Severe Restenosis Research Articles

TCT-499 Predictors of Good Final Lumen Expansion After Treatment of Severe In-Stent Restenosis Neoatherosclerosis as Evaluated by Intravascular Ultrasound

TCT-499 Predictors of Good Final Lumen Expansion After Treatment of Severe In-Stent Restenosis Neoatherosclerosis as Evaluated by Intravascular Ultrasound

Hybrid Surgery for symptomatic chronic internal carotid artery occlusion: a single-center experience.

Patients with symptomatic chronic internal carotid artery occlusion (ICAO) face a high risk of recurrent stroke despite receiving aggressive medical therapy. This study aimed to evaluate the effectiveness and safety of hybrid surgery in treating symptomatic chronic ICAO. This retrospective case series was conducted at a single center. From January 2019 to December 2022, patients with symptomatic chronic ICAO who underwent hybrid surgery were included. We collected baseline data, lesion characteristics, revascularization rates, perioperative complications, and follow-up outcomes. The study enrolled 27 patients, comprising 22 males and 5 females, with symptomatic chronic ICAO. The hybrid surgery achieved a technical success rate of 100% for revascularization (n = 27), with a perioperative complication rate of 14.8% (n = 4). Following a median follow-up of 6.0months (IQR, 4-10), 21 patients underwent a DSA or CT angiography reexamination, confirming a vascular patency rate of 90.5% (n = 19). One patient required surgery for severe in-stent restenosis, and another experienced asymptomatic occlusion. Clinical follow-ups were conducted for all 26 patients; no new strokes were reported in the qualifying artery territory, with 13 patients scoring 0, 12 scoring 1, and 1 scoring 2 on the mRS. Although hybrid surgery represent a promising option for treating chronic ICAO, they are also associated with a relatively high incidence of treatment-related complications. The application of composite surgery should be based on standardized technical guidelines and the careful selection of patients who are genuinely at high risk for recurrent strokes.

Comparative Analysis of Balloon Angioplasty Alone versus Carotid Artery Stenting for Severe Extracranial Carotid Artery Stenosis: A 4-Year Retrospective Study

This retrospective study aimed to compare the efficacy of balloon angioplasty alone (BAA) with carotid artery stenting (CAS) for severe extracranial carotid artery stenosis. The primary outcomes assessed were restenosis requiring retreatment and symptomatic stroke occurrence within a 4-year follow-up period. A total of 77 patients with 89 carotid artery stenoses undergoing endovascular carotid revascularization between January 2015 and December 2019 were included. Neuroradiologic evaluations, including computed tomography angiography or magnetic resonance angiography, were performed at defined intervals. Statistical analyses were conducted to compare patient characteristics, angiographic outcomes, and clinical outcomes between the BAA and CAS groups. The study demonstrated successful outcomes in both groups with low adverse event rates. The overall restenosis rate was 40.2%, but severe restenosis requiring retreatment occurred in only 10 cases (7 in BAA, and 3 in CAS). No significant difference was found in retreatment rates between the 2 groups (P= 0.53). Stroke occurrence within the 4-year follow-up period was observed in 3 patients, with no statistically significant difference between BAA and CAS groups. This study provides valuable insights into the comparative effectiveness of BAA and CAS for severe extracranial carotid artery stenosis. Despite slightly shorter intervals to restenosis in the BAA group, there was no significant difference in retreatment or stroke occurrence rates between the 2 procedures. BAA offers advantages in terms of retreatment options.

Clinical results of 30 consecutive patients of carotid artery stenosis treated with CASPER stent placement: 1-year follow-up and in-stent findings on intravascular ultrasound examination immediately and 6 months after treatment

BackgroundThe CASPER stent is expected to reduce periprocedural ischemic complications, but there is concern about restenosis in the early period. One-year follow-up results of CASPER stenting and findings on intravascular...

Treatment Results of Carotid Artery Stenting with an Open-Cell Stent: Analysis of 734 Consecutive Cases at a Single Center

In carotid artery stenting (CAS) for internal carotid artery stenosis, the stent is often selected according to the plaque properties and arterial tortuosity. In our institute, an open-cell stent is used as the first-line stent regardless of the characteristics of the lesion. This study was performed to examine the outcome of CAS with an open-cell stent as the real-world results. In total, 811 CAS procedures using open-cell stents were performed for internal carotid artery stenosis from April 2002 to December 2019. Of these patients, we excluded those with hyperacute conditions for which CAS was performed within 3days of onset, those in whom acute mechanical thrombectomy was performed simultaneously with CAS, and those with stenosis due to arterial dissection. Thus, 734 patients were retrospectively analyzed. Perioperative and long-term outcomes and risk factors for perioperative infarction were investigated. The periprocedural stroke rate and mortality rate were 3.7% (27/734) and 0.4% (3/734), respectively. Low-echoic plaque was a significant risk factor for periprocedural stroke in both univariate (P<0.03) and multivariate (odds ratio, 2.69; 95% confidence interval, 1.14-6.66; P=0.02) analyses. Cerebral infarction and high grade restenosis were observed in 15 (2.0%) and 17 (2.3%) patients during a median 50-month follow-up. CAS with open-cell stents showed good results in terms of both the postoperative stroke incidence and long-term severe restenosis rate. However, low-echoic plaque was a risk factor for perioperative stroke incidence, which should be considered when deciding on the indication for CAS with an open-cell stent.

Elevated Leukocyte Glucose Index Is Associated with Long-Term Arteriovenous Fistula Failure in Dialysis Patients.

(1) Background: Arteriovenous fistula (AVF) is the preferred type of vascular access for dialysis in patients with end-stage kidney disease (ESKD). However, the primary patency of AVF at one year is under 70% due to several risk factors and comorbidities. Leukocyte glucose index (LGI), a new biomarker based on blood leukocytes and glucose values, has been found to be associated with poor outcomes in cardiovascular disease. The aim of this study is to analyze the impact of LGI on the long-term primary patency of AVF following dialysis initiation. (2) Methods: We conducted a retrospective observational study in which we initially enrolled 158 patients with ESKD admitted to the Vascular Surgery Department of the Emergency County Hospital of Targu Mures, Romania, to surgically create an AVF for dialysis between January 2020 and July 2023. The primary endpoint was AVF failure, defined as the impossibility of performing a chronic dialysis session due to severe restenosis or AVF thrombosis. After follow-up, we categorized patients into two groups based on their AVF status: "functional AVF" for those with a permeable AVF and "AVF failure" for those with vascular access dysfunction. (3) Results: Patients with AVF failure had a higher prevalence of atrial fibrillation (p = 0.013) and diabetes (p = 0.028), as well as a higher LGI value (1.12 vs. 0.79, p < 0.001). At ROC analysis, LGI had the strongest association with the outcome, with an AUC of 0.729, and an optimal cut-off value of 0.95 (72.4% sensitivity and 68% specificity). In Kaplan-Meier survival analyses, patients in the highest tertile (T3) of LGI had a significantly higher incidence of AVF failure compared to those in tertile 1 (p = 0.019). Moreover, we found that patients with higher baseline LGI values had a significantly higher risk of AVF failure during follow-up (HR: 1.48, p = 0.003). The association is independent of age and sex (HR: 1.65, p = 0.001), cardiovascular risk factors (HR: 1.63, p = 0.012), and pre-operative vascular mapping determinations (HR: 3.49, p = 0.037). (4) Conclusions: In conclusion, high preoperative values of LGI are positively associated with long-term AVF failure. The prognostic role of the biomarker was independent of age, sex, cardiovascular risk factors, and pre-operative vascular mapping determinations.

Intervenção coronária percutânea com técnica mini culotte estadiada para reestenose ostial de grande ramo lateral

Understanding the anatomy and physiology of a bifurcation is crucial in today’s interventional field. The bifurcation lesion is one of the most challenging coronary conditions to treat percutaneously. Numerous interventional strategies have been investigated because of the high level of interest in these lesions, but the relatively poor procedural and long-term results. Improvements in stenting and other interventional procedures have reduced the likelihood of adverse clinical outcomes, by creating the most favorable environment for stents to do their work. Provisional stenting has been widely accepted as the initial interventional technique for coronary bifurcation lesions by the medical community for over 15 years. Restenosis of a major branch is possible after angioplasty of the main vessel using a provisional one-stent approach. Although side branch restenosis following bifurcation angioplasty is less common with modern bifurcation procedures, it still occurs in 5% of cases during angiographic follow-up for symptoms. In our case series of five patients, severe side-branch restenosis presented with recuring anginal symptoms, which required target vessel revascularization. By applying bifurcation principles, we improved the “staged mini culotte” part of the culotte bifurcation stent technique, making it more user-friendly, and reducing exposure to radiation and operating time.

Cutting Balloon Angioplasty for Severe In-Stent Restenosis after Carotid Artery Stenting: Long-Term Outcomes and Review of Literature.

Cutting balloon-percutaneous transluminal angioplasty (CB-PTA) is a feasible treatment option for in-stent restenosis (ISR) after carotid artery stenting (CAS). However, the longterm durability and safety of CB-PTA for ISR after CAS have not been well established. We retrospectively reviewed medical records of patients with ISR after CAS who had been treated with CB-PTA from 2012 to 2021 in our center. Detailed information of baseline characteristics, periprocedural and long-term outcomes, and follow-up imaging was collected. During 2012-2021, a total of 301 patients underwent CAS. Of which, CB-PTA was performed on 20 lesions exhibiting severe ISR in 18 patients following CAS. No patient had any history of receiving carotid endarterectomy or radiation therapy. These lesions were located at the cervical segment of the internal carotid artery (n=16), proximal external carotid artery (n=1), and distal common carotid artery (n=1). The median time interval between initial CAS and detection of ISR was 390 days (interquartile range 324-666 days). The follow-up period ranged from 9 months to 9 years with a median value of 21 months. Four patients (22.2%) were symptomatic. The average of stenotic degree before and after the procedure was 79.2% and 34.7%, respectively. Out of the 18 patients receiving CB-PTA, 16 (88.9%) did not require additional stenting, and 16 (88.9%) did not experience recurrent ISR during the follow-up period. Two patients who experienced recurrent ISR were successfully treated with CB-PTA and additional stenting. No periprocedural complication was observed in any case. Regarding favorable periprocedural and long-term outcomes in our single-center experience, CB-PTA was a feasible and safe option for the treatment of severe ISR after CAS.

Anesthetic Challenges in Severe Pulmonary Stenosis Posted for Caesarean Delivery

Isolated Pulmonary stenosis (PS) accounts for 10–12% of adult congenital heart diseases. The effect of PS on pregnancy depends on the severity of the stenosis. There are limited data available in the literature to guide the anesthetic management of pregnant patients with severe PS. We report the successful anesthetic management of a pregnant woman presenting with severe pulmonary re-stenosis 10 years after open pulmonary valvotomy, posted for caesarean section.

Diagnostic accuracy of vessel fractional flow reserve compared to conventional diagnostic tools in patients with coronary artery stenosis

Abstract Background Wire-based fractional flow reserve (FFR) is currently the golden standard in a physiological assessment for intermediate coronary artery stenosis (CAS). However, the clinical advantage of FFR has been limited by its invasiveness. In the previous study with a small number of participants (334 patients), three-dimensional quantitative coronary angiography (3D-QCA)-based vessel FFR (vFFR) has shown non-inferiority to wire-based FFR in diagnostic accuracy. There has been no reports regarding the relationship between vFFR and other conventional physiological assessment tools. Methods The present study was a retrospective registry designed to evaluate the diagnostic accuracy of vFFR compared to the conventional reference standard (wire-based FFR ≤0.80). Between January 2019 and February 2022, patients with stable or unstable angina, and non-ST-elevation acute coronary syndrome who had undergone physiological assessments [wire-based FFR, instantaneous wave-free ratio (iFR), resting full-cycle ratio (RFR), and/or coronary computed tomography angiography-derived FFR (FFRCT)] before percutaneous coronary intervention were included for the present analysis. The exclusion criteria were ST-elevation myocardial infarction, previous coronary artery bypass grafting, cardiogenic shock, and adenosine intolerance. In the present study, we investigate the relationship between vFFR and conventional tools such as wire-based FFR, iFR, RFR, and/or FFRCT in patients with intermediate CAS, including multi-vessel disease, severe coronary calcium, in-stent restenosis, and hemodialysis. Results The study included 722 patients (mean age, 70±10 years; male, 80%) who underwent vFFR in 698 patients (97%), wire-based FFR in 711 (98%), iFR in 523 (72%), RFR in 109 (15%), and FFRCT in 48 (7%). Most patients presented stable angina (93%). In the present study, multi-vessel disease was identified only 20% of all. A total of 1108 target vessels were LAD in 549 (50%), LCx in 287 (26%), and RCA in 272 (24%), respectively. Bifurcation lesions and in-stent restenosis were present in 12% and 13%, respectively. The subjects were diagnosed several comorbidities, such as hypertension (77%), dyslipidemia (57%), diabetes mellitus (40%), and hemodialysis (12%). Overall, vFFR showed good correlations with wire-based FFR (r=0.70; p&amp;lt;0.001), IFR (r=0.57; p&amp;lt;0.001), and RFR (r=0.69; p&amp;lt;0.001). However, the correlation between vFFR and FFRCT was weak (r=0.36; p&amp;lt;0.001). Furthermore, vFFR had a good diagnostic accuracy (sensitivity, specificity, negative predictive value and positive predictive value; 81%, 88%, 82% and 87%, respectively) to identify the lesions with wire-based FFR≤0.80 (AUC, 0.87; 95% CI, 0.84-0.90; p&amp;lt;0.001). Conclusion In this large number cohort, the 3D-QCA based vFFR has a good correlation with wire-based FFR, and a high diagnostic accuracy to detect the lesion with FFR ≤ 0.80 even in patients with severe coronary calcification, in-stent restenosis, and hemodialysis.Scatter plotsBland-Altman plots

Early stent fractures in superficial femoral artery resulting multiple pseudoaneurysm formation within one year: a case report

BackgroundThough fracture is known complication of stenting, pseudoaneurysm asscoiated with stent fracture is an extremely rare complication. This has previoulsy been described to occur at least one or more years following initial stent placement. Here we present a case of multi-site stent fracture leading to two separate SFA pseudoaneurysms within one year of placement, successfully treated with covered stents.Case presentationA 72-year-old male presented with severe claudication of his left lower extremity (Rutherford 3), found to have long segment SFA chronic total occlusion (CTO). Patient successfully underwent endovascular revascularization. Follow-up duplex ultrasound (US) at one year demonstrated a focus of severe in-stent restenosis (ISR). During repeat angiogram for treatment of the stenosis, stent fracture and pseudoaneurysm was seen in the distal SFA, which was treated successfully with a self-expanding covered stent. Additional stent fractures and pseudoanerusyms were subseuqently identified on follow-up, necessitating a third angiogram, and these were successfully repaired using overlapping covered stents, without further recurrence.ConclusionsSuperficial femoral artery stent fractures leading to pseudoaneurysms are extremely rare, particularly within first year of stent placement. Endovascular repair with covered stents has proven to be an effective treatment option with decreased procedural morbidity compared to surgical repair.

Gas station in blood vessels: An endothelium mimicking, self-sustainable nitric oxide fueling stent coating for prevention of thrombosis and restenosis

Stenting is the primary treatment for vascular obstruction-related cardiovascular diseases, but it inevitably causes endothelial injury which may lead to severe thrombosis and restenosis. Maintaining nitric oxide (NO, a vasoactive mediator) production and grafting endothelial glycocalyx such as heparin (Hep) onto the surface of cardiovascular stents could effectively reconstruct the damaged endothelium. However, insufficient endogenous NO donors may impede NO catalytic generation and fail to sustain cardiovascular homeostasis. Here, a dopamine-copper (DA-Cu) network-based coating armed with NO precursor L-arginine (Arg) and Hep (DA-Cu-Arg-Hep) is prepared using an organic solvent-free dipping technique to form a nanometer-thin coating onto the cardiovascular stents. The DA-Cu network adheres tightly to the surface of stents and confers excellent NO catalytic activity in the presence of endogenous NO donors. The immobilized Arg functions as a NO fuel to generate NO via endothelial nitric oxide synthase (eNOS), while Hep works as eNOS booster to increase the level of eNOS to decompose Arg into NO, ensuring a sufficient supply of NO even when endogenous donors are insufficient. The synergistic interaction between Cu and Arg is analogous to a gas station to fuel NO production to compensate for the insufficient endogenous NO donor in vivo. Consequently, it promotes the reconstruction of natural endothelium, inhibits smooth muscle cell (SMC) migration, and suppresses cascading platelet adhesion, preventing stent thrombosis and restenosis. We anticipate that our DA-Cu-Arg-Hep coating will improve the quality of life of cardiovascular patients through improved surgical follow-up, increased safety, and decreased medication, as well as revitalize the stenting industry through durable designs.

Photon counting detector CT can identify mild coronary artery in-stent restenosis more reliably

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University. Introduction The improved spatial resolution of photon-counting detector CT (PCD-CT) allows better image quality and less artefacts even in high-density structures, such as coronary artery stents. Purpose Our aim was to compare the prevalence of coronary artery in-stent restenosis using conventional CT and PCD-CT. Methods Our retrospective study included consecutive patients with coronary artery stents who underwent coronary CT angiography (CCTA) either with PCD-CT between January and December 2022 or with a 280-slice conventional CT scanner in 2019. The following categories were used: none, not severe, severe in-stent restenosis and stents with non-diagnostic image quality. Results Altogether 253 patients were included in our study (215 patients who underwent CCTA with a conventional CT and 38 patients who had PCD-CT examination). The mean age was 62.7±10.8 years and 46.8% were women. In-stent restenosis was detected significantly more frequently in case of PCD-CT examination, as compared to conventional CCTA (47.7% and 27.4%, respectively; p = 0.023). Among the 15 patients who underwent ultra-high resolution PCD-CT examination, only one (6.7%) had a non-diagnostic image quality for the assessment of in-stent restenosis, while 34 cases (15.8%) were non-diagnostic in the conventional CCTA group. Conclusions The better image quality provided by PCD-CT notably helps the evaluation of in-stent restenosis and can therefore contribute to the identification of mild in-stent restenosis. Moreover, the number of non-diagnostic CCTA scans can be decreased by using ultra-high resolution technique.

P98 A CASE OF “RECURRENT” AORTIC VALVE STENOSIS

Abstract Clinical Case A 80–year–old man underwent coronary angiography in 2006 because of stable angina. There was chronic total occlusion of middle left anterior descending artery requiring percutaneous intervention. In 2009 he underwent coronary angiography for recurrent angina: a severe stent restenosis was treated with stenting in stent (DES in BMS). The patient was subsequently asymptomatic till 2018 when he complained of exertional dyspnea and angina. Stent patency and severe aortic valve stenosis (AVA 0.85 cm2) were documented. The patient underwent successful transcatheter aortic valve implantation and discharged with dual antiplatelet therapy (DAPT) (Asa 100 mg and Clopidogrel 75 mg). Clinical and echocardiographic follow–up was unremarkable (mean prosthetic gradient 17 mmHg, DVI=0.45). In July 2021 during a cardiological check the patient complained of bruising: ASA was discontinued. In February 2022 the patient suffered from an exertional angina. A dipyridamole stress–echocardiography failed to demonstrate inducible ischemia, although the patient experienced angina at the peak load step. Transthoracic echocardiogram (TTE) revealed high mean trans–prosthetic aortic gradient (52 mmHg, DVI=0.18). A trans–esophageal echocardiogram (TEE) showed reduced mobility of the thickened left coronary and non–coronary aortic prosthetic leaflets. In the hypothesis of prosthetic valve thrombosis, warfarin (INR range 2–3) was started after stopping clopidogrel. After three months a TTE showed normalized mean trans–prosthetic gradients (17 mmHg, DVI=0.5). When a 6 month–period of anticoagulant therapy was accomplished, warfarin was stopped and DAPT administered again. In September 2022 the patient complained of worsening dyspnea and chest pain on exertion. At TTE mean trans–prosthetic gradients (46 mmHg) was increased. A new TEE showed thickening of non–coronary and right coronary leaflets, suggestive of recurrent valve thrombosis. After stopping DAPT, warfarin was started again with good result (mean prosthetic gradient 12 mmHg, DVI=0.5). Conclusion Thrombosis of aortic valve prothesis is an infrequent event usually occurring in early post–implantation period. In our case it occurred four years after implantation following DAPT interruption. The likely initial prosthetic valve degeneration together with a simplification of DAPT may have had a causative role. Since the proved efficacy of warfarin and the limited experience of DOAC in this field, the patient was given warfarin sine die.

Sex-Related Outcomes in Asymptomatic Patients Undergoing Carotid Artery Stenting.

Aim of the study was to evaluate the influence of sex in asymptomatic patients undergoing carotid artery stenting (CAS). A retrospective observational study was conducted from January 2006 to December 2020. A total of 438 consecutive patients with asymptomatic carotid artery stenosis >70% underwent transfemoral CAS and were stratified in males (M) and females (F). Periprocedural 30-day outcomes were: stroke, death, and myocardial infarction (MI). Follow-up outcomes were: death and stroke rates (primary) and freedom from restenosis (FFR) and reintervention rates (secondary). Follow-up data were analyzed at 1, 5, and 10 years. Data were analyzed with χ2 test and Fisher's exact test and follow-up outcomes with Kaplan-Meier curves. The log-rank test was used to determine differences between the groups and univariate analysis to identify the association between risk factors and intraoperative details with mortality and restenosis rates. A total of 462 procedures were performed (M: n=321, 69.4%), in which 24 CAS were bilateral (5.5%). Mean age was 71.9±7.6 years (M: 72.1±7.8; F: 71.7±7.3). Periprocedural outcomes were: stroke rate 2.2% (n=10; M: n=5, 1.6%; F: n=5, 3.5%; p=0.176), mortality rate 0.6% (M: n=3, p=0.334), and stroke/death rate 2.8% (n=13; M: n=8, 2.5%; F: n=5, 3.5%; p=0.528); no cardiac events (MI) were recorded. A not-disabling (minor) stroke was detected in 3 males (0.9%), while a disabling (major) stroke was reported in 7 patients (1.7%) of whom 5 were ischemic events (M: n=2, 0.6%; F: n=3, 2.2%) and 2 were cerebral hemorrhages (F: 1.3%, p=0.046). Mean follow-up was 73.66±40.83 months (M: 72.66; F: 76.01; p=0.246). Overall survival rate was 96.1% (95% confidence interval [CI]: 93-98), 81.8% (95% CI: 77-86), and 45.5% (95% CI: 38-53) at 1, 5, and 10 years, respectively (p=0.236). The overall stroke rate was 0.3% (freedom from stroke [FFS]: 99.7%; 95% CI: 98-100), 0.9% (FFS: 99%; 95% CI: 98-100), and 4.3% (FFS: 95.7%; 95% CI: 89-98; M: n=6; F: n=2; p=0.774). Stroke-related mortality rate was 0.7% (FFS: 99.3%; 95% CI: 97-100) and 2.9% (FFS: 97.1%; 95% CI: 91-99) at 5 and 10 years, respectively, without differences between the groups (M: n=4; F: n=2; p=0.763). Overall FFR rate was 97.4% (95% CI: 95-99), 93.4% (95% CI: 90-96), and 89.5% (95% CI: 84-93; p=0.322). Two severe symptomatic restenosis (>70%, M) required a new endovascular revascularization. The sex variable does not influence outcomes of CAS in asymptomatic patients at short- and long-term follow-up, although females show a worst incidence of periprocedural major strokes. Carotid artery stenting may be safely proposed when a careful patient selection is applied. The sex variable has been advocated as a considerable factor that could influence the outcomes of transfemoral carotid artery stenting (CAS). Literature data are contrasting, even if different papers mainly reported that CAS is associated to worst outcomes in female patients. Our study shows that the sex-variable does not influence outcomes of CAS in asymptomatic patients at short and long-term follow-up, although females had a worst incidence of periprocedural major strokes. CAS may be safely proposed when a careful patient selection is applied.

A Simplified One-Size-Fits-All Approach to Carotid Stenting.

Carotid artery stenosis causes up to 20% of ischemic strokes. Stenting is used as an alternative to endarterectomy in symptomatic patients. Each commercially available stent offers numerous stent diameters/lengths. Most centers thus carefully match each individual stenosis to a specific stent length/diameter stent size. However, this process can be time-consuming and costly while the relative benefit of a custom stent sizing versus one-size-fits-all approach has not been well evaluated yet. We hypothesized that a 'one-size-fits-all' default approach to carotid stenting results in comparable results to a customized approach. We conducted a descriptive retrospective cohort study on 154 patients who presented to our academic carotid revascularization clinic with symptomatic carotid artery stenosis who underwent carotid artery stenting for peri- and postprocedural carotid artery stenting complications. The primary outcomes were periprocedural (within 24 hours of the procedure) or postprocedural (within 30 days of the procedure) TIA, stroke, or death. The secondary outcome was the estimated degree of stenosis on follow-up ultrasound performed within 6 months of the procedure. The complication rate within the first 24 hours was 4.5% while that during the first 30 days postprocedure was 6.5%. Age over 80 and degree of stenosis on postprocedural cerebral angiogram were associated with an increased risk of complications. Severe restenosis was reported in 16.8% of patients within 6 months postprocedure. Our study suggests that using a simplified, one-size-fits-all, approach to carotid stenting results in safe and effective outcomes, suggesting an alternative to simplify a complex medical procedure.

Feasibility of patchless proximal profundoplasty and common femoral endarterectomy.

Typical repair of common femoral artery (CFA) occlusive disease involves surgical endarterectomy followed by patch closure; however, prosthetic materials may become infected. In addition, in our institution, we have experienced an increased incidence of severe patch-related restenosis. We describe a technique for CFA endarterectomy and patchless proximal profundoplasty, and evaluate its feasibility. We performed a single-centre retrospective cohort study of patients who, between July 1, 2020, and June 30, 2021, underwent a procedure that consisted of transection of the superficial femoral artery (SFA) off the femoral bifurcation in a bevelled manner, eversion endarterectomy of the SFA, remote-type endarterectomy of the CFA, direct visualization of the end point in the profunda femoris artery (PFA) with a longitudinal arteriotomy extension if needed and reimplantation of the SFA "hood" as a patch. We collected clinical information and outcomes from the patients' charts. Ten patients who underwent a patchless profundoplasty procedure during the study period were identified. Indications for repair included tissue loss (3 patients), rest pain (2 patients), claudication (3 patients) and establishing access for other procedures (2 patients). Profunda femoris artery arteriotomy extensions were used in 5 cases. Six cases included simultaneous iliac or infrainguinal revascularization. All cases were technically successful. There was 1 intraoperative complication of remote tibial balloon angioplasty tear. The mean follow-up time was 199 (range 29-381) days. There were no surgical site infections. All patients were asymptomatic, with patent CFAs, at last follow-up. There was 1 case of surgical site restenosis and 1 reintervention for remote stenosis. The average increase in ankle and toe brachial indices was 44% and 75%, respectively. One patient was readmitted for gastrointestinal bleeding. One patient died from an acute myocardial infarction, on postoperative day 34. The patchless profundoplasty technique is feasible and results in autologous anatomic repair of CFA disease without the need for vein, and allows direct visualization and tacking sutures of the proximal PFA. This technique may replace the ubiquitous vascular procedure of patch arterioplasty of the CFA, depending on the anatomic configuration.

Gar²De²Nia Risk Score as a New Scoring for Severe Coronary Artery Restenosis and It’s Introducing as a Web Score CalculatorPilot Study

Objectives: Gar²De²Nia score is designed to predict highly suspicious probability of significant coronary stenosis in patients without proven CAD or those who have already been revascularized. Background: There are a large number of scores that are used for cardiovascular risk assessment and different online calculators are used to perform it. Risk prediction models provide risk estimates that can assist our decision making and improve guiding for individual clinical outcomes and personalized preventive care. Methodology: Gar²De²Nia is an acronym that incorporates following parameters: Gender, Age, Renal impairement, Respiratory disease, Diabetes Melittus, Echo abnormalities, ECG abnormalities, new symptoms, Ischaemia, Atrial fibrillation. The pointing scale was formed (-1 to 2) on the personal interpretation of evidence based data and is applied and designed as web calculator. The established cut-off values for the risk of significant coronary stenosis are 4. For values below 4, the probability of significant CAD is low, below 0 is very low, equal or greater than 4 significant CAD is high and above 8 is very high. https://www.gardenia.estavela.in.rs Results: Standard statistical formulas for sensitivity, specificity, PPN and NPV were used (sensitivity 91, 43%, specificity 73, 33%, PPV 88, 89, NPV 78, 57). Estimated pilot sample size of 100 patients, was tested on patients cohort treated at the Institute for Cardiovascular Disease Dedinje in the year of 2022. Conclusion: This original score is to be checked throughout everyday clinical practice. It is easy to use. It can help in decision making in risk stratification and further treatment of the patients who has never been to cardiologist before, those who has already been revascularized and are symptomatic again or need any kind of non-cardiac surgery and the patients we have doubts about what to do next.

1145 BAIL-OUT INTRAVASCULAR CORONARY LITHOTRIPSY FOR THE TREATMENT OF STENT IN-STENT UNDER EXPANSION

Abstract Background in-stent restenosis remains a significant clinical problem for which optimal treatment is under debate. Intravascular lithotripsy (IVL) is mostly used for safe and effective treatment of de novo coronary calcifications, while the use of this technology to support bailout procedures, including stent under-expansion, is still off-label. One of the advantages of lithotripsy is the possible use after stent deployment. Case presentation a 66-year-old male patient was admitted to our Institution due to a medically refractory angina and a coronary computed tomography (CCT) detecting three vessel disease with multiple critical stenosis. The patient had multiple comorbidities including history of hypertension, dyslipidemia, type 2 diabetes and multiple myocardial rivascularization. In 2003 he underwent coronary artery by-pass (CABG) with left internal mammal artery (LIMA) to left anterior descending (LAD) artery and free saphenous vein graft (VG) to the ramus intermedius (RI). In 2009 the patient underwent percutaneous coronary intervention (PCI) of the right coronary artery (RCA) with the implantation of a stent at the central segment, and a second stent at the crux cordis. For recurrent in-stent restenosis of the stent previously implanted at the central segment the patient was treated in 2013 with percutaneous balloon angioplasty (POBA) and in 2017 with the implantation of another drug eluting stent (Resolute Onyx, Medtronic, Santa Rosa, California) overlapping the proximal part of the scaffold. Coronary angiography revealed, a severe coronary artery disease with 80% stenosis of distal left main. The LAD was occluded at the middle segment and the ramus presented 99% stenosis at the proximal segment. The RCA had a diffuse severe in-stent restenosis involving the Resolute Onyx stent. Therefore, the operator decided to treat the restenosis with a direct stenting (Xience, Abbott Vascular Santa Clara, USA), but he was unaware of the fact that there was already an Onyx stent that was barely visible. After implantation, an inadequate expansion of the stents was observed (Figura 1A-B), which persisted despite post-dilation with non-compliant balloon (NCB) at high-pressure (Figure 1C). Given the persistence of stents under-expansion, it was decided to perform bail-out intravascular lithotripsy (IVL) therapy with a Shockwave balloon catheter (Figure 2A). The stent was then post-dilated with a NCB (Figure 2B). The final angiographic image and intravascular ultrasound (IVUS) showed an optimal stent expansion (Figure 3). Conclusion intravascular lithotripsy could be used to treat undilatable stent-in-stent restenosis. Of interest, the case presented demonstrated, for the first time, the possible use of IVL in 2-stent layers, with an optima final stent expansion.

Patch angioplasty versus primary closure for carotid endarterectomy.

Carotid patch angioplasty may reduce the risk of acute occlusion or long-term restenosis of the carotid artery and subsequent ischaemic stroke in people undergoing carotid endarterectomy (CEA). This is an update of a Cochrane Review originally published in 1995 and updated in 2008. To assess the safety and efficacy of routine or selective carotid patch angioplasty with either a venous patch or a synthetic patch compared with primary closure in people undergoing CEA. We wished to test the primary hypothesis that carotid patch angioplasty results in a lower rate of severe arterial restenosis and therefore fewer recurrent strokes and stroke-related deaths, without a considerable increase in perioperative complications. We searched the Cochrane Stroke Group trials register, CENTRAL, MEDLINE, Embase, two other databases, and two trial registries in September 2021. Randomised controlled trials and quasi-randomised trials comparing carotid patch angioplasty with primary closure in people undergoing CEA. Two review authors independently assessed eligibility and risk of bias; extracted data; and determined the certainty of evidence using the GRADE approach. Outcomes of interest included stroke, death, significant complications related to surgery, and artery restenosis or occlusion during the perioperative period (within 30 days of the operation) or during long-term follow-up. We included 11 trials involving 2100 participants undergoing 2304 CEA operations. The quality of trials was generally poor. Follow-up varied from hospital discharge to five years. Compared with primary closure, carotid patch angioplasty may make little or no difference to reduction in risk of any stroke during the perioperative period (odds ratio (OR) 0.57, 95% confidence interval (CI) 0.31 to 1.03; P = 0.063; 8 studies, 1769 participants; very low-certainty evidence), but may lower the risk of any stroke during long-term follow-up (OR 0.49, 95% CI 0.27 to 0.90; P = 0.022; 7 studies, 1332 participants; very low-certainty evidence). In the included studies, carotid patch angioplasty resulted in a lower risk of ipsilateral stroke during the perioperative period (OR 0.31, 95% CI 0.15 to 0.63; P = 0.001; 7 studies, 1201 participants; very low-certainty evidence), and during long-term follow-up (OR 0.32, 95% CI 0.16 to 0.63; P = 0.001; 6 studies, 1141 participants; very low-certainty evidence). The intervention was associated with a reduction in the risk of any stroke or death during long-term follow-up (OR 0.59, 95% CI 0.42 to 0.84; P = 0.003; 6 studies, 1019 participants; very low-certainty evidence). In addition, the included studies suggest that carotid patch angioplasty may reduce the risk of perioperative arterial occlusion (OR 0.18, 95% CI 0.08 to 0.41; P < 0.0001; 7 studies, 1435 participants; low-certainty evidence), and may reduce the risk of restenosis during long-term follow-up (OR 0.24, 95% CI 0.17 to 0.34; P < 0.00001; 8 studies, 1719 participants; low-certainty evidence). The studies recorded very few arterial complications, including haemorrhage, infection, cranial nerve palsies and pseudo-aneurysm formation, with either patch or primary closure. We found no correlation between the use of patch angioplasty and the risk of either perioperative or long-term stroke-related death or all-cause death rates. Compared with primary closure, carotid patch angioplasty may reduce the risk of perioperative arterial occlusion and long-term restenosis of the operated artery. It would appear to reduce the risk of ipsilateral stroke during the perioperative and long-term period and reduce the risk of any stroke in the long-term when compared with primary closure. However, the evidence is uncertain due to the limited quality of included trials.