Prevention of in-stent restenosis via reduction of thrombo-inflammatory reactions with recombinant P-selectin glycoprotein ligand-1

The binding of leukocyte P-selectin glycoprotein ligand-1 (PSGL-1) to platelet P-selectin is central to post-angioplasty restenosis. Although intracoronary stents limit the mechanical component of restenosis, they cause marked thrombo-inflammation and neointimal proliferation leading to greater late luminal loss. We sought to demonstrate that P-selectin antagonism, using recombinant PSGL-1 (rPSGL-Ig), is effective in reducing platelet-leukocyte reactions and in-stent restenosis in doubleinjured porcine coronary arteries. Two weeks after initial injury by angioplasty to the coronary arteries, stents were implanted at the injury-induced lesion site, 15 min after an IV bolus administration of a vehicle or rPSGL-Ig (1 mg/kg). Four weeks later, adhesion of 51Cr-platelets and 111In-neutrophils and histomorphometric analyses were performed. In-stent residual lumen was almost 3 fold larger in rPSGL-Ig-treated arteries (3.1 ± 0.4 mm2) as compared to control (1.1 ± 0.2 mm2), which correspond to 64% vascular stenosis in control with no change in rPSGL-Ig animals. For a similar injury score, in-stent neointima was significantly reduced by 30 to 40% in the rPSGL-Ig group and quantitative coronary angiography showed a significant 35% reduction in late lumen loss. These effects of rPSGL-Ig were associated with a respective 70% and 53% reduction in platelet and neutrophil adhesion. In conclusion, pretreatment with rPSGL-Ig reduces thrombo-inflammatory responses, neointimal proliferation, and in-stent restenosis. P-selectin antagonism offers a promising therapy to improve clinical outcomes of coronary stenting.

Polyester vascular patches acquire arterial or venous identity depending on their environment

Polyester is commonly used in vascular surgery for patch angioplasty and grafts. We hypothesized that polyester patches heal by infiltration of arterial or venous progenitor cells depending on the site of implantation. Polyester patches were implanted into the Wistar rat aorta or inferior vena cava and explanted on day 7 or 30. Neointima that formed on polyester patches was thicker in the venous environment compared to the amount that formed on patches in the arterial environment. Venous patches had more cell proliferation and greater numbers of VCAM-positive and CD68-positive cells, whereas arterial patches had greater numbers of vimentin-positive and alpha-actin-positive cells. Although there were similar numbers of endothelial progenitor cells in the neointimal endothelium, cells in the arterial patch were Ephrin-B2- and notch-4-positive while those in the venous patch were Eph-B4- and COUP-TFII-positive. Venous patches treated with an arteriovenous fistula had decreased neointimal thickness; neointimal endothelial cells expressed Ephrin-B2 and notch-4 in addition to Eph-B4 and COUP-TFII. Polyester patches in the venous environment acquire venous identity, whereas patches in the arterial environment acquire arterial identity; patches in the fistula environment acquire dual arterial-venous identity. These data suggest that synthetic patches heal by acquisition of identity of their environment. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 3422-3431, 2017.

Platelet inhibition by aspirin is diminished in patients during carotid surgery: a form of transient aspirin resistance?

The majority of patients who suffer peri-operative thromboembolic complication while undergoing vascular procedures do so despite taking aspirin. This study examined the antiplatelet effect of aspirin during surgery in patients undergoing carotid endarterectomy (CEA). Fifty patients undergoing CEA were standardised to 150 mg aspirin daily for ≥2 weeks. Platelet aggregation in response to arachidonic acid (AA) was measured in platelet rich plasma prepared from blood taken prior to, during, and at the end of surgery. Spontaneous platelet aggregation was also studied, as was the role of physiological agonists (ADP, collagen, thrombin, and epinephrine) in mediating the in vivo and in vitro responses to AA. Eighteen patients undergoing leg angioplasty, also on 150 mg aspirin, without general anaesthesia, served as a control group. In the CEA patients aggregation induced by AA (5 mM) increased significantly from 7.6 ± 5.5% pre-surgery to 50.8 ± 29.5% at the end of surgery (p <0.0001). Aggregation to AA was even greater in samples taken mid-surgery from a sub-set of patients (73.8 ± 7.2%; p = 0.0001), but fell to 45.9 ± 7.4% by the end of surgery. The increased aggregation in response to AA was not due to intra-operative release of physiological platelet agonists since addition of agents that block/neutralise the effects of ADP (apyrase; 4 µg/ml), thrombin (hirudin; 10 units/ml), or epinephrine (yohimbine; 10 µM/l) to the samples taken at the end of surgery did not block the increased aggregation.The patients undergoing angioplasty also showed a significant rise in the response to AA (5 mM), from 5.6 ± 5.5% pre-angioplasty to 32.4 ± 24.9% at the end of the procedure (p <0.0001), which fell significantly to 11.0 ± 8.1% 4 hours later. The antiplatelet activity of aspirin, mediated by blockade of platelet arachidonic acid metabolism, diminished significantly during surgery, but was partially restored by the end of the procedure without additional aspirin treatment.This rapidly inducible and transient effect may explain why some patients undergoing cardiovascular surgery remain at risk of peri-operative stroke and myocardial infarction.

Intracerebral hemorrhage as a manifestation of cerebral hyperperfusion syndrome after carotid revascularization: systematic review and meta-analysis

BACKGROUND

Intracerebral hemorrhage (ICH) in the context of cerebral hyperperfusion syndrome (CHS) is an uncommon but potentially lethal complication after carotid revascularization for carotid occlusive disease. Information about its incidence, risk factors and fatality is scarce. Therefore, we aimed to perform a systematic review and meta-analysis focusing on the incidence, risk factors and outcomes of ICH in the context of CHS after carotid revascularization.

METHODS

We searched the PubMed and EBSCO hosts for all studies published in English about CHS in the context of carotid revascularization. Two reviewers independently assessed each study for eligibility based on predefined criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the PROSPERO register was made (register no. CRD42016033190), including the pre-specified protocol.

RESULTS

Forty-one studies involving 28,956 participants were deemed eligible and included in our analysis. The overall quality of the included studies was fair. The pooled frequency of ICH in the context of CHS was 38% (95% CI: 26% to 51%, I2 = 84%, 24 studies), and the pooled case fatality of ICH after CHS was 51% (95% CI: 32% to 71%, I2 = 77%, 17 studies). When comparing carotid angioplasty with stenting (CAS) with carotid endarterectomy (CEA), post-procedural ICH in the context of CHS was less frequent in CEA. ICH following CHS occurred less often in large series and was rare in asymptomatic patients. The most common risk factors were periprocedural hypertension and ipsilateral severe stenosis.

CONCLUSIONS

ICH as a manifestation of CHS is rare, more frequent after CAS and associated with poor prognosis. Periprocedural control of hypertension can reduce its occurrence.

Long-Term Follow-up After Retrograde Recanalization of Superficial Femoral Artery Chronic Total Occlusion

OBJECTIVES

The aim of this study was to assess the safety of the retrograde procedure with long-term follow-up of 86 patients after retrograde recanalization of the superficial femoral artery (SFA).

BACKGROUND

Chronic total occlusion (CTO) of SFAs occurs in >50% of the patient population with peripheral artery disease. The retrograde technique is an option for patients with unsuccessful antegrade percutaneous interventions, but data from long-term follow-up after retrograde recanalization are still limited.

METHODS

The study included 86 patients (67% males), who underwent percutaneous retrograde recanalization. Major adverse cardiovascular or cerebrovascular events and major adverse peripheral events were assessed from long-term (47.5 ± 40 months) follow-up data.

RESULTS

Mean patient age was 64 ± 9 years. Retrograde puncture was successful in all cases. Procedural success rate was 93%. In-hospital observation showed vascular perforation/bleeding in 4.7%, proximal hematoma in 9.3%, distal hematoma in 4.7%, pseudoaneurysm in 1.2%, thrombosis in 1.2%, puncture-site bleeding in 3.5%, and local inflammation in 1.2%. Mortality rate was 6.98%. Target-vessel reintervention was needed in 20.9% of cases, and percutaneous transluminal angioplasty of another artery was done in 27% of cases. Amputation rate was 4.7%.

CONCLUSIONS

Long-term follow-up shows that retrograde recanalization is connected with a high rate of technical success and low percentage of reinterventions. Retrograde technique is safe and related to low complication rates; most complications were localized in nature.

Acute ischemic stroke mimicking subarachnoid hemorrhage after coronary angioplasty

Use of non-ionic contrast media (CM) in coronary arteriography has been reported to cause transient cortical blindness, confusion, amnesia and very rare focal deficits. We report a 69-year old patient with stable angina pectoris who underwent coronary angioplasty with stent placement due to in-stent thrombosis of the right coronary artery and developed stroke symptoms with radiological suspicion of subarachnoid hemorrhage. No vascular malformations were detected on CT cerebral angiography. Dual antiplatelet treatment was continued. Complete neurological recovery was observed within 48 hours post angiography. As observed with repeated CT scans, sulcal hyperdensities mostly faded after 24 hours and totally disappeared within 7 days when she was discharged home. Our case shows transient neurological symptoms and rapid disappearing of sulcal hyperdensities, suggesting temporary blood brain barrier disruption, consequential cerebral infarction and contrast media extravasation as the main mechanisms which allowed us to treat the patient with dual antiplatelet treatment.

Concurrent renal artery stent during endovascular infrarenal aortic aneurysm repair confers higher risk for 30-day acute renal failure

OBJECTIVE

Concurrent renal artery angioplasty and stenting (RAAS) during endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysm (AAA) has been practiced in an attempt to maintain renal perfusion. The aim of this study was to identify the current practice of RAAS during EVAR and its effect on perioperative renal outcome.

METHODS

Patients with infrarenal AAA were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP, 2011-2014) database. Baseline characteristics of patients with concurrent RAAS during EVAR were compared with those of patients who underwent EVAR only. Bivariate and multivariable logistic regression analyses controlling for patients' demographics, comorbidities, and operative factors were used to evaluate the predictors of 30-day acute renal failure (ARF). Sensitivity analysis was done to evaluate the role of RAAS in patients with prior kidney disease.

RESULTS

Overall, 6183 patients underwent EVAR for infrarenal AAA during the study period. Of them, 281 patients had RAAS during EVAR (4.5%). The median age of the patients was 74 years; 81.7% of the cohort was male, but a higher proportion of female patients received EVAR + RAAS compared with patients who underwent EVAR only (26.3% vs 17.9%; P < .001). There was no difference between groups in terms of comorbidities, being on dialysis, or functional status, yet the EVAR + RAAS group had a higher proportion of patients with glomerular filtration rate <60 mL/min/1.73 m2 (45.2% vs 37.2%; P = .011). RAAS was associated with significantly higher odds for development of ARF (adjusted odds ratio [aOR], 4.27; 95% confidence interval [CI], 2.06-8.84; P < .001). Other highly predictive factors of 30-day ARF were glomerular filtration rate <60 (aOR, 2.92; 95% CI, 1.47-5.78; P = .002), emergency status (aOR, 2.97; 95% CI, 1.21-7.27; P = .017), and ruptured AAA as the indication for EVAR (aOR, 4.74; 95% CI, 1.80-12.50; P = .002). Patients with prior kidney disease who had EVAR + RAAS demonstrated a 12-fold higher odds for 30-day ARF (aOR, 12.37; 95% CI, 4.66-32.89; P < .001).

CONCLUSIONS

Concurrent RAAS was found to be a significant determinant of adverse renal outcomes after EVAR for infrarenal AAA. This effect was present even after controlling for patients' risk factors that might contribute to postoperative ARF.

Survival adjusted cancer risks attributable to radiation exposure from cardiac catheterisations in children

OBJECTIVES

To estimate the risk of developing cancer in relation to the typical radiation doses received from a range of X-ray guided cardiac catheterisations in children, taking variable survival into account.

METHODS

Radiation doses were estimated for 2749 procedures undertaken at five UK hospitals using Monte Carlo simulations. The lifetime attributable risk (LAR) of cancer incidence was estimated using models developed by the Biological Effects of Ionising Radiation committee, based on both normal life expectancy, and as a function of attained age, from 20 to 80 years, to take reduced life expectancy into account.

RESULTS

The radiation-related risks from these procedures are dominated by lung and breast cancer (for females). Assuming normal life expectancy, central LAR estimates for cancer incidence, based on median doses, ranged from <1 in 2000 for atrial septal defect occlusions to as high as 1 in 150 for valve replacements. For a reduced life expectancy of 50 years, estimated risks are lower by a factor of around 7. For conditions with especially poor survival (age 20 years), such as hypoplastic left heart syndrome, estimated cancer risks attributable to radiation were <1 in 20 000.

CONCLUSIONS

Based on recent UK radiation dose levels, the risk of cancer following cardiac catheterisations is relatively low and strongly modified by survival and the type of procedure. The risk of breast cancer, especially following pulmonary artery angioplasty and valve replacements, is the greatest concern.

Risk of contrast induced nephropathy in diabetic patients affected by critical limb ischemia and diabetic foot ulcers treated by percutaneous transluminal angioplasty of lower limbs

BACKGROUND

The aim of this study is to evaluate the risk of contrast induced nephropathy (CIN) in diabetic patients with critical limb ischemia (CLI) and foot ulcers (FUs) treated by percutaneous transluminal angioplasty of lower limbs.

METHODS

The study group was composed of 145 diabetic patients who underwent a limb salvage protocol because of CLI and FUs between 2012 and 2015. All patients received a prophylactic strategy against the administration of contrast medium. Serum creatinine (SCr) levels were evaluated the day of procedure and for 3 days after. CIN was considered in case of increase of 25% of SCr in comparison to baseline value or an absolute increase of at least 0.5 mg/dl without other interfering factors.

RESULTS

CIN occurred in 9% (14/145) of the cases. In the 1-year follow-up SCr returned to baseline values in 10 patients (71 %), 3 patients died (21%), and 1 patient had a major cardiovascular event (7%). No patients required dialysis. The risk was independent of chronic kidney disease stage. The rate of contrast nephropathy in each stage (X = 0.27) was as follows: 3/20 (15%) in stage 2; 3/66 (4.6%) in stage 3, 7/51 (13.7%) in stage 4; and 1/8 (12.5%) in stage 5. At the univariate analysis factors predicting this risk were anemia (HR 95% 2.5 [CI 1.8-4.2] P = .039) and heart failure (HR 95% 2.6 [CI 2.1-4.6] P = .038), while any significant variable was found at multivariate analysis.

CONCLUSIONS

Peripheral percutaneous transluminal angioplasty in diabetic patients with CLI and FUs can be performed with a good safety factor and a low risk of contrast medium toxicity.

[Randomized controlled trial to superficial femoral artery recanalization for lower extremity arteriosclerosis obliterans]

OBJECTIVE

To evaluate the safety and effectiveness of neglecting superficial femoral artery (SFA) recanalization for chronic lower extremity arteriosclerosis obliterans (ASO).

METHODS

Thirty-six cases treated for severe stenosis or occlusion of superficial femoral artery resulted from ASO were randomly divided into 2 groups. Twenty of them were treated by endovascular reconstruction of superficial femoral artery and the other 16 cases were not treated with their superficial femoral artery, but were only treated with the accompanied iliac and/or profunda femoral artery lesion.

RESULTS

There was no significant difference between the two groups on mean age, gender, ABI before treatment, accompanied diseases, Rutherford classification and trans-atlantic inter-society consensus (TASC) classification (P>0.05).One week after operation, the reconstruction group had better marked effect and total effective rate [75.0% vs.12.5%(P<0.001); 90.0% vs. 37.5%(P=0.001)] and lower no effective rate [10.0% vs. 62.5%(P=0.001)], There was no significant difference between the two groups on effective rate [15.0% vs. 25.0%(P=0.675)]. The deteriorate cases in both groups were zero, and there was no morbidity of complications and death in both groups during the perioperative period. In the 3-month follow up, the reconstruction group had a better marked effect rate [65.0% vs.25.0%(P=0.017)];There was no significant difference between the two groups on the effective rate, no effective rate and total effective rate [20.0% vs.43.8%(P=0.124); 15.0% vs.31.3%(P=0.422); 85.0% vs.68.8%(P=0.422)]. The deteriorate cases and morbidity of complications and death in both groups during the perioperative period were still zero. In the 6- and 12-month follow ups, there were no significant differences between the two groups on marked effect and total effective rate [60.0% vs.37.5%(P=0.180), 80.0% vs.87.5%(P=0.672); 60.0% vs.43.8%(P=0.332), 85.0% vs.87.5% (P=1.000)]. The deteriorate case was zero in both groups, and there was no morbidity of complications and death in both groups. The limb salvage rate in both groups was 100% during the whole follow up period. The reconstruction group had a higher cost[(53 367.4±24 518.3) yuan vs.(30 397.5±15 354.4) yuan(P=0.011)]. There were 8 cases of SFA restenosis/ reocclusion during the follow up,three of which accepted another endovascular treatment, and the reoperation rate was 15.0%. while in the nonreconstruction group, there was no case that needed another endovascular therapy, and the reoperation rate was zero.

CONCLUSION

Only dealing with accompanied iliac and profunda artery lesion and neglecting superficial femoral artery reconstruction is a safe, effective and inexpensive therapy for chronic lower extremity arteriosclerosis obliterans, and should be the preferred alternative for some patients.

Depressive symptoms, functional measures and long-term outcomes of high-risk ST-elevated myocardial infarction patients treated by primary angioplasty

The presence of major depressive symptoms is usually considered a negative long-term prognostic factor after an acute myocardial infarction (AMI); however, most of the supporting research was conducted before the era of immediate reperfusion by percutaneous coronary intervention. The aims of this study are to evaluate if depression still retains long-term prognostic significance in our era of immediate coronary reperfusion, and to study possible correlations with clinical parameters of physical performance. In 184 patients with recent ST-elevated AMI (STEMI), treated by immediate reperfusion, moderate or severe depressive symptoms (evaluated by Beck Depression Inventory version I) were present in 10 % of cases. Physical performance was evaluated by two 6-min walk tests and by a symptom-limited cardiopulmonary exercise test: somatic/affective (but not cognitive/affective) symptoms of depression and perceived quality of life (evaluated by the EuroQoL questionnaire) are worse in patients with lower levels of physical performance. Follow-up was performed after a median of 29 months by means of telephone interviews; 32 major adverse cardiovascular events (MACE) occurred. The presence of three vessels disease and low left ventricle ejection fraction are correlated with a greater incidence of MACE; only somatic/affective (but not cognitive/affective) symptoms of depression correlate with long-term outcomes. In patients with recent STEMI treated by immediate reperfusion, somatic/affective but not cognitive/affective symptoms of depression show prognostic value on long-term MACE. Depression symptoms are not predictors "per se" of adverse prognosis, but seem to express an underlying worse cardiac efficiency, clinically reflected by poorer physical performance.

Impact of Indoxyl Sulfate on Progenitor Cell-Related Neovascularization of Peripheral Arterial Disease and Post-Angioplasty Thrombosis of Dialysis Vascular Access

Patients with chronic kidney disease (CKD) have an increased risk of vascular disease, which is associated with considerable health care costs. Vascular disease in CKD differs clinically and pathobiologically from that in patients with normal renal function. Besides the traditional risk factors, retention of uremic toxins contributes to the pathogenesis of vascular disease in patients with CKD. Indoxyl sulfate is a protein-bound uremic toxin and is inefficiently removed by conventional dialysis. Accumulating evidence suggests that indoxyl sulfate is a vascular toxin involved in atherosclerosis, arteriosclerosis, vascular calcification and vascular repair. Clinically, indoxyl sulfate is associated with total and cardiovascular mortality in patients with CKD. Recent studies have indicated that in addition to coronary and cerebral arteries, indoxyl sulfate plays a role in peripheral artery disease (PAD) and dialysis graft thrombosis. Emerging evidence suggests that indoxyl sulfate is implicated via novel mechanisms, including progenitor cell-related neovascularization and tissue factor-related hypercoagulability. These findings raise the possibility that strategies targeting serum indoxyl sulfate may have the potential to improve the outcomes of PAD and dialysis vascular access in patients with CKD.

[Comparing the risks for the development of perioperative complications in carotid endarterectomy and carotid angioplasty]

The article is a literature review presenting a comparative analysis of 30-day risks of mortality and complications after carotid endarterectomy and carotid angioplasty with stenting. The risks studied were as follows: myocardial infarction, stroke, transitory ischaemic attacks, bradycardia, hypotension, postoperative haematomas, and damages to the craniocerebral nerves. The authors analysed a series of recently published foreign studies and meta-analyses dedicated to the problem concerned. The obtained findings revealed that carotid endarterectomy turned out to be associated with a higher perioperative risk for the development of myocardial infarction, postoperative haematomas and damages to the craniocerebral nerves, whereas carotid angioplasty with stenting appeared to be associated with an increased risk for the development of stroke, bradycardia and hypotension within the first 30 postoperative days. As far as mortality is concerned, it proved to be relatively similar for both methods of revascularization. The use of systems of protection of the brain from embolism during stenting of carotid arteries decreases the perioperative risks, however, it seems difficult to unequivocally affirm which of the methods of cerebral protection demonstrates better results.

[Remote results of open surgical and endovascular treatment of internal carotid artery stenoses]

The article is a review containing a comparative analysis of the remote results in patients presenting with carotid artery atherosclerosis and treated by means of either stenting or carotid endarterectomy. More than ten international randomized studies have up to now been conducted. Some of them prove the advantage of using either carotid endarterectomy or stenting of carotid arteries, others show equivalence of both methods of treatment. Carotid endarterectomy is currently a preferred operation for carotid artery stenoses, with lower incidence of the development of postoperative strokes and restenoses in the remote period. But stenting is an alternative technique in patients with high operative risk. Therefore, the question of choosing an appropriate type of the intervention should be decided upon for each patient individually. A more definite conclusion to be made on advantages of carotid endarterectomy over endovascular angioplasty, or vice versa, requires further studying therapeutic outcomes during a longer follow-up period.

[Prediction of ischaemic lesions of the brain in reconstructive operations on internal carotid arteries]

The present study was undertaken to examine the relationship between the level of the intensity of the ultrasonic signal reflected from atherosclerotic plaques (ATP) of carotid arteries and the risk for formation of an ischaemic lesion in the brain matter, detected during diffusion-weighted magnetic resonance imaging (DW-MRI) performed 24 hours after carotid endarterectomy (CEA) or carotid angioplasty and stenting (CAS). Our prospective study included a total of 78 patients presenting with stenosis of the sinus of the interior carotid artery. Of these, 42 patients were subjected to CEA and 36 subjects endured CAS. All patients in the preoperative period underwent ultrasonographic examination with determination of the degree of heterogeneity of ATPs and registration of the values of the intensity of acoustic characteristics of the signal. The condition of the brain matter before and 24 hours after the intervention was assesses by the findings of DW-MRI. None of the patients after the reconstructive intervention during the postoperative period demonstrated any evidence of acute cerebral circulation disorders. DW-MRI carried out 24 hours after the operation revealed acute ischaemia foci (AIF) in 9 (21.4%) patients after CEA and in 18 (50%) patients after CAS (p=0.05). It was revealed that the postoperative occurrence of AIF was related to the intensity of the ultrasonographic signal prior to the operation: in the CEA group patients the postoperative ischaemic foci were associated with high-intensity ultrasonographic signals (more than 25 dB), whereas in the CAS group patients, vice versa - with low-intensity signals (less than 25dB). For CEA, sensitivity and specificity of the preoperative ultrasonographic method of predicting postoperative embolic lesions of the brain appeared to be similar, amounting to 100% each (with the cut-off point of high- and low-intensity signals equaling 25 dB), and for CAS, sensitivity of the method turned out to be 75% and specificity - 100% (with the same cut-off point of 25 dB). A conclusion was drawn that quantitative characteristics of the intensity of an ultrasonographic signal from fragments of atherosclerotic plaques of the sinus of the internal carotid artery made it possible with high probability to predict the risk for the development of AIF in the brain matter after both CEA and CAS and may therefore serve as a reliable criterion for appropriate therapeutic decision-making with the lowest risk of inflicting lesions in a particular case. The threshold cut-off points of high- and low-intensity ultrasonographic signals, as well as their clinical significance are yet to be specified and verified with the growing number of cases.

Carotid patch and cerebrovascular event relation after carotid endarterectomy procedure

BACKGROUND

Carotid endarterectomy (CEA) is the treatment of choice for patients with symptomatic and asymptomatic high-grade carotid stenosis. In literature there are papers advocating patch plasty for better results. But there is controversy about which patch material is optimal for use. This study compared rate of neurologic events, and perioperative death in patients undergoing CEA with primary closure versus patch closure.

METHODS

We compared patch angioplasty to primary closure between August 2008 and December 2012 in 57 operations. Patients grouped according to their closure technique. Early (30-day) stroke and mortality rate were evaluated. Mean age of patients was 67.79±10.19 (range 41-85 years). 15 (26.31%) of patients were female.

RESULTS

Primary closure was used in 13 operations, and patch angioplasty was used in 44 (saphenous vein: 5, Dacron: 23, Fabric: 5, Carotid: 11). There were no significant differences among groups' baseline characteristics. Primary closure was associated with significantly more postoperative major stroke compared with patch used closure (P=0.05). None of preoperative variables were associated with postoperative stroke.

CONCLUSIONS

On the basis of our results, avoiding primary closure for CEA is defendable. But choice of patch material needs large trials to conclude.

Carotid artery stenting renaissance: is it safe and effective using new materials?

Data from randomized controlled trials (RCTs) demonstrated significant differences between carotid artery stenting (CAS) and carotid endarterectomy (CEA) in terms of early neurological outcomes (from 0 to 30 days), although mid- and long-term neurological results are indistinguishable. CAS in symptomatic standard risk patients is coupled with a higher risk of any stroke, and death or any stroke at 30 days, while the rates of disabling or major stroke do not vary remarkably between treatments. Since the micro-embolization through the stent struts is the primary suspected cause of suspected early postoperative neurological complications (i.e., non-disabling stroke), surgical technology has focused on the production of a new generation of stents with a double layer of mesh to reduce the "free area" of the cells, and on new cerebral protection devices. Another major determinant of early negative outcomes is believed to be the intraluminal manipulation occurring during carotid engagement from the aortic arch, the crossing maneuvers at the level of the culprit lesion and vessel trauma during angioplasty. To address these subject matters, new embolic protection devices and innovative strategies have been developed, consequently. This review is designed to furnish the current status of CAS results, to update the ongoing RCTs comparing CAS vs. CEA outcomes, and to recapitulate the features and clinical outcomes for a new carotid stent design, the so called "mesh-stents", and new embolic protection tools.

Subintimal angioplasty for lower limb arterial chronic total occlusions

BACKGROUND

In recent years subintimal angioplasty (SIA) has become an established percutaneous procedure for the treatment of symptomatic lower limb arterial chronic total occlusions. However, the clinical benefits of this practice remain unclear. The aim of the review was to determine the effectiveness of SIA on clinical outcomes. This is an update of a review first published in 2013.

OBJECTIVES

To assess the effectiveness of SIA versus other treatment for people with lower limb arterial chronic total occlusions, determined by the effects on clinical improvement, technical success rate, patency rate, limb salvage rate, and morbidity rates.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched January 2016) and Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 12). We also searched clinical trials registries.

SELECTION CRITERIA

We included data from randomized controlled trials comparing the effectiveness of SIA and any other management method in the treatment of lower limb arterial chronic total occlusions. The primary intervention of interest was SIA, with or without a stent, for the restoration of vessel patency in people with occlusions of a lower limb artery. We compared SIA against alternative modalities used to restore vessel patency, including conventional percutaneous transluminal angioplasty, surgical bypass, or any other treatments. We compared different SIA devices and techniques against each other.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. The third review author resolved disagreements.

MAIN RESULTS

Two studies, involving a total of 147 participants with TransAtlantic Inter-Society Consensus (TASC)-II D femoropopliteal lesions, met our inclusion criteria and were included in the review. Both studies were small but otherwise of high methodological quality. However, the treatment techniques and control groups of the two studies differed, precluding the combining of study results and resulting in the evidence being less applicable. We therefore considered the quality of the evidence to be low.In one study, participants with TASC-II D lesions were randomized to receive either SIA with stenting of the superficial femoral artery or remote endarterectomy (RE) with stenting of the superficial femoral artery. Three-year follow-up results showed a Rutherford classification improvement of 64% in the SIA group compared to 80% in the RE group (risk ratio (RR) 0.79, 95% confidence interval (CI) 0.61 to 1.03; 95 participants; P = 0.079). Postexercise ankle brachial index improvements (defined as an increased value of 0.2) were reported in 70% of participants in the SIA group compared to 82% in the RE group (RR 0.86, 95% CI 0.68 to 1.08; 95 participants; P = 0.18). The study reported the technical success rate was 93% for the SIA group and 96% for the RE group (RR 0.97, 95% CI 0.88 to 1.07; 95 participants; P = 0.91). Primary patency at 12 months was 59.1% in the SIA group compared to 78.4% in the RE group (RR 0.75, 95% CI 0.57 to 1.00; 95 participants; P = 0.05). Primary patency at 24 months was 56.8% in the SIA group compared to 76.5% in the RE group (RR 0.74, 95% CI 0.55 to 1.00; 95 participants; P = 0.05) and 47.7% in the SIA group and 62.7% in the RE group at 36 months (RR 0.76, 95% CI 0.52 to 1.11; 95 participants; P = 0.15). Assisted primary patency was 52.3% in the SIA group compared to 70.6% in the RE group (P = 0.01) at 36 months. Secondary patency was better for the RE group (P = 0.03) at 36 months. Limb salvage at three years' follow-up was 95% in the SIA group and 98% in the RE group (RR 0.97, 95% CI 0.90 to 1.05; 95 participants; P = 0.4). There were no perioperative deaths, but complications occurred in two SIA participants (femoral pseudoaneurysm and pulmonary edema) and in three RE participants (seroma, femoral pseudoaneurysm, superficial femoral artery acute occlusion).In the second study, the effects of the SIA OUTBACK re-entry catheter device in people affected by TASC-II D superficial femoral artery chronic total occlusion were compared with the SIA manual re-entry technique. This study did not report clinical improvement and limb salvage. Technical success was achieved in all cases in both the OUTBACK device and manual groups. The primary 6-month patency rate was 100% in the OUTBACK group (26 of 26 participants) compared to 96.2% in the manual group (25 of 26 participants) (RR 1.04, 95% CI 0.94 to 1.15). The primary 12-month patency rate was 92.3% in the OUTBACK group (24 of 26 participants) compared to 84.6% in the manual group (22 of 26 participants) (RR 1.09, 95% CI 0.90 to 1.33). Patency rates at 24 and 36 months were not reported. The study reported that there were no complications.

AUTHORS' CONCLUSIONS

Using the GRADE approach, we classified the quality of the evidence presented by both studies in this review as low due to small study size and the small number of studies. In addition, the two included trials differed from each other in the techniques and control used, and we were therefore unable to combine the data. Consequently there is currently insufficient evidence to support SIA over other techniques. Evidence from more randomized controlled trials is needed to assess the role of SIA in people with chronic lower limb arterial total occlusions.

[Control study of total percutaneous access with preclose technique versus open femoral artery exposure for endovascular aneurysm repair]

OBJECTIVE

To compare total percutaneous access using preclose technique with femoral artery cut-down in endovascular aneurysm repair (EVAR) and assess the safety and feasibility of preclose technique.

METHODS

In the study, 81 cases undergoing EVAR from Dec. 2011 to Nov. 2014 in Peking University People's Hospital were retrospectively reviewed. Preoperative CT angiography (CTA) showed presence of infrarenal abdominal aortic aneurysm or descending aortic aneurysm in all the cases. The maximum diameter of aneurysm >4.5 cm met the indications for surgical treatment. The conditions of bilateral femoral artery and iliac artery CTA showed were good, and there was no moderate or severe stenosis, nor was there any severe calcification in anterior wall of femoral artery. Not only were the cases fit for percutaneous endovascular aortic aneurysm repair (PEVAR), but also feasible with open endovascular aneurysm repair (OEVAR). According to the intention of the patients about the surgical incision, the cases were divided into group PEVAR and group OEVAR. The data of the general situation, operation time, blood loss, technical success rate, length of hospital stay after procedure and wound complications were analyzed statistically.

RESULTS

In the study, 44 cases (78 incisions) were enrolled in group PEVAR and 37 cases (65 incisions) in group OEVAR. There was no significant difference between the two groups in age, gender, body mass index (BMI), accompanying diseases, average number of stents and outer diameter of stent delivery system. Average operation time of group PEVAR was less than that of group OEVAR [(119.1±102.0) min vs. (163.6±61.9) min, P=0.025]. The blood loss in group PEVAR was less than that in group OEVAR [(64.7±97.0) mL vs. (98.6±88.3) mL], but there was no significant difference (P=0.106). There was no difference in the technical success rate (94.9% vs.95.4%, P=1.000). The average length of hospital stay after procedure was significantly shorter in group PEVAR [(7.8±2.8) d vs.(12.3±7.2) d, P<0.001]. There were 2 cases with subcutaneous hematoma of wound in group PEVAR and 7 cases of wound complications that occurred in group OEVAR including 3 cases with lymphatic leakage, 3 cases with lower limb ischemia and 1 case with subcutaneous hematoma. The analysis showed that PEVAR could reduce the wound complications (2.6%vs.10.8%), but there was no significant difference between the two groups (P=0.079).

CONCLUSION

Using preclose technique in EVAR is safe and effective. It can shorten the operation time and length of hospital stay after procedure.

Sense and nonsense of bare metal stents below the knee

INTRODUCTION

Critical limb ischemia (CLI) is increasingly present in daily practice, and diabetes is responsible for a preferential below the knee (BTK) localization of the disease. The objective was to determine if there is still a sense to BTK implantation of bare metal stents (BMSs) in CLI patients in the era of drug eluting strategies.

EVIDENCE ACQUISITION

An extensive review of the literature was carried out over the last 15 years on the use of BMSs in BTK revascularization based on a PubMed (Medline), EMBASE and PubMed Central search.

EVIDENCE SYNTHESIS

The Chromis Deep® (Invatec, Roncadelle, Italy) was the first dedicated stent in BTK lesions, followed by passive coated BMSs developed in an attempt to inhibit platelets deposition. Comparative results showed no advantage of primary BMS implantation over peripheral transluminal angioplasty (PTA) in improving primary patency rates, Rutherford classification or wound healing and the place of BMSs was restricted to bailout spot stenting. The fear of patency loss in connection with possible stent fractures led to an interest towards nitinol stents, but results were disappointing, especially in patients with severely calcified lesions. Drug-eluting stents (DESs) were then developed and showed better long-term primary patency, restenosis and freedom from target lesion revascularization (TLR) rates, even in long calcified lesions against BMS or drug eluting balloons (DEB). However, limb salvage and wound healing rates were not significantly improved.

CONCLUSIONS

Primary BMS implantation showed no advantage over PTA and as of today DES trials have not shown enough clinical or economic benefit. Thus, BMSs are recommended over DESs, and only as a bailout strategy in case of flow limiting dissection or recoil. Quality trials assessing long-term clinically relevant outcomes, evolution in stents designs and vessel preparation could lead to a change in those recommendations.

Percutaneous transluminal angioplasty combined with intra-arterial thrombolysis to treat lower-extremity arterial occlusion in thromboangitis

BACKGROUND

The aim of this paper was to evaluate the efficacy of percutaneous transluminal angioplasty and the intra-arterial infusion of thrombolytic drugs in the treatment of lower extremity (LE) arterial occlusion during thromboangiitis obliterans (TO).

METHODS

Between February 2008 and October 2013, 13 consecutive patients with TO and LE arterial occlusion underwent 18 sessions of PTA. One LE was affected in 11 patients and both LEs in two patients. An antegrade approach with transfemoral access was used in 17 procedures, and a retrograde approach via the contralateral common femoral artery (CFA) in one procedure. Under fluoroscopic guidance, a 260 cm wire (0.014 inch diameter), with a stiff body and a soft tip, was passed through the occlusion, followed by a 2.5-4 mm deep balloon, and the occlusions were dilated. After dilation, the deep balloon was removed and the straight tip of a thrombolysis catheter inserted, through which to intra-arterially infuse the thrombolytic drug.

RESULTS

Percutaneous transluminal angioplasty (PTA) was successful in 39 of the 61 LE occluded arteries, so the technical success was 63.9%. No mortality or serious complication related to PTA was observed. There were significant differences between The Ankle Brachial Index (ABI) at the time of admission (1st-ABI), immediately after the first PTA (2nd-ABI), and at the time of patient discharge (3rd-ABI) (P=0.000). The self-reported maximum walking distance (SRMWD) before and after PTA were also significantly different (P=0.000). All the patients were followed-up for a mean period of 28.4±11.2 months (13-46 months).

CONCLUSIONS

PTA using a deep balloon combined with the intra-arterial infusion of thrombolytic drugs is an effective and safe treatment for TO in patients to recanalize the occluded LE vessels.

Impact of Endograft Material on the Inflammatory Response After Elective Endovascular Abdominal Aortic Aneurysm Repair

The purpose of this paper is to examine the impact of endograft material on the inflammatory response after elective endovascular abdominal aortic aneurysm repair. Consecutive patients (n=22, all men, 53 to 82 years old) were divided into 2 groups according to the graft material used: In group A (n=12) the endovascular device was made of polyester and in group B (n=10) the device was made of expanded polytetrafluoroethylene (ePTFE). All patients received antiinflammatory drugs in the perioperative period. Fever, white blood cells and platelet count, serum concentrations of cytokines (interleukin 6 [IL-6], tumor necrosis factor alpha [TNF-a], interleukin 8 [IL-8], acute-phase proteins high-sensitivity C-reactive protein [hsCRP] and alpha1-antitrypsin [a1-antitrypsin]), and complement protein (C3a) were measured preoperatively and 1, 3, 6, 24, 48, and 72 hours after aneurysm exclusion. One patient in each group had a systemic inflammatory response syndrome with 2 of the systemic inflammatory response syndrome (SIRS) criteria. No other complication associated with inflammation were present in any patient. Fever was more frequent in group A patients. Increases of white blood cells and serum concentrations of IL-6, TNF-a, hsCRP, a1-antitrypsin, and C3a and decrease of platelet count were recorded in both groups, but no statistically significant difference between them was recorded. However, serum concentrations of IL-8 were significantly higher in group A patients 24 hours postoperatively (p=0.01). No significant difference was apparent in the biological response between patients receiving a polyester or an ePTFE stent graft, except for fever and serum concentrations of IL-8.

Platelet Function and Pharmacologic Inhibition

Platelets have traditionally been understood within the context of hemostasis and hemorrhagic disorders. However, with increasing procedures being performed in smaller vessels and with an increasing incidence of atherosclerosis, the often critical role platelets play is more evident. Platelets are no longer viewed as “scaffolding” for the events of the coagulation cascade but rather as important catalysts in hemostasis, thrombosis, and fibrinolysis. Improved understanding of platelet physiology has led to developments of pharmacologic adjuncts resulting in improved patency rates and improved patient outcomes. This review addresses the physiology of platelet function and the impact of new pharmacologic agents in percutaneous intervention.

Clinical Impact of Chronic Renal Insufficiency on Endovascular Aneurysm Repair

Endovascular aneurysm repair of abdominal aortic aneurysms has become a viable alternative to open repair. A significant proportion of this patient population has chronic renal insufficiency. The surgical outcomes associated with endovascular repair in 342 patients, with and without chronic renal insufficiency, are reported. Perioperative mortality, length of admission, length of intensive care unit admission, and rates of acute renal failure, congestive heart failure, myocardial infarction, conversion to open surgery, progression to hemodialysis, and incidence of endoleaks were retrospectively reviewed and analyzed. Endovascular repair demonstrated higher rates of acute renal failure, longer length of stay, and longer intensive care unit admissions in patients with chronic renal insufficiency. Patients with severe renal dysfunction demonstrated markedly elevated mortality and morbidity. These results indicate that chronic renal insufficiency is not an absolute contraindication to endovascular repair in patients with moderate renal dysfunction, but patients with severe renal dysfunction perform poorly after aortic reconstruction.