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Stents: Vascular
Brandt C. Wible, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Preprocedure

      • Procedure

        • Post Procedure

          TERMINOLOGY

          • Synonyms

            • Vascular endoprosthesis
          • Definitions

            • Vascular stent: Catheter-mounted metallic intravascular prosthesis
              • Provides intravascular scaffold
                • Allows for endothelialization
                  • Endothelial cells migrate into stent
                  • Leads to in-stent restenosis
                • Provides intravascular rigidity
                  • Compresses atheroma, dissection flaps
                  • Resists elastic recoil
              • Placed in diseased vascular structures
                • Arteries
                • Pulmonary arteries
                • Veins
                • Portal veins
              • Various indications
                • Recanalization of luminal stenosis/occlusion, including
                  • Arterial atherosclerotic plaque [e.g., peripheral arterial disease (PAD), chronic mesenteric ischemia]
                  • Venous extrinsic compression (e.g., May-Thurner syndrome)
                  • Intimal hyperplasia (e.g., hemodialysis access outflow narrowing)
                • Aneurysm/pseudoaneurysm exclusion
                • Traumatic/iatrogenic arterial perforation
                • Arteriovenous (AV) communications
                • Stent-assisted coil embolization
            • Various delivery systems/calibers
              • 0.035" delivery system
              • 0.014"/0.018" delivery system
            • Vascular stent designs
              • Closed-cell: Every stent segment connected by link
                • Less flexible, may develop kinks
                • Occasional incomplete expansion
                • Better radial force/intravascular scaffolding
              • Open-cell: Some stent segment connections absent
                • Conforms to angled vessels/tortuous anatomy
                • Less radial force/intravascular scaffolding
            • Vascular stent technologies
              • Balloon-mounted: Externally mounted on percutaneous transluminal angioplasty (PTA) balloon
                • Risk of dislodgement; prevent by introducing through guiding catheter/sheath
                  • Balloon inflation to deploy stent
                  • Somewhat variable diameter range
                  • More rigid stent design
                • Conforms poorly to changing vessel diameters
                • Balloon-mounted stent delivery designs
                  • Over-the-wire (OTW): Central lumen for guidewire access/contrast injection, small parallel lumen for balloon inflation/deflation during stent deployment
                  • Rapid-exchange (monorail): Guidewire passes through balloon, exits catheter proximal to balloon, runs alongside catheter shaft
              • Self-expanding: Sheathed in retractable delivery system; spontaneously expands after retraction
                • Most frequently constructed from nitinol
                  • Alloy regains original shape when no longer compressed/constrained
                • Requires appropriate oversizing to achieve secure intravascular fixation
                • Typically more flexible
                • Conforms to changing vessel diameters
              • Drug-eluting: Stent coated with medication (e.g., paclitaxel)
                • Delivers antiproliferative drug to vessel surface
                  • Local drug prevents in-stent stenosis
                  • Drug reduces neointimal proliferation
                • More variable results when treating PAD versus coronary drug-eluting stents (DES)
                  • No benefit over self-expanding stents in superficial femoral artery (SFA)
                  • Ongoing investigational studies
              • Biodegradable: Made of polymers/metal alloys ± drug coating
                • Scaffold artery, allows natural healing to occur
                  • Subsequently biodegrades; may deliver sustained drug release as degradation proceeds
                • Several biodegradable stents in clinical trials
                  • Many more at preclinical stage of development
              • Radioactive: Catheter-based intravascular brachytherapy, mainly from gamma/beta sources
                • Majority of studies relate to coronary arteries
                • High restenosis incidence at stent margins
                • Ongoing investigational studies
              • Covered (stent-graft): Metallic intravascular stent combined with fabric graft of either Dacron or expanded polytetrafluoroethylene (ePTFE)
                • Courses inside vascular lumen; redirects blood flow through device rather than native vessel
                  • Radial force of metallic stent secures graft
                  • Catheter-mounted delivery system
                • 3 FDA-approved peripheral stent grafts
                  • Atrium iCAST (Atrium Medical; Hudson, NH): Balloon-mounted expandable ePTFE stent graft
                  • Bard Fluency (Bard; Tempe, AZ): Self-expanding nitinol stent encapsulated with ePTFE; retractable delivery system
                  • Gore Viabahn (WL Gore; Newark, DE): Inner ePTFE fabric graft attached to external self-expanding nitinol stent

          PREPROCEDURE

          • Indications

            • Getting Started

              PROCEDURE

              • Patient Position/Location

                • Equipment Preparation

                  • Procedure Steps

                    • Alternative Procedures/Therapies

                      POST PROCEDURE

                      • Things to Do

                        OUTCOMES

                        • Complications

                          • Expected Outcomes

                            Selected References

                            1. Basavarajaiah S et al: Treatment of drug-eluting stent restenosis: comparison between drug-eluting balloon versus second-generation drug-eluting stents from a retrospective observational study. Catheter Cardiovasc Interv. 88(4):522-528, 2016
                            2. Liou K et al: Drug-eluting balloon versus second generation drug eluting stents in the treatment of in-stent restenosis: a systematic review and meta-analysis. Heart Lung Circ. 25(12):1184-1194, 2016
                            3. Naghi J et al: New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease. Med Devices (Auckl). 9:161-74, 2016
                            4. Carnelli D et al: Mechanical properties of open-cell, self-expandable shape memory alloy carotid stents. Artif Organs. 35(1):74-80, 2011
                            5. Räber L et al: Current status of drug-eluting stents. Cardiovasc Ther. 29(3):176-89, 2011
                            6. Arbabi A et al: Irradiation and dosimetry of Nitinol stent for renal artery brachytherapy. Appl Radiat Isot. 67(1):129-32, 2009
                            7. Brown DA et al: A new wave in treatment of vascular occlusive disease: biodegradable stents; clinical experience & scientific principles. J Vasc Interv Radiol. 20(3):315-24, 2009
                            8. Minar E et al: New stents for SFA. J Cardiovasc Surg (Torino). 50(5):635-45, 2009
                            9. Pierce DS et al: Open-cell versus closed-cell stent design differences in blood flow velocities after carotid stenting. J Vasc Surg. 49(3):602-6; discussion 606, 2009
                            10. Norgren L et al: Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 45 Suppl S:S5-67, 2007
                            11. Vaina S et al: Progressive stent technologies: new approaches for the treatment of cardiovascular diseases. Expert Opin Drug Deliv. 3(6):783-97, 2006
                            12. Duda SH et al: Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: the SIROCCO II trial. J Vasc Interv Radiol. 16(3):331-8, 2005
                            13. Duerig TW et al: A comparison of balloon- and self-expanding stents. Minim Invasive Ther Allied Technol. 11(4):173-8, 2002
                            14. Taylor AJ et al: A comparison of four stent designs on arterial injury, cellular proliferation, neointima formation, and arterial dimensions in an experimental porcine model. Catheter Cardiovasc Interv. 53(3):420-5, 2001
                            Related Anatomy
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                            Related Differential Diagnoses
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                            References
                            Tables

                            Tables

                            KEY FACTS

                            • Terminology

                              • Preprocedure

                                • Procedure

                                  • Post Procedure

                                    TERMINOLOGY

                                    • Synonyms

                                      • Vascular endoprosthesis
                                    • Definitions

                                      • Vascular stent: Catheter-mounted metallic intravascular prosthesis
                                        • Provides intravascular scaffold
                                          • Allows for endothelialization
                                            • Endothelial cells migrate into stent
                                            • Leads to in-stent restenosis
                                          • Provides intravascular rigidity
                                            • Compresses atheroma, dissection flaps
                                            • Resists elastic recoil
                                        • Placed in diseased vascular structures
                                          • Arteries
                                          • Pulmonary arteries
                                          • Veins
                                          • Portal veins
                                        • Various indications
                                          • Recanalization of luminal stenosis/occlusion, including
                                            • Arterial atherosclerotic plaque [e.g., peripheral arterial disease (PAD), chronic mesenteric ischemia]
                                            • Venous extrinsic compression (e.g., May-Thurner syndrome)
                                            • Intimal hyperplasia (e.g., hemodialysis access outflow narrowing)
                                          • Aneurysm/pseudoaneurysm exclusion
                                          • Traumatic/iatrogenic arterial perforation
                                          • Arteriovenous (AV) communications
                                          • Stent-assisted coil embolization
                                      • Various delivery systems/calibers
                                        • 0.035" delivery system
                                        • 0.014"/0.018" delivery system
                                      • Vascular stent designs
                                        • Closed-cell: Every stent segment connected by link
                                          • Less flexible, may develop kinks
                                          • Occasional incomplete expansion
                                          • Better radial force/intravascular scaffolding
                                        • Open-cell: Some stent segment connections absent
                                          • Conforms to angled vessels/tortuous anatomy
                                          • Less radial force/intravascular scaffolding
                                      • Vascular stent technologies
                                        • Balloon-mounted: Externally mounted on percutaneous transluminal angioplasty (PTA) balloon
                                          • Risk of dislodgement; prevent by introducing through guiding catheter/sheath
                                            • Balloon inflation to deploy stent
                                            • Somewhat variable diameter range
                                            • More rigid stent design
                                          • Conforms poorly to changing vessel diameters
                                          • Balloon-mounted stent delivery designs
                                            • Over-the-wire (OTW): Central lumen for guidewire access/contrast injection, small parallel lumen for balloon inflation/deflation during stent deployment
                                            • Rapid-exchange (monorail): Guidewire passes through balloon, exits catheter proximal to balloon, runs alongside catheter shaft
                                        • Self-expanding: Sheathed in retractable delivery system; spontaneously expands after retraction
                                          • Most frequently constructed from nitinol
                                            • Alloy regains original shape when no longer compressed/constrained
                                          • Requires appropriate oversizing to achieve secure intravascular fixation
                                          • Typically more flexible
                                          • Conforms to changing vessel diameters
                                        • Drug-eluting: Stent coated with medication (e.g., paclitaxel)
                                          • Delivers antiproliferative drug to vessel surface
                                            • Local drug prevents in-stent stenosis
                                            • Drug reduces neointimal proliferation
                                          • More variable results when treating PAD versus coronary drug-eluting stents (DES)
                                            • No benefit over self-expanding stents in superficial femoral artery (SFA)
                                            • Ongoing investigational studies
                                        • Biodegradable: Made of polymers/metal alloys ± drug coating
                                          • Scaffold artery, allows natural healing to occur
                                            • Subsequently biodegrades; may deliver sustained drug release as degradation proceeds
                                          • Several biodegradable stents in clinical trials
                                            • Many more at preclinical stage of development
                                        • Radioactive: Catheter-based intravascular brachytherapy, mainly from gamma/beta sources
                                          • Majority of studies relate to coronary arteries
                                          • High restenosis incidence at stent margins
                                          • Ongoing investigational studies
                                        • Covered (stent-graft): Metallic intravascular stent combined with fabric graft of either Dacron or expanded polytetrafluoroethylene (ePTFE)
                                          • Courses inside vascular lumen; redirects blood flow through device rather than native vessel
                                            • Radial force of metallic stent secures graft
                                            • Catheter-mounted delivery system
                                          • 3 FDA-approved peripheral stent grafts
                                            • Atrium iCAST (Atrium Medical; Hudson, NH): Balloon-mounted expandable ePTFE stent graft
                                            • Bard Fluency (Bard; Tempe, AZ): Self-expanding nitinol stent encapsulated with ePTFE; retractable delivery system
                                            • Gore Viabahn (WL Gore; Newark, DE): Inner ePTFE fabric graft attached to external self-expanding nitinol stent

                                    PREPROCEDURE

                                    • Indications

                                      • Getting Started

                                        PROCEDURE

                                        • Patient Position/Location

                                          • Equipment Preparation

                                            • Procedure Steps

                                              • Alternative Procedures/Therapies

                                                POST PROCEDURE

                                                • Things to Do

                                                  OUTCOMES

                                                  • Complications

                                                    • Expected Outcomes

                                                      Selected References

                                                      1. Basavarajaiah S et al: Treatment of drug-eluting stent restenosis: comparison between drug-eluting balloon versus second-generation drug-eluting stents from a retrospective observational study. Catheter Cardiovasc Interv. 88(4):522-528, 2016
                                                      2. Liou K et al: Drug-eluting balloon versus second generation drug eluting stents in the treatment of in-stent restenosis: a systematic review and meta-analysis. Heart Lung Circ. 25(12):1184-1194, 2016
                                                      3. Naghi J et al: New developments in the clinical use of drug-coated balloon catheters in peripheral arterial disease. Med Devices (Auckl). 9:161-74, 2016
                                                      4. Carnelli D et al: Mechanical properties of open-cell, self-expandable shape memory alloy carotid stents. Artif Organs. 35(1):74-80, 2011
                                                      5. Räber L et al: Current status of drug-eluting stents. Cardiovasc Ther. 29(3):176-89, 2011
                                                      6. Arbabi A et al: Irradiation and dosimetry of Nitinol stent for renal artery brachytherapy. Appl Radiat Isot. 67(1):129-32, 2009
                                                      7. Brown DA et al: A new wave in treatment of vascular occlusive disease: biodegradable stents; clinical experience & scientific principles. J Vasc Interv Radiol. 20(3):315-24, 2009
                                                      8. Minar E et al: New stents for SFA. J Cardiovasc Surg (Torino). 50(5):635-45, 2009
                                                      9. Pierce DS et al: Open-cell versus closed-cell stent design differences in blood flow velocities after carotid stenting. J Vasc Surg. 49(3):602-6; discussion 606, 2009
                                                      10. Norgren L et al: Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 45 Suppl S:S5-67, 2007
                                                      11. Vaina S et al: Progressive stent technologies: new approaches for the treatment of cardiovascular diseases. Expert Opin Drug Deliv. 3(6):783-97, 2006
                                                      12. Duda SH et al: Sirolimus-eluting versus bare nitinol stent for obstructive superficial femoral artery disease: the SIROCCO II trial. J Vasc Interv Radiol. 16(3):331-8, 2005
                                                      13. Duerig TW et al: A comparison of balloon- and self-expanding stents. Minim Invasive Ther Allied Technol. 11(4):173-8, 2002
                                                      14. Taylor AJ et al: A comparison of four stent designs on arterial injury, cellular proliferation, neointima formation, and arterial dimensions in an experimental porcine model. Catheter Cardiovasc Interv. 53(3):420-5, 2001