Cardiovascular Revascularization Medicine - Articles in Press

Randomized trial of insulin versus usual care in reducing restenosis after coronary intervention in patients with diabetes. the STent Restenosis And Metabolism (STREAM) study - Corrected Proof

2012-02-01

Abstract: Background: Diabetes status is an independent marker of restenosis after percutaneous coronary intervention (PCI). Previous studies suggest that metabolic abnormalities associated with diabetes increase stent restenosis by promoting intimal hyperplasia. Preclinical studies have indicated that insulin therapy reduces intimal hyperplasia. The objective of this study was to determine whether insulin-mediated glucose lowering reduces in-stent restenosis in patients with diabetes undergoing PCIs.Methods: We conducted a prospective, randomized, multicenter, open-labeled study with blinded outcomes. Patients were randomized 1:1 to daily bedtime subcutaneous NPH insulin (Novo Nordisk) versus usual therapy with oral hypoglycemic agents. The main outcomes were change in volume of intimal hyperplasia within the stent measured by intravascular ultrasound and late lumen loss by quantitative coronary angiography at 6 months post-PCI.Results: Seventy-eight patients (36 insulin, 42 usual care) were randomized. Eight patients in each group received drug-eluting stents. The insulin group achieved greater reductions in both glycosylated hemoglobin A1c (mean±S.D.) (insulin: 8.0%±1.2% to 6.7%±0.7% vs. control: 7.5%±1.2% to 7.1%±1.0 %, P=.0038) and fasting glucose (insulin: 9.3±3.8 to 5.8±1.7 vs. usual care: 8.4±2.4 to 7.7±2.0 mmol/l, P<.0001). There were no hypoglycemic events. At 6 months, there were no significant differences in either intravascular-ultrasound-determined neointimal volume (insulin: 41.2±38.9 vs. usual care: 48.4±40.2 mm3, P=.33) or late lumen loss by angiography (insulin: 1.29±0.74 mm vs. usual care: 1.02±0.71 mm, P=.17).Conclusions: Addition of a single bedtime dose of insulin in patients with diabetes does not influence in-stent restenosis.

Stenting of the unprotected left main coronary artery in patients with severe aortic stenosis prior to percutaneous valve interventions - Corrected Proof

2012-02-01

Abstract: Aims: High-risk patients with severe aortic stenosis (AS) who are candidates for transcatheter valve implantation (TAVI) or balloon aortic valvuloplasty (BAV) may additionally require revascularization of the unprotected left main coronary artery (UPLM). We aimed to assess the feasibility and procedural safety of UPLM stenting in such patients.Methods and Results: Ten cases of UPLM stenting prior to BAV or TAVI at three medical centers over a 2-year period were identified. Mean age was 84±4 years, aortic valve area was 0.70±0.12 cm2, left ventricular ejection fraction was 58%±3%, and logistic EuroScore was 32±17. Intraaortic balloon counterpulsation was used in three patients. A single stent was used in seven patients, and two stents were used in three patients. One patient received a bare-metal stent, and the others received drug-eluting stents. No procedural complications occurred, and the patients were hemodynamically stable. Three patients subsequently underwent BAV, and seven underwent TAVI. During 6 months of follow-up, two patients died: one due to AS restenosis 6 months after BAV and one due to vascular complications 18 days after TAVI (34 days after UPLM stenting).Conclusions: Stenting of the UPLM in patients with severe AS prior to percutaneous valve intervention seems feasible and safe. This approach may enable more patients to achieve comprehensive percutaneous therapy for severe coronary and valvular disease.

Delivery catheter cone separation and embolization after Corevalve dislocation by subclavian approach - Corrected Proof

Cédric Delhaye, Arnaud Sudre, Gilles Lemesle, Mohamad Koussa, Thomas Modine — 2012-01-19

Abstract: Corevalve dislocation has been reported to significantly increase the perioperative risk for severe complications and poor outcomes. We describe the case of an 87-year-old man who was referred to our center for transcatheter aortic valve implantation and who experienced an original complication after Corevalve dislocation by subclavian approach. Indeed, during the attempt to retrieve the partially expanded and dislocated valve through the subclavian introducer sheath, we experienced a dislodgment of the valve from the housing sheath that led to a delivery catheter cone separation and systemic embolization.

Excessive axial plaque redistribution during coronary stent implantation confirmed by intravascular ultrasound - Corrected Proof

2012-01-09

Abstract: We report a case of excessive axial plaque redistribution leading to luminal narrowing at the reference segment confirmed by serial intravascular ultrasound during coronary stent implantation.

Clinical and silent stroke following aortic valve surgery and transcatheter aortic valve implantation - Corrected Proof

Camille Hauville, Itsik Ben-Dor, Joseph Lindsay, Augusto D. Pichard, Ron Waksman — 2012-01-09

Abstract: Transcatheter aortic valve implantation (TAVI) has been introduced as an alternative to conventional surgery for high-risk patients with aortic stenosis. A recently published randomized clinical trial demonstrated reduction of mortality in high-risk or inoperable patients when compared to medical treatment or balloon aortic valvuloplasty. Despite this evidence of superiority, the rate of TAVI complications is high, and perhaps the most devastating of the nonfatal complications is cerebral injury. This review will compare the incidence of stroke and “silent” cerebral injury after surgical aortic valve replacement and after TAVI and will discuss mechanisms that can lead to cerebral injury during these procedures and subsequently how to prevent this with new protection devices.

Impact of vascular approach (transradial vs. transfemoral) on the efficacy of thrombus aspiration in acute myocardial infarction patients - Corrected Proof

2012-01-09

Abstract: Background: Manual thrombus aspiration improves the efficacy of percutaneous coronary interventions (PCIs) in ST-elevation acute myocardial infarction (STEMI). The transradial approach (TRA) is an emerging vascular approach for PCI but is associated with specific technical requirements. As data on the combination of thrombus aspiration and TRA are scarce, we sought to assess the feasibility of TRA manual thrombus aspiration in STEMI patients.Methods: All consecutive patients treated with manual thrombectomy for acute STEMI in three Italian hospitals were considered. Patients were divided according to the vascular approach into two groups: TRA and transfemoral (TFA). Two primary end points were defined: thrombectomy feasibility (ability to cross the occlusion with the device) and thrombectomy efficacy (absolute thrombus score reduction after device crossing).Results: From January 2008 to December 2009, 303 patients were included: 151 patients (63±13 years) were treated through TFA, and 152 patients (61±12 years, P=.25) were treated through TRA. There were no significant differences in thrombectomy feasibility (75% in the TRA compared to 74.8% in the TFA group, P=.97) or in thrombectomy efficacy (2.6±.8 for TRA and 2.9±2 for TFA, P=.15). In both groups, there was a significant reduction in thrombus score after manual thrombus aspiration. Angiographically evident distal embolization after device crossing was low and observed in seven cases (5%) either for TFA and TRA (P=.99).Conclusions: The present study suggests that, in the setting of acute STEMI, manual thrombus aspiration through TRA is feasible, and its efficacy is comparable to the TFA.

Radial artery spasm during transradial cardiac catheterization and percutaneous coronary intervention: incidence, predisposing factors, prevention, and management - Corrected Proof

Hee Hwa Ho, Fahim Haider Jafary, Paul Jau Ong — 2012-01-09

Abstract: Transradial cardiac catheterization and percutaneous coronary intervention are increasingly being performed worldwide in elective and emergency procedures, with many centers adopting the transradial route as their first choice of arterial access. One of the most common complications encountered during transradial procedures is radial artery spasm. This article reviews the current literature on the incidence, predisposing factors, preventive, and treatment measures for radial artery spasm.

Fluoroscopy use and left anterior descending artery angiography to guide transapical access in patients with prior cardiac surgery - Corrected Proof

2011-12-19

Abstract: Background: Patients with severe aortic stenosis (AS) and prior cardiac surgery undergoing aortic valve replacement (AVR) are at high risk. Transapical AVR might reduce the risk in patients not suitable for the transfemoral approach. We aimed to describe the fluoroscopy and left anterior descending artery (LAD) angiography guidance technique for transapical AVR access and the initial related procedural results.Methods: Patients with severe AS and prior cardiac surgery undergoing transapical AVR using LAD angiographic-guided apical puncture were analyzed (n=9). Additional guidance was added to the standard technique as follows. Minithoracotomy was performed at the level of the intercostal space in closer relationship to the apex identified by fluoroscopy. LAD angiography was performed at the time that the area of interest was recognized by radiopaque marker to ensure puncture lateral to the LAD. Apical needle puncture was performed under fluoroscopy guidance directed towards the aortic root.Results: The population had a mean age of 83 years and was more frequently male (89%) with a high-risk profile (mean Society of Thoracic Surgeons score of 11%). Two patients received the 23-mm Edwards SAPIEN valve, and seven patients received the 26-mm SAPIEN device. All nine patients underwent successful implantation of transcatheter aortic valves with virtual abolishment of transaortic gradient, without procedural complications.Conclusion: Fluoroscopy and angiography for guidance of the transapical approach facilitate a safe and rapid access to the apex, insuring no risk of damage to the LAD or to large diagonals.

Acute myocardial infarction in women: is there a sex disparity between door-to-balloon time and clinical outcomes? - Corrected Proof

Sara D. Collins — 2011-12-12

Coronary artery disease (CAD) has traditionally been thought of as a disease that predominantly affects men. Women, however, are more likely than men to die from a myocardial infarction (MI). Despite increased awareness of heart disease in women and improved outcomes after percutaneous coronary intervention (PCI), women with MI have more mortality and delays to treatment than men. Although all of the reasons behind these differences are not clear, women presenting with MI are a more morbid patient population than their male counterparts. Women consistently demonstrate higher baseline risk, including older age, higher rates of diabetes mellitus (DM), hypertension (HTN) and congestive heart failure (CHF) . This was initially demonstrated in trials conducted in the thrombolytic era, but has persisted in the current era of PCI .

Interventionalists beware: the apical thrombus! - Corrected Proof

Sinjini Biswas, Andrew E. Ajani — 2011-11-24

Abstract: Recent myocardial infarction is a recognized risk factor for ischemic stroke. Patients who have a stroke in the peri-infarct period are usually in hospital and therefore well placed to access early cerebral reperfusion therapy. However, due to the risk of myocardial rupture, recent myocardial infarction is considered a contraindication to intravenous thrombolysis, which is usually the first-line therapy for the treatment of ischemic stroke. We report a case in which intravenous thrombolysis was safely and effectively used to treat acute ischemic stroke in a patient who had suffered an acute myocardial infarct within the previous 48 h. We also highlight the lack of evidence-based guidelines for the treatment of stroke in this important subgroup of patients.

Management of acute left main obstruction after transcatheter aortic valve replacement: the “tunnel technique” - Corrected Proof

2011-11-17

Abstract: Two cases of acute left main (LM) obstruction complicating transcatheter aortic valve replacement (TAVR) and their management are reported. TAVR with a self-expandable transcatheter aortic prosthesis was performed for treating severe aortic stenosis with small aortic root and severe aortic regurgitation of a degenerated stentless bioprosthesis, respectively. Left main coronary obstruction occurred at a different time from the index procedure. A novel stent-based angioplasty treatment, denominated “the tunnel technique,” was successfully applied in both cases and herein described.

Left main coronary artery transradial rescue percutaneous coronary intervention for acute myocardial infarction complicated by cardiogenic shock with Impella ventricular mechanical support - Corrected Proof

Ziad Dahdouh, Vincent Roule, Thérèse Lognoné, Rémi Sabatier, Gilles Grollier — 2011-10-24

Abstract: Mechanical ventricular assist support and especially Impella device that is implanted via femoral access are considered a cornerstone in the therapeutic arsenal of the management of cardiogenic shock. Indeed, the potent antithrombotic agents administered during acute coronary syndromes constitute potential bleeding risk factors. Transradial interventions are nowadays widely used in ST-elevation myocardial infarction patients. However, some operators feel uncomfortable with the transradial approach when facing cardiogenic shock. We report a case of transradial rescue percutaneous intervention for cardiogenic shock in a young man with support of an Impella device via femoral access.

Subclavian stenting in a hostile aortic arch facilitated by a low-profile brachial artery through-and-through access - Corrected Proof

2011-10-13

Abstract: Subclavian stenting can be extremely difficult in a hostile type II aortic arch (with acute angulation of the subclavian artery origin) or type III aortic arch. This case illustrates use of a low-profile system to gain through-and-through (flossing) access through the brachial artery to facilitate stenting via the femoral approach. This approach can be useful in patients with small brachial arteries where the risk of complication may be high if a standard vascular sheath was placed for stenting via the brachial approach. This technique also avoids the use of a surgical cut down.

Ranolazine for the treatment of refractory angina in a veterans population - Corrected Proof

2011-08-19

Abstract: Background: Pivotal ranolazine trials did not require optimization of conventional medical therapy including coronary revascularization and antianginal drug therapy prior to ranolazine use. This case series describes the use of ranolazine for the treatment of chronic stable angina refractory to maximal medical treatment in a veterans population.Results: A total of 18 patients with a median age of 66 years were identified. All patients had prior percutaneous coronary intervention and/or coronary artery bypass graft surgery; 83% had three-vessel coronary artery disease, with left main disease present in 39% of patients. Prior to initiating ranolazine, antianginal use consisted of beta blockers (94%), long-acting nitrates (83%) and calcium channel blockers (61%). Median blood pressure (116.2/61.8 mmHg) and pulse (65 beats per min) were controlled. Median preranolazine angina episodes and sublingual nitroglycerin (SLNTG) doses per week were 14 and 10, respectively, with a Canadian Cardiovascular Society (CCS) angina grade of III–IV in 67% of patients. After initiation of ranolazine, median angina episodes per week and SLNTG doses used per week decreased to 0.7 and 0, respectively, with CCS grade of III–IV declining to 17%. Of the 18 subjects enrolled, 44% had complete resolution of angina episodes.Conclusion: The addition of ranolazine to maximally tolerated conventional antianginal drug therapy post coronary revascularization was associated with decreases in angina episodes and SLNTG utilization and improvement in CCS angina grades. Ranolazine may provide an effective treatment option for revascularized patients with refractory angina.

Giant saphenous vein graft aneurysm treated with covered stent - Corrected Proof

Itsik Ben-Dor, Robert Lager, Ron Waksman, Augusto D. Pichard, Robert Gallino — 2011-03-02

Presented is a 76-year-old female with history of coronary artery disease and post-cardiac bypass surgery 20 years ago. She has chronic atrial fibrillation with severe left ventricular dysfunction and implantable cardiac defibrillator. She was referred for diagnostic coronary angiography due to dyspnea on exertion. Coronary angiography demonstrated occluded left anterior descending and circumflex arteries in the mid third; the right coronary artery was occluded in the ostium. The saphenous vein graft (SVG) to the left anterior descending artery is occluded. The SVG to the right coronary artery is patent with a very large aneurysm in the proximal portion (). The 256-slice computed tomography displayed an aneurysm (maximum diameter 5.8×4.5 cm) of the proximal third of the SVG to the right coronary artery (). After engaging the SVG with a 125-cm Judkins Right 6F coronary guide, the aneurysm was crossed with a 0.014-in. Luge coronary guide wire (Boston Scientific). The Judkins Right guide was retrieved and an 8F 90-cm Flexor shuttle sheath (COOK) was advanced to the ostium of the SVG. The coronary guide wire was exchanged over Quick-Cross support catheter (Spectranetics) to a 0.035-in. Supra Core guide wire. A polytetrafluoroethylene self-expandable covered stent 7/50 mm VIABAHN (GORE) was deployed and a balloon 7/40 mm was inflated at high pressure in the proximal and distal end sealing the aneurysm (). The post-procedure course was uneventful and the patient was discharged on dual antiplatelet therapy and warfarin. Coronary artery aneurysms have been defined as localized coronary dilations with diameters at least 1.5 times the diameters of adjacent normal coronary segments.

Coronary stenting using the radial approach in two women with situs viscerum inversus and acute myocardial infarction - Corrected Proof

2010-09-02

Abstract: A situs inversus with dextrocardia (DC) is a rare condition in adults. Usually, patients have structurally normal hearts and normal life expectancy. The incidence of coronary artery disease in this setting is similar to that in the general population.Coronary revascularization may present potential difficulties related to the unusual anatomy. Although the radial artery is a safe and effective site of access for coronary interventions, some anatomical variations may make this procedure more complicated. We describe two cases of patients with situs viscerum inversus and acute myocardial infarction who underwent successful transradial percutaneous coronary intervention (PCI). We will show that coronary angioplasty with stent application via the radial approach in patients with DC is feasible and effective also in emergency and urgent care.