Paradoxical Embolic Stroke Following Percutaneous Transluminal Angioplasty in a Hemodialysis Patient

Paradoxical embolism is a medical condition characterized by the migration of an embolus from a venous source into the systemic circulation. This occurs through a specific cardiac abnormality known as a right-to-left shunt, ultimately resulting in the possibility of arterial embolism. Patent foramen ovale (PFO) is the most common cause of intracardiac shunting. We reported a rare case of a 56-year-old man on hemodialysis with PFO and arteriovenous fistula dysfunction who suffered a paradoxical embolic ischemic stroke after percutaneous transluminal angioplasty. This case emphasized the potential risk of paradoxical embolism in hemodialysis patients with vascular access problems. We aimed to highlight the importance of searching for PFO, as it may serve as a possible source of embolism in these patients.

Coronary angiotomography in patients with acute coronary syndrome without ST elevation

BACKGROUND

In patients presenting with acute coronary syndrome (ACS) current clinical practice guidelines recommend coronary angiography for its study. This study aims to describe the role of coronary tomography (CT) in non-ST-segment elevation acute coronary syndromes (NSTE-ACS).

RESULTS

Patients over 18 years with a diagnosis of NSTE-ACS who did not meet high-risk criteria and consulted the emergency department of our institution were included. A total of 410 patients were included, in 7% of them, the study was not continued due to an elevated calcium score (>400 AU). 27% had no coronary lesions, 38% had non-obstructive coronary disease (plaques <50%), 27% had plaques over 50%, and 8% were not assessable. Of the total patients, 39% underwent coronary angiography, and 22% required percutaneous angioplasty.

CONCLUSIONS

Performing CT in low and moderate-risk NSTE-ACS patients was feasible, avoiding invasive studies in a significant number of patients and providing extensive anatomical information.

An Integrated Arterial Remodeling Hydrogel for Preventing Restenosis After Angioplasty

The high incidence of restenosis after angioplasty has been the leading reason for the recurrence of coronary heart disease, substantially increasing the mortality risk for patients. However, current anti-stenosis drug-eluting stents face challenges due to their limited functions and long-term safety concerns, significantly compromising their therapeutic effect. Herein, a stent-free anti-stenosis drug coating (denoted as Cur-NO-Gel) based on a peptide hydrogel is proposed. This hydrogel is formed by assembling a nitric oxide (NO) donor-peptide conjugate as a hydrogelator and encapsulating curcumin (Cur) during the assembly process. Cur-NO-Gel has the capability to release NO upon β-galactosidase stimulation and gradually release Cur through hydrogel hydrolysis. The in vitro experiments confirmed that Cur-NO-Gel protects vascular endothelial cells against oxidative stress injury, inhibits cellular activation of vascular smooth muscle cells, and suppresses adventitial fibroblasts. Moreover, periadventitial administration of Cur-NO-Gel in the angioplasty model demonstrate its ability to inhibit vascular stenosis by promoting reendothelialization, suppressing neointima hyperplasia, and preventing constrictive remodeling. Therefore, the study provides proof of concept for designing a new generation of clinical drugs in angioplasty.

Analysis of Medical Malpractice Claims Involving Interventional Radiologists: A Comprehensive Analysis From Two National Legal Databases

PURPOSE

The nature of lawsuits involving interventional radiologists (IRs) is not well understood. The purposes of this article are to provide an overview of the causes of action underlying medical malpractice lawsuits related to IRs and to characterize the associated factors and outcomes.

METHODS

Two large legal databases were used to search for US legal cases in which there were jury awards and settlements involving IRs in the United States. Cases were screened to include only those cases in which the cause of action involved negligence on the part of IRs.

RESULTS

A total of 389 published case summaries were identified, of which 93 were eligible to be included in the analysis. In 46% of the cases (43 of 93), medical malpractice was alleged against an individual IR, whereas in 43% (40 of 93), it was alleged against both an individual IR and a health care institution. Thirty-five percent of IR malpractice cases (33 of 93) involved the performance of a vascular procedure, most commonly embolization procedures (30% [n = 10]), stenting or angioplasty (21% [n = 7]), and diagnostic arteriography and angiography (18% [n = 6]). Twenty-six percent of cases (24 of 93) involved IR performance of a biopsy. Eighteen percent of cases (17 of 93) involved a failure to gain informed consent in addition to an allegation of medical negligence during treatment. Eleven percent of cases (10 of 93) were resolved by settlement, with an average settlement amount of $877,500 (range, $200,000-$2,700,000). Among the 72 cases that went to trial, 74% (53 of 72) resulted in judgments for the defendants, and 26% (19 of 72) resulted in judgements for the plaintiffs, with an average award of $2,012,243 (range, $101,667-$6,400,000).

CONCLUSIONS

Vascular procedures and biopsies were the most frequent reasons for malpractice lawsuits involving IRs. Failure to gain informed consent in addition to an allegation of medical negligence during treatment was not infrequent. Although the majority of published medical malpractice claims involving IRs resulted in judgments in favor of the defendants, the average amount awarded to plaintiffs was higher compared with previous data reported for all physicians.

Changes in retinal vascular density measured by optical coherence tomography angiography in patients with carotid artery stenosis after carotid artery stenting and angioplasty

PURPOSE

The aim of this study was to compare the effect of carotid artery stenting and angioplasty (CASA) on retinal vascular density (VD) in patients with severe carotid stenosis with a healthy control group and to evaluate using optical coherence tomography angiography (OCTA).

METHODS

For this prospective study, eyes on the operated side constituted the ipsilateral eye group, and the other eye constituted the contralateral eye group. 40 eyes of 40 patients with ipsilateral eye of carotisid artery stenosis (CAS), 34 eyes on contralateral side, and 30 healthy eyes (control group) were included in this study. We performed quantitative OCTA analyses of retinal VD changes, before and after CASA. The main outcome measures were the quantitative changes of VD of superficial capillary plexus (SCP) and deep capillary plexus (DCP).

RESULTS

We evaluated the VD of ipsilateral eyes and contralateral eyes separately before and after the procedure. All patients did not have visual symptoms. There was no significant difference in the VD of SCP in all groups before the procedure. No significant change was observed in all groups when the VD of the SCP was compared before and after the procedure. The VD of the DCP in the ipsilateral and contralateral group improved significantly after CASA.

CONCLUSION

OCTA could noninvasively detect retinal VD improvements after CASA in CAS patients. Quantitative changes in VD evaluated using OCTA are thought to be early indicators in the diagnosis of CAS and in the follow-up of treatment success.

Purtscher-like retinopathy following carotid angioplasty and stenting in the treatment of severe carotid stenosis

We present a case of Purtscher-like retinopathy (PLR) following carotid angioplasty and stenting (CAS). A 56-year-old man with a history of severe stenosis of the left carotid artery and treated by CAS refers acute and painless visual loss on the left eye (OS) 48 h after the procedure. Funduscopic examination showed cotton wool spots and intraretinal hemorrhages confined to the peripapillary and posterior pole of the OS. The optical coherence tomography (OCT) showed retinal thickening and hyperintense lesions in the inner nuclear layer retina.

Do Clinical Outcomes and Quality of Life Differ by the Number of Antianginals for Stable Ischemic Heart Disease? Insights from the BARI 2D Trial

Medical therapy, including antianginal treatment, is the cornerstone in the management of stable ischemic heart disease (SIHD). However, it remains unclear whether combining antianginal agents provides benefits beyond monotherapy in terms of quality of life (QoL) and cardiovascular outcomes. We used data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial, which compared cardiovascular and QoL outcomes in patients with SIHD and diabetes mellitus randomized to revascularization with intensive medical therapy or intensive medical therapy alone. We categorized patients into 3 groups: ≥2 versus 1 versus 0 antianginals. We compared patient characteristics, QoL metrics, and cardiovascular end points at baseline and at 5 years, creating a multivariable model to adjust for key clinical confounders. Of 2,368 patients, 348 patients (14.7%) were on 0 antianginals, 1,020 patients (43.1%) were on 1 antianginal, and 1,000 patients (42.2%) were on ≥2 antianginals at baseline. The most common antianginal class was β blockers. At baseline, patients on 0 antianginals had better QoL metrics (self-health score, Duke activity status index, and energy rating) than patients on ≥2 antianginals. However, at the 1-year follow-up, patients taking only 1 antianginal showed greater QoL improvement than those taking 0 antianginal, without any incremental benefit in QoL metrics seen in patients taking ≥2 antianginal agents, even after adjusting for multiple covariates such as age, heart failure, diabetes control, and myocardial jeopardy index. Lastly, at the 5-year follow-up, after adjustment, there were no differences in all-cause mortality, major adverse cardiovascular events, or myocardial infarction between patients taking different numbers of antianginals. Adults on a single antianginal for SIHD and diabetes mellitus had similar or better improvements in QoL than those on 2 or more antianginal agents at 1 year of follow-up. These findings merit further research to better understand the impact of medical therapy intensity on QoL in patients with SIHD and associated co-morbidities.

A case report: new-onset nummular headache after stenting of the middle cerebral artery

BACKGROUND

Nummular headache (NH) is categorized as a primary headache in the International Classification of Headache Disorders, Third edition (ICHD-3) diagnostic criteria, but there are secondary etiologies as well. We present a case of secondary NH that associated with vascular lesion.

CASE PRESENTATION

We report on a 40-year-old man with a medical history of symptomatic intracranial arterial stenosis who developed a headache after percutaneous transluminal angioplasty and stenting because of Intracranial atherosclerotic stenosis(ICAS). This new-onset headache was a pinprick headache confined to the parietal part of the head and 5 cm in size. This headache most closely resembled the phenotype of a NH. And other causes of secondary headache were excluded. Thus, the diagnosis of NH was highly speculated. This patient represents a rare headache phenomenon after intracranial arterial stent placement.

CONCLUSION

This is the first report of NH after stent placement treatment in a patient with ICAS.

Applicability of the Zwolle score for selection of very high-risk ST-elevation myocardial infarction patients treated with primary angioplasty

The Zwolle risk score was designed to stratify in-hospital mortality risk of ST-elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (pPCI) and for decision-making in the unit where patients are admitted. We assessed the accuracy of Zwolle risk score for in-hospital mortality estimation compared with the GRACE score in all patients (n = 4446) admitted for STEMI in 3 university hospitals. Only one fourth of the patients were classified as high-risk by the Zwolle risk score vs 60% by the GRACE score. In-hospital mortality was 10.6%. A statistically significant increase in in-hospital mortality, adjusted by age, gender, and revascularization, was observed with both scores. The assessment of the optimal cut-off points verified the accuracy of Zwolle score ≥4 as optimal threshold for high-risk categorization. In contrast, GRACE score ≥140 had very low specificity as well as percentage of patients correctly classified; GRACE score ≥175 was fairly better. The reclassification index of the Zwolle score after applying the GRACE score was 35.5%. Selection of high-risk STEMI patients treated with pPCI based on the Zwolle risk score has higher specificity than the GRACE score and might be useful in clinical practice.

Sensorized Endovascular Technologies: Additional Data to Enhance Decision-Making

BACKGROUND

Current endovascular procedures rely mostly on anatomic information, guided by fluoroscopy, to perform interventions (i.e. angioplasty, stent placement, coils). However, the structural parameters provided by these imaging technologies do not provide any physiological data on either the disease state or efficacy of intervention. Additional endovascular tools are needed to collect physiologic and other both anatomic and nonanatomic data to further individualize endovascular interventions with the ultimate goal of improving patient outcomes. This review details the current state of the art for these sensorized endovascular technologies and details systems under development with the aim of identifying gaps and new directions. The objective of this review was to survey the Vascular Surgery literature, engineering literature, and commercially available products to determine what exists in terms of sensor-enabled endovascular devices and where gaps and opportunities exist for further sensor integration.

METHODS

Search terms were entered into search engines such as Google and Google Scholar to identify endovascular devices containing sensors. A variety of terms were used including directly search for items such as "sensor-enabled endovascular devices" and then also completing more refined searches bases on areas of interest (i.e. fractional flow reserve, navigation, retrograde endovascular balloon occlusion of the aorta, etc.). For the most part, systems were included where the sensor was mounted directly onto the catheter and implantable sensors such as those that have been investigated for use with stents have been excluded.

RESULTS

The authors were able to identify a body of literature in the area of endovascular devices that contain sensors to measure physiologic information. However, areas where additional sensing capabilities may be useful were identified.

CONCLUSIONS

Several different types of sensors and sensing systems were identified that have been integrated with endovascular catheters. Although a great deal of work has been done in this field, there are additional useful data that could be obtained from additional novel sensing technologies. Furthermore, significant effort needs to be allocated to carefully studying how these new technologies can be employed to actually improve patient outcomes.

[To investigate the role of the AAC-8 scoring in predicting restenosis or occlusion of lower extremity arteries after dilatation and angioplasty with DCB]

Objective: To investigate the role of the Abdominal Aortic Calcification-8 (AAC-8) scoring system in predicting restenosis or occlusion of lower extremity arteries after dilatation and angioplasty with drug-coated balloon (DCB). Methods: In this retrospective study, 62 patients who underwent dilatation and angioplasty with DCB for lower limb atherosclerotic obliterans (ASO) were enrolled from September 2018 to June 2022 in Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School. Among them who aged (73.9±11.3) years, 37 were males and 25 were females. Patients were divided into two groups according to the condition of the lower extremity arteries after dilatation and angioplasty with DCB: recurrence group (n=26) and patency group (n=36). Logistic regression was used to analyze the factors associated with restenosis or occlusion of lower extremity arteries after dilatation and angioplasty with DCB. The predictive value of the AAC-8 score for restenosis or occlusion of the lower extremity arteries after dilatation and angioplasty with DCB was analyzed using the receiver operating characteristic curves (ROC curves). Results: The postoperative follow-up was 16.30 (10.97, 24.10) months in the patency group and 9.03 (6.98, 15.31) months in the recurrence group. The results of multifactorial logistic regression analysis showed that an elevated AAC-8 score (OR=1.388, 95%CI: 1.067-1.806, P=0.015) was an associated factor of restenosis or occlusion of the lower extremity arteries after dilatation and angioplasty with DCB. The ROC curve analysis showed that the area under the curve (AUC) of the AAC-8 score for predicting restenosis or occlusion of the lower extremity arteries after dilatation and angioplasty with DCB was 0.687 (95%CI: 0.550-0.824, P=0.013), with a cut-off value of 5.5 points, a sensitivity of 65.4% and a specificity of 69.5%. Conclusions: Elevated AAC-8 score is associated with restenosis or occlusion of the lower extremity arteries after dilatation and angioplasty with DCB. When the cut-off value is 5.5, the AAC-8 score predicts restenosis or occlusion of the lower extremity arteries after DCB dilation and angioplasty with a sensitivity of 65.4% and a specificity of 69.5%.

Coronary Angiography and Chronic Total Occlusion Angioplasty in a Patient With Situs Inversus from the Right Radial Approach

We present the case of a patient with known situs inversus referred for cardiac catheterization, which revealed a chronic total occlusion of the right coronary artery. Situs inversus, a rare congenital abnormality, is a term used to describe the inverted position of the chest and abdominal organs. Cardiac catheterization is rare in patients with this particular abnormality. It is important to customize techniques to engage coronary arteries and optimize guide support if percutaneous coronary intervention is required in these particular cases.

Retrograde distal access versus femoral access for below the knee angioplasty

BACKGROUND

The prevalence of peripheral artery disease (PAD) in the general population is about 12% to 14% and it increases with age. PAD increased from 164 million people in 2000 to 202 million people in 2010. More than two-thirds of people with PAD are based in low- or middle-income countries. Critical limb ischaemia (CLI) occurs in 1% to 2% of people with intermittent claudication over five years. One third of people with CLI have isolated below the knee (BTK) lesions. CLI and isolated BTK lesions are associated with a higher incidence of limb loss when compared with people with multilevel arterial disease. Endovascular procedures such as angioplasty (with or without stenting) are widely used to treat isolated BTK lesions, aiming to improve blood flow and limb salvage. The technical success of any angioplasty procedure depends on the ability to cross the target lesion. Failed attempts are underestimated in the literature and failures in the real world appear to be higher than reported. People with isolated BTK lesions undergoing angioplasty by conventional femoral access present a high failure rate to cross these lesions. Retrograde distal access may provide some advantages that can lead to successful crossing of the target lesion.

OBJECTIVES

To evaluate the benefits and harms of retrograde distal access versus conventional femoral access for people undergoing below the knee angioplasty.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 September 2022.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised controlled trials comparing people undergoing retrograde distal access versus people undergoing conventional femoral access (ipsilateral antegrade or contralateral retrograde) for BTK angioplasty.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed identified studies for potential inclusion in the review. We used standard methodological procedures in accordance with the Cochrane Handbook for Systematic Review of Interventions. Our primary outcomes were technical success of angioplasty procedure and major procedural complications. Our secondary outcomes were mortality rate, amputation-free survival, primary patency, minor procedural complications and wound healing. We planned to use GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We identified no randomised or quasi-randomised controlled trials that met the inclusion criteria.

AUTHORS' CONCLUSIONS

We identified no randomised or quasi-randomised controlled trials that compared retrograde distal access versus femoral access for BTK angioplasty. High-quality studies that compare retrograde distal access versus conventional femoral access for BTK angioplasty are needed.

Plaque features of the middle cerebral artery are associated with periprocedural complications of intracranial angioplasty and stenting

PURPOSE

The identification of plaque features in the middle cerebral artery (MCA) may help minimize periprocedural complications and select patients suitable for percutaneous transluminal angioplasty and stenting (PTAS). However, relevant research is lacking.

METHODS

We retrospectively included patients with symptomatic MCA stenosis who received PTAS. All patients underwent intracranial vessel wall MRI (VWMRI) before surgery. Periprocedural complications (PC) included ischemic and hemorrhagic stroke within 30 days. Stenosis location, MCA shape, plaque eccentricity and distribution, plaque thickness and length, and enhancement ratio were compared between patients with and without PC.

RESULTS

Sixty-six patients were included in the study, of which 12.1% (8/66) had PC. Of the eight patients with PC, seven (87.5%) had superior wall plaques. In the non-PC group (n = 58), nine (17%) patients had superior wall plaques. Compared with patients without PC, those with PC had more frequent superior wall plaques (17% vs 87.5%, p < 0.001) and s-shaped MCAs (19% vs 50%, p = 0.071), different stenosis locations (p = 0.012), thicker plaques (1.58 [1.35, 2.00] vs 1.98 [1.73, 2.43], p = 0.038), and less frequent inferior wall plaques (79.2% vs 12.5%, p < 0.001). Multivariate analysis showed that only the presence of superior wall plaques (OR = 41.54 [2.31, 747.54]) was independently associated with PC.

CONCLUSION

MCA plaque features were highly correlated with PC in patients with symptomatic MCA stenosis who underwent PTAS.

Contrast-enhanced ultrasound evaluation of renal perfusion before angioplasty and its predictive value for hypertension

BACKGROUND

Atherosclerotic renal artery stenosis (ARAS) is a common disease in the elderly population.

OBJECTIVE

The aim was to develop a contrast-enhanced ultrasound (CEUS)-based model for predicting post-angioplasty improvement in hypertension in patients with severe ARAS.

METHODS

Thirty-five patients with severe ARAS (⩾ 70%) were included in this study, and 42 renal arteries received percutaneous transluminal renal arterial stenting. An optimal integral formula was developed from pre-interventional color-coded duplex sonography (CCDS) and CEUS parameters using least absolute shrinkage and selection operator (LASSO) regression and receiver operating characteristic (ROC) curve analysis. A model for predicting short-term hypertension improvement was established using the integral formula and clinical risk factors. Bootstrapping was used for internal validation.

RESULTS

Two integral formulas, LASSO.CCDS and LASSO.CEUS, were established. ROC curves of the two integral formulas showed that LASSO.CEUS was the better formula for predicting hypertension improvement (AUC 0.816, specificity 78.6%). Univariate and multivariate regression analyses showed that duration of hypertension (OR 0.841, P= 0.027), diabetes (OR = 0.019, P= 0.010), and LASSO.CEUS (OR 7.641, P= 0.052) were predictors of short-term hypertension improvement after interventional therapy. Using LASSO.CEUS combined with clinical risk factors, the following prediction model was established: logit (short-term improvement in hypertension) = 1.879-0.173 × hypertension duration - 3.961 × diabetes + 2.034 × LASSO.CEUS (AUC 0.939).

CONCLUSIONS

The model established using CEUS parameters and clinical risk factors could predict hypertension improvement after interventional therapy, but further research and verification are needed.

An unusual spontaneous recanalization by multiple palmar arteriovenous connections of a chronically occluded radiocephalic hemodialysis fistula

Preservation of a vascular access is crucial in the management of hemodialysis patients. In this regard, percutaneous transluminal angioplasty (PTA) is an effective tool if performed after an adequate understanding of preliminary fistulograms. The present case showed a chronic dysfunction of a radial-cephalic arteriovenous fistula (AVF) due to arterial occlusion and partially relieved by the spontaneous development of multiple small arteriovenous connections in the palmar region of the hand. This dense network had been so far able to ensure a sufficient retrograde blood flow for an effective hemodialytic performance. The angioplasty of the post-anastomotic stenotic segment of the radial artery was effective in restoring this neoformed AVF patency.

Trans-radial Angioplasty of Anomalous Origin of Right Coronary Artery: A Single-Centre Experience

Successful percutaneous coronary intervention (PCI) to anomalous coronary arteries is technically challenging, particularly through transradial route. The application of appropriate techniques and devices may help overcome these challenges. The objective of this study is to explore the technical and procedural challenges in percutaneous coronary intervention (PCI) of anomalous origin of right coronary artery (AORCA) through the trans-radial route. This prospective study consisted of 25 consecutive patients who underwent PCI for an angiographically significant stenosis in AORCA from November 2017 to May 2019 at Ibrahim Cardiac Hospital & Research Institute (ICHRI). Demographic details and procedural data including numbers of catheters used, access, hardware, techniques, duration of procedure, volume of contrast and complications were recorded and statistically analyzed. The origin of AORCA was 48.0% each from the right and left coronary sinus, with 4.0% arising from the ascending aorta. Among those of right coronary sinus origin, superior take off was 83.3% and inferior take-off was 8.3%, with a further 8.3% originating from the left main, with a common origin with the left anterior descending (LAD) artery, from right coronary sinus. The mean age was 55.8±7.5 years. Diabetics were 84.0%, hypertensive 88.0%, dyslipidemic 68.0% and 20.0% had a history of smoking. Percutaneous coronary intervention (PCI) was performed successfully in 100.0% cases. Transradial access was the default route for coronary angiography in all cases. Angioplasty was performed trans-radially in 92.0% and trans-femoral in 8.0%, for two cases requiring switch over from radial to femoral route. The average number of guide catheters used was (2.0±1.0), (range: 1-4). The guide catheter hooked the coronary ostium selectively in 32.0%, off ostium in 56.0% and deep intubation was done in 12.0% cases. Anchoring wire to enhance guide support was used in 12.0%. 6 Fr guide extension catheter Guidezilla was used in 8.0% cases. The average duration of the procedure was 39.4 (range; 15-90) minutes, the average volume of contrast used was 67.0 (range: 30-150) ml. Average stent length was 28.6 (range; 12-43) mm. For PCI, Judkin's left (JL) and Judkin's Right (JR) were most commonly used guides (36.0% and 28.0% respectively), followed by multipurpose angled (MPA) guide (12.0%). The majority of the lesions stented were of ACC/AHA classification of type B (48.0%) followed by type A (36.0%) and type C (16.0%). Thrombus extraction was performed in a single case. One case was complicated by coronary artery dissection. PCI of AORCA through transradial route is technically challenging but feasible with a reasonable amount of contrast and radiation, and appropriate use of guides and techniques. Proper localization of ostium and selection of suitable guide is the key to success, aided by additional devices in the armamentarium of interventional cardiology such as guide extension catheter and anchoring wires.

The outcome of sharp recanalization of chronic central venous occlusions in patients undergoing hemodialysis

BACKGROUND

Patients on hemodialysis are particularly vulnerable to central venous occlusion (CVO). Endovascular treatment has gained wide acceptance for the treatment of CVO. However, difficulties in crossing the occluded segment can be encountered during conventional endovascular management. Sharp recanalization has been adopted when conventional endovascular methods could not recanalize the obstructed region. This study aimed to assess the outcome of the sharp venous recanalization technique with angioplasty and stenting in the treatment of CVO in Egyptian patients undergoing hemodialysis.

METHODS

This retrospective study is based on data from a prospectively maintained department database of patients under regular hemodialysis who underwent the sharp venous recanalization technique for CVO. Routinely, the patients were followed up at 3, 6, and 12 months with a clinical examination. The primary outcomes were technical success and primary patency. Secondary outcomes included complication rates and clinical success.

RESULTS

This study included 40 patients. Thirty-six patients (90%) achieved technical and clinical success. Seven patients (17.5%) had immediate postoperative complications. Four cases had minor complications (10%) and three patients had major complications (7.5%): hemothorax in two patients (5.1%) and pneumothorax in one patient (2.6%). At the 1-year follow-up, reintervention was required in nine patients (22.5%), with primary patency rate of 77.5% and a secondary patency rate of 100%.

CONCLUSIONS

Sharp recanalization offers a solution for patients undergoing hemodialysis who developed CVO and failed to be recanalized using the conventional endovascular method. It offered promising technical success, clinical improvement, and good primary patency rates.

Sirolimus-loaded exosomes as a promising vascular delivery system for the prevention of post-angioplasty restenosis

Restenosis remains the main reason for treatment failure of arterial disease. Sirolimus (SIR) as a potent anti-proliferative agent is believed to prevent the phenomenon. The application of exosomes provides an extended-release delivery platform for SIR intramural administration. Herein, SIR was loaded into fibroblast-derived exosomes isolated by ultracentrifugation. Different parameters affecting drug loading were optimized, and exosome samples were characterized regarding physicochemical, pharmaceutical, and biological properties. Cytotoxicity, scratch wound assays, and quantitative real-time PCR for inflammation- and migration-associated genes were performed. Restenosis was induced by carotid injury in a rat carotid model and then exosomes were locally administered. After 14 days, animals were investigated by computed tomography (CT) angiography, morphometric, and immunohistochemical analyses. Western blotting confirmed the presence of specific protein markers in exosomes. Characterization of empty and SIR-loaded exosomes verified round and nanoscale structure of vesicles. Among prepared formulations, desired entrapment efficiency (EE) of 76% was achieved by protein:drug proportion of 2:1 and simple incubation for 30 min at 37 °C. Also, the optimal formulation released about 30% of the drug content during the first 24 h, followed by a prolonged release for several days. In vitro studies revealed the uptake and functional efficacy of the optimized formulation. In vivo studies revealed that %restenosis was in the following order: saline > empty exosomes > SIR-loaded exosomes. Furthermore, Ki67, alpha smooth muscle actin (α-SMA), and matrix metalloproteinase (MMP) markers were less expressed in the SIR-exosomes-treated arteries. These findings confirmed that exosomal SIR could be a hopeful strategy for the prevention of restenosis.

Long-term patency of aorto-biiliac endoprosthesis for critical lower limb ischaemia in Takayasu arteritis after complicated angioplasty with a drug-coated balloon: Effect of dual antiplatelet therapy combined with tocilizumab

Takayasu arteritis is a chronic granulomatous vasculitis of unknown aetiology affecting the aorta and its major branches. Critical limb ischaemia may occur and eventually require surgical intervention. Surgical outcomes are influenced by disease activity, age, and comorbidities. We report a 43-year-old woman with Takayasu arteritis and stenosis of the left common iliac artery and occlusion of the left external iliac artery with limiting vascular claudication, who underwent angioplasty of the iliac artery with drug-eluting stent while being treated with infliximab. The artery ruptured a week later but was contained by the ilio-psoas muscle. She required subsequent stent placement to correct the lesion. Treatment comprised aspirin and clopidogrel, and the biological was switched to monthly intravenous tocilizumab. During an 8-year follow-up, serial imaging examinations showed a patent aorto-biiliac endoprosthesis, without evidence of thrombosis or restenosis. Clinically, the patient denies vascular claudication and pulses remain palpable in the left lower limb. This case highlights the risks inherent to these procedures in patients with large artery vasculitis and reinforces that the effectiveness of endovascular intervention can be increased by detailed preoperative evaluation, associated with a drug strategy including immunomodulatory and antiplatelet therapy as directed by the multispecialty team. Periodic imaging examinations are required because of the reported high rate of restenosis.

Comparison of drug-coated balloon with conventional balloon for angioplasty in symptomatic intracranial atherosclerotic stenosis

BACKGROUND

Drug-coated balloon (DCB) angioplasty has been studied for reducing the occurrence of restenosis after treatment for intracranial atherosclerotic stenosis (ICAS), but no comparison has been published of the use of drug-coated and non-coated balloons in angioplasty for ICAS. We aim to compare the safety and efficacy of DCB angioplasty with conventional balloon (CB) angioplasty for the treatment of symptomatic ICAS.

METHODS

One hundred cases with symptomatic ICAS treated with DCB (n=49) and CB (n=51) angioplasty were retrospectively analyzed. 1:1 propensity score matching (PSM) was completed to eliminate bias in the patients selected for further analysis. The periprocedural events and follow-up outcomes between the two groups were compared.

RESULTS

There were 32 cases in each group after PSM. Technical success (<50% residual stenosis) was achieved in 30 cases (93.8%) in the DCB group and in 28 cases (87.5%) in the CB group. The rates of stroke or mortality within 30 days were 3.1% in the DCB group and 6.3% in the CB group (p=1). The incidence of restenosis in the DCB group (6.3%) was significantly lower than that in the CB group (31.3%) (p=0.01).

CONCLUSIONS

Compared with CB angioplasty, DCB angioplasty can effectively reduce the incidence of restenosis. Further studies are needed to validate the role of DCB angioplasty in the management of symptomatic ICAS.

Prevention of in-stent restenosis with drug-eluting balloons in patients with postirradiated carotid stenosis accepting percutaneous angioplasty and stenting

OBJECTIVE

To investigate the technical safety and outcome of in-stent restenosis (ISR) prevention with drug-eluting balloon (DEB) in patients with postirradiated carotid stenosis (PIRCS) undergoing percutaneous angioplasty and stenting (PTAS).

METHODS

Between 2017 and 2021, we prospectively recruited patients with severe PIRCS for PTAS. They were randomly separated into two groups based on endovascular techniques performed with and without DEB. Preprocedural and early postprocedural (within 24 hours) MRI, short-term ultrasonography (6 months after PTAS), and long-term CT angiography (CTA)/MR angiography (MRA), 12 months after PTAS, were performed. Technical safety was evaluated based on periprocedural neurological complications and the number of recent embolic ischemic lesions (REIL) in the treated brain territory on diffusion-weighted imaging of early postprocedural MRI.

RESULTS

Sixty-six (30 with and 36 without DEB) subjects were enrolled, with one failure in techniques. For 65 patients in the DEB versus conventional groups, technical neurological symptoms within 1 month (1/29 (3.4%) vs 0/36; P=0.197) and REIL numbers within 24 hours (1.0±2.1 vs 1.3±1.5; P=0.592) after PTAS showed no differences. Peak systolic velocity (PSVs) on short-term ultrasonography was significantly higher in the conventional group (104.13±42.76 vs .81.95±31.35; P=0.023). The degree of in-stent stenosis (45.93±20.86 vs 26.58±8.75; P<0.001) was higher, and there were more subjects (n=8, 38.9% vs 1, 3.4%; P=0.029) with significant ISR (≥ 50%) in the conventional group than in the DEB group on long-term CTA/MRA.

CONCLUSIONS

We observed similar technical safety of carotid PTAS with and without DEBs. The number of cases of significant ISR were fewer and the degree of stenosis of ISR was less in primary DEB-PTAS of PIRCS than for conventional PTAS in the 12-month follow-up.

Unusual approach to popliteal vein bypass graft stenosis following failed angioplasty in popliteal entrapment syndrome

Popliteal artery entrapment syndrome (PAES) is where the popliteal artery is compressed-typically by the medial head of the gastrocnemius muscle. PAES is typically treated surgically with popliteal artery release with or without bypass. Graft stenosis is a recognised complication of vein grafts. These are normally treated endovascularly. Endarterectomy of venous graft stenosis may be a useful tool in selected cases, where an endovascular approach was unsuccessful. Long-term follow-up of graft stenosis endarterectomy will allow us to determine effectiveness of this method of treatment where other options have failed.

Conventional Transseptal Puncture for Left Atrial Appendage Occlusion: a multicentre randomized controlled trial

AIMS

This study was performed to compare the usability, efficiency, and safety of a modified angioplasty guidewire-assisted transseptal puncture (TSP) technique vs. the conventional approach in facilitating access into the left atrium during left atrial appendage occlusion (LAAO) procedures for the treatment of atrial fibrillation.

METHODS AND RESULTS

The ADVANCE-LAAO trial (Angioplasty Guidewire-Assisted vs. Conventional Transseptal Puncture for Left Atrial Appendage Occlusion) was an investigator-initiated, prospective, multicentre, randomized controlled trial (NCT05125159). Patients with atrial fibrillation who underwent LAAO were prospectively enrolled from four centres and randomly assigned to an angioplasty guidewire-assisted TSP group (n = 131) or to a conventional Brockenbrough needle TSP group (n = 132). The primary endpoint was the one-time success rate of TSP. We also analysed the TSP procedure time, failure rate of the assigned TSP type, radiation dose, contrast dose, and procedural complications in both groups. All patients in the guidewire-assisted group underwent successful TSP, whereas five in the standard conventional group switched to the guidewire-assisted approach. The guidewire-assisted puncture improved the one-time success rate (92.4 vs. 77.3%, P = 0.001), shortened the TSP procedure time (109.2 ± 48.2 vs. 120.5 ± 57.6 s, P = 0.023), and tended to have a higher rate of good coaxial orientation of the sheath with the left atrial appendage during the LAAO procedure (66.4 vs. 54.5%, P = 0.059). No TSP-related complications occurred in the guidewire-assisted TSP group, whereas two complications occurred in the conventional TSP group. There was no significant difference in the failure rate of the assigned TSP type, the total procedure time, the total radiation dose, the rate of successful LAAO implantation, or the procedural complication rate between the two groups (all P > 0.05).

CONCLUSION

This study confirmed that angioplasty guidewire-assisted puncture can effectively improve the success rate of TSP during LAAO procedures. This novel technique has high potential for application in interventional therapies requiring TSP.

Angiographic Predictors of Viability During Intervention for a ST Elevation Myocardial Infarction

Objectives

This study aimed to identify angiographic features that would predict myocardial viability after coronary intervention for ST elevation myocardial infarction (STEMI).

Methods

This retrospective study included patients who attended Sultan Qaboos University Hospital, Muscat, Oman, between January and December 2019 with a STEMI.

Results

A total of 72 patients (61 male; mean age = 54.9 ± 12.7 years) were included in the study; 11 patients had evidence of non-viability on echocardiography. There were 13 patients with viable myocardium and 3 with non-viable myocardium who had a myocardial blush grade (MBG) of 2 or lower. Similarly, 10 patients with viability and 1 with non-viable myocardium had thrombolysis in myocardial infarction (TIMI) flow of 2 or lower in the infarct related artery (IRA). However, none of these were statistically significant. The TIMI flow in the IRA at the end of the procedure correlated with the MBG.

Conclusion

There were no clear angiographic features during primary angioplasty that could predict myocardial viability.

Finite element analysis of the interaction between high-compliant balloon catheters and non-cylindrical vessel structures: towards tactile sensing balloon catheters

Aiming for sensing balloon catheters which are able to provide intraoperative information of the vessel stiffness and shape, the present study uses finite element analysis (FEA) to evaluate the interaction between high-compliant elastomer balloon catheters with the inner wall of a non-cylindrical-shaped lumen structure. The contact simulations are based on 3D models with varying balloon thicknesses and varying tissue geometries to analyse the resulting balloon and tissue deformation as well as the inflation pressure dependent contact area. The wrinkled tissue structure is modelled by utilizing a two-layer fibre-based Holzapfel-Gasser-Ogden constitutive model and the model parameters are adapted based on available biomechanical data for human urethral vessel samples. The balloon catheter structure is implemented as a high-compliant hyper-elastic silicone material (based on polydimethylsiloxane (PDMS)) with a varying catheter wall thickness between 0.5 and 2.5 µm. Two control parameters are introduced to describe the balloon shape adaption in reaction to a wrinkled vessel wall during the inflation process. Basic semi-quantitative relations are revealed depending on the evolving balloon deformation and contact surface. Based on these relations some general design guidelines for balloon-based sensor catheters are presented. The results of the conducted in-silico study reveal some general interdependencies with respect to the compliance ratio between balloon and tissue and also in respect of the tissue aspect ratio. Further they support the proposed concept of high-compliant balloon catheters equipped for tactile sensing as diagnosis approach in urology and angioplasty.

Resolute onyx stent more effective than wingspan stent at preventing procedural complications and long-term restenosis

BACKGROUND AND PURPOSE

Angioplasty and stenting is a treatment option for patients with medically refractory symptomatic intracranial atherosclerotic disease (sICAD). Currently the Wingspan Stent System (WSS) is the only FDA approved device for this indication. We find the Resolute (R) Onyx Stent, a drug-eluting balloon mounted stent (DES), a better alternative to the WSS for treatment of sICAD. Herein, we present our findings comparing the two stents based on our single center experience.

METHODS

A prospectively maintained neuro-endovascular databased was queried for patients between January 2013 to June 2021. Inclusion criteria for patients included sICAD with failed medical management, and intracranial stenting with either R-Onyx DES or WSS, including patients treated within 7 days of their last stroke. Primary outcomes were assessed via the occurrence of ischemic or hemorrhagic stroke or death within 72 h of the procedure. Secondary outcomes consisted of recurrent stroke or significant in-stent restenosis evaluated by a clinical or angiographic follow-up at 6 months.

RESULTS

A total of 184 patients, average age 61.26 (SD = 12.53) (44% women), were eligible for analysis with 58 having R-onyx DES and 126 having WSS. Within 72 h, the primary outcome was observed in 1.7% (n = 1) of patients in the R-onyx DES group and 6.3% (n = 8) of patients in the WSS group (p = 0.089). Among 41 angiographic and clinical follow-ups in the R-onyx DES group, none had a recurrent stroke, while among 101 patients who had follow-up in the WSS group, 8.9% (n = 9) had a stroke (p = 0.024). At a 6-month angiographic follow-up, there was a significantly lower rate of symptomatic in-stent restenosis among the R-onyx DES group with 1.7% (n = 1) compared with 21.4% (n = 27) in the WSS group (p = 0.0003).

CONCLUSION

R-onyx DES is more effective than WSS in treating sICAD with low rates of periprocedural complications and long-term strokes and symptomatic in-stent restenosis. Future prospective randomized multicenter trials are needed.

Atherosclerotic renovascular disease: a clinical practice document by the European Renal Best Practice (ERBP) board of the European Renal Association (ERA) and the Working Group Hypertension and the Kidney of the European Society of Hypertension (ESH)

Atherosclerotic renovascular disease (ARVD) is the most common type of renal artery stenosis. It represents a common health problem with clinical presentations relevant to many medical specialties and carries a high risk for future cardiovascular and renal events, as well as overall mortality. The available evidence regarding the management of ARVD is conflicting. Randomized controlled trials failed to demonstrate superiority of percutaneous transluminal renal artery angioplasty (PTRA) with or without stenting in addition to standard medical therapy compared with medical therapy alone in lowering blood pressure levels or preventing adverse renal and cardiovascular outcomes in patients with ARVD, but they carried several limitations and met important criticism. Observational studies showed that PTRA is associated with future cardiorenal benefits in patients presenting with high-risk ARVD phenotypes (i.e. flash pulmonary oedema, resistant hypertension or rapid loss of kidney function). This clinical practice document, prepared by experts from the European Renal Best Practice (ERBP) board of the European Renal Association (ERA) and from the Working Group on Hypertension and the Kidney of the European Society of Hypertension (ESH), summarizes current knowledge in epidemiology, pathophysiology and diagnostic assessment of ARVD and presents, following a systematic literature review, key evidence relevant to treatment, with an aim to support clinicians in decision making and everyday management of patients with this condition.

[Establishment and Validation of an Animal Model of Abdominal Aortic Aneurysm in Beagles Through Vascular Patch Angioplasty and Elastase Infusion]

Objective

To evaluate the effect of an abdominal aortic aneurysm (AAA) animal model established in beagles by way of vascular patch angioplasty combined with elastase infusion.

Methods

A total of 60 beagle dogs were included in this study. Among them, 10 beagles were assigned to a control group to obtain normal abdominal aortic wall tissue, while the other 50 underwent vascular patch angioplasty combined with elastase infusion in order to establish the AAA disease model. In order to evaluate the outcome of modeling, abdominal vascular ultrasonography was performed 14 days after the modeling surgery was performed and ultrasound and computed tomographic angiography (CTA) were performed 28 days after the modeling surgery. The criterion for evaluating modeling success is that the maximum diameter of the abdominal aortic aneurysm is 50% greater than the diameter of the normal abdominal aorta below the renal artery. A total of 20 beagles of the modelling group and 5 control beagles were sacrificed 35 days after the modeling surgery and infrarenal abdominal aortic wall tissues were harvested. Then, hematoxylin and eosin (H&E) staining, Masson's trichrome staining, and elastic van Gieson (EVG) staining were conducted to observe the pathology features of abdominal aortic wall tissues.

Results

A total of 50 beagles underwent the AAA modeling procedures, with the average operative and anesthesia time being (119.4±18.9) and (137.4±15.8) minutes, respectively, the average blood loss volume being (43.6±7.7) mL, the average abdominal aorta block time being (39.7±5.3) minutes during the modeling surgery, and the average abdominal aorta diameter measured during the surgery being (6.5±0.4) mm. Intraoperative mortality was 0%. Mortality within 30 days after the surgery was 2% (1 out of the 50 beagles). Postoperative ultrasound and CTA results revealed that the success rate of AAA modeling was 100%. Pathology examination suggested that the animal model rather successfully simulated the pathophysiologic changes associated with human AAA in regard to the morphological and pathological changes.

Conclusion

Vascular patch angioplasty combined with elastase infusion can be used to successfully establish AAA model in beagles. The AAA modeling method described in our report demonstrates stability and reliability in aneurysm formation effect and the surgical procedures are easy to replicate. The method integrates the advantages of previous animal modeling methods and can be used to study the pathogenesis of AAA.

Ischemic stroke secondary to radiation-induced carotid artery stenosis

INTRODUCTION

Large vessel vasculopathy, such as carotid stenosis, has been shown to be a side effect of radiotherapy (RT) and has received increasing attention especially in recent decades with the improvement of RT technology. These injuries can lead to a higher risk of cerebrovascular events such as ischemic stroke. The management of these lesions may be performed with surgical repair but also with endovascular technique.

OBSERVATION

A 61-year-old man was admitted to the emergency department for an acute ischemic stroke. He was treated 16years prior for laryngeal tumor for which he had received 23 sessions of radiation therapy at the dose of 60Gy per session. The CT scan showed a radiation-induced stenosis of the right internal carotid artery with thrombosis of the right anterior cerebral artery and the right middle cerebral artery. The patient was treated with angioplasty of the right internal carotid artery with good outcome.

CONCLUSION

Radiation-induced vasculopathy of the carotid artery has gained relevance in patients with head and neck neoplasms. These vascular lesions are associated with the risk of late cerebrovascular events.

Temporal Trends and Contemporary Regional Variation in Management of Patients Undergoing Carotid Endarterectomy

INTRODUCTION

The purpose of this study is to investigate regional variation and temporal trends in seven quality metrics amongst CEA patients: discharge on antiplatelet after CEA; discharge on statin after CEA; protamine administration during CEA; patch placement at conventional CEA site; continued statin usage at the time of most recent follow-up; continued antiplatelet usage at the time of most recent follow-up; and smoking cessation at the time of long term follow up.

METHODS

There are 19 de-identified regions within the VQI database in the United States. Patients were placed into one of three temporal eras based on the time of their CEA: 2003-2008; 2009-2015; and 2016-2022. We first investigated temporal trends across the seven quality metrics for all regions combined on a national basis. The percentage of patients in each time era with the presence/absence of each metric was identified. Chi-squared testing was performed to confirm statistical significance of the differences across eras. Next, analysis was performed within each region and within each time metric. We separated out the 2016-2022 patients within each region to serve as the status of each metric application in the most modern era. We then compared the frequency of metric non-adherence in each region utilizing Chi-squared testing.

RESULTS

There was statistically significant improvement in achievement of all seven metrics between the initial 2003-2008 era and the modern 2016-2022 era. The most marked change in practice pattern was noted for lack of protamine usage at surgery (decreased from 48.7% to 25.9%), discharge home postoperatively without statin (decreased from 50.6% to 15.3%), and lack of statin usage confirmed at time of most recent long term follow up (decreased from 24% to 8.9%). Significant regional variation exists across all metrics (P < .01 for all). Lack of patch placement at the time of conventional endarterectomy ranges from 1.9% to 17.8% across regions in the modern era. Lack of protamine utilization ranges from 10.8% to 49.7%. Lack of antiplatelet and statin at the time of discharge varies from 5.5% to 8.2% and 4.8% to 14.4% respectively. Adherence to the various measures at the time of most recent follow up are more tightly aligned across regions with ranges of: 5.3% to 7.5% for lack of antiplatelet usage; 6.6% to 11.7% lack of statin utilization; and 13.3 to 15.4% for persistent smoking.

CONCLUSIONS

Prior studies and societal initiatives on CEA documenting the beneficial effects of patch angioplasty, protamine use at surgery, smoking cessation, antiplatelet utilization and statin compliance have positively impacted adherence to these measures over time. In the modern 2016-2022 era the widest regional variation is noted in patch placement, protamine utilization and discharge medications allowing individual geographic areas to identify areas for potential improvement via internal VQI administrative feedback.

The effect of telephone counseling based on Orem's model on adherence to treatment and resilience of patients with coronary angioplasty: a randomized clinical trial

BACKGROUND

This study aimed to determine the effect of telephone counseling based on Orem's Self-Care Model on adherence to treatment and resilience of patients with coronary angioplasty.

METHODS

This randomized clinical trial was performed on 80 patients in the Cardiac Intensive Care Unit of Shiraz University of Medical Sciences. Patients were randomly divided into two groups of 40 (intervention and control). Questionnaires on adherence to treatment of chronic patients and resilience for patients with cardiovascular and respiratory diseases were filled out before and 8 weeks after the intervention. In the intervention group, the telephone call schedule consisted of three calls per week for 8 weeks.

RESULTS

Before the intervention, no significant difference was found between the groups about adherence to treatment and resilience. However, after the intervention, a significant difference was found between the groups as to adherence to treatment and resilience (P < 0.001).

CONCLUSION

Nursing consultation using telephone calls based on Orem's model increases the adherence to treatment and resilience of patients undergoing coronary angioplasty. Telephone counseling can help the patients adhere to their treatment plans and develop resilience skills.

Quantitative assessment of angioplasty-induced vascular inflammation with 19F cardiovascular magnetic resonance imaging

BACKGROUND

Macrophages play a pivotal role in vascular inflammation and predict cardiovascular complications. Fluorine-19 magnetic resonance imaging (19F MRI) with intravenously applied perfluorocarbon allows a background-free direct quantification of macrophage abundance in experimental vascular disease models in mice. Recently, perfluorooctyl bromide-nanoemulsion (PFOB-NE) was applied to effectively image macrophage infiltration in a pig model of myocardial infarction using clinical MRI scanners. In the present proof-of-concept approach, we aimed to non-invasively image monocyte/macrophage infiltration in response to carotid artery angioplasty in pigs using 19F MRI to assess early inflammatory response to mechanical injury.

METHODS

In eight minipigs, two different types of vascular injury were conducted: a mild injury employing balloon oversize angioplasty only (BA, n = 4) and a severe injury provoked by BA in combination with endothelial denudation (BA + ECDN, n = 4). PFOB-NE was administered intravenously three days after injury followed by 1H and 19F MRI to assess vascular inflammatory burden at day six. Vascular response to mechanical injury was validated using X-ray angiography, intravascular ultrasound and immunohistology in at least 10 segments per carotid artery.

RESULTS

Angioplasty was successfully induced in all eight pigs. Response to injury was characterized by positive remodeling with predominantly adventitial wall thickening and concomitant infiltration of monocytes/macrophages. No severe adverse reactions were observed following PFOB-NE administration. In vivo 19F signals were only detected in the four pigs following BA + ECDN with a robust signal-to-noise ratio (SNR) of 14.7 ± 4.8. Ex vivo analysis revealed a linear correlation of 19F SNR to local monocyte/macrophage cell density. Minimum detection limit of infiltrated monocytes/macrophages was estimated at approximately 410 cells/mm2.

CONCLUSIONS

In this proof-of-concept study, 19F MRI enabled quantification of monocyte/macrophage infiltration after vascular injury with sufficient sensitivity. This may provide the opportunity to non-invasively monitor vascular inflammation with MRI in patients after angioplasty or even in atherosclerotic plaques.

Updated trends in percutaneous renal arteriography among radiologists and other specialties

PURPOSE

Prior studies have demonstrated an overall decline in percutaneous renal artery angioplasty with and without stenting from 1988 to 2009. We evaluated the recent utilization trends in percutaneous renal arteriography (PTRA) among radiologists and non-radiologist providers from 2010 to 2018.

METHODS

Data from the 2010-2018 nationwide Medicare Part B fee-for-service database were used to tabulate case volumes for PTRA. Annual utilization rates per 10,000 Medicare beneficiaries were calculated and aggregated based on physician specialty: radiologists, cardiologists, vascular surgeons, general surgeons, or others.

RESULTS

From 2010 to 2018, the overall utilization rate of PTRA markedly declined (-72% change; from 15.5 to 4.3 cases per 10,000 Medicare beneficiaries). Proportionally, the cardiologist share of PTRA saw the greatest decline, falling from 74% market share in 2010 (11.4/15.5 cases) to only 36% market share in 2018 (1.6/4.3 cases). The market share of PTRA performed by radiologists grew from 12% market share in 2010 (1.9/15.5 cases) to 28% in 2018 (1.2/4.3 cases); despite this, the absolute number of PTRA performed by radiologists saw a smaller decline over this period (-34%; 1.9 to 1.2 cases).

CONCLUSION

The total utilization rates of PTRA in the Medicare population has continued to decline from 2010 to 2018, likely due to clinical trials suggesting limited efficacy of angioplasty and stenting in the treatment of renovascular hypertension and other factors such as declining reimbursement. The overall and per-specialty rates continue to decline, reflecting an overarching trend away from procedural management of renovascular hypertension.

[Angioplasty with Sirolimus-coated Balloon: the New Standard in the Treatment of PAD?]

Endovascular revascularisation with paclitaxel-coated balloons for the treatment of peripheral artery disease has been shown to be an effective therapeutic option in the femoropopliteal segment. The antiproliferative effect of paclitaxel prevents restenosis. In contrast, in the infra-popliteal segment, the evidence is currently conflicting. However, there is evidence of an increased risk of amputation and mortality from the second year after angioplasty with paclitaxel-coated balloons. This may be due to a dose-dependent cytotoxic effect of paclitaxel. Sirolimus-coated balloons might therefore be an alternative because sirolimus is cytostatic rather than cytotoxic and thus has a wide therapeutic window.Three single-arm pilot studies (50, 25, and 50 patients, respectively) show that angioplasty with sirolimus-coated balloons leads to comparable results to those reported from paclitaxel-coated balloons (late lumen loss at 6 months: 0.29 mm; primary patency at 12 months: femoropopliteal 79%-82%, infra-popliteal 59%; freedom from target lesion revascularization at 12 months: femoropopliteal 83%-94%, infra-popliteal 86%). Randomised controlled trials comparing standard balloon angioplasty and paclitaxel-coated balloons for the treatment of intermittent claudication or chronic limb-threatening ischaemia are active and are expected to provide efficacy and safety results from mid 2024.This review presents the results of pilot studies on angioplasty with sirolimus-coated balloons for the treatment of peripheral artery disease and reviews currently ongoing randomised controlled trials.

Comparison of carotid endarterectomy and repeated carotid angioplasty and stenting for in-stent restenosis (CERCAS trial): a randomised study

BACKGROUND AND AIM

In-stent restenosis (ISR) belongs to an infrequent but potentially serious complication after carotid angioplasty and stenting in patients with severe carotid stenosis. Some of these patients might be contraindicated to repeat percutaneous transluminal angioplasty with or without stenting (rePTA/S). The purpose of the study is to compare the safety and effectiveness of carotid endarterectomy with stent removal (CEASR) and rePTA/S in patients with carotid ISR.

METHODS

Consecutive patients with carotid ISR (≥80%) were randomly allocated to the CEASR or rePTA/S group. The incidence of restenosis after intervention, stroke, transient ischaemic attack myocardial infarction and death 30 days and 1 year after intervention and restenosis 1 year after intervention between patients in CEASR and rePTA/S groups were statistically evaluated.

RESULTS

A total of 31 patients were included in the study; 14 patients (9 males; mean age 66.3±6.6 years) were allocated to CEASR and 17 patients (10 males; mean age 68.8±5.6 years) to the rePTA/S group. The implanted stent in carotid restenosis was successfully removed in all patients in the CEASR group. No clinical vascular event was recorded periproceduraly, 30 days and 1 year after intervention in both groups. Only one patient in the CEASR group had asymptomatic occlusion of the intervened carotid artery within 30 days and one patient died in the rePTA/S group within 1 year after intervention. Restenosis after intervention was significantly greater in the rePTA/S group (mean 20.9%) than in the CEASR group (mean 0%, p=0.04), but all stenoses were <50%. Incidence of 1-year restenosis that was ≥70% did not differ between the rePTA/S and CEASR groups (4 vs 1 patient; p=0.233).

CONCLUSION

CEASR seems to be effective and save procedures for patients with carotid ISR and might be considered as a treatment option.

TRIAL REGISTRATION NUMBER

NCT05390983.

Objective Performance Goals Based on a Systematic Review and Meta-Analysis of Clinical Outcomes for Bare-Metal Stents and Percutaneous Transluminal Angioplasty for Hemodialysis-Related Central Venous Obstruction

PURPOSE

To use safety and efficacy outcomes following treatment with percutaneous transluminal angioplasty (PTA) and/or stent placement for thoracic central venous obstruction in hemodialysis-dependent patients to establish objective performance goals (OPGs).

METHODS

A systematic literature review and meta-analysis were conducted for articles published between January 1, 2000, and August 31, 2021. Efficacy outcomes included primary patency rates at 6 and 12 months, and safety outcomes included adverse events (AEs) categorized as access loss, procedure-related AEs, and serious AEs (SAEs). OPGs were derived from the upper and lower bounds of the 95% confidence intervals for primary patency and SAE rates.

RESULTS

Of 66 articles reviewed, 17 met the inclusion criteria (PTA, n = 4; stent placement, n = 5; PTA/stent, n = 8). The 6- and 12-month primary patency rates for PTA were 50.9% and 36.7%, respectively. Based on these findings, the proposed 6- and 12-month primary patency OPGs identifying superiority against PTA were 66.5% and 52.6%, respectively, and those for noninferiority were 39.0% and 25.7%, respectively. For stent placement, the 6- and 12-month primary patency rates were 69.7% and 47.9%, respectively. The proposed 6- and 12-month primary patency OPGs identifying superiority were 82.1% and 64.1%, respectively, and those for noninferiority were 59.3% and 35.8%, respectively. SAE rates for PTA and stent placement were 3.8% and 8.1%, respectively. Proposed safety OPGs for noninferiority versus superiority for PTA and stent placement were 10.1% versus 1.4% and 13.6% versus 4.8%, respectively.

CONCLUSION

The OPGs derived from real-world studies of PTA and stent placement may serve as a benchmark for future interventions indicated for this patient population.

Budd-Chiari Syndrome-A Single Center Experience From the United Kingdom

Pediatric Budd-Chiari syndrome (BCS) is a rare cause of portal hypertension and liver disease in Europe and North America. In order to understand the long-term effect of radiological intervention on BCS we performed a single center retrospective review. Fourteen cases were identified; 6 of 14 (43%) had a congenital thrombophilia with many having multiple prothrombotic mutations. Two were managed with medical anticoagulation alone and two required super-urgent transplant for acute liver failure. The remaining 10 of 14 (71%) underwent radiological intervention: 1 of 14 thrombolysis, 5 of 14 angioplasty, and 4 of 14 transjugular intrahepatic portosystemic shunt (TIPS). Six of 14 (43%) patients required repeat radiological intervention (1 angioplasty, 5 TIPS) but none required surgical shunts or liver transplantation for chronic liver disease. The time between diagnosis and treatment did not predict the need for repeat radiological intervention. These data show that radiological intervention can be highly effective, and reduces the need for surgery, though it requires specialist multidisciplinary teams for monitoring.

Early inadequate venous flow volume after technically successful balloon angioplasty of radiocephalic arteriovenous fistula: causes and follow-up results

OBJECTIVE

The objective of this study was to investigate the causes of inadequate venous flow volume, which may lead to re-dysfunction in the early period after technically successful percutaneous transluminal angioplasty (PTA), and the results after one-week follow-up with or without medical treatment.

PATIENTS AND METHODS

This prospective case-control study included dysfunctional radiocephalic arteriovenous fistula (AVF) cases treated with PTA between December 2021-2022. After PTA, a residual stenosis of less than 30% was considered technically successful. Based on venous flow volume measured 1-2 hours after angioplasty, post-procedural doppler ultrasound (DUS) classified patients as cases (≤400 mL/min) or controls (>400 mL/min). Between groups, pre-post and control DUS parameters were compared. The correlation between fistulography lesion measurements and DUS values was investigated. The pre-procedural DUS resistive index (RI) cut-off value was determined to discriminate groups.

RESULTS

A total of 42 patients, 21 cases and 21 controls, were included in the study. Before PTA, 67% of cases had total venous thrombosis, and 71% of controls had stenosis. Lesion measurements and residual stenosis were similar between groups (p>0.05). After PTA, 48% of cases had a free-floating thrombus in the vein, and 10% had a peri-vein hematoma. In pre-procedural DUS, flow volume was the only spectral analysis parameter paired between groups (p=0.057). In post-procedural and control DUS, controls had higher peak systolic velocity (PSV), end-diastolic velocity (EDV), and flow volume, whereas cases had a higher RI (p<0.05). Lesion length and degree of stenosis correlated positively with pre-procedural RI in both groups (p<0.05). The pre-procedural RI cut-off of 0.76 discriminated groups with 76% sensitivity, 67% specificity, 70% positive predictive value (PPV), and 74% negative predictive value (NPV).

CONCLUSIONS

Low venous flow after PTA has been primarily associated with free-floating thrombi. Routine post-procedural DUS detects low venous flow, high RI, and small thrombi, providing evidence to initiate medical treatment that may prevent early AVF re-dysfunction.

One-step solution for angioplasty, low-profile stent delivery, and intrastent dilation using a dual-lumen angioplasty balloon microcatheter: technical advances, limitations, outcomes, and literature review

Dual-lumen angioplasty balloon microcatheters make it possible to perform percutaneous transluminal angioplasty (PTA), low-profile stent delivery, and intrastent dilation without the microcatheter exchange technique. This technique has shown many advantages in recent years. We reviewed the techniques and applications in different intracranial vascular diseases and summarized the outcomes and indications. Gateway dual-lumen angioplasty balloon was used for PTA and kept in situ. Stent was delivered and deployed via Gateway microcatheter. Intrastent balloon dilation was performed after stent deployment. We retrospectively reviewed the clinical and imaging data, surgical procedures, technique application, and follow-up outcomes of six patients treated from 2020 to 2023. Neurological function was assessed by the modified Rankin scale (mRS). A literature review was performed using PubMed. All seven patients (4 males, 3 females; mean age, 62.6 ± 6.9 years) underwent percutaneous transluminal angioplasty and stent deployment using a balloon microcatheter. There was one middle cerebral artery (MCA) aneurysm with parent artery stenosis, two MCA dissections, and four intracranial atherosclerotic stenoses (ICASs). The mRS score was 0 in five patients and 1 in two patients. Cerebral dissection with stenosis is the best indication, and its application in stent-assisted aneurysm coiling is inappropriate. This technique is controversial in ICAS treatment.