Towards Endovascular Treatment of Type A Aortic Dissection with Smaller Landing Zones and More Patient Eligibility

OBJECTIVE

Type A or ascending aortic dissection is an acute life-threatening condition with high morbidity and mortality. Open surgery remains standard-of-care. Development of minimally invasive endografts for Type A aortic dissection (TAAD) will require detailed understanding of dissection and aortic root anatomy to determine patient eligibility and optimal device specifications.

METHODS

Computed tomography images of TAAD cases at our institution from 2012-2019 were identified and three-dimensional reconstructions were performed using OsiriX 10.0 (Bernex, Switzerland). Analysis of key anatomic structures including centerline length measurements, ascending aorta/aortic root dimensions, as well as location and extent of dissection were determined in relation to coronary ostia.

RESULTS

A total of 53 patients were identified (mean±SD age 60.4±17.1 years; 36 male, 17 female), 46 of whom underwent surgery for TAAD. Four patients died within 30 days of surgery. In 47 patients (88.7%), the entry tear was distal to the highest coronary ostium. These cases were retrospectively considered for endovascular intervention with a non-branched, single endograft stent. Proximal landing zone (LZ) was defined as distance from the highest coronary ostium to entry tear: 35/53 (66.0%) had a proximal LZ length ≥2.0cm, 38/53 (71.7%) had proximal LZ length ≥1.5cm, and 42/53 (79.2%) had proximal LZ length ≥1.0cm. Proximal and distal LZ diameters of the sinotubular junction (STJ) and distal ascending aorta regions were (median [1^st quartile-3^rd quartile]) 3.29cm [2.73-4.10cm] and 3.49cm [3.09-3.87cm], respectively, with length from STJ to innominate takeoff 8.08cm [6.96-9.40cm]. Ascending aorta radius of curvature was 6.48cm [5.27-8.00cm]. 47.2% (25/53) of patients could be treated with a straight tube graft with ≤20% diameter mismatch between the proximal and distal LZ.

CONCLUSIONS

Almost 80% of patients with TAAD had a proximal LZ ≥1.0cm, and of these, 47.2% had anatomy amenable to endovascular therapy with a non-tapered straight tube graft commercially available devices. To increase patient eligibility for TAAD endovascular intervention, enhanced precision deployment with adequate seal in shorter LZs will be required. Our results serve as a guide for endovascular device specifications designed to treat this devastating condition.

Exploring the rapid expansion of office-based laboratories and peripheral vascular interventions across the United States

OBJECTIVE

To characterize the relationship between office-based laboratory (OBL) use and Medicare payments for peripheral vascular interventions (PVI).

METHODS

Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use Files from 2014 to 2017, we identified providers who performed percutaneous transluminal angioplasty, stent placement, and atherectomy. Procedures were aggregated at the provider and hospital referral region (HRR) level.

RESULTS

Between 2014 and 2017, 2641 providers performed 308,247 procedures. The mean payment for OBL stent placement in 2017 was $4383.39, and mean payment for OBL atherectomy was $13,079.63. The change in the mean payment amount varied significantly, from a decrease of $16.97 in HRR 146 to an increase of $43.77 per beneficiary over the study period in HRR 11. The change in the rate of PVI also varied substantially, and moderately correlated with change in payment across HRRs (R2 = 0.40; P < .001). The majority of HRRs experienced an increase in rate of PVI within OBLs, which strongly correlated with changes in payments (R2 = 0.85; P < .001). Furthermore, 85% of the variance in change in payment was explained by increases in OBL atherectomy (P < .001).

CONCLUSIONS

A rapid shift into the office setting for PVIs occurred within some HRRs, which was highly geographically variable and was strongly correlated with payments. Policymakers should revisit the current payment structure for OBL use and, in particular atherectomy, to better align the policy with its intended goals.

A systematic review of the ipsilateral retrograde approach to the treatment of femoropopliteal arterial lesions

OBJECTIVE

The endovascular treatment of femoropopliteal lesions is an integral part of managing peripheral arterial disease. The antegrade approach is the most widely used technique with good evidence for its safety and efficacy. However, crossing a lesion, particularly chronic total occlusions (CTO), can be technically challenging and so the retrograde approach is increasingly used to maximize the chances of procedural success. The objective of this systematic review was, therefore, to assess the safety and effectiveness of the ipsilateral retrograde approach to femoropopliteal lesions.

METHODS

A systematic review conforming to the PRISMA standards was undertaken. MEDLINE, EMBASE, and The Cochrane Register were searched between January 1, 1988, and January 1, 2020. Full-text, English-language, peer-reviewed articles pertaining to peripheral arterial disease, endovascular intervention and access site were included.

RESULTS

A total of 8599 articles were screened, of which 38, involving 1940 patients undergoing 2184 retrograde procedures, were included. The mean number of patients per study was 51.1, with three studies including fewer than 10 and four more than 100 patients. The reported follow-up ranged from 30 days to 3 years, and six articles did not report any long-term outcome data. A retrograde approach was used as the primary access route in 45.% of procedures (648/1438) with relevant data. Primary technical success was achieved in 88% (1920/2184; 64%-100%) with a reported complication rate of 11% (235/2117; 0%-27%). Overall, the quality of evidence was poor, with just seven articles deemed to be of high quality with a low risk of bias. A meta-analysis was not deemed appropriate owing to heterogeneity of data.

CONCLUSIONS

An ipsilateral retrograde approach to femoropopliteal lesions has good primary technical success and a low rate of complications. It has a promising role as a bailout, or even a primary access technique, in complex lesions. Patient positioning, puncture site and technique, lesion anatomy, and the size of catheters and devices used are important considerations to achieve the best outcomes. There remains a paucity of robust evidence for its superiority over traditional antegrade approaches, and further work is required to identify the optimal technique and those patients who would benefit most from the approach.

Vertebral artery stenosis

Symptomatic vertebral artery stenosis is associated with high risk of early recurrent stroke. Vertebral artery stenosis can be treated with angioplasty and stenting with good technical results. In this review we outline the framework for the diagnosis and management of vertebral artery disease with focus on the emerging benefits of angiography and endovascular interventions.

Absence of Consistent Sex Differences in Outcomes From Symptomatic Carotid Endarterectomy and Stenting Randomized Trials

BACKGROUND AND PURPOSE

CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) reported a higher periprocedural risk for any stroke, death, or myocardial infarction for women randomized to carotid artery stenting (CAS) compared with women randomized to carotid endarterectomy (CEA). No difference in risk by treatment was detected for women relative to men in the 4-year primary outcome. We aimed to conduct a pooled analysis among symptomatic patients in large randomized trials to provide more precise estimates of sex differences in the CAS-to-CEA risk for any stroke or death during the 120-day periprocedural period and ipsilateral stroke thereafter.

METHODS

Data from the Carotid Stenosis Trialists' Collaboration included outcomes from symptomatic patients in EVA-3S (Endarterectomy Versus Angioplasty in Patients With Symptomatic Severe Carotid Stenosis), SPACE (Stent-Protected Angioplasty Versus Carotid Endarterectomy in Symptomatic Patients), ICSS (International Carotid Stenting Study), and CREST. The primary outcome was any stroke or death within 120 days after randomization and ipsilateral stroke thereafter. Event rates and relative risks were estimated using Poisson regression; effect modification by sex was assessed with a sex-by-treatment-by-trial interaction term, with significant interaction defined a priori as P≤0.10.

RESULTS

Over a median 2.7 years of follow-up, 433 outcomes occurred in 3317 men and 1437 women. The CAS-to-CEA relative risk of the primary outcome was significantly lower for women compared with men in 1 trial, nominally lower in another, and nominally higher in the other two. The sex-by-treatment-by-trial interaction term was significant (P=0.065), indicating heterogeneity among trials. Contributors to this heterogeneity are primarily differences in periprocedural period. When the trials are nevertheless pooled, there were no significant sex differences in risk in any follow-up period.

CONCLUSIONS

There were significant differences between trials in the magnitude of sex differences in treatment effect (CAS-to-CEA relative risk), indicating pooling data from these trials to estimate sex differences might not be valid. Whether sex is acting as an effect modifier of the CAS-to-CEA treatment effect in symptomatic patients remains uncertain. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00190398 (EVA-3S) and NCT00004732 (CREST). URL: https://www.isrctn.com; Unique identifier: ISRCTN57874028 (SPACE) and ISRCTN25337470 (ICSS).

Comparative Analysis of Patch Angioplasty Versus Selective Primary Closure during Carotid Endarterectomy Performed at a Single Vascular Center in China

BACKGROUND

One of the ongoing debates about carotid endarterectomy (CEA) is the closure technique of arterial wall in the operation. Current guidelines recommend routine patch closure (PAC); this recommendation is based on the evidence reported 10-20 years ago. Therefore, the exact role of PAC and primary closure (PRC) remains uncertain. The objectives of this study were to compare the perioperative and long-term outcomes of patients who underwent CEA with different closure techniques.

METHODS

From January 2013 and December 2018, one senior vascular surgeon performed CEA for 126 patients in the First Affiliated Hospital, Sun Yat-sen University. The closure technique (PAC or PRC) was determined on the characteristics (diameter and level) of carotid arteries. Patient demographics and clinical data were retrospectively collected by two research fellows by reviewing the hospital medical records and relevant radiologic studies, as were carotid duplex reports, indications, intraoperative data, closure technique, and perioperative complications. Data of long-term outcomes were gathered by reviewing outpatient clinic visits and associated supplementary examinations.

RESULTS

PRC was performed in 78 operations (61.9%), and PAC was performed in 48 operations (38.1%). There were no statistical differences in demographic and clinical data between the two groups. Carotid clamp time (P < 0.001) and operating time (P < 0.001) were significantly longer when performing PAC (P < 0.001), and intraoperative blood loss was significantly more when performing PAC than that of PRC (P < 0.001). The postoperative outcome and the follow-up results showed that there was no significant difference in the short-term and middle-term overall survival rate and restenosis-free survival rate between the two groups.

CONCLUSIONS

There are no differences in postoperative and middle-term outcomes between PAC and selective PRC, whereas PRC technique can save operation time and shorten the intraoperative carotid clamp time. PRC can be safely applied in patients with a greater than 5 mm internal carotid artery (ICA).

Safety and efficacy of an integrated endovascular treatment strategy for early hepatic artery occlusion after liver transplantation

BACKGROUND

Hepatic artery occlusion (HAO) after liver transplantation (LT) is typically comprised of hepatic artery thrombosis (HAT) and stenosis (HAS), both of which are severe complications that coexist and interdependent. This study aimed to evaluate an integrated endovascular treatment (EVT) strategy for the resolution of early HAO and identify the risk factors associated with early HAO as well as the procedural challenge encountered in the treatment strategy.

METHODS

Consecutive orthotopic LT recipients (n = 366) who underwent transplantation between June 2017 and December 2018 were retrospectively investigated. EVT was performed using an integrated strategy that involved thrombolytic therapy, shunt artery embolization plus vasodilator therapy, percutaneous transluminal angioplasty, and/or stent placement. Simple EVT was defined as the clinical resolution of HAO by one round of EVT with thrombolytic therapy and/or shunt artery embolization plus vasodilator therapy. Otherwise, it was defined as complex EVT.

RESULTS

Twenty-six patients (median age 52 years) underwent EVT for early HAO that occurred within 30 days post-LT. The median interval from LT to EVT was 7 (6-16) days. Revascularization time (OR = 1.027; 95% CI: 1.005-1.050; P = 0.018) and the need for conduit (OR = 3.558; 95% CI: 1.241-10.203, P = 0.018) were independent predictors for early HAO. HAT was diagnosed in eight patients, and four out of those presented with concomitant HAS. We achieved 100% technical success and recanalization by performing simple EVT in 19 patients (3 HAT+/HAS- and 16 HAT-/HAS+) and by performing complex EVT in seven patients (1 HAT+/HAS-, 4 HAT+/HAS+, and 2 HAT-/HAS+), without major complications. The primary assisted patency rates at 1, 6, and 12 months were all 100%. The cumulative overall survival rates at 1, 6, and 12 months were 88.5%, 88.5%, and 80.8%, respectively. Autologous transfusion < 600 mL (94.74% vs. 42.86%, P = 0.010) and interrupted suture for hepatic artery anastomosis (78.95% vs. 14.29%, P = 0.005) were more prevalent in simple EVT.

CONCLUSIONS

The integrated EVT strategy was a feasible approach providing effective resolution with excellent safety for early HAO after LT. Appropriate autologous transfusion and interrupted suture technique helped simplify EVT.

Six-month results of stenting of the femoropopliteal artery and predictive value of interleukin-6: Comparison with high-sensitivity C-reactive protein

OBJECTIVES

To determine the association of pre- and postinterventional serum levels of interleukin-6 and high-sensitivity C-reactive protein at the six-month evaluation of restenosis after stenting of the femoropopliteal artery.

METHODS

Sixty-eight consecutive patients with steno-occlusive femoropopliteal artery disease of Rutherford category III or IV who underwent stent implantation were included. Six-month patency was evaluated with color-coded duplex ultrasound. The association of in-stent restenosis with interleukin-6 and high-sensitivity C-reactive protein levels at baseline, and 24-h postintervention was assessed with a multivariate logistic regression analysis.

RESULTS

In-stent restenosis was found in 15 patients (22.1%) within six months. Interleukin-6 and high-sensitivity C-reactive protein levels were significantly increased at 24-h postintervention compared to their preintervention values (p < 0.001 and p = 0.002, respectively). Interleukin-6 values at baseline (odds ratio, 1.11; 95% confidence interval: 1.00, 1.23; p = 0.044) and 24-h postintervention (odds ratio, 1.04; 95% confidence interval: 1.02, 1.06; p < 0.001) were independently associated with six-month in-stent restenosis. Twenty-four-hour postinterventional high-sensitivity C-reactive protein levels were also found to be related to restenosis (odds ratio, 1.15; 95% confidence interval: 1.04, 1.26; p = 0.006), but high-sensitivity C-reactive protein levels at baseline did not show an independent association with in-stent restenosis (odds ratio, 0.57; 95% confidence interval: 0.35, 1.80; p = 0.667). Smoking, diabetes mellitus, and cumulative stent length were other parameters associated with an increased risk for in-stent restenosis.

CONCLUSIONS

Femoropopliteal artery angioplasty with stent placement induces an inflammatory response. Interleukin-6 is a powerful independent predictor of intermediate-term outcomes for stenting of the femoropopliteal artery, suggesting that its predictive value may be superior to that of high-sensitivity C-reactive protein.

Asymptomatic, Multiple Stent Fractures of a Superficial Femoral Artery

Certain factors like ostial disease, chronic total occlusion, and long, multiple stents are the main causes of multiple stent fractures, as were present in this case. Such stent fractures are usually associated with significant in-stent restenosis; however, this patient had a patent lumen despite multiple fractures.

Clinical Outcomes of Patients Treated With the Bioresorbable Scaffold

INTRODUCTION

Bioresorbable scaffold (BRS) is a novel device to treat coronary lesions. It may induce a revolution in percutaneous coronary intervention (PCI) and a novel treatment termed vascular restoration therapy. These devices provide short-term scaffolding of the vessel and then dissolve, which would treat the plaque and coronary lumen without inflicting a permanent foreign body in the coronary artery.

AIM

This study sought to describe scaffolding in a cohort of Tunisian coronary diseased patients and assess its immediate and mid-term outcomes.

METHODS

Twenty nine patients with 42 lesions were enrolled. Mean age was 51.4 years. Mean number of scaffolds per patient was 1.57.

RESULTS

Our population was at high cardiovascular risk cumulating at least 3 risk factors. Most of them presented with an acute coronary syndrome (66.6%). In 76.1% there were type A/B1 lesions. Moderate calcification was present in 42.2%. Bifurcation lesions were present in 21.3% and just one chronic total occlusion was treated. Clinical device success and clinical procedural success were respectively 93.1% and 90.3%.Using Kaplan-Meier methods. At 18 months : - The major adverse cardiac events (MACE) rate was 44.8%. - The probability of survival without target lesion revascularization (TLR) was 59.5%. - Definite or Possible scaffold thrombosis rate was 6.9%. In our study, BRS implantation was associated with a high rate of adverse events in the longer term except in case of IVUS guidance with respect of Predilatation + Sizing + Postdilatation (PSP) protocol.

CONCLUSION

The theoretical concept of Scaffolding is attractive. One must put into perspective that it is still significantly evolving and improving.

Endovascular Treatment of Iliac Artery Stenosis Caused by Takayasu Arteritis: A 10-Year Experience

Purpose: To evaluate the safety and efficacy of endovascular treatment for iliac artery stenosis caused by Takayasu arteritis (TA). Methods: Twenty-three consecutive TA patients (mean age 28.6±9.5 years; 17 women) with 30 iliac artery stenoses underwent percutaneous transluminal angioplasty (PTA) and selective stent implantation between January 2007 and December 2016. All had claudication (Rutherford category 2 or 3). The changes in the Rutherford category, ankle-brachial index (ABI), 6-minute walking capacity, and adverse events were assessed. Results: The success rate of endovascular therapy for iliac artery lesions was 93.3% (28/30). Guidewires could not cross either lesion in a patient with bilateral stenoses. Twenty-four lesions were treated by PTA alone and the other 4 lesions with provisional stents. One patient had a puncture site hematoma. Over an average of 4.8±3.3 years, 18 patients remained asymptomatic or had mild intermittent claudication. The other 4 patients developed moderate to severe intermittent claudication due to progression of a previously existing iliac lesion (n=1) or restenosis (n=3); all 4 underwent PTA. At the last follow-up, improvements were seen in the ABI (0.95±0.12 vs 0.51±0.22, p<0.001), 6-minute walking capacity (409.5±46.1 vs 272.6±32.3 m, p<0.001), and the Rutherford category of 22 patients. One patient died of a hemorrhagic stroke at 27 months due to uncontrolled hypertension. Conclusion: Endovascular therapy was safe and effective in treating TA patients with iliac artery stenosis, with good clinical outcomes in the long term.

Creation of Arteriovenous Fistulas and Grafts Concomitantly with Endovascular Correction of Outflow Veins: A Hybrid Procedure

BACKGROUND

Achieving well-functioning dialysis fistulas is a common problem in dialyzed patients, and it is mainly caused by the pathologies of vessels used for fistula creation. Hybrid therapies, combining surgical and endovascular procedures, potentially enable the creation of functional dialysis fistulas in patients with vessels that are otherwise unsuitable for vascular access.

METHODS

Between January 1, 2014 and June 30, 2018, we created dialysis fistulas simultaneously with endovascular correction of outflow pathologies in 15 patients. The included patients had a long history of dialysis (median 10.5 years, range 3-22) and many previous dialysis access procedures (mean 5.3 procedures, range 2-9). In 13 patients (86.7%), the fistula was created on the upper arm; in 5 patients (33.3%), it was arteriovenous graft done with polytetrafluoroethylene (PTFE) prosthesis (in an additional 3 patients, a PTFE prosthesis was used to extend the vein), and 7 patients had native vessel fistulas (46.7%). Endovascular procedures, in some cases performed on more than 1 vein, were applied for correction of the subclavian vein (8 patients, 53.3%); brachiocephalic vein (6 patients, 40.0%); cephalic, basilic, and axillary veins (2 patients each, 13.3%); and superior cava vein (1 patient, 6.7%). Access for the endovascular procedure was achieved through a dissected vein used for arteriovenous anastomosis. The fistula function was monitored, and all complications of dialysis access were noted. The median follow-up in the observed group was 18 months. We compared the patency of dialysis fistula creation combined with endovascular correction of outflow vein pathology to our results of standard dialysis fistula operations: radiocephalic dialysis fistula creation (RCAVF group, 65 patients) and dialysis fistula stenosis angioplasty (PTA group, 30 patients).

RESULTS

The 12- and 24-month primary patency rates of dialysis fistulas created in hybrid procedures with simultaneous outflow vein pathology correction were 72.7% and 63.6%, respectively. No early complications related to endovascular or open procedures were observed.

CONCLUSIONS

A hybrid procedure for the creation of a dialysis fistula with the simultaneous correction of outflow pathologies enables a properly functioning dialysis fistula to be obtained. This procedure can be performed in patients with complicated vascular situations, enabling the creation of dialysis fistulas. Our results of hybrid procedures, involving simultaneous endovascular correction of the outflow vein with dialysis fistula creation, showed the efficiency and good results.

Anatomic eligibility for transcarotid artery revascularization and transfemoral carotid artery stenting

OBJECTIVE

Transcarotid artery revascularization (TCAR) has emerged as an alternative to transfemoral carotid artery stenting (tfCAS). We investigated the proportion of carotid arteries undergoing revascularization procedures that would be eligible for TCAR based on anatomic criteria and how many arteries at high anatomic risk for tfCAS would be amenable to TCAR.

METHODS

We performed a retrospective review of consecutive patients who underwent carotid endarterectomy or carotid stenting between 2012 and 2015. Patients were excluded if computed tomography angiography of the neck was not performed within 6 months of the procedure. We assessed TCAR eligibility on the basis of the instructions for use of the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif) and high anatomic risk for tfCAS on the basis of anatomic factors known to make carotid cannulation more difficult or hazardous.

RESULTS

Of the 118 patients and 236 carotid arteries identified, 12 carotid arteries were excluded for presence of an occluded internal carotid artery (ICA). Of the remaining 224 carotid arteries, 72% were eligible for TCAR on the basis of the instructions for use criteria; 100% had 4- to 9-mm ICA diameters, 100% had ≥6-mm common carotid artery (CCA) diameter, 75% had ≥5-cm clavicle to carotid bifurcation distance, and 96% lacked significant CCA puncture site plaque. In addition, 7% of carotid arteries had bifurcation anatomy unfavorable for stenting; thus, of the entire cohort of arteries examined, 68% were eligible for TCAR. Hyperlipidemia (odds ratio [OR], 6.7; 95% confidence interval [CI], 1.7-26; P < .01), chronic obstructive pulmonary disease (OR, 3.5; 95% CI, 1.5-8.3; P < .01), and older age (OR, 1.1; 95% CI, 1.0-1.1; P < .01) were independently associated with TCAR ineligibility, whereas white race (OR, 0.2; 95% CI, 0.0-1.0; P = .048) and beta-blocker use (OR, 0.3; 95% CI, 0.1-0.7; P < .01) were independently associated with TCAR eligibility. In addition, 24% of carotid arteries were considered to be at high risk for tfCAS for the presence of a type III aortic arch (7.6%), severe aortic calcification (3.3%), tandem CCA lesions (7.1%), moderate to severe stenosis at the carotid ostium (8.9%), and tortuous distal ICA precluding embolic filter placement (4.5%). Active smoking (OR, 4.4; 95% CI, 1.9-10; P < .01), hyperlipidemia (OR, 4.0; 95% CI, 1.2-14; P = .03), and older age (OR, 1.1; 95% CI, 1.0-1.1; P = .02) were independently associated with tfCAS ineligibility, whereas preoperative aspirin (OR, 0.1; 95% CI, 0.0-0.4; P < .001) or clopidogrel (OR, 0.3; 95% CI, 0.1-0.8; P = .01) use was associated with tfCAS eligibility. Of the arteries that were considered to be at high risk for tfCAS, 69% were eligible for TCAR.

CONCLUSIONS

The majority of carotid arteries in individuals selected for revascularization meet TCAR eligibility, making TCAR a viable treatment option for many patients.

Association of Survival With Femoropopliteal Artery Revascularization With Drug-Coated Devices

Importance

In a recent meta-analysis of randomized clinical trials, femoropopliteal artery revascularization with paclitaxel drug-coated devices was associated with increased long-term all-cause mortality compared with non-drug-coated devices. However, to our knowledge, these findings have not been replicated in other data sources and may be subject to confounding from missing data associated with patient withdrawal and loss to follow-up.

Objective

To evaluate differences in all-cause mortality between patients who were treated with drug-coated devices vs non-drug-coated devices for femoropopliteal artery revascularization.

Design, Setting, and Participants

This nationwide, multicenter retrospective cohort study included 16 560 Centers for Medicare and Medicaid Services beneficiaries who were admitted for femoropopliteal artery revascularization from January 1, 2016, to December 31, 2016. All-cause mortality was analyzed through September 30, 2017.

Exposures

Drug-coated devices (drug-eluting stent [DES] or drug-coated balloon [DCB]) compared with non-drug-coated devices (bare metal stent or uncoated percutaneous transluminal angioplasty balloon).

Main Outcomes and Measures

The primary outcome was all-cause mortality analyzed through the end of follow-up.

Results

Among 16 560 patients treated at 1883 hospitals, the mean (SD) age was 72.9 (11) years, 7734 (46.7%) were men, 12 232 (73.9%) were white, 8222 (49.7%) currently or had previously used tobacco, 9817 (59.3%) had diabetes, and 8450 (51.0%) had critical limb ischemia (CLI). Drug-coated devices were used in 5989 participants (36.2%). The median follow-up was 389 days (interquartile range, 277-508 days). Among all patients, treatment with drug-coated devices was associated with a lower cumulative incidence of all-cause mortality compared with treatment with non-drug-coated devices through 600 days postprocedure (32.5% vs 34.3%, respectively; log-rank P = .007). Similar survival trends were observed when treatment was stratified by using a DCB alone or DES with or without DCB. After multivariable adjustment, drug-coated devices were not associated with a difference in all-cause mortality compared with non-drug-coated devices (hazard ratio [HR], 0.97; 95% CI, 0.91-1.04; P = .43). These findings were consistent among those with CLI (HR, 0.93; 95% CI, 0.85-1.01; P = .09) or without CLI (HR, 0.94; 95% CI, 0.85-1.03; P = .20), and for those treated with DCB alone (HR, 0.94; 95% CI, 0.86-1.03; P = .17) or DES with or without DCB (HR, 0.97; 95% CI, 0.89-1.06; P = .48).

Conclusions and Relevance

In this large nationwide analysis of Centers for Medicare and Medicaid Services beneficiaries, there was no evidence of increased all-cause mortality following femoropopliteal artery revascularization with drug-coated devices compared with non-drug-coated devices.

Predictors of antegrade flow at internal carotid artery during carotid artery stenting with proximal protection

BACKGROUND

Carotid artery stenting (CAS) with proximal occlusion effectively prevent distal cerebral embolism by flow arrest at internal carotid artery (ICA); however, the method can expose antegrade flow at ICA due to incomplete flow arrest. The aim of this study was to identify predictors of antegrade flow during CAS with proximal protection.

METHODS

We retrospectively analyzed clinical and angiographic data among 143 lesions treated with CAS with proximal protection by occluding the common carotid artery (CCA) and external carotid artery (ECA). Flow arrest or antegrade flow at ICA was confirmed by contrast injection during proximal protection.

RESULTS

Antegrade flow at ICA was observed in 12 lesions (8.4%). Compared with lesions in which flow arrest of ICA was achieved, the diameter of the superior thyroid artery (STA) was significantly larger (2.4 ± 0.34 vs. 1.4 ± 0.68 mm, p < 0.001), and the rate of ECA branches other than the STA located 0-10 mm above the bifurcation was significantly higher (50 vs. 8.4%, p < 0.001). Results of multivariate analysis revealed that a diameter of the STA ≥ 2.3 mm (OR 44, 95% CI 8.1-237; p < 0.001) and ECA branches other than the STA located 0-10 mm above the bifurcation (OR 6.0, 95% CI 1.1-32; p = 0.036) were independent predictors of antegrade flow.

CONCLUSIONS

Distal filter protection should be combined with proximal protection for the lesions with antegrade flow to prevent distal migration of the carotid debris.

Risk of Stroke or Death Is Associated With the Timing of Carotid Artery Stenting for Symptomatic Carotid Stenosis: A Secondary Data Analysis of the German Statutory Quality Assurance Database

BACKGROUND

Subgroup analyses from randomized trials indicate that the time interval between the neurologic index event and carotid artery stenting is associated with periprocedural stroke and death rates in patients with symptomatic carotid stenosis. The aim of this article is to analyze whether this observation holds true under routine conditions in Germany.

METHODS AND RESULTS

Secondary data analysis was done on 4717 elective carotid artery stenting procedures that were performed for symptomatic carotid stenosis. The patient cohort was divided into 4 groups according to the time interval between the index event and intervention (group I 0-2, II 3-7, III 8-14, and IV 15-180 days). Primary outcome was any in-hospital stroke or death. For risk-adjusted analyses, a multilevel multivariable regression model was used. The in-hospital stroke or death rate was 3.7% in total and 6.0%, 4.4%, 2.4%, and 3.0% in groups I, II, III, and IV, respectively. Adjusted analysis showed a decreased risk for any stroke or death in group III, a decreased risk for any major stroke or death in groups III and IV, and a decreased risk for any death in groups II and III compared to the reference group I.

CONCLUSIONS

A short time interval between the neurologic index event and carotid artery stenting of up to 7 days is associated with an increased risk for stroke or death under routine conditions in Germany. Although results cannot prove causal relationships, carotid artery stenting may be accompanied by an increased risk of stroke or death during the early period after the index event.

Circulating microRNAs identify patients at increased risk of in-stent restenosis after peripheral angioplasty with stent implantation

BACKGROUND AND AIMS

Target lesion restenosis is the most frequent complication after angioplasty and stenting for peripheral artery disease (PAD). MicroRNAs (miRs) regulate crucial pathophysiological processes leading to in-stent restenosis and thrombosis. The aim of this study was to investigate the predictive value of 11 miRs for the composite endpoint of target lesion restenosis and atherothrombotic events (primary endpoint), and target vessel revascularization (TVR, secondary endpoint) in 62 consecutive PAD patients after infrainguinal angioplasty with stent implantation.

METHODS

Circulating miRs were assessed using quantitative real-time polymerase chain reactions.

RESULTS

Within the 2 years of follow-up, the primary endpoint occurred in 26 patients (41.9%), and 21 patients (33.9%) underwent TVR. miR-92a and miR-195 were identified as independent predictors of the primary endpoint after adjustment for age, sex and clinical risk factors with respective HR per 1 increase of standard deviation (1-SD) of 0.55 (95% CI: 0.34-0.88, p = 0.013) and HR per 1-SD of 0.40 (95% CI: 0.23-0.68, p = 0.001). MiR-195 independently predicted TVR with HR per 1-SD of 0.40 (95% CI: 0.22-0.75, p = 0.005). Adding miR-195 to clinical risk factors improved Harrell's C-index to 0.75 (95% CI: 0.66-0.85, p = 0.03) and was superior to a model with miR-92a (C-index: 0.70, 95% CI: 0.60-0.80, p for comparison =0 .012). Assessment of both miR-92a and miR-195 had no incremental value when compared to miR-195 alone (C-index: 0.79, 95% CI: 0.69-0.88, p = 0.313).

CONCLUSIONS

Circulating miR-195 predicts adverse ischemic events and TVR after infrainguinal angioplasty with stent implantation. MiR-195 could improve risk stratification after peripheral endovascular revascularizations.

Concurrent renal artery stent during endovascular infrarenal aortic aneurysm repair confers higher risk for 30-day acute renal failure

OBJECTIVE

Concurrent renal artery angioplasty and stenting (RAAS) during endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysm (AAA) has been practiced in an attempt to maintain renal perfusion. The aim of this study was to identify the current practice of RAAS during EVAR and its effect on perioperative renal outcome.

METHODS

Patients with infrarenal AAA were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP, 2011-2014) database. Baseline characteristics of patients with concurrent RAAS during EVAR were compared with those of patients who underwent EVAR only. Bivariate and multivariable logistic regression analyses controlling for patients' demographics, comorbidities, and operative factors were used to evaluate the predictors of 30-day acute renal failure (ARF). Sensitivity analysis was done to evaluate the role of RAAS in patients with prior kidney disease.

RESULTS

Overall, 6183 patients underwent EVAR for infrarenal AAA during the study period. Of them, 281 patients had RAAS during EVAR (4.5%). The median age of the patients was 74 years; 81.7% of the cohort was male, but a higher proportion of female patients received EVAR + RAAS compared with patients who underwent EVAR only (26.3% vs 17.9%; P < .001). There was no difference between groups in terms of comorbidities, being on dialysis, or functional status, yet the EVAR + RAAS group had a higher proportion of patients with glomerular filtration rate <60 mL/min/1.73 m2 (45.2% vs 37.2%; P = .011). RAAS was associated with significantly higher odds for development of ARF (adjusted odds ratio [aOR], 4.27; 95% confidence interval [CI], 2.06-8.84; P < .001). Other highly predictive factors of 30-day ARF were glomerular filtration rate <60 (aOR, 2.92; 95% CI, 1.47-5.78; P = .002), emergency status (aOR, 2.97; 95% CI, 1.21-7.27; P = .017), and ruptured AAA as the indication for EVAR (aOR, 4.74; 95% CI, 1.80-12.50; P = .002). Patients with prior kidney disease who had EVAR + RAAS demonstrated a 12-fold higher odds for 30-day ARF (aOR, 12.37; 95% CI, 4.66-32.89; P < .001).

CONCLUSIONS

Concurrent RAAS was found to be a significant determinant of adverse renal outcomes after EVAR for infrarenal AAA. This effect was present even after controlling for patients' risk factors that might contribute to postoperative ARF.

Novel Crossing System for Chronic Total Occlusion Recanalization: First-in-Man Experience With the SoundBite Crossing System

Chronic total occlusion (CTO) lesions are frequent in patients with peripheral and coronary artery disease, and are associated with a higher risk of adverse events, including mortality, decreased quality of life, and increased health-care costs. Percutaneous intervention of CTO lesions has been associated with a lower procedural success rate, and current dedicated CTO devices may be of limited use for non-CTO experts, and associated with increased intraprocedural complication rates. The SoundBite Crossing System (SoundBite Medical Solutions, Inc) is a newly-developed device using shockwaves (short-duration, high-amplitude pressure pulses) delivered to the tip of guidewire to facilitate penetration of the proximal cap and crossing of the occlusion. The current report describes the first-in-man use of the SoundBite Crossing System in the recanalization of two occluded lower-limb arteries.

[Remote results of open surgical and endovascular treatment of internal carotid artery stenoses]

The article is a review containing a comparative analysis of the remote results in patients presenting with carotid artery atherosclerosis and treated by means of either stenting or carotid endarterectomy. More than ten international randomized studies have up to now been conducted. Some of them prove the advantage of using either carotid endarterectomy or stenting of carotid arteries, others show equivalence of both methods of treatment. Carotid endarterectomy is currently a preferred operation for carotid artery stenoses, with lower incidence of the development of postoperative strokes and restenoses in the remote period. But stenting is an alternative technique in patients with high operative risk. Therefore, the question of choosing an appropriate type of the intervention should be decided upon for each patient individually. A more definite conclusion to be made on advantages of carotid endarterectomy over endovascular angioplasty, or vice versa, requires further studying therapeutic outcomes during a longer follow-up period.

Angioplasty and Stenting

The high rate of recurrent strokes in patients with intracranial atherosclerotic disease (ICAS) despite medical therapy prompted intracranial angioplasty and/or stenting an adjunctive treatment option. The minute calibers of cerebral arteries, the relative paucity of supporting medial and adventitia layers, the presence of end-anastomosing perforator branches, and the vascular tortuosity from groin to head all demand specialized operative skills and dedicated tools. Since the stroke mechanism of ICAS is diverse, patient selection for endovascular treatment requires a sound understanding of the underlying pathophysiology. Patients with territorial cerebral hypo-perfusion associated with a high-grade steno-occlusive lesion may benefit most from endovascular revascularization. On the other hand, patients with atheromatous branch disease may stand a higher risk of perforator stroke from 'snow plowing' effect if angioplasty or stenting is inadvertently performed. A joint evaluation on the indication, procedural risks and benefits, and an individualized peri-operative care plan by a stroke neurologist and a neuro-interventionist is crucial prior to a procedure. Currently, the U.S. Food and Drug Administration approved Wingspan for patients who have developed two or more strokes despite aggressive medical management. The treatment indication will likely evolve in parallel with the advancement of endovascular techniques and our understanding of ICAS.

Carotid patch and cerebrovascular event relation after carotid endarterectomy procedure

BACKGROUND

Carotid endarterectomy (CEA) is the treatment of choice for patients with symptomatic and asymptomatic high-grade carotid stenosis. In literature there are papers advocating patch plasty for better results. But there is controversy about which patch material is optimal for use. This study compared rate of neurologic events, and perioperative death in patients undergoing CEA with primary closure versus patch closure.

METHODS

We compared patch angioplasty to primary closure between August 2008 and December 2012 in 57 operations. Patients grouped according to their closure technique. Early (30-day) stroke and mortality rate were evaluated. Mean age of patients was 67.79±10.19 (range 41-85 years). 15 (26.31%) of patients were female.

RESULTS

Primary closure was used in 13 operations, and patch angioplasty was used in 44 (saphenous vein: 5, Dacron: 23, Fabric: 5, Carotid: 11). There were no significant differences among groups' baseline characteristics. Primary closure was associated with significantly more postoperative major stroke compared with patch used closure (P=0.05). None of preoperative variables were associated with postoperative stroke.

CONCLUSIONS

On the basis of our results, avoiding primary closure for CEA is defendable. But choice of patch material needs large trials to conclude.

Carotid artery stenting renaissance: is it safe and effective using new materials?

Data from randomized controlled trials (RCTs) demonstrated significant differences between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in terms of early neurological outcomes (from 0 to 30 days), although mid- and long-term neurological results are indistinguishable. CAS in symptomatic standard risk patients is coupled with a higher risk of any stroke, and death or any stroke at 30 days, while the rates of disabling or major stroke do not vary remarkably between treatments. Since the micro-embolization through the stent struts is the primary suspected cause of suspected early postoperative neurological complications (i.e., non-disabling stroke), surgical technology has focused on the production of a new generation of stents with a double layer of mesh to reduce the "free area" of the cells, and on new cerebral protection devices. Another major determinant of early negative outcomes is believed to be the intraluminal manipulation occurring during carotid engagement from the aortic arch, the crossing maneuvers at the level of the culprit lesion and vessel trauma during angioplasty. To address these subject matters, new embolic protection devices and innovative strategies have been developed, consequently. This review is designed to furnish the current status of CAS results, to update the ongoing RCTs comparing CAS vs. CEA outcomes, and to recapitulate the features and clinical outcomes for a new carotid stent design, the so called "mesh-stents", and new embolic protection tools.

High sensitivity C-reactive protein and vascular endothelial growth factor as indicators of carotid plaque vulnerability

BACKGROUND

Carotid atherosclerotic plaques are one of the causes of cerebral stroke. The risk is higher for the vulnerable plaques but there are no specific markers to identify them. The aim of our study was to identify vulnerable carotid plaques by the mean of atherosclerotic serological markers in patients undergoing carotid revascularization by endarterectomy (CEA) or stenting (CAS).

METHODS

High sensitivity C-reactive protein (hsCRP) and vascular-endothelial-growth-factor (VEGF) levels were assessed preoperatively in patients undergoing carotid revascularization. Carotid plaques vulnerability were investigated in two different methods: the "biological vulnerability" with the histological evaluation of the plaques from CEA, scoring five parameters (microvessel density, fibrous-cap-thickness, calcification, inflammatory infiltrate and lipid core), and the "structural vulnerability" with the evaluation of the plaques debris detached during CAS and captured by the cerebral protection filter, in terms of percentage of filter pores occlusion (OP). Results were correlated using χ2, Fisher's, Mann-Whitney, Student's t-tests and regression analysis.

RESULTS

The histological analysis was performed in 40 specimens, vulnerable plaques (30%) were correlated with higher hsCRP levels (>5mg/l; OR, 2.5; CI 95%, 1.1-5.5; P=0.01) and VEGF levels (VEGF>500 pg/l; OR 3.0, CI 95%, 1.1-7.7; P=0.01). All the filters (N.40) contained microscopic debris (mean OP 26.6%±9.9); higher hsCRP levels (>5mg/l) were correlated with greater than 25% OP (OR, 2.6; CI 95%, 1.2-5.7). An increase in the percentage of OP was also observed in patients with VEGF>500 pg/l (OR, 2.9; CI, 95% 1.3-6.3).

CONCLUSIONS

This study suggests that serological determinants are useful in recognizing the structural and biological vulnerability of carotid plaques.

Pulmonary stenting for the treatment of sarcoid induced pulmonary vascular stenosis

BACKGROUND

The best treatment of patients with external pulmonary vascular compression due to advanced sarcoidosis is unknown.

OBJECTIVES

To report a single-center experience of percutaneous treatment for pulmonary vascular stenosis caused by external compression due to advanced sarcoidosis.

METHODS

We report a case series of 5 patients with biopsy confirmed advanced sarcoidosis, seen at our academic institution with worsening dyspnea despite increase of immunosuppressive therapy. All patients were evaluated by a multidisciplinary team (cardiology, pulmonary and radiology) using a multi-modality approach, including chest-computed tomography angiography, ventilation/perfusion scintigraphy, pulmonary function test, 6-minute walk test and heart catheterization.

RESULTS

Three out of five patients underwent pulmonary artery or vein angioplasty and stenting resulting in symptomatic improvement: Patient 1 had persistent symptomatic improvement measured by subjective and objective methods at 30 months; patient 2 required re-intervention due to recurrent pulmonary vein stenosis at 6-months followed by persistent improvement; and patient 3, had a procedure complicated with in-stent thrombosis requiring thrombolysis and anticoagulation with improvement. The remaining two patients were medically treated because underlying thromboembolic disease (patient 4) and diffuse pulmonary vein stenosis not amenable to percutaneous intervention (patient 5).

CONCLUSIONS

Pulmonary vascular stenosis from external compression can be a rare but unrecognized caused of worsening symptoms in advanced sarcoidosis. Pulmonary vascular angioplasty and stenting can provide clinical benefit in select patients.

Sense and nonsense of bare metal stents below the knee

INTRODUCTION

Critical limb ischemia (CLI) is increasingly present in daily practice, and diabetes is responsible for a preferential below the knee (BTK) localization of the disease. The objective was to determine if there is still a sense to BTK implantation of bare metal stents (BMSs) in CLI patients in the era of drug eluting strategies.

EVIDENCE ACQUISITION

An extensive review of the literature was carried out over the last 15 years on the use of BMSs in BTK revascularization based on a PubMed (Medline), EMBASE and PubMed Central search.

EVIDENCE SYNTHESIS

The Chromis Deep® (Invatec, Roncadelle, Italy) was the first dedicated stent in BTK lesions, followed by passive coated BMSs developed in an attempt to inhibit platelets deposition. Comparative results showed no advantage of primary BMS implantation over peripheral transluminal angioplasty (PTA) in improving primary patency rates, Rutherford classification or wound healing and the place of BMSs was restricted to bailout spot stenting. The fear of patency loss in connection with possible stent fractures led to an interest towards nitinol stents, but results were disappointing, especially in patients with severely calcified lesions. Drug-eluting stents (DESs) were then developed and showed better long-term primary patency, restenosis and freedom from target lesion revascularization (TLR) rates, even in long calcified lesions against BMS or drug eluting balloons (DEB). However, limb salvage and wound healing rates were not significantly improved.

CONCLUSIONS

Primary BMS implantation showed no advantage over PTA and as of today DES trials have not shown enough clinical or economic benefit. Thus, BMSs are recommended over DESs, and only as a bailout strategy in case of flow limiting dissection or recoil. Quality trials assessing long-term clinically relevant outcomes, evolution in stents designs and vessel preparation could lead to a change in those recommendations.

Pseudoaneurysm of the Aortic Arch After Aortosubclavian Bypass Treated with Endoluminal Stent Grafting

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump of the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.

Treatment of a Celiac Artery Aneurysm with Endovascular Stent Grafting

As a result of more sophisticated and more commonly performed investigative procedures, aneurysms of the visceral abdominal vasculature, including celiac artery aneurysms, are increasingly recognized. Traditional therapy for visceral artery aneurysms has been limited to open aneurysmectomy or aneurysmorrhaphy to prevent catastrophic aneurysmal rupture. However, these procedures are associated with significant postoperative morbidity and mortality despite technical successes. High complication rates are likely related to poor preoperative conditions among the patient population typically presenting with these visceral artery aneurysms. This report introduces an alternative therapy for visceral artery aneurysms and highlights the potential for catheter-based interventions. This case report depicts a 61-yearold morbidly obese woman diagnosed with a 10-centimeter celiac artery aneurysm during investigation of upper abdominal pain. Given the patient's poor medical condition, punctuated by hemodynamic instability, open operation was avoided, and percutaneous embolization was not feasible owing to a large aneurysm neck. Therefore, inflow to the celiac artery aneurysm was excluded by placing a modular stent graft component within the abdominal aorta at the celiac artery orifice. During the intervening 12 months since stent graft deployment, the aneurysm sac diameter has steadily decreased, as determined by serial computed tomography scans. This report underscores the potential for catheter-based techniques to offer new therapeutic options for patients with visceral artery aneurysms. Careful individualization is required given the highly variable size, location, and character of such lesions.

Carotid artery stenting versus carotid endarterectomy: updated meta-analysis, metaregression and trial sequential analysis of short-term and intermediate-to long-term outcomes of randomized trials

INTRODUCTION

To compare carotid artery stenting (CAS) versus carotid endarterectomy (CEA) in the treatment of carotid stenosis, including two recently published, prospective, randomized trials of these therapies.

EVIDENCE ACQUISITION

A multiple electronic health database search on all randomized trials describing CAS compared with CEA in patients with symptomatic or asymptomatic carotid artery stenosis was performed. Primary outcomes were death, stroke, and myocardial infarction.

EVIDENCE SYNTHESIS

Carotid artery stenting as compared with CEA was associated with a 61% increase in the risk of periprocedural death or stroke (Peto OR, 1.609; 95% confidence interval [CI]: 1.193-2.170; P=0.002). The trial sequential monitoring boundary was crossed by the cumulative Z-curve, suggesting firm evidence for at least a 20% relative risk increase of periprocedural death or stroke and any stroke compared with CEA. Carotid artery stenting as compared with CEA was associated with a 42% increase in the risk for the composite of periprocedural stroke or death plus ipsilateral stroke thereafter (Peto OR, 1.417; 95% CI: 1.074-1.870; P=0.0014).

CONCLUSIONS

In this largest and most comprehensive meta-analysis to date using outcomes that are standard in contemporary studies, CAS was associated with an increased risk of both periprocedural and intermediate- to long-term outcomes.

Conventional carotid endarterectomy versus stenting: comparison of restenosis rates in arteries with identical predisposing factors

BACKGROUND

The aim of the study was to investigate the possible role of individual predisposition in the pathogenesis of carotid restenosis.

METHODS

Over 1700 patients have undergone carotid endarterectomy (CEA) in our institute over the past 15 years. We retrospectively reviewed the charts of those who also had contralateral carotid stenting (CAS) for primary atherosclerotic stenosis and recorded the rates of post-CEA and post-CAS restenosis ≥50%.

RESULTS

In the 29 cases analyzed (21 men/8 women), CEA was performed with conventional technique and direct suturing in most cases. Mean ages at the time of CEA and CAS were 69.2±6.6 and 73±6.7 yrs, respectively, and risk profiles at the 2 time points were similar: hypertension (96.5%), dyslipidemia (55.2%), smoking (51.7%), diabetes (31%), coronary artery disease (48.3%), chronic obstructive pulmonary disease (37.9%), and chronic renal failure (13.8%). Antiplatelet therapy protocols were identical for the two procedures. During follow-up (mean: 67.25±51.6 months after CEA, 24.6±16.9 months after CAS), Duplex scans revealed restenosis in 12 patients (9 arteries treated with CEA, 6 managed with CAS). In three patients, restenosis was bilateral. Restenosis-free survival rates at five years were 85% after CEA and 66% after CAS (P=NS).

CONCLUSIONS

In this selected group of patients, CEA and CAS were associated with a similar incidence of restenosis. Only 25% of the patients who developed restenosis did so after both procedures. These preliminary findings indicate that individual predisposition does not play a crucial role in the pathogenesis of restenosis. To confirm this conclusion, an analysis of a much larger, multicenter cohort is essential.

Drug-Coated Balloons for Infrainguinal Peripheral Artery Disease

Revascularization of infrainguinal peripheral artery disease has traditionally been accomplished via percutaneous transluminal angioplasty. However, long-term results have been hampered by high rates of restenosis. Along with the advent of stents, paclitaxel-coated balloons are an emerging therapeutic option for the invasive management of infrainguinal peripheral artery disease. Paclitaxel has been successful in inhibiting neointimal hyperplasia, the main mechanism for in-stent restenosis. Technological advances have facilitated the development of paclitaxel-coated balloons, which show promise in early trials for femoropopliteal stenosis relative to uncoated balloons. For infrapopliteal stenoses, the data remain scant and conflicted. Therefore, large-scale randomized clinical trials with long-term follow-up evaluating safety and effectiveness between various strategies need to be performed to determine the optimal invasive management strategy for infrainguinal peripheral artery disease.

Endoluminal Repair of a Thoracic Arch Aneurysm Using a Scallop-Edged Stent-Graft

Purpose:

To report a new technique of endoluminal thoracic aortic arch aneurysm repair using a scalloped stent-graft.

Case Report:

A 79-year-old man presented with a 7.5-cm thoracic aneurysm involving the inner curve of the aortic arch. Endoluminal repair was performed with a scalloped stent-graft that allowed perfusion of the brachiocephalic (innominate) artery. Preliminary extra-anatomical left common carotid and subclavian artery bypass grafting had been performed to allow coverage of the origins of these vessels.

Conclusions:

The use of fenestrated endoluminal grafts in the aortic arch can be achieved safely and may increase the treatment options for the high-risk patient.

European Experience with a System for Bifurcated Stent-Graft Insertion

Purpose:

To test an endovascular aneurysm exclusion system in the presence of a wide range of challenging anatomic features.

Methods:

Bifurcated endovascular stent-grafts were inserted in 52 patients and followed with serial computed tomography for up to 3 years. The device underwent several modifications during this time, the most significant of which represent the difference between the homemade (n = 42) and industry-made (n = 10) versions.

Results:

The initial procedural success rate was 92% in the homemade group and 100% in the industry-made group. In the 3 years of follow-up, the long-term success rate was 64% in the homemade group and 90% in the industry-made group. The primary reasons for failure in the homemade group were graft thrombosis due to kinking early in the series and proximal stent migration later in our experience. All cases of migration occurred when the neck was < 15 mm in length, the neck was lined with thrombus, or the stent was implanted > 15 mm from the renal arteries. Kinking was subsequently overcome by implanting Wallstents throughout the graft limbs. The sole failure in the industry-made group was a case in which collateral perfusion reached the aneurysm through patent lumbar arteries.

Conclusions:

The fruits of this experience are a better technique, a better device, and, most importantly, a better understanding of the system's limits, as reflected in the current selection criteria.

Emergency Endovascular Stent Grafting for Thoracic Aortic Pathology

Our aim was to report single-center results of emergency endovascular treatment for thoracic aortic disease.

From March 1998 to January 2006, 30 acute thoracic EVAR procedures were carried out in 29 patients. One patient received two procedures in different settings. Four patients died before treatment could be initiated. The pathology of aortic lesions included atherosclerotic aneurysm ( n = 13), pseudoaneurysm ( n = 6), aortic rupture ( n = 5), type B dissection ( n = 5), aortobronchial or aortoesophageal fistula ( n = 4), and intramural hematoma ( n = 1).

The surgical mortality rate was 21%. Three patients died as a result of technical complications, and three patients died after technically successful procedures.

The mean follow-up was 31 ± 23 months. The late mortality rate was 40% (8 of 20). Four patients died of causes unrelated to the procedure; two patients died at home without autopsy. Two patients died as a consequence of graft infections.

Three late nonfatal complications occurred. Two of these resulted in additional treatment: one patient developed a mycotic aneurysm that was treated with additional stent grafting, and one patient developed a type 3 endoleak after 6 years of follow-up and was successfully treated with a bridging stent graft.

Endovascular treatment for acute thoracic disease is feasible and associated with a reasonable outcome. In selected cases, it may be considered as a first option.

One-pass endovascular treatment of intracranial atherosclerotic stenosis with a novel PTA balloon and self-expanding microstent

INTRODUCTION

We present a novel endovascular technique to treat intracranial atherosclerotic stenosis (ICS) with the specific potential to reduce the procedure-related complications which so far limited safety and efficacy of endovascular ICS intervention.

METHODS

Six consecutive patients were included in this study with the following criteria of inclusion: (1) failure of dual antiplatelet therapy defined as recurrent TIA or ischemic stroke, (2) presence of ICS of ≥70 %, and (3) endovascular accessibility of the target lesion as judged by CTA or MRA. Technical feasibility, safety, and efficacy were observed for the first-ballon-then-stent (FBTS) technique using the percutaneous transluminal angioplasty (PTA) balloon microcatheter over which a self-expandable microstent can be directly delivered obviating the need to exchange microcatheters.

RESULTS

FBTS was performed in six patients (four female, median age 69, median stenosis 82.5 %) all refractory to best medical treatment: three V4, two M1, and one supraclinoid ICA stenosis. PTA and stent deployment were technically feasible in all patients and immediately effective with a median postprocedural stenosis grade of 10 %. Angiographic and clinical safety measures were met with no occult or clinically evident hemorrhage or ischemic complications (four patients discharged without alteration in mRS, two patients with significant clinical improvement). No occurrence of TIA, stroke, or death was observed during follow-up.

CONCLUSION

The FBTS method in this series appeared to be safe and effective for the endovascular treatment of ICS. It bears the specific potential to reduce wire perforations, which so far have been linked to major procedure-related adverse events of endovascular ICS treatment.

Current management of renal artery stenosis

Severe renal artery stenosis may cause renovascular hypertension; in case of bilateral narrowing or in a stenotic solitary kidney, renal insufficiency (e.g. ischemic kidney disease) or pulmonary flash edema may ensue. Renal artery stenosis can be treated by revasularization, using either percutaneous angioplasty (with or without stenting) or less common open surgical procedures, both with excellent primary patency rates. However, several randomized trials of renal artery angioplasty or stenting in patients with arteriosclerotic disease have failed to demonstrate a longer-term benefit with regard to blood pressure control and renal function over medical management. It has not yet been demonstrated that renal revascularization leads to a prolongation of event-free survival. Furthermore, endovascular procedures are associated with substantial risks. If revascularization is envisaged careful patient selection, e.g. patients with refractory hypertension or progressive renal failure, is important to maximize the potential benefit.

Percutaneous Repair of Aortic Pseudoaneurysms: A Case Series

BACKGROUND

Aortic pseudoaneurysms (APSAs) are an uncommon but serious complication of aortic surgery with potentially fatal complications if left untreated. Operative repair is associated with significant morbidity and mortality. Percutaneous APSA repair may reduce the risk of these complications and represents an alternative option for patients. We report our experience with percutaneous intervention for the treatment of APSAs.

METHODS AND RESULTS

We retrospectively reviewed all patients at our institution who underwent percutaneous APSA repair with Amplatzer septal occluders and vascular plugs between January 2004 and September 2014. Ten patients are included in this study, representing our first cases of percutaneous APSA repair. Follow-up was performed with serial computed tomographic angiography. The primary outcome was the success rate of device deployment. Secondary outcomes included success rate of complete APSA exclusion, postprocedural symptoms, and periprocedural and postprocedural complications. Mean clinical follow-up time was 12 months (range, 5-30 months) and mean imaging follow-up time was 29 months (range, 14-52 months). Device deployment was successful in all patients, although 2 patients required reintervention due to device malposition and the discovery of additional defects on postprocedure CT angiography. There were no periprocedural or postprocedure complications. Long-term follow-up imaging was available for 7 patients and revealed complete APSA exclusion in 4 patients. One out of the remaining 3 patients ultimately required operative intervention.

CONCLUSIONS

Percutaneous APSA repair can be performed safely with a good procedural success, albeit with variable long-term results. This procedure may be considered as an alternative to surgical repair in select patients.

New technologies for CAS that might overcome the burden of microembolization

Microembolization during carotid artery stenting (CAS) is the result of embolic events shown by intraprocedural transcranial Doppler (TCD) or postprocedure diffusion-weighted MRI that do not lead to acute neurological deficit. Although the long term clinical outcome of these silent infarcts is not yet well established, there is increasing evidence that these events could be associated with neurological impairments, such as cognitive decline. In order to prevent microembolization due to excessive catheter manipulation at the time of guiding catheter placement in patients with challenging anatomy, a cervical access system with flow reversal protection was developed. Other embolic events are often seen as the result of plaque protrusion through stent struts. A new type of stent, so-called "hybrid" stent, incorporates the flexibility and conformability of an open-cell stent as well as plaque coverage seen with a close-cell stent, with the goal of achieving better plaque stabilization reducing macro and microembolization, while maintaining original vessel anatomy and flow hemodynamic. At the present time there are three different stents under investigation or this application.

How safe are carotid endarterectomy and carotid artery stenting in the early period after carotid-related cerebral ischemia?

Timing of treatment in carotid artery disease is still a matter of debate. So far there is controversial literature available concerning the safety of rapid treatment after a qualifying neurological event. Carotid endarterectomy turned out to be more effective in stroke prevention when carried out closer after the onset of symptoms. The initial "two weeks" cut off for surgery meanwhile turned into a "as soon as possible" treatment policy. In case of a cerebral infarction it seems reasonable, however, to delay surgery. Less evidence exists about the ideal timing of carotid artery stenting. Data analysis from the Carotid Stenosis Trialists' Collaboration showed that the early days after plaque rupture carry a high risk for periprocedural complications after carotid artery stenting. The analysis of a large register series showed, that carotid artery stenting carried a significantly higher risk for complications in patients with and without cerebral infarction when performed within 48 hours after the onset of symptoms.

Patient characteristics and outcomes of carotid endarterectomy and carotid artery stenting: analysis of the German mandatory national quality assurance registry - 2003 to 2014

AIM

In Germany, every surgical or endovascular procedure on the extracranial carotid artery is documented in a mandatory quality assurance registry. The purpose of this study is to describe the patient characteristics, the indications for treatment, and the short-term outcomes as well as to analyse the corresponding trends from 2003 to 2014.

METHODS

Data on demographics, peri-procedural measures, and outcomes were extracted from the annual quality reports published by the Federal Agency for Quality Assurance and the Institute for Applied Quality Improvement and Research in Health Care. Data were available from 2003 to 2014 for carotid endarterectomy (CEA) and from 2012 to 2014 for carotid artery stenting (CAS). The primary outcome event of this study is any stroke or death until discharge from hospital. Temporal trends of categorical variables were statistically analysed using the Cochran-Armitage test for trend.

RESULTS

Between 2003 and 2014, 309,405 CEAs and 18,047 CAS procedures were documented in the database; 68.1% of all patients were male. The mean age of patients treated with CEA increased from 68.9 years in 2003 to 70.9 years in 2014. The proportion of patients with ASA stages III to V increased from 65% to 71% in CEA, whereas it decreased from 44% to 41% in CAS patients. 53.1% of all CEAs were performed for asymptomatic patients (group A), 34.4% for symptomatic patients treated electively (group B), and 11.2% a in a collective group including other indications for CEA or CAS (such as recurrent stenosis, carotid aneurysms, emergency treatment due to stroke-in-evolution). The corresponding data for CAS are 49.3%, 26.1% and 26.3% respectively. In group B, the interval between the neurological index event and CEA decreased from 28 to 8 days (P<0.001). In patients treated with CAS, this interval was 9 days in 2012 (no further data available). On average, 67.1% and 48.2% of surgically treated patients as well as 77.8% and 69.8% of CAS patients were neurologically assessed before and after the procedure, respectively. From 2003 to 2014, CEA procedures were performed more frequently in locoregional anesthesia (10.1% to 29.1%, P<0.001). The same trend was observed for the application of the eversion technique (37.0% to 41.6%, P<0.001), the neurophysiological monitoring (49.8% to 61.8%, P<0.001), and the intra-procedural assessment of the treated artery (44.5% to 69.7%, P<0.001). In contrast, shunting was used less frequently (48.1% to 43.0%, P<0.001). Averagely 95.7% of all endovascular procedures were performed using stent-angioplasty. In 54.2% a protection device was used. Nitinol and bare metal stents were used in 74.1% and 21.4% of cases, respectively. The in-hospital rate of any stroke or death decreased from 2.0% to 1.1% in asymptomatic patients treated with CEA without a contralateral stenosis ≥75% or occlusion, P<0.001). In patients treated with CAS this rate did not increase (1.7% to 1.8%, p=0.909). The corresponding rates in CEA and CAS patients with severe contralateral stenosis or occlusion varied between 1.9%-3.1% and 2.2%-2.6%, respectively. In symptomatic patients (group B) with a stenosis of 50 percent or more, the rate of any stroke or death decreased significantly after CEA from 4.2% to 2.4% (P<0.001) and remained stable after CAS (3.9% to 3.5%, P=0.577).

CONCLUSION

This report on 327,452 carotid procedures analysed one of the largest quality registries on CEA and CAS worldwide. Data indicate that treated patients became older and sicker, whereas in contrast, the in-hospital rates of stroke or death are decreasing over time.

Proximal protection with hybrid stent, a safer combination for carotid artery stenting against carotid endarterectomy?

AIM

Carotid revascularization is an established theurapeutic modality in preventing stroke and death among patients with severe carotid stenosis. Although carotid endarterectomy remains as the primary option, carotid stenting is accepted as an alternative for patients with high risk for carotid endarterectomy. Recently published reports have better results with proximal protection devices when compared with distal protection devices. These studies have revealed less microembolic signals and less periprocedural new ischemic lesions on diffusion weighted magnetic resonance imaging. Stent choice may be also important for these procedures as open cell stent design has advantage of better flexibility whereas closed cell systems have an advantage of better scaffolding. Hybrid stents which are composed of open cells in the proximal and distal part and closed cells in the middle may carry both advantages. The aim of this study is to demonstrate whether combination of proximal protection devices with hybrid stents can be a safe alternative for carotid stenting in terms of periprocedural and 30-day outcomes.

METHODS

Here we retrospectively evaluated 68 symptomatic carotid stenosis patients undergoing carotid stenting with hybrid stent (Cristallo Ideale®, Invatec s.r.l., Medtronic, Italy) and proximal protection device (MO.MA®, Invatec s.r.l., Medtronic, Italy).

RESULTS

Our results showed only 1 minor stroke in the periprocedural period and during the first 30-day after stenting, with no death or myocardial infarction.

CONCLUSION

Although our case number is not large, we propose that carotid stenting may be safer with utilization of proximal protection system and hybrid type carotid stents.

Recruiting RCTs comparing CAS, CEA and best medical treatment for asymptomatic carotid stenosis

The present paper summarizes the similarities and differences between recent and ongoing randomized controlled trials on optimal treatment of patients with severe but asymptomatic carotid stenosis. Protocol details will be discussed as well as needs for outcome and especially differentiation between patients with a low versus high risk for future events.

Stroke risk in the early period after carotid related symptoms: a systematic review

Current guidelines recommend performing carotid endarterectomy in patients with symptomatic carotid disease as soon as possible after the neurological index event. However, early stroke risk has not been well documented for this patient group. We therefore conducted a systematic analysis of the current literature on the recurrent risk of ischemic events in patients with symptomatic carotid stenosis. Systematic review was performed by searching the MEDLINE® database from 1950 until June 8, 2015 (key words: cerebral ischemia, transient ischemic attack, amaurosis fugax, stroke, symptomatic carotid stenosis, recurrent risk, outcome, prognosis, follow-up, cohort and natural history). All studies reporting stroke risks in patients with symptomatic carotid stenosis after neurologic index events within a period of 7 days were included. Cumulative stroke risks with 95% confidence intervals after a neurologic index event were recalculated at 2-3, 7, 14 and 30 days and a meta-analysis including an analysis of heterogeneity were performed using the statistical package R and Excel for Mac 2003. Ten studies with a total number of 2634 patients were included. Results of an overall stroke risk were as follows: 2.0-17.2% at 2-3 days, 0-22.1% at 7 days, 0-29.6% at 14 days and 0-11.1% at 30 days in patients with a symptomatic extracranial carotid stenosis. The pooled stroke risk in the six studies with active follow-up was 6.0% (95% CI 2.4-14.4) at 2-3 days, 10.9% (6.1-18.7) at 7 days and 17.6% (9.7-29.9) at 14 days. Pooled stroke risk in the three studies with uncensored populations was even higher with 6.4% (1.5-23.8%) at 2-3 days, 19.5% (12.7-28.7) at 7 days and 26.1% (20.6-32.5%) at 14 days. Significant heterogeneity (P<0.001) could be explained by the different inclusion criteria and the study's design. Retrospective studies with passive follow-up had the lowest stroke risk whereas prospective studies with active follow-up and without bias through early intervention by carotid endarterectomy or carotid stenting had the highest stroke risk. The risk of recurrence of cerebrovascular events in patients with symptomatic carotid stenosis within the first days after a neurologic index event is as high as 6.4% (1.5-23.8), 19.5% (12.7-28.7) and 26.1% (20.6-32.5) after 2-3, 7 and 14 days respectively. Patients with a symptomatic carotid stenosis are therefore at a very high risk of a definitive stroke. Recommendations by current guidelines to perform carotid endarterectomy as soon as possible after the neurologic index event are therefore justified.