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Peripheral Vascular Stent Insertion

  • Author: Dale K Mueller, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
 
Updated: Dec 02, 2015
 

Background

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 patency of and re-establish flow through the vessel by providing internal structural support. This article discusses the indications, contraindications, anesthesia, necessary equipment, positioning, techniques, and potential complications of endovascular stent therapy.

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Indications

The indications for peripheral vascular stent placement in patient with known peripheral arterial disease are the same as those for open intervention.

Indications for vascular stents in the lower extremities are as follows:

  • Severe, debilitating claudication
  • Lifestyle-limiting claudication refractory to lifestyle modification and exercise regimen
  • Ischemia with rest pain
  • Ischemic nonhealing lower-extremity ulcers

Indications for vascular stents in the upper extremities are as follows:

  • Severe arm claudication with subclavian stenosis
  • Syncope or dizziness with arm use ( subclavian steal syndrome) with evidence of subclavian stenosis and retrograde vertebral flow
  • Ischemic ulcers of the hand

Indications for vascular stents in the visceral arteries are as follows:

  • Difficult to control hypertension on three or more medications with or without elevated creatinine levels, greater than 60% renal artery stenosis
  • Mesenteric ischemia (postprandial abdominal pain, weight loss, “food fear”) and more than 70% stenosis in celiac or superior mesenteric artery

Indications for vascular stents in the carotid arteries are as follows:

  • Most carotid stent procedures are being performed as part of clinical trials
  • Stent therapy for carotid stenosis is reserved for patients at high operative risk (eg, intervention for restenosis following previous surgical repair, prior radiation to the neck, high lesions that are difficult to access surgically, or contralateral carotid occlusion)

Selective stent placement (exclusive of carotid intervention) is indicated as 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 modality for peripheral vascular disease based on lesion characteristics. Their classification for aortoiliac lesions is as follows:

  • TASC A - Unilateral or bilateral stenosis of common iliac artery (CIA); unilateral or bilateral single short (≤3 cm) stenosis of external iliac artery (EIA)
  • TASC B - Unilateral CIA occlusion; single or multiple stenosis totaling 3-10 cm involving EIA but not common femoral artery (CFA); unilateral EIA occlusion
  • TASC C - Bilateral CIA occlusions; bilateral EIA stenosis 3-10 cm long; unilateral EIA stenosis or occlusions extending into CFA; heavily calcified EIA occlusion involving CFA or origin of internal iliac artery (IIA)
  • TASC D - Infrarenal aortic occlusion; diffuse disease involving aorta and both iliac arteries; diffuse multiple stenosis involving CIA, EIA, and CFA; unilateral occlusion of both CIA and EIA; bilateral EIA occlusions; iliac stenosis in patients with abdominal aortic aneurysm (AAA) requiring treatment and not amenable to endograft placement requiring open surgery

The TASC classification for femoral popliteal lesions is as follows:

  • TASC A - Single stenosis ≤10 cm in length; single occlusion ≤5 cm in length
  • TASC B - Multiple stenosis or occlusions each ≤5 cm; single stenosis or occlusion ≤15 cm not involving the infrageniculate popliteal artery; single or multiple lesions in the absence of continuous tibial vessels to improve inflow for distal bypass; heavily calcified occlusion ≤5 cm in length
  • TASC C - Multiple stenosis or occlusions totaling >15 cm; recurrent stenosis or occlusions that need treatment after two endovascular interventions
  • TASC D - Chronic total occlusions of CFA or superficial femoral artery (SFA) >20 cm, involving the popliteal artery; chronic total occlusion of popliteal artery and proximal trifurcation vessels

Preferred treatment is as follows:

  • TASC A lesions - Endovascular therapy is the treatment of choice
  • TASC B lesions - Endovascular therapy is the preferred treatment, but this depends on patient comorbidities, fully informed patient preference, and the operator’s long-term success rate
  • TASC C lesions - Surgery is the preferred treatment for good-risk patients, but this depends on patient comorbidities, fully informed patient preference, and the operator’s long-term success rate
  • TASC D lesions - Surgery is the treatment of choice
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Contraindications

No absolute contraindications to using stents in the peripheral vessels exist. Recommendations against 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 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.

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Technical Considerations

Self-expandable 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 of precise deployment and 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.

When treating 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 superior short-term results with drug-eluting stents as compared with bare-metal stents, with increased patency and freedom from target lesion revascularization; the influence on end points such as limb salvage remains unknown.[2]

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 required diameter guide catheter.

Treatment of aortic lesions can be done with Palmaz stents (large-diameter balloon-expandable stents that must be manually mounted onto a large balloon)[3] ; alternatively, one can consider covered stent grafts such as those used for aortic aneurysmal disease.

Venous stenting has also shown benefit in certain cases[4] ; 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 of at least 25% because veins have much higher capacitance.

Decision-making should always take into consideration that an endovascular intervention could potentially limit future surgical options; for example, placement of a stent in the common femoral artery or the below-knee popliteal artery could limit the option of a bypass in the future and should likely be avoided.[5]

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

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.

Specialty Editor Board

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.

Chief Editor

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.

References
  1. 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].

  2. 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].

  3. Pearce B, Jordan WJ Jr. Nonaortic Stents and Stent-Grafts. Cronenwett JL, Johnston KW. Rutherford’s Vascular Surgery. 7th. Philadelphia, PA: WB Saunders; 2010. 1373-83.

  4. 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].

  5. Sumi M, Ohki T. Technique: Endovascular Therapeutic. Cronenwett JL, Johnston KW. Rutherford’s Vascular Surgery. 7th. Philadelphia, PA: WB Saunders; 2010. 1277-94.

  6. Chu TM, Chan YC, Cheng SW. Evidence for treating peripheral arterial diseases with biodegradable scaffolds. J Cardiovasc Surg (Torino). 2015 Sep 2. [Medline].

  7. 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].

  8. Iftikhar O, Oliveros K, Tafur AJ, Casanegra AI. Prevention of Femoropopliteal In-Stent Restenosis With Cilostazol: A Meta-Analysis. Angiology. 2015 Sep 21. [Medline].

  9. Kokkalis E, Aristokleous N, Houston JG. Haemodynamics and Flow Modification Stents for Peripheral Arterial Disease: A Review. Ann Biomed Eng. 2015 Oct 14. [Medline].

 
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