Scar tissue forming THROUGH stent

Gordon · Post by **Gordon** » Tue Jan 11, 2011 2:55 pm

A great friend of mine has scar tissue forming through the stent. One option is to place a stent within a stent.

ie Stent placement or treatment with thrombolytics for occluded jugular viens with or without stents.

"Knox est all" says there is no evidence that this will help so it is no being done

Cece · Post by **Cece** » Tue Jan 11, 2011 5:46 pm

I am a little unsure what is meant by scar tissue, I think it is probably the regrowth or intimal hyperplasia, when the lining that grows to incorporate the stent into the vein keeps growing and can close off completely. Thrombolytics would not work against this, I don't think? That is for clots. A stent within a stent? That worries me, I'd get a second opinion or a third before going through with that. If it is intimal hyperplasia or the healing regrowth, I've heard of that being ballooned even inside a stent but I also recently read that it takes high pressure balloons to deal with that sort of restenosis because it is firm instead of soft. (I put a link to that radiopedia entry in Dr. Cumming's thread if interested.) Not sure if a high pressure balloon can be done inside of a stent. I wouldn't ignore it, we've heard of stents closing up entirely because of intimal hyperplasia.

DrCumming · Post by **DrCumming** » Wed Jan 12, 2011 1:26 pm

This sounds like typical in-stent intimal hyperplasia. No good treatment options. Can try reballooning and if that fails another stent. In the superficial femoral artery we have successfully use atherectomy devices <shortened url> to shave out the hyperplasia and portions of the stent but these device may not work in the jugular (due to differences in size +/- other factors). If it is not causing severe stenosis, its probably best to watch carefully with monthly US studies.

Cece · Post by **Cece** » Wed Jan 12, 2011 4:24 pm

Is "no good treatment options" because it's in a stent or would you say the same about intimal hyperplasia in a jugular without stents?

DrCumming · Post by **DrCumming** » Wed Jan 12, 2011 4:33 pm

because its a stent....

generally, the only out, is to place more metal. and eventually, that no longer becomes an option and you are done.

the beauty of ballooning only, is you virtually can always come back.

so, in short, ballooning may have a lower primary patency but will likely have a longer secondary patency. stents give you a really pretty picture when you are done and probably will stay open longer primarily, but when they become narrowed, maintaining secondary patency is very problematic.

i'll be interested to see if Dake presents some of his stent follow up at ISET.

eric593 · Post by **eric593** » Wed Jan 12, 2011 6:29 pm

Why is secondary patency more enduring than when primary patency is achieved? So do people who need 2nd angio's due to restenosis have an excellent chance of experiencing a continuing benefit?

Are risks of intimal hyperplasia or clotting greater in subsequent procedures and if so, are stronger anti-coagulants introduced to try to lower the risks?

Cece · Post by **Cece** » Wed Jan 12, 2011 6:56 pm

"The term primary patency denotes a period of uninterrupted patency for the treated target artery segment after the endovascular procedure. ... If the angioplasty site is thrombosed and a secondary procedure is performed to restore patency, the outcome status changes to secondary patency."

http://tinyurl.com/68998uq

That's just the definition of the terms, primary and secondary patency.

DrCumming · Post by **DrCumming** » Thu Jan 13, 2011 8:39 am

eric593 wrote:Why is secondary patency more enduring than when primary patency is achieved? So do people who need 2nd angio's due to restenosis have an excellent chance of experiencing a continuing benefit?

Are risks of intimal hyperplasia or clotting greater in subsequent procedures and if so, are stronger anti-coagulants introduced to try to lower the risks?

If you can maintain patency, then I see no reason why they would not experience continued benefit.

In general, the risks of repeat procedures are no different from the first (in venoplasty patients). No changes for anticoagulation.

As a note, the use of anticoagulation is a complete unknown. In dialysis patients (where most of our experience in venoplasty comes from) we use no anticoagulation at all. These patients have slightly dysfunctional platelets so they are mildly anticoagulated.

eric593 · Post by **eric593** » Thu Jan 13, 2011 1:00 pm

DrCumming wrote:
eric593 wrote:Why is secondary patency more enduring than when primary patency is achieved? So do people who need 2nd angio's due to restenosis have an excellent chance of experiencing a continuing benefit?

Are risks of intimal hyperplasia or clotting greater in subsequent procedures and if so, are stronger anti-coagulants introduced to try to lower the risks?
If you can maintain patency, then I see no reason why they would not experience continued benefit.

In general, the risks of repeat procedures are no different from the first (in venoplasty patients). No changes for anticoagulation.

As a note, the use of anticoagulation is a complete unknown. In dialysis patients (where most of our experience in venoplasty comes from) we use no anticoagulation at all. These patients have slightly dysfunctional platelets so they are mildly anticoagulated.

Thanks for that helpful info, good to know.

Many patients have reported having repeat procedures due to re-stenosis, but have complained of not experiencing a corresponding return of symptom improvement when the veins are re-opened.

DrCumming · Post by **DrCumming** » Fri Jan 14, 2011 7:27 am

eric593 wrote:
Many patients have reported having repeat procedures due to re-stenosis, but have complained of not experiencing a corresponding return of symptom improvement when the veins are re-opened.

I was under the opposite impression - that when people developed recurrent symptoms, repeat venoplasty resulted in similar improvements as the first procedure.

Cece · Post by **Cece** » Fri Jan 14, 2011 7:51 am

DrCumming wrote:
eric593 wrote:
Many patients have reported having repeat procedures due to re-stenosis, but have complained of not experiencing a corresponding return of symptom improvement when the veins are re-opened.
I was under the opposite impression - that when people developed recurrent symptoms, repeat venoplasty resulted in similar improvements as the first procedure.

Most of the time, yes, it's as Dr. Cumming states. We've had cases though where patients expected the same relief of fatigue or improvements that they had the first time and it doesn't happen. Not sure why.

Rokkit · Post by **Rokkit** » Fri Jan 14, 2011 7:52 am

DrCumming wrote:I was under the opposite impression - that when people developed recurrent symptoms, repeat venoplasty resulted in similar improvements as the first procedure.

It seems that the majority of repeat venoplasties have resulted in similar improvements but there has been a (small?) minority of people reporting no return of improvements.

Cece · Post by **Cece** » Fri Jan 14, 2011 8:22 am

Rokkit wrote:It seems that the majority of repeat venoplasties have resulted in similar improvements but there has been a (small?) minority of people reporting no return of improvements.

I think it's extremely small, I can think of maybe three reports (here's vivavie's: http://www.thisisms.com/ftopicp-147548.html#147548).

Another one was told to me by pm, she was treated by one of our top IRs for her second procedure, yet did not experience the relief of fatigue she'd experienced after her first procedure.

Originally the thought was, if you know you're a responder to the procedure the first time, that's good, you know you'll respond again. That still seems to be the case nearly all of the time. Here's a more typical anecdote: http://www.thisisms.com/ftopicp-147949.html#147949 where lucky125 says, "Well, as it was with the last two treatments, I immediately had warm light pink feet. [...] Once again my foot drop magically disappeared!"

Icechick · Post by **Icechick** » Fri Jan 14, 2011 4:46 pm

Unfortunately, I am one of those few challenging patients that had awesome improvements after my first balloon in Sept. and no improvements after the second in Dec. I am working with Dr. Saxon at Del Mar Vein Clinic through the Hubbard Foundation. Now I have to decide if a third time will do the trick or if a stent is the only option. Thank God for everyone here and their input.

Cece · Post by **Cece** » Fri Jan 14, 2011 4:59 pm

Welcome to the site, Icechick. I am sorry to hear your improvements were lost. Do you know if your veins stayed open after the second procedure? Did your doctor have any theory or explanation for why you didn't get the same improvements after the second procedure?

Before going for a stent, has Dr. Saxon considered the aggressive ballooning with higher pressure balloons? Dr. Sclafani has seen some success with them and while the risk profile is not entirely known, it seems less risky than a stent. Wishing you the best, whatever you decide.