Previous Stent Research Articles

Cost-effectiveness of stress CTP versus CTA in detecting obstructive CAD or in-stent restenosis in stented patients

ObjectivesThe aim of this retrospective study was to determine cost-effectiveness of stress myocardial CT perfusion (CTP), coronary CT angiography (CTA), and the combination of both in suspected obstructive coronary artery disease (CAD) or in-stent restenosis (ISR) in patients with previous coronary stent implantation.MethodsA decision model based on Markov simulations estimated lifetime costs and quality-adjusted life years (QALYs) associated with CTA, CTP, and CTA + CTP. Model input parameters were obtained from published literature. Probabilistic sensitivity analysis was performed to evaluate overall model uncertainty. A single-variable deterministic sensitivity analysis evaluated the sensitivity of the results to plausible variations in model inputs. Cost-effectiveness was assessed based on a cost-effectiveness threshold of $100,000 per QALY.ResultsIn the base-case scenario with willingness to pay of $100,000 per QALY, CTA resulted in total costs of $47,013.87 and an expected effectiveness of 6.84 QALYs, whereas CTP resulted in total costs of $46,758.83 with 6.93 QALYs. CTA + CTP reached costs of $47,455.63 with 6.85 QALYs. Therefore, strategies CTA and CTA + CTP were dominated by CTP in the base-case scenario. Deterministic sensitivity analysis demonstrated robustness of the model to variations of diagnostic efficacy parameters and costs in a broad range. CTP was cost-effective in the majority of iterations in the probabilistic sensitivity analysis as compared with CTA.ConclusionsCTP is cost-effective for the detection of obstructive CAD or ISR in patients with previous stenting and therefore should be considered a feasible approach in daily clinical practice.Key Points• CTP provides added diagnostic value in patients with previous coronary stents.• CTP is a cost-effective method for the detection of obstructive CAD or ISR in patients with previous stenting.

Adequate tissue acquisition rate of peroral cholangioscopy-guided forceps biopsy.

BackgroundPeroral cholangioscopy (POCS)-guided forceps biopsy is a method for diagnosing indeterminate biliary strictures and for the preoperative identification of the exact perihilar and distal margins of biliary tract cancer (BTC). However, POCS-guided forceps biopsy may result in an insufficient amount of specimen at times. Therefore, we evaluated the adequate tissue acquisition rate and the factors affecting the adequate tissue acquisition of POCS-guided forceps biopsy for the biliary tract.MethodsPatients who underwent POCS-guided forceps biopsy for biliary disease between September 2016 and October 2018 at our hospital were enrolled retrospectively. We evaluated the adequate tissue acquisition rate of POCS-guided forceps biopsy for the biliary lesion and that for non-stenotic bile duct. In addition, the factors affecting the adequate tissue acquisition rate of POCS-guided forceps biopsy were evaluated.ResultsWe enrolled 47 patients with biliary disease and performed POCS-guided forceps biopsy for biliary lesion and POCS-guided forceps mapping biopsy for non-stenotic bile duct in 40 and 36 patients, respectively. The adequate tissue acquisition rates of POCS-guided forceps biopsy for biliary lesions and that for non-stenotic bile duct were 86.4%, and 68.9%, respectively. In the multivariate logistic regression analyses, age, and previous biliary stenting before POCS were factors affecting the adequate tissue acquisition rate of POCS-guided forceps biopsy for the biliary lesion. For non-stenotic bile duct, the location of the biliary lesion, endoscopic sphincterotomy (EST), and procedure time of POCS were factors affecting the adequate tissue acquisition rate of POCS-guided forceps mapping biopsy.ConclusionsPrevious biliary stenting was a factor affecting a low tissue acquisition rate of POCS-guided forceps biopsy for the biliary lesion. In the POCS-guided forceps mapping biopsy, the location of the biliary lesion, EST, and procedure time were factors affecting tissue acquisition rates.

The Global Limb Anatomic Staging System Predicts Clinical Outcomes in Chronic Limb Threatening Ischemia

The global limb anatomic staging system (GLASS) has recently been proposed to facilitate clinical decision-making in revascularization options for chronic limb-threatening ischemia (CLTI). The purpose of the present study was to define its relationship to treatment outcomes in CLTI. Consecutive angiograms performed at a single institution for CLTI from April 2017 to July 2019 were retrospectively reviewed. Subjects with significant aortoiliac disease, previous infrainguinal stents, or functioning bypass grafts were excluded. The GLASS score was assigned from the preintervention angiograms, and the treating surgeon determined the infrapopliteal target artery pathway for the limb at risk. Demographic data, procedural details, and clinical outcomes were analyzed. The cohort consisted of 167 patients and 194 limbs, of which 175 of 194 (90%) had presented with tissue loss and 149 of 182 (83%) with WIfI (wound, ischemia and foot infection) stage 3 or 4 disease. The GLASS stage was GLASS for 14%, GLASS 2 for 18%, and GLASS 3 for 68%. GLASS 3 anatomy was present in 85% of the 52 limbs treated by bypass and 55% of the 108 limbs that underwent endovascular interventions (P < .001). Revascularization was not performed in 34 limbs, most of which were GLASS 3 (85%). GLASS 3 was associated with a higher rate of endovascular intervention immediate technical failure (ie, failure to reestablish the target artery pathway) than were GLASS 1 and 2 (30% vs 2%; P < .001). After a median follow-up of 10 months, limb-based patency after endovascular intervention was significantly lower for GLASS 3 than for GLASS 1 and 2 limbs (n = 108; P = .018; Fig 1). GLASS 3 was associated with reduced major adverse limb event-free survival in both the endovascular intervention group and the overall revascularized cohort (n = 160; P = .001; Fig 2). GLASS 3 was also associated with decreased survival, amputation-free survival, and reintervention and amputation-free survival (Table). In a Cox proportional hazards model, GLASS 3 (hazard ratio, 2.35; 95% confidence interval, 1.30-4.24; P = .005) and the wound component of the WIfI scale (hazard ratio, 2.64; 95% confidence interval, 1.26-5.53; P = .010) were independent predictors of major adverse limb event-free survival events after revascularization. Preprocedure angiographic GLASS stage 3 is an independent and significant predictor of major adverse clinical outcomes in patients with CLTI.TableLog-rank comparison of clinical outcomes in patients with CLTI undergoing revascularizationEventOverall (n = 160)Endovascular intervention (n = 108)GLASS 1-2 (n = 57)GLASS 3 (n = 103)P valueGLASS 1-2 (n = 49)GLASS 3 (n = 59)P valueMortality7 (12)30 (29).0147 (17)19 (32).03Major amputation6 (11)18 (17).185 (10)11 (19).18Amputation-free survival12 (21)44 (43).00411 (22)28 (47).007Major adverse limb events9 (16)28 (27).0557 (14)16 (27).061MALE-FS15 (26)53 (51).00113 (27)32 (54).002Reintervention amputation-free survival22 (39)62 (60).00819 (39)39 (66).011Limb-based patencyNANANA20 (41)34 (58).018MALE-FS, Major adverse limb event-free survival; NA, not applicable.Data presented as number (%). Open table in a new tab Fig 2Cumulative major adverse limb event-free survival using Kaplan-Meir method with log-rank test (n = 160).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Efficacy of stent-graft placement to salvage central vein stents with recalcitrant restenosis in patients with arteriovenous fistulas.

The purpose of this study was to determine the effectiveness and permanency of stent-graft placement to salvage stents with recalcitrant restenosis due to central vein stenosis (CVS). Between May 2014 and February 2016, VIABAHN stent-grafts were deployed in patients with functioning arteriovenous (AV) fistulas who underwent previous bare metal stent (BMS) placement and had recalcitrant stent restenosis that did not respond to percutaneous transluminal angioplasty (PTA). Surveillance was carried out at 3, 6, 12, 18, and 24months with diagnostic fistulography. Fourteen patients initially underwent 15 BMS placements. In the follow-up period (range, 118-976days), patients presented with symptomatic venous hypertension; subsequently, a total of 52 unsuccessful repeat PTAs for BMS restenosis were undertaken, and the median primary access survival of PTAs was 66±43days. For salvage, 14 stent-grafts were placed in segments with recalcitrant restenosis of a CVS stent. Within 1.25±0.72days after stent-graft placement, patients who initially presented with symptomatic venous hypertension reported complete resolution. The median primary access survival (mean, 1183±312days) was longer than PTAs alone (P<.01). No major or minor complications were associated with stent-graft deployment or any of the subsequent interventions in the study period. The primary patency rate at 6, 12, and 18months was 100%, and it was 85.7% at 24months. The secondary access patency rate was 92.9% at 24months. In conclusion, stent-graft placement to salvage CVS stents with recalcitrant restenosis in patients with AV fistulas is safe and effective if PTAs fails to maintain luminal patency.

Coronary Perforation Leading to a Large Intramural Hematoma: Visualization With Echocardiography

A 76-year-old patient with prior inferior myocardial infarction and multiple previous stenting in all 3 vessels had shortness of breath and recurrent sustained ventricular tachycardia, seriously affecting his quality of life. Thus, he was referred for treatment of a severely diseased right coronary

Coronary Angiography Characteristics as Predictor of Successful Chronic Total Occlusion Recanalization.

Although remarkable progress in percutaneous coronary intervention (PCI) has been achieved over the last decade, the success rate of chronic total occlusion (CTO) recanalization varies greatly. Coronary angiography characteristics may affect the success rate of CTO recanalization. This study sought to establish a scoring model to predict successful CTO recanalization based on coronary angiography characteristics. We analyze 287 angiography data from patients who underwent elective PCI. Angiography characteristics being measured were lesion location, blunt stump, calcification, ostial lesion, bridging collateral, bending, side branch, tortuosity, previous stent attempt, and lesion length of >20 mm. Data were analyzed using SPSS 25.0. Multivariate analysis shows that side branch lesion ( p = 0.000), proximal vessels tortuosity ( p = 0.015), calcified lesion ( p = 0.000), lesion length of >20 mm ( p = 0.000), and blunt stump ( p = 0.000) can predict the successful PCI in the CTO. ROC curve analysis of the score ability to predict successful PCI in the CTO showed area under curve of 0.89 (confidence interval 95%), the cutoff point of ≤2 with a sensitivity of 93.33%, and specificity of 88.23%. We concluded that the five angiography characteristics that strongly associate with successful PCI in the CTO are calcified lesion, blunt stump, lesion length >20 mm, proximal vessel tortuosity, and side branch lesion. This score may help cardiologists to predict the success probability of PCI in the CTO.

Su1270 EFFICACY AND SAFETY OF ENDOSCOPIC ULTRASONOGRAPHY-GUIDED GASTROJEJUNOSTOMY FOR TREATMENT OF GASTRIC OUTLET OBSTRUCTION USING A SAFE-PASS DOUBLE SCOPE (SPDS) TECHNIQUE

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an evolving technique for the management of gastric outlet obstruction (GOO). The optimal approach is yet to be defined with reported technical failures and stent misplacement secondary to small intestinal mobility and proximity of the colon to the puncture site. We aimed to investigate the technical feasibility and safety of a retrograde EUS GJ technique using a safe-pass double scope (SPDs) approach. SPDs EUS-GJ involves the passage of an ultra-thin gastroscope with a stiffening device to the jejunum beyond the obstruction. The EUS scope is then lubricated with silicon and introduced to the stomach, adjacent to the gastroscope, which remains sojourned in the jejunum for stabilization and saline infusion. A long guidewire is then advanced through a 19 gauge needle and grasped by a snare passed through the jejunal scope to create a safe-track and support the lumen-apposing stent to create GJ (figure 1). We performed a single-center comparative cohort study of patients with GOO who received EUS-GJ though standard antegrade approach compared to the SPDs approach. The primary outcome was technical success rate. Secondary outcomes were clinical success and adverse events. We used Fisher’s exact test for the analysis. We included a total of 21 patients with GOO. The mean age was 63.9 ± 8.7 years, with 40% females. The majority had malignant gastric outlet obstruction (86%). Seven patients (35%) had previous enteric stenting without clinical success. We performed EUS-GJ using the SPDs technique in 12 patients and standard antegrade techniques in 9 patients. We achieved technical success in all cases with SPDs 12/12 (100%) and 8/9 (88.9%) with antegrade techniques (p= 0.43). The single failure in the standard antegrade technique arm was salvaged successfully with SPDs approach. Clinical success was achieved in 93% of patients with follow-up. One patient died one week after the EUS-GJ due to advanced cancer, and we were not able to ascertain clinical success, though cross-sectional imaging did show patent EUS-GJ without complications. Serious adverse events requiring intervention developed in 2 patients in the SPDs group (16.6%); one partial stent migration and leak 48 hours after the procedure requiring surgical repair and one requiring endoscopic adjustment. One serious AE reported in the standard antegrade approach (11%); stent deployment into the peritoneum requiring endoscopic repair. There was no significant difference between the two techniques in serious AE, P=0.65. The SPDs EUS guided GJ is a safe and technically feasible technique for palliation of GOO. Given its advantages of small-bowel stabilization and the creation of safe passage, it should be utilized when standard antegrade techniques fail or if an optimal access window is not achieved.

Laparotomy- and groin-associated complications are common after aortofemoral bypass and contribute to reintervention

BackgroundDespite endovascular advancements, aortofemoral bypass (AFB; aortounifemoral and aortobifemoral bypass) remains the most durable option for aortoiliac occlusive disease. Whereas AFB reduces vascular aortoiliac reintervention, the impact of laparotomy-associated and groin wound complications on morbidity and reintervention is unclear. The aim of this study was to establish the incidence of nonvascular complications after AFB and to determine their effect on reintervention. MethodsInstitutional data for AFB (2000-2017) were queried. Primary end points included laparotomy-associated and groin wound complications. Total reintervention was defined as the composite outcome of reinterventions for laparotomy and groin wound complications and graft patency. Kaplan-Meier analysis estimated freedom from reintervention. Fine-Gray method for competing long-term risk determined predictors of laparotomy complications. Logistic regression, adjusting variability for patient-level clustering, determined predictors of wound complications. ResultsThere were 553 limbs in 281 patients (272 aortobifemoral and 9 aortounifemoral bypasses; age, 67.6 ± 11.0 years; 50.5% female). Ninety (32%) patients had prior abdominal surgery, 3.2% had prior ventral hernia (VH) repair, 2.9% had untreated VH, and 0.7% had history of small bowel obstruction. The majority of patients underwent AFB for claudication (66.2%); 87.2% had TransAtlantic Inter-Society Consensus (TASC) D lesions, 31.4% required a suprarenal clamp or higher, 16.4% had concomitant renovisceral revascularization, and 6.4% were receiving anticoagulation. Sixty-seven (12.1%) limbs had redo femoral artery exposures, 32.4% required femoral outflow adjunct, and 1.8% had simultaneous lower extremity bypass. The 30-day mortality was 2.9%. During median follow-up of 5.3 years (interquartile range, 7.3 years), 21% had laparotomy complications (VH, 15.3%; small bowel obstruction, 7.5%; other, 2.1%), including 10.0% requiring operative intervention. Sixty-seven (12%) groins had a wound complication; 4.9% required intervention. Unadjusted 1-, 3-, and 5-year freedom from graft reintervention was 93.3% (95% confidence interval [CI], 90.1%-96.5%), 85.3% (80.7%-90.2%), and 79.6% (74.1%-85.5%), respectively. Freedom from total reintervention at 1 year, 3 years, and 5 years was 82.1% (95% CI, 77.4%-87.1%), 73.6% (68.0%-79.6%), and 65.1% (58.7%-72.2%). Predictors of laparotomy complications were untreated VH (P = .01) and hypertension (P = .01). Protective factors were thoracoabdominal approach (P < .01) and aortounifemoral bypass (P < .01). Predictors of wound complications included body mass index (per kg, 1.07; CI, 1.01-1.15; P = .018), anticoagulation (2.59; CI, 1.01-8.37; P = .049), and previous iliac stents (2.60; CI, 1.36-4.94; P = .004). ConclusionsWhereas AFB is a durable reconstruction with infrequent need for graft reintervention, laparotomy- and groin wound-associated complications contribute significantly to morbidity and reintervention after AFB. Predictive factors for laparotomy and groin wound complications should be considered in preoperative planning and selection of patients for AFB and in the discussion of outcomes.

Effects of Peroral Endoscopic Myotomy on Esophageal Function in the Treatment of Achalasia.

Peroral endoscopic myotomy (POEM) is a new technique to treat achalasia, but the effects on esophageal motor function and structure are still unclear. This study aimed to examine the esophageal function and anatomical changes of patients with achalasia treated with POEM. This was a retrospective study of 43 patients with achalasia treated with POEM between January 2013 and January 2016 at the Second Affiliated Hospital of Xi'an Jiaotong University. The patients were grouped as previous treatments for achalasia (n = 19) versus no previous treatment (n = 24). Surgical success (defined as Eckardt score ≤3 points or decreased by >3 points compared with baseline), recurrence, and reintervention were analyzed. Three patients (7.0%) were Eckardt grade I, 16 (37.2%) were grade II, and 24 (55.8%) were grade III. Operation time was 35 to 150 (median = 49) minutes. Both groups showed improvements in the Eckardt score after surgery (both P < .001), without a difference between the 2 groups (P = .749). The maximal mean diameter of the esophagus was reduced, and the lower esophageal sphincter pressure was improved after surgery (both groups, all P < .001), without difference between the 2 groups (all P > .05). One case of failure was probably due to the presence of an esophageal stent. POEM has a high success rate and is possibly unaffected by previous treatments, except maybe stent implantation. Clinical symptoms of achalasia are significantly relieved by POEM; the function of the esophageal sphincter and the esophagus structure are improved. Previous esophageal stent implantation could increase failure likelihood, but this will have to be confirmed.

Endoscopic placement of pancreatic stent for “Deep” pancreatic enucleations operative technique and preliminary experience at two high-volume centers

Pancreatic enucleation (PE) is a viable option for the removal of non-malignant pancreatic masses leading to complete preservation of organ function. Nevertheless, PE is associated with substantial rates of post-operative pancreatic fistula (POPF), particularly when the mass is close to the main pancreatic duct (MPD). Preoperative stenting of the MPD may prevent its injury when performing PE. This paper describes a novel technique of "deep" PE preceded by endoscopic stenting of the MPD. From January 2017 to May 2019, patients with small pancreatic neuroendocrine tumors proximal to the MPD were candidates for PE with previous stenting of the MPD at the University of Verona, Italy, and at the UCLA Medical Center, Los Angeles, California. The endoscopic stenting was scheduled either the day before or 3weeks before surgery, depending on the participating institute. Ten patients were included in this pilot study. The endoscopic procedure was successful and well tolerated in all cases. Open, laparoscopic and robotic PE were performed. Seven patients had surgical complications. Among these, six developed a post-operative pancreatic fistula (POPF), but neither grade C fistulas nor disruptions of the MPD were detected. At pathology, a low grade pancreatic neuroendocrine tumor was confirmed in all cases. In the setting of high-volume centers, this procedure is safe, and it is associated with acceptable short-term surgical morbidity. The preoperative stenting of the MPD might extend the surgical indications for PE.

Surgical Outcome of Coronary Artery Bypass Graft in Patients with Previous Coronary Stenting

Background: With the advancement of percutaneous coronary interventions, patients are presenting to coronary artery bypass grafting (CABG) older, with several co-morbidities and with prior coronary stenting. The outcome of surgery after stenting continues to be debated. We evaluated the surgical outcome of coronary artery bypass grafting in patients with previous coronary stenting. Methods: This prospective cohort study included 50 patients with previous coronary stent who underwent CABG between February 2016 and June 2017. Thirty-eight patients were males (76%), and the mean age was 57.66±8.81 years. The mean ejection fraction was 41.43±9.25%. Forty-six patients (92%) had previous one stent, and 4 patients (8%) had 2 stents. Results: Nineteen patients had in-stent restenosis (38%), and 31 patients had new lesions (62%). Seven patients had lesions distal to the site of the stent (14%). The mean cardiopulmonary bypass time was 102.66±25.34 minutes. Two patients needed an intraoperative intra-aortic pump and four in the ICU. Five patients (10%) developed acute myocardial infarction. Operative mortality occurred in 4 patients (8%); one patient (2%) had an acute renal failure. Ejection fraction at 6 months post-discharge showed an increase compared to the preoperative value (41.43±9.25%- 44.78±6.99%, P= 0.013). Mortality occurred more frequently in patients with IABP and in patients who had MI and renal failure. Mortality was not associated with in-stent stenosis. Conclusion: Coronary artery bypass grafting in patients with prior coronary stenting could be associated with increased morbidity and mortality. Proper management of coronary artery disease is essential to decrease the risk of future intervention.

Anesthetic Agents and Cardiovascular Outcomes of Noncardiac Surgery after Coronary Stent Insertion.

Patients undergoing noncardiac surgery after coronary stent implantation are at an increased risk of thrombotic complications. Volatile anesthetics are reported to have organ-protective effects against ischemic injury. Propofol has an anti-inflammatory action that can mitigate ischemia-reperfusion injury. However, the association between anesthetic agents and the risk of major adverse cardiovascular and cerebral event (MACCE) has never been studied before. In the present study, a total of 1630 cases were reviewed. Four different propensity score matchings were performed to minimize selection bias (propofol-based total intravenous anesthesia (TIVA) vs. volatile anesthetics; TIVA vs. sevoflurane; TIVA vs. desflurane; and sevoflurane vs. desflurane). The incidence of MACCE in these four propensity score-matched cohorts was compared. As a sensitivity analysis, a multivariable logistic regression analysis was performed to identify independent predictors for MACCE during the postoperative 30 days both in total and matched cohorts (TIVA vs. volatile agent). MACCE occurred in 6.0% of the patients. Before matching, there was a significant difference in the incidence of MACCE between TIVA and sevoflurane groups (TIVA 5.1% vs. sevoflurane 8.2%, p = 0.006). After matching, there was no significant difference in the incidence of MACCE between the groups of any pairs (TIVA 6.5% vs. sevoflurane 7.7%; p = 0.507). The multivariable logistic regression analysis revealed no significant association of the volatile agent with MACCE (odds ratio 1.48, 95% confidence interval 0.92–2.37, p = 0.104). In conclusion, the choice of anesthetic agent for noncardiac surgery did not significantly affect the development of MACCE in patients with previous coronary stent implantation. However, further randomized trials are needed to confirm our results.

A treatment strategy to help select patients who may not need secondary intervention to remove symptomatic ureteral stones after previous stenting.

This study aimed at evaluating whether removal of the ureteral stent the day before scheduled secondary intervention facilitates spontaneous ureteral stone passage and thus can spare the pre-stented patient this surgery. Retrospective analysis of a single-centre consecutive series of 216 patients after previous stenting due to a symptomatic ureteral stone from 01/2013 to 01/2018. Indwelling stents were removed under local anaesthesia. Patients were told to filter their urine overnight. Multivariate analysis was performed to assess predictive factors for spontaneous stone passage. 34% (74/216) of patients had spontaneous stone passage while the stent was indwelling. Of the remaining 142 patients, 41% (58/142) had spontaneous stone passage within 24h after stent removal. Only 84/216 (39%) patients needed secondary intervention. Multivariate logistic regression analysis of all 216 patients showed a significant association between spontaneous stone passage and smaller stone size (p < 0.001), distal stone location (p = 0.046) and stent dwell time (p = 0.02). Predictive factors for spontaneous stone passage after stent removal were smaller size (p < 0.001), distal location (p = 0.001), and stone movement while the stent was indwelling (p = 0.016). A treatment strategy was established that helps select patients suitable for conservative management. The majority (61%) of ureteral stones passed spontaneously after pre-stenting; 34% while the stent was indwelling, 27% within 24h after stent removal. Besides distal stone location, stone size (< 6mm) and stone movement (≥ 5cm) while the stent is indwelling indicate patients who are likely to pass their ureteral stone spontaneously after stent removal. The treatment strategy (decision tree) presented here helps identify those patients. https://doi.org/10.1186/ISRCTN12112914 .

Sigara kulanımının klopidogrel tedavisi alan hastalarda P2Y12 trombosit fonksiyon testi ile değerlendirilen trombosit reaktivitesi üzerine etkisi

Aim: The interaction between cigarette smoking and efficacy of platelet function testing is not definitely shown. We aimed to conduct the effects of smoking on platelet reactivity by P2Y12 platelet function testing on the patients treated with clopidogrel. Materials and Methods: This prospective study contained 200 patients who underwent a previous stent implantation. Diagnostic coronary angiography was performed those patients due to chest pain. The clopidogrel resistance test was applied. Furthermore, the smoking effect on platelet reactivity was investigated. Results: We found that 17% of the patients (34/200) clopidogrel-resistant by P2Y12 platelet function test. We didn’t find any relationship between angiographic stent restenosis and clopidogrel resistance (p&amp;gt;0.05). There was statistically significant relationship between smoking and clopidogrel resistance. The smokers had also higher platelet reactivity level (&amp;gt;208 PRUs) as revealed by VerifyNow P2Y12 assay. Conclusion: The test results achieved through the clopidogrel resistance by P2Y12 platelet function testing did not meet expectation with the angiographically observations. Therefore, P2Y12 platelet function testing can be unclear in smoker patients.

Surgical treatment of recurrent coarctation of the aorta after previous stenting

<h3></h3> Коарктация аорты является одним из наиболее частых пороков в структуре врожденных аномалий сердечно-сосудистой системы. В статье описано хирургическое лечение пациента с рекоарктацией аорты после ранее перенесенного стентирования.

446 Association of Mammalian Oligosaccharide Galactose-α-1,3-galactose (α-Gal) With Atherosclerotic Coronary Artery Disease

An association between type 2 immunity and coronary artery atherosclerosis has recently been described. Ixodes holocyclus (Australian paralysis tick) bites can result in IgE sensitization to the mammalian oligosaccharide galactose-α-1,3-galactose (α-Gal) which in turn is associated with mammalian meat anaphylaxis. A previous angiography-based study identified that IgE sensitization to α-Gal is associated with coronary artery disease plaque burden. We sought to confirm the hypothesis that IgE α-Gal sensitization is associated with coronary artery plaque burden in a subset of the BioHEART-CT cohort. Specific IgE α-Gal antibodies were measured in serum from 220 participants in the BioHEART-CT cohort using a commercially available assay (ImmunoCAP 250). Participants with previous stents or coronary artery bypass grafts were excluded. Demographics, cardiovascular risk factors and current medication information was collected at time of enrolment. CTCAs were scored using the 17 segment Gensini Score. IgE α-Gal association with plaque burden was assessed using simple linear and multivariate linear regression models. IgE α-Gal sensitization was significantly associated with disease burden, Beta coefficient, 1.14; SE, 0.3; p<0.001. The association remained significant when adjusted for age, sex, and standard cardiovascular risk factors, Beta coefficient, 1.03; SE, 0.3; p=0.001. In individuals sensitized to IgE α-Gal, compared to those that were not sensitized, the relative risk of having coronary artery disease was 1.4 (95% CI 1.1-1.7, p=0.002). IgE α-Gal sensitization was associated with coronary artery disease burden in the BioHEART-CT cohort. Further research is needed to investigate potential mechanistic pathways.

P1564 Changes in coronary flow velocity measuring during coronary bypass grafting can predict elevation of cardiac troponin

Abstract Background Stenosis of a coronary artery results in an increase in flow velocity in the pathologic segment. Effective grafting should decrease the stenotic native coronary velocity according to a hemodynamic law. The range of decreased velocity can hypothetically reflect the effectiveness of a graft. Grafting effect insufficiencies often cause elevations in periprocedural cardiac troponin (cTn) elevation. The aim of the study is to determine, if measuring coronary flow velocity changes during coronary artery bypass grafting (CABG) can predict further cTn elevation. Methods and results Consecutive 68 patients (48 men, 64 ± 9 years old), who were referred for CABG, were included into the study. A standard basic perioperative transesophageal echocardiography (TEE) examination was performed with additional scans of the left main, left anterior descending (LAD), and circumflex (LCx) arteries’ proximal segments. Measurements of coronary flow velocities was performed before and after grafting in the same sites of the arteries. The maximal value of cTnI within 48 hours after CABG was accounted for in the analysis. All patients had arterial hypertension, 15 patients (22%) had diabetes mellitus, 12 patients (18%) was current smokers. Forty-one patients (60%) had prior myocardial infarctions, 18 persons (26%) had previous coronary stenting. The ejection fraction before the operation was 56 ± 13%. Before grafting the mean velocity in the left main artery was 79 cm/s (25th-75th quartile, 42-111), in LAD 98 cm/s (25th-75th quartile, 71-125), and in LCx 116 cm/s (25th-75th quartile, 68-156). There was a strong significant correlation between changes in coronary flow velocities and the value of cTnI (R = 0.56, p &amp;lt; 0.0004). The patients with and without significant elevations in cTnI had differences in coronary velocity changes before and after grafting (p &amp;lt; 0.009). Patients with elevated cTnI in more than 5 times, had, on average, an increase in the velocities for native arteries of 21 ± 19 cm/s. Conclusion Coronary flow velocity assessment during CABG could predict an elevation of cardiac troponins after cardiac surgery. Abstract P1564 Figure.

Oval stenting in left pulmonary artery stenosis: a novel double balloon technique to prevent airway compression in single ventricle.

Left pulmonary artery (LPA) stenosis is common in patients with cavopulmonary connections. Stent implantation is the treatment of choice but may be complicated or contraindicated by left main bronchus (LMB) compression due to limited retro-aortic space after a Damus-Kaye-Stansel (DKS) or Norwood operation. This study describes a novel double balloon technique of LPA stenting in patients at risk of LMB compression. A cohort study was performed in 11 patients who underwent LPA stenting with an oval stent technique between 2015 and 2018. Retro-aortic anatomy was evaluated periprocedurally by three-dimensional rotational angiography (3DRA). Pre-existing LMB compression was demonstrated by 3DRA in seven out of eight patients who had undergone previous LPA stenting and in one patient without stenting. Primary ovalisation with immediate stent implantation on double balloons was performed in one patient. Ten patients had secondary ovalisation with single balloon stent implantation followed by the double balloon technique for ovalisation. The procedures were successful in all patients and guaranteed LMB patency without increasing pre-existing compression. The 3DRA-guided oval stent technique with double balloon inflation is successful in treating LPA stenosis after a DKS or Norwood operation in patients at risk of bronchial compression, guaranteeing LMB patency without increasing pre-existing compression.

'Deep' enucleation of pancreatic neoplasms following endoscopic main pancreatic duct stenting: Operative technique and preliminary experience at two high-volume centers

Background: pancreatic enucleation (EN) is a viable option for the radical removal of non-malignant pancreatic masses leading to complete preservation of organ function. Nevertheless, EN is associated with substantial rates of post-operative pancreatic fistula (POPF), particularly when the mass is in close proximity to the main pancreatic duct (MPD). Preoperative stenting of the MPD may prevent its injury when performing EN. The present paper describes a novel technique of 'deep' EN preceded by endoscopic stenting of the MPD. Methods: from January 2017 to April 2018, patients with small pancreatic neuroendocrine tumors proximal to the MPD were candidate to EN with previous stenting of the MPD at the Department of General and Pancreatic Surgery of the University of Verona, Italy, and at the Department of Surgical Oncology, UCLA, California. Results: seven patients were included in this pilot study. The median distance between the tumor and the MPD was 4 mm (1-7) at preoperative endoscopic ultrasound (EUS). After EN, four patients (57%) developed grade B POPF and one patient developed biochemical leak (BL). All resected tumors were G1 pancreatic NETs with Ki67 < 2% at pathology. At the 60-day follow-up, no patients had exocrine or endocrine insufficiency. MRI with MRCP revealed the integrity of both the MPD and parenchyma in all cases. Conclusions: the endoscopic procedure was well tolerated and EN was associated with acceptable short-term surgical morbidity and no disruption of the MPD. In the setting of a high-volume centers, this procedure is safe and effective and may extend the surgical indications for EN. Relevant steps of the surgical enucleation

P1489 Late cardiovascular manifestations of Gregg syndrome: Importance of multimodal imaging approach to optimize diagnosis

Abstract Background Congenital rubella syndrome, also known as Gregg syndrome (after Dr. Norman Gregg’s first description in 1941) is a variable constellation of multisystemic manifestations caused by rubella intrauterine infection. In this case, a patient known to have Gregg syndrome underwent trans-thoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) for optimizing the characterization and determining the status of her disease. Case report A 31-year-old female attends routine cardiology outpatient clinic prior initiation of pregnancy due to prior history of Gregg syndrome. Extent of disease includes congenital cataracts, neurosensorial bilateral hearing loss, supra-valvular aortic stenosis (treated percutaneously at age 4 with a subsequent aortic root reconstruction with homograft at age 6) and pulmonary artery stenosis (status-post surgical correction followed by angioplasty at age 9). The patient was asymptomatic with functional class NYHA I and was taking no medication. A TTE was requested which showed a left ventricle with low-normal systolic function. At the pulmonary valve, she had a residual peak velocity and mean gradient of 2.6 m/sec and 15 mmHg, respectively, with moderate regurgitation; the right ventricle was dilated with mild systolic dysfunction. Doppler evaluation of the ascending aorta revealed a peak velocity of 3,5 m/sec and a mean gradient of 30 mmHg (Figure 1a). Anatomical evaluation was limited because of the acoustic window but due to the cited hemo-dynamics, a CMR was requested for further characterization of her disease prior to pregnancy. CMR showed a normal sized left ventricle with an ejection fraction of 62%, without late gadolinium enhancement. The right pulmonary artery lumen was diminished, probably corresponding to an artifact due to previous stent angioplasty. In the ascending aorta there was residual supra-valvular aortic stenosis 9 mm from the sino-tubular junction with an adjacent, non-mobile, 33 x 39 x 20 mm mass, anterior to the aorta and immediately posterior to the sternum, consistent with aortic pseudoaneurysm (Figure 1b). Due to this finding pregnancy was discouraged, and she was referred to the Cardiovascular Surgery for aortic pseudoaneurysm correction. Conclusion Although infrequent because of successful worldwide vaccination policies, sporadic cases of Gregg syndrome can still be seen, especially in neglected populations with poor access to health services or in unvaccinated patients. Long-term follow-up of all patients undergoing repair procedures is warranted for evaluation of late occurring complications. This case underscores the importance of multimodality imaging for a complete anatomical and functional diagnosis of complex cardiovascular conditions. Abstract P1489 Figure 1