Application of the “covered-stent-in-uncovered-stent” technique for easy and safe removal of embedded biliary uncovered SEMS with tissue ingrowth

Removal of embedded biliary uncovered self-expandable metal stents (uSEMS) is regarded as difficult or even impossible when the duration of indwell exceeds a couple of weeks, because of the ingrowth of tissue. The presence of diffuse and severe ingrowth is the main feature limiting SEMS removal [1]. In the esophagus, placement of a self-expanding plastic stent (SEPS) inside the SEMS has been shown to induce pressure necrosis of this tissue hyperplasia, allowing subsequent removal of the stent. We applied this technique in a 58-year-old patient with a history of alcohol abuse, obstructive jaundice, and suspected malignancy, in whom an uSEMS 10 mm wide and 6 cm long (Wallflex; Boston Scientific, Natick, Massachusetts, USA) had been mistakenly inserted more than 1 year before. The patient had experienced recurrent cholangitis due to stent obstruction caused by tissue ingrowth. Stent removal was therefore considered, but was unsuccessful using conventional maneuvers. A covered SEMS (Wallflex) was then placed inside the uSEMS

Application of the "covered-stent-in-uncovered-stent" technique for easy and safe removal of embedded biliary uncovered SEMS with tissue ingrowth

Removal of embedded biliary uncovered self-expandable metal stents (uSEMS) is regarded as difficult or even impossible when the duration of indwell exceeds a couple of weeks, because of the ingrowth of tissue. The presence of diffuse and severe ingrowth is the main feature limiting SEMS removal [1]. In the esophagus, placement of a self-expanding plastic stent (SEPS) inside the SEMS has been shown to induce pressure necrosis of this tissue hyperplasia, allowing subsequent removal of the stent. We applied this technique in a 58-year-old patient with a history of alcohol abuse, obstructive jaundice, and suspected malignancy, in whom an uSEMS 10 mm wide and 6 cm long (Wallflex; Boston Scientific, Natick, Massachusetts, USA) had been mistakenly inserted more than 1 year before. The patient had experienced recurrent cholangitis due to stent obstruction caused by tissue ingrowth. Stent removal was therefore considered, but was unsuccessful using conventional maneuvers. A covered SEMS (Wallflex) was then placed inside the uSEMS

Biological or mechanical prostheses for isolated aortic valve replacement in patients aged 50-65 years: the ANDALVALVE study

[Objectives]: The decision about whether to use a biological or a mechanical prosthesis for aortic valve replacement remains controversial in patients between 50 and 65 years of age and has yet to be addressed in a Mediterranean population. This research aimed to analyse long-term survival and major morbidity rates (30-day mortality, stroke, any prosthetic reoperation and major bleeding) within this population. [Methods]: Our multicentre observational retrospective study included all subjects aged 50–65 years who had a primary isolated aortic valve replacement due to severe aortic stenosis at 7 public hospitals from Andalusia (Spain) between 2000 and 2015. Concomitant surgery, reoperations and endocarditis were the exclusion criteria. A total of 1443 patients were enrolled in the study (272 with biological and 1171 with mechanical valves). Multivariate analyses including a 2:1 propensity score matching (506 mechanical and 257 biological prostheses) were conducted. [Results]: Bioprostheses were implanted in 18.8% (n = 272): 35% were women; the mean EuroSCORE-I was 3%. The mean follow-up was 8.1 ± 4.9 years in a matched sample: 8.8 ± 4.9 years in those receiving a mechanical vs 7.1 ± 4.5 years in those receiving a biological prosthesis (P = 0.001). In the paired sample, the 15-year survival rate was 73% in those who had a biological vs 76% in those who had a mechanical valve [hazard ratio (HR) 0.80, 95% confidence interval (CI) 0.54–1.20; P = 0.159]. No significant differences were observed in patients ≥55 years old (74% of 15-year survival in both groups: HR 0.88, 95% CI 0.56–1.34; P = 0.527). A higher rate of major bleeding was found in patients with a mechanical prosthesis (P = 0.004), whereas reoperation was more frequent among those with a biological prosthesis (P = 0.01). [Conclusions]: Long-term survival was comparable in patients above 55 years of age. Mechanical prostheses were associated with more major bleeding and bioprostheses, with more reoperations. A bioprosthesis in patients above 55 years old is a reasonable choice.This work was supported by Edwards Lifesciences, which provided funds for an independent statistical analysis