Successful Management of Arterial Pseudoaneurysm Caused by Stent Fracture

Systematic Review of Femoral Artery Stent Fractures

Objective

Primary stenting for long femoropopliteal (FP) lesions remains controversial because of the high risk of stent fracture (SF). This study aimed to summarise current knowledge on SF from randomised control trials about FP stenting.

Methods

A systematic review of the Medline database was performed by a combined strategy of MeSH terms: femoral artery, popliteal artery, stenting, and stent fracture. SF was classified according to a standard classification: 1 = single strut fracture; 2 = ≥ two struts fracture; 3 = type 2 with deformation; 4 = multiple struts fracture with acquired transection; 5, type 4 with gap in the stent body.

Results

The literature search identified 25 publications including covered stents (CSs; n = 3), drug eluting stents (DESs; n = 8), bare metal stents (BMS; n = 17), and bioabsorbable stents (n = 1). Data were extracted from 4 047 patients; mean age ± standard deviation was 68.9 ± 3.0 years and 69% were male. The median lesion length was 87.6 mm (interquartile range [IQR] 70.0, 149) with a median chronic total occlusion proportion of 36.8% (IQR 29.0, 56.5). In 208 patients treated with CS, SF rates ranged from none to 2.6% at 36 months with no clinical correlation. In 1 106 patients treated with DES, SF rates were relatively low in large cohorts, ranging from 0% at 12 months to 1.9% at 60 months. In smaller cohorts (under 100 patients per group), they ranged from 12.5% at six months to 46.7% at 12 months, with no clinical repercussion. In 1 610 patients treated with BMS, SF rates ranged from 2% to 32.7% at 12 months and from 2.9% to 48.9% at 24 months, with no clinical repercussion.

Conclusion

SF rates in large cohorts were low in CF and DES, and quite common in BMS, although none of them had clinical consequences. However, longer follow up and detailed, accurate reports are needed to assess eventual real clinical outcomes.

Early stent fractures in superficial femoral artery resulting multiple pseudoaneurysm formation within one year: a case report

BACKGROUND

Though fracture is known complication of stenting, pseudoaneurysm asscoiated with stent fracture is an extremely rare complication. This has previoulsy been described to occur at least one or more years following initial stent placement. Here we present a case of multi-site stent fracture leading to two separate SFA pseudoaneurysms within one year of placement, successfully treated with covered stents.

CASE PRESENTATION

A 72-year-old male presented with severe claudication of his left lower extremity (Rutherford 3), found to have long segment SFA chronic total occlusion (CTO). Patient successfully underwent endovascular revascularization. Follow-up duplex ultrasound (US) at one year demonstrated a focus of severe in-stent restenosis (ISR). During repeat angiogram for treatment of the stenosis, stent fracture and pseudoaneurysm was seen in the distal SFA, which was treated successfully with a self-expanding covered stent. Additional stent fractures and pseudoanerusyms were subseuqently identified on follow-up, necessitating a third angiogram, and these were successfully repaired using overlapping covered stents, without further recurrence.

CONCLUSIONS

Superficial femoral artery stent fractures leading to pseudoaneurysms are extremely rare, particularly within first year of stent placement. Endovascular repair with covered stents has proven to be an effective treatment option with decreased procedural morbidity compared to surgical repair.

A case report of successful stent implantation through a fractured stent-strut in a superficial femoral artery based on bench testing simulation

BACKGROUND

Stent implantation through the stent-strut of a previously implanted self-expandable stent in the superficial femoral artery (SFA) is not usually performed because the additional stent cannot dilate sufficiently. The key point to achieve sufficient expansion of an additional stent is to break the stent-strut of the previously implanted stent. However, there is no report of how to break the stent-strut.

CASE SUMMARY

A 72-year-old man was admitted to our hospital with acute rest pain and coldness of his left leg; he was diagnosed with acute limb ischaemia. The angiogram demonstrated a fractured stent as well as stent occlusion in the left distal SFA. The guidewire could pass only through the stent-strut because of stent fracture. Fortunately, balloon angioplasty through the stent-strut and thrombolysis achieved successful revascularization. Thereafter, an additional stent was implanted in an attempt to manage the fractured and deformed stent. To obtain sufficient expansion of the additional stent, an experimental study to examine the balloon diameter and pressure to break the stent-strut was performed. Based on the results of the experiment, the stent-strut was successfully broken, and the additional stent was expanded through the stent-strut on the second intervention.

DISCUSSION

If an additional self-expandable stent is deployed through the stent-strut directly, it would not be sufficiently dilated. The key point in such a case is to break the stent-strut of the previously implanted stent by balloon inflation before deployment of the additional stent. The experimental study examined the balloon diameter and pressure that can break the stent-strut. This information would be useful when we implant an additional stent through a stent-strut.

Pseudo-aneurysm caused by stent fracture in the "sub-acute" phase after endovascular therapy for in-stent restenosis lesions

Despite the reported favorable patency of stents in the treatment of femoropopliteal lesions, concern regarding stent fracture is increasing. Development of pseudo-aneurysm by stent fracture is rare and has been reported to occur in the chronic phase owing to mechanical fatigue. Here, we present the first report of a pseudo-aneurysm caused by stent fracture in the "sub-acute" phase after endovascular therapy for in-stent restenosis lesion. A 79-year-old man underwent endovascular therapy for an in-stent restenosis lesion of the right superficial femoral artery. Echography 48 days after the treatment showed a saccular pseudo-aneurysm at the proximal stent site, suggestive of stent fracture. Angiography confirmed the pseudo-aneurysm caused by stent fracture. A self-expandable endoluminal stent graft was deployed, which showed complete resolution of the pseudo-aneurysm. A pseudo-aneurysm caused by stent fracture can occur in the "sub-acute" phase after endovascular therapy for in-stent restenosis lesions. <Learning objective: Although rare, a pseudo-aneurysm owing to stent fracture can occur in the "sub-acute" phase after endovascular therapy for in-stent restenosis lesions.>.

Symptomatic superficial femoral artery pseudoaneurysm due to late stent fracture

Late formation of pseudoaneurysm related to stent fracture is rarely described in the literature. We describe a case of spontaneous 8-cm femoral superficial artery pseudoaneurysm rupture that had developed from fracture of a stent implanted 3 years previously. Surgical repair was performed with fractured stent removal and reverse saphenous vein bypass.

Prospective Evaluation of the TIGRIS Vascular Stent Within a Modern Treatment Algorithm

Purpose: To prospectively evaluate the safety and efficacy of the TIGRIS Vascular Stent in the superficial femoral artery (SFA) and proximal popliteal artery within a treatment algorithm that reserved stent usage for more challenging patients. Materials and Methods: This prospective, single-center study enrolled 97 patients (mean age 68.7 years; 66 men) who were treated for 100 de novo or nonstented restenotic femoropopliteal lesions (≥70% stenosis) and had recoil or dissection after plain balloon predilation. The average lesion length was 5.6±2.3 cm (maximum 8 cm per protocol). The composite primary efficacy outcome was 12-month primary patency, defined as a peak systolic velocity ratio ≤2.5 at the stented target lesion on duplex ultrasound, and no clinically-driven reintervention within the stented segment. The primary safety outcome was freedom from device- and procedure-related target vessel revascularization, target limb major amputation (above the metatarsals), or death through 30 days. Secondary outcomes included secondary patency, clinically-driven target lesion revascularization (TLR), Rutherford category change relative to baseline, and binary restenosis of the target lesion. Results: All devices were successfully implanted with no device-related complications at the time of implant or within the 30-day postimplant window. The average stented length was 7.0±2.5 cm; no stent elongation was observed during deployment. One patient was lost to follow-up before 12 months and another died of an unrelated cause, leaving 95 patients (98 lesions) available for 12-month follow-up and 77 patients/lesions for the 24-month preliminary analysis. The binary primary and secondary patency rates at 12 months were 92.9% and 100%. The binary freedom from TLR was 94.9%. At 24 months, the Kaplan-Meier estimate of primary patency was 90.0%. Conclusion: This prospective study demonstrated that the TIGRIS Vascular Stent is a safe and effective device in a modern treatment algorithm that reserved bare stent use for postangioplasty dissection or recoil in distal femoropopliteal arteries.