Combined therapy with rotational atherectomy and drug coated balloon for superficial femoral artery in-stent restenosis: safety, efficacy, and two-year results of a single center experience

BACKGROUND

The primary patency rate of superficial femoral artery (SFA) after percutaneous transluminal angioplasty (PTA) has improved with the use of self-expanding stents. However, occurrence of in-stent restenosis (ISR) still represents a frequent problem. Despite different studies have assessed the role of atherectomy and drug coated balloons (DCBs), no long-term data exist about combined use. The aim of this study was to evaluate safety and efficacy of combined treatment with Jetstream (Boston Scientific Corp., Marlborough, MA, USA) atherectomy and DCB for SFA intrastent restenosis (ISR) at 2-year follow-up.

METHODS

30 patients treated with PTA from November 2018 to September 2019 at Montevergine Clinic (Mercogliano, Avellino, Italy) were included in this analysis. All patients underwent PTA of SFA-ISR with Jetstream Atherectomy System followed by paclitaxel eluting balloon treatment. Patients were evaluated at 30 days, and every 3 months up to 24.

RESULTS

Technical and procedural success was achieved in every patient. No in-hospital major adverse cardiac and cerebrovascular events occurred. No acute and sub-acute(in-hospital) procedure related complications occurred. During follow-up, 1 patient died due to stroke. Primary patency rate at 12 months was 93.4%. Primary patency rate at 24 months was 83.4%. Secondary patency rate at 24 months was 96.7%. One minor amputation, planned before treatment, was performed in the first 30 days.

CONCLUSIONS

Our data suggest that combined therapy with Rotational Atherectomy and DCBs for SFA-ISR represents a safe and effective procedure with a high rate of primary patency at 2-year follow-up.

Percutaneous Closure of Paravalvular Regurgitation After Third-Generation Transcatheter Aortic Valve Replacement

Significant paravalvular leak regurgitation (PVLR) after transcatheter aortic valve replacement (TAVR) is a well-known complication associated with disabling symptoms related to heart failure and hemolysis or both, with poor prognostic implications. Although challenging and technically demanding, percutaneous closure is an effective treatment option for high-risk patients with symptomatic PVLR. Here, we present two cases of transcatheter PVLR closure after replacement of third-generation (one self-expandable and one balloon-expandable) transcatheter aortic valves, each with peculiar challenges, and the strategies adopted to increase the success rate of percutaneous closure.

Three-year outcome of directional atherectomy and drug coated balloon for the treatment of common femoral artery steno-occlusive lesions

BACKGROUND

Endarterectomy is considered the gold standard therapy for common femoral artery (CFA) steno-occlusive lesions, but a significant risk of perioperative mortality and complications has been reported.

OBJECTIVE

Aim of this study is to evaluate the efficacy at a long-term follow-up of patients with CFA steno-occlusive lesions treated with directional atherectomy and drug coated balloon (DCB).

MATERIAL AND METHODS

In this single-center registry, 78 patients (male: 80.7%; age: 71 ± 15 years; occlusions: 25%) with 80 CFA lesions were included, with 39.7% of them undergoing directional atherectomy and drug coated balloon due to critical limb ischemia and 60.3% due to lower-limb intermittent claudication. The long-term follow-up was completed by 75 patients (3 years). The 31 patients with critical ischemia (39.7%) were further subdivided into 20 (25.6%) patients with pain at rest and 11 (14.1%) with trophic changes, ulcers and/or tissue loss. We considered the primary and the secondary outcome, referring, respectively to peak systolic velocity ratio (PSVR) ≥ 2.4 on duplex or > 50% stenosis on digital subtraction angiography at 36 months and to clinically driven target lesion revascularization at 36 months.

RESULTS

The primary and secondary outcome was obtained in 84% and 86.7% of patients, at 36 months of follow up. Bailout stenting was necessary in 6/80 cases (7.5%) for suboptimal result. Freedom from MALE was obtained in 98.6% of patients.

CONCLUSIONS

These results confirm that directional atherectomy and drug coated balloon strategy for the treatment of CFA lesions is effective at a long-term follow-up and could be considered as a good alternative to surgery.

Obesity-induced activation of JunD promotes myocardial lipid accumulation and metabolic cardiomyopathy

AIMS

Metabolic cardiomyopathy (MC)-characterized by intra-myocardial triglyceride (TG) accumulation and lipotoxic damage-is an emerging cause of heart failure in obese patients. Yet, its mechanisms remain poorly understood. The Activator Protein 1 (AP-1) member JunD was recently identified as a key modulator of hepatic lipid metabolism in obese mice. The present study investigates the role of JunD in obesity-induced MC.

METHODS AND RESULTS

JunD transcriptional activity was increased in hearts from diet-induced obese (DIO) mice and was associated with myocardial TG accumulation and left ventricular (LV) dysfunction. Obese mice lacking JunD were protected against MC. In DIO hearts, JunD directly binds PPARγ promoter thus enabling transcription of genes involved in TG synthesis, uptake, hydrolysis, and storage (i.e. Fas, Cd36, Lpl, Plin5). Cardiac-specific overexpression of JunD in lean mice led to PPARγ activation, cardiac steatosis, and dysfunction, thereby mimicking the MC phenotype. In DIO hearts as well as in neonatal rat ventricular myocytes exposed to palmitic acid, Ago2 immunoprecipitation, and luciferase assays revealed JunD as a direct target of miR-494-3p. Indeed, miR-494-3p was down-regulated in hearts from obese mice, while its overexpression prevented lipotoxic damage by suppressing JunD/PPARγ signalling. JunD and miR-494-3p were also dysregulated in myocardial specimens from obese patients as compared with non-obese controls, and correlated with myocardial TG content, expression of PPARγ-dependent genes, and echocardiographic indices of LV dysfunction.

CONCLUSION

miR-494-3p/JunD is a novel molecular axis involved in obesity-related MC. These results pave the way for approaches to prevent or treat LV dysfunction in obese patients.

Blood pressure control versus atrial fibrillation management in stroke prevention

Hypertension is one of the major risk factors for atrial fibrillation which in turn is the most prevalent concomitant condition in hypertensive patients. While both these pathological conditions are independent risk factors for stroke, the association of hypertension and atrial fibrillation increases the incidence of disabling strokes. Moreover, documented or silent atrial fibrillation doubles the rate of cardiovascular death. Lowering blood pressure is strongly recommended, particularly for primary stroke prevention. However, a relatively small percentage of hypertensive patients still achieve the recommended blood pressure goals. The management of atrial fibrillation with respect to stroke prevention is changing. New oral anticoagulants represent a major advancement in long-term anticoagulation therapy in non valvular atrial fibrillation. They have several benefits over warfarin, including improved adherence to the anticoagulation therapy. This is an important issue since non-adherence to stroke prevention medications is a risk factor for first and recurrent strokes.

Effects of a Long-Term Treatment With Aliskiren or Ramipril on Structural Alterations of Subcutaneous Small-Resistance Arteries of Diabetic Hypertensive Patients

Structural alterations of subcutaneous small-resistance arteries are associated with a worse clinical prognosis in hypertension and non–insulin-dependent diabetes mellitus. The effects of the direct renin inhibitor aliskiren on microvascular structure were never previously evaluated. Therefore, we investigated the effects of aliskiren in comparison with those of an extensively used angiotensin-converting enzyme inhibitor, ramipril, on peripheral subcutaneous small-resistance artery morphology, retinal arteriolar structure, and capillary density in a population of patients with non–insulin-dependent diabetes mellitus. Sixteen patients with mild essential hypertension and with a previous diagnosis of non–insulin-dependent diabetes mellitus were included in the study. Patients were then randomized to 1 of the 2 active treatments (aliskiren 150 mg once daily, n=9; or ramipril 5 mg once daily, n=7). Each patient underwent a biopsy of the subcutaneous fat from the gluteal region, an evaluation of retinal artery morphology (scanning laser Doppler flowmetry), and capillary density (capillaroscopy), at baseline and after 1 year of treatment. Subcutaneous small arteries were dissected and mounted on a pressurized micromyograph, and the media-to-lumen ratio was evaluated. A similar office blood pressure–lowering effect and a similar reduction of the wall-to-lumen ratio of retinal arterioles were observed with the 2 drugs. Aliskiren significantly reduced media-to-lumen ratio of subcutaneous small-resistance arteries, whereas ramipril-induced reduction of media to lumen ratio was not statistically significant. No relevant effect on capillary density was observed. In conclusion, treatment with aliskiren or ramipril was associated with a correction of microvascular structural alterations in patients with non–insulin-dependent diabetes mellitus.

Abstract MP10: Early Functional and Structural Alterations of Resistance Arteries in Mice Treated with an Inhibitor of the Vascular Endothelial Growth Factor Receptor

Background: Inhibition of tyrosine kinases receptors such as vascular endothelial growth factor receptor (VEGFR) and epidermal growth factor receptor (EGFR) improves outcomes in patients with cancers. Only VEGFR inhibitors, however, induce severe hypertension whose mechanisms remain unclear. We hypothesized that VEGFR inhibitors may induce early vascular functional and structural alterations, that may precede the development of hypertension.

Methods and results: Normotensive SV-129 mice (8 weeks old, 5 for each group) were treated or not with the VEGFR inhibitor Vatalanib (VAT, 100 mg/Kg/day) or the EGFR inhibitor Gefitinib (GEF, 100 mg/Kg/day). Vehicle-treated control mice were also studied. Blood pressure (BP) was measured by tail-cuff method. Endothelium-dependent and -independent relaxations were assessed by concentration-response curves to acetylcholine (1 nM to 100 μM) ± L-NAME (100 μM) and sodium nitroprusside (10 nM to 1 mM) respectively, in mesenteric arteries pre-contracted with norepinephrine (10 μM). Media-to-lumen ratio (M/L, an index of early vascular remodeling), and cross sectional area (CSA) were evaluated on pressurized preparations.

After two weeks, BP was similarly preserved in both VAT- and GEF-treated mice as compared to vehicle-treated mice (89.8±1.5 mmHg and 87.2±2.8 mmHg vs 92.2±2.2 mmHg, respectively, NS). Endothelium-dependent relaxation was similarly preserved in vehicle-treated and GEF-treated mice, whereas it was reduced in VAT-treated mice (-17% vs vehicle-treated mice, P<0.05). L-NAME blunted acetylcholine-induced relaxation in all groups except in VAT-treated mice, suggesting an impairment of NO production only in this group. Endothelium-independent relaxation was similar in all groups. Only VAT-treated mice presented increased M/L as compared to vehicle-treated mice (6.3±0.1% vs 5.4±0.1%, P<0.05). M/L resulted similar in GEF-treated and vehicle-treated mice. CSA was similar in all groups.

Conclusion: In normotensive mice, only VAT promoted early vascular alterations such as endothelial dysfunction and vascular remodeling in resistance arteries. Those changes in the vasculature are distinctive of hypertension and might precede and sustain the development of the hypertensive disease.

Abstract 45: Reduced Vascular Remodeling and Improved Endothelial Function in Transglutaminase 2 Knock-Out Mice Treated with Angiotensin II

Transglutaminase 2 (TG2) may modulate cell-matrix interactions by inducing cross-linking of proteins. We previously demonstrated that angiotensin II (Ang II) positively regulated TG2 expression in vascular smooth muscle cells from SHR. Here we hypothesized that Ang II induces vascular remodeling in part through TG2.

TG2-knockout mice (TG2-K/O, 8 weeks old, 6 for each group) and age-matched wild type (WT) control mice were treated or not with Ang II (400 ng/kg/min) for 14 days. Blood pressure (BP) was measured by tail-cuff method. Endothelium-dependent and -independent relaxation were assessed by concentration-response curves to acetylcholine (1 nM to 100 μM) ± L-NAME (100 μM) and sodium nitroprusside (10 nM to 1 mM) respectively, in mesenteric arteries pre-contracted with norepinephrine (10 μM). Media-to-lumen ratio (M/L) and cross sectional area (CSA) were evaluated on pressurized preparations.

BP was higher in TG2-K/O mice compared to WT (120.3±1.3 mmHg vs 88.3±1.9 mmHg, P<0.05), Ang II infusion significantly increased BP only in WT (+28% vs untreated WT, P<0.05), whereas BP was unchanged in TG2-K/O after Ang II infusion. Endothelium-dependent relaxation was similarly preserved in untreated WT, TG2-K/O and Ang II-treated TG2-K/O. Ang II infusion impaired acetylcholine-induced relaxation only in WT (-50% vs untreated WT, P<0.05). L-NAME blunted acetylcholine-induced relaxation in all the groups except in Ang II-treated WT, suggesting an impairment of NO production only in this group. Endothelium-independent relaxation was similar in all groups. TG2-K/O presented reduced M/L as compared to WT (4.8±0.3% vs 6.5±0.2%, P<0.05). Ang II infusion increased M/L only in WT (+13% vs untreated WT, P<0.05). M/L resulted unchanged in TG2-K/O after Ang II infusion. CSA was similar in all groups.

In conclusion, despite the higher BP values, TG2-K/O presented improved vascular remodeling compared to WT. Ang II failed to increase M/L and impair endothelial function in TG2-K/O. Hence TG2 may play a role in Ang II-induced vascular structural and functional alterations.

Abstract 406: Improved Angiotensin II Type 2 Receptor Expression and Function in Transglutaminase 2 Knock-Out Mice Treated with Angiotensin II

Objective: Transglutaminase 2 (TG2) induces transamidation and cross-linking of proteins that can modulate receptor interaction. Angiotensin II (AngII) may regulate TG2 and AngII type 2 receptor (AT2) expression and function. We hypothesized that AngII may impair AT2 expression and function through TG2.

Methods: TG2-knockout mice (TG2-K/O, 8 weeks old, 6 for each group) and age-matched wild type (WT) mice were treated or not with AngII (400 ng/kg/min) for 14 days. Vascular reactivity was assessed in response to sodium nitroprusside (SNP, 10 nM to 1 mM), in mesenteric arteries pre-contracted with norepinephrine (10 μM). AT2 function was assessed by concentration-response curve to the selective AT2 agonist Compound 21 (C21, 1nM to 1 μM) in mesenteric arteries pre-contracted with norepinephrine. AT2 expression in aorta was evaluated by immunoblotting.

Results: C21-induced relaxation was similar in untreated WT, and in untreated TG2-K/O. C21-induced relaxation was improved only in AngII-treated TG2-K/O (2-fold increase vs untreated TG2-K/O, P<0.001). SNP dependent relaxation was similar in all groups. AT2 receptor expression was similar in untreated WT and untreated TG2-K/O. AT2 was reduced by AngII in WT (-36±6% vs untreated WT, P<0.01), and significantly increased in TG2-K/O (+53±4% vs untreated TG2-K/O, P<0.001).

Conclusions: AngII fails to reduce AT2 expression and function in TG2-K/O mice. Therefore, AngII may negatively modulate AT2 receptor expression and function through TG2.

Abstract 533: MAS Receptor Activation Contributes to the Improvement of Vascular Remodeling During Chronic Angiotensin II Type 1 Receptor Blockade in Angiotensin II Type 2 Receptor Knockout Mice

Angiotensin (Ang)-(1-7) through MAS receptor may counteract the Ang II-induced actions. We previously demonstrated that the Ang receptor blocker olmesartan (OLM) improved vascular remodeling in SHR in part through the activation of MAS receptor. Here, we hypothesized that such an effect is independent of Ang II type 2 (AT2) receptor activation. AT2-knockout mice (AT2-K/O, 12 weeks old, n=6 per group) were treated with vehicle (control) or Ang (1-7) (15,5 pmol/kg/min) or Ang II (400 ng/kg/min) ± OLM (10 mg/kg/day) ± the MAS antagonist A-779 (11 pmol/min) for 14 days. BP was measured by tail-cuff method. In isolated mesenteric arteries pre-contracted with norepinephrine (10 μM) endothelium -dependent and -independent relaxation was assessed by dose-response curves to acetylcholine (1 nM to 100 μM) and SNP (10 nM to 1 mM) respectively. Mesenteric arteries media-to-lumen ratio (M/L) and cross sectional area (CSA) were evaluated on pressurized preparations. MAS expression in aorta was evaluated by immunoblotting. Ang II infusion increased BP in AT2-K/O (+20% vs control mice, P<0.05). OLM reduced BP in Ang II-infused mice (104.8±4.4 mmHg vs 121.3±2.8 mmHg, respectively, P<0.05). A-779 had no effect on BP in Ang II-infused mice treated with OLM. Ang (1-7) did not lower BP in AT2-K/O. Endothelium -dependent and -independent relaxations were similar in treated and control mice. M/L was similar in Ang II-infused and control mice. OLM significantly reduced M/L in Ang II-infused AT2-K/O (5.45±0.12 % vs 7.01±0.4%, respectively, -23%, P<0.05). A-779 increased M/L in Ang II-infused AT2-K/O treated with OLM (+18%, P<0.05). Ang (1-7) reduced M/L in AT2-K/O (-21%, P<0.05). CSA was similar in all the groups. MAS expression was similar in Ang II-infused and control mice. MAS expression was increased by OLM in Ang II-infused mice (+108%, P<0.05). A-779 prevented MAS increase in Ang II-infused mice treated with OLM. Ang (1-7) increased MAS expression in AT2-K/O (+81%, P<0.05). In conclusion OLM reduced M/L and improved vascular remodeling in AT2-K/O in part through the increased expression and activation of MAS, independently of BP reduction. Such an effect is indeed independent of AT2 activation, as MAS is functionally active in the vasculature of AT2-K/O.

Vascular inflammation and endothelial dysfunction in experimental hypertension

Essential hypertension is characterized by increased peripheral vascular resistance to blood flow. The endothelium is a crucial regulator of vascular tone. Its function is impaired in patients with hypertension, with reduced vasodilation, increased vascular tone associated with a proinflammatory and prothrombotic state. Low-grade inflammation localized in vascular tissue is therefore recognized as an important contributor to the pathophysiology of hypertension, to the initiation and progression of atherosclerosis as well as to the development of cardiovascular diseases.