One single drug-coated balloon for all shapes/diameters? Neointimal proliferation inhibition in porcine peripheral arteries

BACKGROUND

Long diseased vessel segments of peripheral arteries may display irregular shapes with different diameters. The aim of this study was to investigate inhibition of neointimal proliferation in porcine peripheral vessels with different diameters covered by one single hyper-compliant drug-coated balloon (HCDCB), compared to conventional drug-coated balloons (DCB), each selected according to the respective vessel diameter.

METHODS AND RESULTS

Neointimal proliferation was stimulated in proximal and distal segments of the peripheral arteries by balloon overstretch and stent implantation. Inhibition of neointimal proliferation by one single HCDCB was compared to two vessel diameter-adjusted DCB per artery and to one single uncoated hyper-compliant balloon (HCB). Sixteen HCB, 16 HCDCB, and 32 DCB were used in 16 arteries each. Quantitative angiography (QA), optical coherence tomography (OCT) and histology showed a similar anti-restenotic effect for one HCDCB compared to two vessel diameter-adjusted DCB in narrow distal and wider proximal segments (QA diameter stenosis: 18.7±12.3% vs. 22.8±15.5%, p = 0.535; OCT area stenosis: 21.4±11.6% vs. 23.6±12.3%, p = 0.850; histomorphometry diameter stenosis: 27.5±7.1% vs. 26.9±8.0%, p = 0.952) and indicated significant inhibition of neointimal proliferation by HCDCB vs. uncoated HCB (QA diameter stenosis: 18.7±12.3% vs. 30.3±16.7%, p = 0.008; OCT area stenosis: 21.4±11.6% vs. 34.7±16.0%, p = 0.004; histomorphometry diameter stenosis: 27.5±7.1% vs. 32.5±8.5%, p = 0.038).

CONCLUSIONS

HCDCB were found to be similar effective as DCB in inhibiting neointimal proliferation in vessel segments with different diameters. One single long HCDCB may allow for treatment of segments with variable diameters, and thus, replace the use of several vessel diameter-adjusted DCB.

Vascular management during transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR), as an alternative to open heart surgery, has been established as the standard therapy for patients with severe aortic valve stenosis. Vascular access management, the first step in a TAVR procedure, should be managed properly. Moreover, the transfemoral and alternatives such as the transaxillary/subclavian, transcarotid, transapical, and transcaval approaches are considered access routes during TAVR. More than 90% of cases can be treated via the transfemoral approach in the current TAVR era, whereas other approaches should be considered in patients in whom the transfemoral approach is not suitable. Vascular complications regardless of access route differences are a specific issue of TAVR caused by the use of large sheaths. With the increased number of TAVR cases, we must manage vascular complications and decrease the morbidity and mortality rates associated with TAVR procedures. Thus, this study aimed to review the vascular complications during TAVR and summarize their prognosis, prevention, and adequate management.

Management of Iatrogenic External Iliac Artery Perforation With a Self-Made Covered Stent

Retroperitoneal hemorrhage (RPH) following transfemoral arterial access is a dreaded complication needing immediate management. A 70-year-old female with inferior wall myocardial infarction developed hemodynamic instability following transfemoral percutaneous coronary intervention. The evaluation revealed an RPH due to an iatrogenic guidewire-related perforation of the external iliac artery. This was successfully managed with the deployment of a custom, a self-made covered stent. In this report, we describe our method of creating and deploying this self-made stent and discuss potential issues compared to commercially available covered stent systems.

Vascular Complications in TAVR: Incidence, Clinical Impact, and Management

Transcatheter aortic valve replacement (TAVR) has replaced surgical aortic valve replacement as the new gold standard in elderly patients with severe aortic valve stenosis. However, alongside this novel approach, new complications emerged that require swift diagnosis and adequate management. Vascular access marks the first step in a TAVR procedure. There are several possible access sites available for TAVR, including the transfemoral approach as well as transaxillary/subclavian, transcarotid, transapical, and transcaval. Most cases are primarily performed through a transfemoral approach, while other access routes are mainly conducted in patients not suitable for transfemoral TAVR. As vascular access is achieved primarily by large bore sheaths, vascular complications are one of the major concerns during TAVR. With rising numbers of TAVR being performed, the focus on prevention and successful management of vascular complications will be of paramount importance to lower morbidity and mortality of the procedures. Herein, we aimed to review the most common vascular complications associated with TAVR and summarize their diagnosis, management, and prevention of vascular complications in TAVR.

Iatrogenic Arterial Perforation During Endovascular Interventions

The use of minimally invasive endovascular procedures has increased, and as such, the frequency of associated vascular complications has also increased. Regardless of the access site location, rarely, arterial perforation can occur, which can be fatal if not properly managed. Interventionalists should be aware of the risk factors for perforation, commonly perforated vessels, and how different sites of perforation are diagnosed and managed. Rapid recognition and endovascular management reduce the need for open surgical repair, and thus reduce the morbidity and mortality of these complications. This review outlines the presentation, diagnosis, and management of iatrogenic perforations of the subclavian artery, thyrocervical trunk (TT), common carotid artery, superficial femoral artery (SFA), and external iliac artery.

Transcatheter "thrombin-blood patch" injection: a novel and effective approach to treat catheterization-related arterial perforation

OBJECTIVE

This study aimed to describe the safety and feasibility of transcatheter "thrombin-blood patch" (TBP) injection to treat catheterization-related arterial vascular access perforation.

BACKGROUND

Vascular access complications are infrequent but potentially life threatening conditions related to percutaneous procedures. Surgical vascular repair are associated with high rates of morbidity and mortality due to advanced cardiovascular disease.

METHODS

From October 2007 to July 2010 we studied 23 patients who presented active access arterial bleeding after percutaneous procedures and underwent transcatheter angiographic guided TBP injection across the entry site of the arterial perforation as a primary approach.

RESULTS

The mean age of the population was 67 years, predominantly female (78.3%) with high rate of comorbidities including diabetes (30.4%), prior coronary revascularization (50.0%), chronic renal failure (43.5%), and heart failure (56.5%). Thirteen patients (56.5%) developed severe hypotension after the index procedure. The repair procedure had a mean duration of 82 ± 57 minutes. TBP was injected in all patients. One case additionally required covered-stent to obtain hemostasis. Angiographic success was achieved in the 23 patients; however, one case required a second intervention due to recurrent bleeding, which was effectively treated using covered-stent. All patients were discharged alive and no major cardiovascular events, including myocardial infarction/stroke, were observed.

CONCLUSIONS

Transcatheter "thrombin-blood patch" injection is a safe, novel technique that allows prompt percutaneous approach to treat catheterization-related arterial perforation. This strategy appears particularly attractive to treat patients who cannot tolerate "open" vascular reconstruction and repair.

Transcatheter aortic valve implantation: 10-year anniversary part II: clinical implications

Transcatheter aortic valve implantation (TAVI) has been increasingly recognized as a curative treatment for severe aortic stenosis (AS). Despite important improvements in current device technology and implantation techniques, specific complications still remain and warrant consideration. Vascular complications and peri-procedural neurological events were the first concerns to emerge with this new technology. Recently, significant post procedural para-valvular leak has been shown to be more frequent after TAVI than after surgical aortic valve replacement (SAVR), and its potential association with worse long-term prognostic has raised concerns. In moving toward treatment of lower risk populations, structural integrity and long-term durability of heat valve prosthesis are becoming of central importance. Emerging technologies and newer generations of devices seem promising in dealing with these matters.

Clinical outcomes using a new crossover balloon occlusion technique for percutaneous closure after transfemoral aortic valve implantation

OBJECTIVES

This study sought to evaluate the technical success and clinical outcomes of an adjunctive crossover balloon occlusion technique (CBOT) combined with the 10-F Prostar percutaneous closure device (PCD) on the incidence of vascular and bleeding complications in patients after transfemoral transcatheter aortic valve implantation (TAVI).

BACKGROUND

Vascular closure following large-vessel access has most commonly been performed using a surgical cut-down and repair procedure.

METHODS

Between November 2008 and September 2010, 58 consecutive patients with severe aortic stenosis underwent TAVI via a retrograde femoral artery approach using the Edwards-SAPIEN transcatheter valve. Among these patients, 56 were treated with a CBOT using the "pre-close" technique and the 10-F Prostar system. The technical success of this new CBOT and the 30-day frequency of clinical events, including all-cause mortality, major vascular complications, and major bleeding (defined according to a modified version of the Valve Academic Research Consortium criteria), were assessed.

RESULTS

Successful closure was obtained in all but 3 patients (94.6%). The 30-day frequencies of mortality, major vascular complications, and major bleeding were 7.1%, 14.3%, and 5.4% respectively. No deaths were directly related to access site complications. Fourteen patients (25%) received at least 1 transfusion during the index hospitalization, of which 8 (57.1%) were not related to vascular complications. The mean and median hospital lengths of stay were 7.8 and 6.0 days.

CONCLUSIONS

This new percutaneous adjunctive CBOT combined with the Prostar PCD resulted in controlled, safe, and successful percutaneous closure in most patients after TAVI.

Incidence, prognostic value and management of vascular complications with transfemoral transcatheter aortic valve implantation

Inoperable or high-risk patients with severe aortic stenosis who undergo transcatheter aortic valve implantation (TAVI) have better outcomes compared with those treated with standard medical therapy. As for any other invasive procedure, peri-procedural complications may occur, reducing the procedural success rate and potentially affecting short- and mid-term outcomes. The transfemoral approach prevails over other possible access-site options in most registries. The use of large introducer sheaths and the need for double arterial vascular access can lead to higher rates of vascular complications in this elderly population, with a high prevalence of baseline peripheral artery disease. In this article, we review the results of recent clinical trials and major registries using the two different bioprosthesis currently available for TAVI, focusing on access site-related complications with transfemoral TAVI, their management and relationship with in-hospital and 30-day survival. Awareness of the mechanisms behind these complications might help in their prevention, recognition and management and may ultimately improve the clinical outcome of TAVI procedures.

Evaluation and management of acute vascular trauma

With the technical advances and the increasing availability of sophisticated imaging equipment, techniques, and protocols, and with continually evolving transcatheter endovascular therapies, minimally invasive imaging and treatment options are being routinely used for the clinical management of trauma patients. Thus, the primary treatment algorithm for managing acute vascular trauma now increasingly involves the interventional radiologist or other endovascular specialist. Endovascular techniques represent an attractive option for both stabilizing and definitively treating patients who have sustained significant trauma, with resultant vascular injury. Endovascular treatment frequently offers the benefit of a focused definitive therapy, even in the presence of massive hemorrhage that allows for preservation of major vessels or injured solid organs and serves as an alternative to an open surgical intervention. This article presents an overview of various endovascular techniques that can be used for trauma patients presenting with vascular injuries.

Transcatheter aortic valve implantation: review of the nature, management, and avoidance of procedural complications

Transcatheter aortic valve implantation (TAVI) is becoming a reality in the management of patients with severe aortic stenosis and high or prohibitive risk for standard surgical management. Current understanding of the potential adverse events associated with this procedure is limited. Risks associated with TAVI differ from those related to surgical valve replacement and include vascular injury; stroke; cardiac injury such as heart block, coronary obstruction, and cardiac perforation; paravalvular leak; and valve misplacement. The clinical experience of multiple centers experience with different valve implantation systems and techniques was reviewed. Awareness of how complications occur might help in their avoidance, recognition, and management. Ultimately, improved understanding of the potential complications associated with TAVI might help improve outcomes and allow wider application of this therapy.