Additional Balloon Dilatation Research Articles

Double Kissing Mini-Culotte Stenting in Unprotected Distal Left Main Bifurcation Under Optical Coherence Tomography Guidance: Immediate and Short-Term Outcomes

IntroductionCulotte stenting is an effective strategy for left main coronary bifurcation lesions. Increased side branch ostial restenosis is the main drawback of Culotte stenting. This is due to a napkin ring or potential gap produced at the ostium of the side branch. A bench study by Toth et al. has shown that additional sequential kissing balloon dilation before main vessel stenting can prevent this deformity. AimWe report immediate and short-term results of Double Kissing (DK) mini-Culotte stenting with a one-year angiographic follow-up. MethodsForty-five patients of distal left main (LM) disease underwent DK mini-Culotte stenting at our center between March 2020 and December 2022 under Optical Coherence Tomography (OCT) guidance. ResultsOut of 45 patients [male:35(77.77%); mean age:63.67±4.94years], chronic coronary syndrome was present in 26(57.8%) and unstable angina in rest. All lesions were Medina (1,1,1), (0,1,1), or (1,0,1) with a median Syntax score of 28 (IQR=23-29). All procedures were technically successful with no adverse clinical events (death, myocardial infarction, or stent thrombosis). Under OCT guidance, adequate minimal stent area (MSA) of 13.28 ± 0.77mm2, 8.25 ± 0.29 mm2, and 7.54 ± 0.45mm2 was achieved in LM, left anterior descending (LAD) and left circumflex (LCx) respectively. Adequate stent expansion of >80% was achieved in all cases. At the end of 1 year, the incidence of major adverse cardiovascular events (MACE) was 2.2%. Further, one (2.2%) patient developed restenosis of the side branch which was managed conservatively. ConclusionDK mini-Culotte stenting in the distal left main bifurcation has shown promising results and is effective in preventing side branch stent deformation and its sequelae of in-stent restenosis.

LIMITATIONS OF RADIOGRAPHIC IMAGING IN DIAGNOSING FOREIGN ORGANIC MATTER ASPIRATION

LIMITATIONS OF RADIOGRAPHIC IMAGING IN DIAGNOSING FOREIGN ORGANIC MATTER ASPIRATION

Tissue characterisation and primary percutaneous coronary intervention guidance using intravascular ultrasound: rationale and design of the SPECTRUM study

IntroductionIntravascular ultrasound (IVUS) improves clinical outcome in patients undergoing percutaneous coronary intervention (PCI) but dedicated prospective studies assessing the safety and efficacy of IVUS guidance during primary PCI are lacking.Methods...

Long-term clinical results of per-oral endoscopic myotomy (POEM) for achalasia: First report of more than 10-year patient experience as assessed with a questionnaire-based survey.

Background and study aims Since per-oral endoscopic myotomy (POEM) was introduced in 2010, it has become accepted as one of the standard treatments for esophageal achalasia worldwide. This study aimed to present long-term clinical results of POEM over 10 years and evaluate the technique and outcomes at the institution where it was first used in clinical settings. Patients and methods Questionnaire-based surveys were sent to patients who received POEM in our institution from September 2008 to May 2010. Patient demographics and procedural outcomes and open-ended questions were posed about the postoperative courses, including symptom improvement and recurrence, additional treatments, and post-POEM gastroesophageal reflux disease (GERD) symptoms. Achalasia symptoms and post-POEM GERD symptoms were evaluated with Eckhardt scores and GerdQ systems, respectively. Results Thirty-six consecutive POEMs were performed in that period and 10-year follow-up data were obtained from 15 patients (41.7 %). Although four cases (26.7 %) required additional pneumatic balloon dilatation (PBD), reduction in post-Eckardt scores were observed in 14 cases (93.3 %). GerdQ score was positive in one patient (6.7 %). Proton pump inhibitors (PPI) were taken by four patients (26.7 %) and their symptoms were well-controlled. Conclusions Clinical results of POEM over 10 years were favorable regardless of various factors. Symptoms improved even in patients who required additional treatments, suggesting that POEM plays a significant role in treatment of achalasia.

Interventional therapy via flexible bronchoscopy in the management of foreign body-related occlusive endobronchial granulation tissue formation in children.

Occlusive granulation tissue formation, as one of the most common sequelae of chronic foreign body aspiration, can cause tracheobronchial obstruction and delayed fixed airway stenosis necessitating interventions. The aim of this study was to explore the clinical efficacy and safety of interventional therapy via flexible bronchoscopy for treatment of granulation tissue related airway obstruction secondary to foreign body aspiration in children. Patients with long-term foreign body related granulation tissue were treated with flexible bronchoscopy therapeutic modalities, including forceps, cryotherapy, holmium laser, and balloon dilatation. Clinical efficacy was evaluated by clinical symptoms and endoscopic manifestations. A total of eight patients with granulation tissue hyperplasia caused by foreign body in bronchus, with a median age of 29.5 (range, 18-54) months, underwent interventional therapy between January 2016 and December 2019. Four patients received forceps and CO2 cryotherapy and one patient required forceps only. The remaining three patients received holmium laser combined with CO2 cryotherapy, and one of them required additional balloon dilatation. Four cases required a second cryotherapy procedure, and one case received three cryotherapy procedures for extensive granulation tissue. The treatment efficacy was 100% without complications. Interventional procedure via flexible bronchoscopy is a safe, reliable, and effective method in the management of tracheobronchial obstruction and stenosis caused by foreign body-related granulation tissue hyperplasia. It is worthy of clinical application.

Retrograde three-dimensional rotational angiography: A novel method for the detection of plaque protrusion during carotid artery stenting under continuous distal balloon protection.

To prevent ischemic complications during carotid artery stenting, accurate detection of plaque protrusion and appropriate additional treatment are essential. Here, we introduce a novel method for the detection of plaque protrusion under distal balloon protection using three-dimensional rotation angiography-"retrograde 3DRA." We evaluated the safety and efficacy of this method. We retrospectively analyzed 28 consecutive carotid artery stenting procedures under distal balloon protection at our hospital between July 2017 and August 2019. The first line of protection was dual balloon protection (proximal and distal balloon). After stent deployment, balloon dilatation, and subsequent blood aspiration, 3DRA was performed with the injection of diluted contrast medium from the aspiration catheter positioned just proximal to the distal protection balloon. The stent lumen was analyzed by obtaining the reconstruction maximum intensity projection image. Among the 28 cases, all cases could be assessed for in-stent plaque protrusion using "retrograde 3DRA." We were able to evaluate the stent lumen clearly. There were three cases (10.7%) in which plaque protrusion could be confirmed. Since additional balloon dilatation was performed for all protrusion cases under continuing balloon protection, no ischemic complications occurred. Retrograde 3DRA could be safe and useful for the detection of plaque protrusions and to avoid ischemic complication for tolerable cases of internal carotid artery transient balloon protection.

Stent-retriever thrombectomy in the treatment of infants with acute thrombosis of the superior vena cava and innominate vein.

To describe the efficacy and safety of stent-retriever thrombectomy in infants with thrombosis of the superior vena cava (SVC) and innominate vein. Thrombosis of the SVC and of the innominate vein is a potentially life threatening complication in infants during intensive care treatment following major surgical procedures. To avoid reoperations, we evaluated interventional revascularization by stent-retriever thrombectomy. From 2015 to 2017, five infants were diagnosed with acute thrombosis of the SVC and innominate vein following major cardiac or pediatric surgery. Using a femoral venous access and 4 or 5 French guiding catheters stent-retriever systems (4/20 mm or 6/30 mm) were placed into the thrombus and retrieved under suction. We aimed to revascularize not only the SVC but also the innominate, jugular, and subclavian veins. Following repeated stent retrieving manoeuvers, we were able to reestablish flow in the major veins of all patients. Due to significant residual thrombotic material, we decided to perform additional balloon dilatation of the SVC and innominate vein in 3/5 patients. There were no complications related to the procedure and none of our patients required blood transfusion. Following the intervention, the patients received treatment with low-molecular-weight heparin. Interventional treatment achieved persistent patency of the SVC and innominate vein in all patients. Stent-retriever thrombectomy is a safe and effective method for interventional treatment of acute thrombosis of the central veins in infants. Due to the large amount of thrombotic material, it is frequently required to combine this method with balloon compression of residual thrombotic material.

Impact of Prolonged Inflation Times During Plain Balloon Angioplasty on Angiographic Dissection in Femoropopliteal Lesions

Purpose: To investigate if balloon angioplasty with a prolonged inflation time (>3 minutes) can prevent postdilation dissection in femoropopliteal lesions. Methods: A retrospective single-center analysis examined 294 consecutive patients (mean age 74.1±8.7 years; 215 men) with de novo femoropopliteal lesions treated with balloon angioplasty between 2013 and 2018. The patients were classified into 2 groups to compare angiographic dissection patterns: 175 patients treated with balloon angioplasty for 3 minutes (3-minute group) and 119 treated for >3 minutes (>3-minute group). Results: Mean balloon inflation time was 7.8±2.7 minutes in the >3-minute group. Severe dissections (type C or higher) were observed less frequently after balloon dilation in the >3-minute group (22.7% vs 50.9%, p<0.001); therefore, significantly more patients in the >3-minute group had successful endovascular treatment after initial balloon angioplasty (57.1% vs 38.3%, p=0.001). Additional balloon dilation was attempted more frequently in the 3-minute group (30.9% vs 14.3%, p=0.001); as a result, there were more patients in whom additional balloon dilation repaired severe dissection that occurred after the initial dilation (25.1% vs 10.9%, p=0.001). Multivariate analysis revealed that chronic total occlusion (p<0.001) and longer lesion (p<0.001) were independent predictors of severe dissection, and prolonged dilation time was independently related to preventing severe dissection (p<0.001). Among 171 patients undergoing successful balloon angioplasty without stent implantation, the Kaplan-Meier estimates of primary patency within 1 year did not differ significantly according to inflation time. Conclusion: Balloon dilation with prolonged inflation time (>3 minutes) may be effective as an initial strategy to prevent severe dissection in femoropopliteal lesions compared to inflation for 3 minutes.

Efficacy of local injection of triamcinolone and oral methylprednisolone in preventing stricture formation after endoscopic submucosal dissection in early esophageal cancer

Objective To compare the efficacy and safety between local injection of triamcinolone and oral methylprednisolone in preventing esophageal stricture formation after endoscopic submucosal dissection (ESD) in patients with early esophageal cancer. Methods From January 2014 to January 2016, 67 patients with early esophageal cancer were enrolled, all of them received ESD and were divided into triamcinolone injection group (22 cases), oral methylprednisolone group (22 cases) and control group (23 cases). Patients of triamcinolone group received injection of triamcinolone at injured mucosal under endoscope immediately after ESD. Patients of oral methylprednisolone group took methylprednisolone 30 mg per day since the third day after ESD, and then dosage reduced 5 mg every other week until drug withdrawal. Patients of control group only received ESD. After operation, gastroendoscopy examination was repeated to evaluate the extent of esophageal stricture. Patients with esophageal stricture were treated with an additional endoscopic balloon dilatation (EBD). The rate of esophageal stricture and the frequency of EBD treatment of the three groups were compared. Chi-square test, Wilcoxon rank sum test and Kruskal-Wallis rank sum test were used for statistical analysis. Results The rates of esophageal stricture of triamcinolone injection group, oral methylprednisolone group and control group were 18.2% (4/22), 13.6% (3/22) and 73.9% (17/23), respectively, and the difference was statistically significant (χ2=22.20, P<0.01). There was no significant difference in the rates of esophageal stricture between triamcinolone injection group and oral methylprednisolone group (χ2=0.17, P=0.50), but the rate of esophageal stricture in triamcinolone injection group was lower than control group, and the difference was statistically significant (χ2=14.03, P<0.01); the rate of esophageal stricture in oral methylprednisolone group was lower than control group, and the difference was also statistically significant (χ2=16.55, P<0.01). The median frequency of EBD treatment of triamcinolone injection group, oral methylprednisolone group and control group were 2.1 (range 0 to 4.0), 1.6 (range 0 to 3.0) and 6.0 (range 0 to 13.0) times, respectively, and the difference was statistically significant (H=17.80, P<0.01). There was no significant difference in the frequency of EBD treatment between triamcinolone injection group and oral methylprednisolone group (Z=1.21, P=0.23); but the frequency of EBD treatment in triamcinolone injection group was less than control group, and the difference was statistically significant (Z=4.96, P<0.01); the frequency of EBD treatment in oral methylprednisolone group was less than control group, and the difference was also statistically significant (Z=4.32, P<0.01). There was no severe adverse effect in the three groups. Conclusions Local injections of triamcinolone and oral methylprednisolone both reduced the rate of esophageal stricture after ESD, and decreased frequency of EBD treatment in patients with esophageal stricture. The two regimens showed equal efficacy and good safety. Key words: Triamcinolone acetonide; Methylprednisolone; Esophageal neoplasms, early; Esophageal stenosis

Endoscopic Balloon Dilatation of Nasopharyngeal Stenosis in a Dog

A four-year old, intact male, mixed-breed dog had a history of chronic snoring sound and dyspnea. Based on the results of computed tomography, the patient was diagnosed as nasopharyngeal stenosis. Balloon dilatation in the area of stenosis was performed using a balloon dilator inserted retrograde fashion through the working channel of an endoscope. Clinical signs were relieved but reappeared after 3 weeks. Thirty-four days following the first balloon dilatation treatment, a second procedure was performed; the balloon catheter was inserted in antegrade fashion through the left nostril and was filled with contrast agent under fluoroscopic guidance. Because of the relapse of clinical signs after 6 months, the patient received additional balloon dilatation procedure by the antegrade approach. At the oneyear follow-up, the owner said that the clinical signs of nasopharyngeal stenosis had been completely resolved. Balloon dilatation could be a minimally invasive and effective treatment for nasopharyngeal stenosis, although the repetition of the procedure may be required.

Von Willebrand Factor Multimers during Transcatheter Aortic-Valve Replacement

BackgroundPostprocedural aortic regurgitation occurs in 10 to 20% of patients undergoing transcatheter aortic-valve replacement (TAVR) for aortic stenosis. We hypothesized that assessment of defects in high-molecular-weight (HMW) multimers of von Willebrand factor or point-of-care assessment of hemostasis could be used to monitor aortic regurgitation during TAVR.MethodsWe enrolled 183 patients undergoing TAVR. Patients with aortic regurgitation after the initial implantation, as identified by means of transesophageal echocardiography, underwent additional balloon dilation to correct aortic regurgitation. HMW multimers and the closure time with adenosine diphosphate (CT-ADP), a point-of-care measure of hemostasis, were assessed at baseline and 5 minutes after each step of the procedure. Mortality was evaluated at 1 year. A second cohort (201 patients) was studied to validate the use of CT-ADP in order to identify patients with aortic regurgitation.ResultsAfter the initial implantation, HMW multimers normalized in patients without aortic regurgitation (137 patients). Among the 46 patients with aortic regurgitation, normalization occurred in 20 patients in whom additional balloon dilation was successful but did not occur in the 26 patients with persistent aortic regurgitation. A similar sequence of changes was observed with CT-ADP. A CT-ADP value of more than 180 seconds had sensitivity, specificity, and negative predictive value of 92.3%, 92.4%, and 98.6%, respectively, for aortic regurgitation, with similar results in the validation cohort. Multivariable analyses showed that the values for HMW multimers and CT-ADP at the end of TAVR were each associated with mortality at 1 year.ConclusionsThe presence of HMW-multimer defects and a high value for a point-of-care hemostatic test, the CT-ADP, were each predictive of the presence of aortic regurgitation after TAVR and were associated with higher mortality 1 year after the procedure. (Funded by Lille 2 University and others; ClinicalTrials.gov number, NCT02628509.)

Fluoroscopically guided large balloon dilatation for treating congenital esophageal stenosis in children.

We aimed to evaluate the safety and clinical effectiveness of fluoroscopically guided large balloon dilatation for treating congenital esophageal stenosis in children. Our study included seven children (mean age 4.0 years) who underwent a total of ten balloon dilatation sessions. The initial balloon diameters were 10-15 mm. The technical success, clinical success (improved food intake and reduced dysphagia within 1 month following the first balloon dilatation), dysphagia recurrence, and complications were retrospectively evaluated. Technical and clinical success rates were 100 %. During the mean 38-month follow-up period after the first balloon dilatation, 3 (43 %) patients underwent only one additional balloon dilatation 4-5 months after the first balloon dilatation for dysphagia recurrence. Two of them showed improvement without further recurrence, while the remaining one underwent partial esophagectomy. Well-contained transmural esophageal rupture (type 2) occurred in two (29 %, 2/7) patients and during two (20 %, 2/10) balloon dilatation sessions. All ruptures were successfully treated conservatively. Our study showed that fluoroscopically guided large balloon dilatation seems to be a simple and effective primary treatment technique for congenital esophageal stenosis in children. Esophageal ruptures were not uncommon although they were not fatal.

Su1640 Additional Sphincterotomy Versus Endoscopic Papillary Balloon Dilation for the Management of Recurrent Difficult Bile Duct Stone After Previous Endoscopic Sphincterotomy

Su1640 Additional Sphincterotomy Versus Endoscopic Papillary Balloon Dilation for the Management of Recurrent Difficult Bile Duct Stone After Previous Endoscopic Sphincterotomy

A Prospective Randomized Trial of Catheter-Directed Thrombolysis With Additional Balloon Dilatation for Iliofemoral Deep Venous Thrombosis: A Single-Center Experience

Catheter-directed thrombolysis (CDT) is effective for acute iliofemoral deep venous thrombosis (DVT), but CDT remains partially effective for subacute DVT. The aim of this study was to conduct a prospective randomized controlled single-centre clinical trial to compare CDT alone with CDT with additional balloon dilatation for the treatment of iliofemoral DVT. The trial was performed between February 2007 and January 2011. Iliofemoral DVT patients lacking effective therapy before enrollment were randomly assigned either to CDT (control group) or to CDT with additional balloon dilatation (intervention group). Insufficiency Epidemiological and Economic Study-Quality of Life (VEINES-QOL), Severity of Venous Lower Limb Symptoms (VEINES-Sym), 36-Item Short-Form Health Survey (SF-36), and Villalta scores were obtained at scheduled follow-up. Seven hundred twenty-two patients were screened, and 386 eligible patients were randomized. No significant difference for mean total Villalta score was observed between the intervention group (4.20±3.05) and the control group (4.89±3.45). However, post hoc analysis of the scores in subacute patients showed significant differences between the intervention group and the control group from 1month (6.79±4.23, 8.28±5.03, P=0.02) to 24months (4.21±3.08, 5.67±3.71, P=0.006). A significant difference was also observed in subacute patients at the end of follow-up for VEINES-QOL/Sym (52.87±6.52, 50.31±6.07, P=0.009; 51.87±6.37, 49.72±5.96, P=0.02) and SF-36 PCS/MCS (45.02±12.07, 41.13±11.68, P=0.03; 53.26±11.43, 49.50±11.06, P=0.03). Subacute iliofemoral DVT patients lacking effective therapy during acute phase, might receive more benefits from CDT with additional balloon dilatation. However, CDT alone is highly effective for acute patients.

EndoAnchor Placement in Thoracic and Thoracoabdominal Stent-Grafts to Repair Complications of Nonalignment

To report our early experience in repairing incomplete sealing or nonalignment of thoracic or thoracoabdominal stent-grafts using EndoAnchors. Six patients (5 men; mean age 67 years, range 56-76) with thoracic or thoracoabdominal aortic stent-grafts and persistent type I endoleak (n=4), stent-graft migration (n=2), partial stent-graft infolding (n=2), and/or side branch malperfusion (n=1) were treated using the Heli-FX Aortic Securement System. Stent-graft or uncovered stent extension did not improve alignment in 3 patients prior to the use of EndoAnchors. Intended fixation of the proximal stent-graft in the aortic arch (n=1) and the proximal (n=3) or distal (n=2) descending thoracic aorta was achieved in all 6 patients using 28 EndoAnchors (3-7 per patient). Two to 4 EndoAnchors were placed at the site of the nonalignment and an additional 2 to 4 to fix the entire circumference of the stent-graft. The majority of the EndoAnchors were delivered successfully at the first attempt, but 5 required reapplication during the same intervention (no EndoAnchors were lost). No additional balloon dilation or other adjunctive maneuver was required for improvement of thoracic stent-graft fixation after the deployment of the EndoAnchors. The intraoperative and early postoperative periods were uneventful in 5 patients; however, one TAAA patient with a fenestrated aortic arch stent-graft suffered from multiple visceral and cerebral infarctions and died 4 weeks later. During the mean 11-month follow-up (range 5-22), no stent-graft migration or EndoAnchor dislocation has been observed. There have been no periaortic hematomas or side branch complications. Although the number of patients treated so far is small, the Heli-FX Aortic Securement System seems to be a feasible and safe treatment option for primary or secondary procedures in patients with complications of proximal or distal thoracic stent-graft nonalignment. However, extensive endovascular interventions in the proximal aortic arch should be performed with caution because of an increased risk of severe embolic events.

Two cases of acute myocardial infarction during combined chemotherapy in young patients with testicular cancer

The two patients were males aged over 30 years. To treat testicular tumors, combination chemotherapy with bleomycin, etoposide, and cisplatin (BEP) had been employed. In case 1, during the 4th course of BEP therapy, thoracic pain suddenly appeared. Emergency coronary angiography revealed thrombus formation. Under a diagnosis of thrombus-related acute myocardial infarction, thrombus aspiration was conducted, and stent implantation was performed because mild stenosis and residual thrombus were observed. In case 2, during the 2nd course of BEP therapy, thoracic pain suddenly appeared. Emergency coronary angiography revealed thrombus formation. Intracoronary infusion of pro-urokinase was performed, and additional balloon dilatation was conducted because mild stenosis and residual thrombus were observed. In both cases, the courses were favorable, and the levels of coagulation markers on admission were high. When selecting combination chemotherapy in patients with coronary risk factors, such as obesity and smoking, despite a young age, as demonstrated in these two patients, it may be important to consider combination therapy with anticoagulants or switching to anticancer drugs that do not show vascular toxicity.<Learning objective: When performing combination chemotherapy with bleomycin, etoposide, and cisplatin in young patients with coronary risk factors such as obesity and smoking, it may be important to examine combination therapy with anticoagulants or switching to anticancer drugs that do not show vascular toxicity, considering the possibility of cardiovascular disease onset, including acute myocardial infarction.>

Optical coherence tomography guided in-stent thrombus removal in patients with acute coronary syndromes

The persistence of thrombus inside stent struts is a frequent event in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI), and this phenomenon might be associated with an increased risk of stent thrombosis. We sought to quantify by means of optical coherence tomography (OCT) the presence of in-stent thrombus after achievement of an optimal angiographic result in patients with ACS undergoing PCI. In addition, we evaluated the feasibility and safety of an OCT-guided strategy of in-stent thrombus removal. Eighty consecutive patients with ACS undergoing PCI were treated with two different strategies equally divided into two groups: angio-guided PCI, and OCT-guided PCI, in which additional OCT-driven in-stent balloon dilatation was adopted to reduce thrombus encroachment of the lumen. Overall in-stent thrombus area was 4.3 % with a maximal thrombus encroachment of 16.7 %. In the OCT-guided group, use of high pressure intra-stent dilatation led to a significant increase in stented area (9.6 ± 2.4 vs. 9.1 ± 2.49 mm(2), p = 0.002) and lumen area (9.2 ± 2.4 vs. 8.7 ± 2.3 mm(2), p < 0.001) and also significantly decreased in-stent thrombus area in absolute (0.35 ± 0.29 vs. 0.42 ± 0.30 mm(2), p = 0.001) and relative terms (3.58 ± 3.25 vs. 4.53 ± 3.01 %, p = 0.001). Values of TIMI flow, frame count and blush grade, as well as clinical outcomes were not detrimentally affected by such additional dilatations. The use of additional OCT-driven in-stent balloon dilatations is feasible, safe and might be effective in the treatment of in-stent thrombus for patients with ACS.

COMPARISON OF OSTIAL AND CROSSOVER DRUG-ELUTING STENT IMPLANTATION TECHNIQUE FOR MEDINA (0,1,0) OR (0,0,1) BIFURCATED LESION

Background: For Medina (0,1,0) and (0,0,1) lesion, stent implantation at ostium of bifurcation may finish with incomplete coverage of lesion and may cause proximal edge restenosis. But if we crossover other branch with stent, additional balloon dilatation for healthy vessels through jailed strut to maintain access route for other branch with single balloon or kissing balloon technique may be needed. So this study was aimed to investigate the outcomes of ostial and crossover stent implantation for Medina (0,1,0) and (0,0,1) bifurcated lesion.

Thrombus aspiration alone during primary percutanous coronary intervention as definitive treatment in acute ST‐elevation myocardial infarction

In some patients with ST-segment elevation myocardial infarction (STEMI) who underwent primary percutanous coronary intervention (pPCI) with thrombus aspiration, residual stenosis after thrombus aspiration is non-significant and additional balloon dilatation or stent placement may be unnecessary. We investigated the angiographic, procedural, and clinical outcomes of these patients in our single center pPCI-database. In addition, to gain insight in the pathological mechanisms of coronary thrombosis in these patients, we established the histopathological characteristics and age of the aspirated material. This study consists of STEMI patients who underwent pPCI with thrombus aspiration alone in our institution. Thrombus material was collected and processed and the sections were analyzed for the presence of fresh (<1 day) or older thrombus (>1 day) and plaque components. One year clinical follow-up was obtained and vital status was assessed up to March 2010. We identified 16 STEMI patients who underwent thrombus aspiration alone as the definitive treatment during pPCI. Acceptable flow with minimal non-significant residual stenosis immediately after thrombus aspiration was present in 14 patients (88%). In four patients (25%) repeat angiography was performed after several days and disappearance of the residual thrombus could be confirmed in three patients. During follow-up, repeat target lesion revascularization was performed in one patient at 53 days. No recurrent myocardial infarction was observed. Two patients died 1,166 and 1,228 days after the index-event from non-cardiac causes. In selected STEMI patients undergoing pPCI, thrombus aspiration alone is feasible and safe on the short-term and there appears to be no high risk of recurrent ischemic events during follow-up. Our results suggest that additional balloon inflation or stent implantation may be unnecessary in selected patients, when there is no significant residual stenosis after thrombus aspiration.

Simultaneous resection of Barrett's esophageal cancer and severe stenosis caused by reflux esophagitis

A 60-year-old woman presented with dysphagia. Upper endoscopy revealed severe stenosis in Barrett’s esophagus with the internal diameter narrowed to 8 mm (Fig. 1). Contrast-enhanced CT ruled out metastasis. Tongueshaped brownish areas, where adenocarcinoma had been diagnosed, were approximately 5 to 7 mm in diameter. ESD extending 5 cm in the longitudinal direction was performed to resect the adenocarcinoma and the nearcircumferential stenosis site. Considering the severe fibrosis present, surgical entry was made 3 cm from the proximal end. At the stenosis site, EUS (20 MHz) revealed an intact submucosal layer around 0.5 mm of the circumference. In a retroflexed view from the stomach, we made an incision on the distal side of the stenosis. By advancing the endoscope into the submucosal layer by using the tunnel technique, we observed the most severe scarring (Fig. 2). Circumferential resection was completed (Fig. 3). Postoperative pathology revealed high-grade dysplasia and Barrett’s well-differentiated adenocarcinoma (Fig. 4). Kenacort was applied, and balloon dilation was performed on postoperative day (POD) 5 to prevent stenosis. The muscularis was exposed over the ulcer surface, and it was possible to permeate the gel into the remaining muscularis by expanding the balloon. Granulation tissue accompanied by extensive microvasculature was observed by magnified narrow-band imaging endoscopy on POD 12. By POD 15, granulation tissue was replaced by regenerating epithelium, with no post-ESD stricture formation apparent. On POD 60, Gastrografin contrast imaging confirmed smooth passage past the post-ESD lesion, and additional balloon dilation (to 18 mm) was performed. No stenosis or clinical symptoms were apparent at POD 90. n