Abstract
We evaluated Viabahn stent-graft (W.L. Gore & Associates, Flagstaff, AZ, USA) implanted in the superficial femoral artery at 6 months and one year after implantation because the patient felt claudication due to repeated restenosis of bare nitinol stent which was implanted just proximal to the site of Viabahn stent-graft. At 6 months, angioscopy showed severe thrombosis in the stent-graft while the stent-graft was entirely patent. However, at one year, angioscopic evaluation revealed no thrombosis in the stent-graft. She received the same dual antiplatelet therapy.
<Learning objective: We report a case with Viabahn stent-graft in whom an angioscopy revealed severe thrombosis at 6 months but no thrombosis at one year during the same dual antiplatelet therapy (DAPT). It might be necessary to continue DAPT after Viabahn stent-graft implantation at least over one year to prevent thrombosis.>
Keywords: Endovascular therapy, Angioscopy, Thrombosis, Peripheral artery disease, Stent-graft, Superficial femoral artery
Introduction
Endovascular therapy (EVT) with self-expanding stent-grafts is associated with acceptable clinical outcomes for femoropopliteal lesions. However, the suitable duration of dual antiplatelet therapy (DAPT) after stent-graft implantation in the superficial femoral artery (SFA) has not been well investigated.
Case report
A 60-year-old diabetic woman with hypertension, dyslipidemia, and coronary artery disease was admitted for the treatment of intermittent claudication. Diagnostic angiography showed 99% stenosis with delayed blood flow of the right SFA (Fig. 1, left panel). A self-expanding 6.0 × 60-mm bare nitinol stent (BNS) (S.M.A.R.T. Control™, Cordis, Miami Lakes, FL, USA) in the proximal site and a heparin-bonded, self-expanding 5.0 × 250-mm stent-graft (Viabahn, W.L. Gore & Associates, Flagstaff, AZ, USA) in the distal site were implanted (Fig. 1, right panel). Angioscopy just after stent implantation showed no thrombi in either BNS or the stent-graft (Fig. 2, left panel, Video 1). The ankle brachial index (ABI) was alleviated from 0.61 to 1.02, and her symptoms immediately resolved. The patient received aspirin (100 mg/day lifelong) and clopidogrel (75 mg/day lifelong). At 6 months after EVT, she suffered from intermittent claudication again and the diagnostic duplex-sonography showed restenosis in the stent-graft. The diagnostic angiography showed 90% restenosis in the BNS, and no stenosis at the stent-graft (Fig. 3, left panel). Angioscopy showed neointimal hyperplasia at the BNS, while thrombosis at the stent-graft (Fig. 2, middle panel, Video 2). We performed re-EVT using non-slipping balloon (NSE, Goodman Co., LTD, Nagoya, Aichi, Japan) in the BNS. The ABI increased to 0.94, and the patient’s symptoms immediately resolved. There was no change in DAPT and no addition of anticoagulation therapy. At 6 months after re-EVT, there was decrease of ABI and recurrence of intermittent claudication. The diagnostic duplex-sonography showed restenosis at the stent site. The diagnostic angiography showed 90% restenosis at the BNS and patency at the stent site (Fig. 3, right panel). Angioscopy showed neointimal hyperplasia at the BNS, but no thrombosis at the stent-graft (Fig. 2, right panel, Video 3). The angioscopic findings of the stent-graft were completely different from the previous one which was performed at 6 months before (Fig. 2). We did re-reEVT with cutting balloon (Flextome; Boston Scientific, Minneapolis, MN, USA) at the BNS. The ABI increased from 0.76 to 0.91, and the patient’s symptoms immediately resolved.
Fig. 1.
Left panel: Diagnostic angiography showed 99% stenosis with delayed blood flow of the right superficial femoral artery (SFA). Right panel: After implantation of a self-expanding 6.0 × 60-mm bare nitinol stent in the proximal site (dashed arrow) and a heparin-bonded, self-expanding 5.0 × 250-mm stent-graft (Viabahn) in the distal site (solid arrow) of SFA, the angiography showed no residual stenosis in SFA.
Fig. 2.
Angioscopic images. Upper images: Bare nitinol stent in the proximal site. Middle images: Proximal site of stent graft. Lower images: Distal site of stent graft. Left panel: Immediately after stent implantation. Middle panel: 6 months later. Right panel: 12 months later.
Fig. 3.
Left panel: Diagnostic angiography at 6 months after stent implantation showed 90% restenosis in the bare nitinol stent (BNS) (white arrow) and no stenosis at the stent-graft. Right panel: Diagnostic angiography at 12 months after stent implantation showed 90% restenosis in BNS (white arrow) and no stenosis at the stent-graft. The severity of the BNS stenosis was similar between 6 months and 12 months after stent implantation.
Discussion
In a previous study, the efficacy and suitable duration of DAPT is still unclear in the field of peripheral arterial disease (PAD) interventions [1]. Strobl et al. and Armstrong et al. reported that DAPT may be associated with reduced rates of major adverse cardiac events and death for PAD, although there are a few reports on the DAPT duration [2], [3]. In addition, Banerjee et al. demonstrated that the incidence of the stent thrombosis (ST) was significantly higher in the stent-graft as compared to the bare metal stent [4]. In more recent studies, it has been reported that the ST rates for stent-graft and drug-eluting stent were higher as compared to bare-metal stents [5], [6]. Therefore, the investigation on DAPT duration is crucial to improve the clinical outcome for the PAD, especially in the field of stent grafts.
In a recent study, Ishihara et al. demonstrated that it might be necessary to continue DAPT after stent-graft implantation over the long term to prevent ST and subsequent restenosis from a pathological point of view [7].
Regarding anticoagulants, it has been reported that the marginal patency benefit observed with the addition of warfarin to DAPT was tempered by an observed increased risk of bleeding complications after Viabahn stent graft placement [8]. In addition, large-scale studies have shown PAD is one of the major risk factors for bleeding in the patients who received the anticoagulants [9], [10]. Because our patient had PAD with many comorbidities including hypertension, dyslipidemia, and coronary artery disease, we think it was better not to use the anticoagulant in this patient. In this case, at 6 months after EVT, a large amount of thrombosis in stent-graft was observed by angioscopy, but all of the thrombi disappeared 12 months later during DAPT. According to the anigioscopic findings in our case, we should not stop DAPT within one year after the stent-graft implantation. It might be necessary to continue DAPT for at least one year after the stent-graft implantation, but it is still unclear the suitable duration of DAPT after the stent-graft implantation. Investigation on further cases is necessary to confirm our speculation.
Conclusion
Through this case, continuing of DAPT may cause thrombolysis in the stent-graft. Accordingly, it might be necessary to continue DAPT for at least one year after the stent-graft implantation to avoid stent thrombosis and subsequent restenosis or reocclusion.
Conflict of interest
The authors declared no conflicts of interest.
Footnotes
Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.jccase.2020.05.003.
Appendix A. Supplementary data
The following are Supplementary data to this article:
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