Immediate and follow-up findings after stent treatment for severe coarctation of aorta

Experimental studies have shown that stents implanted at the aorta become incorporated within the aortic wall and can be further expanded in growing animals. Few clinical studies have shown that the stent repair of severe coarctation of aorta provides excellent initial results, and little is known on the follow-up of these patients. We assessed the immediate and follow-up results obtained in a series of 48 patients (mean age 14+/-12 years) with severe coarctation of the aorta who were treated by Palmaz stent implantation; 30 of them (63%) underwent angiographic follow-up studies at a mean of 25+/-11 months after treatment. Quantitative serial analysis of the aortogram (baseline, after treatment, and at follow-up) was performed. Significant relief (mean residual gradient 3+/-4 mm Hg) was always obtained after stent implantation. The isthmus, when hypoplastic (60%), was always expanded with the stent. One associated aneurysm became occluded after the implant. Complications included aortic disruption, stent migration, and decreased or absent femoral pulses. At angiographic follow-up, the stent remained always in place, without recoil. In 22 patients (73%), there were no detectable neointimal proliferation at late angiogram; however, 8 patients (27%) had some degree of intimal thickening (1 to 5 mm), causing mild restenosis in 3 patients treated at early age, and nonsignificant lumen reduction in 5. The serial aortogram analysis revealed a minor but significant increase in nonstented aortic diameters that seemed related to the normal growth of children. No need for stent reexpansion was observed at 2-year follow-up (mean). Two patients (7%) developed late small aneurysm formation at the stented wall; both were occluded by the insertion of coils through the stent orifices. We conclude that stent treatment for severe coarctation of aorta provides excellent immediate and long-term results in young adults and children. However, at early age, restenosis by intimal growth may develop.

[Bilateral aneurysm of the common iliac artery and kidney pelvic ectopia: endovascular treatment]

We report the case of a 65-year-old man who developed chronic ischemia of the lower limbs. The angiogram showed bilateral aneurysm of both common iliac arteries in association with a left congenital pelvic kidney. The vascular supply was made by with three arteries originating in the inferior mesenteric artery. The aneurysms were treated with percutaneous stent grafts.

The role of carotid duplex ultrasound in evaluating plaque morphology: potential use in selecting patients for carotid stenting

PURPOSE

To study the role of duplex ultrasonography in evaluating plaque morphology and its correlation to neurological symptoms and cerebral infarctions on computed tomographic scans.

METHODS

The hospital records of 181 patients (107 males; average age 66 years, range 41 to 89) with > 50% carotid stenosis (29 bilateral lesions) who had undergone duplex ultrasonography, carotid arteriography, and cerebral computed tomography were studied retrospectively. Of 210 duplex examinations, 139 were appropriate for morphological analysis of surface characteristics and echogenicity.

RESULTS

Over half of the plaques examined had irregular surfaces (81, 58%) and displayed mixed (i.e., heterogeneous) echogenic patterns (74, 53%). Irregular (68 of 81, 84%) and heterogeneous (65 of 74, 88%) plaques were associated with ipsilateral neurological symptoms (p < 0.0001). Similarly, 44 (54%) of 81 irregular plaques and 42 (57%) of 74 heterogeneous plaques were found in patients with cerebral infarctions in the carotid territory (p < 0.0001).

CONCLUSIONS

Heterogeneous and/or irregular plaques were more often associated with both neurological symptoms and infarctions than smooth or homogeneous plaques. These findings may have implications in patient selection for endoluminal therapy.

Shortening of endografts during deployment in endovascular AAA repair

PURPOSE

To evaluate the incidence and extent of length changes during implantation of endovascular grafts in a prospective study of patients undergoing endovascular abdominal aortic aneurysm (AAA) repair.

METHODS

Data regarding the occurrence of intraoperative technical difficulties and device complications were recorded prospectively for the Vanguard or AneuRx self-expanding, bifurcated endovascular grafts in 64 patients (56 males; mean age 75 years). Graft length was measured in the sheath system before deployment and again immediately after deployment by fluoroscopic comparison to a graduated marking catheter.

RESULTS

Graft shortening > or = 15 mm was documented in 22 (56%) of 39 Vanguard cases and 11 (44%) of 25 AneuRx endografts. Additional extension grafts were required to correct endoleak caused by inadequate graft length in 9 (14%) patients, but no conversion to open repair was necessary.

CONCLUSIONS

There appears to be a high incidence of intraprocedural graft shortening with 2 current designs of self-expanding endoluminal grafts.

Stents in the treatment of renal artery stenosis: long-term follow-up

PURPOSE

To evaluate the role of percutaneous stenting in the treatment of renal arterial lesions after failure of balloon angioplasty.

METHODS

Two hundred ten patients (139 males; mean age 67.7 +/- 9.9 years, range 27 to 87) had 259 balloon-expandable stents (165 Palmaz and 94 Renal Bridge stents) implanted in 244 renal artery stenoses (171 ostial and 73 nonostial lesions). The patients were suffering from intractable hypertension (n = 210) and/or renal dysfunction (n = 48). The majority of the lesions (n = 234) were atheromatous in origin. Stents were implanted for suboptimal balloon dilation (n = 182, 75%), restenotic lesions (n = 27, 11%), or dissection (n = 9, 4%); 26 (11%) ostial lesions were stented primarily. Mean lesion length was 11.9 +/- 4.4 mm (range 5 to 30) and mean percent stenosis was 81.9% +/- 8.25% (range 70 to 100).

RESULTS

Immediate technical success was 99% (241 of 244). Three (1.2%) major complications included one intraprocedural stent thrombosis, one arterial perforation manifesting as a perirenal hematoma 24 hours after the procedure, and one renal arterial rupture. Follow-up over a mean 25.4 +/- 22.8 months (range 1 to 96) in 185 eligible patients (209 arteries) found 24 cases of restenosis (11.4%). Primary and secondary patencies for all lesions at 60 months were 79% and 98%, respectively, with no significant differences between ostial and nonostial lesions or stent types. Hypertension was reversed in 35 (19%), improved in 112 (61%), and remained unchanged in 37 (20%). Renal function was improved in 29% (14 of 48), unchanged in 67% (32 of 48), and worse in 4% (2 of 48).

CONCLUSIONS

Renal artery stenting is safe, effective, and may be an alternative to surgery, particularly in ostial lesions. Our experience shows reduction in the restenosis rate compared to conventional angioplasty. All ostial stenoses should be stented.

Prevention of recurrent pulmonary edema in patients with bilateral renovascular disease through renal artery stent placement

Pulmonary edema and congestive heart failure (both referred to here as PE) have been reported to be complications of bilateral renal artery stenosis or unilateral stenosis in a solitary functioning kidney (both referred to as BRAS). The goals of this study were to determine whether a history of PE was more common in patients with BRAS than in those with unilateral stenosis and a normal contralateral kidney (URAS), and whether recurrent PE could be prevented by renal artery stent placement. We evaluated 90 consecutive patients with renovascular disease who were treated with percutaneous renal artery stent placement. History and clinical follow-up were obtained through chart review and phone contact with referring physicians. Mean follow-up was 18.4 months after stent placement. Twenty-three of 56 (41%) subjects with BRAS had a history of PE before revascularization, compared with four of 34 (12%) subjects with URAS (P = .05). Twenty-five of the 27 patients with history of PE had adequate clinical follow-up. Seventeen of the 22 (77%) subjects with BRAS and history of PE had no further PE after stent placement in one or both renal arteries. The five BRAS subjects with recurrent PE after stent placement had evidence of stent thrombosis or restenosis. In contrast, only one of three (33%) URAS subjects with a history of PE remained free of PE after stent placement. We conclude that PE is a common complication of BRAS, but not of URAS. In patients with BRAS, recurrent PE can be prevented by successful stent placement in one or both renal arteries.

Treatment of a TIPS-biliary fistula by stent-graft in a 9-year-old boy

We report a 9-year-old male cirrhotic patient with acute occlusion of a transjugular intrahepatic portosystemic shunt (TIPS) due to a biliary-to-TIPS fistula which occurred 9 hr after the TIPS procedure. Immediate TIPS revision was performed and the fistula was treated by placement of an endoluminal stent-graft. At 12-month follow-up color Doppler examination demonstrated a patent shunt.

Phosphorylcholine-coated metallic stents in rabbit iliac and porcine coronary arteries

The arterial wall reaction to phosphorylcholine-coated metal stents was examined in rabbits and pigs. Compared to non-coated stents, no significant difference was found by angiography and histology. We conclude that although phosphorylcholine-coating does not provoke arterial neointima formation or decrease luminal diameter compared to stainless steel stents, the coating does not seem to reduce restenosis.

Acquired aortopulmonary fistula. A case report

A 63-year-old male patient with no prior history of heart disease was admitted in acute heart failure with diagnosis of pulmonary thromboembolism. 2D-echocardiography and color-Doppler echocardiography showed a severe aortic stenosis associated with an acquired aorto-pulmonary fistula bridging the ascending aorta and the main pulmonary artery. The diagnosis was confirmed by aortography. The patient underwent replacement of the aortic valve with a bileaflet mechanical valve. The fistula was obliterated with a Dacron patch anchored on the edges of its aortic opening. He did well postoperatively and was discharged with no complaint.

Coronary revascularization and abdominal aortic aneurysm repair in a patient with Behçet's diseases

Behçet's disease is a systemic disease characterized by oral aphta, genital ulcer, and ocular lesion. Arterial involvement is an uncommon complication of Behçet's disease, and it most frequently affects the abdominal aorta followed by the femoral artery and the pulmonary artery. Coronary lesions in Behçet's disease have been little reported in the literature. In this communication, we present a case with coronary artery stenosis and with subsequently developed supra-renal abdominal aortic aneurysm. The coronary lesions were revasculized with gastroepiploic artery, right internal mammary artery, and saphenous vein graft. Abdominal aortic repair was performed with partial cardiopulmonary stand by, because of the risk of coronary ischemia during the cross clamp including the celiac artery. To our knowledge, this is the first report of successful repair of combined lesions of the coronary and the abdominal aorta in a patient with Behçet's disease.

Dissecting aortic aneurysm involving an anomalous right subclavian artery and isolated left vertebral artery: case report and review of the literature

A 54-year-old hypertensive woman was admitted with severe interscapular back pain. A chest radiograph showed marked widening of the mediastinum. Aortography demonstrated a DeBakey type III, a thoracic aortic dissection and an anomalous right subclavian artery which was associated with an isolated left vertebral artery. The patient underwent aortic arch replacement with 5 branches and made an uneventful recovery. As far as we can determine, this is the first reported occurrence of these anomalies together with acquired disease of the aorta.

Aneurysms of the supra-aortic trunks in Takayasu's disease. Report of two cases

Takayasu's arteritis is a chronic inflammatory disease of unknown etiology, which affects the aorta and its branches. The resulting lesions can be of steno-occlusive or aneurysmatic type; the latter form is relatively rare. The authors report 2 cases which came under their observation for treatment. The first was a young man of 22 years with aneurysm of the common right carotid artery and of the subclavian left intrathoracic artery. The carotid aneurysm was operated first; arterial reconstruction was ensured by means of a dacron bypass as the saphenous vein was not usable. Three months later, exeresis of the subclavian aneurysm was performed with a left thoracotomy in the IV space. The postoperative course was uneventful and no untoward event has been observed during follow-up (15 months). The second case was a young girl of 16 years with poststenotic aneurysmatic dilatation of the anonyma artery, tight stenosis of the left renal artery and occlusion of the right renal artery. The patient underwent median sternotomy and removal of the aneurysmatic wall together with the stenosis, and a dacron patch was applied. During preoperative angiography, the stenosis of the left renal artery had been treated with PTA; one month after the first operation, a right aorto-renal bypass was fashioned with the saphenous vein. Postoperative stay was free from complications on both occasions and complete normalization of the pressure values was obtained, which persists after 12 months.

Bilateral subclavian artery aneurysms with pseudocoarctation of the aorta. Case report and review of the literature

Subclavian artery aneurysms are rare. They occur predominantly on the right side. The most frequent cause of proximal subclavian artery aneurysm is atherosclerosis. An aneurysm of the left subclavian artery with normal origin is less common, and it is extremely rare when associated with an aortic coarctation. This report describes the first case of bilateral subclavian artery aneurysms associated with a pseudocoarctation of the aorta. Successful resection of the left subclavian artery aneurysms and the pseudocoarctation of the aorta was achieved using partial cardiopulmonary bypass.

Successful surgical management of a ruptured abdominal aortic aneurysm in a renal transplant patient. A case report

With extended indications for renal transplantation and increasing survival, it can be expected that atherosclerotic vascular disease in the post-transplant patient will become more frequent. The authors report a case of a ruptured abdominal aortic aneurysm in a renal transplant recipient. A temporary axillo-femoral shunt was used to maintain perfusion of the renal graft during aortic cross-clamping. They review the literature and discuss the available methods for preserving renal function.

Five-year experience with endovascular grafts for the treatment of aneurysmal, occlusive and traumatic arterial lesions

Standard therapy for most aneurysmal, occlusive, and traumatic arterial lesions has historically consisted of surgical exposure and repair or placement of an interposition bypass graft. Endovascular grafting techniques are an alternative treatment. These techniques blend stent and graft technology and enable a vascular graft to be placed from a remote access site under fluoroscopic guidance to treat a variety of arterial lesions. The major advantage of this approach is its less invasive nature. During the last 5 years, 234 endovascular grafts have been implanted at Montefiore Medical Center to treat a variety of arterial lesions including aneurysms, occlusions and traumatic or iatrogenic injuries. Although many of these procedures were complex and difficult, results have improved steadily as appropriate devices, techniques and indications have been developed. These endovascular grafts have facilitated successful treatment in many patients and have permitted correction of limb- or life-threatening lesions in some patients who would otherwise be impossible or difficult to treat. Based on this 5-year experience, it is likely that endovascular grafts will play an important role in the future treatment of various types of arterial pathology. Although the value and limitations of endovascular graft for the treatment of aneurysmal and occlusive lesions in good-risk patients remains to be precisely defined, their usage in high-risk patients and in those with iliac aneurysms and central artery traumatic false aneurysms and arteriovenous fistula already appears justified.

Penetrating atherosclerotic ulcer of the descending thoracic aorta: treatment by endovascular stent-graft

PURPOSE

To present four cases of penetrating ulcer of the descending thoracic aorta treated by transfemoral insertion of an endoluminal stent-graft.

METHODS

Four patients with penetrating aortic ulcers were reviewed. Three cases were complicated by rupture, false aneurysm, or retrograde dissection. All patients were treated by endovascular stent-graft and were followed by helical computed tomography (CT).

RESULTS

Endovascular stent-graft deployment was successful in all patients. However, in one case we observed a perigraft leak that spontaneously disappeared within the first month, and two interventions were needed for another patient. Following treatment, one episode of transient spinal ischemia was observed. The 30-day survival rate was 100%, but one patient died from pneumonia with cardiac failure 34 days after the procedure. In one patient, helical CT performed at 3 months showed a false aneurysm independent of the first ulcer. This patient refused any further treatment and suddenly died at home (unknown cause) after a 6-month follow-up period.

CONCLUSION

Transluminal placement of endovascular stent-grafts for treatment of penetrating ulcers of the descending thoracic aorta appears to be a possible alternative to classical surgery. After treatment, follow-up by CT is essential to detect possible complications of the disease.

Coronary artery stenting for spontaneous coronary artery dissection: a case report and review of the literature

Spontaneous coronary artery dissection is an uncommon cause of acute coronary syndromes. It occurs in three major groups: in young women in the peripartum period, in patients with atherosclerotic disease, and in an idiopathic group. There are a number of associated conditions, but the pathogenesis remains unclear. Diagnosis can only be made at angiography. Treatments include medical therapy, coronary artery bypass grafts, and newer interventional procedures. We report on a case of spontaneous coronary artery dissection involving the left circumflex artery in a young adult male presenting with a myocardial infarction after exercise. There were no risk factors for coronary artery disease and no evidence of atherosclerosis on angiography. The dissection was treated with primary coronary artery stenting without predilation, achieving an excellent result. To our knowledge, this is the third known case of successful coronary artery stenting for this condition and the first case of primary stenting without prior angioplasty.

Repair of coronary artery perforation after rotastenting by implantation of the JoStent covered stent

Coronary artery perforation is an unusual but well recognised complication of Percutaneous Transluminal Coronary Angioplasty (PTCA) and coronary atherectomy and may lead to hemopericardium and cardiac tamponade. If the perforation cannot be sealed by prolonged inflation with a perfusion balloon catheter, emergency cardiac surgery is usually necessary. This case report describes the potential use of a "covered" coronary artery stent for sealing perforations in the coronary circulation.