Allergic Reaction following Implantation of a Nitinol Alloy Inferior Vena Cava Filter

Nickel-related hypersensitivity reactions following endovascular interventions: A review of current evidence

INTRODUCTION

Nickel is a principal alloying agent in the production of vascular endoprostheses, despite persisting as the most habitually identified allergen. Variable nickel-related hypersensitivity manifestations following endovascular intervention were reported, challenging established paradigms in treatment and accuracy of prognostic assessments. The objective of this review is to critically evaluate current metrics to maximise patient-related outcomes.

METHODS

A literature review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 statement. Patients indicative of nickel hypersensitivity reaction following endovascular intervention were discerned. A positive reaction was defined by patch testing, histological analysis, or anamnesis indicative of nickel hypersensitivity. Morphology of implicating prostheses, adverse events and postoperative complications, clinical course, diagnostic and therapeutic strategies alongside patient prognosis were recorded.

RESULTS

Nickel-related hypersensitivity reactions following endovascular repair were identified in 36 patients with a median age of 44.5 years. 20 patients received nitinol-containing intervention. 28 (77.8%) patients are female. Multi-organ adverse reactions occurred in 21 (58.3%) patients with variable latency. 14 (38.9%) patients were presented with neurological adverse reactions manifesting mainly as unilateral hemiparesis. Dermatological reactions implicated 16 (44.4%) patients. Miscellaneous manifestations include suicidal ideation. 13 (36.1%) patients displayed previous metal intolerance and 32 (88.9%) patients had positive patch testing for nickel. Histological analysis of lesions and prostheses indicated lymphocytic infiltration. 5 (13.9%) patients experienced device-specific reactions as in-stent restenosis or auxiliary distal vessel stenosis. 11 (30.1%) patients received solely medical therapy and 5 (13.9%) patients received solely surgical therapy. 19 (52.7%) patients underwent both medical (oral corticosteroid) and surgical therapy (device retrieval). 26 (77.1%) patients achieved symptomatic cessation, 6 (16.7%) patients exhibited symptomatic persistence and 0 patients died.

CONCLUSION

Prophylactic pre-assessment for a history of metal allergy and consideration of prostheses alternatives is recommended to minimise reaction risk and severity. Despite nickel's predominant usage, information paucity urges additional studies to emphasise its implications and maximise patient outcomes.

Implant-Supported Overdentures: Current Status and Preclinical Testing of a Novel Attachment System

Numerous attachment systems exist for implant-supported overdentures, with each having specific limitations in terms of retention, cost, wear, maintenance and cleanability. A retrospective analysis of patients restored with implant-supported overdentures using bars, telescopic crowns and Locator-type attachments was performed and the patients were interviewed. An in vitro strain gauge study compared telescopic crowns, Locator-type attachments and a novel flexible attachment system employing a shape memory alloy (NiTi) with respect to peri-implant strain development during insertion, loading and removal of an overdenture. A significantly lower number of attachment-related complications was observed in bars as compared to telescopic crowns (p = 0.00007) and Locator-type attachments (p = 0.00000), respectively. Greater overall patient satisfaction was noted in bar-retained restorations while Locator-type attachments led to lower levels of satisfaction regarding prosthesis retention. In vitro, telescopic crowns caused maximum strain development during prosthesis insertion and loading, while during removal this was observed in Locators with white retentive inserts. NiTi attachments caused significantly lower strain development during insertion as compared to telescopic crowns (p = 0.027). During loading, NiTi attachments caused significantly lower strain development than Locators with blue retentive inserts (p = 0.039). During removal, NiTi attachments caused significantly less strain development as compared to Locators with white retentive inserts (p = 0.027). Positional discrepancies between male and female attachment parts affected the retention and reaction force between both components, which may be minimized by using the novel NiTi attachment system. This may be beneficial in terms of component wear and implant loading.

Examining the role of nickel and NiTi nanoparticles promoting inflammation and angiogenesis

Nickel titanium (NiTi, or Nitinol) alloy is used in several biomedical applications, including cardiac, peripheral vascular, and fallopian tube stents. There are significant biocompatibility issues of metallic implants to nickel ions and nano-/micro-sized alloy particles. Our laboratories have recently shown that microscale CoCr wear particles from metal-on-metal hips crosslink with the innate immune signaling Toll-like receptor 4 (TLR4), prompting downstream signaling that results in interleukin (IL)-1β and IL-8 gene expression. In vivo, NiTi alloy can also generate wear particles on the nanoscale (NP) that have thus far not been studied for their potential to induce inflammation and angiogenesis that can, in turn, contribute to implant (e.g. stent) failure. Earlier studies by others demonstrated that nickel could induce contact hypersensitivity by crosslinking the human, but not the mouse, TLR4. In the present work, it is demonstrated that NiCl₂ ions and NiTi nanoparticles induce pro-inflammatory and pro-angiogenic cytokine/chemokine expression in human endothelial and monocyte cell lines in vitro. These observations prompt concerns about potential mechanisms for stent failure. The data here showed a direct correlation between intracellular uptake of Ni²⁺ and generation of reactive oxygen species. To determine a role for nickel and NiTi nanoparticles in inducing angiogenesis in vivo, 1-cm silicone angioreactors were implanted subcutaneously into athymic (T-cell-deficient) nude mice. The angioreactors contained Matrigel (a gelatinous protein mixture that resembles extracellular matrix) in addition to one of the following: PBS (negative control), VEGF/FGF-2 (positive control), NiCl_2, or NiTi NP. The implantation of angioreactors represents a potential tool for quantification of angiogenic potentials of medical device-derived particles and ions in vivo. By this approach, NiTi NP were found to be markedly angiogenic, while Ni²⁺ was less-so. The angioreactors may provide a powerful tool to examine if debris shed from medical devices may promote untoward biological effects.

Nickel hypersensitivity and endovascular devices: a systematic review and meta-analysis

OBJECTIVE

Nickel allergy is common; endovascular specialists are often confronted with nickel allergic patients ahead of the implantation of endovascular devices, many of which are nickel-containing. Our aim was to elucidate whether nickel hypersensitivity is significantly associated with worse or adverse outcomes after placement of a nickel-containing endovascular device.

METHODS

Inclusion criteria were: endovascular and transcatheter procedures for coronary, structural heart, neurovascular and peripheral vascular pathology involving nickel-allergic patients. All adverse outcomes were included as defined by included studies. A systematic review and meta-analysis were undertaken using a random-effects model. Searches of MEDLINE and EMBASE were conducted for articles published 1947-2019.

RESULTS

190 records were identified, 78 articles were included for qualitative synthesis and 15 met criteria for meta-analysis. Patch-test confirmed nickel allergy was associated with an increased risk of adverse outcomes following implantation of a nickel-containing endovascular device (n=14 articles, 1740 patients; OR 2.61, 95% CI 1.41 to 4.85). This finding further was observed in coronary (n=12 articles, 1624 patients; OR 1.94, 95% CI 1.16 to 3.23) and structural heart subgroups (n=2 articles, 83 patients; OR 52.28, 95% CI 1.31 to 2079.14), but not in the neurovascular subgroup (n=1 article, 33 patients; OR 3.04, 95% CI 0.59 to 15.72) or with a patient-reported history of nickel allergy (n=2 articles, 207 patients; OR 2.14, 95% CI 0.23 to 19.70).

CONCLUSIONS

Patch-tested nickel allergy is associated with an increased risk of adverse outcomes following endovascular device implantation and alternative treatment options should be considered. Specialists faced with patients' self-reporting nickel allergy should consider proceeding to diagnostic patch-testing.

Influence of an Implant Fixture including a Freely Removable Micro-Locking Implant Prosthesis on Peri-Implant Tissues and Implant Prostheses: A Prospective Clinical Study

This prospective study was undertaken to evaluate the clinical usefulness of a newly developed one-piece, screw-free, and micro-locking implant system, which was designed to overcome the shortcomings of the existing implant systems. Thirty-eight patients were recruited and randomly and equally assigned to an experimental group (micro-locking one-piece fixture, MLF; n = 19) or a control group (micro-locking abutment, MLA). Cumulative implant survival rates, marginal bone resorptions, probing depths, plaque indices, bleeding indices, and complications were obtained by using clinical and radiographic findings at 6 months and 12 months after prosthesis placement. Complications that occurred multiple times for single implants were counted. During the 12 month observation period, survival rates were 100% in both groups. No significant intergroup differences were observed for marginal bone resorption, probe depth, or bleeding index. However, mean plaque index was significantly lower in the MLF group at 12 months (p < 0.05). During the 12-month observation period, food impaction (26.3%) was the main complication in the MLF group and screw loosening (5.3%), prosthesis detachment (5.3%), and food impaction (5.3%) were observed in the MLA group. The results of this study suggest that the one-piece micro-locking implant system offers a predictable treatment method.

Contact dermatitis

Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed.

Successful multi-step catheter intervention for thrombotic inferior vena cava filter retrieval

A 45-year-old man, who was implanted with an inferior vena cava (IVC) filter in his infrarenal IVC, had a complication of deep vein thrombosis (DVT) propagation from the IVC, beyond the IVC filter, to the right calf and left external iliac veins. The entire IVC filter was covered with a massive thrombus. We first decided to retrieve the IVC filter itself, which was suspected of causing metallic allergy. The thrombotic IVC filter was successfully retrieved using multi-step catheter intervention. To our knowledge, this is the first case report to describe successful multi-step catheter intervention for retrieval of an IVC filter covered with a massive thrombus. <Learning objectives: Inferior vena cava (IVC) filter thrombosis is one of the most serious IVC filter complications. It is difficult to retrieve the IVC filter covered with a massive thrombus. Multi-step catheter intervention technique may be useful to retrieve an IVC filter with thrombotic occlusion.>.