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Stents: Vascular
Brandt C. Wible, MD
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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
            • 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
            • Stent delivery systems
              • 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
              • 0.035" and 0.014"/0.018" delivery systems
            • Stent technologies
              • Bare metal (BMS): Mesh-like scaffolding deployed in order to achieve and maintain patency of vessel
                • Not coated with polymers, medications, or fabric/graft
              • Drug eluting (DES): Stent coated with medication (e.g., paclitaxel, sirolimus), which has antiproliferative effect on smooth muscle cells, reducing neointimal hyperplasia
                • More variable results when treating PAD vs. coronary drug-eluting stents (DES)
                  • No benefit over self-expanding stents in superficial femoral artery (SFA)
                  • Ongoing investigational studies
                • 1st-generation DES
                  • Decreased short-term in-stent thrombosis vs. bare metal stents
                  • Late in-stent thrombosis remains problematic
                • 2nd-generation DES: Made with biocompatible materials
                  • Late stent thrombosis remains > 1%
              • 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
                • Peripheral stent-graft examples
                  • iCAST: Balloon-mounted expandable ePTFE stent-graft
                  • Flair: Self-expanding nitinol stent encapsulated with ePTFE; retractable delivery system
                  • Viabahn: Inner ePTFE fabric graft attached to external self-expanding nitinol stent
              • Flow diverting: Directs blood flow within parent vessel
                • Provides scaffolding to endothelial proliferation across diseased segment
                • Ability to maintain patency of critical perforator vessels
                • Pipeline embolization device (Covidien) approved (in USA) for treatment of intracranial aneurysms
              • Bioresorbable vascular scaffold (BVS): a.k.a. absorbable
                • Scaffold artery while natural healing to occur; subsequently biodegrades
                • Stent may/may not deliver drug as degradation proceeds
                • Several biodegradable stents in clinical trials
                  • Many more at preclinical stage of development
                  • Early concern for in-stent thrombosis of cardiac BVS
              • 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
              • Biologic: Coatings applied to stent that promote endothelial healing (vs. antiproliferative DES)
                • Attract endothelial progenitor cells with anti-CD34-positive antibodies/heparin/type IV collagen combinations
                • Gene-eluting stents in preclinical research
                • Stem cell stents proposed

          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. Khan MS et al: Meta-analysis comparing endovascular treatment modalities for femoropopliteal peripheral artery disease. Am J Cardiol. 128:181-8, 2020
                            2. Wernly B et al: A polymeric bioresorbable vascular scaffold versus an everolimus-eluting stent in ST-segment elevation myocardial infarction. J Invasive Cardiol. 31(9):E271-2, 2019
                            3. Hsu CC et al: Angioplasty versus stenting for infrapopliteal arterial lesions in chronic limb-threatening ischaemia. Cochrane Database Syst Rev. 12:CD009195, 2018
                            4. Li HL et al: Current evidence on management of aortic stent-graft infection: a systematic review and meta-analysis. Ann Vasc Surg. 51:306-13, 2018
                            5. Yoon NK et al: Stent technology in ischemic stroke. Neurosurg Focus. 42(4):E11, 2017
                            6. 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):522-8, 2016
                            7. 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):1184-94, 2016
                            8. 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
                            9. Carnelli D et al: Mechanical properties of open-cell, self-expandable shape memory alloy carotid stents. Artif Organs. 35(1):74-80, 2011
                            10. Räber L et al: Current status of drug-eluting stents. Cardiovasc Ther. 29(3):176-89, 2011
                            11. Arbabi A et al: Irradiation and dosimetry of Nitinol stent for renal artery brachytherapy. Appl Radiat Isot. 67(1):129-32, 2009
                            12. 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
                            13. Minar E et al: New stents for SFA. J Cardiovasc Surg (Torino). 50(5):635-45, 2009
                            14. 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
                            15. 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
                            16. Vaina S et al: Progressive stent technologies: new approaches for the treatment of cardiovascular diseases. Expert Opin Drug Deliv. 3(6):783-97, 2006
                            17. 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
                            18. Duerig TW et al: A comparison of balloon- and self-expanding stents. Minim Invasive Ther Allied Technol. 11(4):173-8, 2002
                            19. 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
                                      • 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
                                      • Stent delivery systems
                                        • 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
                                        • 0.035" and 0.014"/0.018" delivery systems
                                      • Stent technologies
                                        • Bare metal (BMS): Mesh-like scaffolding deployed in order to achieve and maintain patency of vessel
                                          • Not coated with polymers, medications, or fabric/graft
                                        • Drug eluting (DES): Stent coated with medication (e.g., paclitaxel, sirolimus), which has antiproliferative effect on smooth muscle cells, reducing neointimal hyperplasia
                                          • More variable results when treating PAD vs. coronary drug-eluting stents (DES)
                                            • No benefit over self-expanding stents in superficial femoral artery (SFA)
                                            • Ongoing investigational studies
                                          • 1st-generation DES
                                            • Decreased short-term in-stent thrombosis vs. bare metal stents
                                            • Late in-stent thrombosis remains problematic
                                          • 2nd-generation DES: Made with biocompatible materials
                                            • Late stent thrombosis remains > 1%
                                        • 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
                                          • Peripheral stent-graft examples
                                            • iCAST: Balloon-mounted expandable ePTFE stent-graft
                                            • Flair: Self-expanding nitinol stent encapsulated with ePTFE; retractable delivery system
                                            • Viabahn: Inner ePTFE fabric graft attached to external self-expanding nitinol stent
                                        • Flow diverting: Directs blood flow within parent vessel
                                          • Provides scaffolding to endothelial proliferation across diseased segment
                                          • Ability to maintain patency of critical perforator vessels
                                          • Pipeline embolization device (Covidien) approved (in USA) for treatment of intracranial aneurysms
                                        • Bioresorbable vascular scaffold (BVS): a.k.a. absorbable
                                          • Scaffold artery while natural healing to occur; subsequently biodegrades
                                          • Stent may/may not deliver drug as degradation proceeds
                                          • Several biodegradable stents in clinical trials
                                            • Many more at preclinical stage of development
                                            • Early concern for in-stent thrombosis of cardiac BVS
                                        • 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
                                        • Biologic: Coatings applied to stent that promote endothelial healing (vs. antiproliferative DES)
                                          • Attract endothelial progenitor cells with anti-CD34-positive antibodies/heparin/type IV collagen combinations
                                          • Gene-eluting stents in preclinical research
                                          • Stem cell stents proposed

                                    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. Khan MS et al: Meta-analysis comparing endovascular treatment modalities for femoropopliteal peripheral artery disease. Am J Cardiol. 128:181-8, 2020
                                                      2. Wernly B et al: A polymeric bioresorbable vascular scaffold versus an everolimus-eluting stent in ST-segment elevation myocardial infarction. J Invasive Cardiol. 31(9):E271-2, 2019
                                                      3. Hsu CC et al: Angioplasty versus stenting for infrapopliteal arterial lesions in chronic limb-threatening ischaemia. Cochrane Database Syst Rev. 12:CD009195, 2018
                                                      4. Li HL et al: Current evidence on management of aortic stent-graft infection: a systematic review and meta-analysis. Ann Vasc Surg. 51:306-13, 2018
                                                      5. Yoon NK et al: Stent technology in ischemic stroke. Neurosurg Focus. 42(4):E11, 2017
                                                      6. 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):522-8, 2016
                                                      7. 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):1184-94, 2016
                                                      8. 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
                                                      9. Carnelli D et al: Mechanical properties of open-cell, self-expandable shape memory alloy carotid stents. Artif Organs. 35(1):74-80, 2011
                                                      10. Räber L et al: Current status of drug-eluting stents. Cardiovasc Ther. 29(3):176-89, 2011
                                                      11. Arbabi A et al: Irradiation and dosimetry of Nitinol stent for renal artery brachytherapy. Appl Radiat Isot. 67(1):129-32, 2009
                                                      12. 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
                                                      13. Minar E et al: New stents for SFA. J Cardiovasc Surg (Torino). 50(5):635-45, 2009
                                                      14. 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
                                                      15. 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
                                                      16. Vaina S et al: Progressive stent technologies: new approaches for the treatment of cardiovascular diseases. Expert Opin Drug Deliv. 3(6):783-97, 2006
                                                      17. 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
                                                      18. Duerig TW et al: A comparison of balloon- and self-expanding stents. Minim Invasive Ther Allied Technol. 11(4):173-8, 2002
                                                      19. 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