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Catheterization and Cardiovascular Diagnosis 40:422426 (1997)

Basic Investigations
Distortion of Palmaz-Schatz Stent Geometry
Following Side-Branch Balloon Dilation
Through the Stent in a Rabbit Model
Richard M. Pomerantz,* MD, and Frederick S. Ling, MD
The compromise of side-branches following coronary angioplasty of the parent vessel
remains a limitation of the procedure. Reports of dilation through a Palmaz-Schatz stent to
salvage a compromised side-branch covered by the stent have been made. We examined
the distortion of stent geometry which occurs following this procedure in a rabbit model.
Palmaz-Schatz stents were placed at the aortoiliac bifurcation in 7 rabbits and the
contralateral iliac artery was dilated through the stent. Despite good angiographic results,
varied degrees of stent distortion were noted on gross pathologic analysis. Most
distortion occurred when the arteries were dilated through the ends of the struts or
through the diamonds, and least distortion occurred during dilation through the
mid-articulation site. While good stent deployment is thought to be necessary for
improved outcomes, the distortion of stents after balloon dilation through the stent,
despite good angiographic results, may have negative implications for both short- and
long-term outcomes. Cathet. Cardiovasc. Diagn. 40:422426, 1997. r 1997 Wiley-Liss, Inc.
Key words: angioplasty; coronary artery disease; restenosis

INTRODUCTION

METHODS

The occlusion or compromise of a side-branch following coronary angioplasty has remained a significant limitation of the procedure [1]. Multiple techniques have been
described for best handling this complication [2]. More
recently, the use of Palmaz-Schatz (P-S) coronary stenting has supplanted angioplasty in the treatment of many
lesions. Although some investigators report that the loss
of side-branches following stenting of the parent vessel is
a rare event [35], the conventional wisdom until recently
has been that covering of side-branches with a P-S stent
would result in irreversible jailing of the branch, making further dilation of the branch through the stented segment difficult, if not impossible. More recently, a number
of operators have employed angioplasty balloons to cross
the stented segment into the side-branch and perform
dilation of the compromised ostia of these branch vessels
[6]. Although a number of particular angioplasty balloons
have shown the ability to perform this in vitro and in vivo
[6,7], the resulting amount of stent distortion has not been
well studied. This study examines the distortion of P-S
stent geometry following side-branch dilation through the
stent in an in vivo animal model.

Seven male New Zealand white rabbits (24 kg) were


anesthetized using intravenous ketamine (35 mg/kg) and
xylazine (5 mg/kg) anesthesia. The study was reviewed
and approved by the University of Rochester Animal
Care Committee. Adequate anesthesia was maintained
using a Harvard pump continuous infusion through an ear
vein. The abdominal aorta was exposed and a 5 French
introducer (USCI, Billerica, MA) was placed in the abdominal aorta. Heparin 100 U/kg and 100 g of nitroglycerin were injected intra-arterially and a baseline aortoiliac
angiogram was performed using a 1:1 dilution of iohexol
and saline. A 0.014 in. Flex wire (USCI) was passed into
the distal iliac artery on one side. A P-S coronary stent
(Johnson & Johnson Interventional Systems, Warren, NJ)
was removed from its delivery system and handcrimped

r 1997 Wiley-Liss, Inc.

Cardiology Unit, University of Rochester Medical Center, Rochester, New York


*Correspondence to: Richard M. Pomerantz, M.D., University of
Rochester Medical Center, Box 679, 601 Elmwood Avenue, Rochester,
NY 14642.
Received 3 September 1996; Revision accepted 30 October 1996

Stent Distortion After Side-Branch Dilation

423

Fig. 1. A: P-S stent placed with the proximal end of the stent at
the iliac bifurcation and contralateral iliac artery dilated through
the end strut of the stent. Note the deformation of the end struts
bent into the central lumen of the abdominal aorta (black arrow).

B: Corresponding final angiogram showing excellent deployment of the stent and no significant residual stenosis at the
ostium of the contralateral iliac artery. White arrow shows
stented iliac vessel.

onto a 3.0 mm Cobra angioplasty balloon (SciMed Corp.,


Minneapolis, MN). The stent was then passed over the
wire and deployed at 8 atm under fluoroscopic guidance
at the iliac bifurcation so that it jailed the contralateral
iliac artery. Stent placement was checked angiographically and the wire was then withdrawn and passed
through the stent struts into the contralateral jailed iliac
artery. A 2.5 or 3.0 mm balloon (SciMed Cobra, ACE, or
Cordis Trackstar) was then advanced over the wire and
centered at the ostium of the side-branch through the stent
and dilated to 9 atm for 60 sec. Full balloon expansion
checked fluoroscopically. The balloon and wire were then
withdrawn and 100 g of nitroglycerin was injected again
intra-arterially to treat distal vessel spasm. A final angiogram was then performed and the animal sacrificed with
intravenous pentobarbital (100 mg/kg). The aortoiliac
segment was then immediately pressure perfused and
fixed with 10% formalin via the abdominal aortic sheath.
The aortoiliac block was then dissected out and harvested
with the stent intact. The vessel block was allowed to fix

in the formalin for several more days and the stents were
then dissected out using a dissecting microscope. Care was
taken not to disturb the stent geometry during dissection
of the vessel. Multiple enlarged photographs were taken
of the stented segments in situ and are reproduced below.

RESULTS

Seven rabbits were treated in the above manner and all


stents revealed varying degrees of distortion following
dilation of the side-branch through the stent. Representative photographs of the exposed stents and the corresponding angiograms are included. Figure 1A shows a stent that
has been placed more distally at the iliac bifurcation and
the dilation was done through or slightly proximal to the
end of the stent. The proximal strut of the stent has been
severely deformed and is bent toward the contralateral
iliac artery. The corresponding angiogram (Fig. 1B)
reveals a good angiographic result with no evidence of

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Pomerantz and Ling

Fig. 2. A: P-S stent placed with one of the diamonds at the


aortoiliac junction. Note the distortion of the stent diamond
following dilation of the contralateral iliac artery (black arrow).
B: Corresponding final angiogram showing an excellent angiographic result at the aortoiliac bifurcation with good stent

deployment and excellent flow to both iliac arteries. White arrow


shows stented iliac vessel. There is distal vessel spasm beyond
the stent in the distal iliofemoral system following stent
placement.

any stent abnormality or distortion with widely patent


iliac arteries bilaterally.
Figure 2A shows a stent following dilation of the
side-branch through a diamond of the stent. There is
distortion of the mid/distal portion of the stent with
deformation of the diamond segment. The corresponding angiogram, however (Fig. 2B), reveals an excellent
angiographic result at the iliac bifurcation. Figure 3A
reveals a stent with the articulation site placed right at the
iliac bifurcation with the dilation done directly through
the articulation segment. This has bent the stent strut into
the aortic lumen toward the contralateral iliac artery, but
the overall distortion of the stent does not appear as
severe as the stents dilated through or proximal to the
diamond segments. Again the final angiogram (Fig.
3B) shows no significant deformation and a good angiographic result. These results, with the greatest distortion
and deformation occurring when the side-branch was

dilated anywhere but the articulation site, were consistent


throughout the other experimental animals.
DISCUSSION

As coronary stenting becomes more ubiquitous, its


indications continue to expand and contraindications
continue to decrease. The use of P-S stents when placed
across major side-branches was initially felt to be a
relative contraindication since access to the side-branch
was felt to be compromised by the P-S stent and the
concept of stent jail was introduced. Although some
operators did not consider the loss of a side-branch a
major problem [8], most operators were hesitant to place
P-S stents across large branches which could not be easily
rescued in the event of side-branch occlusion following
stent deployment. The increased likelihood of balloon
rupture when dilating through the struts of a deployed

Stent Distortion After Side-Branch Dilation

425

Fig. 3. A: P-S stent placed with the articulation site at the iliac
bifurcation. A stent strut is seen in the central aortic lumen bent
toward the contralateral iliac artery (black arrow). B: Correspond-

ing final angiogram showing an excellent angiographic result


when the contralateral iliac artery was dilated through the stent
articulation site. White arrow shows stented iliac artery.

stent as well as the possible inability to withdraw a


winged, non-compliant balloon back through the stent
struts following side-branch dilation made many operators wary of undertaking this procedure. However, recently a number of operators have reported on the
successful salvage of compromised side-branches which
were dilated through already deployed stents [6,9]. Reports of placing stents through the diamonds or articulation sites of previously deployed stents into side-branch
stenoses have also been made [6,9]. Although these
studies have reported on clinical success in small numbers of patients, the distortion of stent geometry and its
possible clinical implications following these procedures
have not been well studied.
It has been reported previously that well-deployed P-S
stents as noted by ultrasound studies lessen the risk of
stent thrombosis as well as the need for intensive
anticoagulation regimens [1012]. Poorly or incompletely deployed stents have been associated with higher
rates of complications [11,12]. Recent data suggest that

when bifurcation lesions are treated with stents, either by


stenting both vessels or via balloon dilation of the
side-branch through the stent, the complication and
coronary event rates may be relatively high [13]. In light
of these findings, our study sought to determine the
distortion of P-S stent geometry and its effect on optimal
deployment, when a major side-branch was dilated through
a previously deployed P-S stent. The use of the iliac
bifurcation of the rabbit which is anatomically similar in
size to the human coronary artery made this a reasonable
model, as did the size and types of balloons used, which
are quite similar to those used when the same situation is
clinically encountered in humans. Attempts were also
made to place different portions of the stent (edge,
diamond, articulation) across the side-branch to simulate
the variation in stent placement and side-branch dilation
seen in human clinical situations. The angiographic
results seen in the above example figures appear quite
adequate, with angiographically good results noted in the
main vessel, as well as the ostium of the side-branch.

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Pomerantz and Ling

However, as the accompanying photographs reveal, P-S


stent geometry is often markedly distorted, especially
when the dilation is done through a stent diamond or near
the edges of the stent, and less so when the stent is dilated
through the articulation site.
The available studies to date suggest that optimal stent
deployment decreases complication and restenosis rates.
Less favorable outcomes could therefore be a possibility
if the stent is not optimally deployed when distorted by
side-branch dilation through the stent. The marked distortion of stent geometry could result in less than optimal
stent deployment with the possibility of an increased
incidence of stent thrombosis, increased rates of restenosis from less than optimal vessel dilation, or possibly the
need for more intensive anticoagulation regimens. Unfortunately, to date there are no randomized studies or large
registries to assess the possibility of less favorable
outcomes in these patients. Further human trials will be
needed to more fully assess this possibility.
This study has several limitations. It is a descriptive,
acute study in a limited number of non-atherosclerotic
animals. Long-term follow-up of patency and thrombotic
complications, however, is not available. Intravascular
ultrasound has not been performed, though it might have
added another dimension to this study, correlating anatomical results with ultrasound findings. Until now, however,
few results of ultrasound findings have been reported in
clinical studies involving side-branch dilation through
P-S stents. In summary, in a rabbit model, significant
distortion of P-S stent geometry can occur from sidebranch dilation through the stent. Its effect on clinical
outcomes has yet to be fully determined before such a
practice can be uniformly recommended.
ACKNOWLEDGMENTS

We thank Ms. Sherry Steinmetz for her assistance in


the preparation and care of animals during the experiments.

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