Transluminal Angioplasty Research Articles

Experience in stent angioplasty for extracranial carotid stenosis

Objective To summarize the experience in clinical application of percutaneous transluminal stent angioplasty in the treatment of extracranial carotid stenosis.Methods The clinical data on 52 patients with extracranial carotid stenosis who had undergone percutaneous transluminal stent angioplasty in our hospital during January 2009 to December 2011 were retrospectively reviewed.The characteristics of the narrowing vessels and the success rate of surgery were analyzed ; correction of vascular stenosis,improvement in clinical symptoms,and incidence of complications were assessed.Results Vascular stenosis was extremely severe in 5 patients,severe in 36,and moderate in 11.Stenosis at internal carotid artery was found in 40 patients,stenosis at common carotid artery in,stenosis at furcation in 5,and stenosis at extracranial carotid artery higher than cervical 2 in 4.56 self-expandable metallic stents were implanted in 52 patients,with a success rate of 96.2％ (50/52).Intraoperative angiography showed the stenotic degree was significantly improved and the percentage of residual stenosis was less than 20％.Symptoms disappeared or improved in 49 patients during the perioperative period,with a rate of 94.2％.Complications occurred postoperatively in 3 patients (5.8％).Conclusions Selection of self-expandable stent therapy for extracranial carotid stenosis according to the surgical indications including degree of carotid artery stenosis,vascular anatomy and body tolerance to surgery can effectively expand vessels,correct of vascular stenosis,and relieve clinical symptoms.The procedure has a higher success rate,lower incidence rates of complications and postoperative ischemic stroke,being an effective and safe therapeutic method for extracranial carotid stenosis. Key words: Extracranial carotid stenosis; Stent angioplasty

Outcomes of Endovascular Interventions for Salvage of Renal Transplant Allografts

As renal transplantation has been performed with increased frequency, interventions to preserve graft function and integrity have been steadily increasing. This study examines the outcomes of endovascular therapy based on indication for renal allograft salvage. A prospective transplant registry was queried for all patients undergoing endovascular interventions for transplant allograft salvage from 2002 to 2011. Demographics, perioperative data, and transplant function outcomes were extracted and analyzed. Among 34 renal transplant recipients who underwent endovascular interventions for graft salvage, the mean age was 48.2 years (18-74 years), and 62% were men. The indications for intervention included worsening serum creatinine (n = 15), renovascular hypertension (n = 11), and structural abnormalities identified on noninvasive imaging (n = 8). Transluminal angioplasty, with or without stenting, was done in 26 patients: 14 (41.2%) with significant transplant stenosis, 11 (32.4%) with peripheral arterial disease (PAD) in proximal iliac vessels, and one with iliac dissection. Five arteriovenous fistulae and two pseudoaneurysms required embolization. One patient had deep venous thrombosis causing obstruction of allograft outflow requiring lysis. There were no periprocedural deaths, and 30-day morbidity was 17.6%. Of patients with worsening renal function, 67% had improvement or stabilization of their renal function. Interestingly, only 36% of patients with renovascular hypertension showed improvement. Mean follow-up was 4.2 years. There were no significant differences in transplant allograft survival over the duration of follow-up based on indication for endovascular intervention (Fig; log-rank test P = .03). Endovascular salvage of renal allograft transplants can be safely done for various indications, although patients with renovascular hypertension were less likely to improve. Despite differences in symptomatic outcome, the indication for initial intervention does not significantly influence the long-term transplant graft survival.

A Case of Successful Percutaneous Transluminal Pulmonary Angioplasty with Chronic Thromboembolic Pulmonary Hypertention

A Case of Successful Percutaneous Transluminal Pulmonary Angioplasty with Chronic Thromboembolic Pulmonary Hypertention

Anesthetic management of endovascular procedures for cerebrovascular atherosclerosis

The article reviews the treatment options for cerebrovascular atherosclerosis and highlights the challenges of anesthesia in this complex group of patients. Percutaneous transluminal angioplasty and stenting is a treatment option for cerebrovascular atherosclerosis in patients at high risk of stroke despite maximal medical therapy and control of risk factors. The majority of carotid lesions are treated using regional anesthesia, but general anesthesia is currently the technique of choice for intracranial lesions because of the length of the procedures and the need for immobility. There is no evidence to guide optimal anesthetic management in this group of patients in whom significant comorbidities are common. The risks of myocardial ischemia, cardiovascular instability and cerebral ischemia and hyperperfusion are high, and anesthesia management should be directed towards their prevention, recognition and treatment. The anesthetist plays a key role in the endovascular management of patients with cerebrovascular atherosclerosis. Optimization of comorbidities, meticulous control of systemic physiologic variables and aggressive management of complications contribute to enhanced patient outcome.

CCSVI and MS: a statement from the European Society of neurosonology and cerebral hemodynamics

To systematically review the ultrasonographic criteria proposed for the diagnosis of chronic cerebrospinal venous insufficiency (CCSVI). The authors analyzed the five ultrasonographic criteria, four extracranial and one intracranial, suggested for the diagnosis of CCSVI in multiple sclerosis (MS), together with the references from which these criteria were derived and the main studies that explored the physiology of cerebrospinal drainage. The proposed CCSVI criteria are questionable due to both methodological and technical errors: criteria 1 and 3 are based on a scientifically incorrect application of data obtained in a different setting; criteria 2 and 4 have never been validated before; criterion 2 is technically incorrect; criteria 3 and 5 are susceptible to so many external factors that it is difficult to state whether the data collected are pathological or a variation from the normal. It is also unclear how it was decided that two or more of these five ultrasound criteria may be used to diagnose CCSVI, since no validation of these criteria was performed by different and independent observers nor were they blindly compared with a validated gold-standard investigation. The European Society of Neurosonology and Cerebral Hemodynamics (ESNCH) has considerable concerns regarding the accuracy of the proposed criteria for CCSVI in MS. Therefore, any potentially harmful interventional treatment such as transluminal angioplasty and/or stenting should be strongly discouraged.

The efficacy of endovascular interventional in severe stenosis of bilateral renal stenosis

Objective To analyze the clinical effect of intravascular intervention for treating the severe stenosis of bilateral renal arteries (BRASS).Methods A total of 40 patients with BRASS admitted in Fuwai Hospital from September 2008 to December 2010 were retrospectively analyzed.These patients,23 males and 17 females,aged from 21 to 76 years with average age of (59.75 ± 17.59) years,with luminal narrowing over 70％ in bilateral renal arteries,met the criteria of BRASS evidenced by angiography of renal arteries,and were subjected to renal artery interventional therapy. The etiological factors included arteriosclerosis (34 cases),Takayasu arteritis (3 cases) and congenital fibromuscular dysplasia (3 cases).After percutaneous endovascular intervention,the therapeutic effects were evaluated by lowering the systemic blood pressure and serum creatinine level in 12-month follow-up in average after operation. The data were analyzed with SPSS 13.0 statistical software.Results Among the 80 reual arteries in 40 patients,18 arteries were treated with percutaneous transluminal balloon angioplasty (PTBA),while the other 62 arteries were treated with percutaneous transluminal renal artery stenting (PTRAS).Mter endovascular intervention,the mean systolic blood pressure decreased from ( 165.0 ± 27.0) mm Hg to ( 135.7 ± 25.3 ) mm Hg on the second day after operation ( P ＜ 0.01 ) ; and the mean diastolic blood pressure decreased from ( 88.9 ±15.1 ) mm Hg to (74.8 ± 13.2) mm Hg on the second day after operation ( P ＜ 0.01 ).Accordingly,the kinds of anti-hypertension drug used decreased from ( 3.1 ± 0.9 ) to ( 2.3 ± 1.2) ( P ＜ 0.01 ).Only one patient died suddenly 3 months after intervention,and one died of acute myocardial infarction 7 months after operation.The other 38 patients were followed up for 12 months.At last,the mean systolic blood pressure of patients decreased from ( 165.0 ±27.0) mm Hg to ( 133.53 ± 15.94) mm Hg and the mean diastolic blood pressure decreased from (88.9 ± 15.1 ) mm Hg to (77.37 ± 13.47 )mm Hg. Of all 38 patients,2 were cured (5.3％),27 were improved (71.1％) and 9 failed to treatment (23.7％).Of all 38 patients,76.4％ got hypertension lowered.Moreover,renal function (Scr) was improved in 2 patients (6.3％ ),steady in 21 patients ( 65.6％ ),declined in 9 patients ( 28.1％ ) resulted in azotemia stage.Of 38 patients,71.9％ patients got overall benefit from endovascular intervention in respect of renal function improved.Conclusions The procedure of PTBA or PTRAS offered a minimally invasive,relatively safe and effective technique for BRASS patients to decrease blood pressure and stabilize renal function. Key words: Bilateral renal artery severe stenosis; Eendovascular interventional treatment; Therapeutic effect

Renal dynamic imaging for the treatment assessment of renal artery angioplasty and stenting in patients with atherosclerotic renal artery stenosis

Objective To investigate the value of renal dynamic imaging with 99Tcm-DTPA on the evaluation and prediction of the outcome after percutaneous transluminal renal artery angioplasty and stenting (PTRAS) in patients with atherosclerotic renal artery stenosis (ARAS).Methods Seventy-six patients with unilateral ARAS underwent PTRAS successfully.All the patients received baseline renal dynamic imaging within 2 weeks before the surgery and follow-up imaging 6 months after PTRAS.GFR ( per 1.73 m2 of body surface area) of kidney with ARAS was measured with the Gates method.ARAS was classified as mild (50％-69％),moderate (70％-89％),and severe ( ≥90％ ) stenosis according to the results of renoarteriography before the surgery.GFR was graded as Ⅰ ( GFR≥30 ml · min -1 ),Ⅱ ( 15 ml · min -1 ≤GFR ＜30 ml · min -1 ) and Ⅲ ( GFR ＜ 15 ml · min-1 ),on the baseline dynamic imaging.Blood pressure was also measured before and after the surgery.The t test,x2 test,Fisher exact test and multiple logistic regression analysis were used for statistical analysis with SPSS 13.0.Results The baseline GFR of kidney with mild and moderate ARAS was significant higher than that with severe stenosis ( (26.79 ± 15.34) vs ( 19.48 ±11.56) ml · min - 1,t =2.262,P =0.027 ).The blood pressure was improved in 32％ (24/75),and not changed in 68％ (51/75) of patients.Improvement of blood pressure was observed in 39.62％ (21/53) of patients with a baseline GFR≥ 15 ml · min-1,and in 13.64％ (3/22) of patients with a baseline GFR ＜15 ml · min - 1 (x2 =4.825,P =0.028 ).Using multivariate analysis,baseline GFR ≥ 15 ml · min - 1 was the only predictor of blood pressure improvement ( OR =0.465,P =0.032 ).GFR in kidney with ARAS was improved in 22.37％ ( 17/76),stable in 68.42％ (52/76),and worse in 9.21％ (7/76) of patients.The 33.33％ (8/24) and 17.65％ (9/51) of patients with and without blood pressure improvement,respectively,achieved GFR improvement.However,the difference was not statistically significant ( Fisher exact test,P =0.081 ).Conclusion Renal dynamic imaging with 99Tcm-DTPA is a useful method for the evaluation and prediction of the therapeutic effect of PTRAS in patients with ARAS. Key words: Renal artery ; Atherosclerosis; Angioplasty; Radionuclide imaging; DTPA

Effects of transluminal balloon angioplasty and stenting on the clinical course of ischemic chronic heart failure with preserved or reduced left ventricular ejection fraction: radionuclide 4D tomoventriculography data

Aim. To study the effects of transluminal balloon angioplasty (TLBAP) and stenting on right and left ventricular (RV, LV) hemodynamics, as well as on long-term clinical prognosis, in patients with ischemic chronic heart failure (CHF). Material and methods. In 20 patients with ischemic CHF, Functional Class (FC) II–III (NYHA), radionuclide 4D tomoventriculography (4D-RTVG) was performed at baseline and 6 and 12 months after TLBAP, in order to assess cardiac hemodynamics. Based on ejection fraction (EF) values, all participants were divided into two groups. Group I (n=10; mean age 57,2 (2,7) years) included men with EF <45%, FC II–III CHF, and mean CHF duration of 3,1 (0,6) years. Group II (n=10; mean age 62,6 (2,7) years) included 5 men and 5 women with EF >45%, FC II CHF, and CHF duration of 2 (0,4) years. Results. Twelve months after TLBAP, Group I demonstrated a significant increase in stroke volume (SV), LV EF, and RV EF, as well as an improvement in LV maximum ejection velocity (MEV), maximum filling velocity (MFV), and maximum filling time (MFT), as well as in LV and RV one-third filling fraction (1/3 FF) (p<0,05). A decrease in LV enddiastolic volume (EDV), LV end-systolic volume (ESV), and RV ESV, some increase in RV EDV, and an improvement in RF MEV, MFV, and MFT were non-significant (p>0,05). In Group II, an increase in LV SV and LV EF, as well as an improvement in RV 1/3FF and MFT, was statistically significant (p<0,05). At the same time, an increase in RF SV, EF, EDV, and ESV, as well as an improvement in LV and RV MEV and MFV, LV 1/3FF and LV MFT, without any substantial changes in LV EDV and ESV, lacked statistical significance (p>0,05). Cardiac hemodynamic changes were associated with improved quality of life (QoL) and reduced CHF FC and angina FC. Conclusion. TLBAP and stenting facilitated an increase in EF and SV, an improvement in LF and RF systolic and diastolic function, an improvement in QoL and exercise capacity, and a reduction in CHF FC and angina FC.

Impact of endovascular treatment of atherosclerotic renal artery stenosis on endothelial function and arterial blood pressure.

Renovascular disease may cause arterial hypertension and decreases renal function, which both impair endothelial function. Endothelial function, a surrogate marker for cardiovascular risk, can be assessed non-invasively by ultrasound. The aim of this study was to investigate the impact of percutaneous transluminal renal artery angioplasty (PTRA) with stenting on endothelial function and arterial blood pressure in patients with renal artery stenosis (RAS). Flow mediated dilatation of the brachial artery, flow velocities and shear stress were measured with high resolution ultrasound in 24 hypertensive patients with renal artery stenosis prior and one day after revascularization by PTRA with stenting. Endothelial-independent brachial dilatation was measured after application of nitroglycerin. Endothelial-dependent dilatation improved from 2.4±0.9% to 6.1±1.4% (P=0.03), whereas endothelial-independent dilatation did not change after PTRA. Endothelial-dependent reactive hyperemic blood flow increased from 195±40 mL/min to 536±94 mL/min (P=0.0008), whereas endothelial-independent hyperemia did not increase after revascularization. After PTRA, shear stress at rest decreased from 37±11 to 23±3 dyne/cm² (P<0.0001), and reactive hyperemic shear stress increased from 89±29 to 107±12 dyne/cm² (P=0.014). The impact of PTRA on arterial blood pressure resulted in a mean decrease of 21±5 mmHg in systolic pressure (P<0.0001), of 9±2 mmHg in diastolic pressure (P=0.03), and of 14±5 mmHg in peripheral pulse pressure (P=0.0003), respectively. Endovascular treatment of renovascular disease improves endothelial function and decreases in resting shear stress.

Percutaneous Transluminal Pulmonary Angioplasty for Distal-Type Chronic Thromboembolic Pulmonary Hypertension

Percutaneous Transluminal Pulmonary Angioplasty for Distal-Type Chronic Thromboembolic Pulmonary Hypertension

Pseudo-occlusion of the extracranial carotid artery caused by intracranial carotid artery stenosis

A 70-year-old female with hypertension and diabetes presented to the emergency room with sudden-onset drowsy mentation and disorientation. Her blood pressure was 130/80 mmHg, pulse rate was 70 beats per minute, respiratory rate was 18 breaths per minute, and body temperature was 36.7 C. Neurologic examination indicated confusion and generalized myoclonic jerks. Blood chemistry tests revealed an elevation of blood urea nitrogen and creatinine (83 and 3.5 mg/dl, respectively). Small deep infarcts on the right basal ganglia and corona radiata were visible on brain MRI (Fig. 1a), but a high signal intensity was not evident on the diffusion weighted image. In addition, her right proximal internal carotid artery (ICA) was invisible on contrast-enhanced magnetic resonance angiography (CE-MRA) (Fig. 1b). MRI was performed with a Signa Excite XI Twin Speed 1.5T system (GE Healthcare, Milwaukee, WI, USA). Her neurological symptoms resolved upon reduction of her blood urea nitrogen and creatinine levels, therefore, the patient was tentatively diagnosed with uremic encephalopathy. After improvement of her symptoms, we performed carotid duplex ultrasonography (CDUS, GE LOGIQ 7 PRO US machine, 12 MHz linear array transducer) to evaluate the right ICA on hospital day 6. There was no sonographic evidence of blood flow from the right carotid bifurcation to the proximal ICA (Fig. 1c). Transcranial Doppler could not be performed because she had a poor temporal window. Since MRI and CE-MRA showed multiple silent infarcts mainly in the right anterior circulation and string sign around the lacerum segment of the ipsilateral distal ICA, we planned further investigation including digital subtraction angiography (DSA) to assess her cerebral vascular reserve and vasculature and to determine how to prevent a stroke. DSA, performed on hospital day 8, revealed that the lacerum segment of the right ICA was severely stenotic, but the bulbous segment was not. Proximal to distal blood flow in the right ICA was significantly slower compared to the external carotid artery blood flow (Fig. 1d). The right anterior cerebral artery was filled by the left anterior cerebral and communicating arteries, but the right middle cerebral artery was only supplied by the ipsilateral ICA and was not visualized on vertebral or contralateral cerebral angiography. On hospital day 12, we decided to perform percutaneous transluminal balloon angioplasty (Fig. 2a). Since the diameters of the proximal and distal parent vessels adjacent to the stenotic lesion were 2.03 and 1.89 mm, respectively, we did not deploy a stent. On hospital day 14, follow-up CDUS showed normal configuration of the ICA and normal blood flow velocity (peak systolic velocity: 69.8 cm/s, end diastolic velocity: 33.2 cm/s; Fig. 2b). Since then she has been healthy and asymptomatic, and the blood flow velocity of the right proximal ICA (peak systolic: 69.1 cm/s, end diastolic: 34.8 cm/s; image not shown) was not reduced on 2-year follow-up CDUS. Pseudo-occlusion of the ICA was defined in previous studies as a collapsed distal ICA due to the reduced flow velocity caused by a severe stenotic lesion of the proximal ICA [1]. In this case, contrary to the classical definition of a D. Lee S. H. Heo D.-I. Chang (&) Departments of Neurology, College of Medicine, Kyung Hee University Hospital, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702, Korea e-mail: dichang@khmc.or.kr

Long-Term Results of 81 Prevertebral Subclavian Artery Angioplasties: A 26-Year Experience

Long-term results of transluminal angioplasty (TLA) of the prevertebral subclavian artery (PVSA) are not well known. The aim of this work was to present a retrospective analysis of a consecutive series of 81 TLAs of the PVSA, with a mean follow-up of approximately 7 years (82 months). From January 1984 to May 2007, 81 TLAs of PVSA were consecutively performed in 72 patients (64% men; median age = 56.7 years) to treat 71 tight stenoses and 10 occlusions. In 58 cases, TLA was carried out under local anesthesia (71.6%), 65 times by femoral approach, and 16 times by humeral approach. A percutaneous approach was used 72 times (89%). A stent was placed in 18 cases (22.2%). Immediate technical success rate was 93%. One transient monoplegia was noticed after TLA and four puncture complications were observed, which occurred significantly more frequently with percutaneous humeral approach (p = 0.024). A recurrent stenosis occurred 28 times (34.6%) and was symptomatic in three cases. With a mean 82-month follow-up (3-299 months), primary patency at 10 years was 85.2% and primary assisted patency was 92.6%. No restenosis occurred after the 25th month of the follow-up. No restenosis factor was statistically predictive. TLA of the PVSA is a mildly invasive and efficient treatment. Early restenoses are frequent but remain accessible to a new TLA with stable long-term results.

Percutaneous Transluminal Pulmonary Angioplasty Improves Pulmonary Hemodynamics in Patients Distal-type Chronic Thromboembolic Pulmonary Hypertension

Percutaneous Transluminal Pulmonary Angioplasty Improves Pulmonary Hemodynamics in Patients Distal-type Chronic Thromboembolic Pulmonary Hypertension

Utilization of Lower Extremity Arterial Disease Diagnostic and Revascularization Procedures in Medicare Beneficiaries 2000–2007

The recent escalation in lower extremity revascularization procedures suggests a concomitant increase in peripheral arterial disease (PAD) screening. We hypothesized that self-referring physicians would show the greatest growth in noninvasive physiologic testing for PAD and similar trends for revascularization procedures. We compared utilization rates for self-referring specialties (vascular surgery, interventional radiology, and cardiology) with the utilization rate for a referral-based specialty (diagnostic radiology), assuming the latter to be "basal"--that is, responsive only to changes in demographics and medical knowledge. We analyzed 100% procedure-specific claims for services provided to Medicare Part B beneficiaries during 6 years over an 8-year span (2000-2007). We extracted all Current Procedural Terminology codes for lower extremity vascular noninvasive physiologic studies, peripheral arterial stent placement, and transluminal angioplasty. Utilization volumes were adjusted per 100,000 beneficiaries. Compound annual growth rates were calculated. Utilization of both noninvasive physiologic and revascularization services increased steadily over the study period. Growth rates of diagnostic services provided by interventional radiologists (7%) and vascular surgeons (8%) were slightly higher than the basal rate (7%), with cardiologists (14%) at the top of the list. For revascularization procedures, vascular surgery showed the greatest growth (28%), a rate more than twice that of cardiology (13%); radiology experienced a decrease in volumes (-2%). Self-referring specialists are screening large volumes of Medicare beneficiaries for lower extremity PAD at an accelerated rate compared with testing done by those who do not self-refer. Similar trends exist for endovascular interventions.

Medical therapy for atherosclerotic renal artery stenosis

Atherosclerotic renal artery stenosis (ARAS) is a common manifestation of generalized atherosclerosis (ATS) and is the most common disorder of the renal arterial circulation [1–3]. Furthermore, ARAS typically occurs in patients at high risk of cardiovascular disease with coexistent vascular disease at nonrenal sites. Indeed, the prevalence of ARAS in a population-based study of people aged 65 years or over is 7%. Prevalence rates for ARAS is 18% in patients with hypertension, 20% in patients with diabetes mellitus and hypertension, 25% in patients with peripheral vascular disease and 33% in those with abdominal aortic aneurysm [4]. Patients affected by ARAS are likely to have more complications and more extensive target-organ damage than patients without ARAS. Indeed, hemodynamically significant ARAS (stenosis >70%) leads to a fall in poststenosis pressure, and if perfusion pressure falls below the limit of renal autoregulation, the glomerular filtration rate decreases. The renin–angiotensin–aldosterone system (RAAS) is activated by the decrease in renal perfusion with increased production of angiotensin II, whose action led to an increase in hemodynamic resistance and systemic blood pressure. Its other nonhemodynamic effects play an important role in structural changes in the ischemic kidney [5]. Recent experimental evidence suggests that ARAS is associated with the activation of intrarenal fibrogenic and inflammatory pathways, oxidative stress and microvascular remodeling, and blocking these mechanisms can improve renal hemodynamics and function. As recent evidence indicates, the relationship between renal artery stenosis and ATS is complex, and mediators implicated in the pathophysiology of atherosclerotic renovascular disease may also contribute to the progression of cardiovascular damage. The therapeutic options to date include revascularization usually by percutaneous transluminal renal angioplasty (PTRA) with or without stenting and/or medical treatment. However, although the angiographic results after PTRA are often remarkable, clinical results are rarely satisfactory regarding hypertension, renal function and survival [6–11]. It is of note that these studies usually concern patients with stable clinical conditions and, in many cases, only moderate ARAS lesions. Recognizing these limitations, the conclusions drawn from these trials are that, compared with best medical management, PTRA with stenting has a very small role in the management of ARAS. Most importantly, there was no difference in the change in renal function and overall cardiovascular mortality. However, these results do not affect patients with ARAS associated to acute kidney injury, flash pulmonary edema or with malignant or treatment-resistant hypertension. Other patients are in great risk for acute kidney injury namely those with critical ARAS and rapid deterioration of renal function on RAAS inhibitors.

In–Vitro model for evaluation of the effects of supercooling and re-warming on vascular cells

Peripheral vascular disease can be treated by transluminal balloon angioplasty when lesions are favorable. However, the initial technical success rates are complicated by restenosis in which both endothelial cells and smooth muscle cells play a critical role. Cryoplasty, a novel form of treatment combining dilatational forces with the delivery of cold temperature to the vessel wall, has been shown to reduce the rate of restenosis. However, the underlying mechanism and the cellular response to supercooling are still poorly understood. In this study, an in vitro model was developed to examine the effect of supercooling and re-warming on cultured endothelial cell survival. Our results demonstrate that apoptosis of endothelial cells, expressed as the percentage of TUNEL-positive cells, was induced by cooling and increased during the re-warming phase.

Noninvasive Positive Pressure Ventilation against Reperfusion Pulmonary Edema following Percutaneous Transluminal Pulmonary Angioplasty

A 69-year-old man with chronic thromboembolic pulmonary hypertension (CTEPH) was on amblatory oxygen inhalation therapy (3 L/min) and scheduled for percutaneous transluminal pulmonary angioplasty (PTPA). The patient's New York Heart Association functional status was class III with recent worsening of dyspnea and apparent leg edema. Transthoracic echocardiography revealed right ventricular enlargement with mean pulmonary artery pressure of 42 mmHg. After PTPA, he was complicated with postoperative reperfusion pulmonary edema, and noninvasive positive pressure ventilation (NPPV) was applied immediately. Hypoxemia was successfully treated with 15 days of NPPV. Although mean pulmonary artery pressure was unchanged, his brain natriuretic peptide level decreased from preoperative 390.3 to postoperative 44.3 pg/dL. In addition, total pulmonary resistance decreased from preoperative 18 to postoperative 9.6 wood unit·m2. The patient was discharged on day 25 with SpO2 of 95% on 5 L/min of oxygen inhalation. Because pulmonary edema is a postsurgical life-threatening complication following PTPA, application of NPPV should be considered.

Electrocardiography Reflects Properly the Changes of Right-Sided Heart Overload in Patients with Chronic Pulmonary Thromboembolism Treated by Percutaneous Transluminal Pulmonary Angioplasty

Background: Chronic pulmonary thromboembolism (CPTE) leads to pulmonary arterial hypertension (PAH). The electrocardiography (ECG) of the patients with CPTE reflects the right-sided heart overload due to PAH. Recently, percutaneous transluminal pulmonary angioplasty (PTPA) has been demonstrated to be effective for some patients with CPTE. The purpose was to investigate the changes of ECG in patients underwent PTPA. Methods: We performed PTPA to 18 patients with CPTE. ECG was recorded before and after PTPA. Hemodynamic variables through right heart catheterization were determined at the same time. Results: The hemodynamics after PTPA was significantly improved compared to the baseline (mean pulmonary arterial pressure, 46.4 mmHg vs. 34.4 mmHg; pulmonary vascular resistance, 14.2 wood units vs. 7.8 wood units). The P amplitude in lead II was significantly decreased (2.7 mV vs. 2.0 mV). The electrical axis of QRS waves went leftward significantly (102.6° vs. 89.9°). The R/S in lead V5 was significantly increased (1.5 vs. 2.7). Conclusions: Our results suggest that the changes of ECG reflect properly the changes of right-sided heart overload by PTPA. The evaluation of ECG is a simple and easy method to assess the treatment efficacy of PTPA.

Nierenarterienstenose: Intervention oder medikamentöse Behandlung?

Angioplasty in patients with renal artery stenosis aims at reducing blood pressure and at improving kidney function. Its efficacy has however been questioned by recent published data. It was the aim of this retrospective study to compare angioplasty with medical treatment in an unselected patient population. Data on 109 patients were retrospectively analysed. This cohort included all those patients admitted to the Lippe-Detmold Hospital between 1992 and 2008 for renal artery stenosis. The data included blood pressure, creatinine-based calculated glomerular filtration rate (cGFR), any renal dialysis, cardiovascular risk factors, events and survival time after transluminal renal angioplasty or drug treatment, respectively. Patients who had undergone angioplasty were younger (p = 0.04), had less cardiovascular co-morbidity (p < 0.01), but a higher degree of stenosis (p < 0.01). After a median follow-up of 32.5 (angioplasty) and 36.0 months (drug treatment), respectively, a significant decrease of cGFR was recorded in drug treated patients (- 16.2 ml/min, 95 %, CI - 25.7 to - 6.7) but not in the angioplasty group (- 4.5 ml/min, 95 %, CI - 13.5 to 4.5). There were no other significant differences were not observed. Younger patients with a high degree of renal artery stenosis but without generalized atherosclerosis more frequently underwent angioplasty in clinical practice. The smaller post-angioplasty reduction in the loss of renal function in this group needs to be validated in a prospective, randomized study.

Prevention of secondary ischemic events by superficial temporal artery–middle cerebral artery bypass surgery after tuberculosis-induced vasculopathy in a 5-year-old child

Tuberculosis-related vasculopathy and resulting ischemic events are a common finding after tuberculous meningitis (TBM) in children. The authors report on a case of recurring ischemic episodes that were refractory to repetitive endovascular procedures (transluminal angioplasty, stent insertion, in-stent vessel dilation). After failure of endovascular treatment, extracranial-intracranial (EC-IC) bypass surgery was performed to prevent further ischemia. This 5-year-old girl presented with a series of ischemic events in the left middle cerebral artery (MCA) territory 12 months after her presentation with TBM. Angiography studies showed a 50% lumen reduction of the left MCA. After failure of antithrombocyte aggregation and repeated endovascular procedures to prevent new ischemia, EC-IC bypass surgery was performed. The left superficial temporal artery-MCA bypass was found to be capable of preventing new ischemic events in the 21-month follow-up period, despite a near-total MCA occlusion on follow-up conventional and MR angiography studies. Bypass surgery seems to be a reliable tool to augment cerebral blood flow in tuberculosis-related stenoocclusive changes of cerebral vasculature after the failure of endovascular procedures.