Peripheral Stenosis Research Articles

Endovascular Treatment of Flow-Limiting Iliofemoral Stenosis Improves Left Ventricular Diastolic Function in Patients With HFpEF by Reducing Aortic Pulsatile Load.

Recent research indicates that there is a high prevalence of heart failure with preserved ejection fraction in patients with peripheral artery disease. We hypothesized that endovascular treatment (EVT) of flow-limiting peripheral stenosis improves left ventricular (LV) diastolic function. Thirty patients with symptomatic peripheral artery disease and heart failure with preserved ejection fraction according to Heart Failure Association-preserved ejection fraction score who were scheduled for EVT or angiography were investigated at baseline, the day after EVT (n=25) or angiography (control, n=5), and at 4 months follow-up. Peripheral hemodynamics were determined by the total peripheral resistance, common femoral artery flow, and ankle brachial index. Aortic function was measured by arterial compliance, augmentation index, and pulse wave velocity. Aortic pulsatile load was estimated as the characteristic impedance of the proximal aorta and the magnitude of wave reflection (reflection coefficient). LV mass index, LV mean wall thickness, and systolic and diastolic function were assessed using echocardiography. Patient-centered outcomes were treadmill walking distance and New York Heart Association class. After EVT, peripheral hemodynamics changed significantly with a decrease in total peripheral resistance and an increase in common femoral artery flow and ankle brachial index. Aortic function improved after EVT, with significantly reduced augmentation index and pulse wave velocity and increased compliance immediately and at follow-up, resulting in a reduction in aortic pulsatile load (characteristic impedance of the proximal aorta and reflection coefficient). Concurrently, LV diastolic function improved after EVT compared with control, acutely and at follow-up, with increased septal and lateral e´ velocities and decreased E/e´ and left atrial volume index. The LV mass index and LV mean wall thickness decreased at follow-up. The New York Heart Association class and treadmill walking distance improved post-EVT at follow-up. Augmentation index, pulse wave velocity, and arterial compliance were identified as independent contributors to E/e´. Endovascular treatment of flow-limiting iliofemoral stenosis reduces aortic pulsatile load and concurrently lowers total peripheral resistance. This beneficial effect is associated with an acute and sustained improvement of left ventricular diastolic function. URL: http://www.clinicaltrials.gov; Unique identifier: NCT02728479.

Safety of non-cuffed tunneled central venous catheters in adults with cystic fibrosis

BackgroundPeripherally inserted central catheters (PICCs) are the most common route of intravenous (I.V.) access for treatment of cystic fibrosis (CF) pulmonary exacerbations, but repeated PICC placement can result in upper extremity peripheral venous stenosis. Once peripheral stenosis develops, a non-cuffed tunneled central venous catheter (NcTCVC) is an alternative route for IV access. While these are regularly used at some CF centers, the safety and complication rate compared to PICCs in adults with CF has not been reported. This study aims to describe the safety of NcTCVCs in adults with CF. MethodsA retrospective cohort study was performed at a CF Foundation accredited institution including adults with CF who received NcTCVCs in interventional radiology from 7/19/2007 to 3/09/2020. Complications analyzed included catheter related deep venous thrombosis (DVT), central line associated blood stream infection (CLABSI), and catheter related central venous stenosis. Complications were considered attributable if they occurred while the catheter was in place or within 30 days of catheter removal. ResultsDuring the study duration, 386 NcTCVCs were placed in 60 unique patients (55 % female) with a mean of 6.4 catheters per patient. Majority of NcTCVCs placed were 4 French (61.4 %). Average duration of indwelling NcTCVC was 16.2 days. No patients demonstrated catheter attributable symptomatic DVT. The incidence of DVT, CLABSI, and central venous stenosis was 0 (0 %), 4 (1 %), and 1 (0.3 %), respectively. ConclusionsMany adults with CF have required insertion of numerous PICCs for the treatment of recurrent pulmonary exacerbations. In those adults that develop PICC-associated peripheral vein stenosis precluding PICC placement, these results indicate NcTCVCs are a safe alternative.

Total-Body Perfusion Imaging with [11C]-Butanol.

Tissue perfusion can be affected by physiology or disease. With the advent of total-body PET, quantitative measurement of perfusion across the entire body is possible. [11C]-butanol is a perfusion tracer with a superior extraction fraction compared with [15O]-water and [13N]-ammonia. To develop the methodology for total-body perfusion imaging, a pilot study using [11C]-butanol on the uEXPLORER total-body PET/CT scanner was conducted. Methods: Eight participants (6 healthy volunteers and 2 patients with peripheral vascular disease [PVD]) were injected with a bolus of [11C]-butanol and underwent 30-min dynamic acquisitions. Three healthy volunteers underwent repeat studies at rest (baseline) to assess test-retest reproducibility; 1 volunteer underwent paired rest and cold pressor test (CPT) studies. Changes in perfusion were measured in the paired rest-CPT study. For PVD patients, local changes in perfusion were investigated and correlated with patient medical history. Regional and parametric kinetic analysis methods were developed using a 1-tissue compartment model and leading-edge delay correction. Results: Estimated baseline perfusion values ranged from 0.02 to 1.95 mL·min-1·cm-3 across organs. Test-retest analysis showed that repeat baseline perfusion measurements were highly correlated (slope, 0.99; Pearson r = 0.96, P < 0.001). For the CPT subject, the largest regional increases were in skeletal muscle (psoas, 142%) and the myocardium (64%). One of the PVD patients showed increased collateral vessel growth in the calf because of a peripheral stenosis. Comorbidities including myocardial infarction, hypothyroidism, and renal failure were correlated with variations in organ-specific perfusion. Conclusion: This pilot study demonstrates the ability to obtain reproducible measurements of total-body perfusion using [11C]-butanol. The methods are sensitive to local perturbations in flow because of physiologic stressors and disease.

Factors affecting the primary patency of native arteriovenous fistulas after ultrasound-guided percutaneous transluminal angioplasty

Objective By analyzing the clinical history, laboratory test indexes, and intraoperative ultrasound imaging data of patients receiving ultrasound-guided percutaneous transluminal angioplasty (UG-PTA) for the first time, the application value of UG-PTA in the treatment of peripheral stenosis of autogenous arteriovenous fistula (AVF) and the related factors affecting postoperative patency were investigated. Methods A total of 381 patients with dysfunction of radio-cephalic AVF were treated with UG-PTA from June 2017 to September 2019. According to the inclusion and exclusion criteria, 199 patients were included in this study. Baseline characteristics of patients, including demographic, clinical, and laboratory data, were collected. Kaplan–Meier’s survival curve was used to demonstrate the cumulative primary patency rate of UG-PTA. Univariate and multivariate Cox regression analysis was performed on clinical, anatomic, biochemical, and medication variables to identify the predictors of postintervention primary patency. Results The early technical success rate of UG-PTA was 98.4% (375/381). One hundred and ninety-nine patients, with an average age of 52.9 years, were analyzed, 97 of whom were males (48.7%). The median follow-up duration was 21 months. No major complication was observed. Postintervention primary patency rates were 87.7%, 75.8%, and 60.0% at 6, 12, and 24 months, respectively. A previously failed AVF (HR, 1.935, 95% CI 1.071–3.494; p = .029) and an increased level of parathyroid hormone (HR per 100 pg/mL increase, 1.105; 95% CI 1.014–1.203; p = .004) were identified as independent negative predictors of primary patency of UG-PTA. Conclusions UG-PTA is a safe and effective method for the treatment of peripheral stenosis of AVF. Previously failed AVF and elevated parathyroid hormone levels are associated with lower primary patency rate.

Good response to plasmapheresis and mycophenolate mofetil in a patient with anti-synthetase syndrome associated with peripheral neuritis and severe prosthetic aortic valve stenosis

BackgroundIdiopathic inflammatory myopathies (IIM) are a disease complex that encompasses several distinctly acquired muscle illnesses. Anti-synthetase syndrome is a subset of IIM that is characterized by the presence of antibodies against aminoacyl-tRNA synthetases (ARS). This syndrome has a characteristic phenotype of IIM. Anti-synthetase syndrome was rarely associated with peripheral nerve involvement and endocarditis.Case presentationWe report a 46-year-old female patient with a history of mitral and aortic valve replacement for seven years and on warfarin, presented with symmetrical muscular weakness, generalized edema, progressive dyspnea, dysphagia, fever, fatigue, myalgia, and polyarthralgia. The motor power grading was 2 in proximal muscles of upper limbs and 3 in the distal muscles involving hands and wrists, and it was 0 in proximal muscles in lower limbs and 2 in distal muscles involving ankle and toes movements. Also, her oxygen saturation decreased remarkably. Echocardiography revealed that the patient had severe stenosis (70%) of the prosthetic aortic valve. Electrophysiological studies showed axonal polyneuropathy with average F wave latencies. She was diagnosed with anti-synthetase syndrome for elevated muscle enzymes, interstitial lung disease (ILD), mechanic’s hands, fever, polyarthralgia, and positive anti-Jo-1 antibody. There was a significant improvement with plasmapheresis, mycophenolate mofetil (MMF), and high-dose prednisolone.ConclusionsTo the best of our knowledge, this is a case of anti-synthetase syndrome accompanied by neuropathic involvement and cardiac valve prosthetic stenosis. These were reported as an unusual presentation of the anti-synthetase syndrome. The significant improvement with plasmapheresis gives us a treatment choice for similar critical cases.

Angioplasty of flow limiting stenosis improves left ventricular diastolic dysfunction in patients with peripheral artery disease

Abstract Background Peripheral artery disease (PAD) is associated with hypertension and left ventricular diastolic dysfunction (LVDD). Objective We hypothesized that endovascular treatment of flow limiting peripheral stenosis may improve LVDD. Methods In this prospective single center trial, 23 patients with PAD Rutherford stage 2–4 were included. Augmentation index (AIx), central systolic blood pressure (cSBP) and ankle brachial index (ABI) were measured at baseline one day before, one day after and at follow up 4 months after angioplasty. LVDD was assessed by echocardiography at baseline and at follow up. Results Mean E/E' ratio was significantly lower at follow up (11.9±4.4 to 10.2±4.4; p&amp;lt;0.01). Likewise, left atrial size (17.2±5.3 to 13.6±4.7 mm; p=0.014) decreased significantly, but not left atrial volume index (LAVI, 49.73±21.6 to 38.29±17.3 mL/m2; p=0.062). ABI acutely increased in the intervened leg and remained stable at follow up (0.71±0.13 to 0.84±0.13 to 0.89±0.18; p&amp;lt;0.001). AIx (from 30.5±6.1 to 26.5±9.2; p=0.03) and cSBP (from 133±21 to 126±20 mmHg; p=0.05) acutely decreased after angioplasty. At follow up, there was no significant change in central hemodynamics (AIx, cSBP) as compared to baseline. Conclusion Chronic effects of angioplasty are associated with favorable improvement of diastolic function but not central hemodynamics. Funding Acknowledgement Type of funding sources: None.

Use of a VBX balloon expandable stent-graft for management of right brachiocephalic vein stenosis.

Here we describe the use of a VBX balloon expandable stent-graft (WL Gore, Flagstaff, AZ, USA) to treat a right brachiocephalic vein stenosis in a haemodialysis patient prior to ipsilateral upper limb arterio-venous (AV) fistula formation. Balloon expandable stent-grafts are unsuitable for treating peripheral fistula stenoses due to their susceptibility of being crushed. The right brachiocephalic vein is both relatively short in comparison to the left and is less susceptible to extrinsic compression and the use of such a device to treat stenosis here allows for very accurate placement and restoration of luminal diameter. The advantages and disadvantages of using these devices in haemodialysis access circuits are also discussed herein, in what we believe to be the first report of the application of a dedicated commercially available balloon expandable stent graft in a haemodialysis patient.

Successful treatment of vanishing bronchus intermedius syndrome following lung transplantation

The vanishing bronchus intermedius syndrome is a type of peripheral bronchial stenosis that develops in lung recipients within two to nine months after transplantation. Lack of timely diagnosis and effective treatment leads to increased mortality and poor quality of life. The clinical case presented demonstrates the successful long-term treatment of vanishing bronchus intermedius syndrome in a lung recipient using interventional bronchoscopy.

Abstract TP455: Race-Ethnic Disparities in Subarachnoid Hemorrhage Outcomes

Introduction: Identification of race/ethnic disparities in stroke outcomes is essential in achieving equity of patient care across demographic subgroups. We sought to identify disparities by race/ethnicity in patient outcomes following subarachnoid hemorrhage (SAH). Methods: Records obtained from the Florida Stroke Registry (FSR), a multi-hospital Get With the Guidelines (GWTG)-Stroke data collaborative, were used to compare descriptive statistics and outcomes by race/ethnicity. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics by race/ethnicity. Outcomes included in-hospital mortality, discharge location, ambulation at discharge, modified Rankin Scale (mRS) score at discharge, and receiving comfort measures only. Logistic regression models with generalized estimating equations accounted for age, insurance, smoking, hypertension, diabetes, dyslipidemia, atrial fibrillation/flutter, coronary artery disease, peripheral vascular disease, prior stroke/TIA, carotid stenosis, prior anticoagulation or antiplatelet use, prior ambulatory status, arrival mode, admission NIHSS, Florida region, number of beds, years in GWTG, and teaching hospital status. Results: The sample consisted of 10, 559 records with SAH discharged between 2010-2018; 63% were non-Hispanic White (NHW), 19.4% non-Hispanic Black (NHB), and 17.6% Hispanic. NHB were younger at onset (median age=54, IQR=45-65; NHW: 62, 53-73; Hispanic: 58, 48-71; p &lt; 0.0001) and had the highest rate of hypertension (62%; NHW: 50%, Hispanic: 51%; p &lt; 0.001), while NHW had the highest rate of smoking (24%; NHB: 20%; Hispanic: 17%; p &lt; 0.0001). NHB had lower odds of in-hospital mortality compared to NHW (adjusted OR 0.8, 95% CI 0.68-0.94), but were less likely to have been discharged home/rehab (0.83, 0.73-0.94), to ambulate independently at discharge (0.71, 0.60-0.84), and to have a discharge mRS score of 0-2 (0.67, 0.49-0.92). Conclusions: While NHB have lowered odds of dying in-hospital from SAH, survivors have worse functional outcomes. These race/ethnic disparities highlight the need for further research into the causes of these differences and to refine approaches to improve acute care of SAH.

The effect of angioplasty of single arteriovenous fistula-associated stenosis on arteriovenous fistula blood flow rate.

Percutaneous balloon angioplasty of arteriovenous fistula-associated stenosis is performed for a variety of indications. Successful percutaneous transluminal angioplasty (PTA) is expected to increase in arteriovenous fistula blood flow rate (Qa). A validated approach to predicting changes in Qa based upon stenosis characteristics is not available. Three baseline parameters were determined in a group of patients with a single arteriovenous fistula-associated stenosis undergoing PTA. These were percent estimated stenosis, stenosis minimum luminal diameter, and baseline Qa. The relationship between these parameters and changes in Qa following PTA was analyzed using Spearman's rank correlation and linear regression. 113 patients (total group) were studied. Of these,106 had peripheral stenosis (total peripheral subgroup) and 7 had central stenosis. For the total group and total peripheral subgroup, a highly significant inverse correlation was seen between changes in Qa and baseline Qa. A weaker correlation was seen between changes in Qa and minimum luminal diameter, but no correlation was seen with percent estimated stenosis. A minimum luminal diameter ⩽2.0 mm was predictive of ⩾300-mL/min increases in Qa, whereas a minimum luminal diameter >4.5 mm was associated with <300-mL/min increases in Qa. PTA of Central vein stenosis was not associated with significant changes in Qa. Baseline Qa is the best predictor for change in Qa following PTA. Stenosis minimum luminal diameter cutoffs of ⩽2.0 and >4.5 mm are useful in predicting the magnitude of changes in Qa. Percent estimated stenosis is not predictive of change in Qa. PTA of central veins does not seem to change Qa.

P4702Blood pressure lowering by peripheral arterial angioplasty

Abstract Objective We hypothesized that the endovascular treatment of flow limiting peripheral stenosis may decrease arterial blood pressure (BP). Methods We prospectively enrolled 381 consecutive patients with PAD scheduled for PTA. Clinical baseline characteristics and BP responses to PTA or angiography were analyzed. In a subgroup of 30 patients, we analyzed intra-procedural central aortic BP before and after PTA of iliac (n=15) and femoropoliteal arteries (n=10) and diagnostic angiography (n=5). Results Systolic BP (SBP) decreased after PTA of iliac (−19 mmHg, 95% CI: −15, −23 mmHg), femoropopliteal (−12 mmHg, 95% CI: −9, −15 mmHg), and BTK arteries (−7 mmHg, 95% CI: −1, −14 mmHg) but not after diagnostic angiography (−2 mmHg, 95% CI: 2, −6 mmHg) as compared to baseline. Diastolic BP (DBP) decreased after iliac (−5 mmHg, 95% CI: −2, −9 mmHg) and femoropopliteal (−4 mmHg, 95% CI: −1, −6 mmHg) angioplasty, but not after BTK PTA (1 mmHg, 95% CI: 6, −8 mmHg) or angiography (5 mmHg, 95% CI: −10, 12 mmHg). Mean central BP (CBP) acutely decreased after iliac (−20 mmHg [95% CI: −12, −32 mmHg] / −7 mmHg [95% CI: −6, −9 mmHg]) and femoropopliteal artery PTA (−9 mmHg [95% CI: −8, −12 mmHg] / −4 mmHg [95% CI: −3, −6 mmHg]) but not after diagnostic angiography. Iliac PTA achieved the most pronounced peripheral and central SBP lowering effect (p&lt;0.05, iliac PTA vs. all other). Baseline clinical and demographic characteristics of overall study population and break-down according to most proximal flow limiting stenosis (a) Baseline characteristics Total Iliac Fempop. BTK Diagnostic n (%) 381 (100) 119 (31) 208 (55) 39 (10) 15 (4) Age (yrs) 70±11 66±11 74±9 70±12 67±12 Male (%) 275 (72) 85 (71) 146 (70) 32 (82) 12 (80) Smoker (%) 241 (63) 98 (83) 114 (55) 20 (50) 9 (60) Hypertension (%) 337 (88) 106 (89) 187 (90) 32 (82) 12 (80) Hyperlipidemia (%) 290 (76) 100 (84) 149 (71) 29 (75) 12 (80) CAD (%) 268 (70) 91 (76) 144 (69) 24 (61) 9 (60) Diabetes (%) 207 (54) 30 (25) 142 (68) 26 (68) 9 (60) Renal failure (%) 167 (44) 38 (32) 101 (48) 22 (57) 6 (40) Antihypertensive treatment (%) 350 (92) 108 (90) 194 (93) 33 (86) 15 (100) Baseline ABI 0.53±0.10 0.56±0.12 0.53±0.1 0.48±0.09 0.54±0.14 ABI before discharge 0.9±0.12 0.94±0.12 0.92±0.11 0.86±0.14 0.54±0.14 pBP baseline vs. post PTA/Angio Conclusion Endovascular treatment of proximal PAD lowers significantly central and peripheral blood pressure. Effect size increases with more proximal lesions.

Vascular access related complications with ipsilateral upper limb oedema in hemodialysis

Background: Central vein-related obstruction is a growing problem in maintenance hemodialysis (MHD). Prior to central vein temporary access, failure to implement “fistula first policy” is an important contributor for this problem. It interferes with the outcomes in dialysis adding to mechanical vascular perturbations, resulting in limb, facial, and chest wall edema. Keeping them in view, we undertook this study on MHD patients, presented with central vein-related vascular access problems and ipsilateral upper limb edema, with the aim to investigate the vascular anatomical obstructive lesions causing the clinical syndrome and their management. Materials and Methods: This cross-sectional study included 25 patients of end-stage renal disease on MHD who manifested with vascular access dysfunction, presented with ipsilateral upper limb edema, and were the study subjects. All patients were evaluated with thorough clinical, laboratory, and computed tomographic (CT) angiography (CTAngio) studies to address the issues. Results: All patients had ipsilateral upper limb edema and 36% of them had in addition facial edema. Fifty percent had difficult cannulation with raising venous pressure during HD sessions and difficulty in securing hemostasis at the end of dialysis. CTAngio revealed central vein stenosis in 48%, peripheral stenosis in 20%, and combined central and peripheral stenosis in 32% patients. Cephalic arch involvement was noted in 16% patients. Depending on the patients preference, dialysis switched over to peritoneal dialysis in 24%, new vascular access was created in 20%, and balloon angioplasty in 16% during management. Conclusions: This study describes the central venous-related problems in MHD patients. We reiterate the importance of three early warning signs: high venous pressure, difficulty to achieve hemostasis at the end of dialysis, and ipsilateral limb, face, chest wall edema as the presage signs to suspect and exclude the underlying central vein obstructions. A continuum of management is discussed.

Numerical modelling of a peripheral arterial stenosis using dimensionally reduced models and kernel methods.

In this work, we consider 2 kinds of model reduction techniques to simulate blood flow through the largest systemic arteries, where a stenosis is located in a peripheral artery, i.e., in an artery that is located far away from the heart. For our simulations, we place the stenosis in one of the tibial arteries belonging to the right lower leg (right posterior tibial artery). The model reduction techniques that are used are on the one hand dimensionally reduced models (1-D and 0-D models, the so-called mixed-dimension model) and on the other hand surrogate models produced by kernel methods. Both methods are combined in such a way that the mixed-dimension models yield training data for the surrogate model, where the surrogate model is parametrised by the degree of narrowing of the peripheral stenosis. By means of a well-trained surrogate model, we show that simulation data can be reproduced with a satisfactory accuracy and that parameter optimisation or state estimation problems can be solved in a very efficient way. Furthermore, it is demonstrated that a surrogate model enables us to present after a very short simulation time the impact of a varying degree of stenosis on blood flow, obtaining a speedup of several orders over the full model.

Ultrasound-guided angioplasty for treatment of peripheral stenosis of arteriovenous fistula - a single-center experience.

In patients with end-stage renal disease, arteriovenous fistulas (AVFs) are the access of choice for hemodialysis but are often complicated by stenosis. We present single-center experience of 78 ultrasound-guided angioplasty procedures for treating peripheral stenoses of AVFs. Between January 2013 and November 2015, 78 angioplasties were performed under ultrasound guidance in 53 patients with end-stage renal disease who were referred from dialysis centers with low flow rate, difficult cannulation, increased cannulation site bleeding, immature or thrombosed AVF. Angioplasties were carried out in the presence of a structural lesion in the AVF resulting in at least 50% reduction in vein diameter with a blood flow of &lt;250 mL/min or a peak systolic velocity &gt;300 cm/s. Clinical success, anatomical success and post-intervention primary and secondary patency rates at 6, 12, 18 and 24 months were studied. In 49/53 patients (92.4%), 74 angioplasty procedures were successfully performed, whereas 4/53 patients (7.6%) had primary failure. A total of 35/49 patients (71.4%) underwent single angioplasty procedure whereas 14/49 patients (28.6%) underwent multiple angioplasty procedures. Post-intervention primary patency rates at 6, 12, 18 and 24 months were 78.6%, 60.2%, 53.8% and 48.9%, respectively. Post-intervention secondary patency rates at 6, 12, 18 and 24 months were 100%, 100%, 95.4% and 89%, respectively. Clinical success and anatomical success was 94.8% and 89.7%, respectively. Ultrasound-guided angioplasty is an effective method with good long-term outcomes in selected dialysis patients with peripheral stenosis of AVF.

Effect of Central Venous Angioplasty on Hemodialysis Access Circuit Flow: Prospective Study of 25 Symptomatic Patients

PurposeTo quantify the effect of central venous percutaneous transluminal angioplasty (PTA) on blood flow within hemodialysis access circuits in patients with symptomatic central venous stenosis (CVS). Materials and MethodsThis prospective study enrolled 30 adults with symptoms attributable to CVS ipsilateral to their access. Five subjects were deregistered because of a lack of CVS (n = 1), untreatable lesion (n = 1), or improper flow measurement timing (n = 3); 25 completed the study (15 men and 10 women; mean age, 62 y; age range, 33–87 y). There were 7 fistulae, 15 grafts, and 3 hybrid access circuits. Mean access age was 675 days (range, 16–3,039 d). Mean CVS symptom duration was 37 days (range, 3–120 d). Peripheral stenoses, if present, were treated first. Intraaccess flow was measured immediately before and immediately after CVS treatment (PTA, stent). ResultsEleven patients had only CVS, whereas 14 had at least 1 peripheral lesion in addition to CVS. All stenoses underwent PTA. Mean flow rates were 1,424 mL/min (range, 565–2,765 mL/min) before PTA and 1,535 mL/min (range, 598–2,545 mL/min) afterward, yielding a mean increase of 111 mL/min ± 456 or 15% ± 34 (range, −70% to +100%; 95% confidence interval, 1%–29%). Flow was decreased in 9 patients (36%). CVS symptoms were reduced in 24 patients (96%) and recurred in 14 (58%) within a mean of 110 days (range, 7–459 d) after initial PTA. Mean follow-up was 371 days (range, 17–592 d). ConclusionsCVS symptoms were observed to occur over a wide range of blood flow rates. On average, central venous PTA only mildly increased flow yet reduced symptoms regardless of flow change.

Diagnostic accuracy of dual energy CT angiography in patients with diabetes mellitus

Peripheral arterial disease (PAD) represents a major and highly prevalent complication in patients with diabetes mellitus. The diagnostic, non-invasive work-up by computed tomography angiography (CTA) is limited in the presence of extensive calcification. The aim of the study was to determine the diagnostic accuracy of dual energy CTA (DE-CTA) for the detection and characterization of PAD in patients with diabetes mellitus. In this study 30 diabetic patients with suspected or known PAD were retrospectively included in the analysis. All subjects underwent DE-CTA (Somatom Definition Flash, Siemens Healthcare, Erlangen, Germany) prior to invasive angiography, which served as the reference standard. Blinded analysis included assessment of the presence and degree of peripheral stenosis on curved multiplanar reformatting (MPR) and maximum intensity projections (MIP). Conventional measures of diagnostic accuracy were derived. Among the 30 subjects included in the analysis (83% male, mean age 70.0 ± 10.5 years, 83% diabetes type 2), the prevalence of critical stenosis in 331 evaluated vessel segments was high (30%). Dual energy CT identified critical stenoses with a high sensitivity and good specificity using curved MPR (100% and 93.1%, respectively) and MIP images (99% and 91.8%, respectively). In stratified analysis, the diagnostic accuracy was higher for stenosis pertaining to the pelvic and thigh vessels as compared with the lower extremities (curved MPR accuracy 97.1% vs. 99.2 vs. 90.9%; respectively, p < 0.001). The use of DE-CTA allows reliable detection and characterization of peripheral arterial stenosis in patients with diabetes mellitus with higher accuracy in vessels in the pelvic and thigh regions compared with the vessels in the lower legs.

Site-specific association between distal aortic pulse wave velocity and peripheral arterial stenosis severity: a prospective cardiovascular magnetic resonance study.

BackgroundVascular disease expression in one location may not be representative for disease severity in other vascular territories, however, strong correlation between disease expression and severity within the same vascular segment may be expected. Therefore, we hypothesized that aortic stiffening is more strongly associated with disease expression in a vascular territory directly linked to that aortic segment rather than in a more remote segment. We prospectively compared the association between aortic wall stiffness, expressed by pulse wave velocity (PWV), sampled in the distal aorta, with the severity of peripheral arterial occlusive disease (PAOD) as compared to atherosclerotic markers sampled in remote vascular territories such as PWV in the proximal aorta and the normalized wall index (NWI), representing the vessel wall thickness, of the left common carotid artery.MethodsForty-two patients (23 men; mean age 64±10 years) underwent velocity-encoded cardiovascular magnetic resonance (CMR) in the proximal and distal aorta, whole-body contrast-enhanced MR angiography (CE-MRA) and carotid vessel wall imaging with black-blood CMR in the work-up for PAOD. Strength of associations between aortic stiffness, carotid NWI and peripheral vascular stenosis grade were assessed and evaluated with multiple linear regression.ResultsStenosis severity correlated well with PWV in the distal aorta (Pearson rP=0.64, p<0.001, Spearman rS=0.65, p<0.001) but to a lesser extent with PWV in the proximal aorta (rP=0.48, p=0.002, rS=0.22, p=0.18). Carotid NWI was not associated with peripheral stenosis severity (rP=0.17, p=0.28, rS=0.14, p=0.37) nor with PWV in the proximal aorta (rP=0.22, p=0.17) nor in the distal aorta (rP=0.21, p=0.18). Correlation between stenosis severity and distal aortic PWV remained statistically significant after correction for age and gender.ConclusionsDistal aortic wall stiffness is more directly related to peripheral arterial stenosis severity than markers from more remote vascular territories such as proximal aortic wall stiffness or carotid arterial wall thickness. Site-specific evaluation of vascular disease may be required for full vascular risk estimation.

Abstract 8: Association Between Hospital "Get With The Guidelines-Stroke" Performance Measures And Outcomes Among Patients With Acute Ischemic Stroke In China

Background: To assess contemporary care practices consistent with the evidence-based performance measures adopted by GWTG-Stroke and whether the composite measure rate was associated with in-hospital outcomes, the Second China National Stroke Registry (CNSRII), a national hospital-based, prospective registry, was initiated by the Ministry of Health of China. Methods: Between January 2012 and February 2013, CNSRII recruited 31,048 patients with stroke or transient ischemic attack from 221 hospitals throughout China. Among 24,597 patients with acute ischemic stroke, adherence to seven GWTG-Stroke performance measures (Intravenous tissue plasminogen activator within 3 hours of symptom onset, Deep Venous Thrombosis prophylaxis, Early and Discharge antithrombotics, Anticoagulation for atrial fibrillation, Lipid-lowering for LDL ≥100 mg/dl, and Smoking cessation), all-or-none measure and composite measure (defined as the total number of performance measure interventions performed among eligible patients divided by the total number of possible performance measure interventions among eligible patients) were assessed. The association between the composite measure adherence quartile and unadjusted in-hospital outcome (death, pneumonia and venous thromboembolism) was evaluated using the Pearson correlation coefficients. The multivariate logistic regression was employed to examine the association between composite measure with in-hospital outcomes and adjusted by age, gender, admission NIHSS, health insurance, history of prior stroke/TIA, diabetes, hypertension, atrial fibrillation or flutter, coronary artery diseases/MI, peripheral vascular disease, dyslipidemia, carotid stenosis, and smoker. Results: Among 24,597 patients with acute ischemic stroke, conformity with 7 performance measures ranged from 13.7% (259 of 1,897) for tPA use to 96.5% (23,247 of 24,079) for early antithrombotics. The all-or-none measure and composite measure were 55.5% and 82.1% separately. The composite measure rate was significantly associated with in-hospital death and pneumonia, with observed mortality rates decreasing from 4.8% (32 of 667) for the lowest adherence quartile to 0.4% (56 of 14212) for the highest adherence quartile (P&lt;.001), and observed pneumonia rates decreasing from 20.3% (133 of 667) for the lowest adherence quartile to 4.8% (670 of 14212) for the highest adherence quartile (P&lt;.001). After risks adjustment, multivariate models showed that composite measure adherence was associated with in-hospital outcomes of death (adjusted OR: 0.075 with 95% CI: 0.048-0.118, P&lt;.001) and pneumonia (adjusted OR: 0.256 with 95% CI: 0.212-0.310, P&lt;.001). Conclusions: A significant association between hospital care process and outcomes was found, supporting the use of GWTG-Stroke performance metrics as a means of assessing and helping improve stroke care quality in China.

Prognostic criteria and treatment for patients candidates for surgery or percutaneous carotid reperfusion

Background. Atherosclerosis is a systemic disease involved in cerebrovascular disease (CVD), coronary arterial disease (CAD), and peripheral arterial disease (PAD). Atherosclerotic carotid artery stenosis is an important cause of ischemic stroke, accounting for approximately 20-30% of all ischemic strokes. Carotid endarterectomy (CEA) and Carotid angioplasty stent (CAS) are interventional treatment for symptomatic and asymptomatic patients with severe carotid artery stenosis. Purpose. The purpose of this study was to evaluate the prognostic and treatment criteria in patients with severe carotid uni/bilateral stenosis in different circumstances: symptomatic/asymptomatic, with recent or old ischemic stroke, candidates for (CEA) or stent (CAS), with/without involvement of coronary arteries and peripheral endothelial function. Material and methods. The study included 85 patients with severe carotid stenosis (over 70%) that have been evaluated for CEA or CAS. Patients were evaluated with Carotid Doppler and/or Angio CT of the cervical region, cardiac ultrasound and cerebral/coronary/peripheral angiography, thus assessing the degree of coronary and peripheral involvement. The following have been calculated: ejection fraction (EF) (%), telediastolic volume (TDV) (ml), overall cardiovascular risk - blood pressure score (Score BP), (ranging 1-4 according to severity) and 2 composite scores: global cardiovascular and hemodynamic risk score (GCVHRS), (ranging 1-10 according to risk factors summation) and organic vascular risk score (OVRS), (ranging 1-10 according to the number and topographic status of stenosis). Patients were divided into four groups: a) with carotid stenosis only (CaAS), b) with CaAS damage and coronary stenosis (CoAS), c) with CaAS damage and peripheral stenosis (PAS) and d) global vascular involvement (CaAS,CoAS,PAS). All study patients were compared with 85 matched patients with cardiovascular risk factors without signs of clinical organ damage. Results. Among the 85 patients with severe carotid stenosis, 52 (61.2%) patients had ICA stenosis between 90%-99%, 37 (43.5%) patients had CaAS involvement and 14(16.5%) patients had multiple organ vascular damage. GCVHRS was significantly higher in the patient group with both CaAS and CoAS (scoring 5.80+/-2.33*) and also OVRS in patients with severe multiple organ vascular involvement (scoring of 6.78+/-1.42*), compared to the other groups of patients (p &lt; 0.05). The hemodynamic risk evaluation in CaAS had a EF mean of 52.27+/-7.56 (%) and a TDV mean of 92.13+/-30.27* (ml) while in the global vascular involvement group EF dropped to a mean of 45.71+/-13.56 (%) and TDV increased to a mean of 124.28+/-51.38 (ml). Conclusions. Higher composite scores (GCVHRS and OVRS) and decrease of EF best correlated with: the degree of carotid stenosis, with the presence of left internal carotid involvement, with the presence of a contralateral involvement (stenosis/occlusion). Secondary vascular disease prevention is mandatory in patients with carotid, coronary and peripheral arterial disease. A composite vascular risk evaluation is useful for individually tailoring our interventional treatment strategy thus improving the global functional outcome of any given patient.*P &lt; 0.05

8:18 AM; Abstract; No. 30 - Percutaneous proximal radial artery arteriovenous fistula creation for hemodialysis using the Ellipsys™ vascular access system

symptoms was 40 (range 3-120) days. Peripheral stenoses, if present, were treated first. Intra-access flow was measured (ReoCath, Transonic) immediately before and immediately after PTA of the CVS. Access characteristics, surgical history, and follow-up data were collected. Results: Eight patients had only CVS (subclavian, brachiocephalic, superior vena cava, infrarenal inferior vena cava, and/or common iliac), while 11 had at least one peripheral lesion in addition to their CVS. All stenoses underwent successful PTA. Mean flow was 1550 (range 565-2765) mL/min before CV PTA and 1625 (range 598-2545) mL/min after, giving a mean increase of 10% 33% (95% confidence interval: -6% to þ26%, p1⁄40.52). CVS symptoms were reduced in 18 (95%) subjects but recurred in 6 (33%) within a mean of 94 (range 63-191) days after initial PTA. Mean follow-up was 159 (range 4-306) days. Conclusion: Despite significant short-term reduction in symptoms, mean intra-access blood flow improvement after successful CV PTA in patients with symptomatic CVS did not reach K/DOQI guidelines’ 20% threshold [1] for therapeutic interventions. Central venous PTA better corrects CVS symptoms than increases flow.