Cardiovascular Revascularization Medicine - Articles in Press

Alcohol septal ablation through a bare metal stent after rotative atherectomy: a complex procedure - Corrected Proof

Nicolas Combaret, Géraud Souteyrand, Pascal Motreff, Jean René Lusson — 2012-05-18

Abstract: We report the case of a patient with severe malignant hypertrophic obstructive cardiomyopathy (HOCM) and calcified stenosis of the proximal and middle left anterior descending (LAD) coronary artery. We elected to treat his ischemic heart disease first. We performed angioplasty of the proximal and middle LAD, after rotative atherectomy, and implanted two bare metal stents. Thirty days later we treated his HOCM by alcohol septal ablation with catheterization of the first septal branch through the mesh of the bare metal stent implanted in the LAD. To our knowledge, this is the first documented report of such a procedure.

Proximal balloon deflation technique: A novel method to retrieve retained or entrapped equipment from the coronary system - Corrected Proof

Takashi Ashikaga, Hiroshi Inagaki, Yasuhiro Satoh, Mitsuaki Isobe — 2012-05-17

Abstract: Complications of retained or entrapped equipment in the coronary system are still encountered during angioplasty procedures. Although these complications are rare, it is extremely difficult to retrieve such equipments. We report on two cases that a retained IVUS catheter or an entrapped filter wire were retrieved from the coronary system using more simplified technique that does not involve in the usage of snare or any other retrieval tool. After placing an additional guidewire and balloon alongside an equipment, it was easily retrieved from the coronary system just after the proximal balloon deflation.

Patent foramen ovale-obstructive sleep apnea relationships: Pro and cons - Corrected Proof

Gianluca Rigatelli, Sunil Sharma — 2012-05-14

Abstract: Patent foramen ovale (PFO) has a prevalence of 25%–27% in the general population and it has been suggested to be the mediator for a wide variety of syndromes based on the paradoxical embolism. The obstructive sleep apnea syndrome (OSAS) is a common disorder in the middle-aged population. An echocardiographically visible PFO was detected in 27%–69% of patients with documented OSAS suggesting a relationship between PFO and OSAS, but the pathophysiology of this potential relationship is still unclear. It has been shown that obstructive apnea can induce right-to-left shunting (RLS) through PFO with two proposed mechanisms including a large swing in pleural pressure and pulmonary hypertension. Pulmonary artery hypertension and oxygen desaturation have been suggested to be caused by the concurrence of OSAS and PFO. Arguments against and in favour of this potential relationship are discussed in this brief review.

Safety and 1-year revascularization outcome of SilverHawk atherectomy in treating in-stent restenosis of femoropopliteal arteries: A retrospective review from a single center - Corrected Proof

2012-05-10

Abstract: Background: Treatment of in-stent restenosis of the femoropopliteal arteries with balloon angioplasty carries a high rate of recurrence and requires frequent repeat stenting. In the “Instructions for Use,” SilverHawk atherectomy (SA) is contraindicated for in-stent restenosis at a peripheral site. SA, however, has a theoretical advantage of reducing the volume of restenotic tissue and potentially delaying the need for frequent repeat revascularization and additional stenting. We present a retrospective analysis from our center on the safety and outcomes of SA in the treatment of in-stent restenosis of the femoropopliteal arteries.Methods: Demographic, clinical, angiographic, and procedural data were collected on all patients who underwent SA for in-stent restenosis from February 2005 to April 2010 at a single medical center. Major adverse events and 1-year target lesion revascularization (TLR) and target vessel revascularization (TVR) were obtained by review of medical records and phone calls. Descriptive analysis was performed on all variables. Kaplan–Meier survival curves for TVR were plotted.Results: A total of 41 consecutive patients (mean age 70.9±9.2years, 56% males) were included and followed for a mean of 331.63days. The following variables were noted: mean ankle brachial index (ABI) of treated leg 0.66±0.2; chronic renal failure (creatinine >2.0 at baseline) 14.6%; diabetes 61%; history of smoking 85.4%; number of vessel runoffs of treated limb 1.9±0.9; hypertension 90.2%; lesion length 126.2±79.3mm; lesion severity 90.7±8.2%; vessel diameter 5.8±0.7mm. All patients received bivalirudin during the procedure and were on aspirin. Ninety-five percent of patients were placed on clopidogrel. Adjunctive balloon angioplasty was performed in 97.6% at a mean pressure of 11.9±3.3atm. Embolic filter protection (EFP) was used in 56.1% of patients. Bailout stenting was 24.4%. Acute procedural success (<30% angiographic residual narrowing) occurred in 100% of patients. Compared to baseline, ABI at 1 month significantly improved to 0.91±0.19 (P<0.05) but was not statistically different at 1 year (0.61±0.28). Debris was noted in 81.9% of filters used; 36.4% were macrodebris. The following adverse events were reported: distal embolization (DE) requiring treatment 7.3%; stent thrombosis 4.9%; planned minor amputation in the nonindex limb 2.4%. No device-related complications occurred. There was no death or amputation. TLR and TVR occurred in 31.7% and 34.1%, respectively.Conclusion: SA has favorable acute results in treating in-stent restenosis of the femoropopliteal arteries. At 1 year, TLR and TVR remain high but compare favorably to published data. DE also occurs significantly with SA and EFP appears to be effective in capturing the debris.

Rotational atherectomy: A “survivor” in the drug-eluting stent era - Corrected Proof

Marco Zimarino, Thierry Corcos, Ezio Bramucci, Corrado Tamburino — 2012-04-23

Abstract: Mechanical debulking of coronary plaques with rotational atherectomy (RA) has been used for more than 20years during percutaneous coronary interventions (PCI). Modification of plaque characteristics may be accomplished with selective ablation of inelastic fibrocalcific tissue. The use of RA, though reduced with the development of bare-metal stents (BMS) and even more with drug-eluting stents (DES), has never been completely abandoned. The present review will analyze reasons for conflicting results obtained in large series and randomized trials on this topic in the past, and will identify criteria for an appropriate use in current times.

Percutaneous mitral balloon valvotomy in a case of situs inversus dextrocardia with severe rheumatic mitral stenosis - Corrected Proof

Prashanth Kulkarni, Prabhu Halkati, Suresh Patted, Sameer Ambar, Suresh Yavagal — 2012-04-23

Abstract: The efficacy, safety and applicability of Inoue balloon technique for BMV are clearly established worldwide in selected subset of patients with rheumatic mitral stenosis (MS). However, in altered cardiac anatomy it offers technical challenges. Distorted cardiac anatomy and cardiac malpositions considerably increase the complications involved in interatrial septal puncture and left ventricular entry during BMV. There are only a few reports worldwide on successful BMV in altered cardiac anatomy using the standard Inoue technique. Here we describe a case of a 27-year-old female with situs inversus and dextrocardia, where BMV was successfully performed with a few modifications of the standard Inoue technique previously described in similar patients.

Transfemoral Edwards-Novaflex valve implantation in a patient with aorto-iliac endoprosthesis and severely tortuous bilateral external iliac arteries-“Railing track” - Corrected Proof

2012-04-20

Abstract: Transcatheter aortic valve implantation (TAVI) has nowadays been introduced as an alternative for surgical aortic valve replacement as a treatment for high risk aortic stenosis patients. This procedure is not free of complications: the SOURCE registry, indeed, showed that vascular complications are more frequent with the transfemoral approach. We present the case of an 82-year-old man with known history of severe aortic stenosis at high-risk for surgery. Pre-TAVI screening shows bilateral severely tortuous iliac arteries and aorto-bi-iliac endoprosthesis. Transapical TAVI as a first choice was rejected due to severe lung disease. The patient was then treated by Transfemoral TAVI using a dedicated interventional technique that is described in this case-report.

Doubling the clopidogrel dose in patients with reduced responsiveness to the standard dose is associated with a limited effectiveness as evaluated by impedance aggregometry - Corrected Proof

2012-04-16

Abstract: Background: Different methods are available for quantifying platelet function inhibition. Measuring vasodilator-stimulated phosphoprotein (VASP) phosphorylation is currently the most specific method for assessing the clopidogrel effect. The aim of our study was to compare different tests in view of a clinically applicable bedside test. Further, we examined whether doubling the clopidogrel dose to 150mg/d in clopidogrel low-responder would lead to a reduction in platelet reactivity.Methods and results: ADP-, ADP Hs-, and TRAP-induced platelet aggregation were measured by impedance aggregometry in 100 patients with CAD and 18 healthy controls. Moreover, platelet aggregation was assessed by flow cytometrical detection of VASP-phosphorylation and surface P-selectin in a subgroup of 34 patients and in healthy controls. Another 10 patients with CAD, identified as low-responder, were treated with a clopidogrel dose of 150mg/d. Thereafter, ADP-induced platelet aggregation was assessed by impedance aggregometry. Significant correlations were observed between ADP-induced platelet aggregation assessed by VASP-phosphorylation and by impedance aggregometry. Doubling the dose of clopidogrel to 150mg/d was associated with a reduction of ADP-induced platelet aggregation in only 60% of the patients.Conclusions: Impedance aggregometry is a valuable bedside test to assess platelet function inhibition. Doubling the clopidogrel dose is not effective to reduce high on-treatment platelet reactivity in almost half of these patients, pointing to the need of a more powerful platelet inhibitor.

Extra-corporeal life support, transradial thrombus aspiration and stenting, percutaneous blade and balloon atrioseptostomy, all as a bridge to heart transplantation to save one life - Corrected Proof

2012-04-05

Abstract: In patients with cardiogenic shock, the Extra-Corporeal Life Support (ECLS) has been shown to be lives saving. But, in some situations, it proves inadequate for the discharge of the left heart. Several device-based techniques have been proposed to decompress the left side either surgically or percutaneously, each of them with the proper potential risks and complications. One technique, the percutaneous blade and balloon atrioseptostomy that requires transseptal catheter based experience and consists of creating an atrial septal defect (ASD) could be an elegant technique as an “add on” to the classic assistance making together a bridge to partial recovery or to heart transplantation. Herein, we present a case of an adult patient who presented with inaugural resistant cardiac arrest with a thrombotic occlusion of the left anterior descending artery (LAD) who required Extra-Corporeal Life Support, thrombus aspiration, stenting of the culprit lesion, and percutaneous blade and balloon atrioseptostomy to bridge “safely” to the heart transplantation.

The impact of intracoronary thrombus aspiration on STEMI outcomes - Corrected Proof

2012-04-04

Abstract: Background: Manual coronary thrombus aspiration was associated with improved outcomes of ST-elevation myocardial infarction (STEMI) patients. We aimed to evaluate the outcome of aspiration in a “real-world” setting of primary percutaneous coronary intervention (PPCI).Methods and materials: We analyzed the outcome of STEMI patients who underwent PPCI (initial Thrombolysis in Myocardial Infarction flow grade 0/1), comparing patients who underwent aspiration (ASP) to those who had standard (STD) therapy. Various subgroups outcomes were further analyzed. Clinical end points included mortality and major adverse cardiovascular events (MACE) at 30 days and at 1 year.Results: One thousand thirty-five consecutive patients were included: 189 (18.26%) with ASP and 846 (81.74%) with STD. ASP patients were younger (58±12 vs. 61±13, P<.05) and had higher incidence of direct stenting compared to STD patients (34% vs. 16.7%, P<.05). No significant differences were noted in the outcome of ASP vs. STD at 30 days (mortality rate 4.2% vs. 4.5%, P=.9; MACE 6.9% vs. 9.8%, P=.2) and at 1 year (mortality rate 8.0% vs. 8.3%, P=.9; MACE 20.0% vs. 22.3%, P=.5). A significant advantage in favor of ASP was evident in patients with proximal culprit lesions, anterior infarcts, and right ventricular involvement.Conclusions: Although this was largely a negative study, when STEMI involved a large jeopardized myocardium, aspiration was associated with sustained improved clinical outcomes.

Spontaneous coronary artery dissection: one entity with several therapeutic options - Corrected Proof

2012-04-04

Abstract: Spontaneous coronary artery dissection is an unusual and a rare cause of acute coronary syndrome and sudden death with multiple predisposing factors. Prompt recognition is crucial for appropriate patient management, but specific guidelines for optimal treatment are lacking. We report four cases of women with spontaneous coronary artery dissection revealed by ST-segment elevation, three in women during postpartum and one case associated with a Marfan syndrome. Our cases span the different therapeutic options from medical treatment, stenting, to coronary artery bypass graft surgery.

Successful percutaneous revascularization of totally occluded left subclavian artery using orbital atherectomy - Corrected Proof

Nuri Ilker Akkus, Faisal Bahadur, Mehmet Cilingiroglu — 2012-03-29

Abstract: Subclavian artery steal (SAS) after coronary artery bypass graft (CABG) has been reported to be as high as 3.4%. These patients with patent left internal mammary artery (LIMA) anastomosis will also have coronary–subclavian steal syndrome (CSSS). Percutaneous intervention (PCI) by balloon angioplasty (BA) and stenting has been done successfully for subclavian artery (SA) stenosis. The visibility of the vertebral artery (VA) and LIMA during BA and stent positioning is extremely important. Debulking total occlusions by orbital atherectomy (OA) and avoiding unnecessary BA, stenting across side branches may decrease the chance of plaque shifting and subsequent loss of flow especially if they have ostial disease. Herein we report successful OA, BA and stenting of chronic total occlusion (CTO) of proximal left subclavian artery in a patient with coronary–subclavian steal syndrome with preservation of LIMA and diseased left vertebral artery (VA).

Successful retrieval of a broken intravascular ultrasound catheter tip from a coronary artery - Corrected Proof

Atila Iyisoy, Murat Celik, Turgay Celik, Uygar Cagdas Yuksel, Samed Samedli — 2012-03-29

Abstract: The fracture of IVUS catheter tip in the coronary artery is a very rare complication. It should be removed as soon as possible. Although it seems to be easy at first glance, percutaneous retrieval of broken IVUS catheter tip has some challenges. We hereby present a case report of successful percutaneous retrieval of broken IVUS catheter, probably caused by calcific left main stenosis, from the left circumflex artery using loop snare technique.

Successful removal of an entrapped and kinked catheter during right transradial cardiac catheterization by snaring and unwinding the catheter via femoral access - Corrected Proof

2012-03-14

Abstract: Since its introduction by Campeau in 1989, the transradial approach for coronary angiography has gained significant popularity among interventional cardiologists due to its lower access site complication rates, cost-effectiveness, and shorter hospital course. Although the transradial approach is much safer than the transfemoral approach, it has its own inherent rare complications including radial artery occlusion, thrombosis, nonocclusive radial artery injury, vasospasm, and compartment syndrome. Herein, we present an unusual case of entrapment and kinking of a catheter in the radial artery, which was successfully removed by using a gooseneck snare via the transfemoral route. The distal and proximal tips were then simultaneously rotated in opposite directions, allowing for the unkinking and removal of the catheter. To our knowledge, this is the first report of this rare complication.

Inappropriate use of risk score models for operative mortality in nonsurgical treatments - Corrected Proof

Luc Noyez — 2012-03-14

In their article Itsik Ben-Dor et al. compare the accuracy of the STS (http://209.220.160.181/STSWebRiskCalc261/de.aspx) and the initial logistic EuroSCORE in predicting 30-day mortality in high-risk patients with severe aortic stenosis who were referred for possible transcatheter aortic valve implantation (TAVI). The total group was divided into three subgroups: group A patients treated by medical therapy, or balloon aortic valvuloplasty, group B, patients undergoing a ‘classic’ aortic valve replacement (AVR), and group C patients with a TAVI. The ability of the two risk scores to predict 30-day mortality for the three groups is poor (C-statistics <70). However the authors misuse the STS score and the EuroSCORE. Both risk stratification models are developed to calculate the risk of mortality of adult cardiac surgery. There is nowadays no discussion that this EuroSCORE overpredicts the risk of mortality of contemporary cardiac surgery and that the STS score is superior for patients undergoing aortic valve replacement . But these two models are not useful to predict mortality of TAVI procedures, and even not of patients undergoing a medical treatment. The most important reason is because these models are based on development data set without patients undergoing TAVI procedures, simply because these procedures didn't exist at that moment. And I agree with the authors that a specific dataset must be developed for these patients .

Embolic myocardial infarction diagnosed with Fourier domain optical coherence tomography - Corrected Proof

Righab Hamdan, Ricardo Garcia Gonzalez, Christophe Caussin, Said Ghostine — 2012-03-09

Abstract: We report the case of a young female with embolic myocardial infarction. The embolic etiology was confirmed by Fourier Domain Optical Coherence Tomography as well as histo-pathology.

Intravascular ultrasound lumen area parameters for assessment of physiological ischemia by fractional flow reserve in intermediate coronary artery stenosis - Corrected Proof

2012-02-16

Abstract: Background: A fractional flow reserve (FFR) of <0.8 is currently used to guide revascularization in lesions with intermediate coronary stenosis. Whether there is an intravascular ultrasound (IVUS) measurement or a cutoff value that can reliably determine which of these intermediate lesions requires intervention is unclear.Aims: We assessed IVUS measurement accuracy in defining functional ischemia by FFR.Methods: The analysis included 205 intermediate lesions (185 patients) located in vessel diameters >2.5 mm. Positive FFR was considered present at <0.8. IVUS measurements were correlated to the FFR findings in intermediate lesions with 40%–70% stenosis. Fifty-four (26.3%) lesions had FFR<0.8.Results: There was moderate correlation between FFR and IVUS measurements, including minimum lumen area (MLA) (r=0.36, P 3.5 mm.Conclusion: Anatomic measurements of intermediate coronary lesions obtained by IVUS show a moderate correlation to FFR values. The correlation was better for larger-diameter vessels. Vessel size should always be taken into account when determining the MLA associated with functional ischemia.

Direct aortic transcatheter aortic valve implantation: a feasible approach for patients with severe peripheral vascular disease - Corrected Proof

Eduardo Alegría-Barrero, Pak Hei Chan, Carlo Di Mario, Neil E. Moat — 2012-02-16

Abstract: Aortic stenosis is a prevalent disease with poor prognosis if left untreated. Transcatheter aortic valve implantation (TAVI) is an emerging treatment for patients at high risk for surgery. We describe a patient withno suitable peripheral access due to peripheral vascular disease (PVD) for TAVI. Direct aortic approachvia an 18-Fr sheath inserted into the ascending aorta was successfully performed with a 29-mm CoreValve implanted. Direct aortic approach is feasible for TAVI in patients with severe PVD without good peripheral access.

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.

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.