Reocclusion Rate Research Articles

Role of infrapopliteal angioplasty in diabetic and non-diabetic patients

ObjectiveTo compare the outcomes of infrapopliteal angioplasty between diabetic patients and non-diabetic patients with critical limb ischemia. Patients and methodsFrom March 2014 to December 2014, infrapopliteal angioplasty was performed on 60 limbs (43 men and 17 women with mean age 70.13years) with the CLI (Fontaine’s grade III or IV). The number of diabetic patients was 40 (66.66%). Follow-up included clinical examination for rest pain improvement and ischemic ulcer healing, and duplex-documented target vessel patency or re-stenosis at discharge and at 3months. ResultsThe technical success rate was 100% in diabetic and non-diabetic groups. The ulcer healing rate was 33/37 (89.18%) in diabetic patients vs. 14/15 (93.3%) in non-diabetic patients. And the re-stenosis and re-occlusion rates of treated vessels after 3months were 10.0% in diabetic vs. 5.0% in non-diabetic groups. ConclusionThere were no significant differences between the 2 groups in the technical success rate, but the 3months clinical success rate and the primary patency rate were better in non-diabetic than in diabetic patients with no significant differences.

The Reconstruction of Hepatic Arteries Using Extra-Anatomical Free Autografts in Living Donor Liver Transplantation

Objectives: In living-donor liver transplantation (LDLT), microsurgical reconstruction of a hepatic artery is essential but requires challenging techniques, because graft arteries are short and usable vessel grafts are limited. Furthermore, hepatic artery thrombosis can be a lethal complication. Extra-anatomical jump graft reconstruction using free grafts is reported to have a high reocclusion rate. However, this technique is necessary when there is no other option. We report 4 cases of LDLT that required extra-anatomical reconstruction technique using free autografting from the aorta to the hepatic artery. In this technique, we used the systemic administration of gabexate mesilate that is the strong serine protease inhibitor. Methods: From 1991 to 2015, we performed 164 LDLTs. We retrospectively investigated 4 cases of extraanatomical reconstruction of the hepatic artery using free autografting from the aorta to the hepatic artery. Results: Two cases initially underwent anatomical reconstruction, but the arteries occluded early, because of the dissection of recipient’s artery. There was no arterial graft, so we performed extra-anatomical reconstruction by using free autografting from the aorta to the hepatic artery. In the other two cases, the recipient arteries could not be used. Therefore, we initially performed extra-anatomical reconstruction by using radial artery free autografting as jump grafts from the aorta to the hepatic artery. In all cases, we used the systemic administration of gabexate mesilate, and could rescue all cases. Conclusion: We experienced and were able to salvage 4 cases that required free autografts. When there is no other means of reconstructing arteries, it is necessary to perform this procedure, depending on the condition of the intima of the recipient artery.

No reflow : quels facteurs prédictifs ?

IntroductionDuring the past 20 years, significant progress has been made in the recanalization of ACS with ST elevation. It is now accepted that the reopening of the large coronary vessels in the acute phase of infarction by thrombolysis or angioplasty is necessary but not sufficient, because in 20–50% of cases, the coronary recanalization is an illusion of reperfusion. This phenomenon is called “no reflow”. ObjectiveThe main objective of our study was to identify predictors of poor perfusion or “no reflow” in the acute phase of myocardial infarction. MethodsObservational prospective study, in the department of cardiology and internal medicine, university hospital of Blida, over a period of 28 months from 1st September 2010 to 31st January 2013. We identified all patients hospitalized for myocardial infarction in acute phase, who underwent primary angioplasty or thrombolysis with angiographic control during a good TIMI flow. The endpoint was regression of ST segment (regression<50% ST-segment defined no reflow). ResultsThree hundred and seventy-nine patients were included. The mean age was 56.3±2.1, 87.8% of patients were male. In total, 35.9% hypertensive, 27.1% diabetic type 2, 50.1% and 10.8% dyslipidemia, smoking. One hundred and forty-seven (38.8%) developed a no reflow. Mortality was 3.9%, strongly correlated with no reflow (P=0.001). Predictors of no reflow after multivariate analysis were: age (OR 98, 0.961–0.996 95%, P=0.02), heart rate (1.01, 95% CI 0.998–1.02, P=0.035), the type 2 diabetes (odds ratio 1.87, CI 1.2–3.0, P=0.08), reaching the core (OR 7, 95% CI 1.2–18.4, P=0.027), direct stenting (OR 0.48, 95% CI 0.31–0.78, P=0.003). An interesting subgroup of patients was identified namely the subgroup strategy deferred primary angioplasty with stenting best reperfusion (OR 3.7, 95% CI 1.5–8.8, P=0.04), a lower rate of reocclusion of culprit artery and a lower rate of stenting with 23/51 (45.1%) versus 136/136 (100%) of immediate stenting group with a P<0.001. ConclusionNo reflow is a common phenomenon, strongly correlated with mortality predictors are age, heart rate, diabetes, achieving the core and direct stenting. The distal embolization in primary angioplasty is an important phenomenon, a delayed stenting strategy appears to limit this phenomenon.

Patterns of failure and morbidity associated with palliative intervention in patients with malignant biliary obstruction.

71 Background: Outcome for patients with malignant biliary obstruction is poor. While endoscopic or percutaneous procedures provide palliative benefit, stents often occlude or migrate, and drains frequently fail requiring repeat procedures in medically fragile patients. As part of a multidisciplinary effort to improve outcomes in this population, we undertook an investigation to determine rates of stent and drain failure and morbidity to identify areas of potential improvement. Methods: After Institutional Review Board approval, retrospective review of all cancer registry patients undergoing percutaneous or endoscopic intervention for biliary obstruction from 1/2004-10/2014 and billing reports from 11/2012-10/2014 identified 230 patients. Cases of biliary obstruction due to malignancy requiring intervention were selected, resulting in 94 evaluable patients. Charts were reviewed to determine dates and cause for stent and/or drain replacement and morbidity. Results: Of 94 analyzable patients, median age was 60 years and 49 were male (52%). Malignant cause of obstruction was gastric/colorectal in 16 (17%), biliary in 37 (39%), hepatocellular in 7 (7%), and pancreatic in 34 (36%). Stenting was part of the initial procedure in 47 (50%), and drain placement in 49 (52%). Ultimately 60 (64%) patients underwent stent procedures and 82 (87%) patients required drains. Of the stented patients, 27 (45%) required repeat stenting, and 13 (22%) required &gt; 1 stent replacement. Of the patients who underwent drainage procedures, 68 (83%) required repeat drainage, and 52 (63%) required &gt; 1 repeat drainage procedure. Cholangitis was observed following stent in 5 (5%) of patients, 60% in patients undergoing &gt; 1 stent procedures. Median survival after initial procedure was 12 months; for patients requiring repeat procedures, median survival was 4.5 months. Conclusions: Malignant biliary obstruction is a morbid disease with high rates of reocclusion requiring repeat procedures, which may negatively impact outcome and increase healthcare cost. Efforts to reduce the rates of repeat procedures are critical to address this clinical need.

Delayed Stenting for ST-Elevation Acute Myocardial Infarction in Daily Practice: A Single-Centre Experience

BackgroundThe minimalist immediate mechanical intervention (MIMI) strategy aims to restore normal anterograde flow in the culprit artery (by using manual thrombectomy or small-sized balloon predilation) and to defer potential stent implantation. This study evaluated the applicability and midterm clinical results of the MIMI strategy for ST-elevation myocardial infarction (STEMI) management. MethodsThis observational study included consecutive patients admitted for ongoing STEMI (<24 hours' evolution) at 1 institution between June 2010 and June 2013. Revascularization was performed at the physician's discretion. We compared retrospectively “intentional immediate stenting” (standard technique) and “intentional delayed stenting” (MIMI technique). ResultsTwenty percent of the 279 included patients were treated with the MIMI strategy. These patients were significantly younger and were more frequently men and smokers compared with patients who underwent the standard procedure. The rate of acute reocclusion of the culprit artery related to STEMI in the MIMI group was 1.8%. Drug-eluting stents were used more frequently in the MIMI group (52% vs 27% in the standard group; P < 0.001). The culprit lesion was stented less frequently in the patients treated with MIMI compared with patients in the other group (28.5% vs 9%; P < 0.001). The 1-year actuarial survival free from major adverse cardiovascular events was higher in the MIMI group than in the standard group (96.3% ± 1.8% vs 83.8% ± 2.5%; P = 0.01). ConclusionsThe MIMI strategy can be applied in selected patients with STEMI. In our centre, this strategy is associated with less systematic culprit lesion stenting and more implantation of drug-eluting stents. However, this needs to be evaluated further in a randomized trial.

Young Women - Problematic Patients in Vascular Surgery

The treatment of peripheral arterial disease (PAD) in young women between 40 and 60 years of age represents a difficult challenge for the vascular surgeon. Excessive smoking, an early menopause and the unfavourable anatomic proportions of thinner arterial vessels or vein grafts during peripheral bypass-surgery lead to a higher rate of complications or re-occlusion following invasive therapy in comparison to male patients. A special anatomic manifestation appearing nearly only in women around the 6th decade is the so-called aortoiliac hypoplastic syndrome with a high rate of re-occlusion after balloon-dilatation or local thrombendarteriectomy and bypass grafting, respectively. Variabilities in coagulation and the undertreatment of classical risk factors of PAD by medical drugs lead to poorer results in the treatment of PAD in young women. Therefore a conservative therapy - whenever feasible - should be the first choice for treating PAD in young women.

Comparison between diabetic and non-diabetic patients after successful percutaneous coronary intervention for chronic total occlusions in the drug-eluting stent era

ObjectiveDiabetes mellitus and chronic total occlusions are associated with unfavorable outcome after percutaneous coronary intervention. We sought to assess the clinical and angiographic outcomes of diabetic and non-diabetic patients who underwent successful percutaneous revascularization of chronic total occlusions with drug-eluting stents. MethodsBaseline clinical and angiographic characteristics, procedural details, nine-month angiographic follow-up and clinical events at 12 months were compared between 75 diabetic and 132 non-diabetic patients included in a clinical trial that randomized successful recanalization of chronic total occlusions to receive sirolimus- or everolimus-eluting stents. ResultsIn both diabetic and non-diabetic groups there was a favorable non-significantly different angiographic result at nine months, with low in-stent late loss (0.14±0.60 mm vs. 0.25±0.68 mm, p=0.305) and rates of binary restenosis (4.0% vs. 10.6%, p=0.180) and reocclusion (0.0% vs. 2.3%, p=0.334). During follow-up similar survival from death (97.3±1.9% vs. 99.2±0.8%, log-rank p=0.273), acute myocardial infarction (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192), target vessel revascularization (88.7±3.8% vs. 88.2±2.9%, log-rank p=0.899) and stent thrombosis (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192) was observed. Furthermore, the presence of more diffuse peripheral and coronary artery disease and higher frequency of calcified lesions in diabetic patients did not lead to significant differences in the approach (20.0% vs. 25.0% radial approach, p=0.413), strategy (6.7% vs. 3.8% retrograde strategy, p=0.353), total stent length (48.1±24.6 mm vs. 49.2±23.9 mm, p=0758) or contrast volume (261.3±116.4 ml vs. 297.4±135.9 ml, p=0.109) required for revascularization. ConclusionsIn the drug-eluting stent era, diabetic and non-diabetic patients have comparable favorable clinical and angiographic outcomes after successful percutaneous revascularization of chronic total occlusions.

Comparison between diabetic and non-diabetic patients after successful percutaneous coronary intervention for chronic total occlusions in the drug-eluting stent era

ObjectiveDiabetes mellitus and chronic total occlusions are associated with unfavorable outcome after percutaneous coronary intervention. We sought to assess the clinical and angiographic outcomes of diabetic and non-diabetic patients who underwent successful percutaneous revascularization of chronic total occlusions with drug-eluting stents. MethodsBaseline clinical and angiographic characteristics, procedural details, nine-month angiographic follow-up and clinical events at 12 months were compared between 75 diabetic and 132 non-diabetic patients included in a clinical trial that randomized successful recanalization of chronic total occlusions to receive sirolimus- or everolimus-eluting stents. ResultsIn both diabetic and non-diabetic groups there was a favorable non-significantly different angiographic result at nine months, with low in-stent late loss (0.14±0.60 mm vs. 0.25±0.68 mm, p=0.305) and rates of binary restenosis (4.0% vs. 10.6%, p=0.180) and reocclusion (0.0% vs. 2.3%, p=0.334). During follow-up similar survival from death (97.3±1.9% vs. 99.2±0.8%, log-rank p=0.273), acute myocardial infarction (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192), target vessel revascularization (88.7±3.8% vs. 88.2±2.9%, log-rank p=0.899) and stent thrombosis (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192) was observed. Furthermore, the presence of more diffuse peripheral and coronary artery disease and higher frequency of calcified lesions in diabetic patients did not lead to significant differences in the approach (20.0% vs. 25.0% radial approach, p=0.413), strategy (6.7% vs. 3.8% retrograde strategy, p=0.353), total stent length (48.1±24.6 mm vs. 49.2±23.9 mm, p=0758) or contrast volume (261.3±116.4 ml vs. 297.4±135.9 ml, p=0.109) required for revascularization. ConclusionsIn the drug-eluting stent era, diabetic and non-diabetic patients have comparable favorable clinical and angiographic outcomes after successful percutaneous revascularization of chronic total occlusions.

Intraluminal Volume Dose Alteplase for the Clearance of Occluded Peripherally Inserted Central Catheter Lines at a Long-Term Acute Care Hospital: Efficacy and Economic Impact.

To evaluate the efficacy and economic impact of a maximum of 2 doses of intraluminal volume 1 mg/1 mL dose alteplase for the clearance of occluded peripherally inserted central catheter (PICC) lines at a long-term acute care hospital (LTACH). Open-label, nonrandomized quasi-experimental trial taking place over a 3-month period from December 2013 to March 2014. Patients had a standing order of either standard (2 mg/2 mL) or intraluminal volume (1 mg/1 mL) dose alteplase entered for any potential occlusions. The primary efficacy outcome was restored line patency after a maximum of 2 doses of alteplase. Secondary efficacy outcomes included restored patency after 1 dose of alteplase, reocclusion rate, mean time to reocclusion, and mean number of occlusions per patient. A total of 168 patients were enrolled into the study (intraluminal volume, n = 54; standard, n = 114) and a total of 270 occlusions were recorded; 90 received intraluminal volume dose alteplase and 180 received the standard dose. The primary efficacy endpoint was 93.3% for the intraluminal volume dose group and 94.4% for the standard dose group. Secondary outcomes were similar between groups. The average cost per dose was $123.77 and $60.62 for the standard and intraluminal volume dose alteplase groups, respectively. For the clearance of occluded PICC lines at our LTACH, there was no statistical difference in the efficacy of a maximum of 2 doses of intraluminal volume dose alteplase versus the standard dose. Use of intraluminal volume dose alteplase was found to be significantly more cost-effective.

Abstract T MP10: Arterial Reocclusion And Distal Embolization During Endovascular Treatment Using New Generation Stent Retrievers In Acute Ischemic Stroke Patients

BACKGROUND AND PURPOSE: Arterial reocclusion and distal embolization have been identified in previous studies of endovascular treatment in patients with acute ischemic stroke. We determined the rates of reocclusion and distal embolization during endovascular treatment using new generation stent retrievers. MATERIALS AND METHODS: Acute ischemic stroke patients underwent mechanical thrombectomy using new generation stent retrievers without intra-procedural heparin or proximal flow arrest for angiographically demonstrated arterial occlusion. "Distal embolization" was defined qualitatively as appearance of an occlusion on a downstream vessel. "Arterial reocclusion" was defined as subsequent reocclusion of the target vessel after initial recanalization had been achieved. The rates were compared with data from 4 previous prospective acute stroke protocols prior to availability of stent retrievers. RESULTS: The median initial National Institutes of Health Scale Score (NIHSS) for these patients was 14 (range 34-0); mean time from symptom onset to treatment was 5.2 +/- 2.6 hr. Arterial reocclusion occurred in 2.3% of these patients, whereas distal embolization occurred in 24% of the 86 patients. The rates of arterial reocclusion (3.0% versus 1.9%) and distal fragmentation (21.2% versus 30.8%) were similar in patients who did or did not receive IV alteplase prior to thrombectomy. Arterial reocclusion, but not distal embolization, was associated with a lower likelihood of favorable outcome at 1-3 months (P = .05; odds ratio, 3.9; 95% confidence interval, 0.01-0.98) after adjusting for age, initial NIHSS, sex, time to treatment, initial angiographic grade, symptomatic intracranial hemorrhage, and final recanalization. The rates of arterial reocclusion (2.1% versus 2.6% of 86 patients, p=0.8) and distal embolization (35.4% versus 18.4% of 86 patients, p=0.8) were not similar in patients treated with and without stent retrievers. CONCLUSIONS: Arterial reocclusion and distal embolization occur in 16%-18% of acute ischemic stroke patients undergoing mechanical thrombectomy with new stent retrievers without IV heparin or proximal flow arrest. The rates are no higher than those observed in cohorts treated without stent retrievers.

Absorbable Polymer Technology - Viable Solutions for Unmet Needs in PCI: Proceedings of two satellite symposia held at EuroPCR, Paris in May 2015.

The use of drug-eluting stents (DES) has improved clinical outcomes in percutaneous coronary intervention procedures, but many challenges remain. In two symposia at EuroPCR 2015, the factors necessary to ensure successful chronic total occlusion (CTO) intervention were presented. Good preparation, sufficient operator experience and the correct approach are key to the success of CTO interventions. A live case demonstrated the challenges of these complex cases. Stent choice in CTO interventions is crucial; second-generation DES are associated with lower rates of restenosis and re-occlusion compared with first-generation DES. The Coracto™ DES features unique structural properties and rapidly absorbable polymer, resulting in excellent conformability, efficacy and safety.

Intra-aortic balloon pump for high-risk percutaneous coronary intervention.

The intra-aortic balloon pump (IABP) was first introduced into clinical practice in 1968.1 Early experimental and clinical trials suggested that intra-aortic balloon counterpulsation could provide circulatory assistance to a failing left ventricle.2,3 Counterpulsation—balloon inflation during diastole and deflation in systole—augments the intrinsic Windkessel effect, whereby potential energy stored in the aortic root during systole is converted to kinetic energy with the elastic recoil of the aortic root. Counterpulsation leads to a decline in afterload, a reduction in cardiac work, and therefore myocardial oxygen requirements of the ventricle. Augmentation of diastolic pressure when the balloon is fully inflated together with reduction in left ventricular (LV) filling pressures contribute to improved coronary perfusion (Figures 1 and 2).4 This proposed improvement in myocardial energetics has been further supported by a significant reduction in systemic lactate.5 These physiological enhancements are thought to be of particular benefit after acute myocardial infarction (AMI), supported by animal studies, which have shown a reduction in infarct size when counterpulsation is used.6,7 Figure 1. Coronary perfusion. Coronary flow is predominantly diastolic and further enhanced by counterpulsation, which augments diastolic blood flow and thus coronary perfusion. In addition, aortic recoil during diastole further improves efficiency of the left ventricle. Figure 2. Systemic arterial pressure waveform on introduction of intra-aortic balloon pump–assisted diastolic augmentation. The intra-aortic balloon pump inflates at the dicrotic notch, leading to peak-augmented diastolic pressure. As the balloon deflates, assisted end diastolic pressure is seen to be lower than unassisted end diastolic pressure and assisted systolic pressure is lower than unassisted systolic pressure. Peak diastolic augmentation should be greater than the unassisted systolic pressure and both assisted pressures should be less than the unassisted pressures. Intra-aortic balloon counterpulsation was initially used as a means of supporting patients undergoing surgical revascularization. Percutaneous delivery …

THIRTY-YEARS OF STANDALONE PCI: EXPERIENCE FROM A HIGH VOLUME CANADIAN CENTRE

The safety of PCI without on-site cardiac surgery has been an ongoing debate since the early 1980’s. However, success rate has improved and acute reocclusion rate reduced since the introduction of stents and new antiplatelet therapy in the 1990s. PCI is now the predominant revascularization modality for coronary disease(CAD) worldwide and where available, primary PCI has become the standard of care for STEMI. In Ontario, 5 new standalone PCI centres have been established in the past 14 years. However, elective standalone PCI remained a Class IIb indication in the 2011 ACCF/AHA/SCAI guidelines. Nonetheless, the recent C-PORT and MASS COM trials in the US concluded that in non-emergency patients, standalone PCI is non-inferior to that performed in centres with on-site cardiac surgery. The Royal Alexandra Hospital performed the first standalone PCI in Canada in 1981 and has provided PCI services to a full spectrum of CAD patients ranging from elective, in-hospital to emergency cases with STEMI and cardiogenic shock. Surgical backup is located at the University of Alberta Hospital 6 km away. Joint case conference is conducted weekly with the cardiac surgery program. In the first 30 years, 23,261 PCIs were performed. We report our 30-year standalone experience, which we believe is the largest single centre experience in literature to date. PCI volumes, clinical and procedural characteristics, lesion success, emergency coronary bypass and mortality rates were collected and reported for the 30-year period. Results for 2006-2011, a period most relevant to current practice were compared with the most recent US PCI data. PCI volumes, CCS Class 4 patients, ad hoc, rescue and primary PCIs all increased significantly over the 30-year period. Success and emergency coronary bypass rates also improved (see Table). For 2006-11, our success, emergency CABG and 30-day mortality rates (96.5, 0.04, 1.1%) compared favorably with National Cardiovascular Data Registry (93-94, 0.3-0.4, 1.2-1.7 %*), C-PORT (93.4-94.1, 0.2, 0.8-0.9 %**) & MASS COM(95.6-97.1, 0.1-0.3, 0.3-0.7 %). PCIs can be performed safely in an experienced, high volume standalone centre with excellent success and very low complication rates. These results support the safety of establishing new standalone PCI centres to meet the growing population demand for percutaneous revascularization for coronary disease.

Long-term Clinical and Angiographic Outcomes of the Mini-STAR Technique as a Bailout Strategy for Percutaneous Coronary Intervention of Chronic Total Occlusion

BackgroundA promising variant of the subintimal tracking and re-entry (STAR) technique, called “mini-STAR,” has been recently described as a successful rescue technique after revascularization failure by conventional techniques for coronary chronic total occlusion (CTO). MethodsThe current study enrolled patients with CTO who underwent successful revascularization by the mini-STAR technique as a bailout strategy. Two-year clinical follow-up and angiographic control procedures were performed. ResultsFrom March 2009-September 2011, 100 of 117 patients (mean age, 61.4 ± 10.9 years) underwent successful recanalization of CTO by the mini-STAR technique as a bailout strategy. Drug-eluting stents (DESs) were implanted in all cases. At 2-year follow-up, the major adverse cardiac events (MACE)-free survival was 89.2%, with a target lesion revascularization (TLR) rate of 6.5%. Angiographic follow-up was performed in 72% of patients. CTO target lesion restenosis was observed in 25% of patients, whereas the reocclusion rate was 12.5%. At multivariate Cox analysis, final thrombolysis in myocardial infarction (TIMI) flow < grade 3 was related to occurrence of MACE (hazard ratio, 5.9; 95% confidence interval [CI], 1.4-24.4; P = 0.013). Final TIMI flow < grade 3 (odds ratio [OR], 5.41; 95% CI, 1.05-27.73; P = 0.043) and CTO stent length (OR, 0.96; 95% CI, 0.93-0.99; P = 0.017) were independent predictors of reocclusion. The independent variables related to restenosis were first-generation DESs (OR, 4.10; 95% CI, 1.23-13.64; P = 0.022) and CTO stent length (OR, 0.97; 95% CI, 0.95-0.99; P = 0.027). ConclusionsAs bailout strategy for CTO revascularization, the mini-STAR technique shows low MACE and TLR rates at long-term follow-up.

Instant Reocclusion following Mechanical Thrombectomy of in situ Thromboocclusion and the Role of Low-Dose Intra-Arterial Tirofiban

Background: An in situ thromboocclusion (IST) is defined as an infarct extensively involving all or most of a stenosed arterial territory, which is one major stroke mechanism related to intracranial atherosclerosis (ICAS). We focused on ISTs occurring in major cerebral arteries and analyzed their rate of instant reocclusion during mechanical thrombectomy (MT) compared with non-ISTs. Also, we introduced a treatment strategy of low-dose intra-arterial tirofiban administration to prevent such reocclusion following repeat recanalization, and evaluated its safety and efficacy. Methods: We analyzed 168 consecutive patients treated with MT over a 2-year period from May 2011 to April 2013. During MT, if angiography following a successful recanalization showed stenosis at the occlusion site, we performed additional angiographic runs every 10 min for 30 min after the recanalization. Then, if angiography revealed reocclusion, we performed a repeat recanalization, using the same MT technique but additionally followed by low-dose intra-arterial tirofiban infusion. Time-of-flight MR angiography or CT angiography was performed to confirm any underlying ICAS at the occlusion site 5-7 days after the procedure. The patients who had confirmed underlying ICAS were included in the IST cohort. Results: Of 168 enrolled patients, we excluded 36 who could not be checked for underlying ICAS at the occlusion site for one of the following reasons: recanalization failure (n = 11), rescue stenting after tirofiban failure (n = 5) and lack of follow-up vascular imaging (n = 20). The incidence of IST was 30.3% (40/132). All IST patients were confirmed to have underlying ICAS by follow-up vascular imaging. Instant reocclusion after successful recanalization was significantly more frequent in the IST cohort [26/40 (65%) vs. 3/92 (3.3%); p < 0.001]. Regarding the efficacy of low-dose intra-arterial tirofiban infusion, 85.7% of the reocclusion patients finally achieved a thrombolysis in cerebral infarction score 2/3 recanalization, but in the remaining 14.3% of the cases, the condition was refractory to the procedure and required rescue stenting. There were no cases of symptomatic intracranial hemorrhage following the procedure. Conclusions: In situ thromboocclusion was characterized by a significantly higher chance of instant reocclusion during MT. In such cases, low-dose intra-arterial tirofiban administration may be effective and safe. However, future confirmation by prospective multicenter trials seems necessary.

Efficacy of axillary-to-femoral vein bypass in relieving venous hypertension in dialysis patients with symptomatic central vein occlusion

Central vein stenosis or occlusion remains an unfortunate complication associated with the use of dialysis catheters. In patients with a functioning arteriovenous fistula, central vein stenosis can lead to debilitating arm, breast, or neck swelling. Treatment typically involves central vein angioplasty or stenting, or both, but restenosis and reocclusion rates remain high. Presented here are the initial results of a unique series of patients with a mature arteriovenous access and symptomatic upper extremity venous hypertension who were treated with axillary vein-to-femoral vein bypass after endovascular therapy failed. This was a retrospective analysis of 10 hemodialysis patients with a functioning right upper extremity access who underwent axillary vein-to-femoral vein bypass between December 2011 and April 2013. The 10 patients (seven men) were a median age of 58 years. All patients had documentation of prior central venous catheter placement and had undergone a previous endovascular procedure that was unsuccessful or technically unfeasible. The median hospital stay was 2 days (range, 1-3 days), and the median assisted-primary patency was 197 days (25th-75th percentile, 114-240 days). Three patients presented with recurrent arm swelling that was successfully managed in one patient with revision of the proximal anastomosis. Three additional patients presented with subsequent lower extremity swelling, with one patient benefitting from femoral vein angioplasty. Ultimately, six patients continued to use their original access, and two required placement of interval central venous catheters for hemodialysis. In patients who have exhausted all endovascular options, axillary-to-femoral vein bypass may represent a safe and efficacious approach to alleviate extremity swelling while simultaneously salvaging a functional dialysis access.

HTUPA as a new thrombolytic agent for acute myocardial infarction: A multicenter, randomized study

BackgroundIt is necessary to develop a new thrombolytic agent which can be used by a single bolus at first aid sites to decrease the time to reperfusion in clinical practice. HTUPA, a genetically engineered new thrombolytic with a longer half-life, is well qualified. We aim to compare the thrombolytic efficacy and safety of human tissue urokinase type plasminogen activator (HTUPA) to recombinant tissue plasminogen activator (rt-PA) in Chinese patients with acute myocardial infarction (AMI). MethodsAMI patients (n=221) were randomized to rt-PA (a standard protocol) or HTUPA (25mg bolus) treatment groups. All patients also received oral aspirin and intravenous heparin. Coronary angiography was performed 90min after therapy initiation to determine infarct-related coronary artery (IRA) patency. Clinical outcomes and changes of clotting variables, heart rate, blood pressure, left ventricular ejection fraction (LVEF), and electrocardiogram were evaluated. ResultsPatent IRA [thrombolysis in myocardial infarction (TIMI) grade 2 or 3] was observed in 77% of HTUPA-treated patients, compared to 76% of rt-PA-treated patients (P=0.76). TIMI grade 3 patency rates were 52% and 44% in the HTUPA and rt-PA groups, respectively (P=0.37). The total patency rate was 77% (86/111 patients) in the HTUPA group and 73% (80/110 patients) in the rt-PA group (P=0.41). Adverse events were infrequent in both groups, and no significant differences were detected in mortality, re-occlusion rate, revascularization rate, adverse effects, clotting index, LVEF, or electrocardiogram between the two groups. ConclusionsIntravenous HTUPA had a safe and efficacious profile as good as rt-PA in patients with AMI.

Abstract 9690: Impact of Lesion Morphology on Angiographic and Clinical Outcomes in Patients With Chronic Total Occlusion After Successful Recanalization With Drug-eluting stents. A Multislice Computed Tomography Study

Background: Which subgroup of patients with chronic total occlusion (CTO) would be likely to derive a benefit from percutaneous coronary intervention (PCI) in the drug-eluting stent (DES) era has not yet been fully clarified. The aim of this study was to investigate the morphological characteristics of CTO associated with angiographic and clinical adverse outcomes after PCI with DES using multislice computed tomography (MSCT). Methods: In this study, 263 patients who underwent MSCT before CTO-PCI were followed clinically (the median follow-up was 4.0 years). Of these, 1 year follow-up angiography was performed in 203 patients. Lesion morphology was assessed with MSCT. Angiographic restenosis, reocclusion, and MACE (a composite of cardiac death, stent thrombosis and target lesion revascularization) were analyzed. Results: MACE was observed in 36 patients (13.6%). Occlusion length was longer (39.5±19.9 mm vs. 22.3±13.7 mm, p&lt;0.01), minimal vessel area was smaller (11.2±5.7mm 2 vs. 14.5±5.6mm 2 , p&lt;0.01) and severe calcification (involving &gt;50% of the coronary wall on cross sectional image) was more common (36% vs. 12%, p&lt;0.01) in the MACE group. In multivariate analysis, occlusion length (Odds ratio (OR); 1.06, p&lt;0.01), minimal vessel area (OR; 0.48, p&lt;0.01) and severe calcification (OR; 3.57, p&lt;0.01) were independent predictors of the MACE. Receiver operating characteristic analysis provided the cut-off value of occluded length (25.4 mm; area under the curve (AUC) 0.79; sensitivity 0.86, specificity 0.62) and minimal vessel area (11.9 mm 2 ; AUC 0.69; sensitivity 0.62, specificity 0.72) to predict the MACE. We defined occluded length &gt;25.4mm, minimal vessel area &lt;11.9mm 2 and severe calcification as CT-derived risk factors. Angiographic restenosis (60% vs. 12% vs. 7%, p&lt;0.01), reocclusion (29% vs. 2% vs. 2%, p&lt;0.01), and MACE (43% vs. 6% vs. 3%, p&lt;0.01) rates were significantly higher in patients with more than 2 risk factors than in those with 1 and 0. Conclusions: MSCT characteristics associated with angiographic and clinical adverse outcomes after CTO-PCI were occluded length, vessel area, and the degree of calcification.

Outcome after mechanical thrombectomy using a stent retriever under conscious sedation: Comparison between tandem and single occlusion of the anterior circulation

In acute ischemic stroke patients, internal carotid artery/middle cerebral artery (ICA/MCA) occlusion in tandem predicts a poor outcome after systemic thrombolysis. This study aimed to compare outcomes after mechanical thrombectomy for tandem and single occlusions of the anterior circulation. This prospective study included consecutive patients with acute ischemic stroke of the anterior circulation who had undergone mechanical thrombectomy performed with a stent retriever under conscious sedation within 6h of symptom onset. Data on clinical, imaging and endovascular findings were collected. In cases of tandem occlusion, distal thrombectomy (retrograde approach) was performed first whenever possible. Tandem and single occlusions were compared in terms of functional outcome and mortality at 3 months. From May 2010 to April 2012, 42 patients with acute ischemic stroke attributable to MCA and/or ICA occlusion were treated. Eleven patients (26.2%) presented with tandem occlusions and 31 patients (73.8%) had a single anterior circulation occlusion. Baseline characteristics were similar between the two groups. Recanalization status also did not differ significantly (P=0.76), but patients with tandem occlusions had poorer functional outcomes (18.2% vs. 67.7% for single occlusions; P=0.01), a higher mortality rate at 3 months (45.5% vs. 12.9%, respectively; P=0.03) and more symptomatic intracranial hemorrhages at 24h (9.7% vs. 0%, respectively; P=0.01). A high rate of early proximal re-occlusion or severe residual stenosis (66%) was also observed in the tandem group. Tandem occlusions had poor clinical outcomes after mechanical thrombectomy compared with single occlusions. The retrograde approach (treatment of distal occlusion first) used in patients under conscious sedation may have contributed to these poor outcomes.

Randomized Comparison of Sirolimus-Eluting and Everolimus-Eluting Coronary Stents in the Treatment of Total Coronary Occlusions

Patients with coronary total occlusions are at especially high risk for restenosis and new revascularizations. Sirolimus-eluting stents dramatically improved the clinical outcome of this subset of patients in randomized trials, but other drug-eluting stents, mainly the everolimus-eluting stent (currently the most frequently used stent), have not yet been evaluated in patients with coronary total occlusions. The objective was to compare the second-generation everolimus-eluting stent with the first-generation sirolimus-eluting stent in patients with coronary total occlusions. A total of 207 patients with coronary total occlusions and estimated time since occlusion >2 weeks were randomized to everolimus- or sirolimus-eluting stent. The primary end point was in-stent late loss at 9-month angiographic follow-up (noninferiority trial). Clinical follow-up was performed at 1 and 12 months. In-stent late loss at 9 months was 0.29±0.60 versus 0.13±0.69 mm in patients allocated to sirolimus- and everolimus-eluting stent, respectively. The observed difference in in-stent late loss between both groups was -0.16 mm (95% confidence interval, 0.04 to -0.36 mm; P for noninferiority <0.01). The rate of binary angiographic restenosis was 10.8% and 9.1% in patients allocated to sirolimus- and everolimus-eluting stent, respectively (P=0.709), whereas the rate of vessel reocclusion was 3.2% and 1.1%, respectively (P=0.339). At 12 months, the rate of major adverse events was 15.9% versus 11.1% with sirolimus- and everolimus-eluting stent, respectively (P=0.335), and probable or definitive stent thrombosis occurred in 3.0% and 0.0% of patients, respectively (P=0.075). In patients with coronary total occlusions, everolimus-eluting stent is as effective as sirolimus-eluting stent. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00793221.