Bare-Metal Stents for Arterial Injuries at Joint Levels: A Promising Treatment Option

Peripheral arterial injuries are a significant concern, especially those near joint levels. These injuries carry a high risk of limb loss, making rapid diagnosis and intervention crucial. While open repair has long been a mainstay, the evolution of endovascular techniques offers new possibilities. In this article, we explore the use of bare-metal stents in treating arterial injuries at joint levels, based on a study published in the Chinese Medical Journal (Li et al., 2020).

Introduction

Imagine a scenario where a person experiences a severe accident, resulting in an arterial injury near a joint. The limb is at risk of losing blood supply, and time is of the essence. Traditional covered stents are often used, but near joints, there’s a risk of covering crucial branch vessels. This is where bare-metal stents come into play.

The Study: A Retrospective Look

The research team (Li et al., 2020) conducted a retrospective chart review of 16 patients with peripheral arterial injuries at joint levels from June 2005 to March 2014. The patients had various types of injuries, including transections, pseudoaneurysms, arteriovenous fistulas, and intimal injuries. All presented with hemorrhagic shock.

Treatment Approach

Instead of surgical repair, urgent intravascular repair with bare-metal stents (LifeStent, Bard Peripheral Vascular) was chosen. The goal was to stop bleeding and reduce limb ischemia time. After the procedure, patients received lifelong antiplatelet therapy. Follow-up evaluations included physical exams, ultrasonography, and angiography.

Results: Success and Long-Term Outcomes

• Immediate Success: All endovascular procedures were successful. There were no perioperative deaths or amputations. Twenty-one bare-metal stents were implanted.
• Long-Term Follow-Up: The average follow-up was 73 ± 14 months. Two patients had non-incapacitating claudication with stent stenosis, which was treated with angioplasty. Overall, all patients were alive, using their limbs, and showed satisfactory blood flow with no stent migration, deformation, or fracture.

Why Bare-Metal Stents?

Avoiding Branch Vessel Coverage

Injured arteries near joints have branch vessels. Coated stents might cover these, leading to ischemia. Bare-metal stents, as shown in this study (Li et al., 2020), avoid this. They act as a passive barrier, reducing blood flow near the injury site. This changed hemodynamic condition can also promote platelet activation and aggregation, which might help in the healing process.

Stent Durability

Conventionally, stents near joints were thought to be at risk of fracture due to joint motion. However, in this study, the endovascular repair was successful. The stents likely have improved radial strength and the ability to recover from mechanical forces. For example, the LifeStent used in the study is more resistant to axial stress, and repetitive bending didn’t cause fractures. Also, the short length of the injured lesions (stents shorter than 10 cm) might be a protective factor.

Neointimal Hyperplasia

In chronic limb ischemia, stent failure due to neointimal hyperplasia is a concern. But in this study, the artery walls were in the normal range. The low-stress effect of the stent on the arterial wall meant no significant neointimal hyperplasia. The local hemodynamics near the joint might also play a role in vascular adaptation and remodeling.

Limitations and Conclusion

The study had limitations, such as a small number of cases and inconsistent follow-up data. However, it clearly demonstrated the advantages of bare-metal stents in preserving side branches. The treatment was safe, feasible, and effective. This research adds to the growing body of evidence supporting the use of bare-metal stents in treating arterial injuries at joint levels, offering hope for better limb salvage in such challenging cases.

References

Li, S., Yang, Z., Li, M., Zhu, J.-Z., & Zhang, X.-Q. (2020). A bare-metal stents treatment of arterial injuries at the joint levels. Chinese Medical Journal, 133(21), 2625–2627. doi: 10.1097/CM9.0000000000001103 (available at doi.org/10.1097/CM9.0000000000001103)

Stahnke, M., & Duddy, M. J. (2006). Endovascular repair of a traumatic axillary pseudoaneurysm following anterior shoulder dislocation. Cardiovasc Intervent Radiol, 29, 298–301. doi: 10.1007/s00270-005-0071-7

Sultan, S., & Hynes, N. (2015). Multilayer flow modulator stent technology: a treatment revolution for US patients? Expert Rev Med Devices, 12, 217–221. doi: 10.1586/17434440.2015.1030339

Biasetti, J., Gasser, T. C., Auer, M., Hedin, U., & Labruto, F. (2010). Hemodynamics of the normal aorta compared to fusiform and saccular abdominal aortic aneurysms with emphasis on a potential thrombus formation mechanism. Ann Biomed Eng, 38, 380–390. doi: 10.1007/s10439-009-9843-6

Schillinger, M., Sabeti, S., Loewe, C., Dick, P., Amighi, J., Mlekusch, W., et al. (2006). Balloon angioplasty versus implantation of nitinol stents in the superficial femoral artery. N Engl J Med, 354, 1879–1888. doi: 10.1056/NEJMoa051303

Cha, S. H., Han, M. H., Choi, Y. H., Yoon, C. J., Baik, S. K., Kim, S. J., et al. (2003). Vascular responses in normal canine carotid arteries: comparison between various self-expanding stents of the same unconstrained size. Invest Radiol, 38, 95–101. doi: 10.1097/01.Rli.0000044932.99555.E1

Freeman, J. W., Snowhill, P. B., & Nosher, J. L. (2010). A link between stent radial forces and vascular wall remodeling: the discovery of an optimal stent radial force for minimal vessel restenosis. Connect Tissue Res, 51, 314–326. doi: 10.3109/03008200903329771

Ando, J., & Yamamoto, K. (2011). Effects of shear stress and stretch on endothelial function. Antioxid Redox Signal, 15, 1389–1403. doi: 10.1089/ars.2010.3361

Was this helpful?

YesNo

0 / 0