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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 3, May/June 2020
AFRICA
e3
popliteal artery was performed. ABI after the operation was 1.27
and the patient was discharged without complications.
Discussion
Femoropopliteal artery disease accounts for a significant proportion
of endovascular interventions in patients suffering from disabling
claudication or chronic limb ischaemia. The femoropopliteal
artery descends along the hip and knee joints and passes through
the muscular adductor canal of the thigh, which places the artery
at increased biomechanical stress.
5
Stents in the femoropopliteal
lesion have historically been associated with increased rates of stent
fracture. The cumulative incidence of stent fractures ranged from
2 to 65%,
6
and stent fracture is associated with increased risk of
in-stent restenosis and re-occlusion of the target vessel.
7
The self-expanding wire-interwoven nitinol stent (Supera
stent) was designed to withstand the unique stressors along
the course of the femoropopliteal artery.
8,9
In the prospective,
multicentre, non-randomised, single-arm trial (SUPERB
trial), 264 patients with symptomatic peripheral artery disease
undergoing endovascular treatment of
de novo
or restenosis
lesions of the superficial femoral or proximal popliteal artery
were enrolled. In this study, absence of stent fracture was
observed by independent core laboratory analysis in the 243
stents evaluated at 12 months.
1
In the final three-year outcomes
of the SUPERB trial, only one stent fracture (0.6% event rate)
was noted in a patient with restenosis who underwent multiple
atherectomy procedures within the stent.
2
Since then, four cases of Supera peripheral stent fracture have
been reported. All cases were detected three months after the
Supera stent implantation and three cases were type V and one
was type III. One case was treated with only balloon angioplasty
and another with an additional Supera peripheral stent. Two
cases were treated with bypass surgery.
10-13
The occurrence of stent fractures is not only determined by
the stent architecture and length but also by the technique of
implantation. In a
post hoc
analysis of the DURABILITY I
study, stent elongation occurred during implantation in 90% of
all fractured stents, which was associated with continuous strain
exerted on the stent struts.
14
Additionally the implantation of
multiple overlapping stents may increase the axial stiffness of the
stent segment.
15
Vigorous exercise by the patient can adversely
affect stent fracture.
16
Our Supera stent fracture case was detected 12 days after
stent implantation. The exact fracture mechanism in our case
could not be postulated; however, because of the premature time
of fracture after implantation, we assumed that it might not be
associated with a fatigue fracture, as seen in the above cases.
We can assume that the most important risk factor for stent
fracture is the lesion location in femoropopliteal arterial disease.
Moreover, our patient was 73 years old but had a very active
lifestyle. So, together with the lesion location, an individualised
approach, considering the patient’s daily activity according to his
age, is needed for better clinical outcomes.
Conclusion
Femoropopliteal artery stenting, especially the Supera stent, is
a promising option for the treatment of claudication. However,
the Supera stent is not fracture-proof. Careful observation after
Supera peripheral stent implantation and an individualised
approach for treatment of femoropopliteal artery disease,
considering the lesion location, patient’s age and exercise capacity
is warranted.
This work was supported by a grant from Yeungnam University.
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