Degree Of Luminal Stenosis Research Articles

Four Different Carotid Atherosclerotic Behaviors Based on Luminal Stenosis and Plaque Characteristics in Symptomatic Patients: An in Vivo Study.

Correct stratification of ischemic stroke risk allows for the proper treatment of carotid atherosclerotic disease. We seek to differentiate plaque types based on stenosis level and plaque morphology. The Chinese Atherosclerosis Risk Evaluation (CARE–II) study is a cross-sectional, observational, multicenter study to assess carotid atherosclerotic plaques in symptomatic subjects using vessel wall magnetic resonance imaging. Plaque morphology and presence of plaque components were reviewed using multi-contrast magnetic resonance imaging. The carotid arteries were divided into four groups based on stenosis level and plaque components. Out of 1072 ischemic stroke subjects, 452 ipsilateral side carotid arteries were included. Significant stenosis (SS) (≥50% stenosis) with high-risk plaque (HRP) features was present in 37 arteries (8.2%), SS(+)/HRP(−) in 29 arteries (6.4%), SS(−)/HRP(+) in 57 arteries (12.6%), and SS(−)/HRP(−) in 329 arteries (72.8%). The prevalence of SS(−)/HRP(+) arteries in this cohort was substantial and had greater wall thickness than the SS(+)/HRP(−) group. These arteries may be misclassified for carotid revascularization by current guidelines based on the degree of luminal stenosis only. These findings have implications for further studies to assess stroke risk using vessel wall imaging.

Factors Associated with Failed Conservative Management in Symptomatic Isolated Mesenteric Artery Dissection

The aim of this study was to assess factors associated with conservative management failure in patients with symptomatic isolated mesenteric artery dissection. Patients with symptomatic isolated mesenteric artery dissection who underwent conservative therapy as first line treatment between February 2010 and May 2018 were included in this retrospective study. Conservative management failure was defined as the persistence or aggravation of symptoms and signs, increasing aneurysmal dilation, or new appearance of a dissecting aneurysm after conservative management. Univariable and multivariable analyses were performed to identify risk factors for failure of conservative management. A total of 123 patients (115 men, 8 women, mean age, 53.7±6.1 years) were included in this study. Conservative management was successful in 89 (72.4%) patients but failed in the remaining 34 (27.6%) patients. Of the 89 for whom conservative management was successful, all of the symptoms were eliminated (n=81) or relieved (n=8) within 3.8±0.7 days after conservative management. All of the 34 patients in whom conservative management failed underwent successful endovascular stenting. Failure of conservative management was associated with type II IMADs as defined by the Sakamoto classification (meaning that there is an entry tear, but no re-entry, and still no thrombosis of false lumen, odds ratio: 33.76; 95% confidence interval 8.65-131.85; p<.001) and with ≥90% luminal stenosis (odds ratio 40.70; 95% confidence interval: 3.76-440.07; p<.01). Conservative management can be used successfully in most patients with symptomatic isolated mesenteric artery dissection. Risk factors for failed conservative treatment were type II IMADs and degree of luminal stenosis ≥90%.

Basic physiology of the new parameter ECOStif: Animal validation of an invasive measurement of coronary pulse wave velocity

Epicardial COronary STIFfness (ECOStif:) represents a new paradigm for caring patients in the cathlab; it can be assessed by measuring coronary pulse wave velocity (PWV) with a regular pressure wire (Harbaoui et al., JAHA 2017); Yet, the basic physiology of ECOStif: is mostly unknown while it should be critical for its interpretation. This study aimed at determining the impact on ECOStif: of 1) mean blood pressure (MBP) and heart rate (HR) variations and of, 2) various degrees of luminal stenosis (St). Ten female pigs weighting 48 ± 3 kg were included. Coronary angiography was performed under general anesthesia via the right carotid artery (6F). ECOStif: was measured in the left anterior artery with 2 pressure wires (Abbott) positioned at the proximal and at the distal part of the artery. ECOStif: was measured in 3 MBP conditions (60, 80, 100 mmHg) and in 3 HR conditions (90, 110, 130 bpm). One condition was repeated for assessing repeatability. At 80 mmHg and 110 bpm, 2 different stenosis were produced by inflating balloons of increasing size (St1, St2) and assessed by measuring fractional flow reserve (FFR). In basal conditions ECOStif 8.12 ± 2,82 m/s. ECOStif: increased significantly with increasing MBP ( P < 0.05) but not with HR (2-way-ANOVA repeated measurements). The average increase was from 0.08 to 0.1 m/s/mmHg for MBP. The repeatability was fair around 6%. ECOStif: decreased with stenosis severity: 6,55 ± 0,95, 5,67 ± 1.63, 4,87 ± 0,76 m/s for basal, St1, and St2, respectively ( P < 0.05) corresponding to FFR at 0.93 ± 0.07, 0.82 ± 0.11, 0.7 ± 0.14, respectively. ECOStif: has a reasonable repeatability. As expected from basic physiology, it is influenced by large MBP variations and at a lesser extent by HR changes. It is also slightly influenced by coronary stenosis. The present study is critical to better understand this new parameter and to address its robustness in the prospect of its clinical use.

Follow-up with computed tomography after spontaneous isolated dissection of the splanchnic artery

The aim of this study was to evaluate radiological changes after spontaneous isolated dissection of the superior mesenteric artery (SIDSMA) and spontaneous isolated dissection of the celiac artery (SIDCA) using computed tomography (CT). This single-center retrospective study was approved by the hospital institutional review board. We reviewed the medical records and morphological CT findings of 33 consecutive patients with SIDSMA or SIDCA who were diagnosed between January 2001 and February 2016. We analyzed changes on follow-up CT images including length of the dissection, presence of a thrombus in the false lumen, maximal outer diameter, degree of luminal stenosis, patency of distal flow, and end-organ injury. We classified short-term (within the first week) and long-term (between the first week and sixth month) follow-up groups and analyzed differences in radiological changes over time using Wilcoxon signed-rank tests (continuous variables) and Fisher exact probability tests (categorical variables). Additionally, we examined patients who completed follow-up CT within 3 days after symptomatic changes. Comparing initial and final CT findings, a majority of patients with SIDSMA and SIDCA showed no significant changes in most CT parameters, including dissection length, thrombus presence, dissection diameter, stenosis degree, and extended distal branch. Between the short-term and long-term CT follow-up groups, there were no significant differences in radiological changes except for in the degree of luminal stenosis at the dissected segment in SIDSMA (P = 0.043). Only 10 patients completed follow-up CT within 3 days after symptomatic changes (progression or regression); of these, 1 patient had radiological findings that matched symptom progression, showing an increase in the degree of luminal stenosis and end-organ injury. There was no splanchnic artery dissection-related mortality, symptom progression, or event recurrence. In conclusion, CT follow-up of SIDSMA and SIDCA was mainly useful in the acute phase of dissection, with no significant radiological changes occurring in the long term. Accordingly, we question the utility of long-term follow-up CT after spontaneous isolated arterial dissection, especially in the absence of symptom progression.

Detection of Hemodynamically Significant Coronary Artery Stenosis With CT Enhancement Ratio: A Validation Study in a Porcine Model.

Although numerous techniques that are based on CT number analysis have been proposed, the assessment of hemodynamically significant coronary artery stenosis remains a great challenge. The purpose of this study is to validate use of the CT enhancement ratio in the detection of hemodynamically significant coronary artery stenosis in a porcine model. Experiments involving eight closed-chest swine were performed. A balloon catheter was placed into the left anterior descending coronary artery to simulate different degrees of luminal stenosis. The myocardial blood flow (MBF) ratio was measured using the colored microsphere technique. The fractional flow reserve was measured using an invasive pressure wire. CT scans were performed during the first-pass phase, while the pigs were undergoing adenosine stress tests. The CT enhancement ratio and the CT attenuation ratio were calculated using data from the CT images obtained. Results suggested that the CT enhancement ratio had a strong correlation (y = 0.07245 + 0.09963x; r2 = 0.898; p < 0.001) with the MBF ratio measured using the microsphere technique, whereas only moderate correlation (y = -1.5508 + 2.2684x; r2 = 0.498; p < 0.001) was noted between the CT attenuation ratio and the MBF ratio measured using the microsphere technique. In ROC curve analysis, the AUC values of the CT enhancement ratio and the CT attenuation ratio were 0.927 and 0.829, respectively, with regard to the detection of significant ischemia during adenosine stress tests, as defined by the fractional flow reserve. The CT enhancement ratio provides a reliable prediction of the MBF ratio measured using the microsphere technique, indicating that this metric has good diagnostic performance in the detection of hemodynamically significant coronary artery stenosis. The CT enhancement ratio may have potential for use as an imaging biomarker for the relative quantitative assessment of myocardial perfusion.

Abstract TP108: Association Between Intracranial Atherosclerotic Calcium Burden and Angiographic Luminal Stenosis Measurements

Background: Recent data have shown that atherosclerotic calcification of the intracranial vasculature is an independent risk factor for ischemic stroke. The relationship between the most commonly used marker of high risk intracranial atherosclerosis, the percent degree of luminal stenosis, and calcium burden in the intracranial circulation has not been investigated. Materials and Methods: We evaluated the relationship between atherosclerotic calcification and luminal stenosis in the intracranial internal carotid arteries (ICAs). Using a prospective stroke registry, we identified patients who had non-contrast computed tomography (NCHCT) and either CT angiography (CTA) or magnetic resonance angiography (MRA) examinations as part of a diagnostic evaluation for ischemic stroke. We used NCHCTs to qualitatively (Modified Woodcock Visual Score) and quantitatively (Agatston-Janowitz calcium score) evaluate ICA calcium burden and angiography to measure arterial stenosis (Figure). We calculated correlation coefficients between the degree of narrowing and calcium burden measures. Results: In 470 unique carotid arteries (235 patients), 372 (79.1%) had atherosclerotic calcification detectable on CT while only 160 (34%) had measurable arterial stenosis (p &lt; 0.001). We found a weak linear correlation between qualitative (R = 0.48) and quantitative (R = 0.42) measures of calcium burden and the degree of luminal stenosis (p &lt; 0.001 for both). Of 310 ICAs with 0% luminal stenosis, 216 (69.7%) had measureable calcium scores. Conclusion: There is only a weak correlation between intracranial atherosclerotic calcium scores and luminal narrowing, which may be explained by the greater sensitivity of NCHCT compared to angiography in detecting the presence of measurable atherosclerotic disease. Future studies are warranted to evaluate the relationship between stenosis and calcium burden in predicting stroke risk.

Abstract TMP27: Role of HIV-related Immune Activation and Plaque Vulnerability: Results From the Brain Arterial Remodeling Study

Introduction: By virtue of their infection, HIV+ patients are subject to chronic inflammation, and show an increased risk for stroke when compared to uninfected controls. We hypothesized that HIV infection would be associated with increased atherosclerotic plaque vulnerability. Methods: Large brain arteries from 162 autopsied individuals (84 with HIV) were stained for metalloproteinase (MMP)-2, MMP-3, MMP-9, Caspase-3, and tumor necrosis factor (TNF)-α, factors reported to increase plaque vulnerability. We measured intensity of staining for each protein in the fibrous cap and scored each as 0 (most intense staining not in cap) or 1 (most intense staining in cap). We then added the ratings from the five stains and created a vulnerability score ranging from 0-5. CD3+ cells (lymphocytes) and CD68+ cells (macrophages) were also rated using semi-quantitative scores. Rating was blind to HIV status. We constructed multilevel models to obtain the β estimates and their 95% confidence intervals (β, 95%CI), adjusting for demographic characteristics, vascular risk factors, and HIV-related immune variables. Results: For the entire sample, the plaque vulnerability score was associated with higher degree of luminal stenosis (0.04, 0.02-0.06) and larger arterial size (0.5 per mm, 0.2-0.8), but not with HIV (-0.65, -2.24-0.95). However, in a subset of individuals with atherosclerosis (n=21), there was a statistical interaction (P&lt;0.04) between HIV and vulnerability score. In a stratified model in HIV+ cases only, a CD4 count of &gt; 200 cells/ul at death was associated with higher vulnerability score (1.42, 0.08-2.76) compared with subjects who remained immunosuppressed. Predictors of vulnerability score among HIV+ subjects included higher CD3 score (1.12, 0.15-2.09), older age (0.18 per year, 0.12-0.25), diabetes (3.00, 1.69-4.24), lower CD4 nadir (-0.01, -0.02to -0.007), antiretroviral use at death (-2.08, -3.84 to -0.32). Conclusions: Plaque vulnerability is positively associated with a higher blood CD4 count, lower CD4 nadir and higher lymphocytic inflammation in brain arteries among HIV+ cases. Investigating the role of HIV-related chronic inflammation and plaque vulnerability may help us better understand the higher risk of stroke among those with HIV.

Variant origin and course of left circumflex coronary artery

Variant origin of left circumflex coronary artery (LCx) from right aortic sinus is a well-recognized coronary variation, usually without any clinical consequences. However, the variant origin and trajectory of the artery may have major implications during percutaneous coronary intervention, coronary artery surgery, aortic and mitral valve replacement procedures. We observed a variant LCx in a heart specimen belonging to 45-year-female with no history of hypertension, diabetes mellitus and coronary artery disease. The artery arose along with the right coronary artery from a common ostium in right aortic sinus and depicted a retroaortic course. The vessel was located at the level of aortic annulus and 6.6mm above mitral valve annulus. The degree of luminal stenosis in variant LCx was higher than that in right coronary artery (RCA) and left anterior descending artery (LAD). Appropriate anatomical knowledge of the location and course of variant LCx is important for successful coronary interventions and valve replacement procedures.

Reproducibility of coronary atherosclerotic plaque characteristics in populations with low, intermediate, and high prevalence of coronary artery disease by multidetector computer tomography: a guide to reliable visual coronary plaque assessments

To evaluate the interobserver agreement of visual coronary plaque characteristics by 320-slice multidetector computed tomography (MDCT) in three populations with low, intermediate and high CAD prevalence and to identify determinants for the reproducible assessment of these plaque characteristics. 150 patients, 50 asymptomatic subjects from the general population (low CAD prevalence), 50 symptomatic non-acute coronary syndrome (non-ACS) patients (intermediate CAD prevalence), and 50 ACS patients (high CAD prevalence), matched according to age and gender, were retrospectively enrolled. All coronary segments were evaluated for overall image quality, evaluability, presence of CAD, coronary stenosis, plaque composition, plaque focality, and spotty calcification by four readers. Interobserver agreement was assessed using Fleiss' Kappa (κ) and intra-class correlation (ICC). Widely used clinical parameters (overall scan quality, presence of CAD, and determination of coronary stenosis) showed good agreement among the four readers, (ICC = 0.66, κ = 0.73, ICC = 0.74, respectively). When accounting for heart rate, body mass index, plaque location, and coronary stenosis above/below 50 %, interobserver agreement for plaque composition, presence of CAD, and coronary stenosis improved to either good or excellent, (κ = 0.61, κ = 0.81, ICC = 0.78, respectively). Spotty calcification was the least reproducible parameter investigated (κ = 0.33). Across subpopulations, reproducibility of coronary plaque characteristics generally decreased with increasing CAD prevalence except for plaque composition, (limits of agreement: ±2.03, ±1.96, ±1.79 for low, intermediate and high CAD prevalence, respectively). 320-slice MDCT can be used to assess coronary plaque characteristics, except for spotty calcification. Reproducibility estimates are influenced by heart rate, body size, plaque location, and degree of luminal stenosis.

Local blood pressure associates with the degree of luminal stenosis in patients with atherosclerotic disease in the middle cerebral artery.

The mechanism underlying atherosclerotic ischemic events within the middle cerebral artery (MCA) is unclear. High structural stress induced by blood pressure might be a potential aetiology as plaque rupture occurs when such mechanical loading exceeds its material strength. To perform reliable analyses quantifying the mechanical loading within a plaque, the local blood pressure is needed. However, data on MCA blood pressure is currently lacking. In this study, the arterial pressure proximal to the stenotic site in the MCA was measured in 15 patients scheduled for intervention. The relationships between these local measurements and pre-intervention and intra-intervention non-invasive arm measurements were assessed. The impact of luminal stenosis on the local blood pressure was quantified. Compared with the pre-intervention arm measurement, the intra-intervention arm pressure decreased significantly by 23.9 ± 11.8 and 9.3 ± 14.7 % at diastole and systole, respectively. The pressure proximal to the stenosis was much lower than the pre-intervention arm measurement (diastole: 65.3 ± 15.7 vs 82.0 ± 9.7, p < 0.01; systole: 81.1 ± 15.9 vs 133.9 ± 18.7, p < 0.01; unit: mmHg). The systolic pressure in the MCA in patients with stenosis <70 % (n = 6) was significantly higher than the value in patients with stenosis ≥70 % (n = 9) (92.0 ± 7.3 vs 73.9 ± 16.1, p = 0.02; unit: mmHg), as was pulse pressure (22.8 ± 6.4 vs 11.1 ± 8.3, p = 0.01; unit: mmHg). However, diastolic pressure remained unaffected (69.2 ± 9.3 vs 62.8 ± 19.0, p = 0.58; unit: mmHg). In conclusion, the obtained results are helpful in understanding the local hemodynamic environment modulated by the presence of atherosclerosis. The local pressure measurements can be used for computational analysis to quantify the critical mechanical condition within an MCA lesion.

Use of ultrasmall superparamagnetic iron oxide particles for imaging carotid atherosclerosis.

Based on the results of histopathological studies, inflammation within atherosclerotic tissue is now widely accepted as a key determinant of the disease process. Conventional imaging methods can highlight the location and degree of luminal stenosis but not the inflammatory activity of the plaque. Iron oxide-based MRI contrast media particularly ultrasmall supermagnetic particles of iron oxide have shown potential in assessing atheromatous plaque inflammation and in determining efficacy of antiatherosclerosis pharmacological treatments. In this paper, we review current data on the use of ultrasmall superparamagnetic iron oxides in atherosclerosis imaging with focus on ferumoxtran-10 and ferumoxytol. The basic chemistry, pharmacokinetics and dynamics, potential applications, limitations and future perspectives of these contrast media nanoparticles are discussed.

SPECT/CT Imaging of High-Risk Atherosclerotic Plaques using Integrin-Binding RGD Dimer Peptides.

Vulnerable atherosclerotic plaques with unique biological signatures are responsible for most major cardiovascular events including acute myocardial infarction and stroke. However, current clinical diagnostic approaches for atherosclerosis focus on anatomical measurements such as the degree of luminal stenosis and wall thickness. An abundance of neovessels with elevated expression of integrin αvβ3 is closely associated with an increased risk of plaque rupture. Herein we evaluated the potential of an αvβ3 integrin-targeting radiotracer, 99mTc-IDA-D-[c(RGDfK)]2, for SPECT/CT imaging of high-risk plaque in murine atherosclerosis models. In vivo uptake of 99mTc-IDA-D-[c(RGDfK)]2 was significantly higher in atherosclerotic aortas than in relatively normal aortas. Comparison with the negative-control peptide, 99mTc-IDA-D-[c(RADfK)]2, proved specific binding of 99mTc-IDA-D-[c(RGDfK)]2 for plaque lesions in in vivo SPECT/CT and ex vivo autoradiographic imaging. Histopathological characterization revealed that a prominent SPECT signal of 99mTc-IDA-D-[c(RGDfK)]2 corresponded to the presence of high-risk plaques with a large necrotic core, a thin fibrous cap, and vibrant neoangiogenic events. Notably, the RGD dimer based 99mTc-IDA-D-[c(RGDfK)]2 showed better imaging performance in comparison with the common monomeric RGD peptide probe 123I-c(RGDyV) and fluorescence tissue assay corroborated this. Our preclinical data demonstrated that 99mTc-IDA-D-[c(RGDfK)]2 SPECT/CT is a sensitive tool to noninvasively gauge atherosclerosis beyond vascular anatomy by assessing culprit plaque neovascularization.

Lesion stability characteristics outperform degree of stenosis in predicting outcomes following stenting for symptomatic intracranial atherosclerosis

BackgroundIntracranial atherosclerotic disease (ICAD) causes substantial morbidity and mortality. Treatment decisions have most commonly been driven by the degree of luminal stenosis. This study compares ICAD lesion stability features with...

Will 18F-sodium fluoride PET-CT imaging be the magic bullet for identifying vulnerable coronary atherosclerotic plaques?

Myocardial infarction remains the commonest cause of premature death worldwide with coronary atherosclerotic plaque rupture often initiating the event. Despite an ever-expanding repertoire of cardiovascular imaging techniques, the race is still on to identify atherosclerotic lesions at high-risk of rupture: the so-called vulnerable plaque. Conventional imaging modalities such as stress testing and coronary angiography have consistently failed to identify such plaques, leading to the increasing appreciation that plaque rupture relates to factors other than just the degree of luminal stenosis. Indeed the focus has recently shifted to molecular imaging, in an attempt to directly target the pathological disease processes leading to rupture and thereby localize high-risk lesions. Histological data indicate that inflammation, necrosis and early stage microcalcification are key imaging targets by which to achieve this aim. Here, we discuss how these processes are related, focusing on the rationale and evidence supporting 18F-fluoride positron emission tomography as a novel non-invasive imaging technique for the identification of vulnerable atherosclerotic plaque.

Euro-ccad: Differing conventional atherosclerosis risk factors for coronary calcification depending on degree of luminal stenosis

Euro-ccad : Differing conventional atherosclerosis risk factors for coronary calcification depending on degree of luminal stenosis

Imaging of the Carotid Artery Vulnerable Plaque

Atherosclerosis involving the carotid arteries has a high prevalence in the population worldwide. This condition is significant because accidents of the carotid artery plaque are associated with the development of cerebrovascular events. For this reason, carotid atherosclerotic disease needs to be diagnosed and those determinants that are associated to an increased risk of stroke need to be identified. The degree of stenosis typically has been considered the parameter of choice to determine the therapeutical approach, but several recently published investigations have demonstrated that the degree of luminal stenosis is only an indirect indicator of the atherosclerotic process and that direct assessment of the plaque structure and composition may be key to predict the development of future cerebrovascular ischemic events. The concept of "vulnerable plaque" was born, referring to those plaque's parameters that concur to the instability of the plaque making it more prone to the rupture and distal embolization. The purpose of this review is to describe the imaging characteristics of "vulnerable carotid plaques."

Duplex color doppler evaluation of carotid atherosclerosis in patient with silent cerebral infarction detected by MRI

Background: Silent cerebral infarction (SCI) detected incidentally by MRI is considered the preliminary stage of accidental stroke and assumed to be secondary to atherosclerotic vascular disease (ASVD).The Duplex Color Doppler study is the initial screening non-invasive modality to identify carotid atherosclerotic changes and is the best approach for preoperative carotid artery evaluation in asymptomatic patients who can be expected to benefit of reduced risk of stroke in future. This cross- sectional study was carried out to assess the diagnostic usefulness of Duplex Color Doppler sonography in the evaluation of asymptomatic carotid atherosclerosis in prediction of silent cerebral infarction. Nature of extracranial carotid plaque and degree of luminal stenosis were compared &amp; associated with MRI findings and risk factors of silent cerebral infarction. Method: This cross sectional study was carried out in the Radiology &amp; Imaging Department of Dhaka Medical College Hospital during the period of July 2009 to June 2011 on 70 adult subjects of both sexes aged &gt;50 years. Clinically suspected patients of silent cerebral infarction referred to Radiology &amp; Imaging department of DMCH from OPD and Indoor Patient department underwent MRI of brain and among them those diagnosed as having Lacunar infarcts (Silent Cerebral Infarction) underwent Extra-cranial Carotid Duplex Color Doppler examination on both sides. Carotid lesions were evaluated by plaque score, maximum percent stenosis and the existence of ulcerated lesions. The relations between the carotid lesions and the incidence, size or localization of the brain lesions were investigated. Results: The incidence of SCI increases with age &amp; more prevalent in male (P&lt;0.05).Most SCI lesions were &lt;1cm in size, single in number and is more prevalent in basal ganglia region (P&lt;0.05) than subcortical white matter of right cerebral hemisphere (P&lt;0.05) associated with ipsilateral high grade carotid stenosis &amp; ulcerated plaque. The percentage of subjects with infarcts increased significantly as the plaque score increased (P&lt;0.001) or subjects had high grade stenosis (P&lt;0.001). The presence of pre-existing risk factors like HTN, DM, IHD, and Dyslipidaemia showed significant correlation with plaque score and SCI of brain. Conclusion: Both the severity and characteristics of asymptomatic carotid lesions estimated by Duplex color Doppler study were closely related to the appearance of silent infarcts.These results demonstrate that noninvasive assessment of carotid lesions can be useful in predicting the existence of silent cerebral infarction even in patients free from neurological deficits. DOI: http://dx.doi.org/10.3329/jdmc.v22i1.15599 J Dhaka Medical College, Vol. 22, No. 1, April, 2013, Page 19-25

Midaortic syndrome: 30 years of experience with medical, endovascular and surgical management

Midaortic syndrome is often associated with refractory hypertension. The aim of our study was to better understand the short- and medium-term outcomes in this patient population utilizing a multidisciplinary management approach. We conducted a review of patients with midaortic syndrome treated at our institution over the past 30 years. Fifty-three patients presented at a median age of 6.7 years (birth to 28.7 years). Thirty-five patients (66 %) underwent invasive management (percutaneous techniques: 21; surgical techniques: 5; both: 9). Percutaneous interventions were acutely successful in decreasing the gradient across the obstruction and degree of luminal stenosis. However, freedom from reintervention was 58 % at 1 year and 33 % at 5 years. Freedom from reintervention after a surgical procedure was longer: 83 % at 1 year and 72 % at 10 years. At the most recent follow-up, the majority of patients (69 %) were normotensive. The median duration between time of presentation and achievement of blood pressure control was 5.7 (0.4-21.1) years. The median number of anti-hypertensive medications was 1 (0-5). A multidisciplinary management strategy which couples comprehensive medical management with catheter-based and surgical interventions can lead to adequate blood pressure control and preservation of end-organ function in patients with midaortic syndrome.

Should We Adopt Micro-Interintimal Dissection: A Novel and Worthwhile Advance in Carotid Surgery Technique, but Does It Prevent Restenosis and Early Neurological Deficits?

therosclerotic cervical carotid artery disease is a significant contributor to the annual incidence of ischemic A stroke, which remains a leading cause of death, and was responsible for almost 130,000 fatalities in the United States in 2011 alone (14). A recent meta-analysis suggests that the prevalence of moderate and severe carotid stenosis (>50% luminal stenosis) is relatively common (6). Almost two decades ago, the Asymptomatic Carotid Atherosclerosis Study and the Asymptomatic Carotid Surgery Trial defined the 5-year cumulative risk of ipsilateral ischemic stroke among asymptomatic patients with more than 60% stenosis to be as high as 12% (8, 12). Among the symptomatic patient population—defined as those patients who have previously experienced a hemispheric transient ischemic attack, nondisabling stoke, or amaurosis fugax—the cumulative risk of ipsilateral ischemic stroke within 3e5 years of diagnosis was even higher, approximately 20%e25%, if the degree of luminal stenosis was greater than 70% (9, 19).

Relation between Mild to Moderate Chronic Kidney Disease and Coronary Artery Disease Determined with Coronary CT Angiography

BackgroundBoth end-stage and milder stages of chronic kidney disease (CKD) are associated with an increased risk of adverse cardiovascular events. Several studies found an association between decreasing renal function and increasing coronary artery calcification, but it remains unclear if this association is independent from traditional cardiovascular risk factors. Therefore, the aim of this study was to investigate whether mild to moderate CKD is independently associated with coronary plaque burden beyond traditional cardiovascular risk factors.MethodsA total of 2,038 patients with symptoms of chest discomfort suspected for coronary artery disease underwent coronary CT-angiography. We assessed traditional risk factors, coronary calcium score and coronary plaque characteristics (morphology and degree of luminal stenosis). Patients were subdivided in three groups, based on their estimated glomerular filtration rate (eGFR) Normal renal function (eGFR ≥90 mL/min/1.73 m2); mild CKD (eGFR 60–89 mL/min/1.73 m2); and moderate CKD (eGFR 30–59 mL/min/1.73 m2).ResultsCoronary calcium score increased significantly with decreasing renal function (P<0.001). Coronary plaque prevalence was higher in patients with mild CKD (OR 1.83, 95%CI 1.52–2.21) and moderate CKD (OR 2.46, 95%CI 1.69–3.59), compared to patients with normal renal function (both P<0.001). Coronary plaques with >70% luminal stenosis were found significantly more often in patients with mild CKD (OR 1.67 (95%CI 1.16–2.40) and moderate CKD (OR2.36, 95%CI 1.35–4.13), compared to patients with normal renal function (both P<0.01). After adjustment for traditional cardiovascular risk factors, the association between renal function and the presence of any coronary plaque as well as the association between renal function and the presence of coronary plaques with >70% luminal stenosis becomes weaker and were no longer statistically significant.ConclusionAlthough decreasing renal function is associated with increasing extent and severity of coronary artery disease, mild to moderately CKD is not independently associated with coronary plaque burden after adjustment for traditional cardiovascular risk factors.