increased in patients with peripheral arterial disease, thus increasing the incidence of reported early and late complications such as acute stent thrombosis, restenosis and stent fractures. The Rotarex transcutaneous mechanical thrombectomy system is an efficient method of treating occlusions in arterial stents. It is also safe when performed by experienced operators.

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          Most cited references 19

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          Prevalence and clinical impact of stent fractures after femoropopliteal stenting.

          The aim of this study was to investigate the occurrence and the clinical impact of stent fractures after femoropopliteal stenting. The development of femoral stent fractures has recently been described; however, there are no data about the frequency and the clinical relevance. A systematic X-ray screening for stent fractures was performed in 93 patients. In total, 121 legs treated by implantation of self-expanding nitinol stents were investigated after a mean follow-up time of 10.7 months. The mean length of the stented segment was 15.7 cm. Overall, stent fractures were detected in 45 of 121 treated legs (37.2%). In a stent-based analysis, 64 of 261 stents (24.5%) showed fractures, which were classified as minor (single strut fracture) in 31 cases (48.4%), moderate (fracture of >1 strut) in 17 cases (26.6%), and severe (complete separation of stent segments) in 16 cases (25.0%). Fracture rates were 13.2% for stented length 8 to 16 cm, and 52.0% for stented length >16 cm. In 21 cases (32.8%) there was a restenosis of >50% diameter reduction at the site of stent fracture. In 22 cases (34.4%) with stent fracture there was a total stent reocclusion. According to Kaplan-Meier estimates, the primary patency rate at 12 months was significantly lower for patients with stent fractures (41.1% vs. 84.3%, p < 0.0001). There is a considerable risk of stent fractures after long segment femoral artery stenting, which is associated with a higher in-stent restenosis and reocclusion rate.
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            Drug-eluting and bare nitinol stents for the treatment of atherosclerotic lesions in the superficial femoral artery: long-term results from the SIROCCO trial.

            To review clinical outcomes of patients with chronic limb ischemia and TASC type C lesions treated with sirolimus-eluting versus bare SMART nitinol self-expanding stents. Data were obtained from a randomized, multicenter, double-blinded study conducted in 2 phases. All 93 patients had chronic limb ischemia and superficial femoral artery (SFA) occlusions or stenoses (average lesion length 8.3 cm). In total, 47 patients (31 men; mean age 66.3+/-9.1 years, range 50-84) received the sirolimus-eluting SMART stent and 46 patients (36 men; mean age 65.9 +/-10.8 years, range 38-83) received a bare SMART nitinol stent. Both groups were followed for a mean 24 months. Both the sirolimus-eluting and the bare SMART stents were effective in revascularizing the diseased SFA and in sustaining freedom from restenosis. For both types of stents, improvements in ankle-brachial indices (ABI) and symptoms of claudication were maintained over 24 months (median 24-month ABI 0.96 for the sirolimus group versus 0.87 for the bare stent group, p>0.05). At 24 months, the restenosis rate in the sirolimus group was 22.9% versus 21.1% in the bare stent group (p>0.05). The cumulative in-stent restenosis rates according to duplex ultrasound were 4.7%, 9.0%, 15.6%, and 21.9%, respectively, at 6, 9, 18, and 24 months; the rates did not differ significantly between the treatment groups. The TLR rate for the sirolimus group was 6% and for the bare stent group 13%; the TVR rates were somewhat higher: 13% and 22%, respectively. Mortality rates did not differ significantly between the groups. These data demonstrate that the sirolimus-eluting and the bare SMART stent are effective, safe, and free from restenosis in a majority of patients for up to 24 months. Because the restenosis rate in the bare stent group is unexpectedly low, no significant difference could be found between the sirolimus-eluting and the bare SMART stents.
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              Influence of stent fracture on the long-term patency in the femoro-popliteal artery: experience of 4 years.

              We investigated the time course of stent patency in the femoro-popliteal artery for as long as 4 years. Stent fracture has been related to poor 2-year patency in the femoro-popliteal artery. We studied 239 consecutive patients who underwent provisional de novo stenting with nitinol stents for 333 limbs (Luminexx stent [C. R. Bard, Inc., Murray Hill, New Jersey] in 91 limbs; Smart stent [Cordis Corp., Miami Lakes, Florida] in 242 limbs) from April 2004 to December 2007. Stent fracture was determined by X-ray with multiple projections. Patency was assessed by duplex ultrasonography as peak systolic velocity ratio <2.4 or by angiography (% diameter stenosis <50%). Primary patency in those with and without stent fracture at follow-up was assessed along with factors influencing stent fracture. Primary patency was 81%, 74%, 68%, and 65% at 1, 2, 3, and 4 years, respectively. Stent fracture occurred in 14% (78 of 544) per stent and 17% (55 of 333) per limbs. Stent fracture was significantly associated with multiple stent deployments (with fracture = 2.3 +/- 0.9 stents vs. without fracture = 1.5 +/- 0.7 stents, p < 0.001) and long lesions (with fracture = 208 +/- 84 mm vs. without fracture = 121 +/- 79 mm, p < 0.001). Primary patency was 68% with fracture versus 83% without fracture at 1 year, p = 0.03; 65% versus 75% at 2 years, p = 0.05; 61% versus 69% at 3 years, p = 0.06; and 61% versus 65% at 4 years, p = 0.07. Neither type 1 nor type 3 fracture affected patency, although type 2 showed the worst patency. Stent fracture worsened the patency during the first 2 years, but it did not apparently affect patency beyond 2 years. In particular, complete stent separation did not affect patency.
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                Author and article information

                Journal
                Pol J Radiol
                Pol J Radiol
                Pol J Radiol
                Polish Journal of Radiology
                International Scientific Literature, Inc.
                1733-134X
                1899-0967
                Jul-Sep 2013
                : 78
                : 3
                : 74-79
                Affiliations
                [1 ]Lower Silesian Diagnostic Imaging Centre, Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
                [2 ] Wrovasc – Integrated Cardiovascular Centre, Wrocław, Poland
                [3 ] Department of Angiology, Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
                [4 ]Department of Vascular Surgery, Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
                Author notes
                Author’s address: Bartosz Dołega-Kozierowski, Lower Silesian Diagnostic Imaging Centre, Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland, e-mail: landy@ 123456wp.pl
                Article
                poljradiol-78-3-74
                10.12659/PJR.889245
                3789939
                © Pol J Radiol, 2013

                This is an open access article. Unrestricted non-commercial use is permitted provided the original work is properly cited.

                Categories
                Case Report

                Radiology & Imaging

                stent fracture, mechanical thrombectomy, femoral artery occlusion

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