Periprocedural Death Research Articles

Abstract 4125996: Outcomes Of Transvenous Lead Extraction As a Function Of Lead Dwell Time: Does Risk Plateau With Very Old Leads?

Introduction: Longer lead dwell time is associated with worse outcomes during transvenous lead extraction (TLE). It has been suggested that risk may plateau beyond a certain dwell time but data on this are lacking. Methods: We identified all TLE procedures at Emory Healthcare from 2007-2023. Clinical characteristics and procedural details were collected from medical records. Procedural outcomes were reported using the 2017 HRS/ACC/AHA consensus statement on TLE. Procedural success was defined as complete removal of all targeted lead hardware without any major complications. Clinical success was defined as retention of a small portion (<4 cm) of targeted lead which does not negatively impact the outcome of the procedure. Results: We identified 1,717 TLE procedures. Mean patient age at extraction was 64.6 ± 15.1 yrs, 61.4% were male, 53% had ICD leads and 21% had CRT systems. Extraction indications included lead malfunction (46%), infection (38%) and venous occlusion with need for system upgrade (11%). The dwell time of the oldest lead targeted for extraction was < 1 yr (n=326, 19%), 1-5 yrs (n=633, 36.9%), 5-10 yrs (n=467, 27.2%), 10-15 yrs (n=178, 10.4%), 15-20 yrs (n=71, 4.1%) and >20 yrs (n=42, 2.4%). Procedural and clinical success rates decreased with longer lead dwell time (Figure 1A). Success rates were excellent (>95%) among leads <5 yrs old whereas success rates dropped to the 70-75% range for leads >20 years old. Most clinical failures among very old leads were due to inability to remove all lead material in the setting of infection. Across the entire cohort, the major complication rate was 1.3% and procedural death rate was 0.5%. Complications increased with increased lead dwell time (Figure 1B). Peri-procedural death occurred in 2.8% of cases with dwell times of 15-20 yrs. There were no major complications or deaths among dwell times of >20 yrs, however, the vast majority of these were pacemakers, not ICDs. Conclusion: TLE success rates decrease and complication rates increase with increased lead dwell time, without any clear evidence of a plateau effect. These data have implications for making decisions about abandoning vs. extracting redundant leads.

Self-expanding intracranial drug-eluting stent system in patients with symptomatic intracranial atherosclerotic stenosis: initial experience and midterm angiographic follow-up.

Symptomatic intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke worldwide. In patients undergoing endovascular treatment for ICAS, in-stent restenosis (ISR) is associated with ischemic stroke recurrence. Intracranial drug-eluting self-expanding stent systems (COMETIU; Sinomed Neurovita Technology Inc., CHN) are new devices for treating ICAS. This study evaluated the perioperative experience and medium-term outcomes of COMETIU in 16 patients. We prospectively analyzed 16 patients with ICAS (≥ 70% stenosis) who underwent intravascular therapy between September 4, 2022, and February 1, 2023. The primary outcome was the incidence of ISR at 6 months postoperatively. The secondary efficacy outcomes were device and technical success rates. The secondary safety outcomes included stroke or death within 30 days after the procedure and the cumulative annual rate of recurrent ischemic stroke in the target-vessel territory from 31 days to 6 months and 1 year. A total of 16 patients with 16 intracranial atherosclerotic lesions were treated with 16 COMETIUs. All procedures were performed under general anesthesia with 100% device and technical success rates, with no cases of periprocedural stroke or death. The mean radiographic follow-up duration was at least 6 months postoperatively, and all patients presented for radiographic and clinical follow-up. There were no reported ischemic or hemorrhagic strokes. Angiographic follow-up for all patients revealed no cases of ISR. COMETIU is safe and effective for treating ICAS, with minimal risk during the procedure and a low rate of ISR during medium-term follow-up.

Clinical Outcomes of Arteriovenous Fistula Treatment Using the Penumbra SMART COIL System: A Subgroup Analysis from the Multicenter SMART Registry

Endovascular embolization procedures are typically the primary treatment modality for arteriovenous fistula (AVF). The objective of this subset analysis was to evaluate the prospective long-term clinical outcomes of AVF patients treated with the SMART COIL System. Patients who had AVFs and underwent endovascular coiling using the Penumbra SMART COIL system were part of a subset analysis within the SMART registry. The SMART registry is a postmarket registry that is prospective, multicenter, and single-arm in design. After the treatment, these patients were monitored for a period of 12±6months. A total of 41 patients were included. No patients (0/41) had a procedural device-related serious adverse event (SAE). Reaccess involving a guidewire due to catheter kickout was unnecessary for 85.4% (35/41) of the patients. Complete occlusion after the procedure was achieved in 87.8% (36/41) of patients. The periprocedural SAE rate was 2.4% (1/41), and no periprocedural deaths occurred (0/41). During the follow-up period, there were instances of retreatment in 3.4% (1/29) of patients. At 1 year, the lesion occlusion was better or stable in 93.3% (28/30) of patients. The rate of SAE from 24hours to 1year (±6months) following the procedure was 26.8% (11/41). The 1-year all-cause mortality rate stood at 2.4% (1/41), and at the 1-year follow-up, 90.9% (20/22) of patients had a modified Rankin Scale score within the range of 0 to2. The coiling procedure for AVFs using the SMART COIL System proved to be safe and effective at the 1-year follow-up.

Impact of Significant Hemoglobin Drop Without Bleeding in Patients Undergoing Transcatheter Aortic Valve Replacement.

Hemoglobin (Hgb) drop without bleeding is common among patients undergoing transcatheter aortic valve replacement; however, the clinical implications of significant Hgb drop have not been fully evaluated. Consecutive patients undergoing transcatheter aortic valve replacement at our institution from 2011 to 2021 were retrospectively reviewed. Three groups were assessed: no Hgb drop and no bleed (NoD-NoB [reference group]), Hgb drop with bleed, and Hgb drop and no bleed (D-NoB). Hgb drop was defined as ≥3 g/dL decrease from pre- to post-transcatheter aortic valve replacement. Outcomes of interest were in-hospital death and 1-year all-cause mortality. A total of 1851 cases with complete Hgb data were included: NoD-NoB: n=1579 (85.3%); D-NoB: n=49 (2.6%); Hgb drop with bleed: n=223 (12.6%). Compared with NoD-NoB, the D-NoB group was older (81.1 versus 78.9 years of age) with higher preprocedure Hgb (12.9 versus 11.7 g/dL). In-hospital death rate was higher among patients with D-NoB versus NoD-NoB (4.5% versus 0.8%, P<0.001) and similar to Hgb drop with bleed (4.5% versus 4.1%, P=0.999). Predictors of in-hospital death were D-NoB (odds ratio [OR], 3.45 [95% CI, 1.32-8.69]) and transfusion (OR, 10.6 [95% CI, 4.25-28.2]). Landmark survival analysis found that D-NoB experienced 1-year mortality rate comparable to NoD-NoB, whereas Hgb drop with bleed had higher midterm mortality (hazard ratio [HR], 3.2 [95% CI, 1.83-5.73]), and transfusion continued to impact mortality (HR, 2.5 [95% CI, 1.79-3.63]). Hgb drop without bleeding is common among patients undergoing transcatheter aortic valve replacement and may represent a higher risk of periprocedural death. Blood transfusion increases short- and midterm mortality risk in patients with and without bleeding, supporting a restrictive transfusion strategy.

Role of mechanical circulatory support in VT ablation procedures: data from the German PROTECT VT registry

Abstract Introduction Ventricular tachycardia (VT) ablation in patients with progressed heart failure (HF) is known to be complex and associated with a high periprocedural risk and mortality, in part due due to hemodynamic instability during ongoingVTs. Use of mechanical circulatory support (MCS) systems has been already implemented in complex high-risk percutaneous coronary intervention (CHIP-PCI) workflows. Use and benefit of MCS in VT ablation is still under debate. MCS protected VT ablation (proVT-A) might be associated with improved clinical outcomebut potentially comes along with an increased risk of periprocedural complications. Based on data of four German high-volume centers we aimed to analyze retrospective data on patient characteristics and impact of proVT-A with respect to safety and mid-term efficacy. Methods All patients undergoing proVT-A as a primary approach from four German EP centers were included in the analysis. Use of MCS in bailout scenariosin VT ablation were not included. Patient characteristics, procedural parameters and clinical outcome were evaluated. The primary endpoint was a combined endpoint of VT/VF recurrence and all-cause death. Results 41 patients who underwent proVT-A were included. Mean age was 64±11a, 92% of patients were male (38/41), 65% (27/41) suffered from ischemic cardiomyopathy, mean left ventricular ejection fraction was 33±13%,76% (31/41) of patients presented with a documented hemodynamically not tolerated VT, mean PAAIN-ESD score was 13±7, and 46% (19/41) had a history of a previous VT ablation w/o MCS. During proVT-A procedure at least one VT was inducible and mappable in 35 patients (85%). Acute procedural success was 85%, with only n=6 patients remaining inducible for VT. Mean procedure duration was 245±46min. With respect to periprocedural safety (30days)a total of n=12 relevant procedural complications were reported in 8 patients. This included n=5 vascular access complications, of which n=3 requiring transfusion or surgery. One case of periprocedural death was reported 6h post proVT-A due to PEA. Three patients developed pericardial effusion, one requiring drainage. Freedom from VT/VF was 78% (n=9 VT/VF recurrences) after a mean follow-up (FU) of 15±14 months (figure 1A). Death of any cause occurred in n=9 patients (figure 1B). In summary, after a mean FU of 15±14 months n=16 patients (39%) met the combined endpoint of VT/VF recurrence and all-cause death (figure 1C). Conclusion Patients enrolled in the German PROTECT VT Registry had significant cardiovascular comorbidities and therefore represent a high-risk population for VT ablation. Use of MCS was feasible, comparably safe, associated with high procedural and promising long-term success rate. These results highlight the need for larger registries and future prospective trials evaluating the potential benefit of proVT-A in selected patients. Further, it should be aimed for optimization of periprocedural vascular access site management.

Hepatic artery stenosis following adult liver transplantation: evaluation of different endovascular treatment approaches

PurposeTo evaluate the efficacy and safety of hepatic artery interventions (HAI) versus extra-hepatic arterial interventions (EHAI) when managing clinically significant hepatic artery stenosis (HAS) after adult orthotopic liver transplantation.Materials and methodsA single-center retrospective cohort analysis was conducted on liver transplant patients who underwent intervention for clinically significant HAS from September 2012 to September 2021. The HAI treatment arm included hepatic artery angioplasty and/or stent placement while the EHAI treatment arm comprised of non-hepatic visceral artery embolization. Primary outcomes included peri-procedural complications and 1-year liver-related deaths. Secondary outcomes included biliary ischemic events, longitudinal trends in liver enzymes and ultrasound parameters pre-and post-intervention.ResultsThe HAI arm included 21 procedures in 18 patients and the EHAI arm included 27 procedures in 22 patients. There were increased 1-year liver-related deaths (10% [2/21] vs 0% [0/27], p = 0.10) and complications (29% [6/21] vs 4% [1/27], p = 0.015) in the HAI group compared to the EHAI group. Both HAI and EHAI groups exhibited similar improvements in transaminitis including changes of ALT (-72 U/L vs -112.5 U/L, p = 0.60) and AST (-58 U/L vs -48 U/L, p = 0.56) at 1-month post-procedure. Both treatment arms demonstrated increases in post-procedural peak systolic velocity of the hepatic artery distal to the stenosis, while the HAI group also showed significant improvement in resistive indices following the intervention.ConclusionDirect hepatic artery interventions remain the definitive treatment for clinically significant hepatic artery stenosis; however, non-hepatic visceral artery embolization can be considered a safe alternative intervention in cases of unfavorable hepatic anatomy.Graphical

Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis

BackgroundAcute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion (“tandem lesion”, TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities.MethodsPatients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected.Results176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome.ConclusionIn our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.

Efficacy and safety of a minimalistic balloon aortic valvuloplasty strategy in a centre without heart surgery.

Balloon aortic valvuloplasty (BAV) is a palliative tool for patients with symptomatic severe aortic stenosis (AS) at prohibitive risk for surgery or as a bridge to surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). BAV is traditionally performed in hospitals with onsite cardiac surgery due to its potential complications. The aim of this study was to evaluate the safety of BAV procedures performed by trained high-volume operators in a centre without onsite surgery and to assess the effect of a minimalistic approach to reduce periprocedural complications. From 2016 to 2021, 187 BAV procedures were performed in 174 patients. Patients were elderly (mean age: 85.0±5.4 years) and had high-risk (mean European System for Cardiac Operative Risk Evaluation score [EuroSCORE] II: 10.1±9.9) features. According to the indications, 4 cohorts were identified: 1) bridge to TAVR (n=98; 56%); 2) bridge to SAVR (n=8; 5%); 3) cardiogenic shock (n=11; 6%); and 4) palliation (n=57; 33%). BAV procedures were performed using the standard retrograde technique via femoral access in 165 patients (95%), although radial access was used in 9 patients (5%). Ultrasound-guided vascular puncture was performed in 118 patients (72%) and left ventricular pacing was administered through a stiff guidewire in 105 cases (60%). BAV safety was confirmed by 1 periprocedural death (0.6%), 1 intraprocedural stroke (0.6%), 2 major vascular complications (1%) and 9 minor vascular complications (5%). Nine cases of in-hospital mortality occurred (5%), predominantly in patients with cardiogenic shock. BAV is a safe procedure that can be performed in centres without onsite cardiac surgery using a minimalistic approach that can reduce periprocedural complications.

Risk factors for peri-procedural stroke or death in internal carotid artery stenting: A neurology team experience

Background and Objectives: Suitable cases of extracranial internal carotid artery (ICA) stenosis can be treated with carotid artery stenting (CAS) or carotid endarterectomy. However, major complications in the peri-procedural period, like stroke and death, are more common with CAS. We therefore investigated the risk factors for stroke and death during the peri-procedural period following CAS. Methods: In this study, the files of patients who were treated with CAS by a neurology team during 2020–2022 were retrospectively analyzed. Patient age, gender, vascular risk factors, use of antiplatelet therapy, type of carotid artery stenosis (symptomatic or asymptomatic), measured stenosis degrees, contralateral carotid stenosis, types of aortic arch, balloon angioplasty, use of a filter-type embolism protection device, stent cell design (open or closed), and peri-procedural death, stroke, or myocardial infarction (MI) were recorded. All patients were followed up for the first 30 days after CAS. Results: The mean age of 219 patients included in our study was 67.8 ± 8.38 years and 68.5% were male. The most common comorbid diseases in the patients were hypertension (76.7%), hyperlipidemia (53.4%) and diabetes mellitus (DM) (43.4%). Stroke or death occurred in the peri-procedural period in 15 (6.85%) of the patients, but MI did not occur. No statistically significant difference was observed in terms of age or gender when comparing with the cases without stroke or death. Of the patients suffering stroke or death, ischemic stroke developed in 13 (86.67%), cerebral hemorrhage in two (13.33%) and two patients (13.33%) died. Two-thirds of the strokes were either minor (n=7, 46.67%) or moderate (n=4, 26.67%); 13 (86.67%) were ipsilateral, and 14 (93.33%) were in the anterior circulation. The complication risk was found to be significantly higher in patients with prior stroke (OR=3.865; 95% CI 1.282 to 11.652 p=.016), DM (OR=3.634; 95% CI 1.102 to 11.992 p=.034) and pre-dilation angioplasty (OR=13.100; 95% CI 1.762 to 97.422 p=.012). Conclusion: Prior stroke, DM and pre-dilation angioplasty increase peri-procedural stroke and death in CAS. However, even if a stroke complication develops after CAS, it is often not severe.

Impact of fetal pulmonary valvuloplasty in in-utero critical pulmonary stenosis: A systematic review and meta-analysis

BackgroundUntreated critical pulmonary stenosis may develop into pulmonary atresia with intact ventricular septum, which is associated with a high risk of morbidity and mortality both in fetuses and neonates. In this meta-analysis, we sought to discover the potential of fetal pulmonary valvuloplasty that might affect patients' survival compared to other available procedures. MethodsThis systematic review and meta-analysis were conducted based on the PRISMA guideline. The authors thoroughly searched the recognized and potential interventions for PA-IVS, including FPV, total ventricular repair, and palliative procedures. The primary outcome was the mortality rate. We used R software (version 4.1.3) to calculate the overall proportion using the random-effects model of proportional meta-analysis. ResultsThe FPV procedure was performed at a mean gestational age of 26.28 weeks (95%CI: 24.83–27.73) and was successful in 87.6 % (95 % CI: 78.3–96.3 %) of patients. A total of 52.9 % patients attained biventricular circulation postnatally (95 % CI: 31.2–74.7 %). Successful FPV was associated with a slightly higher overall mortality rate [periprocedural death 4.7 % (95%CI: 0–10.7 %) and postnatal death 8 % (95%CI: 3–13 %)] compared to the three currently available definitive therapies, namely the Fontan procedure [10 % (95%CI: 4–17 %)], 1.5V repair [11 % (95%CI: 5–17 %), and 2V repair [8 % (95%CI: 1–15 %)]. ConclusionFPV can potentially increase the likelihood of biventricular circulation in fetuses with critical pulmonary valve stenosis.

Mechanical thrombectomy for symptomatic stent thrombosis after carotid artery stenting.

As there is still no consensus on the treatment of carotid stent thrombosis (CST), we would like to describe our experience with the revascularization of CST by mechanical thrombectomy. We retrospectively studied patients who underwent mechanical thrombectomy after CST at Xuzhou Municipal First People's Hospital and Xuzhou Central Hospital between January 2020 and November 2022. The results of the procedures, complications, and clinical and imaging follow-up were recorded. A total of six patients were included in this study. The stenosis grade before stent implantation was ≥85% in all patients, and the stenosis length ranged from 7 to 20 mm. Patients experienced CST within 6 days to 45 months after carotid artery stenting (CAS); the median admission on the National Institutes of Health Stroke Scale (NIHSS) at CST was 12 (range 8-25). Mechanical thrombectomy was successfully performed in all patients. There was no periprocedural death, and the modified Rankin Scale (mRS) at the 3-month follow-up was 0-2. All patients showed recovery from their neurological deficits. The treatment of symptomatic CST with mechanical thrombectomy resulted in satisfactory clinical outcomes. This regimen could be effective and safe, and future prospective and randomized studies are warranted.

Outcomes After Supraventricular Tachycardia Ablation in Patients With Group 1 Pulmonary Hypertension.

Pulmonary hypertension (PH) is associated with right ventricular pressure overload and atrial remodeling, which may result in supraventricular tachycardias (SVTs). The outcomes of catheter SVT ablation in patients with World Health Organization (WHO) group 1 PH are incompletely characterized. We conducted a retrospective cohort study of all patients with WHO group 1 PH undergoing catheter SVT ablation during a 10-year period at a major academic tertiary care hospital. Baseline patient characteristics and procedural outcomes at 3 months and 1 year were extracted from the electronic medical record. Ablation of 60 SVTs was attempted in 38 patients with group 1 PH. The initial procedural success rates were 80% for atrial fibrillation (AF, n = 5), 89.7% for typical atrial flutter (AFL, n = 29), 57.1% for atypical AFL (n = 7), 60% for atrial tachycardia (AT, n = 15), and 75% for atrioventricular nodal reentrant tachycardia (AVNRT, n = 4). The 1-year post-procedural recurrence rates were 100% for AF (n = 4), 25% for typical AFL (n = 20), 50% for atypical AFL (n = 2), and 28.6% for AT (n = 7). No patients had recurrent AVNRT (n = 2). There were seven (18.4%) peri-procedural decompensations requiring pressor initiation and transfer to intensive care and one (2.6%) peri-procedural death. The study demonstrates that SVT ablation in group 1 PH can be performed relatively safely and effectively, albeit with lower initial success rates and higher risk of clinical decompensation than in the general population. Recurrence rates at 1 year were higher in AF and atypical AFL ablations and similar for typical AFL and AT ablations when compared to the general population.

Transcatheter Mitral Valve Repair with MitraClip®: A Nationwide Experience.

Transcatheter mitral valve repair (TMVr), using MitraClip®, is a safe and effective procedure for severe mitral valve regurgitation (MR). However, the therapeutic results of MitraClip® in Qatar remain to be elucidated. A total of 25 patients (mean age 60 ± 14.5 years, 64% males) with symptomatic severe MR and prohibitive surgical risks were enrolled in this study. The procedural success rate was 92% to achieve mild residual MR. There was no periprocedural death. All patients experienced significant improvement in heart failure symptoms and MR grade postprocedure with sustained improvement over 1-year follow-up. The TMVr procedure using the MitraClip® device was safe and resulted in meaningful and sustained functional status and echocardiographic parameter improvement.

Do two operators improve outcomes in left main percutaneous coronary intervention? Insights from the ORPKI Registry.

Significant left main coronary artery (LMCA) disease is prevalent in 7% of patients undergoing angiography. Limited data exists on the impact of double scrubbing in LMCA PCI. We sought to assess periprocedural outcomes in two-operator LMCA percutaneous coronary intervention (PCI). Using data from the Polish National Registry of PCI (ORPKI), we collected data on 28,745 patients undergoing LMCA PCI from 154 centers. Patients were divided into two groups based on the number of operators performing PCI (one vs. two operators). LMCA PCI was performed by a single operator in 86% of the cases and by two operators in 14% of cases. Patients treated by two operators had a greater comorbidity burden including diabetes mellitus, arterial hypertension, previous myocardial infarction, and previous revascularization. In addition, these were more likely to be treated in high-volume centers, by operators with higher volume of LMCA PCIs. The risk of periprocedural death (2.37% vs. 2.44%; P=0.78), as well as cardiac arrest, coronary artery perforation, no-reflow, and puncture site bleeding was comparable between the two groups. On multivariable analysis, we found that a two-operator strategy was an independent predictor of periprocedural death, with this effect being much more profound in an elective setting (OR=5.13 [1.37-19.26]; P=0.015), compared to an urgent (ACS) setting (OR=1.32 [1.00-1.73]; P=0.047). Our study suggests that a two-operator approach is not necessarily routinely recommended for LMCA interventions, although it can be considered for more complex cases.

Rotational Mechanical Thrombectomy to Treat Iliac Limb Occlusion after Endovascular Aortic Aneurysm Repair: The Rotational Mechanical Thrombectomy Italian Study

PurposeTo assess the safety and effectiveness of a rotational mechanical atherothrombectomy device in patients with symptomatic iliac limb occlusion after abdominal endovascular aneurysm repair (EVAR). Materials and MethodsA retrospective analysis was conducted on patients who underwent rotational mechanical thrombectomy using the Rotarex S device for symptomatic acute, subacute, or chronic graft limb thrombosis at 5 vascular centers between 2017 and 2021. This study comprised 23 male patients with a mean age of 74.5 years (SD ± 7.2) at the time of the procedure. The clinical presentation of the patients varied, with 1 patient experiencing acute limb ischemia and 11 patients (47.8%) experiencing disabling intermittent claudication. The remaining patients developed chronic limb-threatening ischemia after iliac limb occlusion. Early outcomes included technical success, postprocedural complications, and periprocedural mortality. Follow-up evaluations encompassed primary patency, patient survival, freedom from reintervention, and the need for surgical conversion. ResultsTechnical success was achieved in all cases, with no occurrences of distal embolization during or after the procedure, and no periprocedural deaths were reported. Endograft relining was performed in 82.6% of patients to establish a new, nonthrombogenic surface within the graft. Over a median follow-up period of 8 months (interquartile range, 3–16 months), 2 patients experienced iliac limb reocclusion. No deaths or other reinterventions occurred during the observational follow-up period. ConclusionsRotational mechanical thrombectomy for iliac limb occlusion after EVAR appears to be both safe and effective. This technique may uncover intraluminal defects contributing to graft occlusion and enable their resolution within the same procedure.

Long-term survival after cardiac arrest in patients undergoing emergent coronary angiography

AimTo determine long-term survival of patients after cardiac arrest undergoing emergent coronary angiography and therapeutic hypothermia. MethodsWe analysed data from patients treated within the regional STEMI Network from January 2015 to December 2020. The primary endpoint was all-cause mortality at median follow-up. Secondary endpoints were periprocedural complications (arrhythmias, pulmonary edema, cardiogenic shock, mechanical complication, stent thrombosis, reinfarction, bleeding) and 6-month all-cause death. A landmark analysis was performed, studying two time periods; 0–6 months and beyond 6 months. ResultsFrom a total of 24,125 patients in the regional STEMI network, 494 patients who suffered from cardiac arrest were included and divided into two groups: treated with (n = 119) and without therapeutic hypothermia (n = 375). At median follow−up (16.0 [0.2–33.3] months), there was no difference in the adjusted mortality rate between groups (51.3 % with hypothermia vs 48.0 % without hypothermia; HRadj1.08 95%CI [0.77–1.53]; p = 0.659). There was a higher frequency of bleeding in the hypothermia group (6.7 % vs 1.1 %; ORadj 7.99 95%CI [2.05–31.2]; p = 0.002), without difference for the rest of periprocedural complications. At 6-month follow−up, adjusted all-cause mortality rate was similar between groups (46.2 % with hypothermia vs 44.5 % without hypothermia; HRadj1.02 95%CI [0.71–1.47]; p = 0.900). Also, no differences were observed in the adjusted mortality rate between 6 months and median follow−up (9.4 % with hypothermia vs 6.3 % without hypothermia; HRadj2.02 95%CI [0.69–5.92]; p = 0.200). ConclusionsIn a large cohort of patients with cardiac arrest within a regional STEMI network, those treated with therapeutic hypothermia did not improve long−term survival compared to those without hypothermia.

Clinical Characteristics and Outcomes of Aortic Arch Emergencies: Takayasu Disease, Fibromuscular Dysplasia, and Aortic Arch Pathologies: A Retrospective Study and Review of the Literature.

In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed. The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11-1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59-0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74-9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis. This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients.

Percutaneous transluminal pulmonary angioplasty for Takayasu arteritis-associated pulmonary hypertension: A single-arm meta-analysis.

The efficacy and safety of percutaneous transluminal pulmonary angioplasty (PTPA) for Takayasu arteritis-associated pulmonary hypertension (TA-PH) remain unclear. To examine the efficacy and safety of PTPA in TA-PH. PubMed, Embase, and the Cochrane Central Register of Controlled Trials Library were searched from inception to August 18, 2022, for articles investigating the efficacy and safety of PTPA for TA-PH. The primary efficacy outcomes were pulmonary vascular resistance (PVR) changes from baseline to re-evaluation and 6-minute walking distance (6MWD). The safety outcome was procedure-related complications. Five articles comprising 104 patients with TA-PH who underwent PTPA were included. The scores of article quality, as assessed using the methodological index for nonrandomized studies tool, were high, ranging from 13 to 15 points. The pooled treatment effects of PVR (weighted mean difference [WMD]: -4.8 WU; 95% confidence interval [CI]: -6.0 to -3.5 WU; I2 = 0.0%), 6MWD (WMD: 101.9 m; 95% CI: 60.3-143.6 m; I2 = 70.4%) significantly improved. Procedure-related complications, which predominantly present as pulmonary artery injury and pulmonary injury, occurred in 32.0% of the included patients. Periprocedural death occurred in one patient (1.0%, 1/100). Patients with TA-PH could benefit from PTPA in terms of hemodynamics and exercise tolerance, at the expense of procedure-related complications. PTPA should be encouraged to enhance the treatment response in TA-PH. These findings need to be confirmed by further studies, ideally, randomized controlled trials. PROSPERO CRD42022354087.

Vein of Galen aneurysmal malformation in newborns: a retrospective study to describe a paradigm of treatment and identify risk factors of adverse outcome in a referral center.

Vein of Galen aneurysmal malformation (VGAM) is a rare cerebral vascular malformation associated with significant morbidity and mortality. Newborns with VGAM without adequate treatment may develop rapidly deteriorating high output heart failure (HOHF) and are at risk for severe neurological outcomes. To describe the clinical course and management of newborns with VGAM, and identify which echocardiographic and neuroradiologic factors may be associated with severe heart failure at birth and adverse short term outcomes. This is a single center retrospective cohort study including all consecutive newborns with VGAM admitted to Gaslini Children's Hospital between 2009 and 2022. We reviewed clinical data, intensive care support, fetal and neonatal cardiologic and neuroradiologic findings and we studied the association with severe HOHF, endovascular complications and death. Out of 40 newborns, 17 (42.5%) developed severe HOHF requiring early endovascular procedures. Medical treatment was focused on the main components of HOHF by providing inotropic support and peripheral vasodilation. Pulmonary vasodilators were avoided to reduce the negative effects of pulmonary overflow and prevent vascular remodeling. Reduction of the obligatory left to right shunt through the VGAM was possible only through endovascular treatment. Fetal cardiothoracic ratio was significantly associated with severe HOHF at birth and death. Cardiologic parameters of right ventricular overload, pulmonary hypertension and systemic steal were the leading findings associated with haemodynamic compromise at birth. The mediolateral diameter of the straight or falcine sinus at its shortest section (SS-MD), and arterial pseudofeeders were significantly associated with severe HOHF at birth in prenatal and postnatal assessments. None of the postnatal echocardiographic and MRI variables, nor a higher inotropic support were associated with major periprocedural complications or death. Mortality was due to palliation for congenital severe brain damage (4/40, 10%), or major periprocedural complications (3/40, 7.5%). None of the patients died due to HOHF and multiorgan failure. Overall survival at discharge was 82.5% (33/40). The complexity of neonatal VGAM pathophysiology requires a multidisciplinary approach, specialized intensive care management, and early endovascular treatment to reduce mortality and optimize clinical outcomes. Cardiologic and neuroradiologic parameters are key to define risk stratification and treatment strategies.

Septal Microsphere Embolization in Hypertrophic Obstructive Cardiomyopathy

Alcohol septal ablation is an established treatment for selected patients with hypertrophic cardiomyopathy and left ventricular outflow tract obstruction (LVOT). The safety and efficacy of septal microsphere embolization (SME) have not been studied. We conducted a retrospective analysis of SME procedures performed at our center from 2006 to 2021 using 75-µm microspheres. The primary end point was LVOT gradient reduction. Secondary outcomes included periprocedural mortality, conduction disturbances, access site complications, and duration of hospitalization. The population comprised 76 patients (median age 61years, men 43%). Dyspnea New York Heart Association ≥III was present in 65 patients (86%); ventricular tachycardia and previous syncope were described in 4% and 18%, respectively. Median duration of hospitalization was 13days, and the time to first follow-up was 4months. SME resulted in a significant reduction at rest (41 vs 12mm Hg, mean Δ PG=-71%, p <0.001) and provoked LVOT gradients (94 vs 29mm Hg, mean Δ PG=-75%, p <0.001). Periprocedural death occurred in 1 patient (1%) who underwent SME after transcatheter aortic valve replacement. Complete atrioventricular block was observed in 5 patients (7%). Left bundle branch block was diagnosed in 1 case (1%) and right bundle branch block in 3 (4%). Access site complications were observed in 4 patients (5%). In conclusion, SME is a safe and effective alternative to alcohol septal ablation. The potential advantages of microspheres are still to be investigated in prospective studies.