Validation of methods for effective orifice area measurement of prosthetic valves by two-dimensional and Doppler echocardiography following transcatheter self-expanding aortic valve implantation

Background The effective orifice area(EOA)is utilized to characterize the hemodynamic performance of the transcatheter heart valve(THV).However,there is no consensus on EOA measurement of self-expanding THV.We aimed to compare two echocardiographic methods for EOA measurement following transcatheter self-expanding aortic valve implantation.Methods EOA was calculated according to the continuity equation.Two methods were constructed.In Method 1 and Method 2,the left ventricular outflow tract diameter(LVOTd)was measured at the entry of the prosthesis(from trailing-to-leading edge)and proximal to the prosthetic valve leaflets(from trailing-toleading edge),respectively.The velocity-time integral(VTI)of the LVOT(VTILVOT)was recorded by pulsed-wave Doppler(PW)from apical windows.The region of the PW sampling should match that of the LVOTd measurement with precise localization.The mean transvalvular pressure gradient(MG)and VTI of THV was measured by Continuous wave Doppler.Results A total of 113 consecutive patients were recruited.The mean age was 77.2±5.5 years,and 72 patients(63.7%)were male.EOA1 with the use of Method 1 was larger than EOA2(1.56±0.39 cm2 vs.1.48±0.41 cm2,P=0.001).MG correlated better with the indexed EOA1(EOAI1)(r=-0.701,P<0.001)than EOAI2(r=-0.645,P<0.001).According to EOAI(EOAI≤0.65 cm2/m2,respectively),the proportion of sever prosthesis-patient mismatch with the use of EOA1 was lower than EOA2(12.4%vs.21.2%,P<0.05).Compared with EOA2,EOA1 had lower interobserver and intra-observer variability(intra:0.5%±17%vs.3.8%±22%,P<0.001;inter:1.0%±9%vs.3.5%±11%,P<0.001).Conclusions For transcatheter self-expanding valve EOA measurement,LVOTd should be measured in the entry of the prosthesis stent(from trailing-to-leading edge),and VTILVOT should match that of the LVOTd measurement with precise localization.

Outcomes of Self-Expanding Transcatheter Pulmonary Valves:Extended Follow-Up of a Prospective Trial

Background:The Venus-P valve was the first self-expanding valve used world-wide for transcatheter pulmonary valve replacement(TPVR)in patients with severe pulmonary regurgitation(PR).We intended to report the extended follow-up results from the prospective trial(No.NCT02590679).Methods:A total of 38 patients with severe PR(mean age 24.2±13.2)were included.Follow-up data were obtained after implanted at 1,6,and 12 months and yearly after.The frame geometry was assessed on post-implant computer tomography(CT)scanning by calculating the non-circularity[circularity ratio(minimum diameter/maximum diameter)<0.9]and under-expansion[expansion ratio(derived external valve area/nominal external valve area)<0.9).Adverse events(all-cause mortality,reintervention,valve dysfunction,stent fracture and endocarditis)were recorded.Results:All valves were implanted successfully with normal function at discharge.Geometric CT analysis showed underexpanded valve was detected in 22 patients(63%)and non-circular valve was seen in 16 patients(46%).During a median follow-up of 4.8 years(range 0.3-8.1),there were 1 death and 1 surgical explant,both resulting from endocarditis.Five-year freedom from valve dysfunction and stent fracture were 84.8%(95%CI 74.8-94.7)and 83.5%(95%CI 73.8-93.2).Endocarditis occurred in 3 patients at a median time of 7 months.Stent fracture was more common in patients with non-circularity stents.Conclusion:TPVR using Venus-P valve is associated with favorable outcomes at 5 years.Non-circular shapes in the valve level may have a higher risk of stent fracture.

On the Describing Functions of PWM Pneumatic High-Speed On-Off Valves

High-speed on-off valves are widey used in PWM electropneumatic servo sys- tems and their characteristics are generally described by their on and off delay time. This paper focuses on establishing the relationships between their on-off switching behaviors and their frequency response characteristics. A method is proposed by which the frequency response characteristics of an analog PWM high-speed on-off valve can be calculated for inputs whose periods are certain multiples of the carrier period, based on its switching be- haviors. Thus, a simple and direct describing function for a PWM high-speed on-off valve is established.

Evaluation of Patients with Severe Aortic Stenosis after TAVI with Self-Expandable vs. Balloon-Expandable Devices

Background: The introduction of transcatheter aortic valve implantation (TAVI) for the treatment of severe aortic stenosis (SAS) has expanded the therapeutic possibilities for successfully managing SAS in cases with intermediate and high surgical risks. However, the complications and outcomes of new devices have not been studied enough. Hence, the purpose of this study is to evaluate the midterm results of the Core Valve and Evolute R self-expandable (SE) devices versus the Edwards SAPIEN balloon-expandable (BE) devices. Methods and Material: This was a quasi-experimental study conducted in Tehran, Iran, from May 2012 to June 2017. SAS patients who were not ideal candidates for surgery were randomly assigned to either SE or BE groups. For each patient, a questionnaire, including four sections comprised of Basic characteristics, echocardiographic, angiographic, and Computed Tomography (CT) scan data was filled. TAVI was followed by echocardiography a week later and after three months they were reevaluated by another questionnaire. Results: The total number of patients was 60. The mean ages of patients undergoing the procedure with SE or BE devices were 81.2 ± 8 and 79.8 ± 7, respectively. Mortality occurred in 20% of the patients (5 cases in the SE group and 7 cases in the BE);mortality causes were 66.6 % cardiac and 33% non-cardiac. Moderate to severe Paravalvular leakage in both groups did not differ significantly. The mortality rate was 5 (41.6%) in the SE group versus 7 (58.3%) in the BE group (P > 0.05). Conclusion: In conclusion, the BE group did not experience fewer paravalvular leaks in comparison with the SE. Morbidity and mortality between the BE and the SE groups did not differ significantly.

eSie Valves四维自动定量分析评价主动脉瓣-二尖瓣机制的应用

目的探讨eSie Valves四维自动定量分析系统在主动脉瓣-二尖瓣偶联机制定量评估中的应用价值。方法2018年9～12月入选38例卵圆孔未闭或房颤患者,应用经食管三维超声心动图(3D-TEE)采集主动脉环及二尖瓣环三维图像,运用eSie Valves四维自动定量分析系统重建主动脉瓣-二尖瓣三维模型,自动获得主动脉瓣及二尖瓣相关参数,以及主动脉瓣环与二尖瓣环间夹角、主动脉瓣-二尖瓣中心距离,观察其在全心动周期变化规律,并取最大值及最小值进行比较。结果入选患者均获得满意图像及完整的心动周期动态分析结果,所有参数最大值及最小值的差异均有统计学意义(P <0. 001)。二尖瓣环与主动脉瓣环面积呈相反变化趋势,二尖瓣环面积于舒张早期达到峰值(866. 4±160. 4) mm^2,主动脉瓣环面积处于最小值(413. 5±62. 9) mm^2;收缩期二尖瓣环面积最小值(621. 7±149. 0) mm^2,主动脉瓣环面积达到峰值(517. 2±71. 8) mm^2。等容收缩期中心距离最大(21. 6±1. 4) mm,其后随左心室容量变化致等容舒张期达到最小值(18. 4±2. 0) mm;主动脉瓣-二尖瓣夹角在收缩末期最小(94. 3±12. 7)°,舒张期达到峰值(124. 8±9. 3)°。结论 eSie Valves四维自动定量分析系统能重建主动脉瓣根部、二尖瓣及二者空间偶联模型,为主动脉瓣-二尖瓣偶联机制定量研究提供了新的方法。

A Study on the Static Characteristics of Typical Composite High Speed On-Off Valves

Natural properties of high speed on-off valves can be described through their on-off behavior and spool movement (static and oscillating) characteristics. High speed on-off valves can be combined with actuators in systems into four typical types of composite valves whose static characteristics are related not only to the structures of the single valves and the composite ones, but also to the PWM control modes. It is proved that the composite valves have similar features as those of servo valves. The nonlinear specific properties of single valves composited can be completely compensated by the suitable PWM control modes.

Output Waveform Analysis of an Electro-hydraulic Vibrator Controlled by the Multiple Valves

The existing research of the electro-hydraulic vibrator mainly focuses on system stability, working frequency width and output waveform distortion. However, this high frequency performance of the electro-hydraulic vibrator is difficult to be improved greatly due to fast insufficiently frequency response of the servo valve itself and limited compensation capability of the control structure in the vibrator system. In this paper, to realize high frequency vibration, an improved two-dimensional valve （here within defined as a 2D valve） as a main control component is adopted to the parallel connection with a servo valve to control the electro-hydraulic vibrator, Because the output waveforms of this electro-hydraulic vibrator are incapable to be verified through timely feedback as in the conventional electro-hydraulic servo system, the analysis to the output waveform becomes crucial to the design and control of the electro-hydraulic vibrator. The mathematical models of hydraulic actuation mechanism and the orifice area of the parallel valves connection are established first. And then the vibration process is divided into two sections in terms of the direction of the flow, the analytical expression of the excited waveform is solved. Based on relationships exist between working states and the control parameters the analytical results, the vibration boundary positions and the are derived. Finally an experimental system was built to validate the theoretical analysis. It is verified that this electro-hydraulic vibration system could achieve high working frequency, up to 2 000 Hz. The excited waveform is similar to the sinnsoidal waveform. And the ascent and decent slopes of the waveforms are somewhat asymmetrical. This asymmetry is not only caused by the change of the direction of the elastic force but also dependent on the bias position of the vibration. Consequentky the distortion of effective working waveform is less tha~ 10%. This electro-hydraulic vibrator controlled by the multiple valves could not only greatly enhance the working frequency but also precisely control the vibration characteristic variables such as waveform shape.

EXPERIMENTAL INVESTIGATIONS OF CAVITATION EFFECTS ON FLOW CHARACTERISTICS OF SMALL ORIFICES AND VALVES IN WATER HYDRAULICS

The flow characteristics and cavitation effects of water passing throughsmall sharp-edged cylindrical orifices and valves of different shapes in water hydraulics areinvestigated. The test results using orifices with different aspect ratios and different diametersshow that the flow coefficients in the case of non-cavitating flow are larger than that of flow inthe case of cavitation occurrence. The flow coefficients of flow with cavitation initially decreaseas Reynolds number increases and ultimately tend to be of constant values close to contractioncoefficient. Large aspect ratio has an effect of suppressing cavitation. The experimental resultsabout disc valves illustrate that the valves with sharp edge at large opening are less affected bycavitation than that at small opening. Throttle with triangle notch has better anti-cavitationability than that with square notch. The flowrate of the throttle with square notch is significantlyaffected by the flow direction or the flow passage shape.

Self-expandable metallic stent placement plus laparoscopy for acute malignant colorectal obstruction

AIM:To investigate the clinical advantages of the stent-laparoscopy approach to treat colorectal cancer(CRC)patients with acute colorectal obstruction(ACO).METHODS:From April 2008 to April 2012,surgeryrelated parameters,complications,overall survival(OS),and disease-free survival(DFS)of 74 consecutive patients with left-sided CRC presented with ACO who underwent self-expandable metallic stent(SEMS)placement followed by one-stage open(n=58)or laparoscopic resection(n=16)were evaluated retrospectively.The stent-laparoscopy group was also compared with a control group of 96 CRC patients who underwent regular laparoscopy without ACO between January 2010 and December 2011 to explore whether SEMS placement influenced the laparoscopic procedure or reduced long-term survival by influencing CRC oncological characteristics.RESULTS:The characteristics of patients among these groups were comparable.The rate of conversion to open surgery was 12.5%in the stent-laparoscopy group.Bowel function recovery and postoperative hospital stay were significantly shorter(3.3±0.9 d vs 4.2±1.5 d and 6.7±1.1 d vs 9.5±6.7 d,P=0.016 and P=0.005),and surgical time was significantly longer(152.1±44.4 min vs 127.4±38.4 min,P=0.045)in the stent-laparoscopy group than in the stent-open group.Surgery-related complications and the rate of admission to the intensive care unit were lower in the stent-laparoscopy group.There were no significant differences in the interval between stenting and surgery,intraoperative blood loss,OS,and DFS between the two stent groups.Compared with those in the stentlaparoscopy group,all surgery-related parameters,complications,OS,and DFS in the control group were comparable.CONCLUSION:The stent-laparoscopy approach is a feasible,rapid,and minimally invasive option for patients with ACO caused by left-sided CRC and can achieve a favorable long-term prognosis.

A comprehensive review of cavitation in valves:mechanical heart valves and control valves

Valves are widely used in various working conditions for their flow control functions,and the cavitation inside valves has been investigated owing to its harm to the valve itself and the connecting downstream parts.This paper presents a comprehensive review of the progress that has been achieved in the past years about cavitation in valves including both mechanical heart valves and control valves.The review is divided in the following parts,namely the location where there is a high possibility of the occurrence of cavitation,the parameters that affect cavitation intensity,and the methods to minimize cavitation intensity.It should be noticed that although simulation has been widely used,advanced experiments are still needed in order to obtain accurate analysis of cavitation in valves and the cavitation model still needs to be improved.

Treatment of malignant gastric outlet obstruction with endoscopically placed self-expandable metal stents

Malignant gastroduodenal obstruction can occur in up to 20%of patients with primary pancreatic,gastric or duodenal carcinomas.Presenting symptoms include nausea,vomiting,abdominal distention,pain and decreased oral intake which can lead to dehydration, malnutrition,and poor quality of life.Endoscopic stent placement has become the primary therapeutic modality because it is safe,minimally invasive,and a cost-effective option for palliation.Stents can be successfully deployed in the majority of patients. Stent placement appears to lead to a shorter time to symptomatic improvement,shorter time to resumption of an oral diet,and shorter hospital stays as compared with surgical options.Recurrence of the obstructive symptoms resulting from stent occlusion,due to tumor ingrowth or overgrowth,can be successfully treated with repeat endoscopic stent placement in the majority of the cases.Both endoscopic stenting and surgical bypass are considered palliative treatments and,to date,no improvement in survival with either modality has been demonstrated.A tailored therapeutic approach,taking into consideration patient preferences and involving a multidisciplinary team including the therapeutic endoscopist,surgeon,medical oncologist, radiation therapist,and interventional radiologist, should be considered in all cases.

Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature

AIM: To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature.METHODS: The Pub Med, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics.RESULTS: Fully covered self-expandable metal stents(FC SEMS)(n = 85), biodegradable(BD) stents(n = 77) and self-expandable plastic stents(SEPS)(n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major(17.7%) and minor(13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks(64.5%), iatrogenic perforations(19.6%), Boerhaave's syndrome(7.8%) and fistulae(3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major(7.8%) and minor(5.5%) complications.CONCLUSION: The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforationsand fistulae is promising.

Research and Development of Electro‑hydraulic Control Valves Oriented to Industry 4.0:A Review

Electro-hydraulic control valves are key hydraulic components for industrial applications and aerospace,which controls electro-hydraulic motion.With the development of automation,digital technology,and communication technology,electro-hydraulic control valves are becoming more digital,integrated,and intelligent in order to meet the requirements of Industry 4.0.This paper reviews the state of the art development for electro-hydraulic control valves and their related technologies.This review paper considers three aspects of state acquisition through sensors or indirect acquisition technologies,control strategies along with digital controllers and novel valves,and online maintenance through data interaction and fault diagnosis.The main features and development trends of electro-hydraulic control valves oriented to Industry 4.0 are discussed.

Self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction caused by stomach cancer

AIM: To ascertain clinical outcome and complications of self-expandable metal stents for endoscopic palliation of patients with malignant obstruction of the gastrointestinal (GI) tract. METHODS: A retrospective review was performed throughout August 2000 to June 2005 of 53 patients with gastric outlet obstruction caused by stomach cancer. All patients had symptomatic obstruction including nausea, vomiting, and decreased oral intake. All received self-expandable metallic stents. RESULTS: Stent implantation was successful in all 53 (100%) patients. Relief of obstructive symptoms was achieved in 43 (81.1%) patients. No immediate stent-related complications were noted. Seventeen patients had recurrent obstruction (tumor ingrowth in 14 patients, tumor overgrowth in 1 patient, and partial distal stent migration in 2 patients). The mean survival was 145 d. Median stent patency time was 187 d. CONCLUSION: Endoscopic placement of self-expandable metallic stents is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach cancer.

Advances in Technologies of Piezoelectric Pumping with Valves

Piezoelectric pump faces unprecedented challenges when higher expectation and requirements need to be met in their applications mainly to medical treatment,hygiene and public health,and preventive healthcare.Specifically,the piezoelectric pump with valve has the disadvantages of complex structure,high duty cycle of valves,and valve movement lagged behind piezoelectric ceramics oscillation.In an attempt to inhibit its shortcomings,some researchers presented novel concepts for structural design of piezoelectric pump with valve,which could become a new research focus.Among them,the investigation into various soft valves,represented by soft structure valves made of rigid materials and soft material valves made of flexible materials,has been fruitful in recent years.The integrated design of both material and structure can tackle the problems encountered in the study of piezoelectric pump with valve,thus simplifying the pump structure,reducing the duty-cycle of valves,and improving the lagging of valve motion.In addition,new inventions of pump structure have sprung up,such as the pumps containing a single-chamber with double-drive,single-chamber with single-drive in series and single-chamber with single-drive in parallel,as well as the mixed-chamber in series and parallel.After surveying the recent progresses made by dominant academia in the development of piezoelectric pump encompassing valve,with a particular emphasis on structure design of both valve and pump body,we also summarize and identify the future research directions.

Efficacy and safety of limited endoscopic sphincterotomy before self-expandable metal stent insertion for malignant biliary obstruction

To evaluate the safety and efficacy of limited endoscopic sphincterotomy (ES) before placement of self-expandable metal stent (SEMS).METHODSThis was a retrospective analysis of 244 consecutive patients with unresectable malignant biliary obstruction, who underwent placement of SEMSs following limited ES from December 2008 to February 2015. The diagnosis of malignant biliary obstruction and assessment of patient eligibility for the study was established by a combination of clinical findings, laboratory investigations, imaging and pathological results. All patients were monitored in the hospital for at least 24 h following endoscopic retrograde cholangio pancreatography (ERCP). The incidence of immediate or early post-ERCP complications such as post-ERCP pancreatitis (PEP) and bleeding related to limited ES were considered as primary outcomes. Also, characteristics and complications according to the cancer type were classified.RESULTSAmong the 244 patients included, the underlying diagnosis was cholangiocarcinoma in 118 patients, pancreatic cancer in 79, and non-pancreatic or non-biliary malignancies in the remaining 47 patients. Early post-ERCP complications occurred in 9 patients (3.7%), with PEP in 7 patients (2.9%; mild, 6; moderate, 1) and mild bleeding in 2 patients (0.8%). There was no significant association between the incidence of post-ERCP complications and the type of malignancy (cholangiocarcinoma vs pancreatic cancer vs others, P = 0.696) or the type of SEMS used (uncovered vs covered, P = 1.000). Patients who had more than one SEMS placed at the first instance were at a significantly higher risk of post-ERCP complications (one SEMS vs two SEMS, P = 0.031). No other factors were predictive of post-ERCP complications.CONCLUSIONLimited ES is feasible and safe, and effectively facilitates the placement of SEMS, without any significant risk of PEP or severe bleeding.

Fully covered self-expandable metal stents for treatment of malignant and benign biliary strictures

AIM:To present a series of covered self-expandable metal stents(CSEMS) placed for different indications and to evaluate the effectiveness,complications and extractability of these devices.METHODS:We therefore retrospectively reviewed the courses of patients who received CSEMS due to malignant as well as benign biliary strictures and postsphincterotomy bleeding in our endoscopic unit between January 2010 and October 2011.RESULTS:Twenty-six patients received 28 stents due to different indications(20 stents due to malignant biliary strictures,six stents due to benign biliary strictures and two stents due to post-sphincterotomy bleeding).Biliary obstruction was relieved in all cases,regardless of the underlying cause.Hemostasis could be achieved in the two patients who received the stents for this purpose.Complications occurred in five patients(18%).Two patients(7%) developed cholecystitis,stents dislocated/migrated in other two patients(7%),and in one patient(3.6%) stent occlusion was documented during the study period.Seven stents were extracted endoscopically.Removal of stents was easily possible in all cases in which it was desired using standard forceps.Twelve patients underwent surgery with pylorus preserving duodenopancreatectomy.In all patients stents could be removed during the operation without difficulties.CONCLUSION:Despite the higher costs of these devices,fully covered self-expanding metal stents may be suitable to relief biliary obstruction due to bile duct stenosis,regardless of the underlying cause.CSEMS may also represent an effective treatment strategy of severe post-sphincterotomy bleeding,not controlled by other measures.

Dynamic Modelling and Design of a Servomechanism for Hydraulic Directional-Control Valves

This paper analyses a control strategy applicable in heaVy-duty hydraulic Systems,namely, the introduction of a servovalve to achieve smoother operation of direCtional-control valves that serve also as flow-control valves over two fanges of operating conditions. A mathematical model of the dynamics of the System is etallished and design criteria are obtained from a linearised form of that model. The influence of variations in tile axial force on the spool of the main valve is investigated, and the use of the resultS in the design of systems of the proposed kind is discussed.

Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy

AIM To investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy.METHODS In this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying(DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed.RESULTS Technical success was achieved in all patients(100%). Early symptom improvement was observed in 15 of 20 patients(75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d(range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients(70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients(95%).CONCLUSION Endoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

Predictive factors for the failure of endoscopic stent-instent self-expandable metallic stent placement to treat malignant hilar biliary obstruction

AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents(SEMSs). METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography(ERCP) procedures between the two groups.RESULTS The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices(ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve(sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell. CONCLUSION A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.