Presentation

Successful treatment of an occluded drug-eluting stent (DES)

The presented case illustrates a successful endovascular approach in a patient with new onset of claudication intermittent after 50m walking distance and angiographic evidence of an occluded drug-eluting stent in the superficial femoral artery.

Comments

    Nice presentation and straight to the point! Kostas, are there any other indications where you would consider covered stents as first-line treatment in SFA lesions?

    Prof. Konstantinos Donas
    June 12, 2018

    Thank you Efstratios for your comment! I am considering the use of covered stents as first-line treatment in case of thrombotic occlusion with suspicion of residual thrombus formation after succesful recanalisation, or in case of accidental perforation of the SFA during endovascular maneuvers. Finally, the current literature supports also the use of covered stents as first line treatment in case of in-stent stenosis in the SFA.
    However, my first choice for the SFA, in general, remains the use of a bare metal stent, because I believe that patent collateral pathway of the SFA is very crucial and should be always preserved.

    Dear Kostas,
    just two comments. I am not so sure that the current literature supports the primary use of stent grafts for the treatment of ISR. A real world study evaluating the performance of stents grafts for denovo and ISRs in femoro- popliteal arterial obstructive disease concluded that stent grafts have high restenosis and failure rates, of both stent patency and limb outcomes (Catheter Cardiovasc Interv. 2018;91:1130–1135.). Quite the contrary, numerous studies support the use of DCBs +/- debulking (laser atherectomy, rotation atherectomy etc) and some registry data the use of DES.
    Regarding the gold standard of SFA treatment, I totally agree that the preservation of the collateral network is crucial. Nonetheless, this can be achieved with all available treatment options except stent grafts (and not only with BMS). Thus, a more individualized approach based on lesions (CTO, calcification, length etc) and patients characteristics (CKD, compliance) seems more reasonable.

    Prof. Konstantinos Donas
    June 13, 2018

    Thank you Kostas for your comment. I had in my mind writing about superiority of covered stents in ISR, the multicenter randomized trial (RELINE trial), which was published in 2015 from Bosiers M, et al and showed significant better outcomes for the covered stents compared to PTA. I believe that this study has a much better impact and value than the retrospective single center study of ca. 25 patients, which you mentioned.
    There is no doubt, that we have more than one options to treat complex SFA lesions with pros and cons for each approach. In my case the possible presence of residual thrombus material after the use of Rotarex was the major argument to deploy a covered stent minimizing the risk of peripheral embolization. Further FU is off course mandatory in order to ensure patency and durability of this treatment option. Again, many thanks for your comment and keep in touch.

    Surely, the RELINE trial (J Endovasc Ther. 2015 Feb;22(1):1-10.) is a very interesting study, which, however, included also a small number of patients (39 in the stent graft group) and reported patency rates of 54% at 24 months.
    Moreover, and similar to the findings of this retrospective single center study, the multi center SALAVAGE registry (Catheter Cardiovasc Interv. 2012 Nov 1;80(5):852-9) reported 12 months primary patency rates of 48% following laser atherectomy and stent graft implantation for ISR. This study included also a small number of patients.
    There is no doubt that a physical barrier might be useful in selected cases but there is no body of evidence to support the use of grafts as primary treatment option of ISR.

    It’s very clear, thanks!

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