Until recently, there have been few options for the management of obstruction across previously placed stents that are fully expanded or highly resistant to redilation. In general, endovascular stents can be expanded after their initial deployment, 4,5 but a combination of factors may contribute to difficulty enlarging a stent beyond a certain point, including but not limited to (1) the diameter limitation intrinsic to all stents once they are fully expanded, (2) stress hardening that occurs on crimping and expansion, which may alter the effective strain modulus of the stent sufficiently to resist further expansion, (3) underlying resistant vascular stenosis, and (4) the vascular and neointimal reaction that occurs in response to dilation and stent placement. One of the most important potential disadvantages to the use of stents is in infants and very young children with congenital cardiovascular disease, that the child may outgrow the known maximum diameter of the stent. 1–10 Although stents have a number of advantages and are useful in a variety of circumstances, there are also potential limitations and drawbacks to stenting. Since their first use in patients with congenital heart disease nearly 20 years ago, balloon-expandable intravascular stents have become indispensable tools in the management of essentially all forms of large vessel obstruction.
There were no vascular or other complications.Ĭonclusions- UHP angioplasty was safe and effective for treatment of stent-related resistant PA stenosis in this series the ability to fracture maximally expanded stents may extend the utility of stents in the pediatric population. In 5 lesions, UHP angioplasty fractured the stent, allowing further vessel expansion. After UHP dilation, lesion diameter increased by a median of 3.1 mm (36%), significantly more than after previous high-pressure dilation (1.3 mm, 19% P<0.001). Balloon:waist diameter ratios were conservative (median 1.26), reflecting the ability of UHP balloons to “fracture” nearly all obstructions. Thirty-one of the 34 (91% ) UHP angioplasty procedures were successful in relieving the resistant stenosis. The median age at UHP angioplasty was 9 years, and a median of 4 years had elapsed since unsuccessful high-pressure angioplasty. Thirty-four lesions in 29 patients, including 8 with multiple concentric, overlapping, or adjacent stents, were included. A resistant stenosis was defined as a residual balloon waist during high-pressure redilation of the stent, along with a pressure gradient and/or angiographic stenosis. Methods and Results- We reviewed patients who underwent UHP angioplasty of in-stent or peri-stent PA stenoses that were resistant to high-pressure redilation.
Angioplasty with ultra-high-pressure (UHP) balloons may facilitate successful treatment of stent-associated PA stenoses that are resistant to high-pressure dilation. Although stents can usually be reexpanded as children grow, resistant in-stent or peri-stent obstruction can complicate the management of PA stents. Customer Service and Ordering Informationīackground- Stents are essential tools in the management of pulmonary arterial (PA) stenosis in patients with congenital heart disease.About Circ: Cardiovascular Interventions.Stroke: Vascular and Interventional Neurology.Journal of the American Heart Association (JAHA).
Circ: Cardiovascular Quality & Outcomes.Arteriosclerosis, Thrombosis, and Vascular Biology (ATVB).