Delayed stent fracture has been observed in many different arteries and may represent a risk factor for restenosis. We describe the case of a delayed rupture of an endovascular brachiocephalic trunk stent. The complete fracture allowed a fragment to migrate distally and tilt, resulting in a hemodynamic pattern similar to that of a prevertebral stenosis with complete inversion of the homolateral vertebral blood flow. The induced vertebral steal syndrome as well as the risk of cerebral embolism was corrected by an aortobrachiocephalic bypass and resection of the ruptured sten

Haesler, E.

Hayoz, D.

Periard, D.

Qanadli, S.

Von Segesser, L.

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CASE REPORTRupture and Migration of an Endovascular Stent in theBrachiocephalic Trunk Causing a Vertebral Steal SyndromeD. Periard Æ E. Haesler Æ D. Hayoz ÆL. K. Von Segesser Æ S. D. QanadliReceived: 31 July 2007 / Accepted: 16 November 2007 / Published online: 3 January 2008 Springer Science+Business Media, LLC 2007Abstract Delayed stent fracture has been observed inmany different arteries and may represent a risk factor forrestenosis. We describe the case of a delayed rupture of anendovascular brachiocephalic trunk stent. The completefracture allowed a fragment to migrate distally and tilt,resulting in a hemodynamic pattern similar to that of aprevertebral stenosis with complete inversion of thehomolateral vertebral blood flow. The induced vertebralsteal syndrome as well as the risk of cerebral embolism wascorrected by an aortobrachiocephalic bypass and resectionof the ruptured stent.Keywords Arteriopathy  Stent rupture Vertebral steal syndromeIntroductionEndovascular stent implantation is a major tool in themanagement of peripheral arterial disease [1–3]. Supra-aortic artery angioplasty and stenting have been performedfor many years with a satisfying outcome [4–6]. Delayedstent rupture has been observed in arteries with highmechanical stress and is considered a risk factor for in-stentrestenosis [7]. We present a case of delayed fracture of abrachiocephalic stent with migration of the distal fragmentcausing a vertebral steal syndrome.Case ReportA 62-year-old man was referred to us for intermittentdizziness and right arm claudication. His cardiovascularrisk factors were type 2 diabetes and past smoking. Clinicalexamination revealed an asymmetry of brachial bloodpressure, with the right-arm systolic pressure 30 mm Hgbelow that of the left arm. A stenosis of the right brachi-ocephalic trunk was diagnosed by echo Doppler, withmonophasic blood flow in the right subclavian artery.Selective angiography by femoral approach confirmed an80% stenosis of the brachiocephalic trunk (Fig. 1). Directstenting was performed with a balloon-expandable siliconecarbide-coated stent (Peiron; Biotronik, Berlin) 8 mm indiameter and 26 mm long. The stent was deployed at 6 atmduring 20 s. The angiogram at the end of the proceduredisclosed no significant residual stenosis and correct posi-tion of the stent, with a small defect in the wall appositionof the cranial segment, due to a poststenotic dilatation ofthe artery (Fig. 2). The stent was not further balloon-expanded. Brachial blood pressure difference disappearedafter angioplasty. A Doppler examination disclosedrestored triphasic arterial flow in the right arm after theprocedure.Two years later, the patient presented a relapse of bloodpressure asymmetry. Doppler analysis showed antegradeD. Periard  E. Haesler  D. HayozService of Angiology, University Hospital (CHUV), Lausanne,SwitzerlandL. K. Von SegesserCardiovascular and Metabolic Diseases Center, UniversityHospital (CHUV), Lausanne, SwitzerlandS. D. QanadliDepartment of Radiology, University Hospital (CHUV),Lausanne, SwitzerlandD. Periard (&)Department of Angiology, PMU 07, Bugnon 44, UniversityHospital (CHUV), 1011 Lausanne, Switzerlande-mail: Daniel.Periard@chuv.ch123Cardiovasc Intervent Radiol (2008) 31:S53–S56DOI 10.1007/s00270-007-9254-8monophasic arterial flow of the right subclavian and rightcommon carotid artery. Right vertebral flow was totallyinverted. We postulated an in-stent restenosis. High-reso-lution (slice thickness of 0.625 mm) multidetector CTangiography (Lightspeed VCT; GE Medical Systems,Milwaukee, WI, USA) showed a rupture of the stent, withmigration of its cranial fragment (Fig. 3). Selectiveangiography was performed to better evaluate the patencyof the stent and revealed that the brachiocepalic trunkremained patent, with a \40% in-stent re-stenosis. It alsoconfirmed that the stent was ruptured (Fig. 4). The cranialfragment was shifted and rotated at a 90 angle. Blood wasflowing through the struts of the stent. There was no ste-nosis on the prevertebral subclavian artery. We estimatedFig. 1 Selective angiography showing an 80% stenosis of the rightbrachiocephalic trunkFig. 2 Angioplasty and stenting of the stenosis resulting in satisfac-tory lumen restoration. Note the lack of perfect apposition of thecranial stent extremity on the wall, due to a poststenotic arterialdilatationFig. 3 CT scan. The ruptured upper extremity of the stent has movedand rotated. Blood is flowing through the meshes of the stentFig. 4 Selective angiography confirming the rupture and rotation ofthe caudal stent extremityS54 D. Periard et al.: Stent Rupture123that the flow through the struts of the stent had a hemo-dynamic effect similar to that of a significant stenosis,especially when associated with an in-flow impairment dueto the moderate in-stent restenosis. We also estimated thatthe shifted and rotated position of the fragment made itprone to migrate farther or to be a potential source of distalemboli in the brain or arm. Since there was no possibilityof endovascular management, the patient was referred to acardiovascular surgeon, who successfully performed anaortobrachiocephalic trunk bypass and resected the stent(Fig. 5), by a localized thoracotomy. Postoperativeassessment showed symmetry of brachial blood pressureand restored triphasic flow in the right subclavian andcommon carotid arteries.DiscussionIsolated cases of stent fracture have been observed in thecoronary artery [8], subclavian artery [9], iliac artery [10],femoropopliteal artery [11], and pulmonary artery [12].Mechanical stress seems to be a risk factor for fracture [7].Stents positioned in arteries frequently bent (i.e., femoro-popliteal artery) or placed near a pulsatile structure (likethe heart or great vessels) also have a higher risk of fracture[13]. Localized stiffness of the arterial wall may play a rolein the breakage of the device, as observed with overlappingstents or stents used for intrastent restenosis [8]. Thestructure of the device certainly has an influence on itsmechanical properties and solidity [14, 15]. A recent pro-spective evaluation of stent fracture found 24.5% fracturedstents at 10 months after femoropopliteal stenting [15].These fractures were classified as single strut fracture in48.4%, moderate fracture in 26.6%, and complete separa-tion of fragments in 25.0%. In that study, fracture rate wascorrelated with the length of the segment that had beencovered by stents. Moreover, stent fracture was a predictorof intrastent restenosis and artery occlusion [15].In this case we postulated that stent rupture may havehad three origins. First, the brachiocephalic trunck is apulsatile large vessel exerting continuous mechanical stresson the device. Second, the ruptured fragment (distal frag-ment) was located in the area of wall apposition defect ofthe stent, while the proximal fragment remained in the siteof the minimum lumen diameter. One could imagine thatthe distal part, in contrast to the proximal one, would havebeen submitted to continuous systolodiastolic motion thatinduced microtraumatism at the junction between the twofragments and, subsequently, complete fracture of the stentstruts. Migration of the stent after the fracture supportedthe absence of re-endothelialization of the stent, probablybecause of the wall apposition defect and the distal frag-ment motion. Third, the stent used may have mechanicalproperties that could explain this event. The Peiron stent isa premounted thermocrimped 316L stainless-steel stentwith a passive coating of amorphous silicon carbide. Thestent contains 10 diamond-shaped cells per link, with twoconnecting struts between each link. This stent is no longercommercially available, having been upgraded to a newgeneration. To our knowledge, no similar complicationwith the Peiron stent has been reported in the literature.\ConclusionStent fracture is a common complication of endovascularprocedures. We have reported a particular case of stentrupture and migration in the brachiocephalic trunk wherethe flow through the stent’s struts caused a unique hemo-dynamic pattern of vertebral steal syndrome. Theapposition defect to the arterial wall seems to have been themajor cause predisposing to rupture in this case.References1. ACC/AHA (2006) ACC/AHA 2005 practice guidelines for themanagement of patients with peripheral arterial disease (lowerextremity, renal, mesenteric, and abdominal aortic). Circulation113:463–6542. Dormandy JA, Rutherford RB (2000) Management of peripheralarterial disease (PAD). TASC Working Group. J Vasc Surg31:S1–S2963. Schillinger M, Sabeti S, Loewe C, Dick P, Amighi J, MlekuschW, Schlager O, Cejna M, Lammer J, Minar E (2006) Balloonangioplasty versus implantation of nitinol stents in the superficialfemoral artery. N Engl J Med 354:1879–18884. Sullivan TM, Gray BH, Bacharach JM, Perl J 2nd, Childs MB,Modzelewski L, Beven EG (1998) Angioplasty and primarystenting of the subclavian, innominate and common carotidarteries in 83 patients. J Vasc Surg 28:1059–10655. Zaytzev AY, Stoyda AY, Smirnov VE, Scherbyuk AN, Kon-drashin SA, Artukchina EG, Kikevitch VA (2006) Endovasculartreatment of supra-aortic extracranial stenosis in patients withvertebrobasilar insufficiency symptoms. CardioVasc IntervRadiol 29:731–7386. Amor M, Eid-Lidt G, Chati Z, Wilentz JR (2004) Endovasculartreatment of the subclavian artery: stent implantation with orwithout predilatation. Cathet Cardiovasc Interv 63:364–370Fig. 5 Surgically resected fragments of the ruptured stentD. Periard et al.: Stent Rupture S551237. Laird JR (2006) Limitations of percutaneous transluminal angi-oplasty and stenting for the treatment of disease of the superficialfemoral and popliteal arteries. J Endovasc Ther 13 (Suppl II):II–30–II–408. Sianos G, Hofma S, Ligthart JM, Saia F, Hoye A, Lemos PA,Serruys PW (2004) Stent fracture and restenosis in the drug-eluting stent era. Cathet Cardiovasc Interv 61:111–1169. Phipp LH, Scott DJ, Kessel D, Robertson I (1999) Subclavianstents and stent-grafts: A cause for concern? J Endovasc Surg6:223–22610. Sachs BA, Miller A, Gottlieb M (1996) Fracture of an iliac arteryPalmaz stent. J Vasc Interv Radiol 7:53–5511. Duda SH, Pusich B, Richter G, Landwehr P, Oliva VL, TielbeekA, Wiesinger B, Hak JB, Tielemans H, Ziemer G, Cristea E,Lansky A, Be´re´gi JP (2002) Sirolimus eluting stent for thetreatment of obstructive superficial artery disease: six monthsresults. Circulation 106:1505–150912. Knirsh W, Haas NA, Lewin MA, Uhlemann F (2003) Longitu-dinal stent fracture 11 months after implantation in the leftpulmonary artery and successfull management by stent-in-stentmaneuver. Cathet Cardiovasc Interv 58:116–11813. Nakanishi T, Kondoh C, Nishikawa T, Satomi G, Nakazawa M,Imai Y, Momma K (1994) Intravascular stents for the manage-ment of pulmonary artery and right ventricular outflowobstruction. Heart Vessels 9:40–4814. Duda SH, Bosiers M, Lammer J, Scheinert D, Zeller T, TielbeekA, Anderson J, Wiesinger B, Tepe G, Lansky A, Mudde C, Ti-elemans H, Beregi JP (2005) Sirolimus-eluting versus bare nitinolstent for obstructiove superficial femoral artery disease: theSIROCCO II trial. J Vasc Interv Radiol 16:331–33815. Scheinert D, Scheinert S, Sax J, Piorkowski C, Bra¨unlich S, Ul-rich M, Biamino G, Schmidt A (2005) Prevalence and clinicalimpact of stent fractures after femoro-popliteal stenting. J AmColl Cardiol 45:312–315S56 D. Periard et al.: Stent Rupture123

Rupture and Migration of an Endovascular Stent in the Brachiocephalic Trunk Causing a Vertebral Steal Syndrome

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Rupture and Migration of an Endovascular Stent in the Brachiocephalic Trunk Causing a Vertebral Steal Syndrome

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