A New Strategy for Transcatheter Left Atrial Appendage Closure With Cerebral Embolic Protection in Patient With Left Auricular Thrombosis and Total Contraindication to Long-Term Anticoagulation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, occurring in 1%-2% of the general population. An important aspect is the treatment of AF in terms of stroke prevention. In patients with absolute contraindication to long-term anticoagulation due to high bleeding risk, a valuable alternative exists in left atrial appendage (LAA) closure. Unfortunately, thrombus in the LAA is a contraindication to the procedure because of high risk of embolization. We describe a clinical case with permanent AF, absolute contraindication to long-term anticoagulation therapy, and persistent thrombus formation in the LAA that was treated with transcatheter LAA closure and supraaortic trunk protection system in order to avoid risk of periprocedural stroke.

Crossing chronic total occlusions with the Ocelot system: the initial European experience

AIMS

The aim of the study was to determine the safety, efficacy and feasibility of a new chronic total occlusion (CTO) device using optical coherence tomography (OCT) technology, the Ocelot catheter (Avinger, Inc., Redwood City, CA, USA), for crossing of SFA CTOs following guidewire failure.

METHODS AND RESULTS

Prospective, multicentre, market preference testing. Thirty-three patients with confirmed CTO (99-100% stenosis by visual estimate) of their superficial femoral artery (SFA) were treated between September 28, 2011, and December 9, 2011, at three European centres. Ocelot crossed 94% (31/33) of CTOs, allowing guidewire placement in the distal true lumen. All (100%) lesions were treated without any major adverse safety events. Procedural time and contrast dose were significantly reduced (p<0.0001) when compared with a similar, non-OCT-guided CTO crossing device (Wildcat catheter; Avinger, Inc.). Overall physician feedback on the catheter performance was positive with an 87% average rating of excellent or good across seven categories. Performance ratings of Ocelot's OCT imaging guidance were consistently positive with an 86% average rating of excellent or good across five OCT categories.

CONCLUSIONS

The Ocelot catheter combines advanced CTO crossing technology with real-time OCT guidance. When compared with a similar non-OCT-guided catheter, crossing efficacy and safety profile improved. Total procedure time and contrast volumes were significantly reduced. The Ocelot is a safe, efficient and effective tool for crossing CTOs.

[Coronary artery aneurysms]

Coronary artery aneurysms are defined as coronary dilations as greater than 1.5 times the largest diameter of the adjacent coronary segment. They are a relatively rare finding on coronary angiography, with prevalence ranging from 0.3% to 5% depending on case series. The identification of a coronary artery aneurysm is often a dilemma for both the clinician and the interventionist in terms of diagnosis, treatment and follow-up. This review summarizes the etiologic, pathogenetic, clinical and therapeutic aspects of coronary artery aneurysms in the light of the latest research on this topic.

Coil embolization for distal left main aneurysm: a new approach to coronary artery aneurysm treatment

Coronary artery aneurysm is an uncommon disease, whose natural history and therapeutic approach are still controversial: medical therapy, surgical revascularization with or without aneurysm ligation or excision, and endovascular exclusion with membrane covered stents are all accepted and viable options, according to anatomic characteristics. Intracranial aneurysms are adequately treated by means of coil embolization, an option that, to our knowledge, has never been tested in coronary interventions. We report the first case of a coronary aneurysm involving the distal left main and the proximal left anterior descending artery treated with "stent-assisted" coil embolization.

Preliminary experience with optical coherence tomography imaging to evaluate carotid artery stents: safety, feasibility and techniques

AIMS

Optical coherence tomography (OCT) is an increasingly used intravascular imaging modality to assess coronary stent implantation and vessel healing. A recently developed catheter (C7 Dragonfly; LightLab Imaging Inc.,Westford, MA, USA) allows visualisation of peripheral arteries up to 10 mm of diameter with high speed pullback. Safety, feasibility and the technique of OCT following carotid artery stenting (CAS) were evaluated in the present study.

METHODS AND RESULTS

OCT was performed in seven consecutive patients following successful CAS using proximal cerebral protection devices, occluding the common and external carotid artery and gentle manual injection of a total of 8-14 ml of 50% diluted contrast media with normal saline in order to displace the blood from the artery. Once the blood was displaced, pullback was started through the stented segment continuing the gentle contrast injection. After completion of the pullback all injected contrast was aspirated and discarded. In the first three patients, OCT was also performed without internal carotid artery flow blockage. Due to the high blood flow in the ICA it was not possible to replace all residual blood and obtain adequate OCT images. No procedural, in-hospital, or 30-day follow-up complications occurred. One patient experienced transient intolerance to vessel occlusion without any neurological sequels. OCT images were of good quality providing important information regarding stent geometry, presence and lack of strut apposition, plaque fracture, and plaque prolapse.

CONCLUSIONS

Intravascular OCT under occlusive proximal protection appears feasible and safe to assess stent implantation in carotid arteries.

Management and Prevention of Vascular Complications Related to Transcatheter Aortic Valve Implantation and Aortic Aneurysm Repair Procedures – A Technical Note

Transcatheter aortic valve implantation (TAVI) and endovascular aortic repair (EVAR) are increasingly being used as therapeutic options for patients with severe aortic stenosis who are ineligible for surgery and who have aortic aneurysm with suitable anatomical features. These procedures can be associated with severe complications, especially related to vascular access and the use of a large introducer sheath (from 18 to 24 French [Fr]). In this article we describe possible vascular complications emerging during TAVI and EVAR and their appropriate management, beginning with patient selection, the correct way to perform vessel puncture and the use of a vascular closure device, up to the recently proposed cross-over technique, which is thought to minimise the risk of dangerous consequences of vascular damage.

Superselective embolization of renal hemorrhage occurring after percutaneous coronary intervention

A 69-year-old female was hospitalized for acute coronary syndrome and received full antiplatelet and anticoagulant therapy. The patient underwent angioplasty and stent implantation on right coronary and left circumflex arteries with good angiographic result. After the procedure, the patient developed hemorrhagic shock due to massive left renal hemorrhage. An emergent digital subtraction angiography showed bleeding from a left segmental renal artery. The hemorrhage was successfully managed with transcatheter superselective embolization. The patient was discharged after 22 days in good general condition with normal renal function. One-year follow-up was uneventful.

Endovascular Treatment of In-Stent Restenosis After Carotid Artery Stenting: Immediate and Midterm Results

PURPOSE

To evaluate the immediate and midterm outcome and analyze the debris captured after repeat endovascular intervention for the treatment of in-stent restenosis after carotid artery stenting (CAS).

METHODS

Thirty-one consecutive patients (27 men; mean age 63.7+/-13.0 years, range 53- 81) underwent repeat endovascular intervention (balloon angioplasty and provisional stenting) for the treatment of 32 in-stent restenoses following CAS.

RESULTS

Procedural success was achieved in all patients. An additional stent was implanted in 10 (31%) cases. No procedural complication was observed. Filter analysis was performed in 17 (53%) procedures; on 12 (71%), macroscopically visible material was captured. The histomorphometric analysis performed on 6 (19%) filters showed fibrin nets entrapping erythrocytes, leucocytes, platelets, and in 2 cases, fibrous hypercellular tissue fragments. At 30 days and during follow-up (mean 17+/-5 months), no deaths, transient ischemic attacks, or strokes were observed. In 1 (3.1%) patient, asymptomatic recurrence of ISR was found on Doppler ultrasonography and successfully treated with balloon angioplasty.

CONCLUSION

Repeat endovascular intervention using balloon angioplasty with provisional stenting and routine cerebral protection appears to be a feasible, safe, and clinically effective strategy for the treatment of in-stent restenosis after CAS.

High-tech primary percutaneous coronary intervention

Coronary recanalization by means of primary percutaneous coronary intervention is actually the treatment of choice in patients with ST-elevation myocardial infarction. However, conventional primary percutaneous coronary intervention still presents several limitations. In recent years sophisticated new devices and techniques have been developed to further improve the results of primary percutaneous coronary intervention: it seems to be appropriate to refer to their utilization using the definition "high-tech primary percutaneous coronary intervention". Although the study data available are controversial and clinical benefits have not clearly been shown, adjunctive devices have been used in many procedures. Patient and lesion selection appears to be crucial and the health economics as well as the safety of high-tech devices should be carefully evaluated.

Intracoronary thrombectomy improves myocardial reperfusion in patients undergoing direct angioplasty for acute myocardial infarction

OBJECTIVES

We sought to evaluate the effects of mechanical thrombectomy on myocardial reperfusion during direct angioplasty for acute myocardial infarction (AMI).

BACKGROUND

Embolization of thrombus and plaque debris may occur during direct angioplasty for AMI. This may lead to distal vessel or side branch occlusion and to obstructions in the microvascular system, resulting in impaired myocardial reperfusion. Mechanical thrombectomy is used to reduce distal embolization.

METHODS

Ninety-two patients with AMI and angiographic evidence of intraluminal thrombus were randomized to either intracoronary thrombectomy followed by stenting or to a conventional strategy of stenting. Thrombectomy was performed using the X-Sizer catheter (EndiCOR Inc., San Clemente, California). Myocardial reperfusion was assessed by myocardial blush and ST resolution.

RESULTS

Postprocedure Thrombolysis in Myocardial Infarction-3 flow was not different between groups (93.5% vs. 95.7%, p = 0.39). Myocardial blush-3 was observed in 71.7% of patients undergoing thrombectomy and in 36.9% of patients undergoing conventional strategy (p = 0.006). ST-segment resolution >or=50% occurred more often in patients undergoing thrombectomy (82.6% vs. 52.2%, p = 0.001). By multivariate analysis, adjunctive thrombectomy was an independent predictor of blush-3 (odds ratio, 3.27; 95% confidence interval, 1.06 to 10.05; p = 0.039).

CONCLUSIONS

Intracoronary thrombectomy as adjunct to stenting during direct angioplasty for AMI improves myocardial reperfusion as assessed by myocardial blush and ST resolution.

Carotid artery stenting with cerebral protection in 100 consecutive patients: immediate and two-year follow-up results

BACKGROUND

Carotid artery stenting is emerging as an alternative to surgical endarterectomy for the treatment of extracranial carotid artery disease. However, few data are available on the long-term clinical efficacy of carotid artery stenting and on the incidence of restenosis.

METHODS

Stent implantation with the routine use of cerebral protection devices was attempted in a single center experience including 100 consecutive patients (104 lesions) with significant stenosis of the internal carotid artery (mean stenosis 82.8 +/- 9%). The mean age of the patients was 70.8 +/- 14 years, 27 lesions were symptomatic (26.0%) with a lesion related to a previous stroke or transient ischemic attack.

RESULTS

Procedural success was achieved in 103 lesions (99%) and the cerebral protection was successfully applied in 102 procedures (98%). The 30-day incidence of stroke and death was 4% (4 patients). Complications consisted of one major stroke (1%) with persistent ipsilateral amaurosis, two minor strokes (2%), and one (1%) fatal myocardial infarction occurring 4 days after the stent procedure. During follow-up (minimum 24 months; mean 31 +/- 6 months) no further neurological events occurred, 6 patients died of non-neurological causes (6%) and 2 (2%) presented with a non-fatal myocardial infarction. Echo color Doppler scan control (minimum 24 months) was carried out in all surviving patients showing a restenosis classified as moderate (50-69%) in 2 cases and as critical (> or = 70%) in another 2 cases (1.8%). Both critical restenotic lesions were successfully treated by repeating balloon angioplasty.

CONCLUSIONS

The present study demonstrates that carotid artery stenting with routine cerebral protection can be performed with an acceptable procedural complication rate. At the 2-year follow-up carotid artery stenting appeared effective in stroke prevention and durable with a low incidence of restenosis.

Distal filter protection during percutaneous coronary intervention in native coronary arteries and saphenous vein grafts in patients with acute coronary syndromes

BACKGROUND

Percutaneous coronary interventions on saphenous vein grafts (SVG) and in patients with acute coronary syndromes (ACS) have been associated with the distal embolization of the thrombus and plaque and to the no-reflow phenomenon. We report on the safety and feasibility of a new distal emboli protection filter.

METHODS

Angioplasty using distal filter protection (Angioguard, Cordis, Warren, NJ, USA) was attempted in 38 patients (mean age 65 +/- 11 years, 79% males) affected by ACS. A percutaneous coronary intervention was performed in 27 native coronary arteries, in 10 SVG and in one arterial graft (mean diameter stenosis 88 +/- 9%). Patients with vessels presenting severe proximal tortuosity, more than mild calcification, a diameter < 3.0 mm and a lesion length > 15 mm were excluded.

RESULTS

It was possible to position the device in all patients (100%); in 7 patients (18%) the lesion could be crossed with the filter only after balloon predilation. Procedural success with final TIMI flow 3 was obtained in all patients and the mean residual diameter stenosis after stent implantation was 5 +/- 8%. Transient procedural complications without clinical sequelae included the no-reflow phenomenon (2 patients, 5%) and vessel perforation (1 patient, 2.5%). In no case was distal embolization observed. As regards the device-related complications, one occlusive dissection (2.5%) occurred and was successfully treated with stent implantation. In-hospital and 30-day major adverse cardiac events consisted of two non-Q wave myocardial infarctions (5%), both occurring during SVG interventions.

CONCLUSIONS

The use of the Angioguard filter for preselected lesions in patients with ACS had a high technical success and carried a low rate of device-related complications. The clinical efficacy of the device needs further evaluation.

Percutaneous endovascular stent-graft placement for the treatment of acute rupture of an aneurysm of the thoracic aorta

A 68-year-old male patient presented with massive hematemesis following the acute rupture of an aneurysm of the descending thoracic aorta into the esophagus. In view of the important cardiac and pulmonary comorbidities, surgical treatment was excluded and successful percutaneous implantation of an endovascular stent-graft in the descending aorta was performed. In selected patients endovascular treatment may constitute an alternative to the surgical repair of ruptured aortic aneurysms.

Cerebral protection during carotid artery stenting: collection and histopathologic analysis of embolized debris

BACKGROUND AND PURPOSE

Histopathologic analysis was performed to better understand quantity, particle size, and composition of embolized debris collected in protection filters during carotid artery stent implantation.

METHODS

Elective carotid stent implantation with the use of a distal filter protection was attempted in 38 consecutive lesions (36 patients) of the internal carotid artery presenting >70% diameter stenosis (mean, 82.1+/-11.1%). Mean age of the patients was 70.7+/-7.7 years; 75% were men, and 50% of patients had previous neurological symptoms.

RESULTS

In 37 lesions (97.4%) it was possible to position the filter device, and in all lesions a stent was successfully implanted. The only complication occurring in the hospital and during the 30-day follow-up was 1 death due to acute myocardial infarction. Neurological sequelae did not occur. Histomorphometric analysis was performed on the filters. Presence of debris was detected in 83.7% of filters. The mean surface area of the polyurethane membrane filter covered with material was 53.2+/-19.8%. Particle size ranged from 1.08 to 5043.5 microm (mean, 289.5+/-512 microm) in the major axis and 0.7 to 1175.3 microm (mean, 119.7+/-186.7 microm) in the minor axis. Collected debris consisted predominantly of thrombotic material, foam cells, and cholesterol clefts.

CONCLUSIONS

By the use of distal protection filters during carotid artery stenting, it was possible to collect particulate debris potentially leading to distal vessel occlusion in a high percentage of cases. Qualitative analysis of embolized material showed debris dislocated during the percutaneous intervention from atheromatous plaques.