Stent Delivery Research Articles

Percutaneous Left Main Coronary Intervention: A Review of Plaque Modification in Left Main Percutaneous Coronary Intervention.

Left main coronary artery (LMCA) stenosis has long been recognized as a marker of increased morbidity and mortality. Current treatment algorithms for LMCA stenosis consider both percutaneous coronary intervention (PCI) with drug eluting stents (DES) and coronary bypass surgery, each with advantages based on individual patient characteristics. Since the LMCA is the largest artery in the coronary tree, plaque volume and calcification is greater than other coronary segments and often extends to the distal bifurcation segment. In LMCA bifurcation lesions, larger minimal stent area is strongly associated with better outcome in the DES era. Plaque modification strategies such as rotational, orbital, or laser atherectomy are effective mechanisms to reduce plaque volume and alter compliance, facilitating stent delivery and stent expansion. We present a case of a calcified, medina class 1,1,1 LMCA lesion where intravascular ultrasound (IVUS) and orbital atherectomy were employed for optimal results. In this context, we review the evidence of plaque modification devices and the rationale for their use in unprotected left main PCI.

Aortic Arch Debranching With Thoracic Endovascular Aortic Repair and Simultaneous Coronary Bypass Grafting

Recent advances have allowed simultaneous hybrid repair with open surgical arch debranching and thoracic endovascular stent placement. We describe an asymptomatic patient with a degenerative aneurysm and concurrent coronary disease who successfully underwent a hybrid aortic arch and descending aorta repair and coronary revascularization. A 78-year-old man presented with a distal aortic arch aneurysm and two-vessel coronary disease. Preoperative computed tomography angiography demonstrated a fusiform aortic aneurysm involving the left carotid and subclavian arteries and proximal descending aorta. Catheterization revealed severe left anterior descending and diagonal branch coronary disease. After cardiopulmonary bypass was initiated, the left anterior descending and diagonal arteries were bypassed with saphenous venous grafts. Two openings were created at the sinotubular junction proximally, and coronary anastomoses were completed. Trifurcation graft (TG) with a separate branch for stent delivery was anastomosed to the proximal ascending aorta. The proximal clamps were then removed. The innominate artery was divided between clamps and then anastomosed to the main limb of the TG. Antegrade cerebral perfusion was established through the anastomosis. Next, the left carotid artery was anastomosed to the second limb of the TG, and antegrade cerebral perfusion was initiated using both arteries. Secondary to extensive atherosclerotic disease, the left subclavian artery was exposed using a left infraclavicular incision. The left subclavian was divided and then ligated at its origin. The third limb of the TG was brought into the left side of the chest and anastomosed to the subclavian artery. The patient was weaned off cardiopulmonary bypass. Initial aortic luminal flap noted the true lumen to be concave. A 40-mm × 15-cm Gore Thoracic TAG endoluminal stent graft (W. L. Gore & Associates, Flagstaff, Ariz) was deployed in the descending aorta proximal to the celiac artery under fluoroscopic guidance through a side branch of the TG. A second 45-mm × 20-cm Gore graft was deployed distal to the TG with significant overlap with the previous graft. Postprocedure completion aortography demonstrated no endoleak, and intravascular ultrasound noted the true lumen to be convex. One-month follow-up computed tomography scan showed the endograft without endoleak and patent bypass grafts. A hybrid approach allows the repair of the distal aortic arch and descending aorta as a one-stage procedure.

Current Status of Coronary Atherectomy

There are several techniques for performing coronary atherosclerotic plaque modification, known as atherectomy. Historically, clinical trials show mostly equivalence between various coronary atherectomy techniques, balloon angioplasty, and percutaneous coronary stenting. In the last several years the use of a given atherectomy technique has been mostly as a means of facilitating stent delivery in vessels that are heavily calcified. No clinical trials have shown superiority of any atherectomy method over more standard techniques of percutaneous coronary intervention. This review begins with a discussion of directional atherectomy, which is no longer available. The rotational atherectomy technique and its clinical trial data are presented. Orbital atherectomy is then discussed in detail, including the relevant clinical trials. Finally, laser atherectomy techniques are reviewed, and the pertinent trial data are presented. Lastly, future directions are detailed.

Anchor-balloon technique to facilitate stent delivery via the GuideLiner catheter in percutaneous coronary intervention.

The GuideLiner (GL) is a widely used catheter primarily in complex percutaneous coronary intervention (PCI). Deep seating of the GL and distal stent placement may be facilitated by the anchor-balloon technique (ABT). We aimed to prospectively analyze procedural details, technical success, complications and in-hospital outcome in patients who underwent PCI using the GL catheter and the ABT. A total of 118 patients underwent PCI with the aid of the GL and ABT. Procedure success rate was 95% (112/118) and only seven patients (5.9%) encountered complications. ABT was indicated and successfully used in 29 patients (25%). GL and ABT successfully aided stent delivery in unfavorable and heavily calcified lesions which otherwise may have been considered unsuitable for PCI.

The application of three-dimensional printing abdominal aortic aneurysm improve the teaching effect for the residents in vascular surgery department

Objective To evaluate 3D printing abdominal aortic aneurysm model in analysis of clinical teaching effect for standardized resident doctors in vascular surgery department. Methods 48 residents in vascular surgery department in our hospital from December 2016 to September 2017 were seleeected and randomly divided into control group and the experimental group. The traditional vascular surgical anatomy atlas, ultrasound, CT abdominal blood vessel 3D reconstruction, digital subtraction, video and so on were used by 24 residents in the control group, while in the experimental group, on the basis of the traditional teaching, abdominal aortic aneurysm model of 3D printing, true aortic coated stent delivery system were increased. After the teaching, the theory of evaluation (abdominal vascular anatomical features, morphological characteristics and classification of AAA, measurement of various parameters and key points of operation in the EVAR) and satisfaction questionnaire were adopted to evaluate the effect of two kinds of teaching methods. SPSS 19.0 was used to conduct t test on two groups of physician evaluation data. Results The results of theoretical assessment showed that there was no significant difference between the control group and the experimental group in the abdominal vascular anatomical features, the morphological features and the classification of the experimental group (P>0.05) in the examination of the common AAA cases and the complicated AAA cases. However, the experimental group was higher than the control group in the measurement of the parameters of EVAR, and the score of the operation points and the total score, and the difference was statistically significant (t=2.283, t=2.263, P<0.05). The results of the questionnaire showed that the students' satisfaction scores on the teaching satisfaction of the normal and complex AAA cases were better than those of the control group, and the difference was statistically significant (P<0.05). Conclusion The 3D printing model can increase the understanding and mastery of the anatomy and treatment of abdominal aortic aneurysm and improve its learning enthusiasm for vascular surgery. We should make full use of the advantages of 3D printing technology on the basis of retaining the advantages of traditional teaching methods and means, and further enhance the teaching effect. Key words: Standardized residents; 3D printing; Vascular surgery; Abdominal aortic aneurysm

From debulking to delivery: sequential use of rotational atherectomy and Guidezilla\u2122 for complex saphenous vein grafts intervention

BackgroundPercutaneous coronary interventions (PCI) of old calcified saphenous vein grafts (SVGs) is challenging and is associated with a considerably high risk of adverse ischemic events in the short- and long-term as compared to native coronary arteries. We report a case in which a non-dilatable, calcified SVG lesion is successfully treated with rotational atherectomy followed by PCI and stenting with local stent delivery (LSD) technique using the Guidezilla™ guide extension catheter (5-in-6 Fr) in the “child-in-mother” fashion.Case presentationA 70 years-old man with a dilated ischemic cardiomyopathy, triple coronary artery bypass grafting (CABG) in 1990 and chronic renal failure (baseline GFR: 45 ml/min/1.73 m2) underwent a coronary angiography for a Non-ST segment elevation myocardial infarction (NSTEMI). Native coronary circulation was completely occluded at the proximal segments. Grafts angiography showed a tandem calcified lesions of SVG on distal right coronary artery (RCA) and an ostial stenosis of the SVG on first obtuse marginal branch (OM1). Left internal mammary artery on the mid left anterior descending artery was patent. Ad Hoc PCI of SVG on RCA was attempted. The proximal calcified stenosis has been crossed with a 1.5 x 12 mm balloon only with the support of Guidezilla™, however the non-compliant (NC) balloon 2.5 x 15 mm was unable to break the hard and calcified plaque. After several attempts, the procedure was interrupted with a suboptimal result. An elective transradial PCI of SVG on RCA with rotational atherectomy was performed. Two runs with 1.25 mm burr and 2 runs with 1.5 mm burr were carried out. Then, the use of distal anchoring balloon warranted support and tracking, made as centring rail for the advance of the tip of the “mother-and-child” catheter into the SVG. During slow deflation of the balloon, the Guidezilla™ was advanced distal to the stenoses to be stented, thus allowing the placement of two long drug eluting stents according to a LSD technique.ConclusionsRotational atherectomy is a feasible option for non-dilatable stenoses in old SVGs when there is no evidence of thrombus or vessel dissection and the subsequent use of “mother-and-child” catheter has a key role, especially in case of radial approach, for long stents delivery.

Mo1327 COMPARATIVE ANALYSIS OF EUS-GUIDED PSEUDOCYST AND WALLED OFF NECROSIS DRAINAGE BETWEEN DIFFERENT METAL (HOT-AXXIOSTM, NAGGITM, SPAXUSTM) AND PLASTIC (DOUBLE PIG-TAIL) STENTS: A SINGLE-CENTER EXPERIENCE

Endoscopic Ultrasound-guided Transmural Drainage (EUS-TD) is a minimally invasive first-line modality for the management of two types of pancreatic fluid collection (PFC): pancreatic pseudocyst (PP) and walled-off necrosis (WON). EUS-TD has demonstrated a shorter hospital stay and less morbidity compared to surgical cystogastrostomy. Stents delivery systems are available in different materials and trademarks. Their specific outcomes on PFC types have not been described, particularly in a Hispanic population. To evaluate the outcomes and seek for differences in the management of EUS-TD of PP and WON, between different stents materials and trademarks. Observational, descriptive, longitudinal, retrospective cohort study. Data from EUS-guided drainages of PFC cases were obtained from medical records, as corresponding: PFC characteristics, type of stent (metal: Hot-AxxiosTM, NaggiTM, SpaxusTM; plastic: double Pig-Tail), technical success (including time of procedure), clinical success (follow-up: adverse events, further EUS, imaging, possible re-interventions and PFC resolution). Variables were described in mean or median values, according to statistical distribution (Shapiro-Wilk test), and contrasted through follow-up with corresponding hypothesis testing. Analyses were performed using R v3.4.2 (R Foundation for Statistical Computing, Vienna, Austria). From May-2014 to Oct-2017, 42 consecutive cases were collected: 29/42 PP and 13/42 WON. Baseline characteristics are summarized in table 1. 7/29 PP had spontaneous remission, 3/29 PP and 3/13 WON were lost on follow-up. 19/19 PP and 10/10 WON underwent on EUS-guided stent placement, with 100% technical success. Time of procedure per stents was as following: Hot-AxxiosTM 5 (4-6) min, NaggiTM 19 (18-22) min, SpaxusTM 20 (18-22) min, double Pig-Tail 20 (18–22) min (p<0.01). In PP cases, a bleeding episode occurred 48 hours after a Hot-AxxiosTM placement (p=0.58). In WON cases, an obstruction was reported with a Hot-AxxiosTM, and a bleeding episode occurred 48 hours after a NaggiTM placement (p=0.69). Both bleeding events required surgical management. Overall adverse events rate was 10% (3/29) with no reports from plastic stent cases. Overall 30-day mortality was 0% (figure 1). All stents were finally removed. On this series, none of the cases needed percutaneous drainage. Overall median time from stent placement to complete drainage & removal was 8 (1–20) weeks; overall median longest follow-up time was 41 (8–120) weeks. 3 cases (2 SpaxusTM, 1 NaggiTM) cannot be released due to device failure, and no cases of Hot-AxxiosTM or Plastic stent. Neither stent material nor trademark present a significant impact on PFC outcomes, even in the presence of adverse events. Compared to other stents, Hot-AxxiosTM seems to be more practical and faster for placement.Tabled 1Table 1. Baseline characteristics.(n = 42)Age (years), median (range)48 (10 – 76)Gender (female), n (%)19 (46.3)Etiology, n (%)Alcohol11 (26.8)Biliary31 (73.8)Type of PFC, n (%)Pseudocyst (PP)29 (69.0)Walled-off necrosis (WON)13 (31.0)Size of PFC (cm), median (range)7 (1 – 14)Site of PFC, n (%)Head – Body16 (38.0)Body – Tail26 (62.0)Indication for drainage, n (%)Pain30 (71.0)Infection12 (29.0)Concurrent ERCP for PFC approach, n (%)5 (11.9)PFC in remission during diagnosis, n (%)7 (16.7)Patients not attempted & lost follow-up, n (%)6 (14.2)Patients addressed to EUS-guided drainage, n (%)29 (69.0)Metal stent delivery system, n (%)25/29 (86.2)Metal stents delivery system, by Trademark, n (%)Hot-AxxiosTM9/25 (36.0)NaggiTM10/25 (40.0)SpaxusTM6/25 (24.0)Plastic stent delivery system, n (%)Pig-Tail4/29 (13.8) Open table in a new tab

IP109. The Learning Curve of Transcarotid Artery Revascularization

Transcarotid artery revascularization (TCAR) is a relatively new procedure that involves access to the proximal cervical common carotid artery (CCA), cerebral blood flow reversal as neuroprotection, and stent delivery. The purpose of this study was to describe the learning curve of TCAR. A retrospective review of all patients sequentially undergoing TCAR at three institutions was ordered chronologically. Procedural time was defined as the time of skin incision to time of the final bandage placed on the neck wound. Flow reversal time was defined as the time when reverse flow was initiated (CCA clamped) until the reverse flow was terminated (CCA unclamped). Operative times were then grouped into bins of five and analyzed using one-way analysis of variance (ANOVA) with P < .05 considered statistically significant. Results from ANOVA led to comparison of cases 1 to 10 vs 11 to 50, accomplished using Wilcoxon signed rank test. Overall, 190 procedures were performed by 7 vascular surgeons at 3 institutions between 2013 and 2017. The mean procedural time for all cases was 68.9 ± 9.5 minutes (Fig). When the procedural time of cases 1 to 10 (mean, 74.8 ± 9.6 minutes) was compared with that of cases 11 to 50 (mean, 67.5 ± 9.0 minutes), a significant difference was noted (P = .014). ANOVA results between all bins of procedural times showed that the first 5 cases were statistically longer than cases 31 to 50. Mean flow reversal time was 9.7 ± 3.5 minutes. When flow reversal times were compared using ANOVA testing, cases 1 to 10 were statistically similar and all cases within 11 to 50 were also similar, but the two groups differed from each other (P < .001). For flow reversal time, the first 10 cases had mean reversal times of 14.5 ± 3.7 minutes compared with 8.6 ± 2.3 minutes for cases 11 to 50 (P < .001). Patients of cases 1 to 10 experienced postoperative stroke (2/68 [2.94%]) not significantly different from patients of later cases (1/122 [0.82%]; P = .292; Table). Similarly, postoperative mortality rates were similar in the <10 and >10 case groups (1.47% vs 1.64%; P = 1.00). All three strokes and two of the three deaths (both in cases 11-50) occurred in symptomatic patients, which represented 42% of the overall cohort. A learning curve does exist for the TCAR procedure, but it is relatively steep. After 10 cases, surgeons are able to reduce procedural times by 10% (74.8 to 67.5 minutes) and, more important, flow reversal times by an average of 40% (14.5 to 8.6 minutes). The critical steps in the TCAR procedure may be easily adopted by a broad group of vascular surgeons learning this technique.TablePostoperative outcomes for cases 0 to 10 vs cases >10Stroke, n/N (%)Death, n/N (%)Stroke and death combined, n/N (%)Cases 0-102/68 (2.94)1/68 (1.47)3/68 (4.41)Cases >101/122 (0.82)2/122 (1.64)3/122 (2.46)P = .2915P = 1.000P = .6684 Open table in a new tab

Optimizing Percutaneous Coronary Intervention in Calcified Lesions: Insights From Optical Coherence Tomography of Atherectomy.

Optimal coronary stent implantation is among the few successful strategies in preventing stent failures, notably in-stent restenosis and stent thrombosis.1 Understanding the intravascular milieu is a prerequisite for optimization of percutaneous coronary intervention (PCI). Calcified lesions limit stent expansion, the most robust predictor of target lesion revascularization, and are thus associated with worst outcomes.2 Coronary angiography is a poor discriminator of calcium distribution and thickness. Reliance on angiography to guide PCI and define procedural success in severe coronary calcification is associated with poor outcomes.3 Both intravascular ultrasound and optical coherence tomography (OCT) enable detailed evaluation of cross-sectional calcium distribution (angle of calcium), and OCT provides additional information on calcium thickness. The combination of large calcium angle (>270°) and thickness (>670 μm) predicts nondilatable lesions.4 OCT is the ideal method to capture these parameters and indicate or defer the use of atherectomy before stent implantation and guide optimization of PCI. Preintervention OCT imaging delineates plaque constituents and provides accurate measurements of the minimal lumen area, lesion length, and reference vessel diameters, as well as visualization of the projected stent landing zones. These parameters can be used for procedural planning, including proper lesion preparation and stent sizing. Knowledge of plaque characteristics can be used to select a plaque modification strategy prior to stent implantation and to minimize stent edge dissection at the stent landing zone.5 Calcified lesions pose a bigger challenge, with difficult device delivery, suboptimal stent expansion, and increased procedural time and complications. Although atherectomy facilitates stent delivery and improves procedural success and acute lumen gain, long-term outcomes in severely calcified lesions are not improved with the routine use of angiographically guided ablative techniques in the drug eluting stent era.6 Indiscriminate use of atherectomy can also increase procedural complications. Intravascular frequency domain OCT is the …

TCTAP C-152 Bad Access to Axxess: A Complication Made During Dedicated Bifurcation Stent Delivery

### Patient Initials or Identifier Number Mr. S. ### Relevant Clinical History and Physical Exam This 82 y/o man had intermittent chest tightness for 2 weeks. He had underlying of hypertension under medication control. He smoked 0.5 PPD for more than 50 years. Due to progressive chest

Safety of Prasugrel loading in ruptured blister like aneurysm treated with a Pipeline device.

Blister like aneurysm (BLA) is extremely challenging to treat; endoluminal reconstruction has emerged as the most promising treatment method. When to treat after the ictus, the timing of administration of antiplatelet and causal relationship between platelet function testing results and thrombo-embolism is unclear. We theorized that Prasugrel with a lower incidence of resistance may be a safe suitable alternative to clopidogrel in patients treated with a flow diverter(FD). Prospectively collected data from consecutive patients treated for a ruptured blister with an FD was reviewed. Device deployment was timed to be at 2 h following Prasugrel loading. Thrombo-embolic and hemorrhagic complications, and occlusion rates were documented. Nine patients were included. Most were females (55%); the median age was 55 (43, 65). The median Fischer grade was 3 (2, 4). A single pipeline device was deployed in all within 24 h of admission; the median time from ictus to device deployment was 4 days (2, 30). There were no thrombo-embolic or hemorrhagic complication. Complete occlusion was noted in 89% (n = 9). Prasugrel loading timed 2 h prior to stent delivery did not increase thrombo-embolic or hemorrhagic complications. Single stent that is well apposed against the wall appears to be an effective treatment strategy to treat BLA. Advances in knowledge: Treatment of acutely ruptured BLA with a single pipeline device deployed at 2 h after Prasugrel loading appears to be safe.

CRT-100.50 Outcomes Of Patients With Left Main Disease Who Underwent Rotational Atherectomy

Significant coronary calcification is a challenge for percutaneous coronary intervention (PCI). Rotational atherectomy is useful for plaque modification prior to stent delivery. In the present study, we report our experience with left main disease and rotational atherectomy. From January 2008 to

Development of new endoscopic irreversible electroporation ablation device: Animal experimental study.

188 Background: Irreversible electroporation (IRE) is a promising novel technique for the ablation of tumors. An advantage of IRE is its mechanism to remove undesired cells by affecting the cell membrane without thermally destructing blood vessels, nerves and the surrounding tissues. Several clinical trials for applying IRE to human organs such as liver, pancreas, and kidney are conducted and studies about IRE ablation for gastrointestinal tumors also have been conducted recently. Here, we developed new endoscopic IRE device, and studied about its effectiveness and feasibility in animal model. Methods: Newly developed endoscopic IRE ablative catheter works with single channel of endoscope. A pair of dipolar electrodes consist of pre-shaped f 0.63mm nitinol wire and the distance between each electrode is 10 mm. The electrodes are loaded within braided tube for stent delivery system then deployed when IRE catheter put in stomach through the endoscope. We performed endoscopy and IRE ablation was done on pig’s stomach mucosa by using endoscopy with newly developed IRE catheter. We divided pig’s stomach into 2 parts(antrum &amp; body), and IRE ablation was applied on each part of the stomach. Pigs were sacrificed after 24hours, and we collected their stomachs with surgical technique. Following fixation, tissues were stained with H&amp;E. Results: Ten male Yorkshire pigs and in vitro stomachs were used in this study. The tissue with H&amp;E stain showed diffuse cell death 24hr after IRE ablation. Consistent with the mechanism of action of IRE on the cell membrane only, there was complete cell death within the IRE lesions without intervening live cells. But there was no difference in histology depending on gastric part in which ablation was applied. During the study, no complication was observed in pigs in 24 hours after ablation. Conclusions: The new endoscopic IRE device, which can perform IRE ablation on gastrointestinal tract using endoscopy showed safe and feasible result.

Emergency coronary angioplasty with stenting using Cordis® diagnostic coronary catheters when there is difficulty in engaging guide catheters and bench evaluation of diagnostic and guide catheters

Introduction and AimsDifficulty in engaging with guide catheters is not uncommon in acute emergencies. We aimed to evaluate the use of Cordis® INFINITI diagnostic catheters to perform angioplasty in patients in whom the coronaries cannot be engaged using standard guide catheters. MethodsIn 34 cases of acute coronary syndrome, when difficulty in engagement with two standard guide catheters was encountered with reasonable manipulations, angioplasty was performed using diagnostic catheters. In total, 40 stents were placed by this technique. Pushability and trackability, distal tip flexion and three-point bending tests were performed to evaluate the performance of the guide and diagnostic catheters. ResultsAngioplasty was performed easily in a setting where it would have been very difficult to perform. Coronary dissection occurred in one patient, treated by a stent. The stent and dilatation balloons were easily passed through the diagnostic catheters. Pressure tracings were clearly preserved with certain stent delivery systems, and at angioplasty, although there was slightly reduced opacification of the respective artery, the coronary anatomy was sufficiently visualized to perform angioplasty. No periprocedural target lesion complications were seen in any cases.Pushability and trackability tests showed good force transmission along a tortuous path with diagnostic catheters, and balanced force-displacement curves from three-point bending tests and distal tip softness tests. ConclusionAngioplasty with stenting can be performed safely through 6F Cordis® infiniti diagnostic catheters when difficulty in engaging guide catheters is encountered.

CRT-100.32 Predictors of Procedural Complication During Rotational Atherectomy vs. Orbital Atherectomy in Calcified Coronary Artery Disease: A Contemporary Retrospective Comparative Analysis (ROCC study)

Severe coronary calcification adversely influences success of percutaneous coronary intervention. Rotational atherectomy (RA) (Boston Scientific) and orbital atherectomy (OA) (Diamondback 360® (CSI)) are used to modify plaque and help facilitate stent delivery to improve clinical outcomes. We

Sex differences in the outcomes of stent implantation in mini-swine model.

Sex-related differences have been noted in cardiovascular anatomy, pathophysiology, and treatment responses, yet we continued to drive evaluation of vascular device development in animal models without consideration of animal sex. We aimed to understand sex-related differences in the vascular responses to stent implantation by analyzing the pooled data of endovascular interventions in 164 Yucatan mini-swine (87 female, 77 male). Bare metal stents (BMS) or drug-eluting stents (DES) were implanted in 212 coronary arteries (63 single BMS implantation, 68 single DES implantation, 33 overlapped BMS implantation, and 48 overlapped DES implantation). Histomorphological parameters were evaluated from vascular specimens at 3–365 days after stent implantation and evaluated values were compared between female and male groups. While neointima formation at all times after implantation was invariant to sex, statistically significant differences between female and male groups were observed in injury, inflammation, adventitial fibrosis, and neointimal fibrin deposition. These differences were observed independently, i.e., for different procedure types and at different follow-up timings. Only subtle temporal sex-related differences were observed in extent and timing of resolution of inflammation and fibrin clearance. These subtle sex-related differences may be increasingly important as interventional devices meld novel materials that erode and innovations in drug delivery. Erodible materials may act differently if inflammation has a different temporal sequence with sex, and drug distribution after balloon or stent delivery might be different if the fibrin clearance speaks to different modes of pharmacokinetics in male and female swine.

Preliminary Outcomes of the LifeStream Balloon-Expandable Covered Stent in Fenestrated and Branched Thoracoabdominal Endovascular Repairs

Purpose: To evaluate the 1-year outcomes of thoracoabdominal aortic aneurysm (TAAA) repair using fenestrated and branched stent-grafts and a novel balloon-expandable covered stent. Methods: Between March 2015 and January 2017, 18 patients (median age 74.7 years; 14 men) received 43 LifeStream balloon-expandable covered stents in conjunction with Zenith fenestrated/branched stent-grafts to bridge 11 celiac trunks, 8 superior mesenteric arteries, and 24 renal arteries (total 32 fenestrations and 11 branches). Results: Stent delivery and deployment was successful in all cases. At 30 days, 5 patients presented with perifenestration endoleaks (type IIIc) secondary to inadequate sealing of the LifeStream covered stent in 7 (22%) of 32 fenestrations. No type IIIc endoleaks were reported in the branched cases. Four patients had a secondary endovascular reintervention with proximal relining by means of a bare balloon-expandable stent at the perifenestration transition area, with complete resolution of the endoleak at 1-year follow-up. One patient refused reintervention. The last 4 fenestrated stent-grafts of this series had prophylactic perifenestration bare stent relining with no evidence of type IIIc endoleaks at imaging. At a median follow-up of 14.1 months (interquartile range 11, 22), the 12-month LifeStream patency rate was 100%. Conclusion: This single-center preliminary experience with the LifeStream balloon-expandable covered stent in fenestrated/branched stent-grafts for TAAA repairs demonstrated good patency; however, an unexpectedly high rate of type IIIc endoleaks was observed. These endoleaks were resolved with reintervention or during the index procedure by proximal relining with a bare balloon-expandable stent, achieving adequate perifenestration sealing.

Up-and-Over Technique for Implantation of Iliac Branch Devices After Prior Aortic Endograft Repair

Purpose: To describe a modified up-and-over access technique for treatment of iliac artery aneurysms in patients with prior bifurcated stent-grafts for endovascular aneurysm repair (EVAR). Technique: This technique uses a coaxial 12-F flexible sheath that is docked with a through-and-through wire into a 7-F sheath advanced from the contralateral femoral approach. This maneuver allows both sheaths to be moved as a unit while maintaining position of the apex of the system as it loops over the flow divider, avoiding damage to or displacing the extant endograft. Once the 12-F sheath is positioned in the iliac limb of the aortic stent-graft and secured in place with the through-and-through wire, the repair is extended into the internal iliac artery using a bridging stent-graft or covered stent introduced via a coaxial sheath. Conclusion: The up-and-over technique with a flexible 12-F sheath mated with a 7-F sheath from the opposite side allows bilateral femoral access to be used for iliac branch device placement after prior aortic endograft procedures that create a higher, acutely angled bifurcation. Use of a through-and-through wire and a coaxial sheath for stent delivery creates a very stable platform for intervention.

PULL STRAIGHTEN AND PUSH TECHNIQUE: A SIMPLE SOLUTION FOR GUIDEWIRE REALIGNMENT TO FACILITATE STENT AND DEVICE DELIVERY IN CORONARY ANGIOPLASTY

Coronary guidewire bias prevents easy passage of interventional devices such as stents and balloons during percutaneous coronaryintervention (PCI). Realigning guidewire into the central part of the lumen, away from the coronary wall helps the tracking devicesin situations with significant guidewire bias. There are several available techniques to facilitate stent delivery in tortuous vessel;however, these techniques have their own limitations and can be expensive and time-consuming. A new maneuver for easy passageof stents and balloons in these situations by guidewire realignment is described in this report. This maneuver namely “pull straightenand push technique” demonstrated an easy procedure to successfully execute stents or devices deployment in challenging PCIs.

Coronary artery bypass grafting versus percutaneous coronary intervention in complex coronary artery disease: looking beyond clinical end-points

The choice of optimal revascularization techniques for complex coronary artery disease (CAD), either unprotected left main (UPLM) or multi-vessel disease (MVD), has been a matter of debate for the last two decades. Initially, randomized controlled trials (RCTs) demonstrated a significant mortality benefit of coronary artery bypass grafting (CABG) over medical therapy in patients with complex CAD (1). However, percutaneous coronary intervention (PCI) with balloon angioplasty alone or bare metal stent (BMS) was limited by higher rates of adverse events due to restenosis when compared to CABG (2). Since then, PCI has evolved in both stent technology and delivery techniques, and drug eluting stents (DES) have been shown to decrease risk of revascularization compared with BMS (3). Therefore, further research has focused on comparing PCI using DES versus CABG for patients with complex CAD.