Fracture of Popliteal Artery Stents

Abstract

tent implantation in the peripheral arteries is a safe and effective treatment not only for obstructive diseases, but also non-obstructive conditions such as aneurysm formation. 1,2 More than 50% of all obstructive lesions are located in the femoropopliteal segment where they tend to be longer and have multiple coexisting atherosclerotic lesions at different levels. Surgical revascularization is the treatment of choice for these diffuse femoropopliteal stenoses and although percutaneous transluminal angioplasty (PTA) has a high risk of occlusion, it is the recommended primary treatment. Stent implantation for femoropopliteal occlusions is not recommended because of poor patency rates, and should only be considered for major dissections after PTA because stenting has been associated with acute thrombosis, stent embolization or migration, distal embolization by plaque contents, vessel rupture or dissection. [3][4][5][6] In addition to these acute complications, late stent restenosis remains an unresolved clinical problem. Although stent fracture occurs rarely, it may contribute to or cause late stent failure when implanted in arteries near or at flexion points in the peripheral arteries. Stent fracture has occurred after iliac arterial stenting 7 and we describe a case of fracture in overlapping stents implanted in the left popliteal artery. Case ReportA 48-year-old man was referred for coronary and peripheral arteriography. He reported left calf claudication of 3 years' duration that had progressively worsened in the past few months. His complaints were pain and numbness with mild exercise. He had had non-insulin dependent diabetes mellitus for 1 year and had smoked 1 pack of cigarettes per day for 33 years. On physical examination, both his lower limbs were pale and cool. His left femoral pulse was present, but the left popliteal and left lower extremity pulses were absent. Right femoral and popliteal pulses were present, and the distal pulses in right lower extremity were also palpable. The ankle -brachial index was 0.32 for the left limb. There was not any ulcer formation related to occlusive arterial disease on either leg.The diagnostic coronary and peripheral arteriography revealed 2-vessel coronary artery disease: a severe stenosis in the proximal segment of the left popliteal artery and 50% narrowing of the right popliteal artery. There was late filling of the vasculature distal to the severely narrowed left popliteal artery (Fig 1). We used a standard angioplasty technique from an antegrade, ipsilateral puncture of the left common femoral artery with an 8F sheath. The lesion was crossed Circ J 2003; 67: 643 -645 (Received November 14, 2001; revised manuscript received January 21, 2002; accepted February 15, 2002

Stent Placement Versus Balloon Angioplasty for the Treatment of Obstructive Lesions of the Popliteal Artery

“…[19][20][21] The lack of broad acceptance for PA stent placement is mainly attributable to the fear of stent fractures, with possible subsequent restenosis in this vascular bed with high biomechanical stress next to the knee joint. 7,9,16,22,23 Published data support assumptions that stent design and technical aspects during stent deployment (eg, stent elongation, stent overlap) play major roles in the appearance of stent fractures. 6,8,9 However, the incidence of fractures in second-generation stents was low and ranged between 0% and 8.1% during a 1-year follow-up.…”

“…Because of excessive mechanical forces applied to the PA during motion, the PA is considered a no-stent zone, and stent placement is currently reserved for suboptimal results after PTA, such as significant recoil, flow-limiting dissection, or significant residual stenosis. [7][8][9] The goal of this prospective, multicenter, randomized trial was to investigate the efficacy and safety of NS placement compared with PTA for the treatment of obstructive lesions in the PA.…”

Stresses in peripheral arteries following stent placement: a finite element analysis

“…The use of more flexible selfexpanding nitinol (shape memory alloy) stents has improved performances somewhat, but binary restenosis is still reported to be 24% at 6 months (compared with 44% for PTA alone) (Schillinger et al, 2006). Stent fracture has also been reported in case studies (Babalik et al, 2003, Solis et al, 2006, while a broader study showed a stent fracture rate of 24.5% in peripheral arteries at a mean follow up of 10 months (Scheinert et al, 2005). While almost half of the fractures were classified as minor (single strut fracture), a quarter were major (complete separation of stent segments) and a strong correlation was shown between stent fracture and restenosis.…”

Bioresorbable Scaffold Technologies

“…BRS may also be suitable for vascular anatomy where scaffolds are prone to crushing and fractures, as seen in the femoral or tibial arteries. 43 Furthermore, BRS can obviate some of the other problems associated with use of permanent metallic stents such as the covering of side branches. BRS also appears to be compatible with noninvasive imaging such as CT angiography or MRI.…”