Moderate Restenosis Research Articles

Anaesthetic Management of Primi with Post Percutaneous Balloon Pulmonary Valvuloplasty (PBPV) with Moderate Restenosis with Right Hemiparesis and Epilepsy Posted for Emergency Lower Segment Caesarean Section (LSCS) Under Graded Epidural Anaesthesia: A Case Report

We report the successful management of a 25-year-old primi with post PBPV with right hemiparesis and epilepsy on treatment with moderate restenosis posted for emergency LSCS and done under graded epidural anaesthesia. The perioperative course was uneventful, with satisfactory maternal and foetal outcomes. Keywords: Pulmonary restenosis, Emergency caesarean section, Graded epidural anaesthesia.

Endoscopic Endonasal Repair of Congenital Choanal Atresia: Predictive Factors of Surgical Stability and Healing Outcomes.

Background: To assess the long-term outcomes and independent predictors of surgical success of a one-stage minimally invasive surgical procedure for congenital choanal atresia (C.C.A.). Methods: a retrospective multicentric study was conducted between 2010 and 2022. An endonasal endoscopic approach was performed in 38 unilateral or bilateral C.C.A. children. All the patients were clinically and radiologically assessed and followed for at least 2 years. Seven outcome measures were applied. Consequently, surgical success was correlated with all the independent variables reported. Results: 18/38 (47.36%) patients presented normal postoperative healing, 8/38 (21.05) had moderate restenosis (<50%), while 12/38 (31.57%) cases were severe (>50%), requiring a surgical revision. No statistical significance was found for average hospital stay between stenosis >50% and <50% patients (p = 0.802) and postoperative pain (p = 0.075); instead, the severe restenosis group demonstrated a higher delay of breast suction (p < 0.001). Among the independent variables predictors of surgical success, the presence of Charge syndrome and rhinopharyngeal stenosis demonstrated higher risks for surgical revision (OR: 4.00, 95% CI: 0.57–28.01, and OR: 2.75, 95% CI: 0.55–13.69, respectively). On the contrary, the hypoplastic inferior turbinate and bilateral C.C.A. showed a lower risk for severe restenosis by a higher endoscopic surgical space and creating a single larger opening (OR: 0.88, 95% CI: 0.22–3.52, and OR: 0.45, 95% CI: 0.10–2.08). Conclusion: Several independent variables could influence the surgical success after C.C.A. endoscopic repair; however, more high-quality evidence is needed to generate an effective predictive model.

698 Acute coronary syndrome in neoatherosclerosis with major stent malapposition and OCT-guided PCI

AimsDue to its bidimensional nature, angiography is not always sufficient to accurately define coronary lesions, in particular when they are ambiguous or indeterminate. Intracoronary imaging, such as intravascular ultrasound or optical coherence tomography (OCT), is often useful in these cases to better characterize the ambiguous angiographic images, to identify the culprit lesion during acute coronary syndrome (ACS) and to guide percutaneous coronary intervention (PCI).Methods and resultsWe report a case of a 61-year-old male with multiple cardiovascular risk factors and a previous ST-segment elevation myocardial infarction treated by PCI of the right coronary artery (RCA) about 7 years before, wo was admitted to our emergency department after acute onset chest pain. At the time of admission, his ECG was normal and cardiac troponin was below the upper reference limit of normality with positive molecular SARS-CoV-2 diagnostic test. Echocardiogram disclosed a mild left ventricular dysfunction with inferior wall hypokinesia. Coronary angiography showed a moderate in-stent restenosis at mid RCA and a hazy, undetermined image at the proximal edge of the previously implanted stent. Left coronary artery angiography showed only diffuse atherosclerotic disease without significant stenoses and a myocardial bridge at the mid tract of left anterior descending artery. OCT pullback of RCA to better characterize the undetermined lesions shown by angiography. OCT revealed significant neointima hyperplasia and a focal area of neoatherosclerosis with unstable features (fissure/microthrombi) at mid RCA. Severe stent strut malapposition embedded neointimal hyperplasia was observed at the proximal stent edge, resulting in ‘dual’ lumen appearance. The two lesions were treated with a single 3.5/48 mm everolimus-eluting stent (stent-in-stent), which was post-dilated with a 3.5/20 mm non-compliant balloon (18 atm) in the mid-to-distal segments, and 4.5/15 mm (16 atm) and 5.0/8 mm (14 atm) semi-compliant balloons in the proximal stent segment. Post-PCI OCT imaging confirmed good stent expansion and apposition. Our case demonstrates the utility of OCT in clarifying the aetiology of ambiguous angiographic lesions and as a guide for PCI. Indeed, the ‘hazy’ appearance on the angiograms corresponded to the major stent malapposition covered by neointima disclosed by OCT as a ‘dual-lumen’. Of note, OCT allowed to confirm the correct guidewire position in the ‘true’ lumen preventing a crush of the previously implanted stent. OCT was also useful as a diagnostic modality for the identification and characterization of the mechanism underlying the ACS (neoatherosclerosis instability).ConclusionsDue to its unprecedented spatial resolution, OCT enables an ‘optical biopsy’ of the coronary artery wall and intrastent tissue. Therefore, OCT imaging should be considered when lesions are ambiguous or indetermined by coronary angiography to guide the diagnosis and treatments of ACS patients. OCT imaging is also useful to guide stenting and to optimize PCI result, and its impact on clinical outcome is under investigation in large randomized clinical trials.

Follow-up after carotid stenting with the CASPER stent system: A duplex ultrasound evaluation

ObjectiveTo report results of duplex ultrasound evaluation of consecutive patients after carotid stenting with the double layer Carotid Artery Stent designed to Prevent Embolic Release (CASPER) stent system. MethodsBetween January 2014 and June 2017, a single-center, retrospective study of 101 consecutive patients (21.8% female; median age, 72.1 years) was performed. Patients with internal carotid artery stenosis treated with the CASPER stent were included. Eligibility criteria for stenting included stenosis of ≥70% of the vessel diameter (or ≥50% diameter with ulceration) in symptomatic carotid artery stenosis or ≥80% stenosis in asymptomatic patients at the carotid artery bifurcation or the proximal cervical internal carotid artery. Duplex ultrasound examination was performed before and within 24 hours of implantation as well as at 14 days, and 3, 6, and 12 months. ResultsAt the 12-month follow-up visit, moderate in-stent restenosis (ISR) (≥50% and <70%) was detected in three stents (2.8%) and severe (≥70%) ISR in two (1.9%; including one case of stent occlusion). All but the two latter patients remained asymptomatic during the follow-up period. One patient required retreatment for ISR after a minor stroke and another patient with stent occlusion also re-presented with a minor stroke. Multivariable logistic regression was unable to detect any significant factors associated with ISR. ConclusionsDuplex ultrasound examination after carotid stenting is a useful tool for patient follow-up and determination of ISR. We found a low incidence of ISR assessed by duplex ultrasound examination at 12 months after CASPER stenting, but further studies are warranted.

Stent Design, Restenosis and Recurrent Stroke after Carotid Artery Stenting in the International Carotid Stenting Study

Multicenter retrospective analysis of patients entered in the prospective, randomized International Carotid Stenting Study between May 2001 and October 2008. Moderate or higher re-stenosis occurred significantly less frequently in patients with open-cell (352) than closed-cell (362) stents (5-year risks of 36% vs 46%, respectively), with a trend but no significant difference in the risk of more than 70% restenosis after open-cell stenting versus closed-cell stenting (5-year risks of 9% vs 13%, respectively). There was no difference in ipsilateral strokes beyond 30 days after treatment with either stent design. Moderate or higher restenosis after carotid artery stenting (CAS) occurred less frequently in patients treated with open-cell stents than closed-cell stents. Both stent designs were equally effective at preventing recurrent stroke during follow-up.

Utility of fractional flow reserve in moderate in-stent re-stenosis and jailed side branches and comparison of fractional flow reserve with single-photon emission computed tomography-myocardial perfusion imaging in native coronary artery stenosis

Background: Functional flow reserve (FFR) is used to determine functional significance of coronary artery stenosis. FFR demonstrated discrepancy between angiographic and functional significance of jailed side branches (JSBs) as well as moderate in-stent restenosis (ISR), with only minority of such lesions having functional significance. An attempt was made to study the utility of FFR and comparison of FFR with single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) in native coronary artery stenoses. Methods: A total of 101 lesions in 79 patients with stable ischemic coronary artery disease were subjected to FFR and SPECT-MPI including native as well as ISR and JSB. Relation between FFR and perfusion imaging was analyzed quantitatively. Sensitivity, specificity, positive predictive value, and negative predictive value were used for diagnostic accuracy. Results: FFR was ≤≤ 0.75 in majority of the lesions having >70% stenosis. Most of the lesions having reversible perfusion defect had FFR ≤≤ 0.80. There was a significant negative correlation between summed difference score (SPECT-MPI) with FFR value. As FFR value decreased, summed difference score increased. Sensitivity and specificity did not differ much when FFR cutoff was taken as 0.75 or 0.80. Conclusion: There was a significant negative correlation between FFR and sum difference score (SPECT-MPI). Sensitivity and specificity of SPECT-MPI did not differ much when FFR value cutoff was taken as 0.75 or 0.80.

Stent Design, Restenosis and Recurrent Stroke After Carotid Artery Stenting in the International Carotid Stenting Study

Multicenter retrospective analysis of patients entered in the prospective, randomized International Carotid Stenting Study between May 2001 and October 2008. Moderate or higher restenosis occurred significantly less frequently in patients with open-cell (352) than with closed-cell (362) stents (5-year risk, 36% vs 46%), with a trend but no significant difference in the risk of >70% restenosis after open-cell stenting vs closed-cell stenting (5-year risk, 9% vs 13%). There was no difference in ipsilateral strokes beyond 30 days after treatment with either stent design. Moderate or higher restenosis after carotid artery stenting (CAS) occurred less frequently in patients treated with open-cell stents than with closed-cell stents. Both stent designs were equally effective at preventing recurrent stroke during follow-up.

Stent Design, Restenosis and Recurrent Stroke After Carotid Artery Stenting in the International Carotid Stenting Study.

Background and Purpose- Open-cell carotid artery stents are associated with a higher peri-procedural stroke risk than closed-cell stents. However, the effect of stent design on long-term durability of carotid artery stenting (CAS) is unknown. We compared the medium- to long-term risk of restenosis and ipsilateral stroke between patients treated with open-cell stents versus closed-cell stents in the ICSS (International Carotid Stenting Study). Methods- Patients with symptomatic carotid stenosis were randomized to CAS or endarterectomy and followed with duplex ultrasound for a median of 4.0 years. We analyzed data from patients with completed CAS procedures, known stent design, and available ultrasound follow-up. The primary outcome, moderate or higher restenosis (≥50%) was defined as a peak systolic velocity of >1.3 m/s on ultrasound or occlusion of the treated internal carotid artery and analyzed with interval-censored models. Results- Eight hundred fifty-five patients were allocated to CAS. Seven hundred fourteen patients with completed CAS and known stent design were included in the current analysis. Of these, 352 were treated with open-cell and 362 with closed-cell stents. Moderate or higher restenosis occurred significantly less frequently in patients treated with open-cell (n=113) than closed-cell stents (n=154; 5-year risks were 35.5% versus 46.0%; unadjusted hazard ratio, 0.68; 95% CI, 0.53-0.88). There was no significant difference in the risk of severe restenosis (≥70%) after open-cell stenting (n=27) versus closed-cell stenting (n=43; 5-year risks, 8.6% versus 12.7%; unadjusted hazard ratio, 0.63; 95% CI, 0.37-1.05). The risk of ipsilateral stroke beyond 30 days after treatment was similar with open-cell and closed-cell stents (hazard ratio, 0.78; 95% CI, 0.35-1.75). Conclusions- Moderate or higher restenosis after CAS occurred less frequently in patients treated with open-cell stents than closed-cell stents. However, both stent designs were equally effective at preventing recurrent stroke during follow-up. Clinical Trial Registration- URL: http://www.isrctn.com/. Unique identifier: ISRCTN25337470.

Stroke Risk with Moderate Restenosis After Carotid Artery Stenting or Endarterectomy

Although the long-term benefits of carotid artery stenting or endarterectomy for symptomatic carotid stenosis are readily apparent, the risk for

Restenosis and risk of stroke after stenting or endarterectomy for symptomatic carotid stenosis in the International Carotid Stenting Study (ICSS): secondary analysis of a randomised trial

SummaryBackgroundThe risk of stroke associated with carotid artery restenosis after stenting or endarterectomy is unclear. We aimed to compare the long-term risk of restenosis after these treatments and to investigate if restenosis causes stroke in a secondary analysis of the International Carotid Stenting Study (ICSS).MethodsICSS is a parallel-group randomised trial at 50 tertiary care centres in Europe, Australia, New Zealand, and Canada. Patients aged 40 years or older with symptomatic carotid stenosis measuring 50% or more were randomly assigned either stenting or endarterectomy in a 1:1 ratio. Randomisation was computer-generated and done centrally, with allocation by telephone or fax, stratified by centre, and with minimisation for sex, age, side of stenosis, and occlusion of the contralateral carotid artery. Patients were followed up both clinically and with carotid duplex ultrasound at baseline, 30 days after treatment, 6 months after randomisation, then annually for up to 10 years. We included patients whose assigned treatment was completed and who had at least one ultrasound examination after treatment. Restenosis was defined as any narrowing of the treated artery measuring 50% or more (at least moderate) or 70% or more (severe), or occlusion of the artery. The degree of restenosis based on ultrasound velocities and clinical outcome events were adjudicated centrally; assessors were masked to treatment assignment. Restenosis was analysed using interval-censored models and its association with later ipsilateral stroke using Cox regression. This trial is registered with the ISRCTN registry, number ISRCTN25337470. This report presents a secondary analysis, and follow-up is complete.FindingsBetween May, 2001, and October, 2008, 1713 patients were enrolled and randomly allocated treatment (855 were assigned stenting and 858 endarterectomy), of whom 1530 individuals were followed up with ultrasound (737 assigned stenting and 793 endarterectomy) for a median of 4·0 years (IQR 2·3–5·0). At least moderate restenosis (≥50%) occurred in 274 patients after stenting (cumulative 5-year risk 40·7%) and in 217 after endarterectomy (29·6%; unadjusted hazard ratio [HR] 1·43, 95% CI 1·21–1·72; p<0·0001). Patients with at least moderate restenosis (≥50%) had a higher risk of ipsilateral stroke than did individuals without restenosis in the overall patient population (HR 3·18, 95% CI 1·52–6·67; p=0·002) and in the endarterectomy group alone (5·75, 1·80–18·33; p=0·003), but no significant increase in stroke risk after restenosis was recorded in the stenting group (2·03, 0·77–5·37; p=0·154; p=0·10 for interaction with treatment). No difference was noted in the risk of severe restenosis (≥70%) or subsequent stroke between the two treatment groups.InterpretationAt least moderate (≥50%) restenosis occurred more frequently after stenting than after endarterectomy and increased the risk for ipsilateral stroke in the overall population. Whether the restenosis-mediated risk of stroke differs between stenting and endarterectomy requires further research.FundingMedical Research Council, the Stroke Association, Sanofi-Synthélabo, and the European Union.

Analysis of Recurrent Stenosis After Carotid Endarterectomy Featuring Primary Plaque Calcification.

The relationship between calcification in primary plaque and restenosis after carotid endarterectomy (CEA) has been seldom investigated. To clarify the relationship between characteristics of calcified carotid plaque and recurrent stenosis after CEA, as well as the disease's natural course. Ninety-four plaques out of 107 consecutive CEAs were retrospectively analyzed with regard to calcification, employing calcium score as well as shape, location, and other characteristics of original plaques. CEA was performed in a standard fashion with primary closure using an internal shunt. Restenosis was assessed by direct measurement of stenosis mainly using multidetector row computed tomography (CT) angiography. Univariate analysis revealed that calcium score and calcification circularity score were significantly lower in more than moderate restenosis (≥50%; 422.1 ± 551.6 vs 84.2 ± 92.0, P < .001; 1.8 ± 1.3 vs 1.1 ± 0.3, P < .001, respectively). Receiver operating characteristic analysis demonstrated a calcium score of 80, which was the optimal cutoff value for restenosis over 50% (sensitivity 0.70, specificity 0.68, pseudopositive ratio 0.32, area under curve 0.71, Youden's index 0.38). Low calcium score (OR 2.88, CI 1.06-7.79, P = .04) and low calcification circularity (OR 5.72, CI 1.42-23.1, P = .01) were independent predictors for more than moderate recurrent carotid stenosis 1 year postoperatively. Cases with decreasing tendency of restenosis showed higher calcium scores than those with increasing or unchanged tendency (217.2 ± 245.3 vs 164.5 ± 155.5, P < .001). Lower calcium score cases showed lower restenosis-free survival. Carotid plaque calcification may be inversely associated with recurrent stenosis 1 year after CEA or later. Preoperative CT assessment for less calcification will benefit restenosis patients by early prediction and close follow-up.

Surgical experience in the rehabilitation and reimplantation of disconnected pulmonary arteries and its effectiveness in restoring pulmonary haemodynamics and function.

We established a policy to restore disconnected pulmonary arteries (PAs), regardless of aetiology or cardiac pathology, using a protocol-based strategy. There are conflicting reports of the need to restore disconnected PA especially if severely hypoplastic with some groups advocating surgical repair of cardiac defects to single lung with moderate to high risk. All patients referred to our PA reconstruction programme (2007-14) with complete separation of one branch PA were included. Our surgical strategy was based on the size of the PA. In patients with mild or no PA hypoplasia, we performed single-stage implantation of the disconnected PA and repair of intracardiac defects. Two-stage approach was used in patients with severe PA hypoplasia where the disconnected PA was retrieved inside the lung then connected to the aorta with a shunt to promote growth. After 6-12 months, the PA was implanted with simultaneous repair of intracardiac defects. Twenty patients were included (age range = 1 week to 8 years). Aetiologies were ductal origin of distal PA in 13 patients and iatrogenic in 7 patients. Group 1 (isolated lesion) consisted of 8 patients who presented with severe pulmonary hypertension. Group 2 consisted of 12 patients with associated intracardiac defects and was subdivided into Group 2a (biventricular hearts) 8 patients and Group 2b (univentricular hearts) 4 patients. Single-stage repair was achieved in 10 patients. Direct tissue-to-tissue connection was achieved in 18 (90%) patients. The follow-up was 100% complete (median = 53.8 months). All patients are alive and asymptomatic. Implanted PAs are patent with good growth demonstrated on serial echocardiography. Only two PAs required balloon dilatation for moderate restenosis at the anastomosis. No surgical reintervention was needed. All Group 1 patients had complete resolution of the pulmonary hypertension. Lung perfusion scans showed increased uptake (24-53% of the total uptake). Our study demonstrated that, in paediatric age group, disconnected PAs can be restored with low risk and excellent outcomes even in patients with severely hypoplastic PA. Strategies to repair intracardiac defects to a single lung might not be the optimal approach.

Evolución natural de la reestenosis tras endarterectomía carotídea

ObjectivesTo determine the incidence of restenosis after carotid endarterectomy (CEA), as well as to observe its natural history and identify the risk factors for its development. Material and methodsRetrospective study of a prospective cohort of CEA performed in 2006-2011. The variables recorded were: clinical data, surgical details, incidence of moderate restenosis (MRE) (50-69%), severe restenosis (SRE) (≥70%), and occlusion. The patients were followed-up with carotid duplex-scan 6, 12, 18 and 24 months after the procedure, and annually thereafter if MRE/SRE was found. All SRE were confirmed with MRI. No restenosis was surgically or endovascularly repaired. A descriptive analysis was performed, and Chi-squared/Fisher's exact test was used for the definition of SRE risk factors. ResultsA total of 186 patients with carotid endarterectomy were included, 77 (41.4%) performed in symptomatic patients, and a patch (dacron) used in 19 (10.2%) cases. During the first year of follow-up 20 (10.8%) MRE were found, with 9 of them (45%) regressed (to <50%) and one (5%) progressed to SRE during the second year. SRE was observed in 12 (6.5%) patients during the first year of follow-up, and 4 (33.3%) regressed (to 50-69%) during the second year, and 3 (25%) more during the third year. No SRE were occluded or became symptomatic. Two carotid arteries became occluded during the first year (one caused a stroke), and one more during the second year, without previous ≥50% restenosis. The use of Kunlin stitches increased the risk of developing SRE (OR 3,61; 95%CI: 1.13-11.57; P=.023). ConclusionsSRE after CEA, mostly with direct suture, is infrequent. The natural history of SRE during follow-up is benign. Kunlin stitches are associated to the development of SRE.

Late Transverse Aortic Stent Fracture in Adolescent with Coarctation of the Aorta. Treatment of the Complication with Covered Stent Insertion with in the Fractured Stent

Male adolescent fourteen years old with Coarctation diagnosed at the age of eleven. He underwent cardiac catheterization with percutaneous balloon dilation and stent implantation. The immediate result was satisfactory but three years later a transverse fracture of the stent was detected on cardiac Magnetic Resonance Imaging with findings of moderate restenosis. This complication was treated with percutaneous implantation of a covered stent. The case of this adolescent is interesting because late fracture of aortic stent is a rare complication and covered stent implantation is a sufficient treatment whether or not there is recoarctation.

Carotid endarterectomy for symptomatic low-grade carotid stenosis

Although the management of carotid disease is well established for symptomatic lesions ≥ 70%, the surgical treatment for a symptomatic ≤ 50% stenosis is not supported by data from randomized trials. Factors other than lumen narrowing, such as plaque instability, seem to be involved in cerebral and retinal ischemic events. This study analyzes the early-term and long-term outcomes of carotid endarterectomy (CEA) performed in patients with low-grade (≤ 50% on North American Symptomatic Carotid Endarterectomy Trial criteria) symptomatic carotid stenosis. The study involves 57 consecutive patients undergoing CEA for symptomatic low-grade carotid disease at our institution over 5 years, and 21 (36.8%) had experienced more than one ischemic event. Overall, 48 (84.2%) had a minor stroke, and nine (15.8%) had an episode of retinal ischemia. Diagnosis was made by a vascular neurologist based on an ultrasound examination combined with noninvasive imaging studies, after ruling out other possible causes of embolization. Before CEA, all patients were receiving antiplatelet treatment, and 87% were taking statins. All patients underwent eversion CEA under general deep anesthesia, with selective shunting. All carotid plaques were examined histologically. Long-term follow-up (median, 28 months; mean, 32 ± 5 months; range, 3-56 months) was obtained for 55 patients. No 30-day strokes or deaths occurred, and no patients had recurrent neurologic events related to the revascularized hemisphere during the follow-up. No late carotid occlusions were detected, but one asymptomatic moderate restenosis was documented. There were seven late deaths (12.7%), none of which were stroke-related. Survival rates were 98% at 1 year and 90% at 3 years. All removed carotid plaques showed different features of ulceration or rupture, with underlying hemorrhage associated with a thrombus. This study shows that CEA is a safe, effective, and durable treatment for patients with symptomatic low-grade carotid stenosis associated with unstable plaque. Patients had excellent protection against further ischemic events and survived long enough to justify the initial surgical risk. Plaque instability seems to play a major part in the onset of ischemic events, regardless the entity of lumen narrowing.

E-021 Acute Interventional Treatment of Atherosclerotic Carotid Occlusion and Intracranial Thromboembolism

The patient presenting with acute carotid occlusion and intracranial embolism poses additional challenges compared with the patient with intracranial embolism and no cervical carotid obstruction. There are technical challenges of...

Usefulness of Functional Assessment in the Treatment of Patients With Moderate Angiographic Paclitaxel-Eluting Stent Restenosis

In recent years there has been a debate about the functional severity of restenosis of drug-eluting stents. The aim of the present study was to assess the functional severity of stenosis in patients with moderate angiographic restenosis after paclitaxel-eluting stents (PES) deployment. Forty-two patients with moderate angiographic restenosis at the in-stent segment and/or approximately 5mm from the stent edge were enrolled. For comparison, furthermore, 42 patients with de novo stenosis lesions matched for angiographic severity were assigned to the control group. Quantitative coronary angiography and functional assessment using fractional flow reserve (FFR) were performed. Although percent diameter stenosis was not significantly different between the 2 groups (PES group, 40.6±11.2%; de novo group, 40.6±9.0%, P=0.981), the functional severity of stenosis was significantly less in the PES group than in the de novo group (FFR: PES group, 0.86±0.07; de novo group, 0.79±0.10, P=0.002). FFR was preserved in patients with moderate angiographic restenosis after PES deployment, and the functional severity of restenosis is often limited. Therefore, revascularization should be performed with caution for patients with moderate angiographic restenosis after PES deployment.

Endovascular treatment of transplanted renal artery stenosis with PTA/stenting

We evaluated the effectiveness of endovascular treatment with percutaneous transluminal balloon angioplasty (PTA)/stenting of transplanted renal artery stenosis (TRAS). Between January 2005 and December 2010, 17 patients (4 women, 13 men; mean age 60.9 years) with TRAS underwent PTA/stenting. The parameters analysed were: technical success, pre- and post-treatment serum creatinine (SCr) and blood pressure (BP), average number of antihypertensive drugs administered before and after treatment and vessel patency on colour Doppler ultrasound (CDUS) at 1, 3, 6 and 12 months and once a year thereafter. Technical success was 100%. During a mean follow-up of 28.3±18.7 months, there was a statistically significant reduction in SCr and BP values. In 18 % of cases, moderate (<60%) restenosis was observed on CDUS without renal failure and not requiring new treatment. There was a reduction in antihypertensive drugs from an average of 3.5±0.5 to 1.5±0.5. Consistent with the literature data, our experience shows that endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS and can thus be considered the method of choice.

Impaired cardiac reserve in asymptomatic patients with moderate pulmonary restenosis late after relief of severe pulmonary stenosis: Evidence for diastolic dysfunction

BackgroundPatients with moderate pulmonary valve restenosis late after relief of severe pulmonary stenosis (PS) may show decreased exercise tolerance. To elucidate the mechanism of decreased exercise tolerance, we evaluated cardiac response to physical and pharmacological stress in these patients and compared results with those of patients with native moderate PS. MethodsTwenty asymptomatic patients with moderate PS were divided into 2 groups: Group I (late after relief of severe PS, n=9), and Group II (no previous intervention, n=11). All patients underwent an exercise test, dobutamine stress (DS) MRI, and delayed contrast enhanced MRI. The response to physical and pharmacological stress was compared between both groups. ResultsGroup I showed impaired exercise capacity compared to Group II (VO2max=72.8%±3.5% vs. 102.5%±16.3%, p<0.001). During DS-MRI, RV-SV increased in Group II, but not in Group I (+13±8ml, −5±8ml, p<0.001). RV end‐diastolic volume decreased significantly in Group I patients (p=0.006) while it did not significantly change in Group II patients. The amount of RV-SV increase (∆ RV-SV) correlated negatively with the period of moderate PS existence and the current PG in Group I (r=−0.82, p=0.007, and r=−0.68, p=0.04, respectively) but not in Group II (r=0.45, p=0.1, and r=0.40, p=0.2, respectively). Furthermore, ∆ RV-SV correlated negatively with the PG before valvuloplasty (r=−0.76, p=0.02). ConclusionImpaired exercise capacity in patients with moderate pulmonary restenosis after relief of severe PS is probably caused by inability to increase RV-SV. Disturbed RV filling properties, worsening in time, might play a role.

Very Late Thrombosis in a Bifurcation

A male patient 65 years old treated with a conventional stent in the second diagonal (D2) branche in 2007. In 2008, he underwent a stent-in-stent procedure for D2 in-stent restenosis, with stent implanation reaching the ostium taking off from the left anterior descending artery (LAD). In June 2011, antiplatelet treatment was discontinued due to non-cardiac surgery; the patient presented a myocardial infarction with ST elevation in V2-V6, so primary angioplasty was indicated. Coronary angiography showed an image compatible with intraluminal thrombus at the LAD/D2 bifurcation, which presented moderate in-stent restenosis and TIMI 3 flow in both branches (Fig. 1A). Angioplasty was not performed, and the patient started treatment with aspirin, clopidogrel and abciximab. After 4 days, follow-up coronary angiography showed angiographic improvement of the thrombus in the LAD (Fig. 1B). Optical coherence tomography (OCT) showed invasion and malapposition to the wall by the LAD stent implanted 3 years ago, lack of endothelialization in some of the struts (Fig. 2D, arrows) and a white thrombus adhering to the external and internal stent walls at the LAD lumen (particularly at the arrows in figures 2A and B — pullback from D2 — and arrows in figures 2C and E — pullback from anterior descending artery). The case presented very late onset thrombosis in the main vessel of a bifurcation that had been treated only in its secondary branch. In most bifurcations treated with precise ostial stent placement, angiography does not show whether the stent is invading the artery that does not require treatment, and non-apposition of the stent can be accompanied by lack of endothelialization and late onset thrombosis. In these cases, the results of prolonging dual antiplatelet treatment are unknown. OCT catheter in D2 Thrombus in AD struts (arrows) OCT catheter in D2 (close-up)