Bare Metal Stents vs Stent Grafts

Transcription

1 Bare Metal Stents vs Stent Grafts ASDIN 12th Annual Scientific Meeting Phoenix, AZ, February 20, 2016 Dirk Hentschel, MD Director, Interventional Nephrology Brigham and Women s Hospital

2 Disclosure Consultant: Gore, Proteon Therapeutics non-fda approved used of stents and stent grafts

3 Stents and stent grafts are used when angioplasty does not or does no longer work

4 Cephalic Arch and Basilic Swing Point basilic outflow vein angioplasty of basilic swing point with recoil swing point basilic outflow vein angiogram after stent graft placement swing point

5 basilic outflow vein swing point Angioplasty Complication A. before angioplasty B. before 2nd angioplasty (10 days interval) basilic outflow vein swing point C. after 2nd angioplasty D. after stent graft basilic outflow vein swing point

6 Central Venous Stenoses / Occlusions brachiocephalic vein brachiocephalic vein occlusion superior vena cava 2008 s/p brachiocephalic vein AP x non-covered stent brachiocephalic vein brachiocephalic vein in 2013 after AP in 2011x2 and 2013 x covered stent 2016 f/u patent

7 non-covered plus covered (n=24) non-covered alone (n=28) comments primary patency for device 17.6 months 12.3 months average angioplasties prior to any stent and days between procedures 2.7 AP 108 days (n=11) 3 AP 143 days (n=12) total occlusions may prompt stent placement for AP interval > days AP at site after noncovered stent and days between procedures 2.75 AP 208 days (n=16) 0.29 AP 12 months 8 angioplasties in 6 patients 22 patient no AP AP at site after stent graft none one early total occlusion 2 AP of immediate stent vicinity

8 Expected long-term consequences of stent and stent graft placement

9 Endothelial proliferation in non-covered stent cephalic arch cephalic arch superior vena cava superior vena cava before after angioplasty

10 Endoluminal Debris in covered stent cephalic arch subclavian vein cephalic arch subclavian vein debris-ectomy by AP, Fogarty balloon mobilization and PTD-basket extraction during inflow occlusion

11 Stents and Stent grafts as Adjuncts in other procedures.

12 Thrombectomy Central venous thrombosis with left upper arm transposed brachial-basilic autogenous access 2012 Total stenosis at BCV-SVC junction brachiocephalic vein

13 Large volume central venous thrombus resistant to lysis and extraction 2012 Limited angioplasty at BCV-SVC junction brachiocephalic vein

14 Immobilization of thrombus and long-term anti-coagulation 2012 Limited angioplasty at BCV-SVC junction brachiocephalic vein

15 Dissolution of thrombus over time, now off anticoagulation for > 1 year 2016 fistulagram for inflow evaluation angioplasty in 2014 and 2015 s/p angioplasty at BCV-SVC junction brachiocephalic vein

16 cephalic vein banding site Stabilize collapsing banding site Banding collapse brachial artery Banding of access to 3mm on , flows from 2400 ml/min to 780 ml/min. Thrombosis of access on , flows 900 ml/min. Re-thrombosis on cephalic vein Stabilization of banding segment with covered stent. brachial artery

17 Anastomotic Revision End-to-Side to End-to-End Conversion common femoral artery femoral artery eptfe graft deep femoral artery femoral artery femoral artery stent stent Left thigh femoral-femoral prosthetic access with prior AKA

18 Endograft Left upper arm brachial-cephalic autogenous access presents with thrombosis cephalic arch cephalic vein cephalic arch cephalic vein

19 cephalic arch after angioplasty to 4 mm cephalic arch stent graft placement

20 cephalic arch brachiocephalic vein cephalic arch brachiocephalic vein flow 840ml/min (131/66)

21 By physical exam no recurrence of outflow stenosis in March and September (16 months f/u: increased pulsatility, decreased clearance) flow 440 ml/min (165/80) to 920 ml/min (187/67)

22 Thrombectomy safety Pre-empt thrombo-embolic complications in body of access - outflow mismatch organized thrombus brachial vein forearm loop biograft venous anastomosis venous anastomosis brachial vein brachial vein

23 deep side-branch obliteration transposed basilic vein basilic outflow vein Right upper arm transposed brachial-basilic autogenous access transposed basilic vein swing point Forearm edema due to retrograde flow into brachial veins (red arrow) transposed basilic vein swing point basilic outflow vein swing point basilic outflow vein

24 Summary Traditional use of stents and stent grafts venous anastomotic stenosis (FDA approved) cephalic arch and basilic swing point aneurysms and pseudo-aneurysms central venous stenoses and occlusions Additional use options thrombus fixation in central or peripheral veins during thrombectomy stabilize banding sites or a recurrent juxta-anastomotic stenosis conversion of end-to-site to end-to-end arterial anastomosis creation of alternate outflow, by using very small existing vein (or de novo by puncture to adjacent vein) secure outflow during thrombectomy with access-outflow diameter mismatch side-branch obliteration