High Risk Of Distal Embolization Research Articles

Isolated coronary artery ectasia presenting as inferior-posterior STEMI—a case-based state-of-the-art review of the current literature

Abstract Background This review is based on the case of a 71-year-old female patient, with cardiovascular risk factors, who was referred for emergency cardiological evaluation after experiencing severe anterior chest pain that had lasted for more than 5 hours at the time of admission. A diagnosis of inferior-posterior ST-segment elevation myocardial infarction was established, and emergency coronary angiography was performed. It revealed severe, diffuse dilation of the entire arterial coronary tree with slow flow and the presence of a large quantity of thrombotic material in the right coronary artery. Thromboaspiration was deemed unfit since the operator believed that there was a high risk of distal embolization with subsequent no-reflow, when passing with the catheter. As such, the patient started receiving anticoagulant therapy, and after one month she was scheduled for a control angiogram. The follow-up coronary angiography identified complete dissolution of the thrombus from the right coronary artery and a moderate stenosis in the distal segment, so no stent implantation was required. Rationale for review After performing a complete and comprehensive differential diagnosis, presence of isolated coronary artery ectasia was established. Coronary artery ectasia is a rare disease, usually found incidentally during coronary angiograms performed for other indications (chronic and acute coronary syndromes) with a vast etiology and complex pathophysiology. Because there are common morphopathologic pathways between coronary artery ectasia and atherosclerotic coronary artery disease, the clinical presentation of the former might have similar characteristics with the latter, but the management and prognosis of these patients is much less studied compared to the patients suffering from different phenotypes of coronary atherosclerosis. This review aims to summarize the etiopathogenesis, clinical presentation, diagnostic modalities, and different management pathways of coronary artery ectasia.

Percutaneous Coronary Intervention of Saphenous Vein Graft in Post-CABG Patients- Experience at a Tertiary Cardiac Centre

Background: Percutaneous Coronary Intervention (PCI) of obstructed & atheromatous venous graft is a real challenge for interventionist to deal with as SVG PCI patients are usually older with significant coronary & non coronary comorbidities. SVG usually presents a degenerated pattern of atherosclerosis with complex friable thrombosis prone lesions, higher risk of distal embolization, poorer long-term outcome with higher ISR rate
 Objectives: In the current era, with the advent and availability of different Drug Eluting Stents, PCI of SVG vessel is an alternative to re-do surgery for the occlusion of graft vessel. Although, PCI is associated with higher risk of instent restenosis, target vessel repeat revascularization, myocardial infarction or death. Uses of embolic protection devices is class I indication by ACC/AHA for SVG PCI. Therefore, we have carried out this prospective study, to see the outcomes of SVG vessel PCI at our center.
 Methods and materials: Patients were enrolled in this observational non-randomized prospective cohort, who underwent routine CAG for the post CABG angina, shortness of breath, dyspnea on minimal exertion or hospital admission with MI, NSTEMI, Angina II-III and planned for PCI of occluded graft vessel. Total 50 patients were enrolled in this study. Distal protection devices were not used in most of the cases as financial costing is an issue.
 Results:Total 46 patients were enrolled in this observational study. Average age of the patient population was (62.1±10.8), female 3(6.5%): male 43(93.5%), BMI (24.9±2.9). Among the CAD risk factors; DM 30(60%), HTN 34(68%), Dyslipidemia 31(62%), Smoking 12(6%) And family history of IHD 9(18%). Graft vessel occlusion occurred average (11.5+5.4 Yrs.) after CABG. SVG to OM is the commonest vessel, that developed significant stenosis in 27(56%), followed by LAD 9(16.1%), RCA 6(10.7%), PDA 6(10.7%), PLB 3(5.4%), DG 3(5.4%)m and LIMA-LAD 1(1.8%). Total 63 stents were deployed in 56 vessels of 46 patients. Double or overlapping stents were deployed; two stents in 11 (17.5%) and three stents in 1 (2%) vessel. One patient had recurrent ISR of SVG-OM stents and had PCI at our center and elsewhere. Common DES were, Sirolimus 25(39.7%), Everolimus 22(34.9%), BMS 9(14.3%), Zotarolimus 3 (4.8%). Average stent size was 3.3mm in Diameter. Total 3 (6%) patient died, in 1 month to 2yrs after the procedure. No acute or late complications were noted in this small group of patients and all were doing well at 12-24 months OPD follow-up.
 Conclusion: We found that our patients developed graft vessel occlusion on an average 11yrs, after CABG. OM is the commonest territory to develope significant stenosis. PCI of SVG survival outcome was 93.5% (43 patient) in this very primitive observational cohort and all were doing well with OPD follow-up. Thus, we recommend percutaneous coronary intervention of occluded or stenosed graft vessel as an alternative to re-do surgery in this part of the world.
 Bangladesh Heart Journal 2020; 35(1) : 6-13

Carotid artery stenting with proximal embolic protection via the transbrachial approach: sheathless navigation of a 9-F balloon-guiding catheter.

Transbrachial carotid artery stenting (TB-CAS) is performed as an alternative procedure for patients with hostile vascular anatomy of the aortic arch and aortic or peripheral artery disease. Proximal protection during TB-CAS is not generally feasible because a small size of the brachial artery may preclude using a large-diameter sheath introducer. We, herein present a novel method that enables proximal protection during TB-CAS by sheathless navigation of a 9-F balloon-guiding catheter equivalent to a 7-F sheath. We analyzed eight consecutive patients who underwent TB-CAS with proximal protection using the sheathless method from April 2016 to June 2017. Relevant demographic, radiographic, and procedural features were retrospectively reviewed. We performed TB-CAS using our method for five patients with a bovine or type 3 aortic arch, for one patient with combined peripheral artery disease, and for two patients with a type 1 or 2 aortic arch. We successfully navigated the balloon-guiding catheter via the brachial artery and performed CAS under proximal flow control in all patients. However, we experienced kinking and exchange of the balloon-guiding catheter in one patient and a periprocedural thromboembolic event occurred. A pseudoaneurysm at the access site developed in one patient. TB-CAS with proximal embolic protection using the sheathless method is feasible and may provide an alternative approach in carefully selected patients who have difficult anatomy in the transfemoral approach and plaques with a high risk of distal embolization.

A Randomized Study of Distal Filter Protection Versus Conventional Treatment During Percutaneous Coronary Intervention in Patients With Attenuated Plaque Identified by Intravascular Ultrasound

ObjectivesThe aim of this study was to evaluate the utility of distal protection during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes at high risk for distal embolization. BackgroundThe results of previous clinical trials indicated that the routine use of distal protection in patients with ST-segment elevation myocardial infarction did not improve clinical outcomes. However, selective use of distal protection by means of a filter-based distal protection system has not been evaluated. MethodsTwo hundred patients with acute coronary syndromes who had native coronary artery lesions and attenuated plaque with longitudinal length ≥5 mm on pre-PCI intravascular ultrasound were randomly assigned to undergo PCI with distal protection or conventional treatment. ResultsThe primary endpoint (no-reflow phenomenon) occurred in 26 patients (26.5%) in the distal protection group and 39 patients (41.7%) in the conventional treatment group (p = 0.026), and the corrected TIMI (Thrombolysis In Myocardial Infarction) frame count after revascularization was significantly lower in the distal protection group (23 vs. 30.5; p = 0.0003). The incidence of cardiac death, cardiac arrest, cardiogenic shock after revascularization requiring defibrillation, cardiopulmonary resuscitation, or extracorporeal membrane oxygenation was significantly lower in the distal protection group than in the conventional treatment group (0% vs. 5.2%; p = 0.028). ConclusionsThe use of distal embolic protection applied with a filter device decreased the incidence of the no-reflow phenomenon and was associated with fewer serious adverse cardiac events after revascularization than conventional PCI in patients with acute coronary syndromes with attenuated plaque ≥5 mm in length. (Assessment of Distal Protection Device in Patients at High Risk for Distal Embolism in Acute Coronary Syndrome [ACS] [VAMPIRE3]; NCT01460966)

TREATMENT OF INTERNAL CAROTID ARTERY OCCLUSION USING PROXIMAL CEREBRAL PROTECTION DEVICE AND ITS EFFECT ON THE BLOOD PRESSURE DYNAMICS. CLINICAL CASE

In 2016, according to the Ministry of Health of the Russian Federation, about 200 thousand people died from stroke. Strokes are considered as the main cause of disability of the population, causing huge economic damage to the country. One of the most common causes of ischemic stroke is atherosclerosis of the branches of the aortic arch. The most common localization of atherosclerotic plaques is the extracranial section of the carotid arteries – bifurcation and ostium of the common carotid artery and the internal carotid artery. Recanalization of occlusion of the internal carotid artery until recently was an insoluble task for interventional surgery due to the high risk of distal embolization. The invention and use of the proximal cerebral protection device, which ensure the complete cessation of blood flow, has changed the situation. Effect of carotid revascularization on arterial hypertension, due to the effect on the baroreceptors of the carotid plexus by balloon angioplasty, which leads to a reflex decrease in arterial pressure, is an additional advantage of the endovascular technique in some cases. This effect requires further study. One also needs to pay careful attention to the diagnosis and imaging of carotid artery lesions before procedure. This clinical case is the illustration that an adequate assessment of the risk factors for intraoperative complications allows to achieve maximum results of endovascular treatment.

Current Status of Distal Embolization in Femoropopliteal Endovascular Interventions.

The application of advanced endovascular techniques in very complex femoropopliteal atherosclerotic lesions has shown to expose patients to a higher risk of distal embolization (DE). This complication can affect both the short- and long-term outcomes, leading to worsening ischemia, early minor/major amputation, and longer hospital stay. Recently, there has been an increasing body of evidence on pathophysiology and clinical-radiological management of DE that however has not been systematically addressed by guidelines. The aim of this review was to analyze the current evidence outlining definition and classification, risk assessment, prevention, and management strategies of DE in femoropopliteal endovascular interventions.

Near-infrared spectroscopy-intravascular ultrasound: scientific basis and clinical applications.

Coronary angiography underestimates the magnitude of the atherosclerotic burden and cannot detect the presence of disease in the early phases. Recognition of these inherent limitations of angiography has been an impetus for the development of other coronary imaging techniques. The novel near-infrared spectroscopy-intravascular ultrasound (NIRS-IVUS) catheters can detect and quantify the presence of lipid core in the atherosclerotic plaque and associate it with other features such as lumen size and plaque architecture. Lipid-rich plaques are known to pose a higher risk of distal embolization during interventions and plaque disruption. The aim of this manuscript is the review of the potential clinical and research applications of this technology as highlighted by recent studies.

Abstract 213: Retrieval of Plaque Debris by Aspiration Thrombectomy is the Sign of High Risk for Distal Embolization in Acute Coronary Syndrome Patients

Background: Slow flow or no re-flow phenomenon during coronary intervention is mainly caused by distal embolization of thrombus and plaque debris, and is associated with unfavorable long-term clinical outcomes. However, its high-risk patients are not well understood. Aspiration thrombectomy in the patients with acute coronary syndrome (ACS) often retrieves thrombus but sometimes plaque debris. Therefore, we examined if the ACS patients in whom plaque debris was retrieved by aspiration thrombectomy were high-risk of distal embolization. Methods: Consecutive patients with ACS (n=151) who received aspiration thrombectomy and coronary intervention with filter-type distal protection device (Filtrap) were prospectively enrolled. We classified them into two groups according to whether (Group A, n=29) or not (Group B, n=122) the plaque debris was retrieved by aspiration thrombectomy. We compared between the groups the frequency of filter slow flow/ no-reflow phenomenon and the frequency of distal embolization captured by filter device. Results: Distal embolization of plaque debris was detected more frequently in Group A than in Group B (90% vs. 30%, P<0.0001). Filter slow flow/ no-reflow phenomenon occurred more frequently in Group A than in Group B (93% vs. 29%, P<0.0001). Conclusion: Retrieval of plaque debris by aspiration thrombectomy is the sign of high risk for distal embolization in ACS patients. Distal protection may potentially be useful for those high-risk patients.

TCT-568 Patients Who Have Ruptured Plaque at Culprit Lesion Are At High Risk of Distal Embolization Even If They Do Not Have Acute Coronary Syndrome

TCT-568 Patients Who Have Ruptured Plaque at Culprit Lesion Are At High Risk of Distal Embolization Even If They Do Not Have Acute Coronary Syndrome

Guiding-catheter thrombectomy combined with distal protection during primary percutaneous coronary intervention of a saphenous vein graft

Primary percutaneous intervention of saphenous vein grafts is associated with a high risk of distal embolization and no reflow. We report a case of acute myocardial infarction with a large intragraft thrombus, successfully treated with a technique combining thrombectomy with a 6 Fr guiding catheter and distal protection with the FilterWire EZ.

If We Require Multiple Aspirations, It Is the Sign of High Risk of Distal Embolization in Acute Myocardial Infarction Patients

If We Require Multiple Aspirations, It Is the Sign of High Risk of Distal Embolization in Acute Myocardial Infarction Patients

MGuard Mesh‐Covered Stent for Treatment of ST‐Segment Elevation Myocardial Infarction with High Thrombus Burden Despite Manual Aspiration

To assess the usefulness of the MGuard stent in patients with ST-segment elevation myocardial infarction (STEMI) in whom a high thrombus burden persists after manual aspiration. In some patients with STEMI, a high thrombus burden may persist after manual aspiration. These patients may be at high risk of distal embolization and therefore impaired myocardial reperfusion. The MGuard is a novel mesh-covered stent designed to minimize thrombus embolization. Single-arm, prospective registry of patients with STEMI and high thrombus burden after aggressive thrombus aspiration treated with the MGuard stent. High thrombus burden was defined as thrombus burden grade 4 or 5 according to the TIMI score. Lesions with a side branch ≥2 mm and patients with cardiogenic shock were not included. The study end-points were proportion of final TIMI 3 flow, normal myocardial blush, and complete ST-segment resolution. Fifty-six patients were included. After MGuard stent implantation >85% of cases had thrombus score = 0. Final TIMI 3 flow was achieved in 82% of cases, normal myocardial blush in 55%, and complete ST-segment resolution in 59%. Occlusion of a side branch (<2 mm) occurred in 2 cases (3.5%), embolization to a distal branch in 5 cases (8.9%), and transient no-reflow in 4 cases (7.1%). Major adverse cardiac events rate at 9 months was 3.6%, including 1 definite acute stent thrombosis and 1 target-vessel revascularization. The MGuard stent may be useful to prevent distal embolization in patients with STEMI and high thrombus burden despite mechanical aspiration.

Immediate evidence of the benefit of distal protection in vein graft intervention

Percutaneous intervention carries a higher risk of distal embolization and fatal outcome in saphenous vein grafts (SVG) than in native coronary vessels. Most of these adverse clinical events, predominantly myocardial infarction and reduced antegrade flow (no reflow phenomenon), are due to distal embolization of atherothrombotic debris and distal microvascular occlusion. For this reason, in current interventional practice, the use of distal protection devices is mandatory. Our case report provides direct and dramatic evidence of the usefulness of a low-profile filter device in the setting of massively thrombotic SVG.

Assessment of Plaque Composition with Near-Infrared Spectroscopy

Histopathological examination of culprit plaques in sudden coronary death has long suggested that accurate in vivo determination of plaque composition may be of equal or greater importance to future coronary event risk assessment as plaque cross-sectional size or volume. Intracoronary near-infrared spectroscopy (NIRS) was developed to detect the most prominent compositional feature of a thin-capped fibroatheroma—the presence of a lipid core. The need for invasive, focal coronary imaging techniques, the added value of compositional measures, and the applicability and principles of operation of intracoronary NIRS are described. Additionally, a combination device with NIRS and simultaneous, co-registered intravascular ultrasound (IVUS) is described, which gives complementary structural and compositional measures. The identification and morphological assessment of lipid core plaque with NIRS-IVUS has potential to improve the safety of stenting, including optimization of length of vessel to stent, assurance of adequate stent deployment, and identification of lipid-core lesions at higher risk of distal embolization possibly leading to effective utilization of distal embolic protection devices in the native coronaries. The NIRS-IVUS device also has promise in the identification of vulnerable plaque, which may lead to strategies to prevent future coronary events.

Detection and Treatment of Acute Thromboembolic Events in the Lower Extremities

Acute procedural thromboembolic events are serious complications affecting both short- and long-term outcome. Patients at high risk include those undergoing catheter-based interventions for acute limb ischemia and long segment de novo or stented occlusions of the lower limb arteries. Additionally, debulking procedures and angioplasty/stenting of complex lesions in patients with advanced disease have also been associated with a higher risk of distal embolization and in situ thrombosis. This article includes a discussion of detection methods as well as preventive and treatment strategies.

Percutaneous intervention of a thrombotic‐occluded saphenous vein graft successfully treated using the undersized stent approach to prevent distal embolization

Percutaneous intervention carries a higher risk of distal embolization and poorer outcome in saphenous vein grafts (SVG) than in native coronary vessels. Embolic protection devices (EPD) have demonstrated value in decreasing the risk of embolization and post-procedural enzymes elevation after SVG intervention. Although there is ample evidence to support the routine use of EPD for SVG interventions, frequently those devices are not utilized or cannot be used because of technical reasons. As we previously reported, the "undersized stenting" approach seems to be an attractive strategy when EPD cannot be used. We present a case with severe SVG degeneration that illustrates the feasibility of this strategy.

Free Floating Thrombus of the Aorta: An Unusual Cause of Peripheral Embolization

Purpose: Free-floating thrombus (FFT) of the aorta is very rare but has a high risk of distal embolization. While the necessity of treating such a condition is evident, the diagnostic and therapeutic modalities remain controversial. Thus, we reviewed seven cases of FFT of the aorta. Methods: A retrospective study was performed usings even patients diagnosed with FFT of the aorta at the Catholic University of Korea between January 1999 and December 2008. We excluded those patients who had thrombi with concomitant atherosclerotic or aneurysmal aorta. Results: The mean patient age was 59.6±13.6 years old. The male-to-female ratio was 3：4. Embolization to arteries of the extremities occurred in two patients and to visceral arteries in four patients. Of these seven patients, four were initially treated with anticoagulation, and two were initially treated with thrombectomy; one patient refused any kind of treatment. Of the four patients treated with anticoagulation, three experienced complete dissolution of the thrombi while anticoagulation proved ineffective in the remaining patient who subsequently underwent thrombectomy. In all of the three patients who had received thrombectomy, postoperative anticoagulation was employed. There was no recurrence of FFT of the aorta during the follow-up period. Conclusion: Were commend systemic anticoagulation with low molecular weight heparin (LMWH) as the first line of treatment for FFT of the aorta. If the thrombus persists or recurrent embolism occurs during anticoagulation therapy, surgery should be undertaken. (J Korean Surg Soc 2011;80:204-211)

Live Echocardiographic Visualization of the Migration of a Voluminous Left Ventricular Thrombus Complicating an Acute Myocarditis

A 52-year-old man was referred to our intensive care unit by the emergency department for chest pain and severe recent-onset dyspnea. The patient had no particular medical history and no cardiovascular risk factors. His complaints started 3 weeks previously after what he described as a severe flu with cough and fever. At clinical examination, the patient was breathless with a respiratory rate of 28 cycles per minute and a fever of 38.3°C. His heart rate was 88 bpm and blood pressure was 112/68 mm Hg. Pulmonary auscultation revealed bilateral wet rales in the lower lung fields. …

Reperfusion Strategies in Acute ST-Elevation Myocardial Infarction: An Overview of Current Status

Several randomized trials and meta-analyses have shown that primary angioplasty is superior to thrombolysis in the treatment of ST-segment elevation myocardial infarction (MI) in terms of death, reinfarction, and stroke. However, primary angioplasty should be regarded as the preferred strategy as long as it can not be applied with a reasonable time delay to treatment, as compared with the administration of thrombolysis. In fact, time-to-treatment has been shown to be a determinant of survival not only for thrombolysis but also for primary angioplasty. Recent guidelines consider a time from first medical contact to PCI of 90 minutes or a PCI-related delay of 60 minutes as reasonable cutoffs to identify the best reperfusion strategy. The beneficial effects of primary angioplasty could be expected particularly after the first 3 hours from symptom onset, when thrombolysis, particularly streptokinase, may be less effective, whereas within the first 3 hours, thrombolysis (started in the prehospital setting, preferably) may represent a valid therapeutic option. Because the survival benefits of primary angioplasty depends on the patient's risk profile and timely application of reperfusion, we would suggest, among patients in the first hours from symptom onset, a strategy of early pharmacologic reperfusion and transfer to primary PCI centers, where the decision of performing angiography acutely may be based on the assessment of myocardial reperfusion and risk profile, whereas after the first 3 hours from symptoms onset, primary angioplasty should be considered the preferred strategy if applicable, particularly in regions when streptokinase still represents the only available lytic therapy. However, even though primary angioplasty is able to achieve thrombolysis and TIMI 3 flow in most patients, a still relevant proportion of patients experience poor myocardial reperfusion, with negative impact on acute and long-term survival. The use of platelet glycoprotein IIb/IIIa complex inhibitors has significantly improved survival, with additional benefits obtained by early administration aiming at early reperfusion, which are to be recommended, particularly among high-risk patients and those presenting within the first hours from symptom onset. The use of adjunctive mechanical devices has reduced the incidence of distal embolization without any apparent benefit in survival. Until the results of larger randomized trials become available, these devices may be considered in patients at high risk for distal embolization, such as those with large thrombotic burden. The use of coronary stenting has significantly reduced restenosis, as compared with balloon angioplasty. Several randomized trials have recently been conducted on drug-eluting stents in ST-segment elevation MI, showing the safety and significant benefits of these devices in terms of restenosis, as compared with bare metal stents (BMSs). However, because of unpredictable compliance to long-term double oral antiplatelet therapy in acute patients, caution should be taken with extensive use of drug-eluting stents in primary angioplasty.

Percutaneous coronary intervention in two occluded arms of a saphenous ‘Y’‐graft: The importance of protecting both of your arms

Percutaneous intervention in saphenous vein grafts (SVG) carries a higher risk of distal embolization than intervention in a native vessel, and use of a distal protection device has been shown to improve the outcomes in SVG interventions. We describe an intervention done in an unexpected 'Y' SVG which required dual distal protection with Filterwires placed in both limbs of the diseased graft and which was performed via a 6 Fr guide catheter.