Previous Stent Research Articles

The Predictive Value of Combining Symptoms, Residual Syntax Score and Non-Invasive Tests in the Diagnosis of Significant Coronary Artery Disease in Elderly Post-PCI Patients.

PurposeTo assess the diagnostic efficiency of a combination of symptoms, residual Syntax score (rSS) and non-invasive tests in elderly post-PCI patients.Patients and MethodsThis was a retrospective study that consecutively enrolled patients ≥60 years old with chronic coronary syndrome and previous stent implantation without lesions requiring further revascularization between March 2013 and June 2020. The patients were scheduled for exercise ECG, CCTA and invasive coronary angiography within 4 weeks. The study then calculated rSS and the sensitivity, specificity, positive and negative predictive values (PPV and NPV) and accuracy of symptoms, rSS, exercise ECG and CCTA, taking computational pressure-flow dynamics derived fractional flow reserve (caFFR) as the standard reference.ResultsA total of 114 patients were enrolled in this study, including 75 patients with caFFR-positive and 39 patients with caFFR-negative. The caFFR-positive group had more patients with typical angina. Furthermore, the rSS in the caFFR-positive group was higher than that in the caFFR-negative category (7.33 ± 6.56 vs 3.34 ± 4.26, p < 0.001). There was no significant difference in exercise ECG results between the two groups. However, the rate of positive CCTA in the caFFR-positive group was higher than that in the caFFR-negative category (89.33% vs 46.15%, p < 0.001). In addition, after combining symptoms, rSS and CCTA, the sensitivity, specificity, PPV, NPV and accuracy for diagnose were 77.5%, 84.2%, 90.2%, 66.7% and 79.8%, respectively.ConclusionThe findings showed that exercise ECG had limited power to diagnose significant CAD in elderly post-PCI patients, but CCTA was more efficient. Moreover, combining symptoms, rSS and CCTA provided more accurate diagnostic performance with feasibility and safety.

The Predictive Value of the Perivascular Adipose Tissue CT Fat Attenuation Index for Coronary In-stent Restenosis.

ObjectivesTo investigate the association between the perivascular adipose tissue (PVAT) fat attenuation index (FAI) derived from coronary computed tomography angiography (CCTA) and the prevalence of in-stent restenosis (ISR) in patients with coronary stent implantation.MethodsA total of 117 patients with previous coronary stenting referred for invasive coronary angiography (ICA) were enrolled in this retrospective observational analysis. All patients underwent CCTA between July 2016 and November 2021. The deep learning-based (DL-based) method was used to analyze and measure the peri-stent FAI value. Additionally, the relationship between hematological and biochemical parameters collected from all the patients was also explored. The least absolute shrinkage and selection operator (LASSO) method was applied to the most useful feature selection, and binary logistic regression was used to test the association between the selected features and ISR. The predictive performance for ISR of the identified subgroups was evaluated by calculating the area under the curve (AUC) of receiver operator curves plotted for each model. The Pearson correlation coefficient was used to assess the correlation of peri-stent FAI values with degrees of ISR.ResultsThe peri-stent FAI values in the ISR group were significantly higher than those in the non-ISR group (−78.1 ± 6.2 HU vs. −87.2 ± 7.3 HU, p < 0.001). The predictive ISR features based on the LASSO analysis were peri-stent FAI, high-density lipoprotein cholesterol (HDL-C), apolipoprotein A1 (ApoA1), and high-sensitivity c-reactive protein (hs-CRP), with an AUC of 0.849, 0.632, 0.620, and 0.569, respectively. Binary logistic regression analysis determined that peri-stent FAI was uniquely and independently associated with ISR after adjusting for other risk factors (odds ratio [OR] 1.403; 95% CI: 1.211 to 1.625; p < 0.001). In the subgroup analysis, the AUCs of the left anterior descending coronary artery (LAD), left circumflex coronary artery (LCx), and right coronary artery (RCA) stents groups were 0.80, 0.87, and 0.96, respectively. The Pearson's correlation coefficient indicated a term moderately correlation between ISR severity and peri-stent FAI values (r = 0.579, P < 0.001).ConclusionsThe peri-stent FAI can be used as an independently non-invasive biomarker to predict ISR risk and severity after stent implantation.

The effectiveness of enterprise stent use on the treatment of intracranial atherosclerosis disease.

To examine the clinical outcome of Enterprise stent in patients with severe and symptomatic intracranial atherosclerosis. Twenty-five patients who underwent Enterprise stenting between January 2012 and March 2019 were included in this study. Exclusion criteria were previous intracranial stenting and inadequate follow-up. Technical success rates of the procedures were recorded. Clinical outcome was evaluated with pre- and post-treatment modified Rankin Scale scores. The patients were monitored for 18months clinically and for 14.3months radiologically. The mean age of the 15 males and 10 females was 61.6 ± 8.19. Of these 25 patients, 6 (24%) were in the anterior system and 19 (76%) were in posterior system. The mean degree of pre-treatment stenosis was 86.4% ± 7 with the mean lesion length of 12.5 ± 7.5mm. The residual stenosis rate was 23.8% ± 8.81. Technical success rate was 100%. There were two major complications within the first 30 days (8%). Late major complications (after 30days) occurred in one case (4%). Stent restenosis was detected in two patients (8%). No intracranial bleeding or mortality was observed. In this single-center study, we achieved high technical success and tolerable complication rates. Enterprise stent may be a good treatment alternative for severe intracranial stenosis especially in patients resistant to medical treatment when correct patient selection is made. However, further randomized controlled studies, including more cases should be carried out.

Treatment of Atherosclerotic Femoropopliteal Artery Disease with Supera Interwoven Nitinol Stent: A Real-World Study in China

To analyze the outcomes of Supera stent deployment in Chinese patients with atherosclerotic femoropopliteal artery (FPA) disease in a real-world setting. This retrospective cohort study collected and analyzed the medical records of 246 consecutive patients who received Supera stents for FPA disease at the China Academy of Chinese Medical Sciences Xiyuan Hospital between February 2017 and December 2019. All study patients underwent balloon angioplasty and were treated with Supera stents (Abbott Vascular, Santa Clara, CA, USA). The primary outcome was the rate of primary patency 12months after discharge. The analyses included 246 consecutive patients and 260 lesions. The mean±SD age was 73.2±9.9years and most patients (60.2%) were males. Of the 260 treated lesions, Supera stents were deployed in eight (3.1%) cases after a previous stent fracture. Critical limb ischemia was diagnosed in 87.3% of the limbs, and 84 (32.3%) and 83 (31.5%) cases were classified as TransAtlantic Inter-Society Consensus (TASC) C and D, respectively. Most of the lesions were in situ (80.8%) and located in the superficial femoral artery (45.0%) or the FPA (45.8%). The mean lesion length was 147.7mm. Nominal deployment (-10 to 10% compression) was the most common deployment scenario (84.1%). The 1-year primary patency rate was 80.6%. Lesions that occurred as restenosis (odds ratio [OR]:=3.34, 95% confidence interval [CI]: 1.03-10.85, P=0.045) or in-stent restenosis (OR:=2.88, 95% CI: 1.03-8.07, P=0.045) were independently associated with occlusion or stenosis after stent deployment. No stent fracture was observed in this study. Our study indicates that the use of Supera stents is feasible for the treatment of Chinese patients with FPA disease. The long-term results reveal high primary patency.

Exocrine pancreas insufficiency in chronic pancreatitis – Risk factors and associations with complications. A multicentre study of 1869 patients

Background/objectivesThere is scarce information about risk factors for exocrine pancreas insufficiency (EPI) in chronic pancreatitis (CP), and how it associates with other complications. The aim of the present study was to examine risk factors for EPI and associations to procedures and other CP related complications in a large, Northern European cohort. Patients and methodsWe retrieved cross-sectional data on demographics, status on EPI, aetiological risk factors for CP, CP related complications as well as surgical and endoscopic treatment from the Scandinavian Baltic Pancreatic Club Database. Associations were assessed by univariate and multivariate logistic regression analyses. Results are presented as odds ratios (OR) with 95% confidence intervals. ResultsWe included 1869 patients with probable or definitive CP in the study. Exocrine pancreas insufficiency was present in 849 (45.4%) of patients. In multivariate analyses, EPI associated with smoking aetiology (OR 1.47 (1.20–1.79), p < 0.001), and nutritional/metabolic aetiology (OR 0.52 (0.31–0.87), p = 0.01) to CP. Pancreatic or common bile duct stenting procedure and pancreatic resection were both associated with EPI (ORs 1.44 (1.15–1.80), p = 0.002 and 1.54 (1.02–2.33), p = 0.04, respectively). The presence of diabetes mellitus (OR 2.45 (1.92–3.15), p < 0.001), bile duct stenosis (OR 1.48 (1.09–2.00), p = 0.02) and underweight (2.05 (OR 1.40–3.02), p < 0.001) were all associated with presence of EPI. ConclusionsSmoking, bile duct stenosis, previous stenting and resection procedures are all associated with EPI in patients with CP. Presence of EPI were also associated with malnutrition and diabetes mellitus. Hence, intensive nutritional surveillance is needed in these patients.

Pulmonary Perfusion Asymmetry in Patients after Repair of Tetralogy of Fallot: A 4D Flow MRI-Based Study

Background: Repaired Tetralogy of Fallot (rTOF) patients may have residual lesions such as main (MPA) and branch pulmonary artery stenosis (BPAS). While MPA stenosis is well studied, few data are available on BPAS in rTOF. We aimed to describe pulmonary perfusion in a large paediatric cohort of rTOF and its impact on right ventricular and outflow-tract hemodynamics using 4D flow CMR. Methods: 130 consecutive patients (mean age at CMR 14.3 ± 4.6 years) were retrospectively reviewed. 96 patients had transannular patch without valve preservation while 34 patients had conserved annulus or valved conduit. A pulmonary blood flow ratio (right pulmonary artery (RPA)/left pulmonary artery (LPA)) between 0.75 and 1.56 was considered normal. Results: Asymmetric pulmonary perfusion was present in 59/130 patients (45%), with 54/59 (91%) having left lung hypoperfusion (blood flow ratio >1.56). RPA/LPA perfusion ratio in the whole cohort was independently associated with the LPA Z-score (−0.053, p = 0.007), the RPA regurgitant fraction (RF) (0.013, p = 0.011) and previous LPA stenting (0.648, p = 0.004). Decreasing LPA % perfusion (and conversely increasing RPA % perfusion) was significantly associated with higher MPA diameter Z-score (−0.06, p = 0.007). On multivariate analysis, MPA Z-score was independently associated with pulmonary RF (0.48, p

Does the previous stenting affects the outcome of coronary artery bypass grafting in patients with multivessel disease

BackgroundDuring the past decade, the number of percutaneous coronary interventions (PCI) performed before coronary artery bypass grafting (CABG) has risen significantly. Patients with more serious coronary pathology are referred for CABG, which can affect the postoperative outcome.Patients and methodsOutcomes of 60 CABG patients, who were recruited in a prospective comparative study, were compared. Group A (n = 30) underwent primary CABG and group B (n = 30), had prior PCI before CABG.ResultsTotal morbidity was substantially higher in the second group than in the first, with six patients in group A (nonstent group) and 19 patients in group B being affected (stent group). Inotropes and intraaortic balloon pump were used more in the previous PCI community than in group A. Group B had a longer ICU stay (50.45 ± 33.49 h in group A vs. 79.56 ± 60.44 h in group B).ConclusionPrevious PCI can have a detrimental effect on the morbidity outcome of the subsequent CABG. However, postoperative mortality has not been affected significantly. Thus, percutaneous coronary revascularization should be carefully weighed against the increased risk of CABG afterward. The guidelines for intervention should be strictly followed, particularly in patients with complex coronary lesions who are more likely to be referred for CABG.

A Case of Late Type Ia Endoleak After Endovascular Aneurysm Sealing Using the Nellix System: Proximal Extension with Triple Chimney and Gutter Endoleak Embolization

An 87-year-old man, who submitted to endovascular aneurysm sealing (EVAS) on 2017, presented a type Ia endoleak 2 years later, with enlargement of the aneurysmal sac. We planned an endovascular procedure of correction consisting of a proximal extension through two covered stent grafts deployed into the previous Nellix stent grafts, with associated triple chimney. However, 3 months later, he had a further 5 mm aneurysmal sac enlargement. He was submitted to angiography with coil embolization of gutters, obtaining a successfully result. At 1 and 3 months, he is free from endoleak, with a stable aneurysmal diameter.

185 Diagnostic accuracy of dynamic stress myocardial CT perfusion as compared with invasive coronary physiology metrics in stented patients: preliminary results of the advantage II study

Abstract Aims To compare the diagnostic performance of adenosine-stress dynamic myocardial perfusion assessed by CT (CTP) as compared with that of coronary CT angiography (CCTA) alone by using invasive fractional flow reserve (FFR) and index of microvascular resistance (IMR) as standard of reference. Diagnostic performance of CCTA for in-stent restenosis (ISR) detection is still challenging. Recently, CTP demonstrated additional specificity and diagnostic accuracy over CCTA alone in patients with previous stent implantation and suspected IRS or progression of coronary artery disease (CAD). However, no data are available in this clinical setting on the performance of CTP by using a new technique allowing for a non-invasive adjudication of regional myocardial blood flow (dynamic CTP) and to assess both macrovascular and microvascular disease status. Moreover, dynamic CTP was never compared vs. a comprehensive assessment of invasive coronary physiology (FFR and IMR). Methods and results We enrolled consecutive stable patients with previous coronary stenting referred for invasive coronary angiography (ICA) for clinical indication. All patients underwent dynamic stress myocardial CTP and rest CTP+CCTA by using a last generation scanner characterized by a 16-cm Z-axis coverage and fast (0.28 s) gantry rotation time. Invasive FFR and IMR were performed during ICA according to the standard practice. The diagnostic rate and diagnostic accuracy of CCTA and CTP were evaluated in a territory-based analyses vs. quantitative coronary angiography (QCA), FFR, and IMR. In 67 enrolled patients (55 men, mean age: 63.1 ± 8.2 years), the diagnostic rate (number of territories interpretable/number of territories evaluated) of CTP was significantly higher than that of CCTA (302/307 = 98.4% vs. 290/307 = 94.4%, P = 0.009). The interpretability of the combined CCTA/CTP approach was 99.7% (306/307 territories). When QCA was used as gold standard, CTP diagnostic accuracy was significantly higher than that of CCTA (84.4% vs. 80.1%, P = 0.01). When coronary physiology metrics were used as gold standard, CTP diagnostic accuracy was significantly higher than that of CCTA vs. both FFR (84.3% vs. 72.2%, P = 0.02) and IMR (83.3% vs. 70.2%, P = 0.02). The radiation exposure of CCTA+CTP was 8.7 ± 2.5 mSv. Conclusions In patients with coronary stents, dynamic CTP significantly improves diagnostic rate and accuracy of CCTA alone in comparison with both FFR and IMR. The non-invasive assessment of ISR is still challenging. The comprehensive assessment by cardiac CT provides anatomical combined to functional evaluation of coronary arteries in revascularized patients with good agreement with invasive physiological evaluation.

Axial views of the postoperative contrasted CT Aorta, demonstrating a satisfactory aortic repair with a ThoraflexTM Plexus. The stented portion sits inside the previous stent of the descending thoracic aorta. The aortic arch was replaced with individual reimplantation of the right subclavian artery and both right and left common carotid arteries. Previous bypass from left subclavian to left common carotid

Axial views of the postoperative contrasted CT Aorta, demonstrating a satisfactory aortic repair with a ThoraflexTM Plexus. The stented portion sits inside the previous stent of the descending thoracic aorta. The aortic arch was replaced with individual reimplantation of the right subclavian artery and both right and left common carotid arteries. Previous bypass from left subclavian to left common carotid

Cutting Balloon Combined with Drug-Coated Balloon Angioplasty for the Treatment of In-Stent Restenosis.

Drug-coated balloon (DCB) has emerged as an alternative therapeutic choice for in-stent restenosis (ISR) lesions. Cutting balloon angioplasty (CBA) is also a strategy utilized to treat tight stenotic lesions or ISR lesions. Few studies have focused on whether CBA plus DCB could achieve a better result in lowering the incidence of recurrent ISR. This study aimed to evaluate the efficacy of CBA plus DCB for ISR lesions.Between August 2011 and December 2017, 681 patients (937 lesions) were diagnosed with ISR and treated with DCBs in our hospital. The CBA plus DCB group comprised 90 patients who underwent PCI with further CBA plus DCB, and the DCB alone group comprised 591 patients who underwent percutaneous coronary intervention (PCI) with DCB alone.Baseline characteristics, the types of previous stents, lesion type, prevalence of ostial lesion and left main lesion, and pre-PCI and post-PCI stenotic percentage showed no significant difference between the two groups. Only post-PCI reference luminal diameter and size of DCB were larger in the CBA plus DCB group. During the one-year follow-up period, late loss and clinical outcomes did not differ between the two groups before and after propensity score matching. The incidence of subtotal/total occlusion with delay flow was lower in the CBA plus DCB group after propensity score matching (4.1% versus 10.9%; P = 0.030).In these patients with ISR lesions, the clinical outcomes and the incidence of repeat target lesion revascularization were similar after treatment with CBA plus DCB versus DCB alone. Further study is warranted, including prospective, randomized comparisons.

C30. Clinical Decision Making in Intermediate Coronary Stenosis: Role of Fractional Flow Reserve

Abstract Background Coronary stenosis can be managed by percutaneous coronary intervention (PCI). However, it has limitation by producing only 2D images of the actual 3D vascular lumen. It is necessary to assess the functional significance of stenosis with fractional flow reserve (FFR). Case Summary There are two patients in this case. The first patient was a 52-year-old man with typical chest pain, with a history of PCI in LAD 2 years earlier. Echocardiography revealed regional wall motion abnormality (RWMA) with reduced left ventricular ejection fraction (LVEF) of 30-40%. PCI with FFR guidance was performed. Previous stent in osteal-distal LAD was patent. In the distal LAD, a stenosis of 60-70% was obtained with FFR of 0.81. In distal LCX, 50-60% stenosis was also obtained with FFR of 0.91. No stent was implanted then. The second patient was a 59-year-old man with typical chest pain. The patient had been stented in proximal-mid LAD and LCX-OM a year earlier. Echocardiography showed RWMA with LVEF of 51-54%. LAD and LCX stents were patent. A 70-80% stenosis was found in both mid and distal RCA. FFR was done in the mid-RCA with result of 0.57, so stent was placed in the mid RCA. FFR at distal RCA was 0.31 so that the stent was also placed in the distal RCA. Both showed good results. Discussion Physiologic assessment is important before deciding to revascularize. FFR-guided PCI is expected to better guide us in managing intermediate coronary stenosis.

C30. Clinical Decision Making in Intermediate Coronary Stenosis: Role of Fractional Flow Reserve

Abstract Background Coronary stenosis can be managed by percutaneous coronary intervention (PCI). However, it has limitation by producing only 2D images of the actual 3D vascular lumen. It is necessary to assess the functional significance of stenosis with fractional flow reserve (FFR). Case Summary There are two patients in this case. The first patient was a 52-year-old man with typical chest pain, with a history of PCI in LAD 2 years earlier. Echocardiography revealed regional wall motion abnormality (RWMA) with reduced left ventricular ejection fraction (LVEF) of 30-40%. PCI with FFR guidance was performed. Previous stent in osteal-distal LAD was patent. In the distal LAD, a stenosis of 60-70% was obtained with FFR of 0.81. In distal LCX, 50-60% stenosis was also obtained with FFR of 0.91. No stent was implanted then. The second patient was a 59-year-old man with typical chest pain. The patient had been stented in proximal-mid LAD and LCX-OM a year earlier. Echocardiography showed RWMA with LVEF of 51-54%. LAD and LCX stents were patent. A 70-80% stenosis was found in both mid and distal RCA. FFR was done in the mid-RCA with result of 0.57, so stent was placed in the mid RCA. FFR at distal RCA was 0.31 so that the stent was also placed in the distal RCA. Both showed good results. Discussion Physiologic assessment is important before deciding to revascularize. FFR-guided PCI is expected to better guide us in managing intermediate coronary stenosis.

Distinct profiles of immune cell populations underlie in-stent restenosis: a cluster analysis approach

Abstract Background In-stent restenosis (ISR) is a major challenge in patients with coronary artery disease due to its association with poor clinical outcomes, quality of life and costs. ISR etiopathogenesis remains unclear, but traditional risk factors cannot fully explain ISR burden. Inflammation-driven loss of endothelial homeostasis and neoatherosclerosis are thought to hallmark ISR. Recently, a number of immune cell subsets have been related to vascular repair failure and endothelial damage, such as angiogenic T-cells (Tang), endothelial progenitor cells (EPC), senescent T-cells (CD4+CD28null), monocyte subsets and low-density granulocytes (LDG). However, these subsets have not been studied in ISR and an integrative analysis is lacking. Purpose 1) to evaluate potential alterations in vascular repair and endothelial damage cellular mediators in ISR and 2) to identify profiles associated with clinical features. Methods Case-control study including 30 patients with ≥1 previous stent implantation (15 bare metal stents (BMS) and 15 drug-eluting stents (DE)) which suffered restenosis and 30 patients with ≥1 BMS without restenosis, both confirmed in a second angiogram performed by clinical symptoms &amp;gt;8 months after index procedure. Cellular mediators of vascular homeostasis were quantified by flow cytometry based on their surface markers in peripheral blood (EPC: CD34+VEGFR2+CD133+; EC: CD34-VEGFR+CD133-; Tang: CD3+CD31+CXCR4+; senescent T-cells: CD4+CD28null) or in peripheral blood mononuclear cells (monocyte subsets, ACE expression; total LDG: CD15+; and LDG subsets: CD15+CD14-CD16- and CD15+CD14lowCD16+). Results Patients with ISR exhibited decreased circulating Tang (p=0.005) and EPC (p&amp;lt;0.001), whereas CD4+CD28null and EC counts were higher (p&amp;lt;0.0001 and p=0.006) compared to ISR-free patients. No differences were observed in the frequency of monocyte subsets (all p&amp;gt;0.050), although ACE expression was found to be increased (non-classical p&amp;lt;0.001; and intermediate p&amp;lt;0.0001) in ISR. Moreover, no differences were noted in the total LDG population (p=0.092), but an increase in the CD14- compartment was observed in ISR (p=0.004). An unsupervised cluster analysis built with these subsets informed the presence of three profiles (Figure 1): group I (hallmarked by a profound impairment in vascular repair and augmented damage, suggestive of central haematopoiesis traits) exhibited an enhanced clinical risk profile compared to group II (hallmarked by a mid-altered vascular repair) and group III (hallmarked by CD16+ shifted LDG and ACE expression) (Figure 2). No differences were observed in stent types or traditional risk factors but hypertension. Conclusions Profound alterations in immune populations related to vascular repair and endothelial damage are found in ISR. Distinct cellular profiles can be distinguished within ISR, suggesting that different alterations may uncover different ISR clinical phenotypes, in terms of severity and extension. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ISCIIIPrograma Intramural ISPA Figure 1Figure 2

Aortocoronary Bypass Surgery in Patients with Recurrent Post-Coronary Stenting Angina

Background. A wide adoption of percutaneous coronary operations has led to an average one-third reduction in the aortocoronary bypass surgery (ACB) rate and altering of the ACB patient profile to mainly represent advanced occlusive coronary atherosclerosis.Materials and methods. The study analyses treatment outcomes in coronary heart disease patients with recurrent angina after a previous endovascular intervention. Over years 2009–2015, 1,023 ACB operations were performed at the Almetyevsk — OAO Tatneft Medical Unit cardiac surgery rooms. Pre-surgery coronary artery stenting (CAS) was rendered at various terms in 96 patients (23 % women, 76 % men; cohort 1). The main cohort (n = 96) was divided into 2 subgroups: IA (n = 64), single CAS; IB (n = 32), multiple CAS patients. For statistical significance, cohort 2 (control) comprised 185 patients (21 % women, 79 % men) to include every 5th history of the remaining 927 patients operated within same period.Results and discussion. The mean aortic occlusion time was shorter in multiple CAS patients vs. other cohorts (61.3 ± 31.2 vs. 72.5 ± 27.8 and 70.7 ± 41.2 min). Cohort 1 had an overall higher emergency resternotomy rate due to ongoing bleeding (7.4 and 8.3 vs. 2.0 %). Furthermore, pre-surgery multiple CAS patients more likely faced the complications of perioperative MI (8.5 vs. 3.1 and 1.4 %) and acute postoperative heart failure (7.2 vs. 2.3 and 1.4 %, p &lt; 0.01). This cohort often required inotropic support (9.3 vs. 3.8 and 2.1 %).Conclusion. Statistical analysis revealed a significantly higher complication and mortality rate in patients with previous coronary stenting compared to ACB patients. Adverse ACB outcomes were observed with multiple-coronary stenting cases, in contrast to the cohort with no pre-surgery interventions.

Retained plastic biliary stent presenting with obstructive jaundice: a case report

Forgotten stents may lead to serious complications. We present a case report of a forgotten common bile duct (CBD) fully covered plastic stent presenting with Obstructive Jaundice. A 66 years-old female patient presented with features of obstructive jaundice. Further enquiry revealed a history of ERCP guided biliary stent placement 12 years ago, after which she was lost to follow up. An endoscopic attempt to retrieve the old stent and relieve biliary obstruction was unsuccessful, and a fresh stent was placed across the CBD following a sphincterotomy. CT showed evidence of a stent in situ, alongside calcified fragments of the previous stent and multiple CBD stones. Patient was taken up for surgery and Roux-en-y hepaticojejunostomy was performed following CBD exploration and retrieval of the stent-stone complex.

The use of double-pigtailed stents to relieve obstruction of a previous endoscopic gastrojejunal lumen-apposing metal stent.

Video 1EGD, which showed obstructed distal flange of the gastrojejunal lumen-apposing metal stent (LAMS) by the contralateral jejunal wall. Two double-pigtail stents were placed across the LAMS to relieve the obstruction.

Thrombectomy and Clip Occlusion of a Giant, Stent-Coiled Basilar Bifurcation Aneurysm: 3-Dimensional Operative Video.

Giant basilar apex aneurysms are associated with significant therapeutic challenges.1-6 Multiple techniques exist to treat giant basilar apex aneurysms, including direct clipping, stent-assisted coil embolization, and proximal occlusion with bypass revascularization.7-9 Hypothermic circulatory arrest was a useful adjunct for surgical repair of these aneurysms but has been abandoned because of associated risks.10,11 Rapid ventricular pacing can achieve similar aneurysm softening with minimal risks and assist in clip occlusion. This case illustrates clip occlusion of a giant, partially thrombosed, previously stent-coiled basilar apex aneurysm in a 15-yr-old boy with progressive cranial neuropathies and sensorimotor impairment. Although a wire was placed preoperatively for ventricular pacing, it was not needed during the procedure. Patient consent was obtained. A right-sided orbitozygomatic craniotomy transcavernous approach with anterior and posterior clinoidectomies was performed. The basilar quadrification was dissected, and proximal control was obtained. After aneurysm trapping, the aneurysm was incised and thrombectomized using an ultrasonic aspirator. Back-bleeding from the aneurysm was anticipated, and ventricular pacing was ready, but back-bleeding was minimal. With the coil mass left in place, stacked, fenestrated clips were applied in a tandem fashion to occlude the aneurysm neck. Indocyanine green videoangiography confirmed occlusion of the aneurysm and patency of parent and branch arteries. The patient was at a neurological baseline after the operation, with improvement in motor skills and cognition at 3-mo follow-up. This case demonstrates the use of trans-sylvian-transcavernous exposure, rapid ventricular pacing, and thrombectomy amid previous coils and stents to clip a giant, thrombotic basilar apex aneurysm. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Diagnostic accuracy of computed tomography angiography compared with catheter angiography in coronary artery disease

Objectives To assess the diagnostic accuracy of the computed tomography-coronary angiography (CT-CA) in detecting coronary artery disease compared with catheter coronary angiography (CCA). Background CT-CA is now considered an alternative tool of accurate and safe detection of coronary artery disease as it is rapid and noninvasive. Patients and methods This prospective study was conducted during the period between January 2017 and October 2018, including 121 patients (74 male and 47 female; mean age, 57.5 + 10.5 years) complaining of chest pain referred from cardiology outpatient clinics, Menoufia University Hospitals, for CT-CA. Patients were classified into two groups: group A underwent both CT-CA and CCA and included 41 patients (24 without previous coronary intervention, 11 had undergone previous coronary artery bypass graft, and six with previous coronary stenting), and group B included 80 patients and underwent only CT-CA, as another cause of chest pain was diagnosed or coronary significant stenosis was excluded, so patients were not candidates for CCA. Results Compared with CCA, CT-CA demonstrated sensitivity, specificity, and accuracy for detecting significant stenosis in coronary arteries of 97.1, 96.8, and 96.8%, respectively. The included 33 grafts CT-CA confirm the patency of additional five (15%) grafts that failed to be cannulation by CCA. The included nine stents showed six patents and three occluded by both CCA and CT-CA. CT-CA visualized extracoronary findings were not visualized by CCA. Conclusion CT-CA is a reliable coronary artery stenosis evaluation tool for assessment of grafts and stent patency, as well as detection of extracoronary pathology; it can reduce the number of invasive CCA studies for those patients.

Predictors of Early Stroke or Death in Patients Undergoing Transcatheter Aortic Valve Implantation

Background/ObjectiveWhile postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI. MethodsA cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure. ResultsIncidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3–7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06–6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95–27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5–6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45–144.39]; p < .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99–21.29]; p = .002) were at significantly higher risk of death within the 30-day period. ConclusionIn this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.