Two cases of fractured esophageal nitinol stents

Spontaneous Endoscopic Esophageal Stent Fracture Post-endoscopic Placement: A Case Report

Endoscopic esophageal stent (EES) placement is an important tool for the non-operative management of esophageal pathologies. A rare and infrequently reported complication of EES placement is stent fracture and subsequent migration of the broken fragments. We report a rare case of a spontaneous EES fracture from Pakistan four weeks following its placement for esophageal perforation management, and an uneventful endoscopic retrieval of the fractured stent pieces. The recommended guidelines from available, albeit limited, research literature are also discussed as part of this case report.

Efficacy and safety of a new fully covered self-expandable non-foreshortening metal esophageal stent

BACKGROUND

Fully covered esophageal self-expandable metal stents (SEMSs) are potentially removable but can be associated with high migration rates. For precise positioning, non-foreshortening SEMSs are preferred. Recently, a new fully covered non-foreshortening SEMS with anti-migration features was introduced.

OBJECTIVE

To evaluate the efficacy and safety of this new esophageal SEMS.

DESIGN

Retrospective study.

SETTING

Single, tertiary-care center.

PATIENTS

Consecutive patients with malignant and benign strictures with dysphagia grade of ≥3 and patients with fistulas/leaks were studied.

INTERVENTIONS

Stent placement and removal.

MAIN OUTCOME MEASUREMENTS

Technical success in stent deployment/removal, efficacy in relieving dysphagia and sealing fistulas/leaks, and adverse events.

RESULTS

Forty-three stents were placed in 35 patients (mean [± standard deviation] age 65 ± 11 years; 31 male), 24 for malignant and 11 for benign (5 strictures, 6 leaks) indications. Technical success in precise SEMS placement was 100%. The after-stent dysphagia grade improved significantly (at 1 week: 1.5 ± 0.7; at 4 weeks: 1.2 ± 0.4; baseline: 3.8 ± 0.4; P < .0001). Twenty stents were removed for clinical indications, with technical success of 100%. All leaks sealed after SEMS placement and did not recur after stent removal. All benign strictures recurred after stent removal. Adverse events included migration (14%), chest pain (11%), and dysphagia from tissue hyperplasia (6%). There was no stent-related mortality.

LIMITATIONS

Nonrandomized, single-center study.

CONCLUSION

The new esophageal SEMS was effective in relieving malignant dysphagia, allowed for precise placement, and was easily removable. It was effective in treating benign esophageal fistulas and leaks. Stent-related adverse events were acceptable.

Esophageal stent fracture: Case report and review of the literature

Endoscopic esophageal stent placement is widely used in the treatment of a variety of benign and malignant esophageal conditions. Self expanding metal stents (SEMS) are associated with significantly reduced stent related mortality and morbidity compared to plastic stents for treatment of esophageal conditions; however they have known complications of stent migration, stent occlusion, tumor ingrowth, stricture formation, reflux, bleeding and perforation amongst others. A rare and infrequently reported complication of SEMS is stent fracture and subsequent migration of the broken pieces. There have only been a handful of published case reports describing this problem. In this report we describe a case of a spontaneously fractured nitinol esophageal SEMS, and review the available literature on the unusual occurrence of SEMS fracture placed for benign or malignant obstruction in the esophagus. SEMS fracture could be a potentially dangerous event and should be considered in a patient having recurrent dysphagia despite successful placement of an esophageal SEMS. It usually requires endoscopic therapy and may unfortunately require surgery for retrieval of a distally migrated fragment. Early recognition and prompt management may be able to prevent further problems.

In situ fracture of stents implanted for relief of pulmonary arterial stenosis in patients with congenitally malformed hearts

BACKGROUND

One of the most common uses of stents in patients with congenitally malformed hearts is treatment of pulmonary arterial stenosis. Although there are reports of fractured pulmonary arterial stents, little is known about the risk factors for, and implications of, such fractures.

METHODS

We reviewed angiograms to identify fractures in stents previously inserted to relieve stenoses in pulmonary arteries from 1990 through 2001 in patients who also underwent follow-up catheterization at least 3 years after placement of the stent. We undertook matched cohort analysis, matching a ratio of 2 fractured to 1 unfractured stent.

RESULTS

Overall, 166 stents meeting the criterions of our study had been placed in 120 patients. We identified fractures in 35 stents (21%) in 29 patients. All fractured stents were in the central pulmonary arteries, 24 (69%) in the central part of the right pulmonary artery, and all were complete axial fractures, or complex fractures along at least 2 planes. Stent-related factors associated with increased risk of fracture identified by multivariable logistic regression included placement in close apposition to the ascending aorta (p = 0.001), and a larger expanded diameter (p = 0.002). There was obstruction across 28 of 35 fractured stents, which was severe in 11. We re-stented 21 of the fractured stents, and recurrent fracture was later diagnosed in 3 of these. A fragment of the fractured stent embolized distally in 2 patients, without clinically important effects.

CONCLUSIONS

In situ fracture of pulmonary arterial stents is relatively common, and in most cases is related to compression by the aorta. There is usually recurrent obstruction across the fractured stent, but fractured stents rarely embolize, and are not associated with other significant complications.

Stent fracture following stenting of a myocardial bridge: report of two cases

Myocardial bridge is the most common congenital coronary anomaly. Patients with this anomaly are usually asymptomatic, but it may cause myocardial ischemia that may lead to myocardial infarction. Treatment for myocardial bridge remains controversial. Current recommendations include medical therapy, surgical treatment (unroofing myotomy), coronary artery bypass, and percutaneous coronary stenting. We report two cases of stent fracture following stenting of a myocardial bridge. The risk of stent fracture leading to restenosis and/or stent thrombosis should be considered when assessing the risks and benefits of coronary revascularization of a myocardial bridge.

Fracture of a Nitinol Carotid Artery Stent That Caused Restenosis

The placement of self-expanding nitinol stents in the carotid artery is rapidly emerging as a minimally invasive alternative in the treatment of cervical carotid artery occlusive disease. Fractures of balloon-expandable stents after placement in the carotid artery have been previously documented. The authors report on a single case of early stent fracture and complete mid-body disruption of a self-expanding stent associated with a significant restenosis necessitating repeat intervention after carotid artery stent placement for a de novo atherosclerotic lesion.

Repeated coaxial colonic stenting in the palliative management of benign colonic obstruction

In inflammatory bowel disease, strictures of the colon, causing bowel obstruction, is not uncommon. Usually an operative procedure can deal with these strictures. We describe a case of an unfit patient with pulmonary malignancy having a Crohn's stricture of the recto-sigmoid junction in which repeated coaxial placement of self-expanding metallic stents eliminated the need to perform an operation. This is the first report of multiple coaxial colonic stenting. It shows that there is a place for stents in selected cases of inflammatory bowel disease with a limited life expectancy and that repeated colonic stenting makes colonic stenting possible also in patients requiring stents for longer time periods.

Coronary artery stent fracture

Coronary stent fracture is a rare but potentially serious complication of coronary artery stenting. In light of the non-specific presentation of stent fracture, it is also an easily missed complication. In order to ensure rapid recognition and treatment of this entity, physicians must be aware of its existence and its possibility under the right circumstances. We present the case of a 61-year-old Guyanese male who presented with unstable angina secondary to a stent fracture within two weeks of elective percutaneous coronary intervention (PCI) for in-stent restenosis.

Fracture of an expandable metallic stent placed for biliary obstruction due to common bile duct carcinoma

We report our second case of fracture of a SMART self-expandable metallic stent (Cordis Endovascular, Warren, NJ) placed to treat biliary obstruction due to an unresectable common bile duct carcinoma. An 82-year-old man presented with jaundice. Computed tomography and ultrasonography on admission demonstrated a mass in the lower common bile duct. The mass was identified as a common bile duct obstruction. A SMART stent was inserted. Ten months after stent insertion, two additional SMART stents were inserted to relieve obstructive jaundice due to occlusion of the first stent. Fourteen months after insertion of the first stent, endoscopic examination revealed stenosis of the duodenum due to invasion of the common bile duct carcinoma, prompting us to perform a gastrojejunostomy 1 month later. Three months after gastrojejunostomy, the patient presented with obstructive jaundice and cholangitis. A fracture of one of the stents was then discovered on plain X-ray films and percutaneous transhepatic cholangiography. Two SMART stents were inserted simultaneously. In conclusion, we report the fracture of a SMART stent placed for common bile duct carcinoma. Fracture should be considered as a possible complication after metallic stent insertion.

A case of popliteal stent fracture with pseudoaneurysm formation

We describe a case of angiographically documented stent fracture and pseudoaneurysm formation in a patient with femoropopliteal disease, which was successfully treated with deployment of an endovascular stent graft. Technical aspects of the procedure are discussed and the experience with stent fractures previously reported in the literature is reviewed.

Clinical evaluation of radiotherapy for advanced esophageal cancer after metallic stent placement

AIM: To evaluate the therapeutic effect of radiotherapy for esophageal cancer after expandable metallic stent placement.

METHODS: Ten cases of advanced esophageal cancer were evaluated, 7 having complete obstruction and 3 with digestive-respiratory fistula. Ten nitinol stents were placed at the site of stenosis. Patients were treated with a total dose of 1200 cGy divided into 3 fractions of 400 cGy 4-7 d after stents placement.

RESULTS: All the 10 stents were placed successfully at one time. After radiotherapy for advanced esophageal cancer, the survival period of the cases ranged from 14 to 22 mo, with a mean survival of 17 mo. No re-stenosis occurred among all the 10 cases.

CONCLUSION: Stent placement combined with radiotherapy for esophageal cancer is helpful to prolong patients’ survival and reduce occurrence of re-stenosis.

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Laser resistance of expandable metal stents in interventional bronchoscopy: an experimental evaluation

BACKGROUND AND OBJECTIVE

Nd-YAG non-contact laser therapy is used to eliminate recurrent tumor tissue within airway stents. This study was performed to determine maximum exposure time until the stent wire is destroyed as well as exposure time necessary to deliberately fracture the wire mesh.

STUDY DESIGN/MATERIALS AND METHODS

Strecker stents, Wallstents, and Nitinol Accuflex stents were implanted into pig bronchi. Then Nd-YAG laser light was directed to the stent wires at different power levels. Portions of the stent surrounded by bronchial tissue as well as bare wires were investigated.

RESULTS

The Strecker stent and the Wallstent revealed a considerably higher laser resistance than did the Nitinol Accuflex stent. At 15 W, minimum exposure time until wire destruction was 4.6 and 6.3 s for the Strecker stent and the Wallstent respectively. In contrast, the Nitinol Accuflex stent tolerated only 1.7 s.

CONCLUSIONS

Laser therapy with bronchial wire stents can be carried out at low power levels. It should, however, be avoided in the case of Nitinol Accuflex stents due to their low heat tolerance.

Endoscopic palliation of malignant dysphagia

Esophageal cancer is the primary cause of malignant dysphagia, a major cause of morbidity and mortality. In patients with esophageal cancer that is unresectable at the time of diagnosis, palliation is the major goal. Surgical treatment as well as radiation and chemoradiation therapy are traditional approaches for such patients. Endoscopic therapy is useful for patients with poor performance status, those in whom other treatments have failed, and those with tracheoesophageal fistulas. In recent years, self-expanding metal stents have become an important new endoscopic treatment modality for palliation of malignant dysphagia in a wide range of patients. Appropriate patient selection is paramount when a mode of palliation for malignant dysphagia is being selected. Although various treatment options exist for palliation of malignant dysphagia, comparative studies among these modalities are needed.

Endobronchial argon plasma coagulation for treatment of hemoptysis and neoplastic airway obstruction

STUDY OBJECTIVE

To evaluate the usefulness of endobronchial argon plasma coagulation (APC) for the treatment of hemoptysis and neoplastic airway obstruction.

DESIGN

Retrospective study.

SETTING

Bronchoscopy unit of a university hospital.

PATIENTS

A total of 60 patients with bronchogenic carcinoma (n = 43), metastatic tumors affecting the bronchi (n = 14), or benign bronchial disease (n = 3). Indications for intervention were hemoptysis (n = 31), symptomatic airway obstruction (n = 14), and both obstruction and hemoptysis (n = 25). Hemoptysis was stratified as a volume of > 200 mL/d (n = 6), > 50 to 200 mL/d (n = 23), or < or = 50 mL/d but persistence for > 1 week (n = 27). The mean (+/- SD) duration of hemoptysis was 16.5 +/- 16.1 days before intervention. Obstruction sites were the trachea (n = 8), mainstem bronchi (n = 21), and lobar bronchi (n = 30). In 24 cases, the patient had obstructions at multiple sites. The mean size of the pretreatment obstruction was 76 +/- 24.9%.

INTERVENTIONS

APC, a noncontact form of electrocoagulation, was performed via flexible bronchoscopy. Sixty patients underwent 70 procedures. Conscious sedation without endotracheal intubation was used in all patients except four, who were mechanically ventilated because of underlying respiratory failure.

MEASUREMENTS AND RESULTS

All patients with hemoptysis experienced a resolution of bleeding immediately after APC. Hemoptysis from treated sites did not recur during a mean follow-up duration of 97 +/- 91.9 days. Patients with endoluminal airway lesions had an overall decrease in mean obstruction size to 18.4 +/- 22.1%. All patients with obstructive lesions, except one who died of sepsis, experienced symptom improvement. In these patients, symptom control was maintained during a median follow-up period of 53 days (range, 18 to 321 days). There were no complications related to the procedure.

CONCLUSIONS

APC is effective for the treatment of endoluminal hemoptysis and airway obstruction. The procedure can be performed in an outpatient setting or at the bedside in the ICUs. APC provides a simpler, lower-risk alternative to other interventional endobronchial techniques.

An update in the palliative management of malignant dysphagia

BACKGROUND

Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration.

METHODS

This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused.

RESULTS AND CONCLUSIONS

Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.

CT appearance of implanted esophageal stents

Three different types of esophageal stents, the Z-stent, Ultraflex, and Wall-stent, exhibit different shapes on CT, which may suggest a difference in the radial forces applied by each of the stents. CT is useful for displaying the relationship between an esophageal stent and adjacent structures and complications.