Patient Underwent Bypass Surgery Research Articles

Abstract 18094: Supersaturated Oxygen Therapy Benefits Late Presenters With Anterior ST-Segment Elevation Myocardial Infarction

Introduction: Patients with late-presentation ST-Segment Elevation Myocardial Infarction (STEMI) are at increased risk of mortality and development of heart failure and have limited therapeutic options besides percutaneous coronary intervention (PCI). Hypothesis: Intracoronary supersaturated oxygen therapy (SSO2) (Zoll / Therox) is approved as an adjunctive therapy to PCI in STEMI patients and may reduce infarct size in patients with less than 6 hours of ischemia. However, in pre-clinical studies, the delivery of SSO2 reduces infarct size even when delivered 24 hours following coronary occlusion. We hypothesized that late-presenting anterior STEMI patients may benefit from SSO2 therapy following PCI. Methods: We studied 12 patients (7M, 5F; 60 ± 9 years) with ongoing anterior STEMIs and prolonged ischemic times (12.2 ± 7.6 hrs). Ten of the 12 patients had an occluded LAD on presentation with TIMI 0 flow and 11 patients had anterior q-waves in at least 2 consecutive leads on the presenting EKG. All patients underwent successful PCI of the LAD with DES followed by 60 minutes of SSO2 therapy delivered through a catheter placed in the left main coronary artery. Cardiac MRI measurement of LV function and infarct size was performed in all patients 1 to 3 days later. Results: Mean infarct size was 32 ± 10 % of LV mass. Baseline left-ventricular ejection fraction (LVEF) measured within 24 hours of PCI was 37.8 ± 10.0 %. LVEF improved to 50.2 ± 11.2 % on follow-up imaging performed at a mean of 2 months following PCI (p < 0.01). To date, all patients remain alive and no patients have been admitted for heart failure. One patient underwent LVAD placement during his baseline hospitalization for persistent cardiac shock and another patient underwent bypass surgery 7 months later after having developed in-stent restenosis and progressive CAD. Conclusions: SSO2 therapy can be safely performed in high-risk STEMI patients with prolonged ischemic times who undergo successful PCI and is associated with a significant recovery of LV function when measured several months later.

Bioresorbable magnesium scaffold in the treatment of simple coronary bifurcation lesions: The BIFSORB pilot II study.

ObjectivesTo evaluate the feasibility, safety, and healing response of a magnesium‐based bioresorbable scaffold (BRS) in the treatment of simple bifurcation lesions using the single stent provisional technique.BackgroundBRS may hold potential advantages in the treatment of coronary bifurcation lesions, however low radial strength and expansion capacity has been an issue with polymer‐based scaffolds. The magnesium BRS may prove suitable for bifurcation treatment as its mechanical properties are closer to those of permanent metallic drug‐eluting stents.MethodsThe study was a proof‐of‐concept study with planned inclusion of 20 patients with stable angina pectoris and a bifurcation lesion involving a large side branch (SB) > 2.5 mm with less than 50% diameter stenosis. Procedure and healing response were evaluated by optical coherence tomography (OCT). The main endpoints were a composite clinical safety endpoint and an OCT healing index at 1 month (range: 0–98).ResultsEleven patients were included in the study. The study was prematurely terminated due to scaffold fractures and embolization of scaffold fragments in three cases requiring bailout stenting with drug‐eluting stents. One patient underwent bypass surgery at 3 months due to stenosis proximal to the study segment. All SB were patent for 1 month. One‐month OCT evaluation showed strut coverage of 96.9% and no malapposition. Scaffold fractures and uncovered jailing struts resulted in a less favorable mean OCT healing index score of 10.4 ± 9.0.ConclusionsImplanting a magnesium scaffold by the provisional technique in nontrue bifurcation lesions was associated with scaffold fracture, embolization of scaffold fragments, and a high need for bailout stenting.

Long-term follow-up of medically treated patients with spontaneous coronary artery dissection: a prospective, Swiss single-centre cohort study

Spontaneous coronary artery dissection (SCAD) is an increasingly diagnosed cause of acute myocardial infarction. However, there is still a limited number of larger cohorts with long-term follow-up. We report on the largest Swiss single-centre cohort to date, with follow-up of up to 22 years. We prospectively collected SCAD cases from June 1998 until December 2020. A strategy of systematic follow-up angiography was applied. Information on long-term follow-up was collected up to the end of 2020. Major cardiovascular events (MACE) were defined as all-cause death, non-fatal MI, and non-fatal cardiac arrest. We identified 105 SCAD patients (mean age 53 ± 11 years, 98 female, 5 peripartum). Presentation was myocardial infarction in all patients. In 102 patients, there was one contiguous dissection. Three patients had two (n = 2) or three (n = 1) non-contiguous dissections. In the majority of patients (n = 97), the primary treatment approach was conservative (dual antiplatelet therapy for 12 months in 90% of patients, statins in 91%). Seven patients were treated with percutaneous coronary intervention (PCI) and one patient underwent bypass surgery. Elective follow-up angiograms were performed in 73 asymptomatic patients after a median follow-up of 6.0 months (interquartile range [IQR] 5.5-6.5). These showed healing of the dissection (n = 65) or a good result after PCI (n = 5) in 70 patients. Three patients had a persistent dissection but conservative treatment was continued. After a median follow-up of 7.5 years (IQR 3.6-12.5) (longest follow-up: 22.5 years) there were 15 MACE. Five MACE occurred within 30 days of the index event: death following catastrophic peripartum left main SCAD (n = 1), out-of-hospital cardiac arrest with successful resuscitation 16 days after SCAD (n = 1), ST-segment elevation myocardial infarction due to occlusion of the dissected artery 10 hours after the index angiogram with subsequent PCI (n = 1), SCAD of a second vessel 8 days after the index SCAD (n = 1), and non-ST-segment elevation myocardial infarction with persistent, multisite SCAD 10 days after the index event (n = 1). There were 10 late MACE, including myocardial infarction and recurrent SCAD (different vessel/lesion) a median of 7.6 years (IQR 3.9-9.6) after the index event in eight patients and death with unclear cause in two patients. This SCAD series highlights its highly variable clinical course during the acute phase and in the long term. Although most SCAD patients can be treated conservatively with subsequent healing of the dissection and good clinical outcome, there are also patients with dramatic acute presentation or MACE several years after the initial presentation.

Dynamic obstruction of the left main coronary artery ostium by a papillary fibroelastoma

Benign tumours of the heart are usually detected as incidental findings during echocardiography. Most cases are intracardiac tumours, with myxoma being the most frequent entity. We present images of a patient with acute myocardial infarction and a concomitant extracardiac benign tumour in the aortic root. Transesophageal echocardiography, coronary computed tomography angiography, cardiac surgery and histology of the excised tumour were performed. A mobile mass was found in the aortic root obstructing the left main coronary artery ostium during diastole. Coronary CT angiography indicated severe coronary artery disease and the patient underwent bypass surgery and excision of the tumour. The excised tumour was identified as papillary fibroelastoma. Papillary fibroelastoma is the second most benign tumour of the heart. More than other tumours it is prone to embolization. Extracardiac location as in our case is very rare but dangerous since embolization may occur spontaneously or associated with catheterization.

A case of isolated middle cerebral artery stenosis with hemichorea and moyamoya pattern collateralization.

Isolated middle cerebral artery (MCA) stenosis in young patients with no other medical condition may be a unique pathologic entity with a benign long-term course. Generally, moyamoya disease shows a progression of stenosis from internal cerebral artery (ICA) to other intracranial vessel. A 26-year-old woman was admitted for choreic movements of the right arm and leg. Brain magnetic resonance imaging showed no stroke. Conventional angiography revealed 48% stenosis of the left M1 without ICA stenosis. Single photon emission computed tomography revealed perfusion asymmetry after acetazolamide injection, suggesting decreased uptake in the left basal ganglia and the cerebral cortex. Her hemichorea was mildly decreased with risperidone. One year later, follow-up angiography showed complete occlusion of the left M1 with neovascularization suggestive of moyamoya disease. The patient underwent bypass surgery and her hemichorea disappeared. This may be an atypical presentation of moyamoya disease. The bypass surgery was an effective measure for restoring the vascular insufficiency and, resultantly, controlling her hemichorea.

Moyamoya syndrome occurred in a girl with an inactive systemic lupus erythematosus

We report the case of a 17-year-old Korean girl with systemic lupus erythematosus (SLE) who presented with sudden weakness of the right-sided extremities and dysarthria. Oral prednisolone was being taken to control SLE. Results of clinical and laboratory examinations did not show any evidence of antiphospholipid syndrome or thromboembolic disease nor SLE activity. Cerebral angiography showed stenosis of the left internal carotid artery and right anterior cerebral artery with accompanying collateral circulation (moyamoya vessels). After the patient underwent bypass surgery on the left side, she recovered from the neurological problems and did not experience any additional ischemic attack during the 14-month follow-up period. This case represents an unusual association between moyamoya syndrome and inactive SLE (inactive for a relatively long interval of 2 years) in a young girl.

Intermediate and Long-Term Outcomes After Treating Symptomatic Persistent Sciatic Artery Using Different Techniques

Persistent sciatic artery (PSA) is a rare congenital vascular malformation. In this article, we have described the case of a 66-year-old woman presenting with a pulsatile mass in the left buttock and bilateral lower limb ischemia, who underwent surgical therapy. Preoperative computed tomography scanning showed a left thrombosed PSA aneurysm (PSAA) with concomitant occlusion of bilateral iliac, bilateral common femoral, and left popliteal arteries. After recanalization of the left common femoral artery occlusion with a systemic heparin treatment, the patient underwent bypass surgery (left femoropopliteal bypass, right iliofemoral bypass) and PSAA exclusion. Postoperative computed tomography scanning 20 months after surgery revealed that the excluded PSAA was thrombosed with no refilling collateral flow, and that the bypass grafts were patent in both legs. In addition to this case report, a literature review of PubMed articles published between 1965 and 2009 that included the treatment and intermediate/long-term management of symptomatic PSAs was conducted. We found 45 articles (67 limbs), of which 24 (29 limbs) described the intermediate/long-term outcomes in patients treated for symptomatic PSA. Regardless of the method of arterial reconstruction or PSAA repair, intermediate/long-term outcomes of different treatments for lower limb ischemia and PSAAs were satisfactory, and the patients were asymptomatic during the follow-up period which ranged from 2 months to 10 years.

Ligation-and-Bypass Technique through the Posterior Approach for Bilateral Popliteal Aneurysms

A 56-year-old man with a painful, progressively enlarging pulsatile mass in the bilateral popliteal fossae was diagnosed with a bilateral popliteal artery aneurysm (PAA) and referred to our hospital to undergo surgical therapy. Computed tomographic scanning demonstrated a large, middle-type PAA with a rich mural thrombus in the bilateral popliteal arteries. Following aneurysm exclusion posteriorly, the patient underwent bypass surgery using a ringed polytetrafluoroethylene graft bilaterally. This procedure was chosen to prevent nerve injury caused by mobilization of the adherent nerves and aneurysmal resection. The patient had a satisfactory postoperative course. This procedure may be recommended for large, middle-type PAAs because (1) the adherent tibial nerve trunk and its branch nerves can be protected by aneurysm exclusion with arterial branch ligation and (2) frequently occurring postexclusion expansion of the aneurysm caused by insufficient branch ligation using the medial approach can be avoided.

Percutaneous intramyocardial stem cell injection in patients with acute myocardial infarction: first-in-man study

Background:Clinical studies on intracoronary stem cell infusion in patients with acute myocardial infarction (AMI) have shown promising results for left ventricular ejection fraction (LVEF). However, preclinical studies have shown that...

Peripheral artery recanalization in humans using balloon and laser angioplasty

The treatment of patients with complex peripheral arterial disease and those who have had previous unsuccessful attempted revascularization procedures can be clinically challenging. Initial treatment was begun using therapy by percutaneous balloon and laser angioplasty, then proceeding to bypass surgery if severe ischemia persisted. Both percutaneous and cut-down approaches were used to access totally occluded arteries. An attempt was made to cross the occlusion mechanically with either a guide wire or an activated laser probe. If laser recanalization was not successful, the patient underwent bypass surgery or was managed with medication unless an amputation was necessary. Following initial screening of 381 patients, 115 procedures were performed on 103 patients. In 31 procedures (28 patients), only balloon angioplasty was performed. In 84 procedures (75 patients), laser recanalization was attempted: 55 percutaneously and 29 by cut-down. Overall technical success (crossing the obstruction without perforation) was 86/115 (75%). Technically successful procedures were characterized by shorter arterial occlusions than were technical failures (8.4 +/- 1 cm vs. 14.3 +/- 1.9 cm; p < 0.004). Clinical success (residual stenosis < 50%, symptom relief, improved ankle brachial index > or = 0.15, and no complications) was achieved in 22/31 (71%) of balloon angioplasty procedures alone. The stenoses decreased from 98 +/- 4% to 31 +/- 24%, p < 0.00001. Combined percutaneous laser and balloon angioplasty had a technical success of 36/55 (65%). Stenoses were reduced from 99 +/- 2% to 56 +/- 14% after laser angioplasty, to 30 +/- 15% after balloon angioplasty, p < 0.0001. Laser angioplasty performed via a cut-down had a clinical success of 9/29 (31%). However, major complications were rare. Device staging for treatment of peripheral vascular disease provides additional options for patients who are at high surgical risk and/or in whom standard therapy has failed.

Occlusion during iliac angioplasty: a salvageable complication.

During transluminal dilation of the iliac artery, occlusion resulting from dissection occurred in four patients. In all four, the deteriorating clinical findings prompted surgical intervention. In three patients, Fogarty balloon catheters easily passed the occluded segments and specimens much the same as surgical endarterectomy specimens were retrieved. A clamp was used to retrieve the dissected portion of the vessel wall in the fourth patient. Three of four vessels have remained patent for 18 months, 18 months, and 6 months, respectively. One patient underwent bypass surgery 4 months after the occlusion episode for recurrent stenosis in a segment of vessel above the occluded segment, which had also been dilated during the same procedure. It is therefore possible in some cases to salvage vessels occluded during angioplasty, making it unnecessary to resort to aortofemoral or other type of bypass.