Barbero, S

Di Savino, R

Gandini, Giovanni

Tappero, C

English

Institutional Research Information System University of Turin

Endovascular Solution for Incorrect Stent PositioningA 58-year-old man presented to our service suffering from clau-dication with a walking distance of 100 m. A preoperative angi-ography was performed showing an occlusion of the right commonfemoral artery with reperfusion of the superficial femoral artery 3cm below the bifurcation, subtotal stenosis of the right commoniliac artery with a residual lumen of 60–70%, and subtotal stenosisof the right external iliac artery with a residual lumen of about 80%(Fig. 1). The vascular surgeons decided to perform a thromboen-doarterectomy (TEA) of the right common femoral artery, butasked us to perform a preoperative percutaneous transluminalangioplasty and stenting of the right common iliac artery in orderto create a sufficient run-in into the common femoral artery.We decided to use a transaxillary approach with a vascularintroducer of 7 Fr and 45 cm and an angiographic guidewire(Terumo angled non-stiff 0.035-inch,180 cm in length) introducedinto the iliac artery. Using the road-mapping technique primarystenting of the right common iliac artery with a self-expandablenitinol stent (Smart Cordis 10 mm memory 6 cm length) wasperformed. The first angiographic control after positioning, how-ever, revealed malpositioning of the distal end of the stent into theinternal iliac artery (Fig. 2). Access to the external iliac arterytherefore became mandatory.The guidewire (Terumo angled non-stiff 0.035-inch) was easilypassed through the meshes of the stent, although subsequent pas-sage of angiographic catheters up to 4 Fr was difficult albeit ulti-mately successful. After expanding the pathway by the use ofballoon catheters of 4 and 6 mm diameter (Wanda, Boston Sci-entific) another stent (Smart Cordis 10 mm memory 4 cm length)was placed with its proximal end in the common iliac artery and itsdistal end within the external iliac artery (Fig. 3). The stent wasthen expanded to 10 mm (balloon catheter 10 mm diameter 4 cmlength; Wanda, Boston Scientific) at the upper end and up to 8 mm(balloon catheter 8 mm diameter and 4 cm length; Wanda, BostonScientific) at the distal end after the iliac bifurcation.The final angiographic control showed good results of the en-dovascular recanalization, with flow in the iliac axis down to theknown occlusion and sufficient run-in for a subsequent femoralTEA (Fig. 4).The patient underwent surgery 48 hr later and is currentlywalking more than 200 m without pain (at 6 month follow-up).Endovascular interventional radiology to treat the iliac axis iswell known [1] and has been accepted for many years. However,experienced centers have also found that the techniques are not freefrom inadvertent complications [2], as in the case above, where ourmistake was not to check the correct position of the guidewire byangiographic control but to trust fluoroscopy alone. Tricks andalternatives to solve even rare complications should be known incenters performing vascular interventions.Stefano BarberoRita Di SavinoCarlo TapperoGiovanni GandiniIstituto Radiologia UniversitariaVia Genova 3 10100, Turin, Italye-mail: stefanobarbero@tele2.itReferences1. Reyes R, Carreira JM, Gude F, Gorriz E, Gallardo L, Pardo MD, Her-mida M (2004). Long-term follow-up of iliac Wallstents. CardiovascIntervent Radiol 27:624–631. Epub Oct06, 2004. PMID: 15578139[PubMed-in process] http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15578139Fig. 1. Diagnostic angiographic ofthe iliofemoral tract: right commonand external iliac artery subtotalstenoses.ª Springer Science+Business Media, Inc. 2005Published Online: 26 September 2005CardioVascularand InterventionalRadiologyCardiovasc Intervent Radiol (2006) 29:166–167DOI: 10.1007/s00270-005-0004-52. Parham WA, Puri S, Bitar SR, Kern MJ (2003) Management of iliacstent movement complicating peripheral vascular intervention: A rescuetechnique when stent deployment malfunctions. J Invas Cardiol15:2772004 279. Epub May 2003: PMID: 12730638 [PubMed-indexedfor MEDLINE] http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12730638Fig. 2. Angiographic control after stenting: wrong distal positioningin the inner iliac artery.Fig. 4. Final angiographic control.Fig. 3. Angiographic control after restenting.Letter to the Editor 167

Endovascular solution for incorrect stent positioning

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Endovascular solution for incorrect stent positioning

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