Long-term Restenosis Rate Research Articles

The relationship between plasma atherogenic index and long-term outcomes after endovascular intervention in superficial femoral artery lesions.

Peripheral arterial disease (PAD) results from the systemic atherosclerotic process. In this study, we aimed to determine the relationship between plasma atherogenic index (AIP), a ratio of molar concentrations of triglycerides to HDL-cholesterol, and long-term outcomes after endovascular therapy (EVT) in patients with superficial femoral artery (SFA) stenosis. We retrospectively evaluated 673 patients who underwent EVT for PAD in our tertiary center between January 2015 and December 2020. In the receiver operating characteristic (ROC) curve analysis, the AIP value with the optimum cutoff value was determined as 0.576 to detect the presence of major adverse limb events (MALEs). Patients were divided into two groups according to low AIP (<0.576 as group 1) and high AIP (>0.576 as group 2). Among the major endpoints, long-term restenosis rates were significantly higher in patients in the high-AIP group than in the low-AIP group (p<.001). The lower extremity amputation rate was not statistically significant between the two groups. All-cause mortality rate (54 (31.6) versus 117 (68.4), p<.001) was significantly higher in patients in the high-AIP group than in the low-AIP group. In addition, the MALE rate (94 (29.2) versus 218 (62.1), p<.001) was significantly higher in patients in the high-AIP group than in those in the low-AIP group. In conclusion, we found that AIP is a significant independent predictor of long-term MALE in patients who underwent EVT for SFA.

Estimated Glomerular Filtration Rate as a Predictor of Restenosis After Carotid Stenting Using First-Generation Stents.

This study evaluated the impact of the baseline estimated glomerular filtration rate (eGFR) on clinical and angiographic outcomes and long-term in-stent restenosis (ISR) rates in patients undergoing elective carotid artery stenting (CAS) procedures. Consecutive patients who underwent CAS were retrospectively enrolled (n = 456). At the end of 3 years of follow-up, patients who had died or were lost follow-up were excluded from the study and a final analysis was performed using data from the remaining 405 patients. The study population (n = 405) was divided into 3 tertiles based on the tertile values of the eGFR level (T1, T2, and T3); then, clinical and procedural characteristics and 3-year ISR rates were compared between the groups. An ISR of 50% was detected in 49 (12%) surviving patients. The 3-year ISR was higher among patients with the lowest eGFR values (T1) by 3.7 times (95% CI: 2.01-11.38) than that among patients with the highest eGFR values (T3). These significant relationships persisted following adjustment for confounders. A lower baseline eGFR level was significantly associated with an increased ISR rate. Decreased renal function may be a predictor of ISR after CAS using first-generation stents.

Comparison of conventional surgical method and eversion technique in carotid endarterectomy operations

Background/Aim: Carotid endarterectomy is a highly effective and safe operation for preventing the risk of stroke in patients with symptomatic internal carotid artery stenosis. Several surgical techniques were described and available: Conventional carotid endarterectomy (CCEA) and eversion carotid endarterectomy (ECEA) are the two most common. Superiority of these two techniques to one another has not yet been clearly demonstrated. We aim to demonstrate the surgical and clinical experience of our institution regarding these two approaches. Methods: In this retrospective cohort study, forty-three consecutive patients operated for symptomatic carotid stenosis were divided into two groups according to the preferred surgical method (CCEA and ECEA), and compared in terms of postoperative hospital stay, use of shunts and antibiotics, early (30-day) complications, long-term restenosis, and mortality rates. Results: Demographic data and preoperative stenosis rates were similar between the two groups (P>0.05). In the CCEA group, subjects had a significantly longer clamping time (19.3 (4.1) vs 15.4 (3.4) min., P=0.002) and significant differences were found between operative time (35.1 (3.2) vs 28.7 (4.3) min) and need for shunting (25.7% vs 2.1%, P<0.001). CCEA patients had a higher percentage of antibiotic use (49.8% vs. 31.1%, P=0.04). Hematoma rates, complications during follow up, including stroke, heart attack, and mortality rate were similar between the groups, along with re-stenosis (P=0.754) and survival rates (P=0.241), according to Kaplan-Meier analysis. Conclusions: Our results showed that ECEA was a convenient surgical technique and more advantageous compared to CCEA with respect to early and long term follow up results. ECEA can be performed within a significantly shorter operative time and may decrease the necessity for shunting, although it may require specific experience.

Risk Factors for Restenosis After Stenting or Angioplasty of Vertebral Artery Origin : Results of Short-term and Long-term Follow-up.

Endovascular treatment represents awell-established therapeutic option in patients with vertebral artery origin (VAO) stenosis. Our aim was to determine which factors affect short- and long-term restenosis rates after endovascular VAO therapy. We conducted asingle center analysis of 52patients (36men; age 64 ± 9.54 years) who underwent 55endovascular procedures (27balloon-assisted angioplasty [BAA], 28stent-assisted angioplasty [SAA]) between 2005-2015. We collected data on patients clinical characteristics, medication and post-interventional follow-up visits. Overall, 15of 55vessels (27%) showed ≥70% restenosis at 1year (short-term follow-up) and 18after amean follow-up of 52.9 ± 31.8months (long-term). BMI ≥ 25 kg/m2 was associated with ≥70% restenosis in short-term (P = 0.014) and long-term (P = 0.003) follow-up. Other risk factors, namely, hypertension, ischemic heart disease, smoking, diabetes mellitus, hypercholesterolemia, atrial fibrillation, CRP (>5 mg/l) or pre-treatment antiplatelet administration, statin intake and platelet count, were not associated with restenosis risk in the entire cohort or in patients in the BAA group (all P > 0.05). BMI (P = 0.003) and ischemic heart disease (P = 0.041) were, in turn, associated with restenosis risk in the long-term follow-up in the SAA group. Patients undergoing BAA developed less frequently (P = 0.032) restenosis (18%) during long-term follow-up as compared to patients treated by stenting (46%). BMI ≥ 25 kg/m2 increases the odds for ≥70% restenosis of VAO while ischemic heart disease represents an additional risk factor in stented patients. Further studies are required to established therapeutic strategies lowering the restenosis rates in overweight individuals after VAO therapy, especially ones undergoing stenting.

Durability of Stroke Prevention with Carotid Endarterectomy and Carotid Stenting

BackgroundCarotid artery stenting remains an effective alternative to carotid endarterectomy for stroke prevention; however, the long-term durability of carotid artery stenting remains poorly defined. We performed a 10-year “real-world” comparative analysis of carotid endarterectomy and carotid artery stenting to help evaluate the success of these procedures in preventing late ischemic stroke events. MethodsThis was a single-center retrospective review of 996 patients (symptomatic and asymptomatic) treated with carotid endarterectomy or carotid artery stenting from January 2001 through December 2011 at a tertiary academic medical center. All-cause death, stroke, and myocardial infarction event rates were analyzed using log-rank analysis. ResultsAmong the 996 patients treated with carotid endarterectomy (n = 787) or carotid artery stenting (n = 209), the 30-day, 1-year, 5-year, and 10-year survival rates for carotid endarterectomy patients were 99.1%, 95.3%, 77.9%, and 54.8%; carotid artery stenting rates were 99.5%, 96.2%, 67.8%, and 40.2%, respectively (P = .005, at 10 years). There was no significant difference in early stroke rates or myocardial infarction rates between the groups. Subgroup analysis comparing symptomatic status demonstrated no statistically significant differences in overall survival, stroke, or myocardial infarction rates at 10 years. In addition to reduced long-term overall survival, carotid artery stenting patients had a higher long-term restenosis rate as compared to carotid endarterectomy (6.3% vs 2.8%, P < .0001) and reduced restenosis-free survival (P = .01). ConclusionsEarly death, stroke, and myocardial infarction rates are comparable after carotid endarterectomy and carotid artery stenting. Carotid artery stenting is an effective means of preventing stroke among patients with carotid artery stenosis. Symptomatic status does not seem to affect rates of stroke, myocardial infarction, or death. Carotid endarterectomy continues to be the preferred long-term solution for extracranial carotid artery occlusive disease as it is associated with better long-term survival and lower restenosis rates.

Revascularization of radiation-induced carotid artery stenosis with carotid endarterectomy vs. carotid artery stenting: A systematic review and meta-analysis.

The incidence of carotid artery stenosis after head and neck radiation is anticipated to rise due to the increasing survival of patients with head and neck malignancies. It remains unclear whether carotid artery stenting (CAS) or endarterectomy (CEA) is the best treatment strategy for radiation-induced carotid artery stenosis. This study was performed according to the PRISMA and MOOSE guidelines. Eligible studies were identified through a comprehensive search of PubMed, Scopus and Cochrane Central until July 20, 2017. A meta-analysis of random effects model was conducted. The I-square statistic was used to assess for heterogeneity. Five studies and 143 patients were included. Periprocedural stroke, myocardial infarction (MI) and death rates were similar between the two revascularization approaches. However, the risk for cranial nerve (CN) injury was higher in the CEA group (OR: 7.09; 95% CI: 1.17-42.88; I2 = 0%). CEA was associated with lower mortality rates after a mean follow-up of 50 months (OR: 0.29; 95% CI: 0.09-0.97; I2 = 0%). No difference was identified in long-term restenosis rates between CEA and CAS. Patients with radiation-induced carotid artery stenosis can safely undergo both CAS and CEA with similar risks of periprocedural stroke, MI and death. However, patients treated with CEA have a higher risk for periprocedural CN injuries and a lower risk for long-term mortality.

202 - Targeting the Oncogenic Nexus of SETBP1-Set-PP2A by Structure Guided Small Molecule Design and Fragment Based Chemical Synthesis

Carotid artery stenting remains an effective alternative to carotid endarterectomy for stroke prevention; however, the long-term durability of carotid artery stenting remains poorly defined. We performed a 10-year “real-world” comparative analysis of carotid endarterectomy and carotid artery stenting to help evaluate the success of these procedures in preventing late ischemic stroke events.This was a single-center retrospective review of 996 patients (symptomatic and asymptomatic) treated with carotid endarterectomy or carotid artery stenting from January 2001 through December 2011 at a tertiary academic medical center. All-cause death, stroke, and myocardial infarction event rates were analyzed using log-rank analysis.Among the 996 patients treated with carotid endarterectomy (n = 787) or carotid artery stenting (n = 209), the 30-day, 1-year, 5-year, and 10-year survival rates for carotid endarterectomy patients were 99.1%, 95.3%, 77.9%, and 54.8%; carotid artery stenting rates were 99.5%, 96.2%, 67.8%, and 40.2%, respectively (P = .005, at 10 years). There was no significant difference in early stroke rates or myocardial infarction rates between the groups. Subgroup analysis comparing symptomatic status demonstrated no statistically significant differences in overall survival, stroke, or myocardial infarction rates at 10 years. In addition to reduced long-term overall survival, carotid artery stenting patients had a higher long-term restenosis rate as compared to carotid endarterectomy (6.3% vs 2.8%, P < .0001) and reduced restenosis-free survival (P = .01).Early death, stroke, and myocardial infarction rates are comparable after carotid endarterectomy and carotid artery stenting. Carotid artery stenting is an effective means of preventing stroke among patients with carotid artery stenosis. Symptomatic status does not seem to affect rates of stroke, myocardial infarction, or death. Carotid endarterectomy continues to be the preferred long-term solution for extracranial carotid artery occlusive disease as it is associated with better long-term survival and lower restenosis rates.

Experimental research on laser interference micro/nano fabrication of hydrophobic modification of stent surface.

Coronary artery disease (CAD) has become one of the important causes of human death, and coronary stent implantation is one of the most effective methods for the treatment of CAD. But the current clinical treatment has a high long-term restenosis rate and is easy to form late stent thrombosis. In order to solve these problems, coronary artery stent surface was directly modified by laser interference lithography and the highly ordered concave structures were fabricated. The morphology and contact angle (CA) of the microstructure were measured with scanning electron microscopy (SEM) and CA system. The water repellent property of the stent was also evaluated by the method of contacting the water drop with the stent and then separating. The result showed that the close-packed concave structure with the period of about 12.194μm can be fabricated on the stent surface under special parameters (laser energy density of 3.5J/cm-2, incident angles of 3°, exposure time of 80s) by the three-beam laser interference of 1064nm and the form structure has good water repellency with contact angle of 120°.

Complication of Stenting in Intracranial Arterial Stenosis.

To evaluate the perioperative complications and long-term restenosis rates following percutaneous transluminal angioplasty and stenting (PTAS) in patients with intracranial atherosclerotic stenosis (ICAS). A retrospective analysis was performed on the clinical data of 102 ICAS patients (103 cases of stenosis) who underwent PTAS. The perioperative complications and long-term restenosis rates were analyzed. The success rate of PTAS was 100%. Six patients (5.83%, 6/103) had perioperative complications. Six cases (6.52%, 6/92) of restenosis occurred and one patient (1.09%) died. Five of the 6 restenosis cases (5.43%) occurred in the blood-supplying region and were associated with ischemic symptoms and one patient (1.09%) had no ischemic symptom. The postoperative restenosis rates at 6, 6 - 12, and 12 - 74 months were 3.26%, 2.56%, and 2.38%, respectively. The postoperative restenosis rates had a significant difference between the residual stenosis rate ≥ 20% and < 20% (P < 0.05), and between postoperative regular medication and non-regular medication (P < 0.05). The postoperative restenosis risk in patients with age ≥ 60 years was 13.481 times to that in patients with age < 60 years. The postoperative restenosis risk in patients with residual stenosis rate < 20% was 31.25 times to that in patients with residual stenosis rate ≥ 20%. The postoperative restenosis risk in patients with regular medication was 12.65 times to that in patients without regular medication. The vasospasm, arterial dissection, arterial occlusion and acute thrombosis are common perioperative complications following PTAS in patients with ICAS. The medium- and long-term postoperative restenosis rate is low. Age is the risk factor for postoperative restenosis.

Fabrication of hydrophobic structures on stent by direct three-beam laser interference lithography

Coronary heart disease has become one of the important causes of human death, and the current clinical treatment has a high long-term restenosis rate and is easy to form late stent thrombosis. In order to solve these problems, coronary artery stent surface was directly modified by laser interference lithography and the highly ordered concave structures were fabricated. The morphology and contact angle (CA) of the microstructure were measured with scanning electron microscopy and CA system. The water repellent property of the stent was also evaluated by the method of contacting the water drop with the stent and then separating. The results show that the close-packed concave structure with the period of about 12μm can be fabricated on the stent surface under special parameters (laser energy density of 3Jcm−2, incident angles of 2.8°, exposure time of 60s) by the three-beam laser interference of 1064nm and the form structure has good water repellency with contact angle of 120°.

Durability and Efficacy of Tibial Arterial Stent Placement for Critical Limb Ischemia

PurposeTo analyze the efficacy and durability of long-term tibioperoneal arterial stent placement for selected cases of symptomatic chronic limb ischemia (CLI). Materials and MethodsFrom January 2005 to June 2012, 168 limbs (155 patients) were treated with percutaneous transluminal angioplasty (PTA)/stent placement for de novo tibial stenosis or occlusion in at least one tibial artery. Most patients (92.9%) were classified with severe disease (Rutherford category 5/6). Concomitant interventions were performed in 58%. Bare metal (84%) and drug-eluting (16%) stents were used. Indications for stent placement were residual stenosis after PTA (> 30%), elastic recoiling, and dissection. Primary endpoints were freedom from symptomatic intrastent restenosis, target lesion revascularization (TLR), major amputation, and overall survival (OS). ResultsTechnical success rate was 99%. Within 30 days, five deaths (3.2%) occurred, and a 1.8% (95% confidence interval [CI], 0.1%–27.2%) major adverse cardiac event rate, 3.6% (95% CI, 0.1%–22.1%) major adverse limb event rate, and 1.8% (95% CI, 0%–27.5%) amputation rate were recorded. Mean follow-up was 33 months (range, 1–96 mo). Symptomatic intrastent restenosis occurred in 20 limbs (12%) at a mean of 10.3 months ± 11.27; this was identified as a prognostic factor for limb loss (P = .045). TLR was necessary in 10.8% of limbs, for a limb salvage rate of 89.2%. OS was influenced by age (> 75 y; P < .001), diabetes (P = .048), and renal insufficiency and/or dialysis (P < .001). Estimated survival rate was 63% at 36 months (hazard ratio, 1.63; 95% CI, 54%–70%). ConclusionsStent placement offers promising short- to long-term restenosis and patency rates, even in cases of multilevel symptomatic disease. Rigorous follow-up is vital.

Stenting of symptomatic vertebral artery ostium stenosis with self-expanding stents

Symptomatic vertebral arterial stenosis carries a stroke risk of 30% at 5years. The efficacy of stenting with balloon-expandable stents remains questionable due to a high long-term restenosis rate. This study aimed to investigate the feasibility and efficacy of using self-expanding stents to treat symptomatic vertebral artery ostium (VAO) stenosis in selected patients. Clinical and angiographic results were retrospectively reviewed in patients with symptomatic VAO stenosis who underwent stenting with self-expanding stents between June 2008 and December 2011. In total, 32 patients were included. Self-expanding stents (25 tapered and seven non-tapered) were deployed with a modified technique of deploying the stents from the V1 segment to the proximal subclavian artery. The mean degree of stenosis before and after stenting declined from 76.4% to 11.4%. No peri-procedural complications occurred. During the mean clinical follow-up of 18.3months, no vertebrobasilar stroke, transient ischemic attack or death occurred. During the mean angiographic follow-up of 12.5months, asymptomatic restenosis occurred in one (3.1%) patient 6months after the procedure. No stent fracture occurred. The involved subclavian artery was patent and no clinically apparent events occurred in the dependent upper extremity. Stenting with self-expanding stents for symptomatic VAO stenosis is technically feasible and safe, with reduced restenosis and stent fracture rates in selected patients. Long-term investigations are warranted to validate its performance.

Cryoplasty for the Treatment of Femoropopliteal Arterial Disease: Extended Follow-up Results

To report the findings from a multicenter study of patients treated with cryoplasty who were then followed for an average of > 2 years post-treatment. Extended clinical follow-up was obtained for 70 patients (45 men; mean age 70.5 +/- 8.8 years) who originally received cryoplasty therapy to treat symptoms of intermittent claudication as part of a multicenter investigational device exemption (IDE) study. For all subjects, cryoplasty was used to treat stenoses or occlusions < or = 10 cm in the femoropopliteal arteries. The original IDE study protocol enrolled 102 patients with a primary endpoint of target lesion patency at 9 months post-treatment. This collection of additional longer term follow-up data was initiated 2.5 years after the onset of study enrollment. Extended clinical follow-up ranged from 11 to 41 months (mean 31). The clinical patency rate (freedom from target lesion revascularization) calculated by the Kaplan-Meier method was 83.2% after the original follow-up period of 300 days. After > 3 years (1253 days), the clinical patency rate was well maintained at 75.0%. Long-term data indicate that cryoplasty is a durable therapy, with relatively low long-term restenosis rates compared to other endovascular treatment approaches.

Cryoplasty for the Treatment of Femoropopliteal Arterial Disease: Extended Follow-up Results

To report the findings from a multicenter study of patients treated with cryoplasty who were then followed for an average of > 2 years post-treatment. Extended clinical follow-up was obtained for 70 patients (45 men; mean age 70.5 +/- 8.8 years) who originally received cryoplasty therapy to treat symptoms of intermittent claudication as part of a multicenter investigational device exemption (IDE) study. For all subjects, cryoplasty was used to treat stenoses or occlusions < or = 10 cm in the femoropopliteal arteries. The original IDE study protocol enrolled 102 patients with a primary endpoint of target lesion patency at 9 months post-treatment. This collection of additional longer term follow-up data was initiated 2.5 years after the onset of study enrollment. Extended clinical follow-up ranged from 11 to 41 months (mean 31). The clinical patency rate (freedom from target lesion revascularization) calculated by the Kaplan-Meier method was 83.2% after the original follow-up period of 300 days. After > 3 years (1253 days), the clinical patency rate was well maintained at 75.0%. Long-term data indicate that cryoplasty is a durable therapy, with relatively low long-term restenosis rates compared to other endovascular treatment approaches.

Thrombospondin 1 as possible key factor in the hemocompatibility of endocoronary prostheses

Intracoronary stenting has markedly improved the patency of native coronary arteries after percutaneous transluminal coronary angioplasty (PTCA). Advances in stent technology and design, including drug releasing stents, have contributed to reduce the long-term restenosis rate. However, stenosis caused by neointimal hyperplasia, vascular remodeling and thrombosis is still a major problem after endocoronary stent procedures. This study focuses on differential gene expression of circulating peripheral blood cells after 90 min exposure to stents to search for initially activated cellular pathways, which may foster restenosis. Fresh human whole blood (1 IU heparin/ml), taken from non-medicated healthy volunteers, was incubated under flow conditions in an in vitro closed-loop stent-testing model (modified Chandler-Loop). Differential gene expression compared to resting conditions and to the experimental controls was investigated by a DNA-microarray technique encoding for over 17,000 genes simultaneously. As expected, a large variety of genes showed differential gene expression. Interestingly, Thrombospondin 1 (TSP-1), which plays a key role in initial immune defense, was found to be the most markedly up-regulated gene. We propose TSP-1 expression as an early indicator for the activation of immune responses following intracoronary stenting. After clarifying the participation of TSP-1 in vivo, future studies will therefore focus on TSP-1 as a potential prognostic factor, which may also help to develop and control new surface materials with an improved biocompatibility.

Long-term Restenosis Rate of Eversion Endarterectomy on the Internal Carotid Artery

Objectives. The eversion endarterectomy of the internal carotid artery was introduced in Hungary in 1991. The aim of this study was to define the long-term restenosis rate of this procedure. Patients and Methods. Between 1991 and 1993, 171 operations, on 151 patients, were performed by single surgeon: with long-term follow up of 109 patients, which included annual physical and ultrasound examinations. Restenosis rate and plaque morphology were defined. Survival and patency rate were analysed by life-tables. Results. The combined perioperative stroke morbidity and mortality rate was 0.8%. The 5-year patient survival rate was 85%, the recurrent stenosis free rate was 88% at 5 years. Only 9% of the patients had carotid restenosis of more than 70% during this period. Ultrasound plaque morphology showed calcification in one case. Two patients had re-operations, with plaque histology showed myointimal hyperplasia in each case. Conclusions. Our results for restenosis are compare favourably with the 2–34% restenosis rate reported in the literature. Ultrasound and histological findings suggest that atherosclerosis does not play a significant role in the development of restenosis after the eversion carotid endarterectomy.

Early and Late Angiographic and Clinical Outcome Following Helistent Stent Implantation

There is still a lack of data on the influence of different stent designs on long-term restenosis rates and major adverse cardiac events (MACE) with the use of new antithrombotic regimens. We evaluated the midterm (6 months) clinical and angiographic and lateterm (2 years) clinical outcome of Helistent stent implantation. The study population consisted of 150 patients with high risk factor rates who had single or multivessel disease and had undergone coronary Helistent stent implantation with new antiplatelet regimens. The control coronary angiographies were done at 6 months and they were followed clinically to the end of 2 years. In 150 patients, 236 Helistent stents were implanted for 224 lesions. Helistent stent implantation was associated with a very high success rate (99%). The angiographic re-stenosis rate was 11.3% at 6 months. Only 16% of the patients experienced target lesion revascularization, 20% of the patients experienced MACE and of them, only 3.3% died at the end of two year follow-up period. The results demonstrate that the Helistent stent can be implanted with a high success rate with encouraging 6 month angiographic and late clinical outcomes.

Intraoperative duplex ultrasound during carotid endarterectomy.

The purpose of this study was to examine the technical aspects of intraoperative duplex ultrasound (DUS) following carotid endarterectomy (CEA), suggest criteria to differentiate significant lesions requiring immediate surgical revision from normal or benign defects, and evaluate how frequently intraoperative DUS provides useful or unsuspected information. A retrospective study was performed on all patients who had both CEA and intraoperative carotid DUS between January 1, 1990, and January 1, 1995. A total of 155 DUS examinations were performed in 149 patients. Findings were grouped into three categories: normal; minor/insignificant lesions; and hemodynamically significant lesions based on the presence or absence of elevated peak systolic velocities, visible stenosis/thrombus, or intimal flap/dissection. Postoperative status was correlated with intraoperative DUS findings. Ninety-one (59%) examinations performed on 87 patients produced normal findings. Forty-seven (30%) examinations performed on 45 patients showed minor abnormalities consisting of insignificant residual plaque, residual external carotid artery stenoses, small intimal flaps, elevated velocities with no associated anatomic lesion, or an arterial kink. Fourteen patients (9%) had significant findings requiring immediate surgical revision. These consisted of large intimal flaps or dissection in six patients, marked residual plaque and significant stenosis in five patients, thrombus in two patients, and a kink in one patient. Three additional patients (2%) had significant findings but were not revised for various reasons. No significant difference was identified in morbidity or mortality rates between those patients with normal findings, those patients with minor technical defects, and those patients with significant abnormalities undergoing immediate surgical revision. However, two of three patients who had significant abnormalities within the common carotid artery that were not revised suffered perioperative ipsilateral strokes. Intraoperative DUS is a safe and accurate method to assess the technical adequacy of CEA. Intraoperative DUS showed significant lesions in 11% of patients. Identification and immediate repair of significant technical defects may decrease perioperative complication rate and long-term restenosis rate.

Percutaneous mitral commissurotomy.

Rheumatic fever is the most common cause of acquired heart disease in children and young adults worldwide, mainly in developing countries, and is the reason that a large number of patients with mitral stenosis will require some modality of treatment during their life span. The early therapeutic approach for this condition was solely surgical, but since the early 1960s, several balloon catheter interventional techniques have emerged as alternatives to surgical treatment. In 1976 Inoue described a novel single-balloon device designed specifically for percutaneous transvenous mitral commissurotomy (PMC), and in 1982 the first clinical application of Inoue's technique was successfully accomplished. Ever since several clinical trials established PMC as an effective and safe procedure for severe mitral stenosis in more than 30,000 patients worldwide, percutaneous balloon techniques have been considered the method of choice in selected patients (functional class >II, mitral valve area <1.5 cm2, and Wilkins' score <8) for several reasons. PMC is a nonsurgical method with results similar to those of surgical intervention, but without the unnecessary risks and complications of general anesthesia and extracorporeal circulation pump. Both PMC and surgical commissurotomy yield comparable acute and long-term results and similar restenosis rates. Moreover, PMC is the strategy of choice in symptomatic pregnant women with mitral stenosis, as well as in some cases with restenosis after a previous PMC. Patient selection and procedural technique are reviewed in detail.

Carotid angioplasty.

Aspirin and carotid endarterectomy represent the current method of prophylaxis against stroke in patients with symptomatic high grade carotid stenoses. Whilst balloon dilatation and stent placement is an accepted form of recannalization, elsewhere in the arterial circulation the technique is in its infancy within the supra-aortic vessels. Carotid endarterectomy is expensive, requires a general anaesthetic and is associated with an acceptable complication rate as demonstrated by the ECST and NASCET studies. The author's experience in 55 patients with symptomatic high grade atherosclerotic disease is described with a disabling stroke rate at 30 days similar to the surgical series (5%). Long-term follow-up is awaited. Metallic intra-arterial stents provide the opportunity to reduce the immediate postintervention residual stenosis and possibly reduce the long-term restenosis rate. Modifications of the technique are in development and may reduce the cerebral embolization that occurs during the procedure.