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
Disclosure Consultant: Gore, Proteon Therapeutics non-fda approved used of stents and stent grafts
Stents and stent grafts are used when angioplasty does not or does no longer work
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
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
Central Venous Stenoses / Occlusions brachiocephalic vein brachiocephalic vein occlusion superior vena cava 2008 s/p brachiocephalic vein AP x2 2008 non-covered stent brachiocephalic vein brachiocephalic vein in 2013 after AP in 2011x2 and 2013 x3 2013 covered stent 2016 f/u patent
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 > 90-100 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
Expected long-term consequences of stent and stent graft placement
Endothelial proliferation in non-covered stent cephalic arch cephalic arch superior vena cava superior vena cava before after angioplasty
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
Stents and Stent grafts as Adjuncts in other procedures.
Thrombectomy Central venous thrombosis with left upper arm transposed brachial-basilic autogenous access 2012 Total stenosis at BCV-SVC junction brachiocephalic vein
Large volume central venous thrombus resistant to lysis and extraction 2012 Limited angioplasty at BCV-SVC junction brachiocephalic vein
Immobilization of thrombus and long-term anti-coagulation 2012 Limited angioplasty at BCV-SVC junction brachiocephalic vein
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
cephalic vein banding site Stabilize collapsing banding site Banding collapse brachial artery Banding of access to 3mm on 11-2-2015, flows from 2400 ml/min to 780 ml/min. Thrombosis of access on 11-3-2015, flows 900 ml/min. Re-thrombosis on 11-4-2015. cephalic vein Stabilization of banding segment with covered stent. brachial artery
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
Endograft Left upper arm brachial-cephalic autogenous access presents with thrombosis 6-20-2013 cephalic arch cephalic vein cephalic arch cephalic vein
cephalic arch after angioplasty to 4 mm cephalic arch stent graft placement
9-24-2013 cephalic arch brachiocephalic vein cephalic arch brachiocephalic vein 9-24-2013 flow 840ml/min (131/66)
By physical exam no recurrence of outflow stenosis in March and September 2014 1-6-2015 (16 months f/u: increased pulsatility, decreased clearance) flow 440 ml/min (165/80) to 920 ml/min (187/67)
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
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
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