Endovascular stenting has been used for seventeen years for the treatment of NCS due to its minimally invasive nature. A survey of the published English literature revealed 124 cases treated in this manner including our largest stenting experiences to date [2]–[9]. Although, the current literature suggests that stenting is a safe and effective procedure, stent migration notes in 7.3 % of all cases [2]–[5]. The reason of endovascular stent migration may be the effect of cardiac motion, early activity, mismatch between renal vein diameter or stent diameter, or inaccurate positioning of the stent within the lesion.

The clinical implications of migration are significant and can lead to thrombosis, vessel trauma, embolization, and its most disastrous consequence (rupture). It requires prompt and effective diagnosis and management to prevent potentially implications.

Sequence of image for diagnosis or follow-up has more or less been rationalized to duplex ultrasound, computerized tomography or magnetic resonance angiography, and finally left renal venography [2]. Duplex ultrasound is the easiest and the least expensive method. Zhelan Zheng et al. [10] pointed out standards for ultrasonic diagnosis of the disease as follows: (1)the low velocity of stenosis of the LRV at supine position accelerates remarkably, and the acceleration is more obvious after standing for 15 min,which is more than 100 cm/s; (2) the inner diameter ratio between renal hilum and stenosis of the LRV at supine position is more than 3, while it is more than 5 after standing for 15 min. When two index are coincident with the standards, NCS may be primary diagnosed. The CTA (including non-invasive 3-D) may be a useful tool in the diagnosis of the NCS and follow-up testing. CTA provided fine outlines that gave a precise depiction of both endovascular stent migration on the left of the SMA and a compression of the LRV between the aorta and the SMA. Furthermore, the stent migrating distance can be measured, and many distorting collateral veins were seen arising from the LRV in the CTA. The CTA imaging was closely correlated to therapeutic interventions and stent migration.

The typical treatment is percutaneous removal of the migrated stent. However, under certain circumstances, such as stent migration to the heart, special stent, or endothelialization of stent, percutaneous removal may be difficult or even impossible, thus surgery may be required. Hartung et al. described a LRV stent that migrated into the retro hepatic inferior vena cava; an attempt to retrieve it with a Goose Neck failed when the stent took a transversal orientation after 5 cm, and further attempts also failed [4]. A patient with a nitinol stent is difficult to manage percutaneously because of its inherent characteristics and probable endothelialization of the stent in 1 year, which makes the procedure more challenging [11]. In our previous case, one stent migrated into the right atrium and the patient required surgery after unsuccessful percutaneous removal [3]. In such cases, surgical removal is a safer and more feasible option. However, surgical removal is associated with high morbidity: Long period of renal congestion and additional anastomoses. Compared with surgical removal, extravascular stenting is a minimally invasive treatment modality.

Compared with vascular displacement, extravascular stenting for NCS is a minimally invasive treatment modality. Especially for children and adolescents, intravascular stenting should be cautiously recommended because the lumen of the LRV may become wider and the stents cannot match any longer during physical development. One may postulate that externally suturing stent could be a way to keep it in place; therefore, Barnes firstly reported extravascular stenting and externally suturing the stent performed by open surgery in 1988 [12]. Currently, sporadic cases of extravascular stenting for the NCS have been reported with excellent outcome at short-term follow up [13]–[17]. The stent has good conformability to adapt to the vessel wall and adhere to the vessel wall tightly [6]. In our opinion, the extravascular approach to treat endovascular stent migration is favored to avoid the potential complications.

Consideration must also be given to the original stent placement. If removal is not possible or failed, the original stent should be fixed to prevent repeated movements of the stent. Both the new and old stents should be sewn to the vessel wall to ensure that the extravascular and endovascular stents did not migrate, as shown in our case.

...

Endovascular stenting has been used for seventeen years for the treatment of NCS due to its minimally invasive nature. A survey of the published English literature revealed 124 cases treated in this manner including our largest stenting experiences to date [2]–[9]. Although, the current literature suggests that stenting is a safe and effective procedure, stent migration notes in 7.3 % of all cases [2]–[5]. The reason of endovascular stent migration may be the effect of cardiac motion, early activity, mismatch between renal vein diameter or stent diameter, or inaccurate positioning of the stent within the lesion.

The clinical implications of migration are significant and can lead to thrombosis, vessel trauma, embolization, and its most disastrous consequence (rupture). It requires prompt and effective diagnosis and management to prevent potentially implications.

Sequence of image for diagnosis or follow-up has more or less been rationalized to duplex ultrasound, computerized tomography or magnetic resonance angiography, and finally left renal venography [2]. Duplex ultrasound is the easiest and the least expensive method. Zhelan Zheng et al. [10] pointed out standards for ultrasonic diagnosis of the disease as follows: (1)the low velocity of stenosis of the LRV at supine position accelerates remarkably, and the acceleration is more obvious after standing for 15 min,which is more than 100 cm/s; (2) the inner diameter ratio between renal hilum and stenosis of the LRV at supine position is more than 3, while it is more than 5 after standing for 15 min. When two index are coincident with the standards, NCS may be primary diagnosed. The CTA (including non-invasive 3-D) may be a useful tool in the diagnosis of the NCS and follow-up testing. CTA provided fine outlines that gave a precise depiction of both endovascular stent migration on the left of the SMA and a compression of the LRV between the aorta and the SMA. Furthermore, the stent migrating distance can be measured, and many distorting collateral veins were seen arising from the LRV in the CTA. The CTA imaging was closely correlated to therapeutic interventions and stent migration.

The typical treatment is percutaneous removal of the migrated stent. However, under certain circumstances, such as stent migration to the heart, special stent, or endothelialization of stent, percutaneous removal may be difficult or even impossible, thus surgery may be required. Hartung et al. described a LRV stent that migrated into the retro hepatic inferior vena cava; an attempt to retrieve it with a Goose Neck failed when the stent took a transversal orientation after 5 cm, and further attempts also failed [4]. A patient with a nitinol stent is difficult to manage percutaneously because of its inherent characteristics and probable endothelialization of the stent in 1 year, which makes the procedure more challenging [11]. In our previous case, one stent migrated into the right atrium and the patient required surgery after unsuccessful percutaneous removal [3]. In such cases, surgical removal is a safer and more feasible option. However, surgical removal is associated with high morbidity: Long period of renal congestion and additional anastomoses. Compared with surgical removal, extravascular stenting is a minimally invasive treatment modality.

Compared with vascular displacement, extravascular stenting for NCS is a minimally invasive treatment modality. Especially for children and adolescents, intravascular stenting should be cautiously recommended because the lumen of the LRV may become wider and the stents cannot match any longer during physical development. One may postulate that externally suturing stent could be a way to keep it in place; therefore, Barnes firstly reported extravascular stenting and externally suturing the stent performed by open surgery in 1988 [12]. Currently, sporadic cases of extravascular stenting for the NCS have been reported with excellent outcome at short-term follow up [13]–[17]. The stent has good conformability to adapt to the vessel wall and adhere to the vessel wall tightly [6]. In our opinion, the extravascular approach to treat endovascular stent migration is favored to avoid the potential complications.

Consideration must also be given to the original stent placement. If removal is not possible or failed, the original stent should be fixed to prevent repeated movements of the stent. Both the new and old stents should be sewn to the vessel wall to ensure that the extravascular and endovascular stents did not migrate, as shown in our case.

...

1. June 2015 – Mississippi Certificate of Need Meeting

During the June 25, 2015, Certificate of Need meeting, Dr. Mary Currier, State Health Officer, concurred with the health and planning staff analysis and approved the following applications for Certificate of Need:

CON Review #HG-MOB-0215-003 – Madison HMA LLC d/b/a Merit Health Madison – Construction of a Medical Office Building (MOB) – Location: Canton, Madison County, Mississippi – Capital Expenditure: $9,000,000 – Staff Recommendation: Approval

CON Review #C-NIS-0215-004 – Cardiovascular Solutions of Mississippi LLC d/b/a Cardiovascular Solutions of Mississippi – Provision of Digital Subtraction Angiography (DSA) Services – Location: Grenada, Grenada County, Mississippi – Capital Expenditure: $250,000 – Staff Recommendation: Approval

The next Certificate of Need meeting is scheduled for July 30, 2015, at 11:00 a.m.

1. Certificate of Need Program Report – Filings/Reports in June 2015

1. Letters of Intent to Change Ownership

1. Holmes County LTC Center – Change of Ownership – Received June 3, 2015

1. Determinations of Reviewability

1. RCG of Oxford d/b/a Oxford Home Therapy – Establishment of a Home Dialysis Program - Received June 1, 2015
2. Mississippi Medical Options LLC – Mississippi Medical Options Geriatric Psychiatric Unit - Received June 1, 2015
3. Anderson Regional Medical Center – Acquisition of a Replacement Cardiac Catheterization System and the Installation of the New Equipment at Anderson Regional Medical Center in Meridian – Received June 1, 2015
4. University of Mississippi Medical Center – Additional MRI for Children’s of Mississippi –Received June 15, 2015
5. Biloxi HMA LLC d/b/a Merit Health Biloxi (f.k.a Biloxi Regional Medical Center) – Merger of Compass Imaging LLC – Received June 19, 2015
6. University of Mississippi Medical Center – Emergency Department Chest Pain Evaluation Unit – Received June 19, 2015

1. Letters of Intent to Apply for CON

1. Bio-Medical Applications of Mississippi Inc. d/b/a Fresenius Medical Care – West Hinds – CON Amendment – Bio-Medical Applications of Mississippi Inc. d/b/a Fresenius Medical Care – West Hinds County – Establishment of Satellite ESRD Facility – Received June 1, 2015
2. Cedar Lake Open MRI LLC d/b/a Cedar Lake Open MRI – Offering of MRI Services and Acquisition of MRI Equipment – Received June 24, 2015

1. Applications Received/Withdrawn

1. St. Dominic Jackson Memorial Hospital – Renovation and Expansion of Emergency Department – Received May 29, 2015
2. Hattiesburg Clinic Professional Association – Offering of Diagnostic Imaging Services of an Invasive Nature, including Digital Subtraction Angiography – Received June 1, 2015
3. Bio-Medical Applications of Mississippi Inc. d/b/a Fresenius Medical Care Dialysis Services of Rankin County – Brandon – Relocation of ESRD Facility within One Mile and Expansion of ESRD Stations – Received June 1, 2015
4. Bio-Medical Applications of Mississippi Inc. d/b/a Fresenius Medical Care – West Hinds – CON Amendment – Bio-Medical Applications of Mississippi Inc. d/b/a Fresenius Medical Care – West Hinds County – Establishment of Satellite ESRD Facility – Received June 1, 2015
5. Singing River Health System d/b/a Singing River Hospital – Exterior Hardening Window Replacement – Received June 1, 2015
6. NeuroTASS LLC – Establishment of Comprehensive Residential Rehabilitation Facility – Received June 1, 2015

1. ?Applications Received for Extension/Renewal of an Expired CON

None

1. Additional Material Received in Response to Negative Staff Analysis

None

1. CON Applications Deemed Complete

None

1. Six-Month Extension Requests Granted

1. SME on HG-RE-0808-030; R-0780 – North Mississippi Medical Center – Replacement and Addition of Electronic Information and Surgery Information Systems – Capital Expenditure: $28,000 – Expiration Date: September 15, 2015
2. SME on HG-R-1209-035; R-0807 – Mississippi Baptist Medical Center – Nursing Units Renovation Project – Capital Expenditure: $58,650,000 – Expiration Date: September 25, 2015
3. SME on HG-CRF-1203-035; R-0636 – Alliance Healthcare Inc. System d/b/a Alliance Health  Care  System  –  Construction  of  Replacement  Hospital  –  Capital  Expenditure: $30,807,769 – Expiration Date: September 25, 2015
4. SME on HG-RC-1109-030; R-0804 – North Mississippi Medical Center – West Bed-Tower Expansion and Renovation – Capital Expenditure: $55,103,273 – Expiration Date: September 25, 2015
5. SME on HG-RC-0613-008; R-0868 – Baptist Memorial Hospital North Mississippi, Inc. d/b/a Baptist Memorial North Mississippi – Hospital Infusion Services Addition – Capital Expenditure: $4,153,323 – Expiration Date: September 28, 2015
6. SME on ESRD-NIS-0612-013; R-0859 – RCG Mississippi Inc. d/b/a Lowndes County Dialysis, Columbus  – Establishment of Satellite  ESRD Facility  – Capital Expenditure: $1,405,966 – Expiration Date: September 28, 2015
7. SME on HG-C-0613-010; R-0870 – Mississippi  Methodist Hospital and Rehabilitation Center Inc. d/b/a Methodist Outpatient Rehabilitation – Construction of Consolidated Outpatient Therapy Facility – Capital Expenditure: $5,872,945 – Expiration Date: September 28, 2015
8. SME on HG-RC-0611-013; R-0847 – Memorial Hospital at Gulfport, Gulfport Neonatal Intensive Care Unit Expansion – Capital Expenditure: $6,663,350 – Expiration Date: September 29, 2015
9. SME on HG-CB-1211-027; R-0848 – Singing River Hospital, Pascagoula – Addition of Level II Comprehensive Medical Rehabilitation Beds – Capital Expenditure: $690,000 – Expiration Date: September 29, 2015
10. SME on NH-CRF-0908-039; R-0786 – Community Place Jackson – Construction/ Replacement/Relocation of Community Nursing Home – Capital Expenditure: $9,870,000 - Expiration Date: October 30, 2015

1. Hearings Requested/Scheduled During the Course of Review

None

1. Request for Hearing on Denial of Six-Month Extension

CON   Review   #ESRD-NIS-0905-041;   CON   #R-0710   –   Healthcare   Engineers   LLC   – Establishment of a Six-Station ESRD Facility in Tallahatchie County – Capital Expenditure: $254,085 – Requestor: Alliance Health Partners LLC d/b/a Tri-Lakes Medical Center – To Be Scheduled

...

(HealthDay News) -- Blacks are more likely than whites to experience sudden cardiac arrest and it often occurs at an earlier age in blacks than in whites, according to research published online in Circulation.

Sumeet Chugh, M.D., associate director of the Cedars-Sinai Heart Institute in Los Angeles, and colleagues collected data on 1,262 whites and 126 blacks. They all had experienced sudden cardiac arrest between 2002 and 2012. While 33% of the whites in the study had diabetes, 52% of the blacks did. Hypertension was an issue for 77% of the blacks, compared to 65% of the whites. Chronic renal insufficiency was nearly twice as likely in blacks, with 34% of them having the condition, the researchers found.

Blacks in the United States tend to have sudden cardiac arrest an average of 6 years earlier than whites, Chugh told HealthDay. In his study, he found other major differences as well. "Blacks, in addition to being younger, tended to have more diabetes, more high blood pressure, and more kidney problems, or chronic renal disease," he said.

Chugh added that he isn't certain what's driving the differences in sudden cardiac arrest between blacks and whites. It's possible it might be genetics, cultural differences in lifestyle or other factors, he suggested. Inadequate health coverage may be another factor.

Source

1. Reinier, K; Nichols, GA; Huertas-Vazquez, A; et al. Circulation, published online before print July 20, 2015; doi: 10.1161/CIRCULATIONAHA.115.015673.

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