Successful Percutaneous Revascularization Research Articles

TCTAP C-218 Successful Percutaneous Revascularization in a Patient with Acute Renal Artery Embolism

TCTAP C-218 Successful Percutaneous Revascularization in a Patient with Acute Renal Artery Embolism

Percutaneous intervention for Optitorque tiger catheter-induced dissection of the right coronary artery and aortic root

A 59-year-old female developed iatrogenic Type F spiral dissection of the right coronary artery (RCA) with retrograde extension as Type III aortic dissection (AD) during diagnostic coronary angiogram using 5 Fr Optitorque Tiger catheter. The spiral dissection of RCA was treated with angioplasty. AD was followed up with conservative management. The prompt identification of the starting point, the true lumen, and exit point of the dissection is the keys to the successful percutaneous revascularization. Visual eyeballing into multiple angiographic views is of immense help in the situation where optical coherence tomography and intravenous ultrasound are not available.

Acute Lower Extremity Paralysis After Lower Extremity Endovascular Intervention

A 61-year-old man underwent successful percutaneous revascularization of both lower limbs with multiple stent implantations. Paralysis of right lower limb was noticed after completion of procedure when transferring the patient from angiography table. Since hematoma compressing lumbosacral neural plexus could be a fatal complication, computed tomography (CT) image was taken. CT showed bulge of distended bladder compressing stent struts. Following placement of Foley catheter, condition improved and he was subsequently discharged uneventfully.

Assessment of Inducible Myocardial Ischemia, Quality of Life, and Functional Status After Successful Percutaneous Revascularization in Patients With Chronic Total Coronary Occlusion

The benefits of chronic total coronary occlusion (CTO) revascularization are not well established. In this prospective cohort study, 47 consecutive patients with successful percutaneous recanalization of CTO underwent adenosine stress cardiac magnetic resonance (CMR), 6-minute walk test (6MWT), and the Short Form-36 Health Survey before and 6 months after the procedure. Successful recanalization of a CTO was followed by significant improvement of (1) global physical and mental health status; (2) the distance walked in the 6MWT; (3) the incidence of chest pain at the end of the 6MWT; and (4) the score of a novel CMR ischemic burden index on the basis of the characteristics of adenosine stress perfusion defects (extension, persistence, transmurality, and induced contractile regional dysfunction). Patients with greater CMR ischemic index before percutaneous revascularization showed better improvement in the 6MWT. In conclusion, successful recanalization of a CTO leads to a concurrent improvement in ischemic burden, exercise tolerance, angina frequency, and quality of life scores. Patients with a high ischemic CMR score before CTO recanalization showed the better improvement in exercise tolerance.

Comparison between diabetic and non-diabetic patients after successful percutaneous coronary intervention for chronic total occlusions in the drug-eluting stent era

ObjectiveDiabetes mellitus and chronic total occlusions are associated with unfavorable outcome after percutaneous coronary intervention. We sought to assess the clinical and angiographic outcomes of diabetic and non-diabetic patients who underwent successful percutaneous revascularization of chronic total occlusions with drug-eluting stents. MethodsBaseline clinical and angiographic characteristics, procedural details, nine-month angiographic follow-up and clinical events at 12 months were compared between 75 diabetic and 132 non-diabetic patients included in a clinical trial that randomized successful recanalization of chronic total occlusions to receive sirolimus- or everolimus-eluting stents. ResultsIn both diabetic and non-diabetic groups there was a favorable non-significantly different angiographic result at nine months, with low in-stent late loss (0.14±0.60 mm vs. 0.25±0.68 mm, p=0.305) and rates of binary restenosis (4.0% vs. 10.6%, p=0.180) and reocclusion (0.0% vs. 2.3%, p=0.334). During follow-up similar survival from death (97.3±1.9% vs. 99.2±0.8%, log-rank p=0.273), acute myocardial infarction (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192), target vessel revascularization (88.7±3.8% vs. 88.2±2.9%, log-rank p=0.899) and stent thrombosis (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192) was observed. Furthermore, the presence of more diffuse peripheral and coronary artery disease and higher frequency of calcified lesions in diabetic patients did not lead to significant differences in the approach (20.0% vs. 25.0% radial approach, p=0.413), strategy (6.7% vs. 3.8% retrograde strategy, p=0.353), total stent length (48.1±24.6 mm vs. 49.2±23.9 mm, p=0758) or contrast volume (261.3±116.4 ml vs. 297.4±135.9 ml, p=0.109) required for revascularization. ConclusionsIn the drug-eluting stent era, diabetic and non-diabetic patients have comparable favorable clinical and angiographic outcomes after successful percutaneous revascularization of chronic total occlusions.

Comparison between diabetic and non-diabetic patients after successful percutaneous coronary intervention for chronic total occlusions in the drug-eluting stent era

ObjectiveDiabetes mellitus and chronic total occlusions are associated with unfavorable outcome after percutaneous coronary intervention. We sought to assess the clinical and angiographic outcomes of diabetic and non-diabetic patients who underwent successful percutaneous revascularization of chronic total occlusions with drug-eluting stents. MethodsBaseline clinical and angiographic characteristics, procedural details, nine-month angiographic follow-up and clinical events at 12 months were compared between 75 diabetic and 132 non-diabetic patients included in a clinical trial that randomized successful recanalization of chronic total occlusions to receive sirolimus- or everolimus-eluting stents. ResultsIn both diabetic and non-diabetic groups there was a favorable non-significantly different angiographic result at nine months, with low in-stent late loss (0.14±0.60 mm vs. 0.25±0.68 mm, p=0.305) and rates of binary restenosis (4.0% vs. 10.6%, p=0.180) and reocclusion (0.0% vs. 2.3%, p=0.334). During follow-up similar survival from death (97.3±1.9% vs. 99.2±0.8%, log-rank p=0.273), acute myocardial infarction (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192), target vessel revascularization (88.7±3.8% vs. 88.2±2.9%, log-rank p=0.899) and stent thrombosis (100.0±0.0% vs. 97.7±1.3%, log-rank p=0.192) was observed. Furthermore, the presence of more diffuse peripheral and coronary artery disease and higher frequency of calcified lesions in diabetic patients did not lead to significant differences in the approach (20.0% vs. 25.0% radial approach, p=0.413), strategy (6.7% vs. 3.8% retrograde strategy, p=0.353), total stent length (48.1±24.6 mm vs. 49.2±23.9 mm, p=0758) or contrast volume (261.3±116.4 ml vs. 297.4±135.9 ml, p=0.109) required for revascularization. ConclusionsIn the drug-eluting stent era, diabetic and non-diabetic patients have comparable favorable clinical and angiographic outcomes after successful percutaneous revascularization of chronic total occlusions.

PP-134 The Successful Percutaneous Revascularization of Subclavian Artery Stenosis Causing Coronary Subclavian and Vertebral Artery Steal Syndrome

PP-134 The Successful Percutaneous Revascularization of Subclavian Artery Stenosis Causing Coronary Subclavian and Vertebral Artery Steal Syndrome

Clinical Evaluation of Different Revascularization Strategies: Unlabelled Use

AIMS: Coronary diseases are the main cause of mortality in the West. Several factors may affect successful percutaneous revascularization, such as the type of stent used or the cardiovascular risk factors associated with the patient. The systolic function of the left ventricle has usually been disregarded in restenosis scores. Our aim is to evaluate restenosis while taking into account the kind of stent used and the systolic function of the left ventricle. METHODS: A prospective, observational and population study. A total of 209 patients with percutaneous revascularization were recruited between March 2011 and January 2013 and monitored every six months. Their clinical data was collected and transthoracic echocardiograms were performed. RESULTS: The average age was 67±11 years old, 64.6% were men. Regarding cardiovascular risk factors, 55.6% were diabetics, 84.2% had hypertension and 81.3% were dyslipemic. A combined revascularization strategy was more often used among the general population than in the diabetic subgroup. The diabetic patient subgroup received a larger number of drug-coated stents. The systolic function was present among 84% of the general population compared to 80% of the diabetic patient subgroup. Both the general population as well as the diabetic patient subgroup presented a significant decreased sistolic function of the left ventricle when the restenosis rate was greater (p<0.001 respectively). Similarly, we observe that there is a significant connection between the ejection fraction and the emergence of a new symptoms. CONCLUSION: The non-combined strategy was used more frequently in the diabetic population with the use of a superior drug-eluting stent Furthermore, systolic function evaluation stratifies the restenosis risk, especially in patients with a depressed ventricular function.

Abstract 19312: A Follow-up Study of Coronary Vasomotor Function in Ischemic and Remote Myocardium Following Successful Percutaneous Revascularization for Acute Myocardial Infarction - a [15O]H2O PET Study

Introduction: In patients with acute myocardial infarction (AMI), coronary vasomotor function is not only impaired in the myocardial territory supplied by the culprit-artery but also in remote myocardium supplied by angiographically normal vessels. Aims: The aim was to investigate the temporal evolution of coronary vasodilatory reserve in patients with AMI by use of [15O]H2O PET, after successful percutaneous coronary intervention (PCI). Methods: Fourty-four patients with AMI and successful revascularization by PCI were included (i.e. TIMI II or III flow after coronary stenting). Subjects were examined one week and three months after AMI with [15O]H2O PET to assess the coronary flow reserve (CFR). CFR was defined as the ratio of myocardial blood flow during hyperemia (hMBF) and rest (MBF). Additionally, 45 age and sex matched subjects without a prior cardiac history underwent similar scanning procedures and served as a control group. Results: At baseline, CFR averaged 1.77 ± 0.63 in infarcted myocardium versus 2.41 ± 0.79 in remote myocardium (p &lt; 0.001). In comparison, CFR in the control group averaged 4.16 ± 1.45 (p = 0.001 versus both). During follow-up, the CFR increased from 1.77 ± 0.63 to 2.75 ± 0.89 in infarcted myocardium (p &lt; 0.001), and from 2.41 ± 0.79 to 2.85 ± 0.75 in remote myocardium (p = 0.001). This was predominantly due to an increase in hMBF, from 1.64 ± 0.54 to 2.19 ± 0.74 mL/min/g in infarcted myocardium (p &lt; 0.001), and 2.20 ± 0.56 to 2.61 ± 0.65 mL/min/g in remote myocardium (p = 0.001). Conclusions: Coronary vasodilatory reserve is impaired in both ischemic and remote myocardium directly after AMI. Following successful revascularization, the coronary vasodilatory reserve significantly improved in both regions. As a consequence, these early and late post-infarct alterations in remote myocardium may also affect temporal infarct evolution and recovery of left ventricular function.

Clinical Significance of Cystatin C in Acute Coronary Syndromes: Something More Than a Marker of Renal Function?

Serum cystatin C (Cys-C) levels perform better than other markers of renal function as indicator of cardiovascular outcome both in population-based studies and in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). Whether the relation between elevated serum Cys-C levels and risk of a worse cardiovascular prognosis reflects a more precise measurement of renal function or an association with non-renal factors such as inflammation is a matter still poorly defined. In a prospective, multicenter study our group evaluated the time course of serum Cys-C levels in 222 patients over the first 6 weeks after an episode of NSTE-ACS and a successful percutaneous revascularization. We observed that Cys-C levels slightly but significantly increased from the admission to 6-week samples (7.1 to 7.8 mg/dL, p <0.0001), contrary to high sensitivity C Reactive Protein (hsCRP), N-terminal portion of the proBNP peptide (NT-proBNP), and Interleukin 6 (IL-6) levels which significantly decreased in the same period. Cys-C levels were not different in patients with or without elevated troponin (c-TnT), whereas the other inflammatory and biomechanical markers showed higher values in patients with versus those without elevated c-TnT. Cys-C was highly correlated with estimated glomerular filtration rate both in ACS and 6-week samples. In conclusion, our data seem to contradict the hypothesis that inflammation is a determinant of the Cys-C levels because they did not show the typical pattern of an acute-phase reactant and secondly they were independent from myocardial necrosis diagnosed by c-TnT levels. Moreover, our results indicate that Cys-C remains a reliable marker of renal function also during ACS because is not affected by myocardial necrosis or by acute left ventricular impairment, as detected by increased NT-proBNP values

Erratum to “The role of oxidized phospholipids, lipoprotein (a) and biomarkers of oxidized lipoproteins in chronically occluded coronary arteries in sudden cardiac death and following successful percutaneous revascularization. Cardiovasc Revasc Med 2012;13:11-9”

Erratum to “The role of oxidized phospholipids, lipoprotein (a) and biomarkers of oxidized lipoproteins in chronically occluded coronary arteries in sudden cardiac death and following successful percutaneous revascularization. Cardiovasc Revasc Med 2012;13:11-9”

Chronic Total Occlusion of the Innominate Trunk: Successful Recanalization with Retrograde Technique and Dedicated Devices Borrowed from Percutaneous Coronary Interventions

The innominate trunk is a short vessel with crucial clinical relevance as in most patients it provides flow to the right subclavian artery and the right common carotid artery. Innominate trunk occlusions are particularly challenging, as results of endovascular therapy are suboptimal in terms of acute success, whereas open surgery poses a high risk of complications. The systematic application of techniques and devices developed for coronary occlusions holds the promise of substantially improving the management of subjects with peripheral artery disease. We hereby present a case of a patient with innominate trunk occlusion who underwent successful percutaneous revascularization by carefully and expertly exploiting techniques and devices well tested in the coronary realm. This clinical vignette suggests that this treatment approach may be feasible and risk-beneficial for otherwise challenging innominate trunk occlusions.

Improvement of myocardial function and perfusion after successful percutaneous revascularization in patients with chronic total coronary occlusion

BackgroundPercutaneous coronary intervention (PCI) for chronic total occlusion (CTO) of a coronary artery can provide benefits in terms of myocardial function and survival but the procedure is complex and the success rate is relatively low. To assess these benefits, myocardial function, ischemia and viability should be clearly determined by means of a reliable diagnostic test. This study aimed to assess ventricular function and myocardial ischemia before and after PCI for CTO using cardiac magnetic resonance (CMR). NYHA functional class was also assessed before and after PCI. Methods and resultsCMR studies were performed in 43 consecutive patients (7 females; aged 64±9.6y.o.) with CTO scheduled for PCI and repeated 6months post-PCI. PCI was successful in 33 (77%) of them. In this group CMR had shown inducible perfusion defects in 26 (79%) before PCI, while they were observed in 10 (30%) post-PCI CMR study (p<0.001). The number of segments showing inducible perfusion defect (3.4±2 prevs. 2.9±4.5 post-PCI, p=0.002) was significantly reduced in this group. Regional contractile function of segments showing viability also improved significantly in the group with successful CTO PCI compared to the group with an unsuccessful procedure. NYHA functional class for angina also improved in patients with successful revascularization while it remained unchanged in the group with unsuccessful procedures. ConclusionsA successful CTO PCI leads to a reduction in inducible myocardial ischemia and to an improvement in regional wall motion, which results in clinical improvement.

Effects of successful percutaneous lower extremity revascularization on cardiovascular outcome in patients with peripheral arterial disease

BackgroundLower extremity peripheral arterial disease (LE-PAD) reduces walking capacity and is associated with an increased cardiovascular risk. Endovascular revascularization of LE-PAD improves walking performance and quality of life. In the present study, we determined whether successful lower limbs revascularization also impacts cardiovascular outcome in LE-PAD patients. Methods479 consecutive LE-PAD patients at stage II of Fontaine's classification, with ankle/brachial index ≤0.90 and one or more stenosis >50% in at least one leg artery, were enrolled in the study. According to the Trans-Atlantic Inter Society Consensus II recommendations, 264 (55.1%) underwent percutaneous lower extremity angioplasty (PTA group), while 215 (44.9%) were managed with conservative therapy (MT group). The incidence of major cardiovascular events (including cardiovascular death, myocardial infarction, ischemic stroke, coronary and carotid revascularizations) was prospectively analyzed by Kaplan–Meier curves. Crude and adjusted HRs (95% CI) of developing a cardiovascular event were calculated by Cox analysis. ResultsNo baseline differences were observed among the groups, except for a lower maximum walking distance in the PTA group. During a median follow-up of 21months (12.0–29.0), the incidence of cardiovascular events was markedly lower in PTA compared to MT patients (6.4% vs. 16.3%; p=0.003), and patients in the MT group showed a 4.1-fold increased cardiovascular risk compared to patients in the PTA group, after adjustment for potential confounders (95% CI 1.22–13.57, p=0.023). ConclusionsThis study shows that successful revascularization of LE-PAD patients affected by intermittent claudication, in addition to improving functional status, reduces the occurrence of future major cardiovascular events.

Successful percutaneous revascularization of totally occluded left subclavian artery using orbital atherectomy

Subclavian artery steal (SAS) after coronary artery bypass graft (CABG) has been reported to be as high as 3.4%. These patients with patent left internal mammary artery (LIMA) anastomosis will also have coronary-subclavian steal syndrome (CSSS). Percutaneous intervention (PCI) by balloon angioplasty (BA) and stenting has been done successfully for subclavian artery (SA) stenosis. The visibility of the vertebral artery (VA) and LIMA during BA and stent positioning is extremely important. Debulking total occlusions by orbital atherectomy (OA) and avoiding unnecessary BA, stenting across side branches may decrease the chance of plaque shifting and subsequent loss of flow especially if they have ostial disease. Herein we report successful OA, BA and stenting of chronic total occlusion (CTO) of proximal left subclavian artery in a patient with coronary-subclavian steal syndrome with preservation of LIMA and diseased left vertebral artery (VA).

Long-Term Follow-Up of Endovascular Treatment for Trans-Atlantic Inter-Society Consensus II Type B Iliac Lesions in Patients Aged

To study the initial and long-term results of endovascular treatment in patients aged <50 years with trans-Atlantic inter-society consensus-II type B unilateral iliac lesions and chronic limb ischemia. From January 2000 to February 2010, 60 consecutive endovascular interventions were performed on 23 women and 37 men aged ≤50 years. After successful treatment, all patients were followed up at 1, 3, 6, and 12 months after the procedure and every 6 months thereafter. Successful percutaneous revascularization of the iliac artery was achieved in 56 patients (93.3%). The early vascular-related complication rate was 6.7%. The primary patency rates at 1, 3, and 5 years were 88%, 59%, and 49%, respectively. Cox univariate analysis revealed that an age range of 45 to 50 years (hazard ratio [HR]: 0.290; 95% confidence interval [CI]: 0.152-0.553; P = 0.0001), lower preprocedural ankle-brachial index (HR: 2.438; 95% CI: 1.04-5.715; P = 0.047), lesion length >5 cm (HR: 0.838; 95% CI: 0.746-0.943; P = 0.003), and diabetes (HR: 2.005; 95% CI: 1.010-3.980; P = 0.047) had significant influence on decreasing primary patency. Endovascular treatment of TASC-II type B iliac lesions in patients aged <50 years is a safe procedure with low procedural risk. Primary patency rates at 1, 3, and 5 years were 88%, 59%, and 49%, respectively.

Percutaneous panvascular intervention in an unusual case of extensive atherosclerotic disease

It is common to see patients with atherosclerotic coronary disease and peripheral arterial disease in routine clinical practice. One needs to have a comprehensive and integrated multi-speciality approach and panvascular revascularization in such patients. We report a 54-year-old diabetic hypertensive male with extensive atherosclerotic coronary and peripheral arterial disease, who presented with congestive heart failure, claudication of both lower limbs and mesenteric ischemia. He underwent successful percutaneous panvascular revascularization of coronary, renal, mesenteric, aorto-iliac and superficial femoral arteries. Long-term patency of all the stents was also documented.

The role of oxidized phospholipids, lipoprotein (a) and biomarkers of oxidized lipoproteins in chronically occluded coronary arteries in sudden cardiac death and following successful percutaneous revascularization

OxPL are pro-inflammatory and may mediate atherogenesis, thrombosis and endothelial dysfunction. We studied the histological presence and temporal increases in oxidized phospholipids on apolipoprotein B-100 particles (OxPL/apoB), lipoprotein (a) [Lp(a)] and biomarkers of oxidized lipoproteins in subjects with chronic total coronary occlusions (CTO) with sudden cardiac death (SCD) and following percutaneous coronary intervention (PCI). Eight subjects with SCD and CTO and 33 patients with successful PCI of CTO were included. Blood samples were drawn before PCI, immediately post-PCI, at 6 and 24 h, at 3 days and at 1 week. Plasma levels of OxPL/apoB, Lp(a), IgG and IgM autoantibodies to malondialdehyde (MDA) low-density lipoprotein and apoB-immune complexes were measured in all samples and compared with previous data from 141 patients undergoing PCI of non-CTO vessels. Immunohistochemistry of coronary CTOs revealed OxPL and MDA-like epitopes, particularly in areas of recanalized and organized thrombus and neovascularization. Following PCI, OxPL/apoB and Lp(a) levels, expressed as percent change from baseline levels before PCI, rose gradually and progressively over the next 7 days. In contrast, levels of OxPL/apoB and Lp(a) in non-CTO vessels rose immediately post PCI and then dropped rapidly to baseline within 24 h. CTOs contain immunohistological evidence of OxPL and MDA-like epitopes. Successful PCI of CTOs results in a slower increase in OxPL/apoB and Lp(a) but higher increase in IgM immune complexes compared to non-CTO vessels. Pro-inflammatory oxidation-specific epitopes may impact development of CTOs and affect outcomes following PCI that can be evaluated in larger clinical trials.

Intramural myocardial hemorrhagic rupture in a patient with metastatic cancer and myocardial infarction

A 77-year-old man with anterior ST-elevated myocardial infarction and lateral myocardial rupture underwent successful percutaneous revascularization. Cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET) unveiled a disseminated metastatic cancer, likely responsible not only for a prothrombotic paraneoplastic syndrome but also for ventricular metastasis and myocardial rupture. The patient unfortunately died because of noncardiovascular complications of cancer.

Recurrent episodes of very late stent thrombosis in a patient with aspirin hypersensitivity, stent fracture and malapposition

Late stent thrombosis represents a life-threatening event, usually triggered by inadequate antiplatelet therapy and promoted by multiple risk factors, such as stenting of a chronic total occlusion, overlapping stenting, an abnormal vascular response to the eluted drug, stent malapposition and stent fracture. A 57-year-old man with aspirin hypersensitivity underwent successful percutaneous revascularization of a chronic total occlusion of the left anterior descending artery (LAD). He received two sirolimus-eluting stents overlapping for 2 mm and was discharged on clopidogrel and picotamide. Two years later, 15 days after clopidogrel discontinuation, he experienced an anterior ST-segment elevation myocardial infarction and underwent rescue percutaneous LAD thrombectomy after unsuccessful fibrinolysis. Coronary angiography showed fracture of the distal stent, with a 5 mm gap between the two portions, as well as severe late stent malapposition, confirmed by optical coherence tomography. Despite treatment with clopidogrel and picotamide, in the following days the patient experienced two new episodes of stent thrombosis, treated with thrombectomy and deployment of bioengineered stents. The patient underwent successful oral aspirin desensitization, with a complete in vitro inhibition of platelet function, and was discharged on aspirin, clopidogrel and warfarin, without experiencing other events at 6-month follow-up.