nitinol and Gastrointestinal-Hemorrhage

Blakemore probe-obturator was previously preferable for primary hemostasis in patients with bleeding from esophageal varices. Currently, Danis self-expanding nitinol stent became an effective alternative. According to some manufacturers, Danis stent has some advantages over balloon tamponade. We report implantation of nitinol stent for hemostasis in a patient with multiple recurrent bleeding and ineffective endoscopic manipulations. A method of stent fixation for prevention of distal migration as the most common complication is described.. Ранее единственным методом первичного гемостаза при кровотечениях из варикозно расширенных вен пищевода являлся зонд-обтуратор Blakemore, в настоящее время появилась альтернатива в виде саморасширяющегося нитинолового стента Danis, который, по мнению производителей, обладает рядом преимуществ перед баллонной тампонадой. Рассмотрен клинический случай применения нитинолового стента с целью достижения гемостаза у пациента с многократными рецидивами кровотечений, неэффективностью эндоскопических манипуляций. Представлен метод фиксции стента с целью предотвращения самого частого осложнения установки стента — миграции в дистальном направлении и, как следствие, потери его тампонирующей функции.

Topics: Alloys; Biocompatible Materials; Esophageal and Gastric Varices; Esophagoscopy; Gastrointestinal Hemorrhage; Hemostasis, Surgical; Humans; Hypertension, Portal; Prosthesis Failure; Prosthesis Implantation; Stents

This paper reports our experience with a new over-the-scope clip in the setting of recurrent bleeding and oesophageal fistula. We treated five patients with the over-the-scope Padlock Clip™. It is a nitinol ring, with six inner needles preassembled on an applicator cap, thumb press displaced by the Lock-It™ delivery system. The trigger wire is located alongside the shaft of the endoscope, and does not require the working channel. Three patients had recurrent bleeding lesions (bleeding rectal ulcer, post polypectomy delayed bleeding and duodenal Dieulafoy's lesion) and two patients had a persistent respiratory-esophageal fistula. In all patients a previous endoscopic attempt with standard techniques had been useless. All procedures were conducted under conscious sedation but for one patient that required general anaesthesia due to multiple comorbidities. We used one Padlock Clip™ for each patient in a single session. Simple suction was enough in all of our patients to obtain tissue adhesion to the instrument tip. A remarkably short application time was recorded for all cases (mean duration of the procedure: 8 min). We obtained technical and immediate clinical success for every patient. No major immediate, early or late (within 24 h, 7 d or 4 wk) adverse events were observed, over follow-up durations lasting a mean of 109.4 d. One patient, treated for duodenal bulb bleeding from a Dieulafoy's lesion, developed signs of mild pancreatitis 24 h after the procedure. The new over-the-scope Padlock Clip™ seems to be simple to use and effective in different clinical settings, particularly in "difficult" scenarios, like recurrent bleeding and respiratory-oesophageal fistulas.

Topics: Aged; Aged, 80 and over; Alloys; Equipment Design; Esophageal Fistula; Esophagoscopes; Esophagoscopy; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Operative Time; Postoperative Complications; Surgical Instruments; Time Factors; Tomography, X-Ray Computed; Treatment Outcome

Placement of self-expandable nitinol stents is useful for the treatment of esophageal and upper gastrointestinal (GI) obstruction. However, complications such as stent migration, tumor overgrowth, and bleeding occur. Although stent migration and tumor overgrowth are well documented in previous studies, the occurrence of bleeding has not been fully evaluated.. To evaluate the incidence, management strategies, and predictors of bleeding after placement of self-expandable nitinol stents in patients with esophageal and upper GI obstruction.. We retrospectively reviewed the medical records and results of computed tomography and endoscopy of 1485 consecutive patients with esophageal and upper GI obstructions who underwent fluoroscopically guided stent placement.. Bleeding occurred in 25 of 1485 (1.7%) patients 0 to 348 days after stent placement. Early stent-related bleeding occurred in 10 patients (40%) and angiographic embolization was used for 5/10. Late bleeding occurred in 15 patients (60%) and endoscopic hemostasis was used for 7/15. Twenty-two of 25 (88%) patients with bleeding had received prior radiotherapy and/or chemotherapy.. Bleeding is a rare complication after placement of expandable nitinol stents in patients with esophageal and upper GI obstruction, but patients with early bleeding may require embolization for control. Care must be exercised on placing stents in patients who have received prior radiotherapy or chemotherapy.

Topics: Adult; Aged; Aged, 80 and over; Alloys; Constriction, Pathologic; Embolization, Therapeutic; Esophageal Stenosis; Esophagoscopy; Female; Fluoroscopy; Gastrointestinal Hemorrhage; Hemostasis, Surgical; Humans; Incidence; Male; Middle Aged; Patient Selection; Prosthesis Design; Retrospective Studies; Risk Factors; Stents; Tomography, X-Ray Computed; Tracheal Stenosis; Treatment Outcome

Topics: Aged, 80 and over; Alloys; Biocompatible Materials; Duodenal Ulcer; Equipment Design; Female; Gastrointestinal Hemorrhage; Hemostasis, Endoscopic; Humans; Male; Surgical Instruments

The closure of the gastrotomy in Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a prerequisite for transgastric endoscopic procedures in the abdominal cavity. Different techniques have been proposed and are under experimental or early clinical investigation. We describe the technique of using an over-the-scope-clip system (OTSC), made of super-elastic Nitinol and a specially designed tissue-approximating double jaw endoscopic grasper for gastric closure. The OTSC is a clipping system mounted at the tip of the endoscope and is used for the treatment of gastrointestinal bleeding or gastrointestinal organ perforations. An enlarged version of the OTSC is now under investigation for NOTES. The closure procedure consists of two steps. First the margins of the perforation are approximated by means of an endoscopic grasper that has two mobile and one fixed jaw, thus providing two independent tissue grasping areas. Each half of this twin grasper is used to grasp one side of the perforation wound margins. Then the margins are approximated and pulled towards the OTSC cap at the tip of the scope. Then the clip is released and the access hole is closed by compression. The OTSC clip can be applied for organ closure in NOTES in experimental studies. The technique allows closing the access site from inside the gastric cavity without leaving material on the peritoneal surface of the organ.

Topics: Alloys; Animals; Endoscopes, Gastrointestinal; Endoscopy, Gastrointestinal; Equipment Design; Gastrointestinal Hemorrhage; Humans; Intestinal Perforation; Suture Techniques; Swine

To prospectively evaluate the use of a recently developed expanded polytetrafluoroethylene (PTFE)-covered nitinol stent-graft in preventing the need for repeated intervention after transjugular intrahepatic portosystemic shunt (TIPS) creation.. Fifty-three consecutive patients underwent TIPS procedures between January 2000 and February 2002. Minimum patient follow-up was 9 months (mean, 16.3 months). Fifty-six stent-grafts were implanted in 53 patients; eight of the devices were 8 mm in diameter and 48 were 10 mm in diameter. The stent length varied from 4 to 7 cm. Indications for the procedure included recurrence of bleeding after sclerotherapy (28 patients with cirrhosis, one patient without), refractory ascites or hydrothorax (21 patients with cirrhosis, one patient without), and Budd-Chiari syndrome (two patients).. A technical success rate of 100% was obtained, with an early clinical success rate of 96.2%. During the follow-up period, the recurrence rate was 3.4% (one of 29 patients) for bleeding and 9.0% (two of 22 patients) for ascites. Shunt malfunction occurred in nine of 53 patients (16.9%); in one of these nine patients, shunt occlusion was evident after revision, and a parallel shunt was created. The 1-year primary and secondary patency rates were 83.8% and 98.1%, respectively. In this series, the incidence of encephalopathy (included even as a single short-lived episode) was 47.1% (25 of 53 patients). The 30-day mortality rate was 3.8% (two of 53), and the late mortality rate was 17.3% (eight of 46), excluding seven patients who underwent transplantation.. The new PTFE-covered nitinol stent-graft used appears to be excellent in preventing the need for repeated interventions. A primary patency rate of 83.8% and a secondary patency rate of 98.1% were achieved.

Topics: Adolescent; Adult; Aged; Alloys; Ascites; Budd-Chiari Syndrome; Coated Materials, Biocompatible; Esophageal and Gastric Varices; Female; Gastrointestinal Hemorrhage; Humans; Male; Middle Aged; Polytetrafluoroethylene; Portasystemic Shunt, Transjugular Intrahepatic; Recurrence; Stents; Treatment Outcome

The purpose of our study was to evaluate the feasibility and the safety of transjugular intrahepatic portosystemic shunts (TIPS) with a new expanded-polytetrafluoroethylene-covered stent and the influence of the covering on occlusion rate.. Twenty cirrhotic patients (57 +/- 11 years old) admitted with a history of esophageal variceal bleeding (n = 11), refractory ascites (n = 5), or both (n = 4) were included. Five of the patients were treated for TIPS revision, and 15 as de novo TIPS placements. The endoprostheses used were composed of a 2-cm noncovered nitinol stent and a 4- to 8-cm expanded-polytetrafluoroethylene graft covering, and were placed from the portal vein to the ostium of the hepatic vein. Patients underwent Doppler sonography at discharge and again at 1, 3, 6, 9, 12, and 15 months and underwent venography with portosystemic pressure gradient measurement at 6 months and whenever necessary.. At the time of this writing, complications included three TIPS restenoses and one recurrent ascites successfully treated by balloon dilation, two cases of segmentary liver ischemia, and one patient with encephalopathy that required shunt reduction. After TIPS placement, the portosystemic pressure gradient dropped from 18 +/- 5 to 5 +/- 4 mm Hg. Primary and secondary patency rates were 80% and 100%, respectively, at 387 days.. These results clearly show the feasibility of TIPS placement with the Gore TIPS endoprosthesis stent-graft and its improved patency compared with results in the literature for bare stents. These preliminary results must be certified further with randomized comparative trials between covered and noncovered TIPS stents.

Topics: Adult; Aged; Alloys; Coated Materials, Biocompatible; Esophageal and Gastric Varices; Feasibility Studies; Female; Gastrointestinal Hemorrhage; Humans; Liver Cirrhosis; Male; Middle Aged; Polytetrafluoroethylene; Portal Pressure; Portasystemic Shunt, Transjugular Intrahepatic; Portography; Stents; Treatment Outcome; Ultrasonography, Doppler