Covered Stents?

[JCB]

Has any one had a covered stent in a jugular? If so did it help with the coagulation?

[DrCumming]

I have placed 2 covered stents in the last month. One in an occluded proximal IJ that we were able to open up, second in a mid - distal IJ which was occluded after being too aggressively dilated. Still waiting to see the patients for follow up. We use them occasionally in dialysis patients where they definitely last longer then bare metal stents. There is essentially no tissue ingrowth into the stent. Migration of a proximally placed stent is a risk.

[dania]

That is interesting news, Dr Cumming.

[munchkin]

I hate to ask what feels like a dumb question, but is the proximal IJV closer to the jaw line and is the distal IJV closer to the collar bone?

Is the risk for clotting and having scar tissue form from the clots an issue with the covered stents?

[Cece]

(proximal=closer to the heart; distal=further from the heart)

In the one case where there was a reported ccsvi stent migration to the heart (radeck's case), it was the distal stent that migrated.

Specifically the distal stent had been placed first (at the top of the jugular, near the jawline), then the lower stent was placed at the area of the valves. The placement of the lower stent improved the flow so much that the upper portion widened and the upper stent migrated to the heart. In order for the upper portion to widen like that, it is because it was not a true stenosis. This was in 2009.

I think, learning from that situation, it is important to get an accurate measurement of the vein (such as through IVUS) and verify that it is a true stenosis and only place a stent after all other balloonings in the vein are complete.

Really interested in hearing how the covered stent works out. I also like hearing about successful treatments of occluded areas. Just getting them open again is successful, but especially so if the covered stent does the job.

[DrCumming]

The difference between covered and non covered stents is the mode of failure. In bare metal (non covered) stents, the primary mode of failure is tissue ingrowth (intimal hyperplasia). For covered stents, the primary mode of faillure is at the end points (again due to tissue ingrowth). The downside is that when one end of stent occludes, the remainder can fill with thrombus which then can break free and embolize. This is especially a problem when used in the femoral artery in the leg as it can ruin the smaller outflow vessels in the calf and foot.

We will see if we can get greater durability with a covered stent. And maybe better options for maintaining stent patency versus bare metal.

[Cece]

very interesting...seems like there are no easy answers.

[munchkin]

Can the ultrasound see the intimal hyperplasia developing? Or is it only found once the stent is fully occluded?

If the tissue ingrowth is detected early enough can it be treated and does this just cause more tissue ingrowth?

Does using Warfarin/Coumaden (sp?) limit the issue of clots more effectively than Plavix or Aspirin?

[Cece]

DrCumming, about what percentage of your patients are you able to see for follow-up?

Especially when we talk about things like stents with ingrowth, keeping on top of it seems really important, but of course this is difficult if patients are travelling.

[JohnAm]

yes, intimal hyperplsia can be detected by ultrasound, before there is total ingrowth inside the stent, if the sonographer or the doctor is experienced...

it can be treated by re-stenting, possible by just balloning or mechanical removal...

The vasc doctor that I see, says that warfarin works better in veins than what plavix does... in other word if a clot develops in a vein warfarin is more effective in managing the clot. must then be regurlarly monitored for INR value so that blood does not get too thin (there is a therapeutic interval).
beware also that warfarin increase the risk of bleeding...

[JCB]

Thanks for all the good info. to think about.

[Cece]

Mechanical removal works for some clots, but not for intimal hyperplasia. It is literally the vein that is growing over the stent. I cannot remember the word right now (brachiatherapy???) but there is the possibility of using super-cooled balloons to freeze the vein lining to stop intimal hyperplasia. (I think bestadmom knew someone in Florida who had this done as part of her procedure? Memory failing here...).

Typically a stent is put inside the stent. Dr. Sclafani tried in one TIMSer's case to put two mesh stents inside the stent (so there were three layered) but that was not effective, he would not do it again.

[JCB]

So far, covered stent remains patent. Still feel alert and awake during the morning and thru out the day. Still have right foot drop, and general right side weakness. Hoping the covered stent is the answer for me, for keeping the vein open.

[DrCumming]

So far, covered stent remains patent. Still feel alert and awake during the morning and thru out the day. Still have right foot drop, and general right side weakness. Hoping the covered stent is the answer for me, for keeping the vein open.

How long has your stent be in? What location?

[JCB]

The stents (actually two, overlapped for length) were deployed in the left Internal Jugular on September 1st. Still on Fondaparinux until further notice.