[Transumbilical cholecystectomy using hybrid technique: a new promising approach]

OBJECTIVES

The use of magnets in transumbilical cholecystectomy improves triangulation and achieves optimal critical view. However, the attraction between magnets can cause collisions and their management complicates the procedure, and this will become more important in children. In order to simplify the technique, we have developed a hybrid model with a single magnet.

MATERIAL AND METHODS

Retrospective review of cholecystectomies performed in our department between June 2011 and July 2012. The technique combines the use of a magnet and a curved grasper. Through transumbilical incision, a 12 mm trocar and another flexible 5 mm are placed. Laparoscope with working channel uses the 12 mm trocar. The magnet is introduced to the abdominal cavity using the working channel to provide cephalad retraction of gallbladder fundus. Curved grasper is run by the assistant to mobilize the infundibulum across flexible trocar. The surgeon operates through the working channel of the laparoscope.

RESULTS

Twenty-six patients were operated on with this technique. Mean age was 14 years (4-17) and weight 50 kg (18-90). 65% were girls. The mean operative time was 62 minutes (50-70) and the critical view of safety was achieved in all cases. Instrumental collision or hands crossing were not seen. There were no intraoperative or postoperative complications. The hospital stay was 1.4 +/- 0.6 days and the median follow-up 201 days (42-429).

CONCLUSIONS

The hybrid technique, combining magnet and a curved grasper, simplifies transumbilical surgery. It seems a feasible and safe for transumbilical cholecystectomy and potentially reproducible.

Do Men and Women Respond Differently to Percutaneous Renal Artery Interventions?

Background: Women have higher risk of contrast-induced nephropathy than men. The purpose of this study was to determine the relative impact of gender on long-term renal function after percutaneous renal interventions (PRI). Methods and Results: We included all patients undergoing PRI. Men (n = 72) and women (n = 28) had similar age, men had more diabetes, coronary and peripheral artery disease, higher serum creatinine and similar glomerular filtration rate (GFR), and prevalence of chronic kidney disease (CKD) stage ≥3 when compared with females. At follow-up, men had a significant improvement in GFR and systolic blood pressure, while females did not. The presence of severe CKD and male gender were the only predictors of long-term GFR improvement. Conclusion: Male patients and patients with poor baseline renal function showed an important benefit with PRI, suggesting that it is not too late for renal revascularization if properly indicated.

Value of coronary stenotic flow velocity acceleration in prediction of angiographic restenosis following balloon angioplasty

INTRODUCTION

Quantitative angiographic assessment after balloon angioplasty is a poor predictor of immediate and long-term outcome. However, the measurement of blood flow velocity during angioplasty has been proved clinically useful.

AIMS

To analyse the value of the maximal stenotic flow velocity and the presence of stenotic flow velocity acceleration (aSV) for the long-term outcome after balloon angioplasty.

METHODS AND RESULTS

Patients undergoing single lesion angioplasty within the DEBATE trial were included. aSV was defined as acceleration in the stenotic coronary flow velocity >50% baseline velocity assessed at a reference site of the target vessel. After balloon angioplasty diameter stenosis, minimal lumen diameter (MLD) and coronary flow velocity reserve were similar between the aSV (n=54) and non-aSV group (n=125). At follow-up, the aSV group had a higher restenosis rate (52% vs 30%, P=0.006) The presence of aSV was the strongest independent predictor of restenosis (OR 3.08, 95% CI 1.35 to 7.05, P=0.008). The best predictive cut-off value of SV was 101cm.s(-1) (sensitivity of 46%, specificity of 81%, positive predictive value of 85% and a negative predictive value of 58%).

CONCLUSION

Following angioplasty, SV appears to be exquisitely sensitive to the changes experienced at the treated area without depending on the status of the microcirculation.

Coronary flow velocity reserve after percutaneous interventions is predictive of periprocedural outcome

BACKGROUND

Because heterogeneous results have been reported, we assessed coronary flow velocity changes in individuals who underwent percutaneous transluminal coronary angioplasty (PTCA) and examined their impact on clinical outcome.

METHODS AND RESULTS

As part of the Doppler Endpoints Balloon Angioplasty Trial Europe (DEBATE) II study, 379 patients underwent Doppler flow-guided angioplasty. All patients were evaluated according to their coronary flow velocity reserve (CFVR) results (> or =2.5 or < 2.5) at the end of the procedure. A CFVR < 2.5 after angioplasty was associated with an elevated baseline blood flow velocity in both the target artery and reference artery. CFVR before PTCA and CFVR in the reference artery were independent predictors of an optimal CFVR after balloon angioplasty (CFVR before PTCA: odds ratio [OR], 2.26; 95% confidence interval [CI], 1.57 to 3.24; CFVR in reference artery: OR, 1.90; 95% CI, 1.21 to 2.98; both P<0.001) and stent implantation (before PTCA: OR, 2.54; 95% CI, 1.47 to 4.36; reference artery: OR, 1.97; 95% CI, 1.07 to 3.87; both P<0.05). A low CFVR at the end of the procedure was an independent predictor of major adverse cardiac events (MACE) at 30 days (OR, 4.71; 95% CI, 1.14 to 25.92; P=0.034) and at 1 year (OR, 2.06; 95% CI, 1.16 to 3.66; P=0.014). After excluding MACE at 30 days, no difference in MACE at 1 year was observed between the patients with and without a CFVR < 2.5 at the end of the procedure.

CONCLUSIONS

A low postprocedural CFVR was associated with a worse periprocedural outcome (which was related to microcirculatory disturbances), but there was no significant difference at late follow-up.

Flow velocity and predictors of a suboptimal coronary flow velocity reserve after coronary balloon angioplasty

AIMS

This study was conducted to analyse flow velocity parameters and predictors of a suboptimal coronary flow reserve (<2.5) following balloon angioplasty.

METHODS

Two hundred and twenty-five patients underwent sequential intracoronary Doppler as part of the DEBATE I study. Of these, 183, with complete angiography and Doppler at the 6-month follow-up, were included. Univariate and multivariate logistic analysis was performed to identify independent predictors of post-procedural suboptimal coronary flow reserve, defined as coronary flow reserve <2.5.

RESULTS

Forty-eight per cent (n=88) of the patients achieved a suboptimal coronary flow reserve. These patients had higher baseline velocities (cm.s(-1)) before balloon angioplasty (18+/-9 vs 14+/-6, P=0.004), after balloon angioplasty (22+/-11 vs 14+/-5, P<0.001) and at follow-up (19+/-9 vs 16+/-6, P=0.011) than the optimal coronary flow reserve group. Although the suboptimal group had lower hyperaemic velocities (cm.s(-1)) after balloon angioplasty than the optimal group (42+/-17 vs 49+/-16, P=0.008), these velocities became similar at follow-up. Increasing age (odds ratio, OR 1.071, P=0.0002), female gender (OR 2.52, P=0.014) and increasing pre-procedural baseline average peak velocities (OR 1.056, P<0.001) were found to be independent predictors of a suboptimal coronary flow reserve following balloon angioplasty.

CONCLUSION

A suboptimal coronary flow reserve was associated with (1) a chronically elevated baseline average peak velocity (2) a transient deficit in the hyperaemic average peak velocity (3) the elderly, and female gender.

Uncomplicated moderate coronary artery dissections after balloon angioplasty: good outcome without stenting

OBJECTIVE

To study the relation between moderate coronary dissections, coronary flow velocity reserve (CFVR), and long term outcome.

METHODS

523 patients undergoing balloon angioplasty and sequential intracoronary Doppler measurements were examined as part of the DEBATE II trial (Doppler endpoints balloon angioplasty trial Europe). After successful balloon angioplasty, patients were randomised to stenting or no further treatment. Dissections were graded at the core laboratory by two observers and divided into four categories: none, mild (type A-B), moderate (type C), severe (types D to F). Patients with severe dissections (n = 128) or without available reference vessel CFVR (n = 139) were excluded. The remaining 256 patients were divided into two groups according to the presence (group A, n = 45) or absence (group B, n = 211) of moderate dissection.

RESULTS

Following balloon angioplasty, there was no difference in CFVR between the two groups. At 12 months follow up, a higher rate of major adverse cardiac events was observed overall in group A than in group B (10 (22%)v 23 (11%), p = 0.041). However, the risk of major adverse events was similar in the subgroups receiving balloon angioplasty (group A, 6 (19%) v group B, 16 (16%), NS). Among group A patients, the adverse events risk was greater in those randomised to stenting (odds ratios 6.603v 1.197, p = 0.046), whereas there was no difference in risk if the group was analysed according to whether the CFVR was < 2.5 or ⩾ 2.5 after balloon angioplasty.

CONCLUSIONS

Moderate dissections left untreated result in no increased risk of major adverse cardiac events. Additional stenting does not improve the long term outcome.

Uncomplicated moderate coronary artery dissections after balloon angioplasty: good outcome without stenting

OBJECTIVE

To study the relation between moderate coronary dissections, coronary flow velocity reserve (CFVR), and long term outcome.

METHODS

523 patients undergoing balloon angioplasty and sequential intracoronary Doppler measurements were examined as part of the DEBATE II trial (Doppler endpoints balloon angioplasty trial Europe). After successful balloon angioplasty, patients were randomised to stenting or no further treatment. Dissections were graded at the core laboratory by two observers and divided into four categories: none, mild (type A-B), moderate (type C), severe (types D to F). Patients with severe dissections (n = 128) or without available reference vessel CFVR (n = 139) were excluded. The remaining 256 patients were divided into two groups according to the presence (group A, n = 45) or absence (group B, n = 211) of moderate dissection.

RESULTS

Following balloon angioplasty, there was no difference in CFVR between the two groups. At 12 months follow up, a higher rate of major adverse cardiac events was observed overall in group A than in group B (10 (22%) v 23 (11%), p = 0.041). However, the risk of major adverse events was similar in the subgroups receiving balloon angioplasty (group A, 6 (19%) v group B, 16 (16%), NS). Among group A patients, the adverse events risk was greater in those randomised to stenting (odds ratios 6.603 v 1.197, p = 0.046), whereas there was no difference in risk if the group was analysed according to whether the CFVR was < 2.5 or >/= 2.5 after balloon angioplasty.

CONCLUSIONS

Moderate dissections left untreated result in no increased risk of major adverse cardiac events. Additional stenting does not improve the long term outcome.

Value of coronary stenotic flow velocity acceleration on the prediction of long-term improvement in functional status after angioplasty

BACKGROUND

The coronary flow velocity acceleration at the stenotic site (SVA), defined as a > or = 50% increase in resting stenotic velocity when compared with the reference segment, has been shown to be highly sensitive and specific for the diagnosis of a hemodynamically significant stenosis. In this study, we describe the value of postprocedural SVA for the prediction of a lack of improvement in functional activity at long-term follow-up balloon angioplasty (BA).

METHODS

We investigated the improvement in functional activity in patients undergoing single native vessel angioplasty and intracoronary Doppler (before BA, after BA, and again at 6-month follow-up) as part of the Doppler Endpoints Balloon Angioplasty Trial Europe (DEBATE) I trial. Lack of improvement was defined as no change in Duke Activity Status Index (DASI) at 6-month follow-up, whereas SVA was defined as > or = 50% elevation in resting velocity at the treated area compared with the distal measurement.

RESULTS

SVA was found more frequently in patients without improvement in DASI (45% vs 31%, P =.03). Similar percent diameter stenosis and coronary flow velocity reserve were observed in patients with and those without improvement in DASI at follow-up. By multivariate regression analysis, the presence of SVA (P = .029; odds ratio, 1.97; 95% confidence interval, 1.07 to 3.63) and an elevated DASI at baseline (P < .001; odds ratio, 1.05; 95% confidence interval, 1.03 to 1.07) were associated with a lack of improvement at follow-up.

CONCLUSIONS

The detection of SVA was associated with failure of improvement in functional activity at follow-up after coronary intervention.

Comparison of mechanical properties of the left ventricle in patients with severe coronary artery disease by nonfluoroscopic mapping versus two-dimensional echocardiograms

In 40 patients, we compared linear local shortening assessed with nonfluoroscopic electromechanical mapping as a function of regional wall motion with echocardiographic data in a subset of patients with severe coronary artery disease and subsequently decreased left ventricular function. Our study showed that nonfluoroscopic electromechanical mapping can accurately assess regional wall motion. In addition, this study showed a significant decrease in unipolar voltages among segments with declining regional function.

Evaluation of left ventricular volumes and ejection fraction with a nonfluoroscopic endoventricular three-dimensional mapping technique

BACKGROUND

Recently, a novel nonfluoroscopic 3-dimensional electromechanical mapping technique was introduced in the clinical arena. Although initial in vitro and in vivo studies suggested the reliability of the system in volumetric and hemodynamic evaluation of the left ventricle, no validation in human beings has been performed.

METHODS

A nonfluoroscopic electromechanical mapping (NOGA, Biosense-Webster) procedure was performed in 44 patients. All patients received a contrast left ventriculogram during the same session. Volumetric (end-diastolic [EDV] and end-systolic volumes [ESV]) and hemodynamic (left ventricular ejection fraction [LVEF] and stroke volume) parameters of both systems were compared.

RESULTS

Two uncomplicated pericardial effusions occurred with the first-generation mapping catheters. No procedural complications were noted with the new-generation mapping catheters. Significant correlations were found between mapping-derived and ventriculography-based measurements for both ESV (r = 0.67, P <.001) and LVEF (r = 0.78, P <.001). Absolute volumes, however, were only comparable for ESV (46.6 +/- 25.3 mL vs 48.8 +/- 37.0 mL, respectively; P =.13) but differed greatly for LVEF (35% +/- 13% vs 65% +/- 19%, respectively; P <.001), EDV (69.1 +/- 28.6 mL vs 125.9 +/- 53.4 mL, respectively; P <.001) and stroke volume (22.4 +/- 9.9 mL vs 77.1 +/- 33.7 respirations; P <.001). Moreover, Bland-Altman analysis showed the clinical noninterchangeability between these techniques for the measurement of hemodynamic parameters.

CONCLUSION

Measurement of hemodynamic parameters with nonfluoroscopic mapping of the left ventricle is feasible and safe. The system provides data that strongly correlate but that are in clinical disagreement with angiographic data. Therefore the interchangeability of these techniques may be questioned.

Positive geometric vascular remodeling is seen after catheter-based radiation followed by conventional stent implantation but not after radioactive stent implantation

BACKGROUND

Recent reports demonstrate that intracoronary radiation affects not only neointimal formation but also vascular remodeling. Radioactive stents and catheter-based techniques deliver radiation in different ways, suggesting that different patterns of remodeling after each technique may be expected.

METHODS AND RESULTS

We analyzed remodeling in 18 patients after conventional stent implantation, 16 patients after low-activity radioactive stent implantation, 16 patients after higher activity radioactive stent implantation, and, finally, 17 patients who underwent catheter-based radiation followed by conventional stent implantation. Intravascular ultrasound with 3D reconstruction was used after stent implantation and at the 6-month follow-up to assess remodeling within the stent margins and at its edges. Preprocedural characteristics were similar between groups. In-stent neointimal hyperplasia (NIH) was inhibited by high-activity radioactive stent implantation (NIH 9.0 mm(3)) and by catheter-based radiation followed by conventional stent implantation (NIH 6.9 mm(3)) compared with low-activity radioactive stent implantation (NIH 21.2 mm(3)) and conventional stent implantation (NIH 20.8 mm(3)) (P:=0.008). No difference in plaque or total vessel volume was seen behind the stent in the conventional, low-activity, or high-activity stent implantation groups. However, significant increases in plaque behind the stent (15%) and in total vessel volume (8%) were seen in the group that underwent catheter-based radiation followed by conventional stent implantation. All 4 groups demonstrated significant late lumen loss at the stent edges; however, edge restenosis was seen only in the group subjected to high-activity stent implantation and appeared to be due to an increase in plaque and, to a lesser degree, to negative remodeling.

CONCLUSIONS

Distinct differences in the patterns of remodeling exist between conventional, radioactive, and catheter-based radiotherapy with stenting.

Angiographic and clinical outcome of mild to moderate nonocclusive unstented coronary artery dissection and the influence on coronary flow velocity reserve. The Debate I Study Group

Limited data are available regarding the angiographic healing rate and physiologic impact of coronary artery dissections. Therefore, we studied the impact of coronary dissections on coronary flow velocity and outcome as well as their healing rate at 6-month follow-up balloon angioplasty. Of 297 patients who underwent balloon angioplasty, 225 underwent intracoronary Doppler measurements and 184 had Doppler and angiographic assessment at 6-month follow-up. Dissections were scored by an independent core lab (Cardialysis BV) and divided in 4 groups: mild (types A to B), moderate (type C), severe (D to F), and patients without dissections. Severe dissections (types D to F) were excluded from the analysis. Clinical, angiographic, and Doppler data were compared among the remaining 3 patient groups. From the 67 dissections detected after balloon angioplasty, only 3 (4.5%) remained unhealed at follow-up. Immediately after balloon angioplasty, the moderate dissection group was associated with a lower coronary flow velocity reserve than the patients with mild (2.16 +/- 0.60 vs 2.82 +/- 1.00, p = 0.037) or no dissections (2.16 +/- 0.60 vs 2.71 +/- 0.88, p = 0.046), respectively. In addition, higher recurrence of angina at 30 days was observed in the moderate group rather than in the mild group (5 [50%] vs 8 [16%], p = 0.0160) and in the patients without dissections (11 [12%], p = 0.007). After standard balloon angioplasty, the occurrence of unhealed dissections is a rare phenomenon. An impaired coronary flow reserve was observed after the development of nonocclusive type C dissections, which was associated with a worse short-term outcome.

Acute changes of global and regional left ventricular function immediately after direct myocardial revascularization

Direct myocardial revascularization (DMR) has been proposed to treat patients with severe coronary artery disease who are not amenable for classical revascularization techniques such as percutaneous coronary intervention (PCI) or bypass surgery (CABG). Although recent reports suggest its benefit in alleviating patients' complaints in the long term, there is still a paucity of data on the immediate impact on regional and global myocardial functioning following this treatment. In this overview we discuss our own experience and provide a summary of other data currently available.

Saphenous vein graft disease treated with the Wiktor Hepamed stent: procedural outcome, in-hospital complications and six-month angiographic follow-up

OBJECTIVES

To evaluate the effectiveness of electively placed heparin-coated stents in the treatment of coronary saphenous vein bypass grafts with de novo lesions less than 15 mm in diameter in a prospective study with all eligible consecutive patients presenting to Middelheim Hospital, Antwerp, Belgium between September 1997 and August 1998.

PATIENTS AND METHODS

Fifty patients with 53 lesions were studied. Anginal class, risk factors, quantitative coronary angiographic measurements pre- and postprocedure, procedural outcome, in-hospital events, clinical status on discharge, and six-month clinical and angiographic follow-up (in 48 patients) were recorded. All patients received acetylsalicylic acid and ticlopidine, unless known intolerance was present.

RESULTS

On average, 1.1 stents/patient were placed in very old saphenous vein grafts (11. 7+/-3.9 years). Procedural success was 98%. Only two non-Q wave myocardial infarctions (MIs) occurred, with no Q-wave MIs and no deaths during hospital stay. Length of hospital stay was short (2. 4+/-1.7 days), and 96% of patients were free of angina on discharge. At six-months' follow-up, two patients had died, one of whom died of a noncardiac cause. One patient suffered a non-Q wave MI. At six months, 86% of patients were free from angina. Minimal luminal diameter decreased from 1.14 mm before to 3.33 mm after stenting and to 2.52 mm at six months. Restenosis was present in 22% of patients (21.6% of lesions).

CONCLUSIONS

In a selected population with coronary saphenous vein bypass graft disease, Wiktor heparin-coated stents can be delivered with an excellent periprocedural outcome. Six-month outcome appears favourable with a low recurrence of angina (18%) and a low rate of angiographic restenosis (21.6%).

Three-dimensional intravascular ultrasonic volumetric quantification of stent recoil and neointimal formation of two new generation tubular stents

Currently, several different designs of coronary stents are available. However, only a few of the new generation stents have been investigated in large randomized trials. Mechanical behavior of first-generation stents (Palmaz-Schatz, Gianturco-Roubin) may not be applied to the new designs. We investigated the chronic mechanical behavior (recoil) of 2 stents recently approved by the Food and Drug Administration (MULTILINK and NIR). Forty-eight patients with single-stent implantation (23 MULTILINK and 25 NIR) were assessed by means of volumetric 3-dimensional intravascular ultrasound analysis after the procedure and at 6-month follow-up. In addition, volumetric assessment of neointimal formation was performed. No significant chronic stent recoil was detected in both groups (delta MULTILINK stent volume: +5.6+/-41 mm3 [p = NS] and delta NIR stent volume + 2.1+/-26 mm3 [p = NS]). A similar degree of neointimal formation at 6 months was observed between the 2 stents (MULTILINK 46+/-31.9 mm3 vs NIR 39.9+/-27.6 mm3, p = NS). In conclusion, these 2 second-generation tubular stents did not show chronic recoil and appeared to promote similar proliferative response after implantation in human coronary arteries.

Elective Wiktor GX stenting for symptomatic stenosis in old aortocoronary saphenous vein bypass grafts: the Antwerp experience

PURPOSE

We compared initial outcome, peri-procedural complications and long-term clinical follow-up of elective Wiktor GX stent implantation in severely narrowed vein grafts to a historic register of elective angioplasties in saphenous vein grafts in the same center.

METHODS

Eighty-one consecutive patients with angina and a history of coronary artery bypass grafting (CABG), all received elective angioplasty (PTCA) of the diseased graft; we described them as group P. The next 38 consecutive patients were treated with elective angioplasty and Wiktor Stent implantation, followed by one month ticlopidine; they were called group S.

CONCLUSION

This retrospective study suggests that elective Wiktor stenting in old saphenous vein graft stenosis, in combination with one month ticlopidine, leads to: 1) a better angiographic result, with reduction of peri-procedural complications; and 2) a lower incidence of recurrent angina, need for invasive or surgical re-intervention, myocardial infarction and death during follow-up.