Revascularization Options Research Articles

Intramyocardial Autologous Bone Marrow-derived Stem Cells Injection for Ischemic Heart Disease Ineligible for Revascularization: A Systematic Review and Meta-analysis

Intramyocardial autologous bone marrow-derived stem cells injection (IM-BMCs) has been used in patients with ischemic heart disease (IHD) who are ineligible for revascularization; however, the procedure has yielded mixed results. The objective of this meta-analysis was to evaluate the safety and therapeutic benefits of this treatment on a relatively large scale. PubMed, EMBASE, and Cochrane Library databases through September 2014 were searched for randomized clinical trials (RCTs) of IM-BMCs to treat IHD. Outcome measures were defined as mortality after treatment, change in left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV) and left ventricular end-diastolic volume (LVEDV). Weighted mean differences for the changes were estimated with a random-effects model. Nine RCTs were eligible for inclusion. IM-BMCs significantly reduced the risk of mortality (RR, 0.33; 95% CI, 0.17-0.65; p = 0.001). IM-BMCs significantly improved LVEF by 2.57% (95% CI, 0.34-4.80%; p = 0.02) and reduced LVESV by 9.67 mL (95% CI, -16.43 mL to -2.91 mL; p = 0.005). No significant improvement in LVEDV (WMD = 4.73 mL; 95% CI, -7.22 mL to 16.68 mL; p = 0.44) was detected in patients who received IM-BMC therapy. IM-BMC therapy showed clinical safety while being used as stand-alone treatment in IHD with no option of revascularization. The therapeutic efficacy requires further confirmation in large well-powered trials with long-term follow-up.

Surgical intervention for peripheral arterial disease.

The prevalence of peripheral arterial disease (PAD) is increasing worldwide, with recent global estimates exceeding 200 million people. Advanced PAD leads to a decline in ambulatory function and diminished quality of life. In its most severe form, critical limb ischemia, rest pain, and tissue necrosis are associated with high rates of limb loss, morbidity, and mortality. Revascularization of the limb plays a central role in the management of symptomatic PAD. Concomitant with advances in the pathogenesis, genetics, and medical management of PAD during the last 20 years, there has been an ongoing evolution of revascularization options. The increasing application of endovascular techniques has resulted in dramatic changes in practice patterns and has refocused the question of which patients should be offered surgical revascularization. Nonetheless, surgical therapy remains a cornerstone of management for advanced PAD, providing versatile and durable solutions to challenging patterns of disease. Although there is little high-quality comparative effectiveness data to guide patient selection, existing evidence suggests that outcomes are dependent on definable patient factors such as distribution of disease, status of the limb, comorbid conditions, and conduit availability. As it stands, surgical revascularization remains the standard against which emerging percutaneous techniques are compared. This review summarizes the principles of surgical revascularization, patient selection, and expected outcomes, while highlighting areas in need of further research and technological advancement.

Classification Systems for Lower Extremity Occlusive Disease

The management of lower extremity occlusive disease involves some of the most complex decision making in the field of vascular surgery. Patients with lower extremity occlusive disease often present with a wide spectrum of clinical manifestations ranging from mild intermittent claudication to severe ischemia with gangrene. Moreover, the prognosis and clinical management are dependent on the location and extent of the atherosclerotic disease burden, the presence of comorbid conditions that affect life expectancy and procedural patency, the revascularization options available, and the functional status of the patient. In an effort to bring order to this challenging disease, a number of lower extremity classification systems have been developed. This review discusses challenges of establishing a classification system, anatomic classification systems, classification systems based on presenting symptoms/clinical presentation, morbidity/mortality risk stratification systems, and disability classification systems. Tables outline the Society for Vascular Surgery runoff score, clinical categories of acute limb ischemia, Rutherford clinical categories of chronic limb ischemia, Fontaine clinical stages of chronic limb ischemia, LEGS (Lower Extremity Grading System) score used to recommend invasive treatment for patients with chronic lower extremity ischemia, WIfI (Wound Ischemia foot Infection) classification system grades, consensus estimate of 1 year amputation risk and likelihood of benefit of/requirement for revascularization based on WIfI spectrum score, predicted and observed 1-year outcomes (limb amputation, wound nonhealing) based on WIfI clinical stage classification, morbidity and mortality risk stratification methods, US social security administration disability criteria for patients with lower extremity occlusive disease and amputation, and criteria for rating impairment due to lower extremity peripheral vascular disease. Figures illustrate the TransAtlantic Inter-Society Consensus classification of aortoiliac and femoropopliteal lesions and Graziani System classes of progressive vascular disease severity and distribution in patients with diabetes mellitus presenting with foot wounds. This review contains 3 figures, 11 tables, and 35 references.

A single stent strategy in patients with lifestyle limiting claudication: 3-year results from the Durability II trial.

ObjectivesTo evaluate longer‐term safety and efficacy of a single self‐expanding stent up to 20 cm in length in patients with atherosclerotic disease of the superficial femoral (SFA) and proximal popliteal arteries.BackgroundAngioplasty and stenting are options for revascularization of symptomatic peripheral artery disease. While angioplasty alone is effective in short lesions, outcomes in longer lesions (i.e., mean 8.7 cm) show suboptimal patency rates of 33% at one year.MethodsTwo hundred eighty‐seven patients (mean age 68 years, 66% male) were treated with the EverFlex™ Self‐Expanding Peripheral Stent System. Patients were followed through 3 years with yearly core lab adjudicated duplex ultrasonography for patency, radiographic assessment of stent fractures, and resting ankle brachial indices.ResultsOverall freedom from loss of primary patency at 3 years was 60.0%. Patency was significantly higher for lesions ≤8 cm compared with lesions >8 cm (71.0 vs. 50.5%, P < 0.0001). There was no significant difference in patency between single‐stent and multistent recipients (60.4 vs. 52.4%, P = 0.343). The three‐year freedom from clinically driven target lesion revascularization was 70.0%. At 3 years, the overall stent fracture rate was 0.9%.ConclusionsDURABILITY II is the first investigational device exemption trial to report 3‐year duplex Doppler defined stent patency and CD‐TLR outcomes in long SFA and proximal popliteal lesions and demonstrated acceptable stent patency and freedom from CD‐TLR with a low fracture rate. These data suggest that use of a single long stent provides reasonable long‐term outcomes when intervention is required for symptomatic SFA and proximal popliteal arterial disease. © 2015 Wiley Periodicals, Inc.

How to balance risks and benefits in the management of CKD patients with coronary artery disease.

Chronic kidney disease (CKD) is associated with a high burden of coronary artery disease (CAD), which remains the most common cause of morbidity and mortality in CKD patients. Although the management of CAD is more challenging in patients with CKD than in the general population, and coupled with concerns about further deterioration of renal function and therapy-related toxic effects, CKD patients and those receiving dialysis have not traditionally been included in randomized trials evaluating either medical or revascularization therapies. Thus, only scant data from small prospective studies or retrospective analyses of controlled trials and registries are available, and to date no optimal treatment approach has been defined for this subgroup of patients. However, they potentially have much to gain from the pharmacological, interventional, and surgical strategies used in the general population. Thus, the objective of this review is to summarize the current evidence regarding the management of CAD in CKD patients, in particular with respect to uncertainties regarding coronary revascularization options, and their risk-benefit relationship in such a high-risk population.

Outcomes of On-Pump versus Off-Pump Coronary Artery Bypass Graft Surgery in the High Risk (AusSCORE > 5)

Coronary artery bypass graft surgery (CABG) has been established as the preferred intervention for coronary revascularisation in the high-risk population. Off-pump coronary artery bypass (OPCAB) may further reduce mortality and morbidity in this population subgroup. This study presents the largest series of high-risk (AusSCORE > 5) OPCAB patients in Australia and New Zealand. We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for high-risk patients (n=7822) undergoing isolated CABG surgery and compared the on-pump coronary artery bypass (ONCAB) (n=7277) with the OPCAB (n=545) technique. Preoperative and intraoperative risk factors, and postoperative outcomes were analysed. Survival analysis was performed after cross-matching the database with the national death registry to identify long-term mortality. The ONCAB and OPCAB groups had similar risk profiles based on the AusSCORE. Thirty-day mortality (ONCAB vs OPCAB 3.9% vs 2.4%, p=0.067) and stroke (ONCAB vs OPCAB 2.4% vs 1.3%, p=0.104) were similar between the two groups. OPCAB patients received fewer distal anastomoses than ONCAB patients (2.5±1.2 vs 3.3±1.0, p<0.001). The rates of new postoperative atrial arrhythmia (28.3% vs 33.3%, p=0.017) and blood transfusion requirements (52.1% vs 59.5%, p=0.001) were lower in the OPCAB group, while duration of ICU stay in hours (97.4±187.8 vs 70.2±152.8, p<0.001) was longer. There was a non-significant trend towards improved 10-year survival in OPCAB patients (74.7% vs. 71.7%, p=0.133). In the high-risk population, CABG surgery has a low rate of mortality and morbidity suggesting that surgery is a safe option for coronary revascularisation. OPCAB reduces postoperative morbidity and is a safe procedure for 30-day mortality, stroke and long-term survival in high-risk patients.

CRT-153 Defining Optimal Stent Overexpansion Strategies for Left Main PCI- Insights from bench testing

With improved percutaneous coronary intervention (PCI) techniques, PCI has emerged to be a safe option for revascularization with good long term outcomes in selected patients with unprotected left main coronary artery (uLMCA) lesions. Overexpansion beyond nominal size is a common procedure to ensure

Spliced Arm Vein Grafts Are a Durable Conduit for Lower Extremity Bypass

Many patients with peripheral vascular disease (PAD) requiring revascularization do not have adequate ipsilateral great saphenous vein (GSV) for constructing a bypass because of intrinsic vein disease or prior harvesting for limb or coronary bypass. Prosthetic conduits have poor long-term patency, especially for distal bypass. With advancing endovascular sophistication, tibial angioplasty may be a good revascularization option, but we hypothesize that using spliced arm vein for distal lower extremity bypass is still a well-tolerated and more durable solution. A retrospective chart review was conducted of all PAD patients undergoing lower extremity bypass or tibial angioplasty for lifestyle-limiting claudication or critical limb ischemia at a single institution over a 7-year period. Statistical analysis was conducted by Kaplan-Meier survival analysis and Cox proportional hazards model. Statistical significance was set at P=0.05. From 2005 to 2012, there were 120 patients who underwent infrageniculate revascularization with conduit other than GSV. Over half of the patients (66 patients, 71.2% male, mean age 62 years) underwent bypass operations using arm vein conduit, and 88% of those bypasses were to tibial vessels. Patency was 100% at 1 year and 85% at 2 years. There was no impact on patency or amputation rate based on the source of vein or the number of splices. Forty-three patients underwent tibial angioplasty and patency was 70% at 1 year and 50% at 2 years. When GSV is not available, spliced arm vein grafts provide durable lower extremity revascularization with favorable patency and limb preservation rates. Spliced arm vein grafts should be considered over prosthetic grafts and angioplasty alone in patients with distal occlusive disease.

Appropriate use of bioresorbable vascular scaffolds in percutaneous coronary interventions: a recommendation from experienced users : A position statement on the use of bioresorbable vascular scaffolds in the Netherlands.

Percutaneous coronary interventions (PCI) have become a reliable revascularisation option to treat ischaemic coronary artery disease. Drug-eluting stents (DES) are widely used as first choice devices in many procedures due to their established good medium to long term outcomes. These permanent implants, however, do not have any residual function after vascular healing following the PCI. Beyond this initial healing period, metallic stents may induce new problems, resulting in an average rate of 2 % reinterventions per year. To eliminate this potential late limitation of permanent metallic DES, bioresorbable coronary stents or ‘vascular scaffolds’ (BVS) have been developed. In a parallel publication in this journal, an overview of the current clinical performance of these scaffolds is presented. As these scaffolds are currently CE marked and commercially available in many countries and as clinical evidence is still limited, recommendations for their general usage are needed to allow successful clinical introduction.

Results of combined vascular reconstruction and free flap transfer for limb salvage in patients with critical limb ischemia

Combined vascular reconstruction and free flap transfer has been established in centers as a feasible therapeutic option in cases with critical limb ischemia (CLI) and large tissue defects otherwise destined for major amputation. However, the number of patients treated with this combined approach is limited, and data regarding long-term follow-up and functional outcome are scarce. We therefore report our 10-year experience in free flap transplantation after vascular reconstruction as a last attempt for limb salvage, with special emphasis of complication rate, limb salvage, and postoperative mobility. CLI patients undergoing combined vascular reconstruction and consequent free flap transfer from 2003 to 2013 were retrospectively observed. Of 80 cases in total, patients with traumatic and oncologic indications were excluded; 33 (mean age, 66 years; range, 51-82 years) of these cases were performed for limb salvage and were included in this study. Long-term follow-up was possible in 32 of 33 patients (mean, 58 months; range, 2-126 months). Thirty-three patients were analyzed. We performed arterial revascularization with 9 arteriovenous loops, 23 bypass grafts (10 popliteal-pedal, 9 femoral-crural, and 4 femoral-popliteal), and 1 venous interposition graft. For defect coverage, tissue transfer was comprised of six different flap entities (10 latissimus dorsi, 2 gracilis, 1 anterior lateral thigh, 7 rectus abdominis, 11 radialis, and 2 greater omentum flaps). Complications occurred in 16 of 33 patients (49%). Early complications included eight acute occlusions of arterial reconstructions; major bleedings were seen in eight patients as well. There were two flap losses and one major amputation in the early postoperative period. No in-hospital deaths were observed. Late results revealed a limb salvage rate of 87% after 1 year and 83% after 5 years. Amputation-free survival was 87% after 1 year and 75% after 5 years. Overall survival was 100% and 87% after 1 year and 5 years, respectively. Follow-up showed 42% of patients with no limitations in ambulation, 54% with maintained preoperative ambulatory status, and one bedridden patient. The combined approach for limb salvage in CLI patients is associated with excellent results in limb salvage and functional outcome in patients who would otherwise be candidates for major amputation, despite an initially elevated complication rate. The option of combined revascularization with free tissue transfer should be evaluated in all mobile patients with CLI, large tissue defects, and exposed tendon or bone structures before major amputation. However, further studies are required to support these results.

Impact of Pharmacologic Interventions on Peripheral Artery Disease

Pharmacologic interventions are an integral component of peripheral artery disease (PAD) management, supported by high-quality clinical studies. Those affected by this potentially debilitating and life-threatening disease process often have multiple contributing conditions, such as tobacco abuse, diabetes, hypertension, and hyperlipidemia. In addition to medications aimed at improving claudication symptoms, risk factor modification and appropriate use of antiplatelet agents are essential to decreasing rates of major adverse clinical events and improving vessel patency following intervention. While lower extremity PAD is increasingly recognized as a prevalent condition, affected individuals remain undertreated with optimal pharmacotherapy. Novel approaches to treatment of PAD include stem cell therapy, which may play a beneficial role in those with minimal revascularization options but disease placing them at high risk for limb amputation. Additionally, timely initiation of optimal pharmacotherapy represents a cost-effective approach to management of this chronic condition.

Stem cell therapy to treat heart ischaemia: implications for diabetes cardiovascular complications.

Diabetes mellitus is a well-known risk factor for coronary artery disease (CAD), which can lead to acute myocardial infarction, chronic myocardial ischaemia and heart failure. Despite the advantages in medical treatment, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), morbidity and mortality is still high in patients with CAD. Along with PCI and CABG or in patients without options for revascularization, stem cell regenerative therapy in controlled trials is a possibility. Stem cells are believed to exert their actions by angiogenesis and regeneration of cardiomyocytes. Recently published clinical trials and meta-analysis of stem cell studies have shown encouraging results with increased left ventricle ejection fraction and reduced symptoms in patients with CAD and heart failure. There is some evidence of mesenchymal stem cell being more effective compared to other cell types and cell therapy may be more effective in patients with known diabetes mellitus. However, further investigations are warranted.

What can I do with a patient with diabetes and critically impaired limb perfusion who cannot be revascularized?

A patient with limb-threatening diabetic foot syndrome in whom relevant peripheral arterial occlusive disease is proven should receive arterial revascularization as soon as possible to avoid major amputation. However, 3 conditions may make it impossible to effectively restore limb perfusion: the patient will not profit from arterial revascularization owing to excessive tissue loss or sepsis ("too late"), the patient cannot be revascularized due to severe comorbidities ("too sick"), and arterial reconstruction is impossible because of technical and anatomical shortcomings in a patient who is otherwise fit for operation ("nonreconstructible limb perfusion"). This review outlines the therapeutic options specifically in the third group of patients in whom no technical option for surgical or endovascular revascularization exists.

Endovascular thrombectomy and stenting in the management of carotid fibromuscular dysplasia presenting with major ischemic stroke

Fibromuscular dysplasia (FMD) affecting the internal carotid artery (ICA) is considered a benign condition; however, retinal and cerebral ischemic events may occur. We present a patient with carotid FMD presenting with a major ischemic stroke due to major embolic occlusion of the ICA in conjunction with a hemodynamic component caused by narrowing and beading of the lumen associated with FMD. The patient was successfully treated with intracranial stent-assisted thrombectomy followed by cervical ICA stenting that aimed to reconstruct and angioplasty the FMD-affected arterial segment. Recently, stent-based thrombectomy has emerged as the most effective endovascular option for the rapid revascularization of major intracranial occlusions; however, to our knowledge, its use in a rare case of FMD-associated major stroke has not yet been reported.

Outcome of coronary artery bypass grafting in a tertiary-care center in Pakistan.

Coronary artery bypass grafting and percutaneous coronary intervention are revascularization options for significant coronary artery disease. While international data support the use of coronary artery bypass in high-risk groups, regional data on outcomes in these groups are rare. We conducted a retrospective study to determine the outcomes of patients undergoing coronary artery bypass for left main and multivessel disease. Two thousand eight hundred and fifty-one patients undergoing coronary artery bypass at the Aga Khan University Hospital from 2006 to 2013 were included; patients undergoing redo surgery were excluded. Demographic data, comorbidities, angiography findings, in-hospital complications, one-month and one-year follow-up were analyzed. Of the 2851 patients, 568 had left main disease (group 1) and 2283 (group 2) had multivessel disease (≥2 vessels excluding the left main). Group 1 had significantly more chronic lung disease, cardiogenic shock, and congestive heart failure than group 2 (p < 0.001); 50.6% of patients were diabetic and 71.8% were hypertensive. Mortality was 5.1% and 2.2% during hospital stay, 6.5% and 2.6% at 30 days, and 6.7% and 2.7% at 1 year in groups 1 and 2, respectively. Our comparable results and international data advocate revision of the current practice of using percutaneous coronary intervention over coronary artery bypass in the developing world. Institutional results are essential to determine the outcome of coronary artery bypass in high-risk populations with a high burden of diabetes and hypertension. We noted increased complications and mortality in patients with left main rather than multivessel disease.

Bone marrow aspirate injection for treatment of critical limb ischemia with comparison to patients undergoing high-risk bypass grafts

Bone marrow cell therapy (BMCT) for patients with critical limb ischemia (CLI) is a potential treatment in candidates with poor options for standard revascularization procedures. Whereas clinical trials are ongoing, there are few comparative data to assess its efficacy compared with bypass. Patients with poor revascularization options underwent BMCT between 2011 and 2013. Outcomes were compared with those of a cohort of CLI patients undergoing infrainguinal bypass thought to be at high risk for graft failure (tissue loss, a tibial target, and a previous endovascular treatment or bypass). BMCT patients underwent harvest of bone marrow that was then concentrated and injected intramuscularly into the ischemic limb. There were 20 BMCT patients and 35 high-risk bypass patients. All BMCT patients had either rest pain (80%) or tissue loss (80%). The majority (65%) had a prior intervention (bypass, 30%; endovascular, 58%) compared with high-risk bypass patients, all of whom had previous revascularization attempts (bypass, 43% [P = .35]; endovascular, 77% [P = .14]). Mean follow-up was 773 days after BMCT and 972 days after high-risk bypass. All patients tolerated BMCT without issues or complications. A second BMCT treatment was performed in 21% because of clinical deterioration. Wound healing occurred in 75% at 1.5 years, including patients receiving second injections, all of which resolved. Rest pain improved in 87.5% of patients. Pain completely resolved in 58% at 1.5 years. Ankle-brachial index improvement was 0.23 (±0.25). Three BMCT patients went on to amputation. One-year freedom from major amputation or death was 78% for BMCT vs 69% for high-risk bypass (P = .60). BMCT is a potential option in CLI patients who are not candidates for bypass or endovascular intervention. Limb salvage is unexpectedly high in this population with few other options.

Autologous bone marrow mononuclear cell therapy improves symptoms in patients with end-stage peripheral arterial disease and reduces inflammation-associated parameters

Background aimsThe purpose of this study was to evaluate the effect of autologous bone marrow mononuclear cells (BM-MNCs) on symptoms and perfusion indices in severely symptomatic patients with peripheral arterial disease (PAD) without further option for endovascular or surgical revascularization. MethodsOnly patients with severe symptomatic PAD (Fontaine class IIb-IV, Rutherford category 3–6) not amenable for revascularization were treated. Bone marrow from both cristae iliacae was harvested; MNCs were isolated by the Ficoll density-gradient method and transplanted by means of intra-arterial and intramuscular injection in the index limb. Functional (pain score, ulcer healing, maximum walking distance) and perfusion indices such as ankle-brachial-index and transcutaneous oxygen pressure were documented before and after BM-MNC therapy. Additionally, serum concentration of C-reactive protein and interleukin-6 were measured as markers of inflammation before and after BM-MNC treatment. ResultsSixteen consecutive patients (four women; mean age, 63.0 ± 13 years) were treated with a mean dose of 4.2 ± 2.2 × 108 BM-MNCs. At 6 months' follow-up, ankle-brachial-index, transcutaneous oxygen pressure and maximum walking distance significantly increased, whereas C-reactive protein and interleukin-6 conversely decreased (P < 0.01 versus baseline values), resulting in 88% limb salvage, 75% pain reduction and 71% complete wound healing and/or reduction of ulcer size. One major and one minor amputation were performed, both in patients with Rutherford category 6. ConclusionsAutologous BM-MNC therapy in patients with end-stage PAD improves tissue perfusion indices and decreases markers of inflammation. If our observations could be confirmed by large-scale, randomized controlled trials, BM-MNC transplantation could become an alternative therapeutic option for patients with end-stage PAD.

Clinical effectiveness of gene therapy on critical limb ischemia: a meta-analysis of 5 randomized controlled clinical trials.

Therapeutic angiogenesis using gene therapy is a novel strategy for the treatment of critical limb ischemia (CLI). We conducted a meta-analysis to evaluate the efficacy and safety of gene therapy for the treatment of CLI with no option of revascularization. Randomized placebo controlled trials of gene therapy on CLI were identified by searching PubMed (from 1990 to October 2013) and EMBASE (from 1990 to October 2013). Five eligible studies were selected for the meta-analysis. Among these studies, a total of 425 patients received gene therapy of either fibroblast growth factor 1 or hepatocyte growth factor, and 365 patients were given placebo. No statistical differences were observed between the 2 groups in major amputation or death at 1 year (risk ratio [RR], 0.83; 95% confidence interval [CI], 0.51-1.39; P = .48) and wound healing at 6 months (RR, 1.55; 95% CI, 0.73-3.28; P = .25). Gene therapy had similar occurrence of serious adverse events as control (RR, 1.05; 95% CI, 0.97-1.14; P = .23).

Transcatheter intervention in carotid artery disease: when and how?

In general population, in 5.7% of patients between 70 and 80 years of age and 9.5% of patients over 80 years of age, carotid stenosis over 50% is diagnosed. Carotid stenosis can be asymptomatic or diagnosed when TIA (transient ischemic attack) or cerebral stroke occurs (symptomatic). In patients with symptomatic carotid stenosis, the risk of recurrent stroke is much higher. Carotid stenosis could be easily and promptly diagnosed with Doppler ultrasound, CT scan or MR imaging. The degree of stenosis, morphology and homogeneity of adjacent plaque, presence of thrombus, intracranial pathologies and asymptomatic cerebral embolic events must be evaluated. Optimal medical treatment has to be provided to patients, both with symptomatic and asymptomatic carotid stenosis. Antiplatelet and statin therapy should be administered to all patients, irrespective of symptoms or disease progression. Risk factors (arterial hypertension, diabetes, obesity, smoking etc.) must be recognized and promptly cured. Although many large scale trials (CAVATAS, EVA-3S, ICSS, SAPPHIRE, CREST, etc.) recognize carotid endarterectomy advantages in the treatment of carotid stenosis, carotid stenting as a revascularization option has its place in certain subgroups of patients. The patients with high perioperative risk, infavourable neck anatomy, prior neck dissection, restenosis after carotid endarterectomy or post-irradiation stenosis benefit from transcatheter interventions. The aim of this research is to explore the indications and to detail the most used techniques in carotid artery stenosis transcatheter interventions.

Complex percutaneous coronary intervention for unprotected distal left main bifurcation lesion in a patient with cardiac allograft vasculopathy

Introduction: Cardiac allograft vasculopathy (CAV) is a progressive form of coronary disease that defines the long term prognosis in heart transplant patients. The mortality of surgical revascularization in post-transplant patients is very high. Percutaneous coronary intervention (PCI) has a relatively low periprocedural mortality and high acute angiographic success, but still high restenosis rate and poor long-term results. Bypass surgery (CABG) is considered the gold-standard for unprotected left main coronary artery (LMCA) disease in non-transplant patients, especially with the distal bifurcation lesion. Optimal PCI techniques are needed to improve the results and complex double kissing crush technique seems to be promising. Case Report: We present a case of a 27-year-old patient who received heart transplant at the age of 24. During the second post-transplant year, he developed acute inferior ST-elevation myocardial infarction and primary PCI of RCA was performed. An eccentric LMCA stenosis with an involvement of large ramus intermedius (RI) and almost occluded, minor left circumflex (LCx) were detected on control angio. We decided to perform PCI on this complex lesion with double kissing crush technique. Two wires were positioned distally to the lesions in both the LAD and ramus intermedius (RI). A stent was positioned in the RI with few proximal millimeters protruding into the LMCA, a balloon with a length long enough to cover the protruding stent segment was concurrently positioned in the LAD. The RI stent was deployed. The SB stent-balloon and wire were removed. The balloon in LAD was then inflated at a high pressure to crush the protruding RI stent. The RI ostium was rewired and dilated with a balloon. The bifurcation was then kissed with two balloons. Afterwards, a stent was deployed in the LMCA toward LAD at a high pressure. The RI ostium was rewired for the second time through the LMCA stent strut and dilated with a balloon at a high pressure. The final kissing balloon inflation in the bifurcation was performed at a high pressure and finished with proximal optimization of LMCA. The control angio performed 6 months later showed no signs of restenosis. Summary: The treatment of CAV is very challenging and while CABG remains a poor revascularization option, PCI of complex lesions such as those of LMCA require optimal technique to reduce the incidence of adverse cardiac events and prevent further graft deterioration.