Periprocedural Ischemic Complications Research Articles

Coil embolization of the middle cerebral artery bifurcation aneurysms: Feasibility and durability

ObjectiveTo evaluate the feasibility and durability of coil embolization for MCAB aneurysms by analyzing clinical and radiological results. MethodsFrom January of 2008 to June of 2018, we treated a total of 1785 aneurysms using coil embolization. The aneurysms were treated by both coiling and stent-assisted coiling. Among these cases, 223 MCAB aneurysms were analyzed retrospectively. Clinical and radiological assessments were conducted at admission, after treatment, at discharge, and at last clinical follow-up. ResultsCoil embolization was performed on 223 MCAB aneurysms in 217 patients. Peri-procedural ischemic, hemorrhagic, and other complications within 30 days after coil embolization occurred at rates of 8.0 %, 8.0 %, and 2.0 %, respectively, in the ruptured group and at 2.9 %, 1.2 %, and 0 %, respectively, in the unruptured group. The overall morbidity and mortality rates associated with complications were 2.3 % and 2.0 %. The cumulative major recurrence rates were 5.1 % at 12 months, 7.1 % at 18 months, and 11.9 % at three years after coil embolization. The mean follow-up period was 33.27 ± 25.48 months. Independent risk factors for major recurrence after coil embolization for MCAB aneurysms were a ruptured aneurysm, initial incomplete occlusion, the aneurysm size, and the neck size. ConclusionCoil embolization is a good alternative treatment option for MCAB aneurysms compared to surgical clipping. Considering the risk factors for major recurrence, the follow-up angiography should continue up to three years after coil embolization.

Clinical results of 30 consecutive patients of carotid artery stenosis treated with CASPER stent placement: 1-year follow-up and in-stent findings on intravascular ultrasound examination immediately and 6 months after treatment

BackgroundThe CASPER stent is expected to reduce periprocedural ischemic complications, but there is concern about restenosis in the early period. One-year follow-up results of CASPER stenting and findings on intravascular...

Indications for alternative endovascular techniques in carotid-cavernous fistulas: A 20-year single-center experience.

While coiling is considered the standard treatment for carotid-cavernous fistulas (CCFs), studies demonstrating excellent results using new materials, especially flow diverter (FD) stents and liquid embolisates, are becoming more frequent. The indications and effectiveness of these alternative endovascular techniques remain unclear. A total of 22 direct and 20 indirect CCFs were included in the study. These were further subdivided based on the embolic material used: coils versus FD stents for direct and coils versus liquid embolisates for indirect CCFs. The subgroups were subjected to statistical analysis. An angiographic cure was achieved in 88% of all CCFs, 93% of patients' experienced clinical improvement or remained stable. Direct CCFs were treated with coiling (41%) or with both coils and FD stents (55%). One (4%) patient with a direct CCF was treated with FD stent alone. Statistical analysis comparing these subgroups revealed a significantly higher complete occlusion rate immediately after treatment in the coiling subgroup (67% vs. 23%, p = 0.0409). The occlusion rates at the last follow-up were similar (89% vs. 85%). Indirect CCFs were treated with coiling (35%) or liquid embolisates (65%). All three periprocedural ischemic complications were recorded within the liquid subgroup, resulting in a significantly higher clinical deterioration rate (p = 0.0333). FD stents in direct and liquid embolisates in indirect fistulas did not demonstrate better angiographic or clinical outcomes compared to convetional coiling. Liquid agents carried a higher risk of ischemic complications. Alternative embolization materials should be reserved for CCFs that cannot be treated with simple coiling.

Abstract 132: Angioplasty and Stenting for Symptomatic Vertebral Artery Atherosclerotic Disease: A Systematic Review and Meta‐Analysis

Introduction Vertebral artery stenting represents a viable option in treating symptomatic vertebral artery atherosclerotic stenosis. However, its safety and efficacy in improving neurological status and reducing recurrent strokes remain to be established. Methods We systematically searched PubMed, Embase, and Cochrane databases using keywords with Boolean operators to increase search sensitivity and specificity (‘extracranial’; ‘stenting’; ‘vertebral artery’; ‘stenosis’). We included articles reporting patients > 18 years old with symptomatic extracranial vertebral artery stenoses due to atherosclerosis treated with stenting (with or without angioplasty). Those reporting patients with vertebral dissections were excluded. Patients’ characteristics, procedural details, complications, and outcomes were extracted. Estimated rates weighted for sample size were generated for each variable using fixed and random effects models. Results From 89 unique studies identified, 21 met our inclusion criteria and were included in the analysis, comprising 1499 patients with 1570 lesions. The mean age was 65 years, and 74.4% were men. The mean baseline NIHSS was 4.6. The most frequent stenosis location was the V1 segment of the vertebral artery (88.4%). Device‐related issues occurred in 1.8%. Periprocedural ischemic and hemorrhagic complications occurred in 2.1% and 1.7%, respectively. Neurological improvement post‐procedure was observed in 84.2%, and the in‐hospital mortality rate was 2.1%. During follow‐up, in‐stent stenosis >50% was observed in 12.8%, and retreatment with either re‐stenting or angioplasty was performed in 10.8%. Ischemic complications during follow‐up occurred in 5%, and the overall mortality rate was 5%. Conclusion Stenting for the treatment of atherosclerotic vertebral artery stenosis is technically feasible, associated with a high rate of neurological improvement and low short and long‐term complication rates.

Reconstructive endovascular treatment for basilar artery trunk aneurysms: complications and clinical and angiography outcomes

BackgroundBasilar artery trunk aneurysms (BTAs) are rare intracranial aneurysms. We aim to investigate the procedural complications and clinical and angiographic outcomes of BTAs treated with reconstructive endovascular treatment (EVT).MethodsWe retrospectively...

Can carotid ultrasound predict neurological risk after carotid intervention?

<p>&nbsp;To prevent ischemic strokes caused by carotid artery stenosis, carotid artery stenting (CAS) and carotid endarterectomy (CEA) have been utilized. However, complications could be linked to either or both procedures. The pur&shy;pose of our study is to find the most efficient carotid ultrasound method to forecast peri&shy;pro&shy;cedural risk (embolization, new neu&shy;ro&shy;logical symptoms). &nbsp;</p>. <p>We used Pubmed, EMBASE, and the Cochrane Library to conduct a sys&shy;te&shy;ma&shy;tic literature search for the years 2000 to 2022.</p>. <p>The grayscale medium (GSM) scale of plaque is the most promising criterion for evaluating periprocedural complications. According to the published observations (relatively small cohorts), peri-procedural problems would be significantly predicted by &le; 20 of grayscale medium cut-off values. The diffusion-weighted MRI (DW-MRI) is the most sensitive method for assessing whether stenting or carotid endarterectomy resulted in peri-procedural ischemic lesions on diffusion-weighted MRI. &nbsp;</p>. <p>A future, large-scale, multi-center study should confirm which grayscale medium value is optimal to forecast periprocedural ischemic complications.</p>.

Endovascular treatment of intracranial vertebral artery unruptured dissecting aneurysms: Comparison of flow diversion and stent-assisted coiling or stenting alone.

PurposeTo investigate the effect and safety of flow diverters in the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery in comparison with stent-assisted coiling or stenting alone.Materials and methodsPatients with unruptured dissecting intracranial aneurysms of the vertebral artery treated with the flow diverter, stent-assisted coiling, or stenting alone were retrospectively enrolled. The clinical data were analyzed and compared.ResultsTwenty-five patients were enrolled in the flow diversion group and 42 patients in the stenting group. Twenty-six flow diverters were deployed in the flow diversion group. Immediate angiography revealed contrast agent retention within the aneurysm cavity in all patients. In the stenting group, 48 stents were deployed, and immediate angiographic outcome showed O'Kelly-Marotta (OKM) grade D in 18 (42.9%) aneurysms, grade C in 16 (38.1%), and grade B in 8 (19.0%). Periprocedural ischemic complications of thrombosis occurred in two (4.8%) patients and were treated with thrombolysis. In the flow diversion group, 19 (76%) patients underwent angiographic follow-up 3–46 (median 24) months after the procedure, with the OKM grade D in 11 (57.9%) patients, C in two (10.5%), and B in six (31.6%). The aneurysm recurrence rate was zero, and all diverters remained patent. Asymptomatic instent stenosis occurred in two (10.5%) patients. In seven of the ten patients with mild or moderate parent artery stenosis before the procedure who experienced angiographic follow-up, the stenosis was improved in five (71.4%) patients. In the stenting group, angiographic follow-up was carried out in 33 (78.6%) patients 6–58 months (median 34) after the procedure, with OKM grade D in 22 (66.7%) patients, grade C in five (15.2%), grade B in three (9.1%), and aneurysm recurrence (grade B, with increased contrast agent into the aneurysm cavity) in three (9.1%). Five (16.7%) patients experienced asymptomatic instent stenosis, and six of the 12 patients (50%) with parent artery stenosis were improved.ConclusionFlow diverters with or without selective adjunctive coiling for the treatment of unruptured dissecting intracranial aneurysms of the vertebral artery may be safe and effective with good occlusion effects not inferior to those of stent-assisted coiling and stenting alone even though the long-term effect still warrants confirmation.

Pipeline Embolization Device for the Treatment of Ruptured Intracerebral Aneurysms: A Multicenter Retrospective Study.

Background and Purpose: The utilization of flow diversion for ruptured intracerebral aneurysms (IAs) is still limited. We aimed to demonstrate our multicenter experience using the pipeline embolization device (PED) for ruptured IAs that were difficult to treat by clipping and coiling.Methods: Thirty-eight patients with ruptured IAs who underwent PED treatment from 2015 to 2020 were retrospectively reviewed. Factors associated with procedure-related stroke (ischemic and hemorrhagic) and clinical and angiography outcomes were analyzed.Results: There were 14 (36.8%) saccular IAs, 12 (31.6%) blister-like IAs, and 12 (31.6%) dissecting IAs. Perforator involvement was noted in 10 (26.3%) IAs. Early PED placement ( ≤ 15 days) and adjunctive coiling treatment were performed in 27 (71.1%) and 22 (57.9%) cases, respectively. The overall rate of stroke-related complications was 31.6% (12/38) (including rates of 10.5% for procedure-related hemorrhagic complications and 15.8% for procedure-related infarction). The mortality rate was 13.2% (5/38), and 84.2% of patients (32/38) had favorable outcomes. Thirty-two (84.2%) patients underwent follow-up angiographic evaluations; of these, 84.4% (27 patients) had complete occlusion and 15.6% had incomplete obliteration. Multivariate analysis revealed that early PED placement was not associated with a high risk of procedure-related stroke or an unfavorable outcome. Adjunctive coiling exhibited an association with procedure-related stroke (p = 0.073). Procedure-related hemorrhagic complications were significantly associated with an unfavorable outcome (p = 0.003). Immediate contrast stasis in the venous phase was associated with complete occlusion during follow-up (p = 0.050).Conclusion: The PED is a feasible and effective treatment to prevent rebleeding and achieve aneurysm occlusion, but it is associated with a substantial risk of periprocedural hemorrhage and ischemic complications in acute ruptured IAs. Therefore, the PED should be used selectively for acutely ruptured IAs. Additionally, adjunctive coiling might increase procedure-related stroke; however, it may reduce aneurysm rebleeding in acutely ruptured IAs. Patients with immediate contrast stasis in the venous phase were more likely to achieve total occlusion. A prospective study with a larger sample size should be performed to verify our results.

Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study

BackgroundIntracranial hemorrhage (ICH) represents the most serious complication of oral anticoagulant therapy (OAT) in patients with atrial fibrillation (AF), and AF patients with previous ICH are a challenge for clinicians. Left atrial appendage (LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT. Currently, few data are available on long term outcomes after LAA occlusion in this population. We evaluated the safety and efficacy of LAA occlusion in a cohort of patients with AF and previous ICH. MethodsThis is a multicenter, observational, retrospective study involving 5 LAA occlusion centers in Italy. It includes all consecutive patients (n = 120) with previous ICH who underwent LAA occlusion for nonvalvular AF and high thromboembolic risk. Procedural outcomes, post-procedural therapies and 12-months follow-up data were analyzed. ResultsThe device was successfully implanted in 100% of cases, with a 6% of major peri-procedural complications. 59% had a prior ICH during OAT. The sample had a high risk of stroke (5.18%/year) and bleeding (6.62%/year). 30% were discharged on single and 54.2% on dual antiplatelet therapy.The expected annual risk for thromboembolism was 5.1%. Excluding periprocedural ischemic complications, the stroke annual rate was 1.8%. The expected annual risk of bleeding was 6.7%. The observed annual bleeding rate was 5.45%. ConclusionsPercutaneous LAA occlusion is an effective option for AF patients and previous intracranial hemorrhage. After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of recurrent bleeding.

Ticagrelor versus clopidogrel in elective percutaneous coronary intervention (ALPHEUS): a randomised, open-label, phase 3b trial

Percutaneous coronary intervention (PCI)-related myonecrosis is frequent and can affect the long-term prognosis of patients. To our knowledge, ticagrelor has not been evaluated in elective PCI and could reduce periprocedural ischaemic complications compared with clopidogrel, the currently recommended treatment. The aim of the ALPHEUS study was to examine if ticagrelor was superior to clopidogrel in reducing periprocedural myocardial necrosis in stable coronary patients undergoing high-risk elective PCI. The ALPHEUS study, a phase 3b, randomised, open-label trial, was done at 49 hospitals in France and Czech Republic. Patients with stable coronary artery disease were eligible for the study if they had an indication for PCI and at least one high-risk characteristic. Eligible patients were randomly assigned (1:1) to either ticagrelor (180 mg loading dose, 90 mg twice daily thereafter for 30 days) or clopidogrel (300-600 mg loading dose, 75 mg daily thereafter for 30 days) by use of an interactive web response system, and stratified by centre. The primary outcome was a composite of PCI-related type 4 (a or b) myocardial infarction or major myocardial injury and the primary safety outcome was major bleeding, both of which were evaluated within 48 h of PCI (or at hospital discharge if earlier). The primary analysis was based on all events that occurred in the intention-to-treat population. The trial was registered with ClinicalTrials.gov, NCT02617290. Between Jan 9, 2017, and May 28, 2020, 1910 patients were randomly assigned at 49 sites, 956 to the ticagrelor group and 954 to the clopidogrel group. 15 patients were excluded from the ticagrelor group and 12 from the clopidogrel group. At 48 h, the primary outcome was observed in 334 (35%) of 941 patients in the ticagrelor group and 341 (36%) of 942 patients in the clopidogrel group (odds ratio [OR] 0·97, 95% CI 0·80-1·17; p=0·75). The primary safety outcome did not differ between the two groups, but minor bleeding events were more frequently observed with ticagrelor than clopidogrel at 30 days (105 [11%] of 941 patients in the ticagrelor group vs 71 [8%] of 942 patients in the clopidogrel group; OR 1·54, 95% CI 1·12-2·11; p=0·0070). Ticagrelor was not superior to clopidogrel in reducing periprocedural myocardial necrosis after elective PCI and did not cause an increase in major bleeding, but did increase the rate of minor bleeding at 30 days. These results support the use of clopidogrel as the standard of care for elective PCI. ACTION Study Group and AstraZeneca.

Outcomes and strategy of tailored antiplatelet therapy with ticagrelor in patients undergoing transcarotid artery revascularization

ObjectiveAntiplatelet drug resistance is associated with periprocedural ischemic complications in patients undergoing intravascular stent implantation. Nonresponders are subject to increased risk of stent thrombosis and in-stent stenosis, and high on-treatment platelet reactivity (HTPR) is present in up to 44% of patients taking clopidogrel, a widely used component of dual antiplatelet therapy (DAPT). Evidence points to ticagrelor as a viable alternative to overcome HTPR on clopidogrel. Studies have shown fewer thromboembolic events with ticagrelor therapy; however, results on bleeding risk are mixed, and its safety and efficacy in hybrid operative techniques have yet to be established. Transcarotid artery revascularization (TCAR) is a hybrid procedure to treat severe carotid stenosis. The objective of this study was to establish the safety and efficacy of ticagrelor as part of DAPT in patients undergoing TCAR and to develop a protocol to ensure adequate antithrombotic protection throughout the operative course. MethodsData were collected retrospectively for patients undergoing TCAR on DAPT of aspirin and ticagrelor for symptomatic (≥50%) or asymptomatic (≥80%) carotid stenosis. Preoperative platelet reactivity was determined using Thromboelastography with Platelet Mapping (Haemonetics Corporation, Braintree, Mass), with adequate platelet reactivity defined as maximal amplitude produced by adenosine diphosphate <50 mm. The primary safety end point was 30-day major bleeding event rate. Primary efficacy end points were 30-day incidence of ipsilateral cerebrovascular ischemic event (stroke or transient ischemic attack), myocardial infarction, and death. Secondary end points were postoperative length of hospital stay, procedure time, and clamp/flow reversal time. ResultsSixty-seven TCAR procedures with patients receiving periprocedural DAPT of ticagrelor and aspirin were performed during the study period. Patients had an average age of 79 years, and 28 (42%) were symptomatic. The mean procedure time was 45.8 ± 9.2 minutes, with a mean clamp/flow reversal time of 4.8 ± 1.5 minutes, and mean postoperative length of hospital stay of 3.1 ± 2.2 days for inpatients and 1.3 ± 0.8 days for outpatients. Technical success was achieved in all cases, with no 30-day major bleeding events and no occurrence of ipsilateral cerebrovascular ischemic event, myocardial infarction, or death. ConclusionsInitial experience with ticagrelor as part of DAPT in patients undergoing TCAR demonstrated its safety and efficacy in both symptomatic and asymptomatic disease. No bleeding events or thromboembolic complications occurred. Furthermore, a protocol to administer ticagrelor to assay for HTPR on ticagrelor and consequent medication and patient management is proposed. Ticagrelor may represent a safe and effective alternative to overcome clopidogrel nonresponsiveness in DAPT regimens for TCAR.

Blunting periprocedural myocardial necrosis: Rationale and design of the randomized ALPHEUS study

Clopidogrel associated with aspirin is the recommended treatment for patients undergoing elective percutaneous coronary intervention (PCI). Although severe PCI-related events are rare, evidence suggests that PCI-related myocardial infarction and myocardial injury are frequent complications that can impact the clinical prognosis of the patients. Antiplatelet therapy with a potent P2Y12 receptor inhibitor such as ticagrelor may reduce periprocedural ischemic complications while maintaining a similar safety profile as compared with conventional dual antiplatelet therapy by aspirin and clopidogrel in this setting. Assessment of Loading with the P2Y12 inhibitor ticagrelor or clopidogrel to Halt ischemic Events in patients Undergoing elective coronary Stenting (ALPHEUS) (NCT02617290) is an international, multicenter, randomized, parallel-group, open-label study in patients with stable coronary artery disease who are planned for an elective PCI. In total, 1,900 patients will be randomized before a planned PCI to a loading dose of ticagrelor 180 mg or a loading dose of clopidogrel (300 or 600 mg) in addition to aspirin. Patients will then receive a dual antiplatelet therapy with aspirin and ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily for 30 days. The primary ischemic end point is PCI-related myocardial infarction (myocardial infarction type 4a or 4b) or major myocardial injury within 48 hours (or at hospital discharge if earlier) after elective PCI/stent. Safety will be evaluated by major bleeding events (Bleeding Academic Research Consortium type 3 or 5) at 48 hours (or discharge if it occurs earlier). ALPHEUS is the first properly sized trial comparing ticagrelor to clopidogrel in the setting of elective PCI and is especially designed to show a reduction in periprocedural events, a surrogate end point for mortality.

Effect of high-dose strong statin for preventing periprocedural ischemic complications of carotid artery stenting.

Statin therapy has been shown to induce carotid atherosclerotic plaque regression and reduce the periprocedural ischemic complications of carotid artery stenting (CAS). This study assessed the safety and usefulness of pretreatment using a high-dose strong statin (HDSS) to reduce the periprocedural ischemic complications of CAS. We analyzed 117 carotid lesions treated by CAS that were evaluated with magnetic resonance imaging (MRI) within 48h after the procedure. For 67 lesions, an HDSS (rosuvastatin 20mg or atorvastatin 40mg daily) were prescribed from at least 14days before CAS to at least 14days after procedure (HDSS group). Clinical and angiographic data, as well as in-hospital outcomes, of the HDSS group were retrospectively compared with 50 lesions with conventional treatment without an HDSS (non-HDSS group). There were no significant differences in the baseline clinical and procedural characteristics between the two groups. There was no side effect related to the HDSS. Stroke rates were similar between the two groups (3.0% in HDSS group vs 8.0% in non-HDSS group, p = 0.22). All were minor strokes. Compared to the non-HDSS group, the HDSS group had a lower frequency of new lesions on diffusion-weighted imaging (DWI) with MRI (25.4% vs 44.0%, p = 0.0345). New ipsilateral DWI-positive rate in the HDSS group was significantly lower than in the non-HDSS group (16.4% vs 34.0%, p = 0.0275). Nonipsilateral (contralateral or posterior circulation) DWI-positive rates were similar between the two groups (13.4% vs 20.0%, p = 0.34). Pretreatment with an HDSS might reduce the periprocedural ischemic complications of CAS.

Comparative Evaluation of Angioscopy and Intravascular Ultrasound for Assessing Plaque Protrusion During Carotid Artery Stenting Procedures

Evaluation of plaque protrusion after carotid artery stenting (CAS) is important for predicting periprocedural ischemic complications. In contrast to intravascular ultrasound (IVUS), angioscopy allows direct visualization of the plaque. The aim of this study was to evaluate utility and safety of angioscopy during CAS and compare it with IVUS. The study included 13 carotid artery stenosis lesions in 11 consecutive patients (mean age 70.5 years; 10 men) at a single center. During CAS procedure, poststenting plaque protrusion was evaluated with angioscopy and IVUS. Mean level of internal carotid artery stenosis was 79.2%. Eight lesions were symptomatic, and 5 lesions were predicted to have vulnerable plaque by preprocedural magnetic resonance imaging. A carotid WALLSTENT was placed in all cases. After stenting, angioscopy provided good visualization in all cases. Plaque protrusions were observed in 1 case by IVUS and in 8 cases by angioscopy. Diffusion-weighted imaging showed positive lesions in 3 cases (23%). For 2 of these lesions, plaque protrusions were observed by angioscopy but not by IVUS. All lesions associated with positive diffusion-weighted imaging findings were observed to have yellow plaque on angioscopy. Angioscopy provided direct visualization of stent lumens after CAS. Angioscopy detected more plaque protrusion than IVUS and allowed clearer observation of plaque characteristics. Angioscopy may be more useful than IVUS for examination of plaque protrusion and plaque evaluation after CAS, especially for plaque identified as potentially vulnerable by preprocedural examination.

Changing Paradigms of Periprocedural Antithrombotic Therapy in Neuroendovascular Therapy: Analysis of JR-NET 3.

To evaluate the changing paradigms of periprocedural antithrombotic management in neuroendovascular therapy in Japan, we analyzed the details of the current periprocedural antithrombotic therapy and compared it with those of the previous generations. We retrospectively analyzed the data from the Japanese Registry of Neuroendovascular Therapy (JR-NET) 3, a nationwide survey in Japan for neuroendovascular therapy between January 2010 and December 2014. A total of 26,233 patients underwent endovascular treatments to usually perform periprocedural antithrombotic therapy were retrospectively analyzed. We compared the results of JR-NET 3 with those of JR-NET 1 (January 2005 and December 2007) and JR-NET 2 (January 2008–December 2009). Post-procedural anticoagulant therapy was less utilized in JR-NET 3 than in JR-NET 2 (53.9% vs. 60.6%, P <0.001). Pre-procedural antiplatelet therapy became more frequent and more intensive with each generation. The frequency of aggressive therapy (dual, and triple or more therapy) was 65.2% in JR-NET 3, which was significantly higher than that of JR-NET 1 and JR-NET 2 (41.5% and 61.2%, respectively, P <0.001). However, periprocedural ischemic complications (2.0% vs. 5.8%, P <0.001) significantly increased, despite aggressive antiplatelet therapy. Neuroendovascular periprocedural antithrombotic therapy is focused more on antiplatelet therapy than on anticoagulant therapy. Currently, antiplatelet therapy is more frequently used with a larger number of multiple agents, however, periprocedural ischemic complications significantly increased.

Usefulness for Predicting Cardiac Events After Orthotopic Liver Transplantation of Myocardial Perfusion Imaging and Dobutamine Stress Echocardiography Preoperatively

Patients undergoing orthotopic liver transplantation have high rates of cardiac morbidity and mortality. Although guidelines recommend noninvasive stress testing as part of the preoperative evaluation, little data have evaluated clinical outcomes following orthotopic liver transplantation. A retrospective study at 2 high-volume liver transplantation centers was performed. All patients undergoing noninvasive stress testing (myocardial perfusion imaging [MPI] or dobutamine stress echocardiography [DSE]) over a 5-year period were included. Descriptive analyses, including clinical outcomes and perioperative and postoperative ischemic events, were performed. Comparisons were made between subsets of patients within each stress modality based on abnormal versus normal results. A total of 506 patients were included, of which 343 underwent DSE and 163 MPI. Few patients had abnormal results, with 19 (5.5%) in the DSE group and 13 (8%) in the MPI group. Perioperative and postoperative cardiac complications were low (n= 20, 5.8% and n= 3, 0.9% in DSE group and n= 15, 9.2% and n= 3, 1.8% in MPI group). Comparisons between abnormal versus normal findings showed a trend toward periprocedural cardiac complications in the abnormal DSE group (n= 3, 15.8% vs n= 17, 5.25%; p= 0.09) with no difference in 6-month postprocedural complications (n= 0 vs n= 3, 0.9%; p= 1.0). In the MPI group, a trend toward periprocedural ischemic complications (n= 3, 23.1% vs n= 12, 8%; p= 0.1) was noted with no difference in 6-month postprocedural complications (n= 0 vs n= 3, 2%; p= 1.0). In conclusion, our study found a significantly lower than reported cardiac event rate. In addition, it demonstrated that ischemic cardiac events are uncommon in patients with normal stress testing.

Descriptive Analysis of Patients Undergoing Conventional Non-invasive Stress Testing as Part of the Pre-orthotopic Liver Transplant Evaluation

Introduction: Patients undergoing orthotopic liver transplantation (OLT) have high rates of cardiac morbidity and mortality. Although guidelines recommend non-invasive stress testing as part of the preoperative evaluation, little data has evaluated clinical outcomes following OLT. Methods: A retrospective study at two high volume liver transplantation centers was performed. All patients undergoing non-invasive stress testing (myocardial perfusion imaging [MPI] or dobutamine stress echocardiography [DSE]) over a 5-year period were included. Descriptive analyses, including clinical outcomes and peri- and post- operative ischemic events, were performed. Comparisons were made between subsets of patients within each stress modality based on abnormal versus normal results. Results: A total of 506 patients were included, of which 343 underwent DSE and 163 MPI. Few patients had abnormal results, with 19 (5.5%) in the DSE group and 13 (8%) in the MPI. Peri- and post-operative cardiac complications were low (n=20, 5.8% and n=3, 0.9% in DSE group and n=15, 9.2% and n=3, 1.8% in MPI group). Comparisons between abnormal versus normal findings showed a trend toward periprocedural cardiac complications in the abnormal DSE group (n=3, 15.8% versus n=17, 5.25%; p=0.09) with no difference in 6-month post-procedural complications (n=0 versus n=3, 0.9%; p=1.0). In the MPI group, no difference in peri-procedural ischemic complications (n=3, 23.1% versus n=12, 8%; p=0.1) or 6-month post-procedural complications (n=0 versus n=3, 2%; p=1.0) was noted. Conclusion: Our study found a significantly lower than reported cardiac event rate. Additionally, it demonstrated that ischemic cardiac events are uncommon in patients with normal non-invasive stress testing.

Transfemoral Stenting of Stenoses at the Common Carotid Artery Origin Using an Anchoring Technique With a Balloon Protection Device.

Transfemoral stenting of stenoses at the common carotid artery (CCA) origin is technically difficult because of poor stability of the guiding catheter. To describe an anchoring technique using a balloon protection device that provides excellent stability of the guiding catheter. Four patients (5 stenotic lesions) with stenosis of the CCA origin underwent transfemoral stenting with a balloon protection device (PercuSurge GuardWire; Medtronic, Santa Rosa, California). These 5 stenotic lesions of the CCA origin included 1 on the right side and 4 on the left side. Two of the stenoses were symptomatic, and 3 were asymptomatic. A balloon-expandable stent (Express LD stent; Boston Scientific, Natick, Massachusetts) was used in all patients. All stenoses were successfully dilated. With the balloon protection device as an anchor in all patients, the guiding catheter was highly stable during the procedure. There were no intraprocedural or periprocedural ischemic complications in any patients. None of the patients developed a stroke during a mean follow-up period of 8.4 months. The anchoring technique using a balloon protection device is useful for transfemoral stenting of stenoses at the CCA origin. CCA, common carotid arteryECA, external carotid arteryICA, internal carotid arteryPTA, percutaneous transluminal angioplasty.

Transfemoral Stenting of Stenoses at the Common Carotid Artery Origin Using an Anchoring Technique With a Balloon Protection Device

BACKGROUND: Transfemoral stenting of stenoses at the common carotid artery (CCA) origin is technically difficult because of poor stability of the guiding catheter. OBJECTIVE: To describe an anchoring technique using a balloon protection device that provides excellent stability of the guiding catheter. METHODS: Four patients (5 stenotic lesions) with stenosis of the CCA origin underwent transfemoral stenting with a balloon protection device (PercuSurge GuardWire; Medtronic, Santa Rosa, California). These 5 stenotic lesions of the CCA origin included 1 on the right side and 4 on the left side. Two of the stenoses were symptomatic, and 3 were asymptomatic. A balloon-expandable stent (Express LD stent; Boston Scientific, Natick, Massachusetts) was used in all patients. RESULTS: All stenoses were successfully dilated. With the balloon protection device as an anchor in all patients, the guiding catheter was highly stable during the procedure. There were no intraprocedural or periprocedural ischemic complications in any patients. None of the patients developed a stroke during a mean follow-up period of 8.4 months. CONCLUSION: The anchoring technique using a balloon protection device is useful for transfemoral stenting of stenoses at the CCA origin. ABBREVIATIONS: CCA, common carotid artery ECA, external carotid artery ICA, internal carotid artery PTA, percutaneous transluminal angioplasty

Treatment of symptomatic basilar artery atheronatous ischemic disease with Wingspan stent system

Objective To explore the safety and efficacy of the Wingspan stenting of basilar artery atherosclerosis stenosis though the analysis of single center massive clinical data. Methods Ninety one consecutive patients received Wingspan stenting because of basilar artery stenosis in our center from July 2007 to April 2013. The patients were classified into three groups: early term (n=30), middle term (n=30), and late term (n=31) according to the operation time in our center. The basic clinical data and the factors which may affect the ischemic events were retrospectively analysed,t test andChi-Square test were used to analyze the factors related to the periprocedural ischemic complications. Results All of patients were stented successfully and the technical success rate was 100% (91/91). The mean stenosis was reduced from (82.2±5.8)% to (15.9±5.7)%; strokes or death happened in 13 cases within 30 days, including perforator stroke in 8 patients (8.8%, 8/91), thrombosis in 4 patients (4.4%, 4/91), subarachnoid hemo rrhage in 1 patient (1.1%, 1/91) , 2 patients with disabling or fatal strokes. Lesions involving in the middle segment of basal artery (P=0.049), long-segment disease (P=0.002), severe stenosis (P=0.001) may be a risk factor affecting perioperative ischemic stroke, and the surgeons' surgical technique was not risk factors for ischemic complications (P=1.000). Seventy seven patients (84.6%, 77/91) had the clinical follow-up and the mean follow-up period was (31.3±15.1) months. Four patients suffered from posterior circulation strokes during the clinical follow-up, one of them (1.3%, 1/77) had disabling stroke, another 3 patients (3.9%, 3/77) suffered from TIA. The 2-year accumulate probability of stroke (any stroke or death within 30 days and stroke in the territory of the qualifying artery beyond 30 days) was 16% (95%CI, 8.2% to 23.8%). Forty six patients had the imaging follow-up and the mean follow-up period was (9.5±8.3) months, 6 patients (13.0%,6/46) had in- stent restenosis (ISR) and 2/6 patient had the symptomatic ISR. Conclusions The stroke or death rate of symptomatic basilar atherosclerosis Wingspan stenting within 30 days is high, but the disabling or fatal stroke rate is low. The middle segment of basilar artery involved, the long stenosis, the severe atherosclerosis may be the factors related to the periprocedural ischemic strokes. The incidence of disabling or fatal strokes was low following Wingspan stenting. Key words: Atherosclerosis; Basilar artery; Stent; Stenosis