How Should I Retrieve a Stent · Thomas M. Vesely, MD Saint Louis, Missouri Disclosure Consultant for: W.L. Gore & Associates Transonic, Inc. Phase One Medical R4 Vascular, Inc. “

ASDIN 9th Annual Scientific Meeting

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How Should I Retrieve a Stent

Nuts & Bolts of Endovascular Intervention

Thomas M. Vesely, MD

Saint Louis, Missouri

Disclosure

Consultant for:

W.L. Gore & Associates

Transonic, Inc.

Phase One Medical

R4 Vascular, Inc.

“ An ounce of prevention is worth a pound of cure ”

Benjamin Franklin

Use a long, stable guidewire

and leave it in position until

the procedure is completed

Measure vessel diameter and

select appropriate stent

Avoid

stent deployment

problems

ruler

MA Schechter et al.

Department of Surgery

Duke University

“Under-sizing of stent with resulting

poor wall apposition is the cause

of most stent migrations.”

Review Manufacturer’s

Stent Sizing Tables

ASDIN 9th Annual Scientific Meeting

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Management of Stent Migration

Do nothing

Percutaneous retrieval of stent

Open surgical retrieval of stent

Combined percutaneous and surgical procedure

“Leaving some types of foreign bodies

in place is reasonable,

particularly in asymptomatic patients

with a limited life expectancy.”

MA Schechter et al.

Department of Surgery

Duke University

Stent Manufacturer’s Recommendations

for Stent Retrieval / Removal

Stent/System Removal

“In the event of complications such as infections, pseudoaneurysm

or fistulization, surgical removal of the stent may be required.

Standard surgical procedure is appropriate.”

From Instructions for Use document

No official guidelines or recommendations from stent graft manufacturers;

Nothing in IFU documents for Flair, Fluency, or Viabahn.

Where is the stent located?

How long has it been there?

Does the patient have any symptoms?

Management of stent migration is dependent upon:

Stent deployment Discovery of stent migrationtime period

Time course for development

of neointimal hyperplasia

around stent struts

ASDIN 9th Annual Scientific Meeting

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Stents and stent grafts become incorporated

into vascular wall within 1 – 3 months

Percutaneous options:

Snare stent and remove through large sheath

Move stent and deploy into common iliac vein

Move stent to peripheral vein for surgical removal

Percutaneous Retrieval ToolsIntravascular Snares

• Used for intravascular retrieval / manipulation

• Snare loop at 90° to shaft of guidewire

• Nitinol - kink resistant

• Used within snare catheter

Guiding Catheters

• no hemostatic valve

• catheter tip is not tapered

• inserted with inner cannula

• should be hemostatic sheath

• allows use of multiple catheters & guidewires

• provides access for stent removal

Large diameter sheaths (16 Fr – 24 Fr)

Right femoral vein is often used

for stent retrieval procedures

• large diameter vein

• superficial location

• compressible against femoral head

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Tightening of snare causes deformation of metal stent

Balloon stabilization may improve movement

of stent or stent graft

Need large diameter sheath or guiding catheter

to accommodate angioplasty balloon and snare catheter Stent retracted into sheath

using snare and pigtail

stent in

sheath

20 French vascular sheath inserted

to level of right common iliac vein

ASDIN 9th Annual Scientific Meeting

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Management of Stent Migration

Do nothing

Percutaneous retrieval of stent

Open surgical retrieval of stent

Combined percutaneous and surgical procedure

Summary