Transluminal Dilatation Research Articles

Balloon Angioplasty - The Legacy of Andreas Grüntzig, M.D. (1939-1985).

In 1974, at the Medical Policlinic of the University of Zürich, German-born physician-scientist Andreas Grüntzig (1939–1985) for the first time applied a balloon-tipped catheter to re-open a severely stenosed femoral artery, a procedure, which he initially called “percutaneous transluminal dilatation”. Balloon angioplasty as a therapy of atherosclerotic vascular disease, for which Grüntzig and Charles T. Dotter (1920–1985) received a nomination for the Nobel Prize in Physiology or Medicine in 1978, became one of the most successful examples of translational medicine in the twentieth century. Known today as percutaneous transluminal angioplasty (PTA) in peripheral arteries or percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI) in coronary arteries, balloon angioplasty has become the method of choice to treat patients with acute myocardial infarction or occluded leg arteries. On the occasion of the 40th anniversary of balloon angioplasty, we summarize Grüntzig’s life and career in Germany, Switzerland, and the United States and also review the developments in vascular medicine from the 1890s to the 1980s, including Dotter’s first accidental angioplasty in 1963. The work of pioneers of catheterization, including Pedro L. Fariñas in Cuba, André F. Cournand in France, Werner Forssmann, Werner Porstmann and Eberhard Zeitler in Germany, António Egas Moniz and Reynaldo dos Santos in Portugal, Sven-Ivar Seldinger in Sweden, and Barney Brooks, Thomas J. Fogarty, Melvin P. Judkins, Richard K. Myler, Dickinson W. Richards, and F. Mason Sones in the United States, is discussed. We also present quotes by Grüntzig and excerpts from his unfinished autobiography, statements of Grüntzig’s former colleagues and contemporary witnesses, and have included hitherto unpublished historic photographs and links to archive recordings and historic materials. This year, on June 25, 2014, Andreas Grüntzig would have celebrated his 75th birthday. This article is dedicated to his memory.

Vascular smooth muscle cell proliferation in restenosis.

Current therapeutic approaches to restore blood flow in stenotic blood vessels involve the use of percutaneous devices and coronary bypass surgery. In all procedures that disrupt the normal integrity of the blood vessels, there is an increased incidence of vessel luminal narrowing, termed restenosis. Restenosis, arbitrarily defined as greater than 50% narrowing of vessel diameter compared with the reference vessel, is modulated by genetic background and diseases that affect the cardiovascular system, including diabetes, hypertension, and hypercholesterolemia. In the 1970s, Andreas Gruntzig pioneered the use of transluminal dilatation of coronary arteries for symptomatic coronary artery disease and reported a 19% rate of restenosis (6 of 32 patients).1–3 Subsequent studies demonstrated a restenosis rate of approximately 33%.4 More than 25 years later, despite pharmacological and mechanical approaches to reduce the incidence of restenosis, it remains a significant problem, especially in high-risk patient groups, limiting overall success. Restenosis after percutaneous intervention is characterized by platelet aggregation, release of growth factors, inflammatory cell infiltration, medial smooth muscle cell proliferation and migration, and extracellular matrix remodeling. The vascular response to injury depends not only on the cells within the vessels but is also modulated by circulating bone marrow–derived cells. Understanding the molecular mechanisms underlying the physiological healing response and the pathological restenosis response has been the focus of extensive investigations, which have led to the development of novel approaches to control the pathological formation of the neointima. In this review, we will focus on some of the molecular mechanisms responsible for the abnormal neointimal hyperplasia, specifically focusing on cell cycle and microRNA (miRNA) in the vascular smooth muscle. Acute occlusion at the percutaneous intervention site within hours to days after the procedure is usually caused by an intimal flap, thrombus formation, subintimal hemorrhage extending into the media, or elastic recoil …

Percutaneous transluminal dilatation of the renal arteries. Results and indications

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Embolies artérielles des membres

Arterial embolism of extremities results from the obstruction of the artery by a blood clot originating in the heart and travelling through the bloodstream. Rheumatismal causes have been progressively discarded drawing attention to atheromatosis. Apart from cardiac embolism, experience has shown the existence of emboli developing in other arteries and veins called paradoxical emboli. The aetiology of emboli has been supplemented by modern techniques, including the Holter electrocardiogram (ECG), transoesophageal echocardiography (TEE), computed tomography angiography (CTA) and magnetic resonance angiography (MRA). The role of arteriography is to be considered based on the degree of emergency and the condition of artery before blockage. Technology advances have also improved the treatment of emboli, together with the Forgarty's catheter which is still widely used aspiration thrombectomy can be achieved percutaneously. Catheter directed thrombolysis is another useful technique in the treatment of distal ischemia. However, in pathologic arteries, embolism often requires transluminal dilatation or by pass grafting. Nonetheless, the prognosis tends to remain severe due to a high risk of amputation and death related to the aetiology, terrain and other embolic localizations.

Urologic Complications After Renal Transplantation

Background Renal transplantation is associated with several nonimmunological problems. Although urologic complications may be serious and carry a high risk of graft loss, they are amenable to successful treatment if diagnosed early and treated properly. Their incidence in the literature varies from 2.5% to 15%. Objective We sought to assess the incidence, pattern, management options, and outcomes of urologic complications in 560 consecutive renal transplantations performed at a single center between November 1993 and October 2004. Patients and methods Twenty-one (16 male and 5 female) recipients developed posttransplantation urinary complications at 2 days to 76 months after renal transplantation. Their kidney grafts were obtained from 13 living and eight deceased donors. Complications included ureteric stricture in 11 and urine leak in 10 recipients. Ultrasonography and isotope renal scanning were the main diagnostic tools. Complications were treated either conservatively, by percutaneous dilatation and stenting, or by surgical reconstruction. Results The incidence of urologic complications following renal transplantation in the present series was 3.7%. All cases were successfully treated with no graft loss secondary to these complications. Conclusions Posttransplantation urologic complications are associated with a good prognosis if diagnosed early and properly treated. Percutaneous transluminal dilatation of ureteric stenosis in renal transplant patients has good initial success, low morbidity, few recurrences, and long-term effectiveness.

Percutaneous Transluminal Laser Angioplasty Versus Balloon Dilation for Treatment of Popliteal Artery Occlusions

<b>Percutaneous Transluminal Laser Angioplasty Versus Balloon Dilation for Treatment of Popliteal Artery Occlusions</b>

Treatment of renovascular disease with percutaneous stent insertion: long-term outcomes.

Renal artery stenosis is a common, progressive cause of hypertension and renal impairment, and is frequently treated with percutaneous transluminal dilatation and stenting. The outcome of this procedure is still being evaluated. The records of 198 consecutive patients who had stents inserted at the Royal Melbourne Hospital were analysed retrospectively, and adequate follow-up information on 148 (75%), in whom a total of 182 renal arteries had been treated was obtained. Technical success was achieved in 144 patients (97%). Complications occurred in 19 patients (13.3%), with major complications occurring in 10 (7.0%) and one death occurring in relation to the procedure. A fall in average systolic blood pressure of 13.2 mmHg (12.1-14.3 mmHg) was seen and a fall in diastolic blood pressure of 10.1 mmHg (9.3-10.9 mmHg), without an increase in the number of antihypertensive drugs used. Renal function remained stable in the majority of patients, particularly those who had minimal baseline renal impairment. Restenosis was common after 6 months, occurring eventually in 29% of screened patients, but was not shown to affect clinical outcomes. Insertion of renal artery stents is a safe and effective treatment for renal artery stenosis.

Coarctation of the aorta

Controversy still exists in the literature regarding definitive therapy for repair of coarctation of the aorta. Major factors involve not only the timing of repair, but also the method of repair, whether surgical or by percutaneous transluminal balloon dilatation. Results and complications of coarctation repair using various methods of classification present a diversity of results. This report will focus on these issues and attempt to dispel the statement that either one method or the other is the "choice method" of repair for any and all types of coarctation. Also presented is a proposed classification we believe will assist in clarifying the choice of therapy and perhaps improve not only the reporting of results, but also the results themselves. Methods of repair are discussed to provide the surgeon with a complete armamentarium of operations that the surgeon would tailor to the individual anatomicopathological patterns of the patient who presents at the time of surgery. Copyright 2000 by W.B. Saunders Company

Balloon Dilatation of Membranous Obstruction of the Inferior Vena Cava

Membranous obstruction of the inferior vena cava is a rare congenital anomaly that results in the primary type of Budd-Chiari syndrome. We describe the case of an 8-year-old boy initially diagnosed with intrahepatic portal hypertension, who underwent percutaneous transluminal balloon dilatation of an inferior vena cava membrane located in the suprahepatic inferior vena cava, which resulted in successful palliation of his symptoms.

Stent implantation in patients with superior vena cava syndrome.

The purpose of this study was to determine the feasibility of using Wallstent implantation to treat superior vena cava syndrome due to malignant tumors. Digital subtraction angiography showed obstruction of the superior vena cava in 13 patients who then underwent transluminal dilatation and Wallstent implantation. The patients were treated with IV heparin and monitored in the emergency department. Thereafter, they were treated with a platelet inhibitor for 4 weeks. Because their signs and symptoms improved, patients were able to resume radiation therapy, chemotherapy, or both. One patient died of cardiac arrhythmia 1 day after stent placement. Although eight patients have subsequently died of their bronchial or thyroid gland tumors, superior vena cava syndrome did not recur in any patient. Percutaneous implantation of Wallstent endoprostheses provides excellent palliation for superior vena cava syndrome.

Endovascular Repair of Peripheral Aneurysms, Pseudoaneurysms, and Arteriovenous Fistulas

Endovascular repair of peripheral arterial lesions was performed in 10 patients including two iliac aneurysms, two iliac anastomotic pseudoaneurysms, one subclavian pseudoaneurysm, one axillary anastomotic disruption, two prosthetic pseudoaneurysms, and two posttraumatic arteriovenous (AV) fistulas. The indications for repair were aneurysm size in five cases, massive hematoma in one, threatened prosthetic dialysis graft in two, venous hypertension with non-healing ulcer in one, and arm pain in one. Vascular access was obtained through surgical cutdown in all cases, via the femoral artery in five patients, the proximal brachial artery in three and a prosthetic graft in two. Stented prosthetic grafts were used in five cases (1 polyester and polytetrafluoroethylene 4 [PTFE]), and PTFE-covered stents in five cases. Concomitant procedures were done in four patients including two open repairs of a common femoral artery aneurysm, a transluminal dilatation of a proximal aortic anastomotic stenosis, and an iliac artery transluminal angioplasty. Eight of 10 cases were technically successful. Completion arteriography revealed complete exclusion of all lesions, except for one minimal proximal stented graft leak in a pseudoaneurysm, and an incomplete obliteration of an AV fistula. No complications occurred. Operative time ranged from 45 min to 5 hours. Postoperative hospital stay was 1 day in five patients, 2 days in three patients, and 4 days in two patients. Follow-up contrast CT scan, arteriography, or duplex scanning demonstrated complete exclusion of all lesions except an AV fistula, and decrease in size in three aneurysms. The proximal leak initially present in a stented graft resolved. All grafts and covered stents remained patent at 2-19 months of followup. Endovascular exclusion of peripheral arterial aneurysms, pseudoaneurysms, and AV fistulas can be done with a high degree of technical success, low morbidity, and short hospital stay. Short-term follow up is encouraging, however, long term follow up of these procedures is warranted to assess durability of the repair and absence of complications.

Original extrahilar approach for hepatic portal revascularization and relief of extrahepatic portal hypertension related to later portal vein thrombosis after pediatric liver transplantation. Long term results.

Original extrahilar approach for hepatic portal revascularization and relief of extrahepatic portal hypertension related to later portal vein thrombosis after pediatric liver transplantation. Long term results.

Familial hypercholesterolaemia with severe cardiac involvement in a boy: successful management and mid‐term follow‐up

A 13-year-old boy with double heterozygosity for familial hypercholesterolaemia with a 90% left coronary artery main stem stenosis is reported. The patient's cholesterol levels were effectively controlled with weekly sessions of selective low-density lipoprotein cholesterol removal through immunoadsorption by use of an extracorporeal system. Left main coronary artery stenosis was successfully treated with percutaneous transluminal balloon dilation. At 30 months after the intervention and still under treatment with weekly sessions of low-density lipoprotein apheresis the patient is free of cardiac symptoms. He shows normal exercise capacity and normal myocardial perfusion. It is concluded that aggressive management is justified in such patients and may result in a near-normal quality of life.

A new therapeutic approach to popliteal artery entrapment syndrome (PAES)

An alternative therapeutic approach to popliteal artery entrapment syndrome (PAES) with vascular complications. Three male patients (16, 42 and 68 years) with thrombotic and/or embolic obstructions of popliteal or crural vessels as a consequence of popliteal entrapment syndrome. Combined catheter treatment consisting of percutaneous transluminal thrombembolectomy (PTEE), local thrombolysis (LTL) and percutaneous transluminal dilatation (PTA) was performed for thrombotic and embolic obstructions of popliteal or crural vessels. The aberrant tendomuscular structures were surgically corrected at a later date. After the procedure systolic ankle/arm pressure ratios in the three patients improved from 0.66 to 1.13, 0.57 to 1.07 and 0.46 to 1.10. Twelve, 8 and 4 months later the patients were asymptomatic. None of the patients showed popliteal artery compression during plantar flexion on Duplex scanning. This new therapeutic approach avoids direct vascular surgery with bypass or patch implantation in patients with PAES who are often young. The long term results remain to be evaluated.

Factors influencing long-term results of transluminal dilatation or electrocautery incision with stenting of ureteral or ureteropelvic junction strictures

SummaryThis retrospective study analyses the results of 129 transluminal balloon dilatations, and 38 endopyelotomies and endoureterotomies, of strictures of the ureter and ureteropelvic junction, performed from 1977 to 1989 (a total of 192 patients, 25 lost to follow-up). The results were assessed over a follow-up period of at least 4 and up to 14 years, and stratified according to demographic criteria (location and length of stricture), aetiology (benign versus malignant) and viability, i.e. vascular supply to stricture and adjacent ureter. The success rate for endopyelotomy and endoureterotomy in non-neoplastic lesion was 90%. The success rate of transluminal balloon dilatation was 83% in short strictures with intact vascular supply but only 30% in strictures with compromised vascular supply. For lesions with compromised vascular supply with underlying malignant aetiology, the rate of failure of transluminal balloon dilatation was 92%. Based on this experience: endopyelotomy and endoureterotomy are reco...

Diffuse spasm of a free gastroepiploic artery graft during percutaneous balloon angioplasty

Percutaneous transluminal balloon dilation of an 8-month-old free graft of the gastroepiploic artery was followed by diffuse and profound graft spasm. Because free arterial grafts are more prone to spasm, suitable precautions, such as administration of calcium channel antagonists, should be taken before attempting any interventions on these vessels.

Biology of Restenosis and Therapeutic Approach

Numerous attempts have been made to prevent restenosis after successful transluminal dilation of an atherosclerotic vessel using a variety of pharmacologic and mechanical approaches. This article reviews the pathobiology of the restenosis process, offers a hypothesis as to its cause, reviews attempts to modify the process, and outlines therapeutic approaches to future treatment.

Changing patterns in surgery for chronic renal artery occlusive diseases

We report 66 patients undergoing 69 operations for chronic renal artery occlusive diseases operated on at two institutions between January 1985 and June 1990. Etiology was atherosclerosis in 59 patients (90%); fibromuscular disease in four (6%), and three children with nonfibromuscular disease stenosis (4%). Atherosclerosis was local in 10 and generalized in 49 (83% of all patients). Fifty operations (72%) were for salvage of renal function. Average serum creatinine was 2.3 mg/dl and was elevated in 46 patients (70%). Donor arteries for reconstruction were aorta 20 (29%), aortic graft 16 (23%), and other abdominal arteries 33 (48%). Twenty-one patients had concomitant vascular procedures including 16 aortic replacements. The two operative deaths (3%) followed aortic replacements. Three grafts (4%) occluded before discharge from the hospital. Eighty-six percent of patients undergoing renal salvage avoided long-term dialysis. In past decades fibromuscular disease and localized atherosclerosis were the most frequent renal artery occlusive diseases undergoing surgery, hypertension was the predominant indication, and the most frequent operation was aortorenal bypass. As a result of improved pharmacologic management of hypertension and the development of percutaneous transluminal dilation, most patients in this series had far advanced generalized atherosclerosis, and renal salvage was the most frequent indication for operation. As a consequence of the severity of the atherosclerosis, 48% of operations avoided the aorta, 23% replaced the aorta, and aortorenal bypass was used in only 29%.

Fibromuscular Disease of the External Iliac Artery

Fibromuscular disease is rarely observed in the external iliac artery. During the last 15 years, eight symptomatic cases were encountered in six women and two men whose ages ranged from 29 to 63 years (mean: 47 years). Clinical onset was always recent, either progressive with claudication (three cases) or sudden with abdominal and pelvic pain and acute ischemia due to dissection (five cases). Diagnosis was established by arteriograms showing either a typical appearance of fibromuscular hyperplasia or a segmental dissection or occlusion. Two patients had associated fibromuscular disease of the renal arteries. One of these patients had dysplastic aneurysm of the thyrocervical trunk. Histopathological findings were typical of medial fibromuscular hyperplasia in the seven cases examined. Even though transluminal dilatation is presently simple, adequate, and durable for the management of non-complicated forms, all of our cases were treated surgically either because they were observed before transluminal dilatation was readily available or because of associated dissection. Results of surgery were satisfactory in all cases except one with a mean follow-up of 12.6 years. One patient was reoperated upon 13 years later.

Echocardiographic Determinants of Outcome After Percutaneous Transluminal Balloon Dilatation of Discrete Subaortic Stenosis

Echocardiographic Determinants of Outcome After Percutaneous Transluminal Balloon Dilatation of Discrete Subaortic Stenosis