In-Stent Restenosis: A Case Study

Mr. Howard, a 57-year-old man, had a 3-month history of progressive typical anginal chest pain. He reported that the symptoms first occurred with heavy exertion and involved what he described as“heaviness” in his chest. The symptoms were promptly relieved with rest. Over the past weeks, he had been experiencing increasingly frequent episodes of chest pain and diaphoresis. The episodes had become more prolonged, and he had experienced one episode of pain occurring at rest after a heavy meal. Mr. Howard was moderately obese and had a 20-year history of hypertension, which was being treated. Other risk factors in Mr. Howard’s history include hypercholesterolemia (350 mg/dL), which he was attempting to treat with dietary modifications, and a 30-year two-pack-a-day smoking history which continued up to the present time. Mr. Howard previously had surgery for a bilateral inguinal hernia repair, cholecystectomy, and arthroscopic surgery on his left knew. He also gave a history of problems with gastric reflux and was currently taking cimetidine (Tagamet).

A stent definitely would have helped in general, but they wanted to avoid it since it would cause the man’s insurance to go up as he would be a higher risk. It was interesting to see how much thought goes into every decision and how it isn’t always related to just the medical side of it. Reichard had another surgeon come in and do a test where they measure the pressure on both sides of the blockage to see if a stent was actually necessary. They cutoff point they were looking for was about .85, any lower and they would put a stent in during his next procedure. It ended up being .91. This second test was important not only because it prevented a stent that wasn’t totally necessary, but it also allowed the man to be eligible for some procedures that he may not have been if a stent was placed. Another interesting angiogram case was on an older woman who most likely needed a replacement of her aortic valve. The aortic valve is usually the size of a quarter, but through initial imagining it was clear that hers was more the size of a pea. However, they wanted to verify this data through an angiogram where they measured the pressure drop-off from before to past the

Aortic arch angiogram: shows right aortic arch with the following branching pattern (from proximal to distal): left common carotid, right common carotid, right subclavian artery. The origin of left subclavian (with anomalous origin) was not seen as it was ligated previously. However, the distal portion is filled with diluted contrats likely through a retrograde flow through the left vertebral artery. Patent Rt MAPCA with no intimal ingrowth was seen in the previously placed stent at the origin of Rt MAPCA. Dilated tortus RIMA which is likely profusion the right upper lung lobe (aortopulmonary collaterals) left BT shunt is wide patent (connected left common carotid artery to the interposition graft) with good caliber with mild narrowing at its insertion in the interposition graft.

The acetabular components have a "spherical outer surface with at least one hole to permit the surgeon to determine if the prosthesis is fully impacted into place" (Skinner 399). The inner surface of the acetabular component then locks the UHMWPE to limit rotation and dissociation (Skinner 399). There are two crucial factors when choosing the implants. First, if the prosthesis is too stiff then the patient may suffer from proximal osteopenia. Second, the stiffer the prosthesis is the more likely the patient will experience pain in the thigh. To avoid these two factors the surgeon should elect to use titanium ally instead of the cobalt chromium alloy.

1). Chest X-ray was normal. Initial laboratory studies were remarkable for white blood cells count of 12.1K, a creatine kinase MB fraction of < 3 mm was associated with significant reductions in restenosis and the rate of target vessel revascularization19. In SES-SMART trial patients were randomly assigned to receive a Sirolimus-eluting or bare-metal stent in small coronary artery. Sirolimus stent was associated with significant reductions in the rates of angiographic restenosis (primary outcome), target lesion revascularization and MI at 8 months20. The composite clinical endpoint ( death, non-fatal MI, ischemia- driven target lesion revascularization, and cerebrovascular accidents) was significantly lower with the sirolimus-eluting stent21. In the TAXUS V trial, in the subset of patients with small coronary arteries, the paclitaxel stent was associated with significant reductions in angiographic restenosis and target lesion revascularization at nine months compared to bare metal stents22. Although DES improves target lesion revascularization rates compared to bare-metal stents in small vessels, the absolute rates are still higher in small vessels than large

[7] However, diabetes still remains a major risk factor for restenosis after both bare-metal stents and DESs. [10] Diabetes mellitus is regarded as a proinflammatory and prothrombotic condition, and patients with diabetes mellitus are more frequently resistant to aspirin and clopidogrel than those without diabetes mellitus. [2] The minimum necessary duration of DAPT may be longer in diabetic than in nondiabetic patients. [2] Among diabetic patients, target vessel failure occurred more frequently with 6-month DAPT than with 12-month DAPT. [2] Prolonged DAPT for >6 months might be needed to prevent late stent thrombosis because of delayed vascular healing and inflammatory reaction after implantation of drug-eluting stents.

The stent is inserted into the artery by balloon angioplasty, to expand the vessel walls in order to return blood flow back to normal. There are two types of stents, bare-metal stents and drug-eluting stents. Once a BMS is inserted into the vessel, it become fully endothelialized.. However, The animation explains that in about 1/3 of BMS implants, restenosis occurs. On the other hand DES were developed to combat this issue. The polymer coating on the DES contains a drug which aids in the inhibition of restenosis. However, the endothelialization process for drug-eluting stents has shown to be problematic, which can in time cause stent thrombosis, which can possibly lead to myocardial infarction. It is important to note that these stents should be used in patients how do not have complex coronary stenosis because the off-label use is not completely understood and has a higher risk of

The blood vessel that Dr. Eltahawy was concerned about was thin and looked as though it would collapse in on itself. First, Dr. Eltahawy tried a balloon catheter. At the top of the catheter was a small balloon that could inflate to maintain a shape or structure of a blood vessel. However, because the blood vessel was so thin, the balloon catheter was not very effective. Instead, Dr. Eltahawy installed a stent. A stent is a wire mesh tube. It is placed in a blood vessel permanently to maintain the shape of the vessel and to allow for the free flow of blood. Throughout this entire independent study, I realize that shadowing in the medical field is less about learning about medicine and more about discovering about whether becoming a doctor is the right step. This independent study has been a step in the right

Stent devices were invented in the 1980s and refined in the 1990s. Stenting techniques have transformed and expanded the therapeutic capabilities of angioplasty. There are two classification for stents based on their mode of deployment balloon-expandable and self-expandable. Stents are small mesh tubes which inserted to keep arteries open after angioplasty procedure. Drug -eluting stents have a polymer coating over mesh. This Polymer coatings have been proven to be durable and deliver drug in a uniform and controlled way ( White, Hollier 2007).

The stent will be placed where it can be expanded to hold the artery open. Some stents are designed to simply keep the artery held open. Other stents used are drug-eluting stents. These stents are coated with pharmacologic agents that work to prevent restenosis of the artery.

Internal fixation devices in the past had been made of stainless steel or titanium, but with problems resulting from those permanent devices, an innovative approach is being considered. Bioresorbable implants are a possible replacement to the original implants that would eliminate the need for removal, which has shown to be a problem for traditional implants.

Hospitals should use this kind of IT in their hospitals. Today many hospitals are not prepared to treat stroke patients, because of the technology that is available now. This technology can also help doctors assist and better care for a patient in after the surgery. A clot-retrieving stent can dramatically reduce long-term healthcare cost as well, and enhance the quality of life for people who have had strokes. But it is only used in 150 stroke centers in the United States. Even though cost for installation of the stent is about $17,000 more than a traditional treatment, it has better outcomes, and long-term savings could be about $23,000. The effects and its location on accessibility is an issue at this time. Cost can clearly play a role

Mr. R is a 69-year-old male admitted to the cardiac intensive care unit with angina pectoris. He has a history of coronary artery disease, hyperlipidemia, and hypertension. The patient is planned to have a coronary artery bypass graft (CABG) this afternoon to repair his ventricular function. My preceptor and I spent the morning preparing Mr. R for his approaching surgery.

Besides echocardiography, cardiac magnetic resonance (CMR) and Multi-slice computed tomography angiocardiography (MSCT) have gained particular importance. (8) The presence of image degrading artifacts from implanted metal, such as intravascular stents and embolization coils; higher cost; limited availability; contraindication in imaging of

appear similar to conventional stents.”8 Middleton, Teefey and Darcy8 note that the use of PFTE endografts will likely become standard as their performance outweighs the early stent materials used. Color Doppler as well as pulsed Doppler should be used to interrogate the stent and supporting vessels. Velocity measurements are taken using angle correct and spectral waveforms are recorded. Careful examination of the liver vasculature is imperative to verify proper stent function. Specifically, thrombosis or occlusion can be assessed with color and Doppler ultrasound. Velocity parameters may vary from patient to patient and also will change from immediate post procedure velocities to those obtained during long term follow up. Universal Doppler