Small Femoral Arteries Research Articles

<b>Low-profile KA microplug set for transarterial occlusion of patent ductus arteriosus in a small dog: First experience in interventional cardiology</b>

Background: Cardiologists occlud most patent ductus arteriosus (PDA) defects in dogs using the Amplatz® canine duct occluder (ACDO) via a transarterial approach. However, this approach can be problematic in small dogs due to their small femoral artery diameters. In such cases, cardiologists have opted for lower-profile devices or use coils or vascular plugs deployed using a more challenging transvenous approach. Case Description: The present report describes a 1 year-old, 6 kg male Cavalier King Charles Spaniel with a small PDA, which was successfully occluded using the Micro Plug Set (KA Medical, Minneapolis, MN, USA) via a transarterial approach Conclusion: This is the first case report in medicine of PDA closure with a KA Micro Plug Set. This approach, which has been describedfor PDA closure in a few dozen premature human infants, could be considered as a minimally invasive PDA closure in small dogs by using a transarterial approach. Furthermore, in pediatric cardiology, the use of the device has been described only via a transvenous approach. The information from this case report could inspire a different and simpler approach in human medicine.

Cryoballoon ablation for atrial fibrillation in octogenarians: a propensity-score matching comparison with a cohort of younger patients

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is the most frequent sustained cardiac arrhythmia in adults with a current estimated prevalence between 2-4% in the general population. AF prevalence increases with advancing age and it is estimated that nearly 10% of octogenarians may be affected by this arrhythmia. In terms of safety and efficacy Cryoballoon ablation (CB-A) has become a valid option for achieving pulmonary vein isolation (PVI) in patients affected by AF. However, data regarding CB-A in octogenarians are still scarce and limited to single center experiences, therefore the present multicenter study aimed to compare the outcomes and complications of index CB-A in patients older than 80 years-old with a cohort of younger patients. Methods and Results We retrospectively enrolled 97 consecutive patients aged ≥ 80 years who underwent PVI by means of the second generation CB-A. This group was compared with a younger cohort of patients using a 1:1 Propensity score matching. After the matching, 70 patients of the elderly group were analyzed and compared with 70 younger patients (control group). Mean age was 81.4 ± 1.9 years among octogenarians and 65.2 ± 10.2 years in the younger cohort. The global success rate after a median follow up of 23 [18 - 32.5] months was 60.0% in the elderly group and 71.4% in the control group (p = 0.17) (Fig.1). Phrenic nerve palsy (PNP) was the most common complication occurring in a total of 11 patients (7.9%): in 6 (8.6%) patients for the elderly group and in 5 patients (7.1%) of the younger group (p = 0.51). PNP always recovered within the day after CB-A and did not hinder electrical isolation of any of the septal PVs. Only 2 (1.4 %) major complications occurred: 1 (1.4%) small femoral artery pseudoaneurysm in the control group, which resolved with a tight groin bandage without the need of surgical repair and 1 (1.4%) case of urosepsis in the elderly group with subsequent acute kidney failure and need of renal replacement therapy. Arrhythmia recurrence during the blanking period (BP) and need of electrical cardioversion (ECV) to restore sinus rhythm after PVI were found to be the only independent predictors of late arrhythmia relapses (Fig.2). Conclusions The present study showed that CB-A PVI is as feasible, safe and effective among octogenarians as it is in younger patients.

Post-Transcatheter Aortic Valve Replacement (TAVR) Vascular Complications: Femoral Artery Minimal Surgical Access Versus Percutaneous Approach.

Percutaneous transfemoral access approach for the transcatheter aortic valve implantation (TAVI) is still associated with significant vascular complications. Hence, evaluation of best techniques for the reduction of vascular injury via the femoral access remains a key subject of research. We report on a single centre's experience with TAVI performed via the Femoral Artery Minimal Surgical Access (MSA) and percutaneous approach (PC). The primary endpoints were to evaluate the incidents of vascular complications by comparing the MSA versus the PC approach according to the VARC-2 criteria. The secondary endpoint included the impact of vascular complications on the in-hospital 30-day mortality and morbidity. Between June 2010 and September 2020, two hundred and thirty-seven consecutive patients who underwent TAVI for severe symptomatic aortic stenosis in our department were divided into two groups: patients treated using the femoral artery minimal surgical access (n = 173), and patients treated using the percutaneous approach (n = 64). Overall rate of access site complications according the VARC-2 were significantly more frequent in the percutaneous cohort (n = 12/64, 18.8% vs n = 2/173, 1.1%, p = 0.0012). The minor access complications including haematoma, bleeding, aneurysm, dissection, stenosis, seroma and infection were more frequent in the PC group (n = 8/64, 12.5% vs n = 2/173, 1.1%, p < 0.001). There were no major access site complications and hospital deaths in the MSA group, which was statistically significant (p < 0.001). Major access complications (n = 4, 6.3%, p < 0.001) and hospital death (n = 2, 3.1%, p < 0.001) were found in the PC cohort. The minimal surgical access approach provided direct and controlled access and significantly reduced the incidence of access site vascular complications in our TAVI patients. It also significantly reduced the in-hospital vascular-related mortality and morbidity. Though both approaches are complementary to each other, minimal surgical access approach would be a better choice for a calcified or tortuous femoral artery, and for a relatively small femoral artery diameter.

Transcatheter aortic valve replacement using the iSleeve expandable sheath in small femoral arteries

BackgroundSmall femoral arteries have been associated with a higher risk of vascular complications in transfemoral transcatheter aortic valve replacement (TAVR). We investigated the feasibility and safety of TAVR in patients...

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Minimally invasive and robotic approaches to mitral valve surgery: Transthoracic aortic crossclamping is optimal

Enhanced Vasoconstriction Mediated by α1-Adrenergic Mechanisms in Small Femoral Arteries in Newborn Llama and Sheep Gestated at Low and High Altitudes.

The authors previously demonstrated that newborn llama (NBLL) express high levels of α1 adrenergic receptors, which provide a potent vasoconstriction response when compared with newborn sheep (NBSH) gestated at sea level. However, data regarding the impact of chronic gestational hypobaric hypoxia on α-adrenergic vasoconstriction in the neonatal life has not been studied. We evaluated if gestation under chronic hypobaric hypoxia modifies α1-adrenergic vasoconstrictor function in NBLL and NBSH. We compared the vasoconstrictor response induced by potassium and α-adrenergic stimuli in isolated small femoral arteries of NBLL and NBSH gestated at high altitude (HA; 3,600 m) or low altitude (LA; 580 m). The maximal contraction (RMAX) and potency (EC50) to potassium, noradrenaline (NA), and phenylephrine (PHE) were larger in HA-NBLL than LA-NBLL. RMAX to potassium, NA, and PHE were lower in HA-NBSH when compared with LA-NBSH and potency results were similar. Competitive blockade with prazosin showed that RNLL LA/HA have a similar pA2. In contrast, NBSH had increased pA2 values in HA when compared with LA. Finally, small femoral arteries denudated or treated with LNAME in LA and HA lacked NO or endothelium participation in response to PHE stimulation. In contrast, NBSH displayed that denudation or blockade with LNAME support NO or endothelium participation in response to PHE activation. In conclusion, HA chronic hypoxia enhances α1 adrenergic receptor activity in small femoral arteries in NBLL to a higher degree than NBSH, implying a higher vasoconstriction function.

Surgical Cutdown Avoids Vascular Complications in Transcatheter Aortic Valve Replacement in Calcified and Small Femoral Arteries.

Third-generation transcatheter heart valves (THV) are predominantly implanted through a percutaneous, transfemoral access. To reduce vascular complications, we selectively performed surgical vascular access (cutdown) in patients with particular calcified or small femoral arteries. We aim to review our experience with this approach. All patients who underwent transfemoral transcatheter aortic valve replacement (TAVR) with a third-generation THV at our institution between March 2014 and April 2019 were included in the study. All available computerized tomography studies were reassessed for access vessel diameter and visual graduation of calcifications. Vascular complications are reported according to Valve Academic Research Consortium-2 criteria. A total of 944 patients were included. Among them, 879 patients underwent a percutaneous access and 65 patients underwent surgical cutdown. Also, 459 Evolut R/PRO and 420 Sapien 3/ultra were implanted percutaneously and 40 Evolut R/PRO and 25 Sapien 3 were implanted with a surgical cutdown. Patients with surgical cutdown were older (80.0 ± 7.5 vs. 83.8 ± 7.5 years, p < 0.001), had smaller femoral arteries (8.0 ± 1.6 vs. 7.6 ± 1.6 mm, p = 0.034) and more severe vessel calcifications (17.5 vs. 1.0%, p < 0.001). Procedure time was similar for cutdown and percutaneous access (64.0 vs. 64.5 minutes, p = 0.879). With percutaneous access, 80 major vascular complications (10%) occurred, whereas with surgical cutdown, no major vascular complications occurred (p < 0.005). No wound infection occurred after surgical cutdown. The mean length of stay was 8 days in both groups. Surgical cutdown for vascular access avoids vascular complications in patients with small or severely calcified femoral arteries.

Impact of standardized computed tomographic angiography for minimally invasive mitral and tricuspid valve surgery

BackgroundFemoral cannulation for extracorporeal circulation (ECC) is a standard procedure for minimally invasive cardiac surgery (MICS) of the atrio-ventricular valves. Vascular pathologies may cause serious complications. Preoperative computed tomography-angiography (CT-A) of the aorta, axillary and iliac arteries was implemented at our department.MethodsBetween July 2017 and December 2018 all MICS were retrospectively reviewed (n = 143), and divided into 3 groups.ResultsIn patients without CT (n = 45, 31.5%) ECC was applied via femoral arteries (91.1% right, 8.9% left). Vascular related complications (dissection, stroke, coronary and visceral ischemia, related in-hospital death) occurred in 3 patients (6.7%). In patients with non-contrast CT (n = 35, 24.5%) only femoral cannulation was applied (94.3% right) with complications in 4 patients (11.4%). CT-angiography (n = 63, 44.1%) identified 12 patients (19.0%) with vulnerable plaques, 7 patients (11.1%) with kinking of iliac vessels, 41 patients (65.1%) with multiple calcified plaques and 5 patients (7.9%) with small femoral artery diameter (d ≤ 6 mm). In 7 patients (11.1%) pathologic findings led to alternative cannulation via right axillary artery, additional 4 patients (6.3%) were cannulated via left femoral artery. Only 2 patients (3.2%) suffered from complications.ConclusionsCT-A identifies vascular pathologies otherwise undetectable in routine preoperative preparation. A standardized imaging protocol may help to customize the operative strategy.

Frequency, Impact, and Predictors of Access Complications With Plug-Based Large-Bore Arteriotomy Closure - A Patient-Level Meta-Analysis

Background/purposeThe MANTA is a dedicated plug-based large-bore vascular closure device (VCD) providing safe hemostasis in most patients, but data on the clinical impact and mechanisms of MANTA related complications are limited. This study sought to determine the frequency, impact and predictors of MANTA-related access complications. Methods/materialsThis patient-level meta-analysis included data from 2 medical device approval studies and 1 post-approval registry. The primary endpoint was the composite of major and minor access complications. Technical success was defined as hemostasis with MANTA closure device without need for vascular surgery or stenting. ResultsEight hundred ninety-one patients (mean age 80) underwent transcatheter aortic valve replacement (n = 814), endovascular aortic repair (n = 71), balloon aortic valvuloplasty (n = 4) or mechanical circulatory support (n = 2). Technical success was 96.4% and median time to hemostasis was 31 (interquartile range: 17–76) seconds. The primary endpoint occurred 9.1% and bailout vascular surgery or stenting was necessary in 32 patients (3.6%). Female gender (OR: 2.63, CI: 1.46–4.73, p = 0.001), left femoral access (OR: 2.18, CI: 1.17–4.06, p = 0.015) and unfavorable arteriotomy phenotype (combination of a small femoral artery diameter with a deep arteriotomy; OR 2.27: 1.26–4.10, p = 0.006) independently predicted access complications. Access complications most often consisted of vessel dissection, stenosis or occlusion and predominantly occurred in patients with an unfavorable arteriotomy phenotype. ConclusionsLarge-bore arteriotomy closure with MANTA VCD provided fast and safe hemostasis with an acceptable complication rate. Refined procedure planning and risk-stratification may further improve MANTA VCD performance.

Correlations between age, body size, sex, and conformation and ultrasound-measured femoral vessel diameter in the dog, with implications for transvascular procedural planning.

Transvascular interventional radiology procedures have advanced in veterinary medicine, but basic knowledge about expected vascular size and vascular imaging requires further exploration. A prospective analytical study of 230 client-owned dogs was carried out to investigate correlations between ultrasound-measured femoral artery (FA) and femoral vein (FV) diameter and various morphometric and demographic dog variables, compare ultrasound-measured femoral vessel diameter to diameter predicted by body weight, compare right- and left-sided femoral vessel diameter, and assess measurement repeatability. Internal diameter of the FA and FV was measured with ultrasound bilaterally. Allometrically scaled body weight had the strongest correlation with FA and FV diameter (correlation coefficients: 0.92 and 0.80, respectively), although thigh circumference (FA: 0.89; FV:0.78) and withers height (FA: 0.84; FV: 0.76) were also strongly correlated. Within the entire population, males had a smaller FA (P=.005), but not FV (P=.278), than females and age was negatively associated with FA (P=.031) and FV (P<.001) diameter. Compared to ultrasound-derived measurements, body weight-predicted diameter overestimated by at least one French gauge in 32.6% and 35.2% of dogs for the FA and FV, respectively. Comparison of left and right FA and FV diameter revealed minimal mean differences, though limits of agreement could encompass multiple French gauge sizes: (Mean difference [limits of agreement]: FA=0.00mm [0.85-0.84mm]; FV=0.04mm [1.92-1.99mm]). Intra- and interoperator repeatability coefficients of variation were<9%. Femoral vessel diameter in dogs is influenced by multiple factors, with potential for clinically relevant differences between right- and left-sided vessels. Ultrasound measurement of femoral vessels could improve transvascular preprocedural planning.

Prenatal Diagnosis of Vein of Galen Aneurysmal Malformation Allows Early Transumbilical Endovascular Treatment

AbstractNeonates with vein of Galen aneurysmal malformation (VGAM) presenting with severe cardiac failure and pulmonary hypertension represent a challenge for endovascular therapy. When early treatment is required, the small femoral arteries in this population are usually difficult to cannulate. Alternatively, the umbilical vessels offer a natural pathway to reach the lesion. Therefore, prenatal diagnosis of VGAM allows for delivery planning, perinatal management, and embolization through umbilical approach, thus leading to better outcomes.

Outcomes of routine use of percutaneous access with large-bore introducer sheaths (>21F outer diameter) during endovascular aneurysm repair

ObjectiveThe objective of this study was to evaluate the performance of percutaneous femoral access with large-bore sheaths (>21F outer diameter) mainly employed for thoracic and thoracoabdominal aortic endovascular treatment and to stratify the outcomes on the basis of the introducer size. MethodsBetween December 2015 and December 2018, all consecutive patients who received endovascular repair through a percutaneous approach with a suture-mediated vascular closure device (VCD) and the preclose technique were included in a retrospective single-center study called Totally Percutaneous Approach to Endovascular Treatment of Aortic Aneurysms (PEVAR-PRO). The morphologic characteristics of the access vessels and patients' demographics were recorded, and 30-day closure success was defined as the primary end point. Analysis of the closure success comparing large-bore sheaths vs small-bore sheaths (≤21F outer diameter) was performed after 1:1 propensity score matching of preoperative confounding variables. ResultsThe closure success rate of the entire study cohort was 94% (622 femoral accesses in 360 patients; median age, 74 years; 84% male). Univariate analysis identified eight different factors associated with failure, but only two remained significant on multivariate analysis: diabetes (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .011) and common femoral artery stenosis >50% (OR, 4.5; 95% CI, 1.3-13.7; P = .019). After propensity score matching (1:1, 172 femoral accesses per group), closure success rate was not significantly different between large-bore and small-bore sheaths (90.7% vs 93.0%; P = .43). Multivariate analysis of the large-sheath group identified two factors associated with failure: small (<9 mm) femoral arteries (OR, 6.9; 95% CI, 1.5-31.6; P = .13) and access vessel calcifications involving more than one-third of the circumference (OR, 7.9; 95% CI, 2.1-29.4; P = .002). Neither previous femoral cutdown (44 accesses [23%]) nor percutaneous closure with VCDs (38 accesses [20%]) affected the closure success rate in the large-sheath group. Closure failure did not significantly increase the need for postoperative blood transfusions or hospital length of stay. ConclusionsOff-label use of VCDs and the preclose technique for percutaneous approach with large-bore sheaths needed for complex aortic endovascular procedures is safe and feasible. Closure success rate is not significantly different from that obtained with on-label application of VCDs with smaller sheaths.

Transumbilical arterial embolization of a large dural arteriovenous fistula in a low-birth-weight neonate with congestive heart failure

The purpose of this study was to report transumbilical arterial embolization of a large dural arteriovenous fistula (AVF) in a low-birth-weight neonate with congestive heart failure (CHF). A female neonate was delivered by cesarean section at 31 weeks of gestation. Her birth weight was 1538 g and Apgar scores were 6 at both 1 and 5 min. Because of dyspnea and retracted respiration immediately after birth, she required mechanical ventilation. Ultrasound revealed right cardiac overload and a large cystic mass at the posterior brain. Magnetic resonance imaging on day 1 showed a large dural AVF (dural sinus malformation with arteriovenous (AV) shunts) at the torcular herophili. Umbilical artery and vein catheterization were performed on the same day for neurointervention. CHF prompted emergency embolization on day 8. The transfemoral arterial route could not be used because of its small size and compromised femoral artery blood flow. Transumbilical arterial embolization shrank the AV shunts markedly, resulting in clinical improvement, thus requiring no further intervention. Follow-up angiography at 4 months confirmed no residual AVF. Her growth and development were normal at the last follow-up at age 4 years. This patient apparently was the lowest birth weight neonate with a large AVF successfully treated by embolization, which is usually performed through the transfemoral arterial route. The transumbilical arterial route is an alternative for neonates with birth weight <2000 g and very small femoral arteries.

83 Retention of Surgically Mediated Access Improves Vascular Outcome in Transfemoral Tavi

BackgroundThe transfemoral approach is the most widely used access route for transcatheter aortic valve implantation (TAVI). Early experience incorporated surgical cutdown and closure. As the equipment size has been reduced...

Novel Technique Confirms Femoral Line Placement Using Cardiac Ultrasound

Accidental placement of a femoral venous catheter into the artery can cause limb ischemia, especially in children, who have small femoral arteries.

Fast track occlusion of aorta with atrial septal defect sizing balloon

We describe the case of a 57-year-old woman referred to our emergency service with ruptured abdominal aneurysm. We placed a 34-mm Amplatzer sizing balloon II into the suprarenal level of aorta to immediately control the active massive bleeding and to get the patient out of hemorrhage shock into the stable condition. After the bleeding control, endovascular repair was successfully performed. This is the first case report, to our knowledge, of atrial septal defect (ASD) sizing balloon use for blocking the blood flow through aorta to control the bleeding. ASD sizing balloon has some different properties compared to aortic occlusion balloon catheter (AOBC). Due to availability of sheathless usage, ASD sizing balloon may be preferred over AOBC for some of patient groups with peripheral artery diseases and small femoral artery diameters.

Endovascular Stent-Graft Exclusion of Adult Giant Patent Ductus Arteriosus Through a Hybrid Transabdominal Approach

Endovascular stent-graft exclusion has proven to be a safe and effective alternative for adult patients with patent ductus arteriosus. We present a case of a 38-year-old woman with a large, symptomatic ductus. However, her small femoral and iliac arteries limited the access options. The patient underwent laparotomy and end-to-side anastomosis of a Dacron graft to the abdominal aorta. Then, the laparotomy was temporarily closed with the graft externalized, and the patient was transported to the radiology suite for successful stent-graft deployment. This hybrid transabdominal approach may be preferred in patients without suitable peripheral arteries to accommodate the device.

Role of the α-adrenergic system in femoral vascular reactivity in neonatal llamas and sheep: a comparative study between highland and lowland species

Using an integrative approach at the whole animal, isolated vessels, and molecular levels, we tested the hypothesis that the llama, a species that undergoes pregnancy under the influence of the chronic hypoxia of high altitude, delivers offspring with an increased α-adrenergic peripheral vascular reactivity compared with neonates from lowland species. We studied the femoral vascular response to acute hypoxia in vivo, the reactivity of femoral vessels ex vivo, and the expression of femoral α1-adrenergic receptor subtypes using RT-PCR in vitro. The increase in femoral resistance during hypoxia was 3.6 times greater in newborn llamas than newborn sheep (P < 0.05). The sensitivity of the contractile response to noradrenaline (pD2 = 5.18 ± 0.06 vs. 4.84 ± 0.05, P < 0.05) and the maximal response (Rmax = 101.3 ± 1.4 vs. 52.4 ± 1.4% K+max, P < 0.05) and sensitivity (pD2 = 5.47 ± 0.03 vs. 4.57 ± 0.05, P < 0.05) to phenylephrine were higher in femoral vessels from newborn llamas than newborn sheep. Competitive inhibition with prazosin of noradrenaline-induced contraction followed by Schild analysis showed higher affinity in the llama than the sheep (pA2 = 10.08 ± 0.093 vs. 8.98 ± 0.263, respectively, P < 0.05), consistent with greater α1B-adrenergic receptor transcript expression observed in small femoral arteries from neonatal llama. The llama newborn demonstrates significantly greater α-adrenergic peripheral vascular reactivity compared with neonates from lowland species that could be partially explained by preferential expression of α1B-adrenergic receptor subtype.

Alternative Approach for Endovascular Treatment of Aortic Aneurysms

Endovascular treatment of thoracic aortic aneurysms is limited in patients with small or calcified femoral arteries, with the most serious complication being rupture at the insertion site or distal sections of the artery. To overcome this, an iliac conduit is normally created by surgical exposure. We used an original access in a patient with a thoracoabdominal aortic aneurysm and narrow femoral artery to introduce the endovascular prosthesis directly into the surgically exposed iliac artery by a small laparotomy and abdominal wall tunnel without iliac conduit. The endoprosthesis was easily implanted, and complete hemostasis was achieved with minimal blood loss.

Superoxide constricts rat pulmonary arteries via Rho-kinase-mediated Ca2+ sensitization

Reactive oxygen species play a key role in vascular disease, pulmonary hypertension, and hypoxic pulmonary vasoconstriction. We investigated contractile responses, intracellular Ca2+ ([Ca2+]i), Rho-kinase translocation, and phosphorylation of the regulatory subunit of myosin phosphatase (MYPT-1) and of myosin light chain (MLC20) in response to LY83583, a generator of superoxide anion, in small intrapulmonary arteries (IPA) of rat. LY83583 caused concentration-dependent constrictions in IPA and greatly enhanced submaximal PGF2α-mediated preconstriction. In small femoral or mesenteric arteries of rat, LY83583 alone was without effect, but it relaxed a PGF2α-mediated preconstriction. Constrictions in IPA were inhibited by superoxide dismutase and tempol, but not catalase, and were endothelium and guanylate cyclase independent. Constrictions were also inhibited by the Rho-kinase inhibitor Y27632 and the Src-family kinase inhibitor SU6656. LY83583 did not raise [Ca2+]i, but caused a Y27632-sensitive constriction in α-toxin-permeabilized IPA. LY83583 triggered translocation of Rho-kinase from the nucleus to the cytosol in pulmonary artery smooth muscle cells and enhanced phosphorylation of MYPT-1 at Thr-855 and of MLC20 at Ser-19 in IPA. This enhancement was inhibited by superoxide dismutase and abolished by Y27632. Hydrogen peroxide did not activate Rho-kinase. We conclude that in rat small pulmonary artery, superoxide triggers Rho-kinase-mediated Ca2+ sensitization and vasoconstriction independent of hydrogen peroxide.