Carotid Interventions for Women: The Hazards and Benefits

The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients. Stroke and cerebrovascular disease are prevalent in women. There are inherent biological and other differences in men and women, which affect the manifestations and outcome of stroke, with women experiencing worse disability and higher mortality following ischemic stroke than men. Due to the underrepresentation of female patients in most clinical trials, the ability to make firm but alternative recommendations for women specifically on the management of carotid stenosis is challenging. Although some data suggest that women might have worse periprocedural outcomes as compared to men following all carotid revascularization procedures, there is also an abundance of data to support a similar risk for carotid procedures in men and women, especially with carotid endarterectomy and transcarotid artery revascularization. Therefore, the indications for carotid revascularization are the same in women as they are in men. The choice of a carotid revascularization procedure in women is based upon the same factors as in men and requires careful evaluation of a particular patient’s risk profile, anatomic criteria, plaque morphology, and medical comorbidities that might favor one technique over the other. When performing carotid revascularization procedures in women, tailored techniques and procedures to address the small diameter of the female artery are warranted.

262 An attractive endovascular strategy for combined—aneurysmal and stenotic—coronary artery disease

In patients undergoing coronary angiography the coexistence of aneurysmal and stenotic lesions in adjacent segments of the same epicardial vessel is uncommon. We describe a rare case of single-vessel coronary artery disease (CAD) in a 70-year-old male, presenting with progressive effort-induced angina of 3-months’ evolution. The coronary angiogram revealed a critical calcified stenosis in the context of diffuse ectasia affecting the right coronary artery (RCA). Our report focuses on a complex revascularization procedure using the self-expandable Carotid Wallstent. Highlighting the importance of a multidisciplinary approach, we provide an original and effective endovascular solution for an unusual pathological angiographic finding, which could be of potential interest for interventional cardiologists.

Early and midterm outcomes of hybrid first line treatment in patients with chronic limb threatening ischemia

Objective The aim of the study was to evaluate the outcome of first line hybrid treatment in patients with chronic limb threatening ischemia (CLTI) and to evaluate possible predictors of primary patency (PP) loss and limb clinical improvement (LCI). Methods This was a retrospective non-randomized study. All patients underwent one-stage hybrid common femoral artery (CFA) endarterectomy combined with an inflow and/or outflow endovascular revascularization procedure. Demographic, clinical, and lesion characteristics for each patient were reported. Primary patency analysis was performed using Kaplan–Meier life tables, and univariate and multivariate analysis was used to assess possible predictors of PP loss and clinical improvement. Results Complete data were obtained from 132 patients. Patients were divided into two groups according to their Rutherford’s category (RC), group 1 (Rutherford 4) and group 2 (Rutherford 5 and 6). Technical success was 98%. The overall surgical peri-operative complication rate was 8%. At a mean follow-up of 32 ± 23 months, the rate of major adverse limb events (MALE) was 30%; only the rate of major amputation between two groups was significant statistically different ( p = .006). Group 1 had significantly lower amputation rate at 36 months ( p = .01). The presence of high iliac peripheral artery calcium scoring system (PACCS) grade (HR 9.43, 95% CI 2.40–36.9, p = .001), the poor run-off of leg vessels (HR 0.15, 95% CI 0.02–0.92, p = .04), and undergoing CFA endarterectomy combined with outflow endovascular revascularization procedure (HR 4.25, 95% CI 1.07–16.89, p = .04) were independent predictors of PP loss, while severe iliac artery stenosis (OR 0.09, 95% CI 0.02–0.32, p = <.001) and the presence of pre-operative patent leg vessels (OR 8.03, 95% CI 2015–29.95, p = .002) were the significant independent predictors of LCI. Conclusion The use of hybrid first line approach in patients with CLTI is a safe and feasible technique. From the analysis of the current study, it is clear that any effort should be made to achieve as many patency leg vessels as possible in order to obtain better and longer lasting clinical outcomes.

Acute hepatitis post arteriovenous graft thrombectomy of hemodialysis vascular access

The following paper reports the case of a woman on in-center hemodialysis through an arteriovenous graft, who attended with an acute vascular access thrombosis. Post percutaneous thrombectomy, the patient presented a rare case of self-limited acute hepatitis secondary to the revascularization procedure. We explain the probable trigger for this complication, its pathophysiology, management, and evolution.

MO103PREDICTION OF CARDIOVASCULAR OUTCOMES WITH PERIDIALYTIC, INTRADIALYTIC, SCHEDULED INTERDIALYTIC AND AMBULATORY BP RECORDINGS IN HEMODIALYSIS PATIENTS

Background and Aims Ambulatory-BP-monitoring (ABPM) is recommended for hypertension diagnosis and management in hemodialysis subjects due to high accuracy and strong associations with outcomes. The agreement and prediction of averaged intradialytic BP readings and home BP readings with ABPM and clinical outcomes is not known. This study assesses in parallel the association of pre-dialysis, intradialytic, scheduled interdialytic and ambulatory BP recordings with cardiovascular outcomes and mortality in this population. Method We prospectively followed for 49.1±25.6 months 242 hemodialysis patients with valid 48-hour ABPMs to examine the association of pre-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings, scheduled interdialytic BP (the average of out-of-dialysis day readings at 8:00 am and 8:00 pm) and 44-hour ambulatory BP with outcomes. The primary end-point was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary revascularization procedure or peripheral revascularization procedure. Results Cumulative freedom from the primary end-point was significantly lower with increasing 44-hour SBP (group 1, &lt;120 mmHg, 64.2%; group 2, ≥120 to &lt;130 mmHg 60.4%, group 3, ≥130 to &lt;140 mmHg 45.3%; group 4, ≥140 mmHg 45.5%; logrank-p=0.016). Similar were the results for intradialytic (logrank-p=0.039), intradialytic plus pre/post-dialysis (logrank-p=0.044), and scheduled interdialytic SBP (logrank-p=0.030), but not for pre-dialysis SBP (logrank-p=0.570). With group 1 as the reference group, the Hazard Ratios of the primary end-point showed a gradual increase with higher BP levels with all BP metrics, except pre-dialysis SBP. An inverse association of DBP levels with outcomes was shown with all BP metrics. Conclusion Averaged intradialytic and scheduled home BP measurements (but not pre-dialysis readings) display similar patterns of prognostic associations with 44-hour ambulatory BP in hemodialysis patients and represent valid metrics for hypertension management in these individuals.

Abstract P518: Intravascular Ultrasound Assisted Endovascular Revascularization in Patients With Subacute and Chronic Internal Carotid Artery Occlusions

Background: Revascularization of subacute or chronic internal carotid artery occlusion is technically feasible in some patients but carotid revascularization procedure needs to be optimized to improve the clinical success of the procedure. Objective: To describe our experience using intravascular ultrasound (IVUS) as adjunct to carotid revascularization procedure in patients with subacute or chronic internal carotid artery occlusion. Materials and Methods: Endovascular recanalization was attempted in 7 patients with symptomatic internal carotid artery occlusions between 3 and 11 days of symptoms onset. Distal protection device was deployed in all the patients followed by advancement of IVUS catheter (Eagle Eye Gold, 20 MHZ Digital, s5 Imaging System, Volcano Corp.) to obtain gray-scale and virtual histology (VH) images at regions of interest. IVUS images used to categorize occlusion content as: dark green- fibrous; yellow/green- fibrofatty; white- calcified; red- necrotic lipid core plaque on images. Intravascular thrombus was diagnosed an echolucent, homogeneous, well-delineated, diaphragm-like intraluminal structure. Results: The occlusion was recanalized successfully in all of 7 patients with median age 67.4±7.5 years. IVUS demonstrated intravascular thrombus in 5 of 7 patients. Fibrous and fibrofatty constituents of plaque were seen in 5 of the 7 patients in whom VH was done. Calcification and lipid necrotic core each were seen in 3 of 5 patients.5 patients with large thrombus burden on IVUS were treated using aspiration thrombectomy. Six of seven patients underwent stent placement and one patient underwent primary angioplasty. 5 of 7 patients had modified Rankin Scale of 0-2 at follow up (3 weeks to 4 months post procedure). Conclusions: IVUS provided valuable information to optimize carotid revascularization procedure in patients with subacute or chronic internal carotid artery occlusion.

Occipital artery to middle cerebral artery bypass in pediatric moyamoya disease: rescue therapy after failed revascularization

OBJECTIVEPatients with pediatric moyamoya disease (PMMD) showing recurrent symptoms or decreased cerebral blood flow after initial revascularization therapy may require additional revascularization to improve their clinical condition. The authors evaluated the clinical and hemodynamic benefits of an occipital artery (OA)–middle cerebral artery (MCA) bypass for patients with PMMD who have undergone an initial revascularization procedure.METHODSThe authors retrospectively identified 9 patients with PMMD who had undergone OA-MCA bypass between March 2013 and December 2017, and who had received a previous superficial temporal artery–MCA bypass. The following clinical data were collected: initial revascularization procedure, symptoms (presence or recurrence), pre- and postoperative cerebral blood flow and cerebrovascular reactivity (CVR) changes, posterior cerebral artery (PCA) stenosis, PCA-related and nonrelated symptoms, and latest follow-up.RESULTSPreoperatively, all patients (n = 9) suffered non–PCA-related recurrent symptoms, and 4 had PCA-related symptoms. At 1-year follow-up, all patients with PCA-related symptoms showed complete recovery. Additionally, 8 (89%) patients with non-PCA symptoms experienced improvement. Only 1 (11%) patient showed no improvement after the surgical procedure. The mean pre- and postoperative CVR values of the MCA territory were 14.8% and 31.3%, respectively, whereas the respective mean CVR values of the PCA territory were 22.8% and 40.0%.CONCLUSIONSThe OA-MCA bypass is an effective rescue therapy to improve the clinical condition and hemodynamic changes caused by PMMD in patients who experience recurrent symptoms after initial revascularization.