crush stenting” an alternative approach to manage · pdf file 2 disclosure i have the...
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Thursday, January 1, 20187 – 12:24-12:30
“Crush Stenting” An Alternative Approach toManage Occluded Femoropopliteal Stents
S.Müller-Hülsbeck, MD, EBIR, FCIRSE, FICA, FSIR
ACADEMIC HOSPITALS Flensburg of Kiel University – Faculty of Medicine
Ev.-Luth. Diakonissenanstalt zu Flensburg
Knuthstraße 1, 24939 FLENSBURG
Dept. of Diagnostic and Interventional
Radiology / Neuroradiology
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Disclosure
I have the following potential conflicts of interest to
report:
Consulting – Boston Scientific, Terumo, GE,
Eurocor
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Objectives
• Crush-stenting
What is beyond this term?
• Crush-stenting
What is the exact technique, when used as
Treatment For Occluded Fempop Stents ?
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Crush-Stenting (I): BES + BES
• A. Colombo, G. Stankovic, D. Orlic, et al.Modified T-stenting withcrushing for bifurcation lesions: immediate results and 30-day outcome. Catheter CardiovascInterv, 60 (2003), pp. 145-151
BEScrushed
BES
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• A large, self-expanding stent was implanted from the lower aorta to one iliac branch, followed by deployment of a balloon-expandable stent in the contralateral iliac artery such that its proximal edge protruded a few millimeters through the struts of the self-expanding stent into the aorta
Crush-Stenting (II): SES + BES
Midulla M, Martinelli T, Goyault G, Lions C, Abboud G, Koussa M, Mounier-Véhier C, Beregi JP. T-stenting with small protrusion technique (TAP-stenting) for stenosed aortoiliac bifurcations with small abdominal aortas: an alternative to the classic kissing stents technique. J Endovasc Ther. 2010 Oct;17(5):642-51.
[TAP (T And Protrude)-stenting technique]
n=23
100% primary patency @ 16 months
SES
BES
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Crush-Stenting (III): BES + BES
Complication management of intraoperative „blind“ subintimal stenting
BEScrushed
BEScrushed
BES
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Crush-Stenting (IV): SES + SES
Complication management of misplaced SES (sidebranch)
SEScrushed
SES
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Treatment For Occluded Fempop Stents
Standard: PTA-DCB Literature: Debulking+DCB
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Treatment For Occluded Fempop Stents
Standard: PTA-DCB Literature: Debulking+DCB
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Treatment For Occluded Fempop Stents
If intraluminal RECA fails?
•Unintentially pass of the occluded stent:
Older occlusion
Fibrosed tissue
Re-organized thrombus
•Go ahead with PIER (per-interventional extraluminal recanalization) !
Duterloo D, Lohle PN, Lampmann LE. Subintimaldouble-barrel restenting of an occluded primarystented superficial femoral artery. CardiovascIntervent Radiol. 2007 May-Jun;30(3):474-6.
„Trespassing PIER-wise + subintimalstenting of the neo-lumen“
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Treatment For Occluded Fempop Stents
If intraluminal RECA fails?
•Unintentially pass of the occluded stent:
Older occlusion
Fibrosed tissue
Re-organized thrombus
•Go ahead with PIER (per-interventional extraluminal recanalization) !
„Trespassing PIER-wise + subintimalstenting of the neo-lumen“
Double-Barrel Restenting
SEScrushed
SES
SES
Duterloo D, Lohle PN, Lampmann LE. Subintimaldouble-barrel restenting of an occluded primarystented superficial femoral artery. CardiovascIntervent Radiol. 2007 May-Jun;30(3):474-6.
12http://diako.de
Treatment For Occluded Fempop Stents
If intraluminal RECA fails?
•Unintentially pass of the occluded stent:
Older occlusion
Fibrosed tissue
Re-organized thrombus
•Go ahead with PIER (per-interventional extraluminal recanalization) !
Nakamura A, Nakajima S, Endo H, Takahashi T, Nozaki E. Successful outside-the-stent stentingfor an occluded primary stented superficialfemoral artery. Cardiovasc Interv Ther. 2014 Apr;29(2):187-92.
„Trespassing PIER-wise + subintimalstenting of the neo-lumen“
Double-Barrel Restenting
SEScrushed
SES
SES
@1yr 100% patency
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Case 1: Index procedure
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Case 1: @12 months
• PIER
• Hydrophylic guidewire
0.035-inch or 0.018-inch
• Re-entry
technology
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Case 1: @12 months
• High-pressure PTA
Neo-lumen creation
• SES
Crush- or double-barrel stenting
• Final PTA
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Case 1: @12 months
Coloured duplex US @18months
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Case 2:
Intraluminal –Sure?
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SEScrushed
SES
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Treatment For Occluded Fempop Stents-If intraluminal RECA fails…
• PIER • Re-entrytechnology
• Support technology
Kirk J, Wilson R, Kovacs F, Tennant W, Braithwaite B, Habib S. Successful extra-anatomical recanalization of occluded superficialfemoral arteries using the Outback device--a report of 2 cases. Vasc Endovascular Surg. 2012 Jan;46(1):62-5.
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Treatment For Occluded Fempop Stents
•Can be a challenge…
•Dedicated techiqueand technology isrequired:
•Advantages:
•Stents required:
• PIER-technique
Hydrophylic guide wire tip
Support catheter
• Re-entry-technique
Re-entry catheters
• Aggressive re-stenting-technique
Double-barrel- or crush-stenting
• High technical success + high mid-term patency
•SES, intervoven Nitinol?
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Thursday, January 1, 20187 – 12:24-12:30
“Crush Stenting” An Alternative Approach toManage Occluded Femoropopliteal Stents
S.Müller-Hülsbeck, MD, EBIR, FCIRSE, FICA, FSIR
ACADEMIC HOSPITALS Flensburg of Kiel University – Faculty of Medicine
Ev.-Luth. Diakonissenanstalt zu Flensburg
Knuthstraße 1, 24939 FLENSBURG
Dept. of Diagnostic and Interventional
Radiology / Neuroradiology