What are the alternatives to stent placement in patients who are not suitable candidates or have failed stent placement?

Alternatives to Stent Placement

For patients who are not suitable candidates for stenting or have failed stent placement, the primary alternatives depend on the clinical context: in coronary disease, optimal medical therapy with dual antiplatelet therapy (aspirin plus clopidogrel) is the foundation; in vascular stenoses, angioplasty alone or surgical revascularization are the main options; and in central airway obstruction, ablative techniques like laser resection or dilation should be prioritized before considering stents.

Coronary Artery Disease Context

Medical Management as Primary Alternative

Patients should be counseled on alternative therapies if they are unwilling or unable to comply with the recommended duration of dual antiplatelet therapy (DAT) before stent placement is even considered. 1

• Aspirin monotherapy at 75-162 mg daily should be continued indefinitely for all patients with coronary disease, regardless of whether stenting is performed 1
• Clopidogrel 75 mg daily can be added to aspirin as dual antiplatelet therapy even without stenting, as this combination reduces cardiovascular ischemic events 1
• High-dose statin therapy is mandatory for all patients with coronary disease if tolerated 2
• Aggressive risk factor modification including blood pressure control, diabetes management, and smoking cessation must be implemented 3

Balloon Angioplasty Without Stenting

• Plain balloon angioplasty remains an option when stenting is contraindicated, though restenosis rates are higher 1
• For patients at high bleeding risk who cannot tolerate prolonged dual antiplatelet therapy, balloon angioplasty alone avoids the mandatory 12-month DAT requirement associated with drug-eluting stents 1

Surgical Revascularization

• Coronary artery bypass grafting (CABG) is the definitive alternative when percutaneous intervention is not feasible or has failed 1
• Surgery may be preferred in patients with multivessel disease, diabetes, or left main disease 1

Peripheral Vascular Disease Context

Angioplasty Without Stenting

For TASC A lesions in the common iliac artery, percutaneous transluminal angioplasty (PTA) alone is usually appropriate, with selective stent placement only if PTA results are suboptimal. 2

• Balloon angioplasty can achieve adequate results in focal, short stenoses without requiring stent placement 2
• This approach avoids the need for prolonged dual antiplatelet therapy (4-6 weeks for bare metal stents, 6-12 months for drug-eluting stents) 4

Surgical Revascularization

In patients with an indication for renal artery revascularization where angioplasty and stenting is technically unfeasible or has failed, open surgical revascularization may be considered. 1

• For peripheral arterial disease, endovascular and open surgical approaches have equivalent 2-year survival, limb salvage, and primary patency, though endovascular approaches have decreased hospital length of stay and fewer postoperative complications 2
• Surgical options include mesocaval shunts, porto-caval shunts, or meso-atrial shunts depending on the specific vascular anatomy 1

Medical Management Alone

• Single-agent antiplatelet therapy is mandatory for all symptomatic peripheral arterial disease patients to reduce major adverse cardiovascular events 2
• Supervised exercise programs should be initiated along with risk factor modification 2
• For acute thromboembolism, anticoagulation is usually indicated except in contraindicated situations like recent surgery 2

Hepatic Vascular Disease (Budd-Chiari Syndrome)

Anticoagulation as Primary Therapy

Patients with Budd-Chiari syndrome should receive anticoagulant therapy as soon as possible for an indefinite period, starting with low molecular weight heparin for 5-7 days plus warfarin targeting INR 2-3. 1

• This approach can be effective as monotherapy in patients who respond to medical treatment 1
• Treatment of underlying prothrombotic causes (such as myeloproliferative neoplasms) should be initiated concomitantly 1

Thrombolysis

• Local and early infusion of thrombolytic agents combined with angioplasty has shown good results in patients with recent and incomplete thrombosis, though complications can be fatal 1

Derivative Techniques When Stenting Fails

Patients with Budd-Chiari syndrome non-responsive to medical treatment or who are not candidates for angioplasty/stenting must be treated with derivative techniques, either surgical shunts or transjugular intrahepatic portosystemic shunt (TIPS). 1

• The most frequent surgical shunt is the mesocaval shunt with PTFE or autologous jugular vein interposition 1
• TIPS transforms the portal system into an outflow tract and is appropriate when medical management fails 1

Central Airway Obstruction

Ablative Techniques Without Stenting

For patients with symptomatic central airway obstruction, stent placement should only be suggested if other therapeutic bronchoscopic and systemic treatments have failed, as stenting should be avoided if airway debridement can achieve airway patency. 1

• Dilation is a primary alternative, though it may require repeat interventions 1
• Endoscopic resection with mechanical therapy (ERMT) shows lower recurrence rates than dilation alone (12.4% vs 28% at 3 years for idiopathic subglottic stenosis) 1
• Laser incisions can be used for stenotic lesions 1
• A multimodality approach utilizing dilation, ablative resection, and medical treatment is more likely to achieve optimal outcomes 1

Important Caveats About Stenting

• The FDA issued a public health notification in 2005 about complications of metallic stents in benign tracheal disorders 1
• Stent complications include mucus plugging, granulation tissue formation, migration, fracture, and infections 1
• Stents should be reserved for indications when airway patency cannot be maintained without the stent or prior treatment has failed 1

Critical Contraindications to Stenting

Age Considerations

Age >70 years is a relative contraindication to carotid stenting, with endarterectomy being definitively superior in this population (stroke risk 1% for endarterectomy versus 3% for stenting). 3

Operator Requirements

• Stenting should not be performed if the operator/center cannot demonstrate periprocedural stroke/death rates <6% for symptomatic patients 3
• The operator must have established periprocedural morbidity/mortality rates of 4-6% for symptomatic patients 3

Bleeding Risk

• Patients at significant increased risk of bleeding may require alternative approaches, as dual antiplatelet therapy carries bleeding risks (historically up to 50% in some cohorts, though more recent data shows 17% with better management) 1
• Lower-dose aspirin (75-162 mg daily) is reasonable for long-term therapy to reduce bleeding complications 1