Covered stent delivery in tortuous internal carotid artery for treatment of direct carotid cavernous fistula

Direct carotid cavernous fistulas (dCCF) are high-flow shunts between the internal carotid artery (ICA) and cavernous sinus and are commonly caused by traumatic injuries. Endovascular intervention using detachable coils, with or without stenting, is often the treatment of choice; however, migration or compaction of the coils can occur due to high-flow nature of dCCFs. Alternatively, deployment of a covered stent in ICA can be considered for treatment of dCCFs. We report a case of dCCF with tortuous intracranial ICA successfully treated by placement of a covered stent graft and we will illustrate the technical aspects of the procedure. In the presence of a tortuous ICA navigation and deployment of covered stents is technically complicated and requires modified maneuvers.

Cigarette Display Regulation At Point Of Sales (POS) And Its Impact On Cigarette Sales

OBJECTIVE

This study aims to determine the impact of cigarette display settings on cigarette sales in the stores in Semarang City.<br /><br />Methods: The research was conducted in August-October 2020 using a quasi-experimental study approach. It was conducted by setting the cigarette display in 3 methods where (1) the cigarette display was opened for 35 days in 5 stores, (2) the cigarettes display was covered with cloth for a pre and post-intervention period of 15 and 30 days, respectively, at five stores and (3) the cigarette display was hidden for a pre and post-intervention period of 15 and 30 days, respectively, at three stores. Cigarette sales were recorded based on how many packs or sticks were sold per day, and a visit to the store was made every two or three days without prior notification to the store owner to ensure the cigarette display was appropriate and recorded data. The sales data was descriptively evaluated using a paired t-test with a 95% confidence level. <br /><br />Result: The results showed that one hidden cigarette display store (R3-1) experienced a significant decrease in sales, three hidden/covered display stores had a less significant decrease in cigarette sales and four hidden/covered display stores didn't have any decline in cigarette sales while the average decline in cigarette consumption in stores was -1.4packs/day. From the analysis of sales per day and the paired pre-post intervention test, the store with a covered display showed no difference in the pre-post intervention sales, while the stores with hidden displays showed differences. <br /><br />Conclusion: Thus, covered displays did not affect stores and cigarette sales, while stores with hidden displays showed differences in sales.

Smaller-Diameter Covered Transjugular Intrahepatic Portosystemic Shunt Stents Are Associated With Increased Survival

BACKGROUND & AIMS

We studied the effects of diameter of covered, self-expandable, nitinol stents on survival times of patients with a transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

We collected data from 185 patients (median age, 55 y; 30% female) who received a covered nitinol stent, from February 2006 through September 2010, using the online multicenter German TIPS registry. TIPS were given to 107 patients for refractory ascites and to 78 patients for variceal bleeding. Patients at risk of hepatic encephalopathy (owing to advanced age, prior episodes) or liver failure (bilirubin level, >3 mg/dL), and bleeding patients receiving variceal embolization at TIPS, received 8-mm stents (n = 53). The remaining patients received 10-mm stents (n = 132). Eighty-one of the 10-mm stents were underdilated using 8-mm dilation balloons. Clinical and biochemical data were collected after TIPS placement at 1 month, 3 months, 6 months, 9 months, 1 year, and thereafter every 3 to 6 months. Groups were compared using propensity score analysis.

RESULTS

Patients who received 8-mm stents survived significantly longer (34 ± 26 mo) than patients who received 10-mm stents (18 ± 19 mo), regardless of whether they were fully dilated or underdilated. When we compared 10-mm stents with or without underdilation, we found that a significantly higher proportion of patients who received underdilated stents survived for 1 month after TIPS placement (95% vs 84%; P = .03), but not for 3 months (P = .10). In multivariate analysis, 1-year mortality correlated with full dilation of the stent to 10 mm (hazard ratio [HR], 2.0; 95% CI, 1.1-3.5) and with serum creatinine concentration at baseline (HR, 1.5; 95% CI, 1.0-1.7). Five-year mortality was associated with use of the 10-mm stents (HR, 1.8; 95% CI, 1.4-2.7) and baseline concentration of creatinine (HR, 1.3; 95% CI, 1.1-1.6).

CONCLUSIONS

A smaller stent (nominal diameter of 8 mm, but not underdilation of a 10-mm stent) is associated with a prolonged survival compared with 10-mm stents, independent of liver-specific prognostic criteria.

Antireflux Metal Stent as a First-Line Metal Stent for Distal Malignant Biliary Obstruction: A Pilot Study

Background/Aims

In distal malignant biliary obstruction, an antireflux metal stent (ARMS) with a funnel-shaped valve is effective as a reintervention for metal stent occlusion caused by reflux. This study sought to evaluate the feasibility of this ARMS as a first-line metal stent.

Methods

Patients with nonresectable distal malignant biliary obstruction were identified between April and December 2014 at three Japanese tertiary centers. We retrospectively evaluated recurrent biliary obstruction and adverse events after ARMS placement.

Results

In total, 20 consecutive patients were included. The most common cause of biliary obstruction was pancreatic cancer (75%). Overall, recurrent biliary obstruction was observed in seven patients (35%), with a median time to recurrent biliary obstruction of 246 days (range, 11 to 246 days). Stent occlusion occurred in five patients (25%), the causes of which were sludge and food impaction in three and two patients, respectively. Stent migration occurred in two patients (10%). The rate of adverse events associated with ARMS was 25%: pancreatitis occurred in three patients, cholecystitis in one and liver abscess in one. No patients experienced non-occlusion cholangitis.

Conclusions

The ARMS as a first-line biliary drainage procedure was feasible. Because the ARMS did not fully prevent stent dysfunction due to reflux, further investigation is warranted.

Partially Covered Metal Stents May Not Prolong Stent Patency Compared to Uncovered Stents in Unresectable Malignant Distal Biliary Obstruction

BACKGROUND/AIMS

Controversy still exists regarding the benefits of covered self-expandable metal stents (SEMSs) compared to uncovered SEMSs. We aimed to compare the patency and stent-related adverse events of partially covered SEMSs (PC-SEMSs) and uncovered SEMSs in unresectable malignant distal biliary obstruction.

METHODS

A total of 134 patients who received a PC-SEMS or uncovered SEMS for palliation of unresectable malignant distal biliary obstruction were reviewed retrospectively. The main outcome measures were stent patency, stent-related adverse events, and overall survival.

RESULTS

The median stent patency was 118 days (range, 3 to 802 days) with PC-SEMSs and 105 days (range, 2 to 485 days) with uncovered SEMSs (p=0.718). The overall endoscopic revision rate due to stent dysfunction was 36.6% (26/71) with PC-SEMSs and 36.5% (23/63) with uncovered SEMSs (p=0.589). Tumor ingrowth was more frequent with uncovered SEMSs (4.2% vs 19.1%, p=0.013), but migration was more frequent with PC-SEMSs (11.2% vs 1.5%, p=0.04). The incidence of stent-related adverse events was 2.8% (2/71) with PC-SEMSs and 9.5% (6/63) with uncovered SEMSs (p=0.224). The median overall survival was 166 days with PC-SEMSs and 168 days with uncovered SEMSs (p=0.189).

CONCLUSIONS

Compared to uncovered SEMSs, PC-SEMSs did not prolong stent patency in unresectable malignant distal biliary obstruction. Stent migration was more frequent with PC-SEMSs. However, tumor ingrowth was less frequent with PC-SEMSs compared to uncovered SEMSs.

Complex endovascular repair of bilateral iliac artery stenosis and coexisting aneurysm

Concomitant stenosis and aneurysmal disease in the iliac artery lumen are a rare finding. Surgery has been the modality of choice for this degree of complexity; however, advancement in techniques, evolution of stent grafts and increasing operator experience have made endovascular intervention a feasible option. TransAtlantic InterSociety Classification (TASC) categorizes the presence of iliac stenosis adjacent to iliac aneurysm as the most severe category for aortoiliac lesions or a TASC II D lesion. The 2014 Society of Cardiovascular Angiography and Interventions (SCAI) expert consensus statement advocated endovascular approach for TASC II A, B and C lesions with a trend to favor endovascular approach for TASC II D lesions as well. If surgery is not an option or is refused, covered stent provides a viable option due to its ability to treat severe atherosclerotic disease and exclude the aneurysmal lumen at the same time. We here describe a case of a patient with Rutherford II (4) claudication symptoms who was found to have bilateral iliac artery stenosis with adjacent co-existing aneurysmal disease. After surgical intervention was refused, endovascular repair was performed with multiple Gore Viabahn covered stents with resolution of symptoms and good angiographic results.