A clinical case of secondary hypertension in a young woman with coarctation of the aorta

The article presents a case of diagnosis and treatment of coarctation of the aorta in a 20-year-old woman, who previously received follow-up care with the diagnosis of hypertension. This case demonstrates the importance of qualitative examination of young patients with hypertension, including tonometry in the lower extremities and transthoracic echocardiography. The peculiarities of this clinical case encompass a rarer, isolated type of coarctation of the aorta and high physical fitness of the patient, which reduced doctors’ alertness regarding this anomaly. After surgical correction, a significant decrease in the blood pressure was achieved; however, such patients need longterm follow-up in order to detect complications, such as aneurysms, restenosis, or residual stenosis.

SIroliMus coated angioPlasty versus plain balloon angioplasty in the tREatment of dialySis acceSs dysfunctION (IMPRESSION): study protocol for a randomized controlled trial

Background Percutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain balloon angioplasty (PBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to PBA, concern over its safety profile has recently arisen after a reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus-coated balloon (SCB), has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. Methods/design This is an investigator-initiated, prospective, multicenter, double-blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to PBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or PBA at a 1:1 ratio, stratified by location of AVF and followed up for up to 1 year. The inclusion criteria include [1] adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula [2]; matured AVF, defined as being in use for at least 1 month prior to the angioplasty; and [3] successful angioplasty of the underlying stenosis with PBA, defined as less than 30% residual stenosis on digital subtraction angiography (DSA) and restoration of thrill in the AVF on clinical examination. The exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that requires treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary endpoint of the study is access circuit primary patency at 6 months. The secondary endpoints are target lesion primary patency; access circuit-assisted primary patency; access circuit secondary patency at 3, 6, and 12 months; target lesion restenosis rate at 6 months; total number of interventions; complication rate; and cost-effectiveness. The trial is supported by Concept Medical. Discussion This study will evaluate the clinical efficacy and safety of SCB compared to PBA in the treatment of AVF stenosis in hemodialysis patients. Trial registration ClinicalTrials.govNCT04409912. Registered on 1 June 2020

Long-term outcomes of angioplasty for pediatric renovascular hypertension: A single-center experience

Objectives We used single-center data to evaluate the long-term outcome of percutaneous transluminal angioplasty (PTA) for pediatric renovascular hypertension (RVH) and to analyze the factors that influence effectiveness. Methods We retrospectively evaluated 33 pediatric RVH patients (18 boys; mean age: 9.1 ± 4 years, range: 2–16) who underwent PTA from January 2007 to December 2019. 15 patients had Takayasu arteritis (TA) and 18 were non-TA. The median follow-up from the initial PTA was 69 months (range: 12–157; IQR: 25.5–89). Results The technical success rate of 52 PTA procedures was 90.4% in 33 children. Renal artery stents were implanted in two patients, external guidewires were used in two patients, and a drug-coated balloon was used in only one patient. The overall effective rate of PTA was 63.6%, including cured 39.4% and improved 24.2%, at the end of follow-up. Overall clinical outcomes were not statistically different between the TA and non-TA groups ( p = 0.316), nor were cure rates ( p = 0.072). 15 patients received reintervention due to restenosis after the first successful PTA; the interval was 2–56 months (median: 12 months). Four patients received reintervention due to a failed PTA. A total of four patients received open surgery. Binary logistics regression analysis showed that stenosis length and residual stenosis rate were strongly correlated with effective PTA ( p = 0.045, p = 0.044). Conclusions As a primary treatment for pediatric RVH, PTA can achieve satisfactory results, which are influenced by lesion length and residual stenosis rate.

Comparison of Doty and McGoon techniques for surgical reconstruction of congenital supravalvular aortic stenosis

Background: We aimed to compare the results of two surgical methods for the treatment of congenital supravalvular aortic stenosis. Methods: From May 2004 to January 2020, 29 patients underwent surgical repair for supravalvular aportic stenosis in a single centre. The perioperative evaluation of the patients was retrospectively reviewed. Results: Fifteen (51.7%) and 14 (48.2%) patients were treated with the Doty and the McGoon methods, respectively. The median age of our cohort was 4.5 (3.0–9.9) years. Ten (34.5%) patients had Williams–Beuren syndrome, and pulmonary stenosis was observed in 12 (41.3%) patients. The median follow-up time was 2.5 (0.7–7.3) years. On follow-up, five patients had residual stenosis with the McGoon technique and one with the Doty technique (p = 0.05). One patient died early in the post-operative period in the Doty group, and three patients were re-operated on due to restenosis in the McGoon group. Freedom from re-operation in the Doty group at 1, 3, 5, and 10 years was 100%. In the McGoon group, freedom from re-operation rates at the 1-, 3-, and 7-year follow-up were 100, 88.9, and 44.4%, respectively (p = 0.08). Conclusion: Our results with both surgical techniques suggest that supravalvular aortic stenosis can be treated with good results. The Doty method provided better relief for the supravalvular aortic segment, considering the residual stenosis and the re-operation rates.

Combined Anticoagulation and Antiaggregation in Acute Cervical Artery Dissection

Cervical artery dissection (CAD) is a frequent cause of stroke in young adults. Previous studies investigating the efficiency of anticoagulation (AC) versus antiplatelet therapy (AT) found an insignificant difference. We therefore retrospectively evaluated a combination of AC plus AT in patients with acute CAD regarding safety and efficacy. Twenty-eight patients with CAD and minor neurological symptoms/no major infarction received either single (n = 14) or dual AT (n = 14) combined with AC. Angiographic follow-up during hospitalization, 4-8 weeks and 3–6 months after CAD focused on occlusion, residual stenosis, and functional recanalization. Possible adverse events were surveyed. We compared the AC plus AT group to 22 patients with acute CAD treated with AC or AT. Compared to preceding AC-/AT-only studies, AC plus single or dual AT resulted in more frequent, faster recanalization. Frequency and severity of adverse events was comparable. No major adverse events or death occurred. Preceding works on conservative treatment of CAD are discussed and compared to this study. Considerations are given to pathophysiology and the dynamic of CAD. Combining AC plus AT in CAD may result in more reliable recanalization in a shorter time. The risk for adverse events appears similar to treatment with only AC or AT.

Comparative analysis of sequential pot-side-pot and kissing balloon techniques in patients with coronary bifurcation lesions treated with single stent strategy: propensity score analysis

Objectives It is unknown whether the novel re-POT technique is more effective than commonly preferred kissing balloon inflation (KBI) in patients with non-complex coronary bifurcation lesions (CBL) treated with single-stent strategy. Our aim was to compare the efficacy of re-POT and KBI techniques in one-stent strategy of non-complex CBL. Methods 283 patients were retrospectively analyzed (re-POT group, n=149; KBI group, n=134). Primary end-points of the study were defined as; in-hospital and 30-day mortality, contrast induced acute kidney injury (CI-AKI), stent thrombosis (ST), side branch (SB) dissection and need for SB stenting. Characteristics of patients at baseline were balanced by using propensity score inverse probability weighting (IPW). Results Procedure time (minute, 30.6±8.5 vs 34.3±11.6; p=0.003) and contrast volume (mL, 153.7±42.4 vs 171.1±58.2; p=0.004) were significantly lower in re-POT group. Besides, SB residual stenosis and number of patients with >50% SB residual stenosis remained significantly higher in re-POT group both in general and true bifurcation subgroup analysis (20.3±19.8% vs 16.5±16.4%, p=0.02; 11.9% vs 5.7%, p=0.01 and 24.1±23.2% vs 18.8±18.7%, p=0.03; 17.6% vs 6.6%, p=0.005; respectively). Combined clinical adverse outcomes were similar between groups. (Figure 1) SB dissection (10.2% vs 20.1%, p=0.001) and need for SB stenting (12.6% vs 19%, p=0.04) were reached statistically significance in KBI group after adjustment. (Figure 2) Conclusions Re-POT may be a simple and safe technique with a shorter procedure time and lower incidence of adverse events in non-complex CBL treated with single-stent strategy. FUNDunding Acknowledgement Type of funding sources: None. Adverse clinical outcomes; weighted

Multiple predictors of in-stent restenosis after stent implantation in symptomatic intracranial atherosclerotic stenosis

OBJECTIVE This study aimed to identify predictors of intracranial in-stent restenosis (ISR) after stent placement in symptomatic intracranial atherosclerotic stenosis (ICAS). METHODS The authors retrospectively collected data from consecutive patients who suffered from symptomatic ICAS and underwent successful stent placement in Beijing Tiantan hospital. Eligible patients were classified into “ISR,” “indeterminate ISR,” or “no-ISR” groups by follow-up digital subtraction angiography or CT angiography. A multivariate logistic regression model was used to explore the predictors of intracranial ISR after adjustments for age and sex. In addition, ISR and no-ISR patients were divided into two groups based on the strongest predictor, and the incidence of ISR, recurrent stroke, and symptomatic ISR was compared between the two groups. RESULTS A total of 511 eligible patients were included in the study: 80 ISR, 232 indeterminate ISR, and 199 no-ISR patients. Elevated high-sensitivity C-reactive protein (hs-CRP; odds ratio [OR] 4.747, 95% confidence interval [CI] 2.253–10.01, p < 0.001), Mori type B and C (Mori type B vs Mori type A, OR 3.119, 95% CI 1.093–8.896, p = 0.033; Mori type C vs Mori type A, OR 4.780, 95% CI 1.244–18.37, p = 0.023), coronary artery disease (CAD; OR 2.721, 95% CI 1.192–6.212, p = 0.017), neutrophil/lymphocyte ratio (NLR; OR 1.474 95% CI 1.064–2.042, p = 0.020), residual stenosis (OR 1.050, 95% CI 1.022–1.080, p = 0.001) and concurrent intracranial tandem stenosis (OR 2.276, 95% CI 1.039–4.986, p = 0.040) synergistically contributed to the occurrence of intracranial ISR. Elevated hs-CRP (hs-CRP ≥ 3 mg/L) was the strongest predictor for ISR, and the incidence of ISR in the elevated hs-CRP group and normal hs-CRP group (hs-CRP < 3 mg/L) was 57.14% versus 21.52%, respectively, with recurrent stroke 44.64% versus 16.59%, and symptomatic ISR 41.07% versus 8.52%. CONCLUSIONS Elevated hs-CRP level, NLR, residual stenosis, Mori type B and C, CAD, and concurrent intracranial tandem stenosis are the main predictors of intracranial ISR, and elevated hs-CRP is crucially associated with recurrent stroke in patients with symptomatic ICAS after intracranial stent implantation.

Association of residual stenosis after balloon angioplasty with vessel wall geometries in intracranial atherosclerosis

BackgroundPercutaneous transluminal balloon angioplasty (PTBA) may be an alternative treatment for patients with symptomatic intracranial atherosclerotic disease (ICAD) refractory to medical treatment. This study aimed to investigate the association of vessel wall geometric characteristics on high-resolution magnetic resonance vessel wall imaging (MR-VWI) with low residual stenosis in patients with ICAD after PTBA.MethodsPatients with symptomatic ICAD who underwent PTBA were prospectively and consecutively enrolled. High-resolution MR-VWI was performed before the PTBA. Vessel wall geometries of the target artery, including normalized wall index (NWI: wall area/vessel area × 100%), normalized wall thickness index (NWTI: mean wall thickness/vessel radius × 100%), and remodeling index (RI) were evaluated. Low residual stenosis was defined as postprocedural stenosis degree ≤50%. Perioperative complications including symptomatic ischemic stroke/intracranial hemorrhage, death, and arterial dissection were recorded. The baseline characteristics, vessel wall geometries, and perioperative complications were compared between the patients with low residual stenosis and high residual stenosis.ResultsAmong 60 patients prospectively enrolled, low residual stenosis was achieved in 46 participants (77%). Three patients (5%) suffered from symptomatic ischemic stroke within 30 days. Multivariable logistic regression showed that a lower NWI and lower NWTI were associated with low residual stenosis after PTBA (adjusted OR 0.57, 95% CI 0.35 to 0.94, p=0.027; and adjusted OR 0.88, 95% CI 0.80 to 0.98, p=0.015).ConclusionsLower NWI and NWTI of the target artery on high-resolution MR-VWI were associated with low residual stenosis in patients with ICAD after PTBA.

SIroliMus Coated angioPlasty Versus Plain Balloon Angioplasty in the tREatment of dialySis acceSs dysfunctION (IMPRESSION): Study Protocol for a Randomized Controlled Trial

BackgroundPercutaneous transluminal angioplasty is the current standard treatment for arteriovenous fistula (AVF) stenosis. The mid- and long-term patency with plain old balloon angioplasty (POBA) is however far from satisfactory. While paclitaxel-coated balloon angioplasty has been shown to be superior to POBA, concern over its safety profile has recently arisen after reported possible increased mortality risk with a meta-analysis of large lower limb studies. An angioplasty balloon with a new type of drug coating, the sirolimus coated balloon (SCB) has been proven to improve patency in the coronary arteries. However, its effect on AV access has yet to be studied. Methods/DesignThis is an investigator-initiated, prospective, multicenter, doubled blinded, randomized controlled clinical trial to assess the effectiveness of SCB compared to POBA in improving the patency of AVF after angioplasty. A total of 170 patients with mature AVF that requires PTA due to AVF dysfunction will be randomly assigned to treatment with a SCB or POBA at a 1:1 ratio, stratified by location of AVF and followed-up for up to 1 year. Inclusion criteria includes (1) adult patient aged 21 to 85 years who requires balloon angioplasty for dysfunctional arteriovenous fistula, (2) matured AVF, defined as being in use for at least 1 month prior to the angioplasty, (3) successful angioplasty of the underlying stenosis with POBA, defined as less than 30% residual stenosis on Digital Subtraction Angiography (DSA) and restoration of thrill in the AVF on clinical examination. Exclusion criteria include thrombosed or partially thrombosed access circuit at the time of treatment, presence of symptomatic or angiographically significant central vein stenosis that require treatment with more than 30% residual stenosis post angioplasty, and existing stent placement within the AVF circuit. The primary end point of the study is access circuit primary patency at 6 months. The secondary end points are target lesion primary patency, circuit assisted primary patency, circuit secondary patency at 3,6 and 12 months, target lesion restenosis rate at 6 months, total number of interventions, complication rate and cost effectiveness. The trial is supported by Concept Medical. DiscussionThis study will evaluate the clinical efficacy and safety of SCB compared to POBA in the treatment of AVF stenosis in hemodialysis patients.Trial registration: ClinicalTrials.gov Identifier: NCT04409912 on 1 June 2020https://clinicaltrials.gov/ct2/show/NCT04409912Protocol Version: 4