Safety Of Percutaneous Transluminal Angioplasty Research Articles

Iliofemoral artery predilation prior to transfemoral transcatheter aortic valve implantation in patients with aortic valve stenosis and advanced peripheral artery disease

To investigate the feasibility and safety of percutaneous transluminal angioplasty (PTA) of the iliofemoral arteries (IFA) before transfemoral transcatheter aortic valve implantation (Tf-TAVI) in patients with advanced peripheral artery disease (PAD). Although Tf-TAVI represents the access of choice, alternative vascular access routes are preferred for patients displaying advanced PAD. PTA of the IFA represents a less invasive option, broadening the spectrum of patients eligible for Tf-TAVI. All patients requiring PTA of the IFA before Tf-TAVI, between 2012 and 2021, were included. Primary efficacy endpoint was the rate of successful transcatheter heart valve (THV) delivery and implantation. Primary safety endpoint was the rate of PTA and access-site-related vascular complications, procedural- and in-hospital complications. Among 2726 Tf-TAVI procedures, 59 patients required IFA predilation. Successful THV delivery and implantation was achieved in 57 (96.6%) patients, respectively. Sheath placement was achieved in 59 (100%) patients with only one minor dissection and no major vascular complications following iliofemoral PTA. Regarding access site complications, two (3.4%) vessel perforations and one (1.7%) vessel rupture were observed, with eight (13.5%) patients requiring unplanned endovascular interventions. There was one intraprocedural death due to THV-induced vessel laceration, while in-hospital all-cause mortality was 8.5% in the present high-risk patient cohort. Predilation of IFA is safe and effective in patients with advanced PAD. Careful preprocedural planning is paramount in improving procedural safety and efficacy. This strategy has the potential to broaden the spectrum of patients eligible for Tf-TAVI.

A single-centre, retrospective analysis of mortality over 80 months comparing paclitaxel-coated balloon versus standard balloon angioplasty in the treatment of dysfunctional arteriovenous access.

Percutaneous transluminal angioplasty (PTA) is a standard treatment for arteriovenous fistula (AVF) stenosis to preserve haemodialysis vascular access, promoting improved dialysis adequacy and better outcomes for those dependent on renal replacement therapy. Drug coated balloons (DCB) may help reduce the rate of neointimal hyperplasia and recurrent stenosis, but their use in femoropopliteal angioplasty has been associated with increased mortality at 2 and 5 year follow-up. This study aims to address the long-term safety of PTA for AVF stenosis with clinical correlation to participant co-morbidity and mortality. All patients undergoing PTA for AVF stenosis at a single centre between 2013 and 2017 were identified and grouped according to the use of DCB versus standard balloon angioplasty. All data was anonymised and correlated to verify independent predictors of mortality. 481 (400 standard balloon; 81 DCB) procedures were performed in 313 patients (250 standard balloon; 63 DCB). Follow-up at 80 months did not show any difference in mortality (p = 0.546). Multivariate analysis identified time on dialysis (p < 0.001), age (p = 0.001) and Charlson comorbidity index (p = 0.02) as independent predictors of mortality. In this study, mortality was not associated with the use of DCBs, but was related to established factors of dialysis longevity, age and comorbidity.

Outcomes of Venoplasty-Assisted, Peripherally Inserted Central Catheter Placement in Patients with Upper-Arm Venous Stenosis: Comparison with Midlines and Contralateral Placement

PurposeTo compare the effectiveness and safety of percutaneous transluminal angioplasty and peripherally inserted central catheter (PTA + PICC), contralateral PICC, and midline catheterization (MC) in patients with venous stenosis. Materials and MethodsA total of 7,327 PICC procedures were performed in 5,421 patients at a single institution between 2013 and 2019. Among them, 87 patients had upper-arm venous stenoses and were managed with PTA + PICC, contralateral PICC, or MC. Data on catheter-dwell time, clinical success rate, and adverse events were recorded. The procedure was considered to have clinically succeeded when a PICC was removed from the patient just before discharge or after the completion of therapy. Catheter survival time and the chance of adverse events were compared among the groups using the Kaplan-Meier method and log-rank test. ResultsPTA + PICC, contralateral PICC, and MC procedures were performed for 57 (65.5%, 57/87), 10 (11.5%, 10/87), and 20 (23.0%, 23/87) patients, respectively. The mean catheter-dwell time in the PTA + PICC, contralateral PICC, and MC groups was 49.7, 28.7, and 15.1 days, respectively, and the clinical success rate of each group was 86.0% (49/57), 80.0% (8/10), and 50.0% (10/20). The PTA + PICC group had a significantly longer catheter survival time than the MC group (P < .001). The chance of a catheter-related infection (P = .008) was significantly lower in the PTA + PICC group than in the MC group. ConclusionsPTA + PICC or contralateral PICC should be considered prior to ipsilateral MC when venous stenosis is encountered during PICC procedures.

Clinical and Diagnostic Profile and Management of Inferior Vena Cava Obstruction- A Descriptive Study at a Tertiary Care Centre, Hyderabad

Introduction: Obstruction to hepatic venous outflow is a rare disease with a potentially fatal outcome, if not recognised and managed promptly. The level of obstruction can vary, anywhere from the small hepatic venules to the entry point of the Inferior Vena Cava (IVC) into the right atrium. The original patients that Budd-Chiari described had acute hepatic vein thrombosis but this syndrome now encompasses various hepatic venous outflow blocks, of which a membrane in the IVC is the most common anatomical form of obstruction. Pure IVC obstruction is commonly seen among Asians. Aim: To study the clinical and diagnostic profile of patients presenting with IVC obstruction and to evaluate the treatment efficacy and safety of percutaneous transluminal angioplasty. Materials and Methods: For this prospective, descriptive study, from November 2015 to August 2019, a total of 21 patients were admitted with obstruction of hepatic venous flow. Most of the patients were young adults. Clinical features, aetiologies and coagulation profiles were studied. Ascites, pain abdomen and pedal oedema were common presentations. Diagnosis was established by clinical examination and was confirmed by ultrasound-doppler study, computed tomography and conventional angiography. Statistical analysis was done by using statistical package for social sciences IBM SPSS statistics for Windows, version 20.0. The data were expressed as percentages of study population while, continuous data were expressed as mean±standard deviation. Results: The mean age of the population was 24.7±2.9 years, with a female preponderance. (male: female=1:2). IVC angiography was done in 15 patients. Seven of the 15 patients had diffuse narrowing of IVC. Eight patients had focal or segmental narrowing of IVC, among them seven patients underwent Percutaneous Transluminal Angioplasty (PTA) with stenting. The venous access was obtained from femoral vein. The stenoses were crossed with either guide wire or Brocken brough needle with Mullins sheath. Three patients did not need predilatation. In four patients, obstructed IVC was dilated with Inoue balloon and then self-expanding stents were placed. Success was achieved in all cases, with significant drop in the pressure gradients from 20±5 mmHg before procedure to 3±2 mmHg immediately after the procedure. After PTA, all seven patients had either total relief or decrease of symptoms and clinical signs of hepatic venous obstruction. No major complications were observed and no repeat interventions were required. The mean postprocedural follow-up was six months that showed good outcomes with good stent patency. Conclusion: Chronic obstruction of IVC presents with abdominal pain, progressive ascites and portal hypertension in young adults, with mild abnormality of liver function tests. The IVC obstruction can be due to an obstructive membrane or segmental stenosis or diffuse narrowing of IVC. PTA with stenting can be done safely and it effectively relieves the symptoms and venous congestion and can be considered as the first line decompressive procedure in patients with IVC stenosis.

Angioplasty versus stenting for infrapopliteal arterial lesions in chronic limb-threatening ischaemia.

Chronic limb-threatening ischaemia (CLTI) is a manifestation of peripheral arterial disease (PAD) that includes chronic ischaemic rest pain or ischaemic skin lesions, ulcers, or gangrene for longer than two weeks. The severity of the disease depends on the extent of arterial stenosis and the availability of collateral circulation. Treatment for CLTI aims to relieve ischaemic pain, heal ischaemic ulcers, prevent limb loss, improve quality of life, and prolong survival. CLTI due to occlusive disease in the infrapopliteal arterial circulation (below-knee circulation) can be treated via an endovascular technique by a balloon opening the narrowed vessel, so called angioplasty, with or without the additional deployment of a scaffold made of metal alloy or other material, so called stenting. Endovascular interventions in the infrapopliteal vasculature may improve symptoms in patients with CLTI by re-establishing in-line blood flow to the foot. Controversy remains as to whether a balloon should be used alone to open the vessel, or whether a stent should also be deployed.To determine the efficacy and safety of percutaneous transluminal angioplasty (PTA) alone versus PTA with stenting of infrapopliteal arterial lesions (anterior tibial artery, posterior tibial artery, fibular artery (formerly known as peroneal artery), and common tibioperoneal trunk) for patients with chronic limb-threatening ischaemia (CLTI).The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, as well as World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 25 June 2018. We applied no language restrictions.We planned to include randomised or quasi-randomised controlled trials comparing PTA versus PTA with a stent and including patients aged 18 years or over with CLTI. We defined CLTI as Fontaine stage III (ischaemic rest pain) and IV (ischaemic ulcers or gangrene) or consistent with Rutherford category 4 (ischaemic rest pain), 5 (minor tissue loss), and 6 (major tissue loss), with stenotic (> 50% luminal loss) or occluded infrapopliteal artery, including tibiofibular trunk, anterior tibial artery, posterior tibial artery, and fibular artery. We included all types of stents irrespective of design (e.g. bare-metal, drug-eluting, bio-absorbable).Two review authors (CC-TH and GNCK) independently selected suitable trials, assessed trial quality, and extracted data. An additional third review author (MLvD) assessed trial quality and, when necessary, acted as arbiter for study selection and data extraction. Outcomes included technical success of the procedure, procedural complications, patency, major amputation, and mortality. We assessed the quality of evidence using the GRADE approach.We included in the review seven trials with 542 participants. One trial randomised limbs to undergo PTA alone or PTA with stent placement, and the remaining studies randomised participants. Five trials with 476 participants show that the technical success rate was greater in the stent group than in the angioplasty group (odds ratio (OR) 3.00, 95% confidence interval (CI) 1.14 to 7.93; 476 lesions; 5 studies; I² = 23%). Meta-analysis of three eligible trials with 456 participants did not show a clear difference in short-term (within six months) patency between infrapopliteal arterial lesions treated with PTA and those treated with PTA and stenting (OR 0.88, 95% CI 0.37 to 2.11; 456 lesions; 3 studies; I² = 77%). Results also did not show clear differences between treatment groups in procedure complication rate (OR 0.87, 95% CI 0.01 to 53.60; 360 participants; 5 studies; I² = 85%), rate of major amputations at 12 months (OR 1.34, 95% CI 0.56 to 3.22; 306 participants; 4 studies; I² = 0%), and rate of mortality at 12 months (OR 0.71, 95% CI 0.43 to 1.17; 497 participants; 6 studies; I² = 0%). Heterogeneity between studies was high for the outcomes procedure complications and primary patency. The overall methodological quality of the trials included in this review was moderate due to selection and performance bias. Studies used different regimens for pretreatment and post-treatment antiplatelet/anticoagulant medication. We downgraded the certainty of the overall evidence for all outcomes by one level to moderate due to inconsistency of results across studies and large confidence intervals (small numbers of trials and participants).Trials show that the immediate technical success rate of restoring luminal patency is higher in the stent group but reveal no clear differences in short-term patency at six months between infrapopliteal arterial lesions treated with PTA with stenting versus those treated with PTA without stenting. We ascertained no clear differences between groups in periprocedural complications, major amputation, and mortality. However, use of different regimens for pretreatment and post-treatment antiplatelet/anticoagulant medication and the duration of its use within and between trials may have influenced the outcomes. Limited currently available data suggest that high-quality evidence is insufficient to show that PTA with stent insertion is superior to use of standard PTA alone without stenting for treatment of infrapopliteal arterial lesions. Further studies should standardise the use of antiplatelets/anticoagulants before and after the intervention to improve the comparability of the two treatments.

The impact of the double blinded randomized control trial Brave Dreams on the nursing staff

The objective of this study is a qualitative pilot survey to evaluate the impact of the double-blinded randomized controlled surgical trial Brave Dreams on the nursery staff. Chronic cerebrospinal venous insufficiency (CCSVI) is a condition frequently associated to multiple sclerosis, and characterized by impaired venous drainage of the brain and spinal cord as a result of outflow obstruction in the extracranial venous system. The trial was of paramount importance, because the main objective was to test whether re-establishing a correct venous drainage could have therapeutic implications for multiple sclerosis patients, when the disease was associated to CCSVI. Basically, Brave Dreams assessed the efficacy and safety of percutaneous transluminal angioplasty of extracranial veins. To assess the impact of the trial on the nursery staff, an ad hoc questionnaire was used to test a sample of 8 nurses. The tests investigated 5 macro areas: i) managing of patient assistance; ii) how the research team trained the nursery staff; iii) unmasking efficacy; iv) the overall satisfaction of the nursery staff; v) possible introduction of subjects that explain the methodology of clinical trials during degree nursing education. Data analysis showed that assistance in a trial context must be personalized and based on primary nursing principles. It also showed that staff training was extremely satisfying and helpful to the study successful outcome. Furthermore, it showed that each patient was convinced to have undergone a percutaneous transluminal angioplasty, and not a sham procedure. Moreover, the survey showed a strong synergy between the patients and the nursery staff involved in the study. Our conclusions are to examine in depth the notions of professional deontology, ethical behavior and patients’ psychology whenever nurses are called to take part in clinical randomized trials.

Transplant renal artery stenosis: clinical manifestations, diagnosis and therapy.

Transplant renal artery stenosis (TRAS) is a well-recognized vascular complication after kidney transplant. It occurs most frequently in the first 6 months after kidney transplant, and is one of the major causes of graft loss and premature death in transplant recipients. Renal hypoperfusion occurring in TRAS results in activation of the renin–angiotensin–aldosterone system; patients usually present with worsening or refractory hypertension, fluid retention and often allograft dysfunction. Flash pulmonary edema can develop in patients with critical bilateral renal artery stenosis or renal artery stenosis in a solitary kidney, and this unique clinical entity has been named Pickering Syndrome. Prompt diagnosis and treatment of TRAS can prevent allograft damage and systemic sequelae. Duplex sonography is the most commonly used screening tool, whereas angiography provides the definitive diagnosis. Percutaneous transluminal angioplasty with stent placement can be performed during angiography if a lesion is identified, and it is generally the first-line therapy for TRAS. However, there is no randomized controlled trial examining the efficacy and safety of percutaneous transluminal angioplasty compared with medical therapy alone or surgical intervention.

Percutaneous transluminal angioplasty for treatment of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis patients

Multiple sclerosis (MS) is a leading cause of neurological disability in young adults. The most widely accepted hypothesis regarding its pathogenesis is that it is an immune-mediated disease. It has been hypothesised more recently that chronic venous congestion may be an important factor in the pathogenesis of MS. This concept has been named 'chronic cerebrospinal venous insufficiency' (CCSVI) and is characterised by stenoses of either the internal jugular or azygos veins, or both. It is suggested that these stenoses restrict the normal blood flow from the brain, causing the deposition of iron in the brain and the eventual triggering of an auto-immune response. The proposed treatment for CCSVI is percutaneous transluminal angioplasty, also known as the 'liberation procedure', which is claimed to improve the blood flow in the brain thereby alleviating some of the symptoms of MS. To assess the effects of percutaneous transluminal angioplasty for the treatment of CCSVI in people with MS. We searched the following databases up to June 2012: The Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register, CENTRAL in The Cochrane Library 2012, Issue 5, MEDLINE (from 1946), EMBASE (from 1974), and reference lists of articles. We also searched several online trials registries for ongoing trials. Randomised controlled trials assessing the effects of percutaneous transluminal angioplasty in adults with multiple sclerosis, that have been diagnosed to have CCSVI. Our searches retrieved 159 references, six of which were to ongoing trials. Based on assessment of the title or abstract, or both, we excluded all of the studies, with the exception of one which was evaluated following examination of the full text report. However, this study also did not meet our inclusion criteria and was subsequently excluded. No randomised controlled trials met our inclusion criteria. There is currently no high level evidence to support or refute the efficacy or safety of percutaneous transluminal angioplasty for treatment of CCSVI in people with MS. Clinical practice should be guided by evidence supported by well-designed randomised controlled trials: closure of some of the gaps in the evidence may be feasible at the time of completion of the six ongoing clinical trials.

Randomized Controlled Trial of Symptomatic Middle Cerebral Artery Stenosis

To investigate the efficacy and safety of percutaneous transluminal angioplasty and stenting (PTAS) for symptomatic middle cerebral artery stenosis compared with standard medical treatment in a low-risk Chinese population. A prospective, randomized, controlled, single-center clinical trial was conducted comparing PTAS with medical treatment for symptomatic middle cerebral artery stenosis (≥70%). Patients were enrolled according to 1:1 enroll ratio (PTAS: medical). The PTAS group received stenting or balloon angioplasty, whereas the medical treatment group received standard medical treatment (aspirin 100mg plus clopidogrel 75 mg/d), and all the patients were under strict control of the risk factors. The end point events were any kind of ipsilateral stroke or transient ischemic attack, or death from any origin during 1-year follow-up. The enrollment was stopped after 70 patients were enrolled from August 2007 to December 2010, with a 30-day rate of end point events of 8.3% versus 5.9% (P=0.69) for PTAS and medical group, respectively, and 1-year rate of end point events of 19.4% versus 17.6% (P=0.85), respectively. There was no significant difference in baseline characteristics between the 2 groups. The mean follow-up time, which was ongoing, was 9.9±3.9 and 9.7±4.4 months, respectively. Among the risk factors, hypertension was the independent related to the outcome (P=0.015). This study showed that endovascular treatment is as safe but not better than medical treatment for symptomatic middle cerebral artery stenosis in a low-risk Chinese population. History of hypertension increases the risk of recurrent ischemic events.

O uso de stents farmacológicos no tratamento da estenose das artérias vertebrais

OBJETIVO: Relatar a viabilidade e segurança da angioplastia transluminal percutânea com stents recobertos com paclitaxel para tratamento de estenose de artéria vertebral em 14 pacientes, após seguimento de dois anos. MATERIAIS E MÉTODOS: Catorze pacientes com idade média de 67,2 anos foram submetidos a tratamento endovascular mediante angioplastia percutânea e implante de stent farmacológico. O objetivo primário deste trabalho foi assegurar a segurança do procedimento. O desfecho secundário foi a eficácia clínica, definida como sintomas isquêmicos recorrentes e taxas de reestenose. RESULTADOS: O grau de estenose variou de 50% a 99% (média de 73,3% ± 10,9). A taxa de sucesso técnico da angioplastia foi de 100%. Não houve complicações diretamente relacionadas ao procedimento. Aos 24 meses de seguimento, nenhum paciente apresentou recorrência dos sintomas. A taxa de reestenose intra-stent foi de 7,1%, embora tenha sido assintomática na totalidade dos casos. CONCLUSÃO: Este estudo sugere que a angioplastia da artéria vertebral com o uso de stents recobertos com paclitaxel é uma técnica viável e promissora em termos de segurança e eficácia na prevenção da isquemia recorrente e reestenose.

Outcomes of Thrombectomy Procedures Performed in Hemodialysis Grafts with Early Failure

Purpose Percutaneous declotting is usually not offered for hemodialysis access grafts clotting < 30 days after placement because of concerns regarding safety of percutaneous transluminal angioplasty in fresh anastomoses, potential need for surgical correction of the underlying cause, and poor outcomes. The authors sought to determine acute and long-term outcomes of declotting of grafts with early failure. Materials and Methods Of 860 percutaneous mechanical thrombectomies performed between July 2001 and June 2007, 23 were performed in grafts < 30 days after initial placement. In addition, 16 percutaneous thrombectomies performed in grafts 31–60 days after placement were identified. Data collected included medical history, graft characteristics, immediate technical and clinical success, complications, and subsequent graft patency and survival. Kaplan-Meier analysis compared outcomes in grafts < 30 days (U30) versus those 31–60 days (U60) old. Results There was no difference between the U30 and U60 groups in primary patency (13 vs 19 days, respectively, P = 0.17) or in postintervention access patency (38 vs 189 days, respectively, P = 0.63). A strong trend toward shorter secondary patency in U30 grafts was observed (17 vs 73 days, P = 0.06). Underlying lesions not amenable to percutaneous treatment were found in 62% of U30 grafts and 33% of U60 grafts ( P = 0.18). Neither group achieved the K/DOQI Guidelines' recommended 85% technical success or 40% 90-day primary patency; in the U30 group it was 0% and in the U60 group 17%. Conclusions Percutaneous declotting of grafts yields poor outcomes, well below the K/DOQI threshold not only within 30 days but also within 60 days of placement.

Percutaneous Endovascular Treatment of Innominate Artery Lesions: A Single-centre Experience on 77 Lesions

Purpose To assess primary success and safety of percutaneous transluminal angioplasty and/or stenting of innominate artery lesions and to compare its 30-day stroke/mortality level with the literature data. Methods A total of 72 patients (77 stenoses, five recurrent, 58 symptomatic and 39 female) with seven innominate vessel occlusions, nine subocclusive lesions and 61 significant (>60%) stenoses of innominate artery treated between 2000 and 2009 were retrospectively reviewed. With the exception of seven, all procedures were performed using a transfemoral approach. A stent was implanted in 49 (63.6%) cases. Follow-up included neurological examination, carotid duplex scan and office/telephone interview. Results Primary technical success was 93.5% (72/77). There was neither periprocedural (<48 h) death, nor major neurological complication. Minor periprocedural neurological complications consisted of 2/72 (2.6%) ipsilateral TIAs. Access site complications included 4 (5.2%) access site bleedings. Follow-up was achieved in 65/72 (90.3%) of all patients and 68 (88.3%) of all procedures for a mean of 42.3 months and revealed neither major neurological complication, nor additional TIA. The cumulative primary patency rate was 100% at 12 months, 98 ± 1.6% at 24 months, and 69.9 ± 8.5% at 96 months. The cumulative secondary patency rate was 100% at 12 and at 24 months, and 81.5 ± 7.7% at 96 months. Log-rank test showed no significant difference ( p = 0.79) in primary cumulative patencies between PTA alone ( n = 28) or PTA/stent ( n = 49). Conclusion Transfemoral PTA with or without stent appears to be a safe treatment option for innominate artery lesions.

Transfemoral endovascular treatment of proximal common carotid artery lesions: A single-center experience on 153 lesions

To assess primary success and safety of percutaneous transluminal angioplasty (PTA) and/or stenting of ostial/proximal common carotid artery lesions (pCCA) and to compare its 30-day stroke/mortality level with the literature data for surgical options. A total of 147 patients (153 stenoses, 6 recurrent) (71 female; 121 left) with significant diameter stenosis (>70% in symptomatic, n = 46; >85% in asymptomatic, n = 101 patients) of pCCA treated between 1994 and 2006 were retrospectively reviewed. With the exception of one, all procedures were performed using a transfemoral approach. A stent was implanted in 108 (70.5%) of cases. Stents were not available in the early years of our experience, but gradually became a routine practice. Embolic protection devices were used in 16 cases. Follow-up included neurological examination, carotid duplex scan, and office/telephone interview. Primary technical success was 98.7% (151/153 stenoses). There were no deaths. Periprocedural (<48 hours) neurological complications included 3/153 (2.0%) ipsilateral major strokes and 4/153 (2.6%) TIAs (including one contralateral TIA). There were 8/153 (5.2%) access site hematomas, 1/153 (0.7%) bradycardia, and 1/153 (0.7%) acute left ventricular failure with respiratory distress. Follow-up was achieved in 115/147 patients (78.2%) undergoing 120 procedures for a mean of 24.7 months and revealed one additional contralateral TIA and one additional minor stroke in an asymptomatic patient. In patients with follow-up, the 30-day procedural death/all-stroke rate was 3/120 (2.5%) The cumulative primary patency rate in the 115 patients with follow-up was 97.9% +/- 2.1% at 1 year, 82.0% +/- 7.1% at 4-years, and 73.5% +/- 12.7% at 7 years. The cumulative secondary patency rate was 100% at 1 year, 88.0% +/- 7.0% at 4 years, and 88.0% +/- 11% at 7 years. Log-rank test showed no statistical difference (P = .82) in primary cumulative patency between PTA alone (n = 34) or PTA/stent (n = 86). Transfemoral PTA/stenting appears to be appropriate treatment option for ostial/proximal common carotid artery significant stenoses. This study should also draw attention to the lack of data on natural history or effect of best medical treatment alone for these lesions, making evidence-based decision currently impossible for treatment of symptomatic or asymptomatic ostial and proximal common carotid artery significant stenoses.

The site of atheromatosis in the subclavian and vertebral arteries and its implication for angioplasty.

We analysed the site of plaques and stenoses in the subclavian and vertebral arteries, to improve the safety of percutaneous transluminal angioplasty (PTA) in high-risk patients. These lesions were assessed on arteriograms of 35 patients with stenoses and occlusions of the subclavian and vertebral arteries; the degree of stenoses was measured. Of 19 subclavian artery stenoses 17 (89%) were in the segment proximal to the vertebral artery; 30 (79%) of 38 vertebral artery stenoses were on the medial wall. With this knowledge, a double-balloon technique using a simultaneous transbrachial and transfemoral approach for angioplasty of high-risk subclavian or combined subclavian and vertebral artery stenoses and occlusions was used successfully in seven patients. This new technique may broaden the endovascular therapeutic possibilities in the rare but dangerous situation where plaque extends directly from the stenotic subclavian artery into the origin of the vertebral artery.

Percutaneous Transluminal Angioplasty of Visceral Arterial Stenoses: Results and Long-term Clinical Follow-up

To determine the efficacy and safety of percutaneous transluminal angioplasty (PTA) of the visceral arteries. We retrospectively evaluated the results of PTA performed in 20 visceral arteries in 19 patients (10 men, nine women; mean age, 63 years). Eleven patients had symptoms characteristic of mesenteric ischemia, four had atypical abdominal pain, and four were undergoing prophylactic dilation before undergoing another procedure involving the abdominal aorta. Clinical follow-up was possible in all patients. PTA was technically successful in 15 of 19 patients (79%); among these 15 patients, 12 (80%) did well clinically. Of the seven PTA procedures that were immediate failures, five failed secondary to an occult malignancy or to extrinsic arterial compression by the median arcuate ligament. Ten (83%) of the 12 patients in whom the procedures were immediate clinical successes are still clinically improved at 4-73 months follow-up (mean, 25 months). PTA was successful in only one of the four patients who had symptoms atypical of mesenteric ischemia, but it was successful in 11 of the 15 patients who had symptoms of mesenteric ischemia or who underwent prophylactic dilation. Major complications occurred in three (16%) of the 19 patients. PTA of visceral artery stenoses is effective in patients with symptoms of mesenteric ischemia. It is also effective as prophylaxis in patients undergoing additional procedures in the abdominal aorta.

Percutaneous Transluminal Angioplasty for Transplant Renal Artery Stenosis

A recent report has challenged the efficacy and safety of percutaneous transluminal angioplasty (PTA) for the treatment of transplant renal artery stenosis (TRAS). From January 1983 to December 1990, 24 PTA procedures were performed for TRAS in 18 patients. The stenoses were anastomotic in two cases, in the main renal artery in 14, and segmental in eight. After PTA, the residual stenosis was less than 20% in 14 (58%), 20%-50% in four (17%), and greater than 50% in six (25%). The mean diastolic blood pressure decreased from 106 mm Hg 1 day prior to PTA to 82 mm Hg 1 day after PTA. Long-term follow-up mean diastolic blood pressure (at 2-32 months) was 93 mm Hg (P less than .01). Eleven of the 18 patients (63%) had a 10% or greater reduction in diastolic blood pressure on long-term follow-up. Major complications occurred in two patients; one groin hematoma required surgical evacuation, and one polar infarct led to hypertension that was difficult to control. No surgical revisions of the transplant renal artery were necessary. The authors' data indicate that PTA should remain the treatment of choice for nonanastomotic TRAS.