Degree Of Residual Stenosis Research Articles

Endovascular treatment of acute arteriosclerotic vertebrobasilar occlusion: A single center experience.

Few experiences on vertebrobasilar occlusion over underlying intracranial atherosclerotic disease have been reported in literature and the optimal strategy on how to perform a mechanical thrombectomy is unclear. The aim of this paper is to bring our experience based on patients admitted with acute vertebrobasilar occlusion with underlying atheromatous lesions. Several data were collected from August 2009 to October 2022 including clinical history, pre- and post-treatment neurological objectivity, diagnostic images and angiographic procedural images, and clinical outcome at 6months. We selected 13 patients from August 2009 to October 2022, 12 men and 1 woman, aged 40 to 82years (mean age, 62.6years). Mechanical thrombectomy with a thromboaspiration was performed in all patients as beginning of the procedure. In three patients, the procedures resulted in excellent angiographic result and clinical outcome, while in three patients, we observed a failure of the procedural and clinical outcome. For residual intracranial stenosis in three patients, an angioplasty was performed obtaining an ischemic area related to the posterior circulation. In four patients, a stent was placed, in three patients, we obtained a good clinical outcome with a mRS between 0 and 2, while one treatment resulted in death, probably due to a late endovascular treatment. Endovascular treatment with stent deployment appears to result in an excellent outcome in patients with occlusion of the vertebrobasilar circulation in cases of occlusion on atheromatic plaque. The degree of residual stenosis after thrombospiration can significantly affect subsequent type of treatment.

Effects of plaque characteristics and artery hemodynamics on the residual stenosis after carotid artery stenting

ObjectiveCarotid artery stenting (CAS) has become an alternative strategy to carotid endarterectomy for carotid artery stenosis. Residual stenosis was an independent risk factor for restenosis, with the latter affecting the long-term outcomes of CAS. This multicenter study aimed to evaluate the echogenicity of plaques and hemodynamic alteration by color duplex ultrasound (CDU) examination and investigate their effects on the residual stenosis after CAS. MethodsFrom June 2018 to June 2020, 454 patients (386 males and 68 females) with a mean age of 67.2 ± 7.9 years, who underwent CAS from 11 advanced stroke centers in China were enrolled. One week before recanalization, CDU was used to evaluate the responsible plaques, including the morphology (regular or irregular), echogenicity of the plaques (iso-, hypo-, or hyperechoic) and calcification characteristics (without calcification, superficial calcification, inner calcification, and basal calcification). One week after CAS, the alteration of diameter and hemodynamic parameters were evaluated by CDU, and the occurrence and degree of residual stenosis were determined. In addition, magnetic resonance imaging was performed before and during the 30-day postprocedural period to identify new ischemic cerebral lesions. ResultsThe rate of composite complications, including cerebral hemorrhage, symptomatic new ischemic cerebral lesions, and death after CAS, was 1.54% (7/454 cases). The rate of residual stenosis after CAS was 16.3% (74/454 cases). After CAS, both the diameter and peak systolic velocity (PSV) improved in the preprocedural 50% to 69% and 70% to 99% stenosis groups (P < .05). Compared with the groups without residual stenosis and with <50% residual stenosis, the PSV of all three segments of stent in the 50% to 69% residual stenosis group were the highest, and the difference in the midsegment of stent PSV was the largest (P < .05). Logistic regression analysis showed that preprocedural severe (70% to 99%) stenosis (odds ratio [OR], 9.421; P = .032), hyperechoic plaques (OR, 3.060; P = .006) and plaques with basal calcification (OR, 1.885; P = .049) were independent risk factors for residual stenosis after CAS. ConclusionsPatients with hyperechoic and calcified plaques of the carotid stenosis are at a high risk of residual stenosis after CAS. CDU is an optimal, simple and noninvasive imaging method to evaluate plaque echogenicity and hemodynamic alterations during the perioperative period of CAS, which can help surgeons to select the optimal strategies and prevent the occurrence of residual stenosis.

Assessment of hemodynamic significance of renal artery stenoses in endovascular treatment of resistant vasorenal arterial hypertension

Objective. To determine the significance of renal artery stenosis according to different methods of assessing the functional significance of stenosis and to evaluate the safety and efficacy of stenting of unilateral renal artery stenosis after 6 months and 1 year according to office BP and ABPM.Materials and methods. The study included 44 patients with resistant arterial hypertension and renal artery stenosis (mean age 69 ± 11 years), while receiving multicomponent antihypertensive therapy, including diuretic. After assessing the degree of RA stenosis according to selective angiography and additional methods of assessing the functional significance of RA stenosis (iFR, Pd/Pa, translesional gradient and FFR) the patients underwent RA stenting. The safety of the procedure was assessed by creatinine and glomerular filtration rate dynamics (MDRD equation). The effectiveness of the procedure was study according to office blood pressure (BP) and ambulatory BP monitoring (ABPM).Results. According to the results of angiography, the patients were divided into two groups: group A – patients with subtotal PA stenosis (&gt; 90%) and group B – patients with moderate stenosis (60-90%), who underwent additional assessment of the functional significance of stenosis. The immediate angiographic result in both groups was optimal (the degree of residual stenosis was less than 5%). In group B, after stent implantation in the PA, there was a decrease of the translesional gradient by 38 ± 10 mm Hg (p &lt; 0,0001), FFR &gt; 0,8(p &lt; 0.0001). iFR &gt; 0.89, Pd/Pa&gt;0.9 (p = 0,093). In both groups, there was a significantly significant reduction in arterial blood pressure at distant times, according to clinical BP measurement and ABPM.Conclusion. The measurement of such parameters as translesional gradient and fractional reserve is the most reliable in assessing the hemodynamic significance of PA stenosis in comparison with iFR and Pd/Pa measurements in patients with moderate PA stenosis. PA stenting in patients with uncontrolled resistant AH and severe renal artery lesions, as well as moderate stenosis confirmed by additional methods of stenosis functional significance assessment is reasonable to consider in order to enhance the antihypertensive effect.

A retrospective study of drug-coated balloon angioplasty for vertebral artery origin stenosis.

Angioplasty using drug-coated balloon (DCB) for treatment of symptomatic vertebral artery origin stenosis (VAOS) is promising, but of uncertain benefit. This study aimed to evaluate the feasibility, safety, and effectiveness of using DCB in the treatment of severe VAOS. This study included 20 patients with severe VAOS treated with DCB alone between April 2018 and December 2019. Vascular death, transient ischemic attack (TIA), and stroke related to the responsible artery within 30days after procedure were recorded as primary endpoints. Restenosis, late TIA, and stroke related to VAOS and satisfied clinical outcome [modified Rankin Scale (mRS) ≤ 2] were documented at follow-up visit as secondary endpoints. Of 20 patients, 16 were performed DCB dilation successfully, and 4 were excluded due to further bailout stenting. After the procedure, no adverse event occurred within 30days. Ten of 16 patients achieved residual VAOS (rVAOS) < 50% (lower rVAOS group), and the remaining 6 patients achieved rVAOS ≥ 50% but < 70% (higher rVAOS group). During follow-up, vertebral artery origin restenosis was detected in 3 (18.8%) of 16 patients by ultrasound. Among the 3 patients with restenosis, 2 were belonged to the higher rVAOS group, which might indicate a tendency that the more severe the residual stenosis, the higher the restenosis rate. All patients had no complaint in the whole follow-up period (median, 7months; InterQuartile Range, 1-18months). Angioplasty using DCB for VAOS may be feasible, safe, and effective. The degree of residual stenosis after using DCB alone may affect the restenosis rate.

Evaluation Of Safety And Effectiveness Of The Biomimics 3D Stent System In The Femoropopliteal Arteries Of Patients With Symptomatic Peripheral Arterial Disease: Single-centre 24 Months Results

Aim: The aim of the study was to evaluate the safety and effectiveness of the BioMimics 3D stent for the treatment of femoropopliteal stenosis or occlusion. The BioMimics 3D stent has a unique 3D helical geometry designed to improve haemodynamics and increase wall shear for a long-term atheroprotective effect. Materials and methods: Between September 2015 and May 2016, 22 patients (12 men, 10 women) were included in the study after giving their written informed consent. The mean age was 69.1 ± 8.4 years. The mean Rutherford category was 2.91 ± 0.42 (2-4). The mean visual estimate of lesion length was 83.2 ± 34.0 mm with an average grade of stenosis of 93.1 ± 8.5%. Complete occlusion was present in 36.4% of patients. A total of 27 stents were implanted, 17 patients received a single stent, and 5 required 2 stents. The total stent length was 102 ± 33 mm. Results: The technical success rate was 100%. The mean degree of residual stenosis after stenting was 9.1 ± 7.7%. No serious complications were observed in the first 30 days. The primary patency rate of the stents was 100% after 30 days, 81.8% after 12 months, and 77.8% after 24 months. On duplex ultrasound, the mean PSVR was 0.71 ± 2.4 immediately after stenting, and 0.80 ± 3.6 and1.03 ± 2.9after 12 and 24 months. One patient (4.5%) had undergone clinically driven target lesion revascularisation after 12 months, and a total of 2 patients after 24 months (9.1%). Clinically, there was a significant increase in ABI from 0.63 ± 0.10 before stenting to 0.93 ± 0.09 after 30 days, 0.90 ± 0.12 after 12 months, and 0.95 ± 0.21 after 24 months. The mean Rutherford category also improved significantly, to 0.95 ± 0.09 after 1 month and 1.19 ± 0.12 and 1.09 ± 0.27 after 12 and 24 months. X-ray imaging after 12- and 24-months follow-up found no stent fracture at either time point. Conclusion: The safety and effectiveness of the BioMimics 3D stent for the treatment of femoropopliteal lesions was confirmed overall; based on the long-term follow-up in particular, the positive effect of the helical stent structure seemed associated with stable patency values.

Balloon-mounted versus self-expanding stents for symptomatic intracranial vertebrobasilar artery stenosis combined with poor collaterals

ABSTRACTObjectives: To compare the technical and 1-year outcomes of balloon-mounted versus self-expanding stents for symptomatic intracranial vertebrobasilar artery stenosis.Methods: 167 patients with severe intracranial vertebrobasilar artery atherosclerotic stenosis with poor collaterals were enrolled. Both balloon-mounted stenting and self-expanding stent placement were selected to treat patients. The baseline characteristics, cerebral angiography and clinical follow-up were assessed between the two groups.Results: The overall mean stenosis degree was reduced from 82.8 ± 11.8% pre-stent placement to 9.41 ± 8.20% post-stent placement. Patients treated with self-expanding stent were more likely to undergo general anesthesia (81.2% versus 67.3%; P = 0.048) and have longer operative times (91.0 ± 25.1 min versus 67.9 ± 17.1 min, P = 0.012) than those treated with self-expanding stents. Patients treated with self-expanding stents were more likely to require longer and larger diameter stents (14.99 ± 3.26 mm versus 9.23 ± 2.46 mm, P = 0.000; 3.28 ± 0.57 mm versus 2.74 ± 0.30 mm, P = 0.000, respectively). The degree of residual stenosis in self-expanding stent group was higher than patients treated with balloon-mounted stents (13.39 ± 8.64% versus 6.70 ± 6.62%, P = 0.000). The rates of stroke, transient ischemic attack or death at 1-year follow-up were not significantly different between two groups (P > 0.05).Conclusions: Stenting for patients with severe symptomatic intracranial vertebrobasilar arterial stenosis with poor collaterals can be performed safely with efficacy. Patients treated with balloon-mounted stents appear to have shorter operative times and lower re-stenosis rates than treated with self-expanding stents.

Submaximal primary angioplasty for symptomatic intracranial atherosclerosis: peri-procedural complications and long-term outcomes.

The aim of our study is to report the peri-procedural complications and long-term stroke recurrent rate of symptomatic intracranial atherosclerosis (ICAS) patients who underwent submaximal primary angioplasty. This is a retrospective analysis of consecutive patients in a single center who underwent submaximal primary angioplasty between January 1, 2012 and December 31, 2015. The peri-procedural complications and long-term outcomes are reported. Primary angioplasty was successfully performed in 129 patients (97.0%). The mean degree of pre-procedural stenosis was 81.9 ± 10.2%, and the degree of residual stenosis was 40.7 ± 19.1%. There were nine (6.8%) peri-procedural complications within 30days, including seven ischemic strokes, one subarachnoid hemorrhage, and one asymptomatic intracerebral hemorrhage. None of them resulted in death. One-year follow-up was available in 122 patients (91.7%). Three more ischemic strokes (2.3%) which were in the territory of the treated artery occurred between 30days and 1year. The 1-year stroke and death rate was 9.0%, including peri-procedural stroke. Kaplan-Meier analysis showed a 3-year stroke-free survival of 87.2%. Submaximal primary angioplasty can be performed with a low peri-procedural complication rate and relatively good clinical outcome at long-term follow-up for symptomatic ICAS patients.

The Incidence and Risk Factors of In-Stent Restenosis for Vertebrobasilar Artery Stenting.

In-stent restenosis (ISR) remains a challenge for vertebrobasilar artery stenting (VBAS). We aimed to investigate the incidence and risk factors of ISR. This was a retrospective study. From July 28, 2005, to July 30, 2015, patients who received VBAS with an angiographic follow-up time of 6 to 12 months after surgery were enrolled. The clinical and angiographic issues were recorded and analyzed. In total, 283 patients with 335 stents were incorporated into the study. Vertebral ostial lesions accounted for 73.4% (246/335) of the lesions. During the follow-up period, 58 patients with 60 stents experienced ISR (>50%). Stepwise logistic regression analysis showed that the degree of residual stenosis, stent diameter, and alcohol consumption were independent predictors of ISR. Our study demonstrated the incidence and risk factors of ISR after VBAS. This retrospective study with the largest cohort to date provided insight into the occurrence of ISR after VBAS.

Multimodal Therapy for Non-Superacute Vertebral Basilar Artery Occlusion

Objective: The aim of this study was to evaluate the feasibility and safety of multimodal therapy for patients with non-superacute vertebral basilar artery occlusion. Method: We performed a retrospective analysis of multimodal therapy for patients with vertebral basilar artery occlusion. All patients who were beyond the time window to receive intravenous thrombolysis and who had deterioration of symptoms after drug treatment received small-balloon dilatation of the occlusive artery to estimate vascular occlusion aetiology. Thrombectomy with a Solitaire AB system was applied to the thrombus, and angioplasty with intracranial stents was used to treat stenosis. During the 3-month follow-up, National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) scores were recorded regularly. Results: We included 12 patients with a mean age of 60.4 (SD: 12.9) years. The average score on the NIHSS was 16.6 (SD: 11.6), and the average time from onset to admission was 95 h (SD: 121). The arteries were recanalized for all patients, but the degree of residual stenosis in the parent artery was 17.5% (SD: 20.1). During the follow-up period, one patient died of pulmonary haemorrhage and infection, and another patient died from haemorrhage related to high perfusion. After 3 months of follow-up, the 10 surviving patients showed an average NIHSS score of 7.9 (SD: 8.7) and an average mRS score below 2 (1.3 ± 1.4). Conclusion: For patients with posterior circulation stroke due to basilar artery or vertebral artery occlusion who present to the hospital 6 h after symptom onset and who exhibit deterioration of symptoms after drug treatment, multimodal recanalization of the occluded artery may be a feasible and safe therapy.

Three-dimensional numerical simulation of a failed coronary stent implant at different degrees of residual stenosis. Part I: Fluid dynamics and shear stress on the vascular wall

ABSTRACTThe influence of the degree of residual stenosis on the hemodynamics inside coronary arteries is investigated through three-dimensional (3D) numerical simulations. The present paper, which is the first of a series of two, focuses on the influence that the degree of residual stenosis (DOR) has on the fluid dynamics and the shear stresses acting on the stent and the artery wall. The pulsatile nature of the blood flow and its non-Newtonian features are taken into account. Four models of artery are investigated. The results show that the wall shear stress (WSS) increases monotonically, but not linearly, with the DOR.

Abstract TMP31: Hyperacute Extracranial Internal Carotid Artery Stenting vs Angioplasty: Which is the Best for Recanalization?

Background: Up to 20% of acute intracranial occlusions have an associated extracranial internal carotid artery (ICA) severe stenosis or occlusion, and they often need specific treatment. However, it remains unclear which is the best option for extracranial revascularization. We aimed to study differences in restenosis, complications, and stroke recurrences between patients treated with stenting and those who underwent angioplasty without stenting. Methods: Prospective study of consecutive patients with non-cardioembolic ischemic stroke and occlusion or severe stenosis of the extracranial ICA, who underwent hyperacute endovascular procedure from April 2013 to December 2015. We divided patients depending on the extracranial treatment they received. We compared the rate of stenosis &gt;50% or occlusion of the ICA at 24 hours (evaluated by carotid ultrasound or CTA). Besides, we analyzed differences in complications and stroke recurrences within 1 year of follow-up. Results: From 97 patients who underwent hyperacute revascularization of the extracranial ICA, 63 fulfilled the inclusion criteria: mean age 65.6±13.6 years, median time from symptoms onset to treatment 249 [161-330] minutes. Thirty-one (49.2%) were treated with angioplasty and 32 (50.8%) with stent. Both groups were comparable in demographic data, vascular risk factors, previous treatment (including antiplatelets), and ASPECTS score. Thirty-seven (58.7%) received intravenous rtPA and 58 (92.1%) intracranial thrombectomy. Patients who underwent angioplasty presented stenosis &gt;50% or occlusion at 24h more frequently than those who underwent stenting (67.7% vs 21.9% , p =0.002), regardless the degree of residual stenosis after the angioplasty. Thirteen (38.1%) of the angioplasties were permeable at 24 hours, nevertheless 39.1% needed a deferred stenting. There were no differences in complications, including intracranial hemorrhage, despite intravenous rtPA or early double antiplatelet therapy, as well as in stroke recurrences within 1 year ( p &gt;0.05 for all comparisons). Conclusions: Hyperacute extracranial ICA stenting seems to have a lower risk of restenosis compared to angioplasty, without a significant increase of complications and stroke recurrences

Endovascular Treatment of Juxta-anastomotic Venous Stenoses of Forearm Radiocephalic Fistulas: Long-term Results and Prognostic Factors

PurposeTo evaluate long-term results of endovascular procedures in treatment of venous juxta-anastomotic stenoses (JASs) of native forearm radiocephalic arteriovenous fistulas (AVFs) and to identify prognostic factors influencing these results. Materials and MethodsDuring a 124-month period, 147 endovascular interventions were performed in 75 forearm radiocephalic AVFs with JASs defined as stenoses located within the first 5 cm of the outflow vein. Prognostic factors included patient characteristics (age, sex, diabetes), AVF-related characteristics (location on forearm, age, maturity), stenosis-related characteristics (position relative to anastomosis, length, and degree), and degree of residual stenosis and delay of restenosis after the first endovascular procedure. ResultsAt 1 and 3 years, access primary patency (PP) rates were 46.6% (95% confidence interval [CI], 36.3%–59.9%) and 25.5% (95% CI, 15.7%–41.6%) and assisted PP (APP) rates were 81.3% (95% CI, 72.6%–91.1%) and 63.2% (95% CI, 50.6%–79.0%), respectively. Stenosis degree of 50%–75% (P = .017), stenosis length of 10 mm or more (P = .017), and time before first restenosis of less than 6 months (P = .03) significantly increased the frequency of endovascular procedures during follow-up. However, only the degree of residual stenosis after the first endovascular treatment significantly affected long-term APP (P = .039). When residual stenosis was less than 50%, 1- and 2-year access APP rates were 84.6% (95% CI, 75.8%–94.4%) and 76.1% (95% CI, 64.6%–89.6%), respectively. When it was at least 50%, the respective APP rates were 62.3% (95% CI, 38.9%–99.9%) and 46.8% (95% CI, 22.4%–97.7%). ConclusionsEndovascular treatment of JASs in forearm radiocephalic AVFs provides good long-term results except when the residual stenosis after the first procedure is 50% or more. In that case, the optimal treatment remains to be determined.

Risk Factors and Complications Associated with Difficult Retrieval of Embolic Protection Devices in Carotid Artery Stenting

This study was designed to investigate the risk factors and complications of difficult retrieval (DR) of embolic protection devices (EPDs) in carotid artery stenting (CAS). A total of 195 consecutive patients who underwent CAS between December 2007 and March 2010 in a general hospital were enrolled and divided into two groups: with DR and without DR. The risk factors of DR were analyzed with univariate and multivariate analyses. The complications of DR were recorded and analyzed. A total of 30 (15.4%) patients with DR of EPDs were observed, of whom EPDs were successfully retrieved in 29, and in 1 was it taken out by surgical treatment. The retrieval time was significantly longer in patients with DR (490.5±143.9s) than in patients without DR (157.2±15.7s, p=0.000). Vasospasm was observed more frequently in patients with DR than in patients without DR (55.2% vs. 14.5%, p=0.000). Intracranial compilations were more frequent in patients with DR than in those without DR (17.2% vs. 0.6%, p=0.000). Calcified plaques, degree of residual stenosis, types of the stents, and tortuosity index (TI>80°) were all associated with DR. A logistic regression analysis indicated that calcified plaques (odds ratio (OR)=6.5; p=0.000) and TI>80° (OR=18.8; p=0.000) were independent predictors of DR. Calcified plaques and TI>80° may be related to DR in patients with CAS. DR may lengthen the retrieving time and increase the complications of the procedure.

Interventional Nephrology: Core Curriculum 2009

Interventional Nephrology: Core Curriculum 2009

Comparative effect of streptokinase and alteplase on electrocardiogram and angiogram signs of myocardial reperfusion in ST segment elevation acute myocardial infarction

Modern pharmacological reperfusion in ST segment elevation acute myocardial infarction means the application of fibrin specific thrombolytics combined with modern antiplatelets therapy--dual antiplateles therapy, acetylsalicylic acid and clopidogrel, and enoxaparin. The contribution of each agent has been widely examined in large clinical studies, but not sufficiently has been known about the effects of a combined approach, where the early angiography and percutaneous coronary intervention is added during hospitalization, if necessary. The aim of the paper is to compare the effects of streptokinase and alteplase, together with the standard modern adjuvant antiplatelets and anticoagulation therapy (aspirin, clopidogrel, enoxaparin) in patients with ST segment elevation acute myocardial infarction, on electrocardiographic and angiographic signs of the achieved myocardial reperfusion. The prospective study included 127 patients with the first ST segment elevation acute myocardial infarction who were treated with a fibrinolytic agent in the first 6 hours from the chest pain onset. The examined group included 40 patients on the alteplase reperfusion therapy, while the control 87 patients were on the streptokinase therapy. All the patients received the same adjuvant therapy and all were examined by coronary angiography on the 3rd to 10th day of hospitalization. Reperfusion effects were estimated on the basis of the following: ST segment resolution at 60, 90 and 120 minutes, the appearance of reperfusion arrhythmias at the electrocardiogram, percentage of residual stenosis at the "culprit" artery, TIMI coronary flow at the "culprit" artery and the appearance of new major adverse coronary events in the 6-month-follow-up period. By analysing the resolution of the sum of ST segment elevation in infarction leading 60 minutes after the beginning of the medication application, we received a statistically significantly higher resolution of ST segment in the group of patients who received alteplase (p < 0.05). 60 minutes after the application of thrombolytics, 64% of patients at streptokinase showed the absence of ST segment resolution (<30%), and 32% of patients at alteplase (p < 0.0001). Reperfusion arrhythmias as the sign of successful myocardial reperfusion were present in 62.5% of patients at alteplase and in 57.4% of patients at streptokinase, but the difference is not statistically significant.There was no statistically significant difference in the degree of residual stenosis at the,culprit" artery in the compared groups of patients. TIMI 3 flow was achieved in 75% of patients at alteplase and in 38% of patients at streptokinase (p < 0.0001). There was no statistically significant difference in the frequency of major adverse coronary events in the 6-month-follow-up period after acute myocardial infarction. Alteplase with modern adjuvant therapy of ST segment elevation acute myocardial infarction shows the earlier achievement of coronary perfusion as well as better coronary flow compared to streptokinase. There is no statistically significant difference in the frequency of reperfusion arrhythmias, degree of residual stenosis at the"culprit"artery and the frequency of new coronary events in the 6-month-follow-up period after acute myocardial infarction.

Aortic Arch Morphology and Late Systemic Hypertension Following Correction of Coarctation of Aorta

To reproduce in an adult population a pediatric study that found an association between aortic arch geometry and late systemic hypertension following successful repair of aortic coarctation. Fifty-one patients with successful repair of coarctation of the aorta had blood pressure measurement at rest and during exercise. After cross-sectional imaging of the aortic arch, patients were assigned to 1 of 3 previously defined morphological categories: normal, gothic, or crenel. The degree of residual stenosis and the ratio of the height/transverse diameter of the arch (A/T ratio) were calculated. No relationship was found between arch geometry and either resting- or exercise-induced hypertension. We found the classification into 3 morphological types difficult and did not find an association between gothic arch or a high A/T ratio and hypertension.

Correlation of Intragraft Blood Flow with Characteristics of Stenoses Found During Diagnostic Fistulography

To determine if intragraft blood flow measurements correlate with the anatomical characteristics of stenoses found during diagnostic fistulography. This investigation was a retrospective review of 40 patients with decreased intragraft blood flow (<600 mL/min) in patent polytetrafluoroethylene hemodialysis grafts who underwent diagnostic fistulography and angioplasty. Intragraft blood flow was measured with the ultrasonic dilution technique. The fistulogram images were reviewed and the anatomic characteristics of all stenoses were measured and recorded. These characteristics were correlated with the intragraft blood flow values. The mean intragraft blood flow was 476 mL/min (range, 270-600 mL/min). Fistulography revealed a total of 71 stenoses and all 40 patients had at least one lesion with > 50% stenosis. There was no correlation between the intragraft blood flow and the location, length, or number of stenoses. There was a moderate inverse correlation between the intragraft blood flow and the degree of stenosis (P =.08). Fifty-nine stenoses were treated with angioplasty. The mean postangioplasty blood flow was 796 mL/min (range, 470-1565 mL/min). The mean change in blood flow after angioplasty was 311 mL/min (range, 15-1154 mL/min) There was no association between the change in blood flow after angioplasty and the number, length, or degree of residual stenosis. Intragraft blood flow < 600 mL/min is an excellent predictor of the presence of at least one significant (>/=50%) stenosis. There was an inverse correlation between intragraft blood flow and the degree of stenosis. There was no association between the intragraft blood flow and the location, length, or number of stenosis.

C-Reactive protein on admission and the success of thrombolytic therapy with streptokinase: is there any relation?

Background: Recent evidence has demonstrated that inflammation plays a major role in the initiation and progression of atheroma plaques. C-reactive protein (CRP) is shown to have prognostic significance in acute coronary syndromes. We investigated the influence of CRP levels before thrombolytic therapy on infarct-related artery (IRA) patency and the degree of residual stenosis. Methods: 45 consecutive patients with a first attack of acute myocardial infarction (MI) who underwent streptokinase therapy and subsequently coronary angiography were enrolled into the study. Patients were divided into 2 groups according to the level of CRP on admission. Results: Serum CRP levels were ≥0.5 mg/dL in 26 patients (Group-I) and <0.5 mg/dL in 19 patients (Group-II). The patency of IRA (TIMI-2 and 3) evaluated at 90th minute after the initiation of thrombolytic therapy was similar between the two groups (62% vs. 68%, p>0.05). However, the presence of TIMI-3 flow was significantly lower and TIMI-2 flow was higher in Group-I as compared to Group-II (12% vs. 53%, p=0.003 and 50% vs. 16%, p=0.018 respectively). Additionally, among patients with patent IRA, the degree of residual stenosis was significantly higher in Group-I (80±14% vs. 68±15%, p=0.032). Conclusion: High serum CRP levels on admission in patients within 6 hours after the start of acute ST-segment elevation MI are associated with lower TIMI flow grades and higher residual stenosis of IRA after intravenous streptokinase. Our observations imply that patients with higher CRP levels on admission require closer follow-up during and after acute MI.

Percutaneous Intervention for Permanent Hemodialysis Access

Purpose: To evaluate the effectiveness of percutaneous transluminal angioplasty (PTA) and pulse-spray pharmacomechanical thrombolysis (PSPMT) using urokinase for the management of insufficient hemodyalitic access, and to identify contributory patency-related factors following interventional procedures. Materials and Methods: Between August 1995 and July 2001, 105 cases of insufficient hemodyalitic access involving 38 artificial arteriovenous fistulae (AVF) and 67 graft arteriovenous fistulae (AVG) were treated interventionally. The patients underwent PTA alone in 53 cases and PSPMT combined with PTA in 47, and procedural success and long-term patency were evaluated in terms of a patient's age and sex, the presence of diabetes, the location of access, the type of AVG, the draining vein of AVG, the presence of central vein stenosis, the degree of residual stenosis, and the method of interventional procedure, and contributory factors were thus identified. Results: The overall technical success rate of interventional management was 83.8% (88/105), while the overall primary patency rate was 58.75.2% at 6 months, 43.06.0% at 1 year, and 18.16.0% at 2 years. In AVF/AVG groups, primary patency rates were 55.99.2%/57.86.5% at 6 months, 45.810.0%/42.78.4% at 1 year, and 21.8%9.8%/18.96.5% at 2 years. The overall secondary patency rate was 40.08.1% at 2 years. No contributory factors were found (95% confidence level), though patency of access decreased when residual stenosis was more than 30% (p=0.054). Conclusion: Interventional management of insufficient hemodyalitic access has high success and patency rates, and is an effective primary method. There appear to be no contributory factors, though residual stenosis of more than 30% tends to decrease the patency of hemodialytic access.

Outcome after thrombolysis and selective thoracic outlet decompression for primary axillary vein thrombosis

Purpose: Treatment for primary subclavian-axillary vein thrombosis (SAVT) at our institution consists of thrombolysis and anticoagulation for 3 months. Thoracic outlet decompression has been performed for a small number of patients. We wanted to review the functional outcomes of patients treated in such a manner. Material And Methods: The records of all patients treated for a first episode of SAVT at our hospital over the past 10 years were reviewed. Demographics, comorbidities, method of diagnosis, and treatment for SAVT were recorded. Long-term follow-up was obtained by chart review and asking patients to complete the DASH (disabilities of the arm, shoulder and hand) questionnaire that was developed by the American Academy of Orthopedic Surgeons. Results: Twenty-eight patients, 20 men and eight women, with a mean age of 36 were treated during the study period. The median time between onset of symptoms and treatment was 5.5 (range, 1-100) days. All patients had confirmation of the diagnosis by venography. Twenty-five patients received thrombolytic treatment with catheter-directed infusions of urokinase; in the other three patients the vein was chronically occluded. Twelve patients had some degree of residual stenosis and were treated with percutaneous transluminal angioplasty after thrombolysis. During the study period two patients underwent decompressive surgery. Twenty-one patients responded to the DASH questionnaire a mean of 2.9 years (range, 2 months to 8 years) after the episode of SAVT. Six (28%) of 21 patients were completely symptom free, 13 patients (62%) had DASH scores consistent with mild symptoms, and two patients had more severe symptoms. Twenty percent (4 of 21) of patients report some difficulty with work. Conclusions: Thrombolysis, followed by selective thoracic outlet decompression on the basis of the severity of patients' symptoms can be used as a therapeutic approach to SAVT without undue morbidity. The DASH questionnaire is a useful tool to evaluate results after therapy for SAVT. (J Vasc Surg 2001;33:783-8.)