Evidence Of Restenosis Research Articles

In Situ Saphenous Vein Bypass Grafting in Peripheral Arterial Disease of the Lower Extremities

Objective: To evaluate the efficacy and safety of the valvulotome device used to cut venous valves and in situ bypass in the treatment of peripheral arterial disease (PAD) of the lower extremities. Methods: In this study, the basic principles of in situ saphenous vein bypass are mentioned, specifically for a novel valvulotome device (NODⓇ Valvulotome device, Invamed/ Ankara/Turkey). In this context, the effectiveness of the method was evaluated by interpreting the results of some studies on in situ saphenous vein bypass. Results: In situ bypass has an effective rate for long-term outcomes with approximately 80%, 90% and 95% for primary patency (no evidence of restenosis with a maximum systolic rate >2.5 or sonography-based occlusion), secondary patency (patency maintained by repeated intervention after complete bypass occlusion), and limb salvage (absence of major amputations), respectively. The side effects, including vessel perforation and intramural bleeding, are very low. The technical success rate is very high. Valvulotomes are easy to use by the surgeons and provide comfort for the patients. Conclusions: In situ bypass is effective and safe in PAD treatment. Valvulotome provides ease of use for surgeons and comfort for patients.

Transcarotid artery revascularization of a symptomatic carotid artery with a tortuous intrathoracic component

We present the case of a tortuous intrathoracic common carotid artery (CCA) with a symptomatic right internal carotid artery lesion. This patient had a complex medical history, including a previous intraoperative cardiac arrest during attempted carotid endarterectomy (CEA) initially attributed to heparin anaphylaxis. She received maximum medical management but presented 6 months later to our institution with a secondary transient ischemic attack. Surgical options for the case were discussed amongst a multidisciplinary team. Transfemoral and transradial stenting were deemed non-viable due to the tortuous nature of the CCA. Repeat CEA under general anesthesia was deemed risk-prohibitive from a cardiac risk perspective. For these reasons, the patient was offered transcarotid artery revascularization (TCAR) under regional anesthesia. Intraoperatively, the “sheath stopper” was removed from the TCAR device, allowing the sheath to be advanced to 6 cm, effectively removing the tortuous component of the CCA. Flow reversal was established, and the operation proceeded in the standard fashion without neurologic change. The patient has remained on dual antiplatelet therapy and completed 2-year follow-up without evidence of restenosis, access site complication, or repeat neurologic event. This case demonstrates the potential applicability of TCAR to benefit a subset of patients who previously lacked a surgical option due to anatomical constraints.

Bronchoscopic Management of Benign Bronchial Stenosis by Electrocautery and Balloon Dilatation

Benign bronchial stenosis is managed by surgical or bronchoscopic methods. Although surgical approach is definitive, it is technically demanding and is costlier than bronchoscopic treatment. Here, we report the case of a 27-year-old female patient with symptomatic benign bronchial stenosis of the left main bronchus. The stenosis was dilated successfully through a fibreoptic bronchoscope by electrocautery followed by balloon bronchoplasty and application of mitomycin-C. On follow up, there was no evidence of re-stenosis.

Early and chronic phased local coagulative responses following bioresorbable-polymer drug-eluting stent implantation

Abstract Background Neointimal maturation after bioresorbable-polymer (BP) drug-eluting stent (DES) implantation will not be complete in the absorption phase of the polymer. We have previously reported local persistent hypercoagulation after sirolimus-eluting stent (SES) implantation by measuring local plasma prothrombin fragment 1+2 (F1+2) levels. The aim of this study is to examine time-dependent local coagulative response after BP-DES implantation. Methods Sixty-four patients who were treated about ten months earlier with coronary angioplasty, with no evidence of restenosis, were studied [durable-polymer (DP)-DES {SES; Cypher®: 26pts and everolimus-eluting stent (EES); Xience®: 16pts} and BP-DES (BP-EES; Synergy®: 10pts and BP-SES; Ultimaster®: 12pts)]. We measured plasma levels of F1+2 sampled in coronary sinus (CS) and sinus of Valsalva (V) at the early (2±1 months) and chronic (10±2 months) phases. The transcardiac gradient (Δ) was defined as CS level minus V level. Results No significant differences were observed in the percent diameter stenosis between the DP- and BP- DES groups (11.5±15.5 vs 14.1±11.9%). The ΔF1+2 was significantly lower in the BP-DES group than in the DP-DES group at the chronic phase (7.5±16.1 vs 16.4±17.1pmol/l, p<0.05). In the BP-DES group, the ΔF1+2 did not differ significantly between the early and chronic phases (7.0±14.1 vs 7.5±16.1pmol/l, NS). Conclusion Lower local coagulative response was observed at the chronic phase after BP-DES implantation compared to DP-DES implantation, and local hypercoagulation after BP-DES implantation was not observed at the early phase compared to the chronic phase. These findings might lead to the possibility of shorter dual antiplatelet therapy after BP-DES implantation. Funding Acknowledgement Type of funding sources: None.

Abstract 12894: Suppressed Local Coagulative Response After Newer-generation Ultrathin Strut SES Implantation Compared to Older-generation SES Implantation

Background: We have previously demonstrated local persistent hypercoagulation after durable polymer (DP)-sirolimus-eluting stent (SES) implantation by measuring plasma prothrombin fragment 1+2 (F1+2) levels. The aim of this study is to evaluate local coagulative response after newer-generation ultrathin strut SES implantation. Method: Forty-five patients who were treated about 6-12 months earlier with coronary stenting, with no evidence of restenosis, were studied [DP-SES (Cypher): 26pts, biodegradable polymer (BP)-SES (older BP-SES, Ultimaster): 12pts and ultrathin strut BP-SES (newer BP-SES, Orsiro): 7pts]. We measured plasma levels of F1+2 sampled in coronary sinus (CS) and sinus of Valsalva (V). The transcardiac gradient (Δ) was defined as CS level minus V level. Results: No significant difference was observed in the percent diameter stenosis among DP-SES, older BP-SES, and newer BP-SES groups (10.1 ± 16.5 vs 13.1 ± 12.9 vs 12.1 ± 11.9 %). The ΔF1+2 was significantly lower in the BP-SES groups than in the DP-SES group (8.9 ± 10.1 vs 23.4 ± 21.1 pmol/l, p<0.05). The ΔF1+2 was lower in the newer BP-SES group than in the older BP-SES group, however, significant difference was not observed (7.0 ± 7.0 vs 9.7 ± 12.3 pmol/l). Conclusion: Suppressed local coagulative response after newer-generation ultrathin strut SES implantation was observed. These findings might indicate that lower strut thickness is more important factor than faster polymer resorption in the newer-generation DES era.

Stent-grafts are the best way to treat complex in-stent restenosis lesions in the superficial femoral artery: 24-month results from a multicenter randomized trial.

This clinical trial aims to evaluate the outcome (up to 24-months) of the treatment of in-stent restenotic or reoccluded lesions in the femoropopliteal arteries, by comparing the treatment of the GORE® VIABAHN® Endoprosthesis with PROPATEN Bioactive Surface (W. L. Gore & Associates, Flagstaff, AZ, USA) with a standard PTA treatment. The primary effectiveness endpoint of the study is the primary patency at 12 months, defined as no evidence of restenosis or occlusion within the originally treated lesion based on color-flow duplex ultrasound (PSVR≤2.5) and without target lesion revascularization (TLR) within 12 months. The primary safety endpoint is the proportion of subjects who experience serious device-related adverse events within 30 days postprocedure. A total of 83 patients meeting inclusion and exclusion criteria have been enrolled in this prospective, randomized, multicenter, controlled study in 7 sites between June 2010 and February 2012. Patients with an in-stent restenosis lesion in the femoropopliteal region and a Rutherford classification from 2 to 5 could be enrolled. After screening, the patient was randomized to either treatment with the GORE® VIABAHN® Endoprosthesis with PROPATEN Bioactive Surface or treatment with a standard PTA balloon. After the index procedure, follow-up visits at 1 month, 6 months, 12 months and 24 months were required. A color flow Doppler ultrasound was performed on all follow-up visits and a quantitative vascular angiography at the 12-month follow-up visit. In the VIABAHN® group, 39 patients (74.4% male; mean age 67.69±9.77 years) were enrolled and in the PTA group, 44 patients (72.7% male; mean age 68.98±9.71 years) were enrolled, which is comparable for both treatment groups. In the VIABAHN® group, 34 (87.2%) patients presented with claudication (Rutherford 2 and 3) and 5 (12.8%) patients had critical limb ischemia (Rutherford 4 and 5). In the PTA group, 36 (81.8%) patients were claudicants (Rutherford 2 and 3) and 8 (18.2%) presented with critical limb ischemia (Rutherford 4 and 5). The 12-month primary patency rates were 74.8% for the VIABAHN® group and 28.0% for the PTA group (P<0.001). No patients were reported to have device-related serious adverse events within 30 days postprocedure. The primary patency rate for the 24-month follow-up was 58.40% in the Viabahn group and 11.60% in the PTA group (P<0.001). The treatment of femoropopliteal in-stent restenosis with a VIABAHN® Endoprosthesis shows significantly better results than the treatment with a standard PTA balloon. This demonstrates that the use of the VIABAHN® Endoprosthesis is a very promising tool for the treatment of complex in-stent restenosis.

P2813The improvement of chronic local coagulative response according to the progress of drug eluting stent

Abstract Background We have previously reported local persistent hypercoagulation after sirolimus-eluting stent (SES) implantation by measuring local plasma prothrombin fragment 1+2 (F1+2) levels. The aim of this study is to examine chronic local coagulative response after each generation- drug eluting stent (DES) implantation. Methods Ninety-five patients who were treated about eight months earlier with coronary angioplasty, with no evidence of restenosis, were studied [1stgeneration durable polymer (DP)-DES {SES; Cypher®: 26pts, paclitaxel-eluting stent (PES); Taxus®:16pts}, 2ndgeneration DP-DES {everolimus-eluting stent (EES); Xience®:15pts, zotarolimus-eluting stent (ZES); Endeavor®:15pts}, and 3rdgeneration biodegradable polymer (BP)-DES {BP-biolimus-eluting stent (BES); Nobori®: 11pts and BP-SES; Ultimaster®: 12pts}]. We measured plasma levels of F1+2 sampled in coronary sinus (CS) and sinus of Valsalva (V). The transcardiac gradient (Δ) was defined as CS level minus V level. Results No significant differences were observed in the percent diameter stenosis among 1st, 2nd, and 3rd DES groups (12.5±15.5 vs 16.1±12.9 vs 13.1±11.9%). The ΔF1+2 was significantly lower in the 2nd and 3rd DES groups than in the 1st DES group (9.0±15.4 and 10.0±17.4 vs 27.3±23.8pmol/l, p&lt;0.05, respectively). The ΔF1+2 was significantly lower in the BP-DES groups (BP-BES and BP-SES) than in the DP-DES groups (DP-SES, DP-PES, DP-ZES, and DP-EES) (10.0±17.4 vs 18.1±19.5pmol/l, p&lt;0.05). The ΔF1+2 was significantly lower in the thin strut-DES groups (BP-SES, DP-ZES, and DP-EES) than in the thick strut-DES groups (DP-SES, DP-PES, and BP-BES) (8.4±15.4 vs 21.7±18.5pmol/l, p&lt;0.05). In the BP-DES groups, the ΔF1+2 was lower in the BP-SES group than in the BP-BES group (8.0±16.1 vs 12.7±18.1pmol/l, p=0.08). Conclusions The improvement of chronic local coagulative response was observed according to the progress of DES. These findings might be associated with lower strut thickness and faster polymer resorption in the newer-generation DES.

Safety and Efficacy of Flow Reversal in Acute and Elective Carotid Angioplasty and Stenting Using the Mo.Ma Device with Short-Term Follow-Up

Objective: To determine the safety and efficacy of flow reversal following proximal flow arrest as an embolic protection strategy for carotid angioplasty and stenting (CAS) with short-term follow-up. Method: We performed a retrospective review of our CAS database for patients who underwent stent-supported carotid revascularization in the setting of acute/subacute stroke or TIA. We reviewed clinical and radiographic data during a 36-month period. Primary outcome was clinical evidence of ipsilateral stroke in the first 30 days. Secondary outcomes include clinical outcomes and sonographic and/or angiographic follow-up over 6 months, 6-month functional scale, and all-cause mortality. Results: Fifty-five patients underwent CAS using flow reversal: 26 females and 29 males with a mean age of 69.7 years. Median time to treatment from index event was 3 days. 11% underwent stenting as part of hyperacute stroke therapy. Average luminal stenosis was 86%. The 9-Fr Mo.Ma device was used in combination with Penumbra aspiration in all cases. There were no ipsilateral strokes. Incidence of any ischemic event was 3.64%, but only 1 (1.82%) patient had a postoperative stroke. Clinical follow-up was available for 94.5%, while lesion follow-up was available for 73% of patients. Three patients had evidence of restenosis, but none were symptomatic. Luminal restenosis was ≤30% in all three. Median pre- and post-NIHSS were 1 and 1, respectively. Conclusion: Flow reversal using the Mo.Ma device is a safe and effective strategy in preventing distal embolization during carotid artery revascularization.

Bilateral choanal stenosis in a craniosynostosis child: a case report

&lt;p class="abstract"&gt;Congenital bilateral choanal stenosis is a rare developmental condition and is highly associated with craniosynostosis syndromes. It can present with life threatening asphyxia. Diagnosis is made clinically using simple bedside tests and nasoendoscopy. Computed tomography of paranasal sinus confirms the diagnosis and facilitates pre-operative planning. Although the definitive treatment is surgery, the surgical options are based on involvement of unilateral or bilateral as well as bony or membranous. We report a rare case of bilateral choanal stenosis in a child with Pfeiffer syndrome who presented with severe respiratory distress at day 32 of life. Clinically, there was failure to insert suction catheter size 6 French through both nasal cavities. A high-resolution computed tomography (HRCT) of paranasal sinus confirmed the diagnosis of bilateral choanal stenosis. Endoscopic repair of the choanal stenosis was performed and stent was inserted for 14 days. Post-operatively, there was no evidence of restenosis after 3 months of clinical follow up.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Management of left renal vein compression in patients presenting left gonadal vein reflux.

Background Compression of left renal vein is an atypical cause of reflux in pelvic veins resulting in pelvic varices that in turn causes frequently lower limb varices in many cases. Methods A monocentric study was undertaken to report the treatment and five-year follow up of patients presenting left renal vein compression. Embolization of refluxive gonadal/pelvic veins was performed generally as the initial procedure. Left renal vein stenting was performed in patients presenting haematuria, severe lumbar pain or persistent pelvic/lower limb varices after embolization. Results From 462 cases of left renal vein compression, 40 were treated by stenting as first procedure. Four hundred twenty-two were treated by gonadal/pelvic vein embolization and only 15 needed complementary stenting. After follow-up, all cases with haematuria had improved and lumbar pain was eliminated in 81.5%. Patients with recurrent or persistant varices were all improved. Conclusion Left renal vein stenting should be considered an effective and safe procedure, with demonstrated durable efficacy and safety and no evidence of restenosis.

Ascites Due to Hepatic Vein Stenosis: A Rare Complication Post Liver Transplant

A 40 year old male underwent orthotopic liver transplant for Laennec's cirrhosis and Hepatitis C. Early postoperative duplex ultrasound of the liver demonstrated patent vasculature. His hospital stay was prolonged due to acute kidney injury, mild abdominal pain, and ascites formation, resulting in debilitation. He had no ascites preoperatively. By post-operative day 35, the ascites became problematic, requiring therapeutic paracentesis of greater than 7 liters every few days-not responsive to diuresis or albumin. He had associated abdominal pain, and elevation of serum AST, ALT and alkaline phosphatase which peaked in the 400's. Work-up of the post-operative ascites began with a repeat duplex ultrasound, which showed a large right hepatic vein but no stenosis or obstruction. MRI/MRV abdomen showed portal hypertension manifested by the ascites, splenomegaly, enlarged splenic and coronary veins. Due to persistent massive ascites, a trans-jugular liver biopsy with portal pressure measurement was done. Hepatic vein wedge gradient was 4mmHg and liver biopsy showed dilated hepatic veins without thrombosis. Biopsy showed sinusoidal dilatation. Venogram showed a dilated proximal right hepatic vein, suggesting hepatic congestion, and a 1cm 35% stenosis at the right hepatic vein-IVC anastomosis. The stricture was dilated so that the flow gradient decreased from 5mmHg to 2mmHg, and stricture resolution was noted. Following balloon angioplasty, patient's transaminitis, and his need for therapeutic paracentesis, decreased; however his symptoms recurred within one week. A repeat venogram with pressures, showed a 50% stenosis of the right hepatic vein at the junction of its anastomosis with the IVC. He underwent stenting of the lesion, and had resolution in his symptoms. He required no paracentesis once the stent was placed. In the 8 months following discharge, multiple duplex ultrasounds performed have all shown a patent stent in right hepatic vein and no evidence of re-stenosis or ascites. Venous stenosis following liver transplant presents abdominal pain, transaminitis and refractory ascites, and is usually in the setting of prior vascular complications. It is unusual that an isolated right hepatic vein stenosis would present this way. Early diagnosis of vascular complications is imperative, as early intervention could prevent graft failure and the need for re-transplantation.

Reversible Changes of Posterior Cerebral Artery after Angioplasty for Moyamoya Disease: Report of a Case

Background: The changes of posterior cerebral arteries (PCAs) in Moyamoya disease (MMD) are often involved in the clinical setting. However, the changes of PCAs after recovering the hemodynamics of anterior circulation in MMD are not reported. Case Description: A 14-year-old patient was diagnosed as MMD with symptomatic stenosis in the right middle cerebral artery (MCA), asymptomatic stenosis in the left terminal internal carotid artery, and moyamoya-like vessels, stenotic lesion and an aneurysm were found in the right PCA, who was treated with balloon angioplasty in the right MCA. One month later, the patient suffered from transient ischemic attack in the right. DSA showed deteriorated severe stenosis in the left terminal portion of ICA and the proximal segment of MCA. The patient was performed angioplasty in the left ICA and MCA again. The follow-up angiography did not show any evidence of restenosis at the previous sites of stenosis after 18 months. Interestingly, the aneurysm and collateral vessels were disappeared as well as the stenotic vessel in the right PCA was recovered completely. Conclusion: Our findings indicated that the pathologic changes of PCA are reversible after recovering the hemodynamic of the anterior circulation in MMD. It is important to understand the pathophysiological changes of posterior circulation in MMD.

0182: Bioresorbable everolimus eluting stents in coronary arteries. Preliminary implantation data and follow up of 65 patients

Between february 2013 and april 2014, of 1450 coronary angioplaty procédures realized in our institution, 65 patients, aged 64.3 (40-94), underwent coronary artery stenting with Absorb Biovascular Scaffold (BVS) exercise angina 22 patients, acute coronary syndromes 37 (including acute myocardial infarction 5), silent ischemia 7, heart failure 2. Ten patients suffered diabètes (15%) and 14 experienced previous coronay interventions (20%). all stents have been implanted under angiographic control (except two cases including IVUS imaging) in de novo lésions through a radial approach with 6F guiding catheters following mandatory predilatation. 44 patients had single vessel desease (67%) and 21 multivessel desease. Target vessel was the left anterior descending artery in 35 cases, left circumflex in 10 and right artery in 14. 68 stents have been delivered; three patients had two BVS; 16 patients had also metallic drug eluting stents in other arteries. Side branch dilatation had to be performed in 4 patients. Implantation was successfull in all cases. No death Complications: side branch occlusion with non Q wave infarction in one case and transient ischaemic attack in one another. 58 patients left the institution the day after the procedure under conventionnal dual antiplatelet therapy. at 6.2 month (1-15) all patients were event free (100%) Three patients had angiographic control at one year and were free of restenosis; one another had 70% angiographic restenosis at the edges of the stent and underwent longer DES implantation (TLR: 1.5%). Three other patients had computed tomography scanner control at one year with no evidence of restenosis, including one case demonstrating restoration of systolic compression of the stented segment in a myocardal bridging whereas diastolic diameter was normal. at that time our preliminary data confirm the safety of the BVS device at implantation and at six months follow up.

Abstract 13607: Differential Response of Local Coagulation after Implantation of New Generation Drug-Eluting Stents Compared with Sirolimus-Eluting Stent

Purpose: We have previously demonstrated local persistent hypercoagulation after sirolimus-eluting stent (SES) implantation by measuring plasma prothrombin fragment F1+2(frF1+2) levels. The aim of this study is to examine local coagulation response after biolimus-eluting stent (BES) and everolimus-eluting stent (EES) implantation. Methods: Sixty-eight patients who were treated with stents about eight months earlier to the mid-segment of the left anterior descending coronary artery, with no evidence of restenosis, were studied (BES: 12pts, EES: 15pts, SES: 23pts, and BMS: 18pts). We measured plasma levels of frF1+2 sampled in coronary sinus (CS) and sinus of Valsalva (V). The transcardiac frF1+2 gradients (ΔfrF1+2) were defined as CS level minus V level. The patients were divided into 2 groups according to total stent length [longer stent group (≥24mm) or shorter stent group (&lt;24mm)]. Results: A larger percent diameter stenosis was observed in the BMS group than in the SES, EES, and BES groups (25.1±15.6 vs 7.1±16.5, 12.5±12.8, 10.3±14.2%, p&lt;0.05, respectively). The ΔfrF1+2 was greater in the SES group than in the BMS, EES, and BES groups, and no significant differences were observed among the BMS, EES, and BES groups (23.4±21.1 vs 4.7±13.4, 3.2±11.7, 1.5±11.1 pmol/l, p&lt;0.05, respectively). The ΔfrF1+2 in longer stent group (n=11) was significantly greater than in shorter stent group (n=12) (27.4±12.1 vs 19.2±10.1 pmol/l, p&lt;0.05) only in the SES group, however, no significant differences were observed according to total stent length in other groups. Conclusions: A lower response of local coagulation after BES and EES implantation was shown, and significant correlation between local hypercoagulation and total stent length was observed only after SES implantation. These findings might be associated with lower strut thickness and unique characteristics of polymer in second-generation drug-eluting stents.

Differential responses of local coagulation after implantation of everolimus-eluting and zotarolimus-eluting stents compared with early-generation drug-eluting stents in patients with stable angina

Purpose: We have previously demonstrated local persistent hypercoagulability after sirolimus-eluting stent (SES) implantation by measuring plasma prothrombin fragment F1+2 (frF1+2) levels. The aim of this study is to examine local coagulation response after everolimus-eluting stent (EES) and zotarolimus-eluting stent (ZES) implantation compared with early-generation drug-eluting [SES and paclitaxel-eluting stent (PES)] and bare metal stents (BMS). Methods: Eighty-five patients who were treated about eight months earlier with stents to the mid-segment of the left anterior descending coronary artery, with no evidence of restenosis, were studied (EES:12, ZES:15, PES:18, SES:20, and BMS:20). We measured plasma levels of frF1+2 sampled in coronary sinus (CS) and sinus of Valsalva (V). The transcardiac frF1+2 gradients (ΔfrF1+2) were defined as CS level minus V level. Results: A larger percent diameter stenosis (%DS) was observed in the ZES and BMS groups than in the SES (17.1±13.2, 25.1±15.6 vs 7.1±16.5%, p<0.05, respectively). There were no significant differences in %DS among SES, PES, and EES groups (7.1±16.5, 10.5±15.2, 12.6±12.9%, NS). There were no significant differences in ΔfrF1+2 among BMS, ZES, and EES groups (4.7±13.4, 5.5±8.4, 3.3±11.7 pmol/l, NS). The ΔfrF1+2 was smaller in the ZES and EES group, and larger in the PES group than in the SES group (5.5±8.4, 3.3±11.7, 32.3±24.2 vs 23.4±21.1 pmol/l, p<0.05, respectively). The ΔfrF1+2 significantly correlated with the total stent length in the SES group (r=0.53, p<0.05), however, it did not correlate in the EES, ZES, and PES groups. Conclusions: A decreased response of local coagulation after ZES and EES implantation and an increased one after PES implantation were observed, as compared to SES implantation. These findings might be associated with lower strut thickness, unique characteristics of polymer, and lower cytotoxic effect of eluted drug in second-generation drug-eluting stents.

Is isolated bilateral choanal atresia a real emergency? Two case reports

Bilateral choanal atresia (BCA) in newborns is thought to be a potentially life threatening anomaly. Unlike unilateral choanal atresia, its' early detection and management is considered to be an emergency. The aim of the present case presentation is an attempt to explain how a newborn, who is an obligatory nasal breather can survive this anomaly and adapt a new pattern of breathing. In this study, we present two rare cases of isolated BCA. According to our knowledge, only few similar cases were reported in the literature. The first one is a 60-year-old female that was discovered accidentally during clinical examination for a different complaint. The second case is a 24-year-old male presenting with bilateral nasal obstruction since childhood. The female declined the offer of surgical interference while the male underwent endoscopic drilling of the atretic plate, no stent was required post-operative. He was followed-up for more than a year with no evidence of restenosis. It can be concluded that isolated missed BCA in infants is compatible with life. Why these patients survive this anomaly, is a topic for discussion. We propose a trial of pacifier as a first line of management to allow the newborn with isolated BCA to adapt a new pattern of mouth breathing, thus avoiding early surgical interference with its risk of complications.

Mini‐Nasoseptal Flap for Recalcitrant Sphenoid Sinusitis

Objective: To describe the use of a modified nasoseptal flap for select cases of chronic sphenoid sinusitis. Method: Description and illustration of the surgical technique and indications for the modified nasoseptal flap for chronic sphenoid sinusitis. We report 3 cases of recurrent sphenoid fungal sinusitis treated with revision endoscopic sinusotomy and a mini-nasoseptal flap. Results: The mini-nasoseptal flap was used successfully in all cases without evidence of restenosis in the follow-up period. There were no complications related to flap harvest or inset. Conclusion: Inflammatory sphenoid lesions such as fungal balls may increase the risk of postoperative ostial stenosis especially in cases when postoperative surveillance or debridement is difficult or impossible. The mini-nasoseptal flap may expedite healing and decrease the risk of restenosis after sphenoid sinusotomy by avoiding cicatricial scarring.

Surgical Treatment of Carotid In-Stent-Restenosis: Novel Strategy and Current Management

Associated with increasing use of carotid artery stenting (CAS), the occurrence of late complications is likely to rise. The surgical strategies of CAS complications like in-stent-restenosis (ISR) are not yet to be determined. Thus different situations require individual operative techniques. This study contains our experience in the operative management for significant recurrent carotid stenosis following angioplasty and stent placement. As a novel strategy, we report successful stent removal and endarterectomy with eversion technique (ECEA). Four complete stent removals were performed in three patients with three different techniques and anesthesiological protocols (general anesthesia n = 1, regional anesthesia n = 3). First stent removal with excision of common carotid artery (CCA) and internal carotid artery (ICA) following interposition of CCA-ICA with Dacron graft (n = 1). Second carotid endarterectomy with stent removal followed by patch angioplasty (n = 2). Third stent removal and ECEA and thus biological reconstruction without synthetic material (n = 1). Mean operative time was 131 minutes (±19.25). Mean follow-up was 11.5 months (±7.7). As postoperative complications, one major bleeding, one transient neurologic deficit and one postoperative neck hematoma, requiring operative revision, occurred. During a 30-day follow-up, all patients made an uneventful recovery. There was no evidence of restenosis or neurological deficit during the following postoperative controls. A review and comparison of the current surgical management and strategies in the treatment of ISR was also performed (Pubmed). Surgical treatment of ISR after CAS is beneficial but in literature infrequently reported. We could demonstrate in this study that even stent removal and ECEA is feasible and safe with durable outcome. The current strategies are therefore extended as well as the reported performance under regional anesthesia. However, surgical treatment in ISR remains a challenging option and larger series are highly recommended.

Endovascular management of carotid artery stenosis secondary to sclerosing mediastinitis

Sclerosing mediastinitis is a rare, progressive condition characterized by extensive fibrotic reaction. We report the first known case of symptomatic, extrinsic compression of the carotid artery by fibrotic extension of sclerosing mediastinitis. A 54-year-old woman began experiencing neurologic symptoms from extension of a known mediastinal mass resulting in 70% to 79% stenosis of the right internal carotid artery. The stenosis was treated with endovascular stenting. Completion angiogram revealed a good result with <10% residual stenosis. At 18-month follow-up, the patient was symptom free without evidence of re-stenosis. Endovascular therapy provides a novel and durable solution in the midterm to this very rare problem.

Arteriolar remodeling limits maximal perfusion after percutaneous revascularization of a chronic stenosis in pigs with hibernating myocardium

Chronic myocardial ischemia results in remodeling of the coronary microcirculation in hibernating myocardium but the reversibility of these changes is unknown. Accordingly, we evaluated parameters of arteriolar structure and measured transmural myocardial perfusion during adenosine vasodilation before and up to one month after percutaneous coronary intervention (PCI) of a chronic LAD stenosis in swine (n=12). Regional function was depressed at rest (LAD wall thickening 38.6±4.0 vs. 92.2±7.5%, p&lt;0.05). Immediately after PCI, subendocardial flow during adenosine vasodilation increased from 1.5±0.3 to 4.6±0.8 ml/min/g, but fell to 2.7±0.3 ml/min/g one month later without evidence of restenosis. Histological assessment of subendocardial resistance vessel remodeling is shown below: Group Subendocardial Arterioles Lumen Area (μm2) Density (arterioles/mm2) WT/Lumen Diameter (%) Hibernating (n=148) 721±67* 10.7±1.8* 37.3±1.5* Revascularized (n=54) 659±88* 5.8±0.4 40.3±2.2* Sham (n=54) 1184±173 6.2±0.3 28.7±1.3 Values are mean±SEM; n=total number of vessels analyzed; WT=wall thickness; p&lt;0.05 vs. Sham. These data indicate that there is subendocardial microvascular remodeling in hibernating myocardium with an increase in arteriolar density compensating for a reduction in arteriolar lumen area. After revascularization, arteriolar density returns to normal but lumen area remains reduced and decreases maximal perfusion. These chronic microvascular structural changes could precipitate subendocardial ischemia in the absence of coronary restenosis. Supported by NIH HL61610.