Aortic Angioplasty Research Articles

Aortic Angioplasty Facilitated by Intravascular Lithotripsy

Aortic Angioplasty Facilitated by Intravascular Lithotripsy

Interventional cardiac catheterization in neonates and premature infants with congenital heart disease: a single center experience.

The increased survival of patients with congenital heart disease over the last three decades has been associated with improvements in diagnosis and treatment. This study aimed to evaluate therapeutic interventional catheterization, outcomes and complications of these procedures in neonates and premature infants. In this study, therapeutic catheterization procedures performed on neonates and premature infants with congenital heart disease at a university hospital between February 2000 and October 2019 were retrospectively evaluated. A total of 322 procedures were performed on 279 neonates and 26 premature infants. Of the patients, 217 (67.4%) were male. The median age of the patients was 8 days (interquartile range [IQR] 2-20) and the median body weight was 3050 g (IQR 2900-3600). The most common procedures were balloon atrial septostomy, balloon aortic angioplasty, balloon pulmonary valvuloplasty and balloon aortic valvuloplasty (35.4%, 20.8%, 18.3% and 12.4% respectively). The most common diagnoses were transposition of the great arteries, coarctation of the aorta, pulmonary stenosis and aortic stenosis (26.7%, 19.3%, 15.2% and 11.5% respectively). Most procedures, 274 (85.1%), were successful. Complications were observed in 74 procedures (23%). Of these complications, 45 (14%) were minor and 29 (9%) were major. The most common complication was transient dysrhythmia (6.9%). There was no significant relationship between body weight, age and the rate of complications. However, longer procedure time and fluoroscopy time were associated with higher complication rates (p < 0.05). Four procedurerelated deaths were observed. Procedure-related complications are higher in the neonatal period. Although the complication rate varies according to the type of procedure, longer fluoroscopy time and procedure duration are associated with an increased complication rate. Procedures performed with the right indications, appropriate equipment and by experienced teams will play a key role in reducing complication rates.

Egg Shell Membrane as an Alternative Vascular Patch for Arterial Angioplasty.

Introduction: The egg shell membrane (ESM) is always considered as waste, but recent studies have shown that it has the potential to yield rapid re-endothelialization in vitro. We hypothesized that ESM and heparin-conjugated ESM (HESM) can be used as arterial patch in a rat aortic angioplasty model. Method: Sprague-Dawley rat (200 g) abdominal aortic patch angioplasty model was used. Decellularized rat thoracic aorta (TA) patch was used as the control; ESM patch was made of raw chicken egg; heparin-coated ESM (HESM) patch was made by using dopamine; anticoagulation properties were verified using platelet adhesion tests; the TA, ESM, and HESM patches were implanted to the rat aorta and harvested at day 14; and the samples were examined by immunohistochemistry and immunofluorescence. Result: The ESM patch showed a similar healing process to the TA patch; the cells could migrate and infiltrate into both patches; there was a neointima with von Willebrand factor-positive endothelial cells; the endothelial cells acquired arterial identity with Ephrin-B2- and dll-4-positive cells; there were proliferating cell nuclear antigen (PCNA)-positive cells, and PCNA and alpha smooth muscle actin dual-positive cells in the neointima in both groups. Heparin was conjugated to the patch successfully and showed a strong anticoagulation property in vitro. HESM could decrease mural thrombus formation after rat aortic patch angioplasty. Conclusion: The ESM is a natural scaffold that can be used as a vascular patch; it showed a similar healing process to decellularized TA patch; HESM showed anticoagulation property both in vitro and in vivo; and the ESM may be a promising vascular graft in the clinic.

Does age at aortic coarctation repair have an impact on left ventricle size and function?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Adults with repaired aortic coarctation (CoA) require lifelong follow-up due to late complications, including left ventricular (LV) myocardial dysfunction. Age at the time of CoA repair is an important prognostic factor in these patients (pts). Purpose To evaluate LV size, ejection fraction (EF) and global longitudinal strain (GLS) values using 2D speckle tracking echocardiography (STE) in a population of adult pts with repaired CoA and to assess the relationship between these echocardiographic parameters and age at the time of CoA repair. Methods Retrospective analysis of adult pts with repaired CoA, followed in a Grown Up Congenital Heart Disease Centre. Pts with hemodynamically significant concomitant cardiac lesions were ruled out. Epidemiologic and clinical data were obtained from clinical records. Transthoracic echocardiograms were reviewed in order to assess GLS using 2DSTE (Echopac Software, GE). Results The study population consisted of 63 pts (61.9% male), with a mean age of 35.3 years at the time of the echocardiographic evaluation. The mean age at the time of the CoA repair was 117 months (95% CI 89.8-144.1 months). Surgical repair was performed in 46 pts (73%): resection with subclavian artery flap aortoplasty (n = 21); patch aortoplasty (n = 15) and head-to-head anastomosis (n = 10). In 10 pts there was no data regarding the type of surgical repair. Seven pts (11.1%) were submitted to percutaneous intervention (6 with aortic stent implantation and 1 with balloon aortic angioplasty). Mean LVEF was 63.4% (CI 95% 55.6 – 71.2%) and mean LV end-diastolic diameter (LVEDD) was 50mm (CI 95% 43-57mm). Mean GLS was - 17.3 (CI 95% 14.8- 19.8), which is inferior to the mean normal values reported for the software used. Age at the time of CoA repair had a statistically significant positive linear relationship with LVEDD (r= 0.282; p= 0.026) and a linear negative relationship with both GLS (r= -0,29; p= 0.022) and LVEF (r= -0.33; p= 0.05). Conclusion Older age at the time of CoA repair was associated with increased LVEDD and decreased GLS and LVEF. Also, GLS may be an important tool for the identification of subclinical LV dysfunction in adult pts with repaired CoA.

Abstract No. 374 Juxtarenal aortic angioplasty in the patients of Takayasu arteritis presenting in emergency with uncontrolled hypertension: experience from a tertiary care center

Takayasu’s arteritis (TA) can involve aorta and its major branches. With recent technical advances, endovascular treatment gaining attention in the management of TA. The involvement of juxta-renal abdominal aorta is quite challenging to treat because of close vicinity of visceral branches and renal arteries, which has got potential for obstructing these important branches and further worsening the clinical symptoms. Stenting in this territory is also fought with fear because of the same reasons. We retrospectively analyzed safety and outcome of juxta-renal abdominal aortic angioplasty in TA patients presenting in emergency with uncontrollable hypertension. We retrospectively analyzed the departmental data of aortic interventions in TA between 2015 to 2019. We found total of 38 patients of TA, in whom supra to infrarenal aortic interventions were performed. Among these patients, 8 patients met our study criteria and all of them underwent only juxtarenal abdominal aortic angioplasty. The patients aged from 7 to 40 years. 6 patients were females and 2 were males. All of them had uncontrollable hypertension with significant juxta-renal aortic stenosis (pressure gradient > 20 mm Hg). Juxta-renal aortic angioplasty was performed in all the patients, leaving residual stenosis of 30-40% stenosis and residual pressure gradient of 20 to 30 mm Hg. All the patients except one patient developed non obstructive focal dissection flap. However, none of them were causing visceral branch obstruction and managed conservatively. In one patient, the flap was extending to right renal artery which was managed with renal angioplasty. None of the patients underwent aortic stenting. Despite intermediate angiographic results, there was short-term clinical improvement with adequate control of BP. The juxta-renal aortic lesions are quite challenging, whether it is surgical or endovascular treatment. Surgical management is associated with high morbidity and mortality. Endovascular technique provide alternative treatment option in these kind of challenging anatomy. It is feasible and provide good early outcome results. Despite intermediate angiographic results, the clinical outcomes are adequate.

55 Determination of local interventional reference levels in heart surgery using a dose archiving and communication system

Introduction In cardiology, exposure of patients to ionizing radiations can reach significant levels and may sometimes cause serious complications. By taking advantage of the connection of a cardiac surgery room to the DACS (Dose Archiving and Communication System), we are seeking to determine the Local Interventional Reference Levels (IRLs) for procedures performed in this room. Methods The heart surgery department of the Pitie-Salpetriere hospital has a fixed installation (Allura Xper FD20, Philips) connected to the institutional DACS, RDM (Radiation Dose Monitor, Medsquare) since June 2016. This retrospective study examines the files recorded in the DACS of all the patients that underwent a surgery using this installation from June 2016 to December 2017. For all the files considered, the procedure indicated in the DACS is reassigned as a function of the act performed. Three main groups were defined: ECMO (ExtraCorporeal Membrane Oxygenation), Endoprosthesis and TAVI (Transcatheter Aortic Valvular Implantation). Acts such as aortic dilatation, pacemaker insertion or angioplasty, less frequent in this room, are clustered in ”Other acts”. Patients for whom the procedures are not known are gathered in a last group: NA. For the 3 main groups, medians, 75th percentiles (local IRLs), means, standard deviation, minimum and maximum values for the Dose Area Product (DAP, in mGy.cm2), the air kerma (Kair, in mGy) at the interventional reference point and the fluoroscopy time (min) are extracted using the DACS. Results A total of 430 files are recorded in the DACS: 16 in ECMO, 16 in Endoprosthesis, 275 in TAVI, 37 in Other Acts, 80 in NA. 6 files are excluded for recording reasons. For the ECMO, Endoprosthesis and TAVI groups, local IRLs of Kair are 120, 999 and 762 mGy, respectively. For DAP, the local IRLs are 46,867, 233,923 and 146,539 mGy.cm2, respectively. All the extracted values are shown in Table 1. Conclusions Once each of the surgical acts has been reassigned to a given procedure, the use of the DACS allows us to determine, quickly and globally, local IRLs for each procedure performed in this room. However, the reassignment of retrospective acts for this study is time-consuming: a priori assignment will be considered in the remainder of this work. The small number of files for ECMO and Endoprosthesis groups limits robustness of IRLs proposed for these acts. These acts being infrequent in this room, we will seek to expand the data to include a minimum of 30 files. On the other hand, for the TAVI group, the values obtained will be set as local IRLs in the DACS. Download : Download high-res image (638KB) Download : Download full-size image

Blunt Injury of the Innominate Artery: What Surprises to Expect? A Case Report

Injuries of the supra-aortic trunk after blunt chest trauma are rare. This is a case report of a blunt traumatic lesion of the innominate artery (IA) origin that exhibited aortic arch involvement with a focus on imaging and treatment. A 41-year-old fisherman presented an IA injury secondary to a high-impact blunt chest trauma. Upon physical examination, vital signs were stable and upper extremity pulses were present. In addition to several bone fractures (costal ribs, clavicle, scapula, temporal, maxillary, and sphenoid), computed tomography angiography revealed dissection/pseudoaneurysm of the IA sparing the bifurcation. The patient underwent emergent angiography, which confirmed that the IA dissection was not ruptured, but it was unclear whether there was a pseudoaneurysm at the origin of the IA or aortic arch involvement. The patient was considered for open surgery. An ascending aorta-to-IA bypass was achieved by the off-pump beating heart approach. The IA stump was carefully observed, but oversewing was not possible due to the extension of the intimal-medial lesions into the artic arch. An on-pump intervention was then required for aortic angioplasty with a pericardial patch that was reinforced by Gel Seal. The postoperative course was uneventful. The patient was discharged without any complications. Conventional surgery provides good results and should remain in the armamentarium for the treatment of traumatic lesions at the IA origin, particularly if aortic arch involvement cannot be ruled out, to ensure a truly patient-tailored approach.

Abstract 102: A Novel Swine Model of Infrarenal Abdominal Aortic Aneurysm

Introduction: A reproducible large animal model for abdominal aortic aneurysms (AAAs) does not exist. This study sought to develop a large animal AAA model in swine using β-aminopropionitrile (BAPN), a lysyl oxidase inhibitor, an enzyme responsible for collagen cross-linking. We hypothesized that elastase/collagenase perfusion and balloon dilatation in combination with BAPN administration would result in AAA formation. Methods: Uncastrated Yorkshire male swine were fed BAPN (0.12g/kg) daily for one week prior to surgery and continued throughout the experiment. After anesthesia, the aorta was exposed from the renal arteries to the aortic bifurcation. The infrarenal aorta was cannulated via the caudal mesenteric artery and an aortic angioplasty was performed to dilate the aorta to 200% of its original diameter. Next, a 30 mL solution consisting of 500 units of elastase and 8,000 units of Type I collagenase was perfused into the infrarenal aorta for 10 minutes. This solution was also then topically applied for 10 minutes. The abdomen was irrigated and closed. Antibiotics and analgesic medications were administered. Results: BAPN-fed swine sacrificed at 28 days (n=5) had a 101% increase in infrarenal aorta diameter compared with day 0 (p=0.008). Swine (n=4) sacrificed at 7 and 14 days showed an increase of 114 and 75%, respectively. Histologically on day 28, collagen decreased by 20% and smooth muscle cell expression decreased by 40% (p=0.0001) in the aortic wall compared with control suprarenal aorta. Infrarenal aortas also showed a strong predilection for M1-polarized macrophages (MCP-1 positive staining, p=0.0165) compared with M2 macrophages (Arg-1 positive staining). MMP2 activity by zymography (p=0.0127) and IL-18 by array was also significantly increased (p=0.0202) on day 28 in the infrarenal AAA. Conclusions: Compared with previous large animal AAA models, this model using conventional techniques including balloon dilatation, elastase/collagenase perfusion, in addition to oral BAPN led to robust AAA with similar molecular and histologic changes to those seen in human AAA. This novel swine AAA model may serve as a much-needed link that will allow for the progression of studies from rodents to humans.

Endovascular Treatment of Focally Dissected Infrarenal Abdominal Aorta with Self-expandable Closed Cell Design Bare Metal Stents

Summary Dissection restricted to the infrarenal aorta is very rare and accounts for less than 1% of all aortic dissections. Up to date, there are only few cases reported about endovascular repair of spontaneous infrarenal aortic dissection [1]. We present 49 years old female, hospitalized to emergency department with spontaneous onset of severe lower back pain. Laboratory tests were not remarkable. Abdominal CTA revealed focal dissection of infrarenal aorta. In order to avoid thrombosis of infrarenal aorta and prevent further distribution of intimal dissection, endovascular aortic angioplasty with self-expanding bare metal stents (SEMS) in overlapping technique was performed, avoiding otherwise complicated and traumatic open aortic repair. No intra- or postoperative complications were observed. In 3 month follow-up patient was asymptomatic, control CTA revealed only slight wall thickening in the area of aortic wall dissection with no signs of further extension of dissection upstream or downstream.

Lipoprotein associated phospholipase A2 mass level is elevated after transcatheter aortic valve implantation or ballon angioplasty in elderly patients

Lipoprotein associated phospholipase A2 mass level is elevated after transcatheter aortic valve implantation or ballon angioplasty in elderly patients

A piece of the aorta as patch material for angioplasty of the left main coronary artery

Harling et al. [1] had a motivating article about surgical patch angioplasty of the left main coronary artery (LMCA). They gave a comprehensive and up-dated review of the issue including the different surgical methods and the variety of patch materials used so far: pericardium, saphenous vein, internal thoracic artery and pulmonary artery. However, they also stated that the optimal patch graft material remains to be defined. It gives the opportunity to add to the list of possible useful graft material yet another one, which is a piece of the ascending aorta. We have treated 2 patients with an aortic patch angioplasty and both had a postoperative course without complications and shortterm follow-up was unremarkable as well. The technique is similar to that described by Liska et al. [2] with one major exception. Before transection of the aorta, an oval piece of the aorta is harvested from the anterior part of the aorta in the intended transection line. Instead of using a segment of the right internal thoracic artery as used by Liska et al. [2], the harvested piece of aorta is used as a patch material on the incised LMCA and the patch is sutured in a continuous fashion enlarging both the coronary ostium and the aortotomy as advised by Dion et al. [3]. The transected aorta is reconstructed with a running suture. The gap after the removal of the oval piece of aorta represents no problem during this closure. The aortic wall should not be thickened or arteriosclerotic. We do believe that a piece of aorta could also be harvested when performing surgical angioplasty on the right coronary ostium. It might be done as a separate horizontal incision or as part of the vertical aortic incision going into the right coronary artery. We have only a short-term clinical follow-up. The long-term result is needed including radiological or ultrasound assessments to evaluate whether the aorta is a comparable alternative to other patch materials used in surgical patch angioplasty for the treatment of proximal coronary artery stenosis

Lipoprotein-associated phospholipase A₂ mass level is increased in elderly subjects with type 2 diabetes mellitus.

Objective. Lipoprotein-associated phospholipase A2 (Lp-PLA2) is extensively expressed by advanced atherosclerotic lesions and may play a role in plaque instability. We selected a group of elderly subjects that underwent transcatheter aortic valve implantation (TAVI) or balloon angioplasty (BA) and separated them into two groups, diabetic and nondiabetic, to compare the level of Lp-PLA2 mass between them. Methods. 44 patients aged 79.6 ± 5.6 years with symptomatic severe aortic valve stenosis underwent TAVI (n = 35) or BA (n = 9). 21 subjects had confirmed type 2 diabetes mellitus. Lp-PLA2 mass was measured using an enzyme-linked immunosorbent assay kit (USCN Life Science, China) before and 3 days after the procedure. Results. Lp-PLA2 mass was significantly elevated in this population (1296 ± 358 ng/mL before TAVI; 1413 ± 268 ng/mL before BA) and further increased after TAVI (1604 ± 437 ng/mL, P < 0.01) or BA (1808 ± 303 ng/mL, P < 0.01). Lp-PLA2 mass was significantly increased on the diabetic group before these interventions. Conclusion. Lp-PLA2 may be a novel biomarker for the presence of rupture-prone atherosclerotic lesions in elderly patients. Levels of Lp-PLA2 in diabetic patients may accompany the higher amount of small dense LDL particles seen in these subjects.

A Prospective Multicenter Study of Balloon Angioplasty for the Treatment of Native and Recurrent Coarctation of the Aorta

Balloon angioplasty (BA) is an important therapeutic treatment option for coarctation of the aorta. However, previous data regarding efficacy and complications have largely been restricted to relatively small retrospective studies from single centers. The Congenital Cardiovascular Interventional Study Consortium (CCISC) represents a multi-institutional and multi-national effort to prospectively investigate congenital cardiac interventions. A prospective analysis of the efficacy of balloon aortic angioplasty was conducted.

The diagnostic and interventional procedures performed in Angiography Laboratory of Pediatric Cardiology Section

Our aim was to compare the diagnostic and interventional procedures performed in our clinic and evaluate the increase in number and diversity of interventional procedures. Between July 2003 and May 2011 medical records of 1989 patients on whom diagnostic and interventional procedures had been performed was examined. 1036 of the patients (52%) were female and 953 of the patients (48%) were male. Diagnostic procedures were performed in 998 (50.2%) patients, while interventional procedures were performed in 991 (49.8%) patients. The interventional procedures are coil occlusion for patent ductus arteriosus, trans-catheter closure of atrial septal defect, pulmonary balloon valvuloplasty for pulmonary stenosis, aortic coarctation angioplasty, pericardiocentesis for pericardial effusion, aort balloon valvuloplasty for valvular aortic stenosis, permanent and temporary pacemaker insertion for acquired or congenital third degree atrioventricular block and /or sinus node disfunction in 321 (16.1%), 210 (10.6%), 146 (7.3%), 50 (2.5%), 45 (2.3%), 42 (2.1%), 40 (2%) and 33 (1.6%) patients; retrospectively. Interventional procedures were performed in 2,4 and 35 patients in 2003, 2004, and 2005; respectively. Following Angiography Laboratory of Pediatric Cardiology Section set up, interventional procedures were performed in 234 and 439 patients in 2009 and 2010; respectively. Number and variety of interventional procedures have been increased over the years after increased experience of Angiography Laboratory of Pediatric Cardiology Section. Diagnostic angiography procedures have been decreasing over the years by increase in development of new devices and progress of use of interventional treatment techniques. Therefore, interventional procedures have been replaced by diagnostic procedures.

Emergent thoracic aortic angioplasty and stenting for middle aortic syndrome in non-specific aortitis

A 61-year-old Japanese male was admitted to hospital due to severe congestive heart failure and pre-renal failure with middle aortic syndrome. The patient was successfully treated with emergent aortic angioplasty and kissing stents implantation whilst in a hemodynamically unstable state. Our experience confirms that stenosis of the descending aorta when treated with catheter intervention may be palliative, however, it was a very effective method for life threatening clinical conditions in the short and mid-term and may be an alternative to surgery.

Punção da artéria axilar para intervenções percutâneas em lactentes portadores de cardiopatias congênitas: "à procura de um caminho mais curto e mais seguro"

BACKGROUND: Axillary artery access (AxA) has been used in adults with good results, however, its use in neonates and infants has not been extensively reported. This study was aimed at reporting our initial experience using this access in different cardiac interventions in this age group. METHOD: From January 2009 to September 2010, 11 children were submitted to different cardiac interventions using AxA. The procedure was performed with a 21 G needle followed by the insertion of a 4 F or a 5 F pediatric sheats. RESULTS: Mean age was 26 ± 12 days and mean weight was 4.2 ± 1.7 Kg. The cardiac interventions performed were: stenting of the arterial duct (6), aortic valvoplasty (1), aortic angioplasty (2), stent implantation in a Blalock-Taussig shunt (1) and stent redilation in the arterial duct (1). Right AxA puncture was successfully obtained in all patients without technical difficulties. Mean procedure and fluoroscopy times were 52 ± 15 minutes and 13 ± 4 minutes, respectively. Pneumothorax without hemodynamic involvement was the single complication in one patient. The other patients did not have any abnormalities. There were no ischemic or neurologic complications in the ipsilateral limb. Mean time of Intensive Care Unit (ICU) stay was 48 ± 16 hours. There were no deaths during the interventional procedures and one patient died of sepsis at the ICU 5 days after the procedure. CONCLUSION: In our experience AxA proved to be a safe and effective alternative for different interventional procedures in neonates and infants with congenital heart diseases.

Comparison of surgical and transcatheter treatment for native coarctation of the aorta in patients ≥1 year old. The Quebec Native Coarctation of the Aorta Study

The objectives of this study were to compare, in the current era, the immediate results, complications, and midterm outcomes obtained by surgical repair versus transcatheter treatment of coarctation of the aorta (CoA). The study was of retrospective nature and included 80 consecutive patients > or = 1 year old (mean age 12 +/- 10 years) treated for an isolated CoA in 4 university centers in Quebec between 1998 and 2004. Fifty patients underwent aortic angioplasty, with stent implantation in 19, and 30 had surgical repair. Immediate results, procedural complications, clinical events, and the incidence of aortic aneurysm at follow-up were compared between groups. There were no differences between the 2 groups in clinical baseline characteristics. Percentage reduction in peak systolic pressure gradient across the coarctation was similar between the 2 groups (angioplasty 72% +/- 23% vs surgery 75% +/- 18%, P = .55). Procedure-related complications occurred more frequently after surgical repair compared with angioplasty (50% vs 18%, P = .005), and median hospitalization time was longer in the surgical than in the angioplasty group (7 vs 1 day, P < .001). At 38 +/- 21 months' follow-up, no patient in the surgical group and 16 patients in the angioplasty group had at least 1 aortic reintervention (0% vs 32%, P < .0001). The presence of an aortic aneurysm was diagnosed more frequently in the angioplasty group compared with the surgical group (24% vs 0%, P = .01). Aortic angioplasty provided comparable immediate hemodynamic results to surgery, with reduced morbidity and hospitalization length for the treatment of CoA in patients > or = 1 year old. However, angioplasty was associated with a higher rate of reintervention and aneurysm formation at a mean follow-up of 3 years.

Feasibility of Angioplasty and Stenting for Abdominal Aortic Lesions Adjacent to Previously Stented Visceral Artery Lesions in Patients with Takayasu Arteritis

Two young female patients with Takayasu arteritis presented with symptomatic long-segment abdominal aortic stenosis in the vicinity of previously deployed celiac and renal artery stents that projected markedly into the narrowed aortic lumen. Crushing or distortion of the visceral artery stents during aortic angioplasty was avoided by performing simultaneous or alternating balloon dilatations in the aorta and in the visceral artery stents. Consequently, the visceral artery stents remained patent and shortened longitudinally, allowing unhindered deployment of Wallstents in the adjacent aorta and abolition of a pressure gradient across the aortic lesions. Access to side branches covered by the Wallstent was obtained without difficulty, enabling the performance of balloon dilatation in multiple side branches and ostial stent deployment in a renal artery. These techniques could increase the scope of endovascular therapy in the treatment of patients with Takayasu arteritis.

Calcitonin Gene-Related Peptide Receptor Activation by Receptor Activity-Modifying Protein-1 Gene Transfer to Vascular Smooth Muscle Cells

The neuropeptide calcitonin gene-related peptide (CGRP) is a potent vasodilator that plays a protective role in the cardiovascular system. The receptor for CGRP is an unusual complex of the G protein-coupled calcitonin-like receptor and an obligate receptor activity modifying protein-1 (RAMP1). In this report we provide the first evidence that RAMP1 is rate limiting in vascular smooth muscle cells. Although cultured rat aorta smooth muscle cells express calcitonin like-receptor and RAMP1, we found that CGRP is not a potent activator of the receptor. After overexpression of RAMP1 by adenoviral gene transfer, there was a striking increase in CGRP-induced production of cAMP, with a 75-fold decrease in the EC(50) and a 1.5-fold increase in the maximal response. The biological consequence of this increased receptor activity was observed in three different paradigms. First, RAMP1 gene transfer caused a CGRP-dependent decrease in cell proliferation. Second, RAMP1 and CGRP treatment led to a 3-fold greater free radical-induced reduction in cell number. Finally, RAMP1 gene transfer resulted in a 5-fold CGRP-dependent increase in terminal deoxynucleotidyltransferase-mediated deoxyuridine triphosphate nick end labeling-positive apoptotic cells upon serum withdrawal. The mechanisms underlying these effects involved cAMP-dependent pathways. We propose that RAMP1 gene transfer may be an effective strategy for increasing the effectiveness of CGRP-induced decrease in restenosis after aortic angioplasty.

Percutaneous Intervention for Severe Aortic Stenosis and Left Main Artery Disease in a Morbidly Obese Patient

Obesity increases significantly the rate of postsurgical complications and mortality in patients undergoing major surgery. We present the case of a morbidly obese 65-year-old female with severe aortic stenosis and left main coronary artery disease who underwent successful aortic valvuloplasty and angioplasty, with placement of a stent in the left main coronary artery. After undergoing bariatric surgery and losing 30% of her body weight, the patient was accepted for cardiac surgery to replace the aortic valve and to bypass the left anterior descending coronary artery using the mammary artery. There were no surgical complications.