Endovascular Treatment of Acute MI Occlusions Due To Underlying Intracranial Atherosclerotic Severe Stenosis

Objective: Endovascular treatment (EVT) for acute ischemic stroke with an occlusion of the M1 segment due to intracranial atherosclerotic severe stenosis (ICASS) remains challenging. This study aimed to evaluate the safety and efficacy of EVT for ICASS-related M1 acute occlusion.Methods: We retrospectively reviewed all patients with an ICASS-related M1 acute occlusion underwent EVT at our institution between January 2015 and December 2020. Clinical presentation, baseline characteristics, angiographic and clinical results, technical feasibility, perioperative complications, and follow-up results were evaluated.Results: Twenty-two patients with ICASS-related M1 acute occlusion were included. Eight patients (36.4%) received bridging therapy and the other 14 patients (63.6%) directly underwent EVT. Fifteen patients (68.2%) treated with balloon dilations and stenting as rescue treatment. Six patients (27.3%) received single balloon angioplasty and 5 of these patients treated with staged stenting. One case (4.5%) failed recanalization at the first EVT and successful revascularization was achieved a month later. The mean procedure time was 67.2±20.8 min. Successful revascularization (mTICI≥2b) was achieved in 95.5% (21/22) of patients. Perioperative complications developed in two patients (9.1%) including one hemorrhagic event and one thromboembolic event. Anangiographic follow-up was available in 20 patients (90.9%) at an average of 8.6±3.0 months. The degree of stenosis was worse (10%-30%) in 6 cases (30%) compared with the initial outcomes. The favorable outcomes (mRS≤2) at 3 months follow-up was achieved in 19 patients (86.4%).Conclusions: ICASS-related occlusion in the M1 segment often required a rescue therapy including balloon angioplasty with/without stenting, and this treatment strategy was safe and effective. But single balloon angioplasty at the first EVT generally cannot achieve satisfactory results and often needed staged stenting treatment.

The role of coronary collateral circulation in patients presenting with acute left main coronary artery occlusion

Introduction Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes. Methods In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)]. Results Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p<0.001) and inotropic/vasopressor therapy use (25.0 vs 69.0%, p=0.01) were less frequent in CC Rentrop 2–3 patients. The CC Rentrop 2–3 group had a significantly lower in-hospital (16.7 vs 53.5%, p=0.02) and 30-day mortality (9.1 vs 52.2%, p=0.01). In patients surviving hospitalization there was no significant difference in 1-year (30.0 vs 19.4%, p=0.48) and 5-year mortality (70.0 vs 77.4%, p=0.68). Conclusion A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients. FUNDunding Acknowledgement Type of funding sources: None.

Effect of Balloon Embedded Bifurcating Stenting with Single Stent Strategy for Side Branch Protection

Background: Intervention for bifurcation lesions is associated with increased risk of adverse events and includes acute side branch (SB) occlusion during main branch (MB) stenting. This acute occlusion of side branch can often be catastrophic for the patient. We here in describe our experience in National Institute of Cardiovascular Diseases and Hospital (NICVD), Dhaka, Bangladesh with a technique which can be incorporated into bifurcation stenting to reduce or almost eliminate the incidence of side branch occlusion or catastrophe. Methods: A prospective, observational, non-blinded study in patients from a single tertiary referral cardiac center National Institute of Cardiovascular Diseases & Hospital (NICVD), Dhaka, Bangladesh. Patients with an indication for percutaneous coronary intervention (PCI) of a denovo bifurcation lesion were screened. The study included 51 patients who underwent coronary angiogram in our institution and had bifurcation lesions suitable for single stent strategy between March 2017 to September 2018. Results: 51 patients with bifurcation lesion were included in the study and underwent a balloon embedded bifurcation stenting with a semi inflated balloon placed across the SB ostium. Angiographic success was achieved in all the patients but procedural success was achieved in 88.2% of the patients. TIMI 3 flow of main branch (MB) was achieved 96.08% and side branch (SB) was achieved 88.2%. Incidence of dissection was 5.9%, acute occlusion of SB was 2.0% and MACE was 3.9%. Mean fluoroscopy time and contrast volume was similar to that of conventional bifurcation stenting. The jailed SB balloon and wire could be successfully removed in all patients. Conclusion: The present study suggests that balloon embedded bifurcation stenting with a semi inflated balloon to protect the SB is feasible, with minimal procedural adverse events and successful in minimizing or almost eliminating the incidence of acute side branch occlusion or dissection as well as MACE. Bangladesh Heart Journal 2021; 36(1): 17-23

Benefits and Role of Carbon Dioxide Angiography in Case of Misalignment Between Fenestration and Target Vessel During Fenestrated Endovascular Aneurysm Repair

Purpose: To report the benefits and the role of carbon dioxide (CO2) angiography in case of misalignment between fenestration and target vessel during fenestrated endovascular aneurysm repair (F-EVAR). Technique: During F-EVAR, misalignment between fenestration and target vessel is a potentially catastrophic complication. In 2 patients, we experienced that one of the target vessels were not visible during standard angiography in different projections after positioning a fenestrated graft and even after cannulation of the corresponding fenestration. In both cases, the graft was sealed to the aortic wall but not in the predictable position. Consequently, acute occlusion of the target vessel was hypothesized. However, CO2 angiography was useful to evaluate patency of the target vessel clarifying the relative position of the fenestration versus the target vessel. Rescue maneuvers were feasible under the guidance of CO2 angiography in order to obtain the cannulation of both renal arteries. In both cases, the procedure was successfully accomplished. Conclusion: In case of misalignment of a fenestration during F-EVAR and non-visualization of the target vessel with standard angiography, CO2 angiography could have the unique and complementary role of clarifying the patency and position of the target vessel. In addition, CO2 could guide the rescue maneuvers.