Choosing the wrong stent - and how to solve the situation

Clinical History

Eccentric iliac artery stenosis and insufficient PTA result Eccentric iliac artery stenosis and insufficient PTA result

Imaging Findings

The patient was admitted because of left-sided upper thigh and hip claudication with a walking distance of less than 200 m. Duplex sonography was abnormal and diagnostic angiography via a transbrachial arteiography was performed revealing a severe but eccentric stenosis of the left common iliac artery that involved the iliac orifice. In a second session, retrograde puncture of the left common femoral artery and balloon dilatation by use of a 7 mm 4cm long balloon was performed yielding a limited success with major residual stenosis (Fig. 1). Therefore, it was decided to place a stent.

Discussion

A 10 mm wide Wallstent (BSIC) of 4.5 cm length was implanted into the stenosis. Despite redilation of the stent in place, the stent did not completely open and collapsed again after repeat balloon dilation leaving a major residual stenosis (Fig. 2). To open, up the stent, a 2.8 cm long Corinthian balloon-expandable stent (Cordis Inc.) was crimped on the 7 mm balloon and placed within the proximal end of the Wallstent. After that, the orifice was widely patent and the stent did not collapse anymore after balloon deflation (Fig. 3). The highly calcified and eccentic plaque formation is very rigid and resistant against displacement by stents if no large radial force is delivered. In that particular case, the compression of the stent started at the very proximal end of the self-expanding Easy Wallstent. At the extremities, the Easy Wallstent is particularly vulnerable for external compression while in the middle section, it is more able to withstand compression. Leaving the stent in place without additional reintervention would have risked secondary thrombosis due to residual flow impairment. In that particular case, a primary balloon-expandable stent or a more rigid self-expanding nitinol stent would have been a better and finally more costeffective solution. However, secondary placement of the balloon-expandable stent solved the situation.

Differential Diagnosis List

Final Diagnosis

Stent in stent placement to correct insufficient opening of a self-expanding stent

URL:	https://www.eurorad.org/case/570
DOI:	10.1594/EURORAD/CASE.570
ISSN:	1563-4086