how should i retrieve a stent · thomas m. vesely, md saint louis, missouri disclosure consultant...
TRANSCRIPT
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ASDIN 9th Annual Scientific Meeting
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How Should I Retrieve a Stent
Nuts & Bolts of Endovascular Intervention
Thomas M. Vesely, MD
Saint Louis, Missouri
Disclosure
Consultant for:
W.L. Gore & Associates
Transonic, Inc.
Phase One Medical
R4 Vascular, Inc.
“ An ounce of prevention is worth a pound of cure ”
Benjamin Franklin
Use a long, stable guidewire
and leave it in position until
the procedure is completed
Measure vessel diameter and
select appropriate stent
Avoid
stent deployment
problems
ruler
MA Schechter et al.
Department of Surgery
Duke University
“Under-sizing of stent with resulting
poor wall apposition is the cause
of most stent migrations.”
Review Manufacturer’s
Stent Sizing Tables
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ASDIN 9th Annual Scientific Meeting
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Management of Stent Migration
Do nothing
Percutaneous retrieval of stent
Open surgical retrieval of stent
Combined percutaneous and surgical procedure
“Leaving some types of foreign bodies
in place is reasonable,
particularly in asymptomatic patients
with a limited life expectancy.”
MA Schechter et al.
Department of Surgery
Duke University
Stent Manufacturer’s Recommendations
for Stent Retrieval / Removal
Stent/System Removal
“In the event of complications such as infections, pseudoaneurysm
or fistulization, surgical removal of the stent may be required.
Standard surgical procedure is appropriate.”
From Instructions for Use document
No official guidelines or recommendations from stent graft manufacturers;
Nothing in IFU documents for Flair, Fluency, or Viabahn.
Where is the stent located?
How long has it been there?
Does the patient have any symptoms?
Management of stent migration is dependent upon:
Stent deployment Discovery of stent migrationtime period
Time course for development
of neointimal hyperplasia
around stent struts
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ASDIN 9th Annual Scientific Meeting
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Stents and stent grafts become incorporated
into vascular wall within 1 – 3 months
Percutaneous options:
Snare stent and remove through large sheath
Move stent and deploy into common iliac vein
Move stent to peripheral vein for surgical removal
Percutaneous Retrieval ToolsIntravascular Snares
• Used for intravascular retrieval / manipulation
• Snare loop at 90° to shaft of guidewire
• Nitinol - kink resistant
• Used within snare catheter
Guiding Catheters
• no hemostatic valve
• catheter tip is not tapered
• inserted with inner cannula
• should be hemostatic sheath
• allows use of multiple catheters & guidewires
• provides access for stent removal
Large diameter sheaths (16 Fr – 24 Fr)
Right femoral vein is often used
for stent retrieval procedures
• large diameter vein
• superficial location
• compressible against femoral head
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ASDIN 9th Annual Scientific Meeting
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Tightening of snare causes deformation of metal stent
Balloon stabilization may improve movement
of stent or stent graft
Need large diameter sheath or guiding catheter
to accommodate angioplasty balloon and snare catheter Stent retracted into sheath
using snare and pigtail
stent in
sheath
20 French vascular sheath inserted
to level of right common iliac vein
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ASDIN 9th Annual Scientific Meeting
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Management of Stent Migration
Do nothing
Percutaneous retrieval of stent
Open surgical retrieval of stent
Combined percutaneous and surgical procedure
Summary