Peripheral Vascular Stent Insertion
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Various peripheral arterial occlusive lesions have traditionally been managed with surgical therapy. However, endoluminal intervention with catheter-based techniques has become quite common and, in many cases, is now the treatment of choice. Several interventional products are available for the endovascular specialist, but balloons and stents make up the core of these technologies.
Placement of a metal stent across a stenotic or occluded blood vessel is intended to maintain the patency of the vessel and reestablish flow through it by providing internal structural support. This article discusses the indications, contraindications, anesthesia, necessary equipment, positioning, techniques, and potential complications of endovascular stent placement.
The indications for peripheral vascular stent placement in a patient with known peripheral arterial disease (PAD) are the same as those for open intervention.
Indications for vascular stents in the lower extremities are as follows:
Indications for vascular stents in the upper extremities are as follows:
Indications for vascular stents in the visceral arteries are as follows:
Indications for vascular stents in the carotid arteries are as follows:
Selective stent placement (exclusive of carotid intervention) is indicated as a secondary intervention following balloon angioplasty when the result is residual stenosis greater than 30% or a flow-limiting dissection.
Primary stent placement is generally indicated as initial intervention for iliac, renal, subclavian, and carotid stenosis.
The Trans-Atlantic Inter-Society Consensus II (TASC II) [1] established recommended guidelines for treatment of peripheral vascular disease on the basis of lesion characteristics. An update published in 2015 expanded the TASC classification to include arteries below the knee. [2]
The TASC classification for aortoiliac lesions is as follows:
The TASC classification for femoropopliteal lesions is as follows:
The TASC classification for infrapopliteal lesions (with the anterior tibial artery as the selected example) is as follows:
Preferred treatment is as follows:
There has been an increase in the adoption of an endovascular-first approach for even complex (TASC C/D) lesions. However, more and better-quality data comparing open with endovascular therapy are needed is needed, particular with regard to meaningful outcomes (eg, limb viability, wound healing, quality of life, and survival) besides anatomic patency. [2]
No absolute contraindications for using stents in the peripheral vessels exist. Recommendations against the use of stents for peripheral intervention are outlined in the general guidelines for high-category TASC lesions listed above (see Indications).
Other limiting factors may relate more to those that would be considered in any angiographic procedure, such as renal insufficiency, which may limit the ability to use iodinated contrast for the procedure, or pregnancy, which would contraindicate the use of radiation.
It generally is not recommended to place stents across areas of extreme flexion or compression points that could lead to stent crushing and fracture—for instance, across the inguinal ligament (CFA) or across the knee flexion point in the popliteal artery (which is actually proximal to the knee joint itself). Again, most limitations are based on guidelines only and must be assessed on a case-to-case basis.
Self-expanding stents are preferred for long lesions, tortuous vessels, or areas where concern for external forces or compression exists because they are more flexible, more trackable, and available in much longer lengths (currently in the range of 2-17 cm for a single stent); these are ideal for femoral-popliteal lesions.
Balloon-expandable stents are recommended for ostial lesions, calcified lesions, and short-segment lesions because they can be deployed precisely and exert a stronger radial force; these are ideal for treatment of renal, mesenteric, iliac, and subclavian lesions.
If stent insertion is considered a likely possibility, a minimum sheath diameter of 6 French should be considered.
In the treatment of contralateral femoral-popliteal lesions, a long sheath extending to the contralateral CFA gives a more stable position through which to work. A meta-analysis by Antoniou et al demonstrated that drug-eluting stents yielded better short-term results than bare-metal stents, with increased patency and freedom from target lesion revascularization; the influence on end points such as limb salvage remains unknown. [3]
In treating subclavian, mesenteric, and renal lesions, a guide catheter is useful to help track a balloon-expandable stent to the desired vessel; this requires a larger-diameter sheath to accommodate the guide catheter of the required diameter.
Treatment of aortic lesions can be done with Palmaz stents (large-diameter balloon-expandable stents that must be manually mounted onto a large balloon) [4] ; alternatively, one can consider covered stent grafts such as those used for aortic aneurysmal disease.
Venous stenting has also shown benefit in certain cases [5] ; this is mostly seen in iliac vein stenosis (eg, May-Thurner syndrome) and can be performed with larger-diameter Wallstents with much more significant oversizing (≥25%) because veins have much higher capacitance.
Decision-making should always take into consideration the possibility that an endovascular intervention might limit future surgical options. For example, placement of a stent in the CFA or the below-the-knee popliteal artery could limit the option of a bypass in the future and thus should probably be avoided. [6]
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007 Jan. 45 Suppl S:S5-67. [Medline].
Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, et al. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II): The TASC Steering Comittee(.). Ann Vasc Dis. 2015. 8 (4):343-57. [Medline]. [Full Text].
Antoniou GA, Chalmers N, Kanesalingham K, Antoniou SA, Schiro A, Serracino-Inglott F, et al. Meta-analysis of outcomes of endovascular treatment of infrapopliteal occlusive disease with drug-eluting stents. J Endovasc Ther. 2013 Apr. 20 (2):131-44. [Medline].
Pearce B, Jordan WJ Jr. Nonaortic stents and stent-grafts. Cronenwett JL, Johnston KW, eds. Rutherford’s Vascular Surgery. 8th ed. Philadelphia: Elsevier Saunders; 2014. Vol 2: 1443-55.
Raju S, Owen S Jr, Neglen P. The clinical impact of iliac venous stents in the management of chronic venous insufficiency. J Vasc Surg. 2002 Jan. 35(1):8-15. [Medline].
Sullivan TM, Rizvi AZ. Technique: endovascular therapeutic. Cronenwett JL, Johnston KW, eds. Rutherford’s Vascular Surgery. 8th ed. Philadelphia: Elsevier Saunders; 2014. Vol 2: 1322-37.
Chu TM, Chan YC, Cheng SW. Evidence for treating peripheral arterial diseases with biodegradable scaffolds. J Cardiovasc Surg (Torino). 2017 Feb. 58 (1):87-94. [Medline].
Wressnegger A, Kaider A, Funovics MA. Self-expanding nitinol stents of high versus low chronic outward force in de novo femoropopliteal occlusive arterial lesions (BIOFLEX-COF trial): study protocol for a randomized controlled trial. Trials. 2017 Dec 14. 18 (1):594. [Medline]. [Full Text].
Schillinger M, Sabeti S, Loewe C, et al. Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery. N Engl J Med. 2006 May 4. 354(18):1879-88. [Medline].
Iftikhar O, Oliveros K, Tafur AJ, Casanegra AI. Prevention of Femoropopliteal In-Stent Restenosis With Cilostazol: A Meta-Analysis. Angiology. 2016 Jul. 67 (6):549-55. [Medline].
Kokkalis E, Aristokleous N, Houston JG. Haemodynamics and Flow Modification Stents for Peripheral Arterial Disease: A Review. Ann Biomed Eng. 2016 Feb. 44 (2):466-76. [Medline].
Dale K Mueller, MD Co-Medical Director of Thoracic Center of Excellence, Chairman, Department of Cardiovascular Medicine and Surgery, OSF Saint Francis Medical Center; Cardiovascular and Thoracic Surgeon, HeartCare Midwest, Ltd, A Subsidiary of OSF Saint Francis Medical Center; Section Chief, Department of Surgery, University of Illinois at Peoria College of Medicine
Dale K Mueller, MD is a member of the following medical societies: American College of Chest Physicians, American College of Surgeons, American Medical Association, Chicago Medical Society, Illinois State Medical Society, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons, Rush Surgical Society
Disclosure: Received consulting fee from Provation Medical for writing.
Nabeel R Rana, MD Assistant Professor of Surgery, University of Illinois College of Medicine at Peoria; Vascular and Endovascular Surgeon, HeartCare Midwest, OSF Health System
Nabeel R Rana, MD is a member of the following medical societies: American College of Surgeons, Society for Vascular Surgery, Society for Clinical Vascular Surgery
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Karlheinz Peter, MD, PhD Professor of Medicine, Monash University; Head of Centre of Thrombosis and Myocardial Infarction, Head of Division of Atherothrombosis and Vascular Biology, Associate Director, Baker Heart Research Institute; Interventional Cardiologist, The Alfred Hospital, Australia
Karlheinz Peter, MD, PhD is a member of the following medical societies: American Heart Association, German Cardiac Society, Cardiac Society of Australia and New Zealand
Disclosure: Nothing to disclose.
Peripheral Vascular Stent Insertion
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