Development of coronary aneurysm after cutting balloon angioplasty: assessment by intracoronary ultrasound

Interventions in Infrainguinal Bypass Grafts

The interventional radiologist plays an important role in the detection and prevention of infrainguinal bypass failure. Early detection and evaluation of flow-limiting lesions effectively preserve graft (venous bypass and polyester or expanded polytetrafluoroethylene bypass) patency by identifying stenoses before occlusion occurs. Delay in treatment of the at-risk graft may result in graft failure and a reduced chance of successful revascularization. For this reason, surveillance protocols form an important part of follow-up after infrainguinal bypass surgery. As well as having an understanding of the application of imaging techniques including ultrasound, MR angiography, CT angiography and digital subtraction angiography, the interventional radiologist should have detailed knowledge of the minimally invasive therapeutic options. Percutaneous transluminal angioplasty (PTA), or alternatively cutting balloon angioplasty, is the interventional treatment of choice in prevention of graft failure and occlusion. Further alternatives include metallic stent placement, fibrinolysis, and mechanical thrombectomy. Primary assisted patency rates following PTA can be up to 65% at 5 years. When the endovascular approach is unsuccessful, these therapeutic options are complemented by surgical procedures including vein patch revision, jump grafting, or placement of a new graft.

Rupture of the Renal Artery After Cutting Balloon Angioplasty in a Young Woman With Fibromuscular Dysplasia

A 24-year-old woman with uncontrollable high blood pressure for 3 months had significant stenosis of the left renal artery caused by fibromuscular dysplasia (FMD). The lesion was resistant to percutaneous transluminal angioplasty at 18 atm with a semicompliant balloon. Angioplasy with a 6 x 10 mm cutting balloon (CB) caused rupture of the artery. Low-pressure balloon inflation decreased but did not stop the leak. An attempt to place a stent-graft (Jostent; Jomed, Rangendingen, Germany) failed, and a bare, 6-mm balloon-expandable stent (Express SD; Boston Scientific, MN) was deployed to seal the leak, which had decreased considerably after long-duration balloon inflation. The bleeding continued, and the patient underwent emergent surgical revascularization of the renal artery with successful placement of a 6-mm polytetrafluoroethylene bypass graft. CBs should be used very carefully in the treatment of renal artery stenosis, particularly in patients with FMD.

Cutting Balloon Angioplasty for Resistant Venous Stenoses of Brescia-Cimino Fistulas

Peripheral cutting balloons with diameters of 5-8 mm were employed to dilate eight resistant stenoses among 62 venous stenoses in 48 Brescia-Cimino fistulas. The grade of stenosis after high-pressure balloon angioplasty ranged from 57% to 87% (median, 75%). The residual stenosis after cutting balloon angioplasty ranged from 0 to 24% (median, 10.5%). Two complications occurred among these eight cases, one of which was treated by stent placement. No repeated intervention was necessary during follow-up (range, 74-249 days; median, 141 days). Cutting balloon angioplasty was effective to overcome the resistance of venous stenosis in hemodialysis fistulas.

Early Results with Infrainguinal Cutting Balloon Angioplasty Limits Distal Dissection

Infrainguinal angioplasty has less initial and long-term success compared with more proximal sites. These suboptimal initial technical results may be related to the heavy calcific burden in the femoral and popliteal arteries and, subsequently, higher incidence of distal dissection. Cutting balloon angioplasty (CBA) is a newer technique that is thought to limit distal dissection in heavily calcified vessels; although CBA has been evaluated in the coronary circulation, there are few reports of its use in peripheral vessels. This study evaluates our initial experience with CBA for the management of femoropopliteal disease. Eleven patients underwent infrainguinal CBA for symptomatic limb ischemia at a community hospital. Ten procedures (91%) were technically successful, with no distal dissections, iatrogenic vessel perforations, or surgical target vessel revascularizations. In eight patients available for follow-up, the limb salvage rate was 100% and of seven and eight CBA sites (88%) were still widely patent (mean follow-up, 3 months; range, 2-12 months). This preliminary study suggests that CBA is safe and feasible for electively performed femoropopliteal chronic occlusive disease with acceptable success rates on short-term follow-up. Long-term results and comparison with other endovascular modalities require evaluation.

Inadvertent intracoronary stent extraction 10 months after implantation complicating cutting balloon angioplasty for in-stent restenosis

We report the case of an unusual complication for Cutting Balloon Angioplasty (CBA) during treatment for instent restenosis (ISR), which resulted in inadvertent intracoronary stent extraction 10 months after implantation. In this case report, CBA was utilized to treat an ISR lesion in the distal right coronary artery (RCA). Due to difficulty in withdrawing the cutting balloon into the guide after treatment of the lesion, the entire system (guide, cutting balloon, and guidewire) was removed as a unit from the body. Upon examination of the system, the previously placed stent in the distal RCA was attached to the microtomes of the cutting balloon. Although the precise mechanisms for stent extraction in this case remain speculative, the initial stent used in the distal RCA may have been undersized, and this may have played a major role in this complication. Although there is limited data regarding the optimal strategy to treat the site of the inadvertent stent extraction, we opted to re-stent the area with a properly-sized coronary stent. Following the intervention, there was no residual stenosis with TIMI 3 flow through the vessel. The patient remained asymptomatic and a serum troponin drawn 18 hours after the procedure was normal, and he was discharged the next day. The interventionist must be vigilant about this rare but serious complication when applying CBA in the treatment of ISR, particularly when an undersized or underdeployed stent is suspected.

The Cutting Balloon--a new technology?

The Cutting Balloon consists of a standard balloon dilatation catheter with four microtome-sharp blades that incise the plaque and minimize arterial wall trauma. It was used in 31 patients; nine had calcified arteries, ten had non-compliant lesions, three had in-stent restenosis and nine had aorto-ostial lesions. Seventeen lesions were predilated, 28 were post-dilated and 18 required stent implantation. The procedure was very effective in aorto-ostial lesions, non-compliant lesions that were not responsive to high-pressure balloon dilatation, and was partially successful in calcified arteries. It has a very specific niche in selected lesions.

Delayed appearance of coronary artery perforation following cutting balloon angioplasty

Coronary artery perforation is a potential complication of percutaneous coronary intervention (PCI). It usually develops immediately following PCI, particularly when an atheroablate device is used. We report a case in which coronary artery perforation developed 4 days after PCI with a nondebulking device, a cutting balloon catheter.

Using 6-mm Cutting Balloon angioplasty in patients with resistant peripheral artery stenosis: preliminary results

OBJECTIVE

The objective of this study was to assess the efficacy of 6-mm Cutting Balloon angioplasty in patients with resistant peripheral stenoses caused by neointimal hyperplasia or irradiation-induced arteriopathy in vascular territories that are not amenable for use of the smaller Cutting Balloons that are used in cardiology.

CONCLUSION

Peripheral Cutting Balloon angioplasty with the new 6-mm Cutting Balloon device proved useful in the short term for treatment of peripheral arterial stenoses resistant to conventional angioplasty.

Cutting balloon percutaneous transluminal angioplasty for salvage of lower limb arterial bypass grafts: feasibility

PURPOSE

To evaluate the feasibility of cutting balloon percutaneous transluminal angioplasty (PTA) for treatment of neointimal hyperplasia in peripheral arterial bypass grafts.

MATERIALS AND METHODS

Fifteen consecutive patients (six women, nine men; age range, 57-89 years; mean age, 71 years) were treated with cutting balloon PTA for 16 anastomotic stenoses after infrainguinal bypass (prosthetic grafts, seven patients; prosthetic-vein composite grafts, two; venous grafts, five; and ileofemoral stent-graft, one). Cutting balloon PTA was followed by conventional PTA to improve anastomotic diameter. Patients with stenotic vein grafts underwent cutting balloon PTA after failed conventional PTA; the other patients were treated primarily with cutting balloon PTA. Criteria for success were a lumen diameter improvement of greater than 50% or residual stenosis of 20% or less. Follow-up was performed with color duplex ultrasonographic surveillance. Patency rates and durations were calculated with Kaplan-Meier survival curves and log-rank statistics.

RESULTS

Attempted conventional PTA (n = 6) prior to cutting balloon PTA was unsuccessful. Cutting balloon PTA was technically successful in 15 (94%) of 16 lesions, without clinical complications. Two local restenoses and one graft occlusion occurred between 5 and 7 months. The cumulative 6-month primary and secondary graft patency rates were 84% and 92%, respectively. At 12 and 18 months, they were 67% (95% CI: 0.34, 0.86) and 83% (95% CI: 0.48, 0.96), respectively; mean follow-up was 10.0 months.

CONCLUSION

Cutting balloon PTA proved feasible for treatment of resistant peripheral arterial bypass graft stenosis, commonly caused by neointimal hyperplasia, with excellent technical success. Short-term patency with this technique appears to be superior to that with conventional PTA, and it compares well with patency of atherectomy for salvage of infrainguinal bypass grafts.

Polytetrafluoroethylene-covered stent and coronary artery aneurysms

Angiographically detected coronary aneurysms (i.e., coronary segment greater then 1.5 times the normal artery) have an incidence of 0.3%-4.9% among patients undergoing coronary angiography and have been reported after an intervention procedure with a frequency of 2%-10%. The indication for treatment and the best modality still need to be defined. Some authors reported the successful treatment of coronary aneurysms with the polytetrafluoroethylene (PTFE)-covered stent implantation, supporting the role of this strategy. In our institution, from September 1997 to December 1999 eight PTFE-covered stents were implanted to treat seven coronary aneurysms in seven patients. All aneurysms were successfully treated by the PTFE-covered stent. In one case, there was the necessity of an additional PTFE stent to cover the aneurysm completely. In no case did the loss of stent occur. No in-hospital MACE occurred. At 35 +/- 8 (21-44) months, six patients were symptom-free. Angiographic follow-up was performed in all patients at 10 +/- 6 months. Restenosis occurred in one patient (14%) who had repeat percutaneous coronary interventions. This preliminary experience suggests that PTFE-covered stent may be useful in the treatment of coronary artery aneurysms.

Cutting balloon angioplasty for resistant renal artery in-stent restenosis

A 76-year-old woman presented with recurrent arterial hypertension 6 months after uncomplicated primary renal artery stent placement. Diagnostic arteriography revealed severe renal artery in-stent restenosis. On repeat intervention, the lesion was resistant to attempted conventional percutaneous transluminal angioplasty (PTA) with unchanged systolic pressure gradients across the stent. Cutting balloon angioplasty (CBA) was performed with use of a 4-mm cutting balloon (IVT, San Diego, CA). CBA successfully reduced the pressure gradient to below the level of significance. Subsequent conventional PTA enhanced the lumen diameter inside the stent. The arterial hypertension reverted to normal values and duplex ultrasonography (US) at 10-month follow-up demonstrated normal renal artery hemodynamics without stenosis. CBA for potential use in renal artery in-stent restenosis and other peripheral neointimal hyperplasia is discussed.