Novel Use of Dual Guiding Catheters Technique to Prevent Distal Embolization and Slow Flow during PCI of Coronary Stent Thrombosis

Despite having an incidence of 0.5 to 2%, stent thrombosis has an in-hospital mortality of 15% and myocardial infarction (MI) incidence of 67%. Even with the usage of thrombus aspiration devices and microvasculature vasodilators such as nitroprusside, verapamil, adenosine, and Gp2b/3a inhibitors, the angiographic result of percutaneous coronary intervention of coronary stent thrombosis remains frequently suboptimal due to distal embolization and subsequent slow flow. We describe a novel use of dual guide catheter technique, where one guide acts as conduit for thrombus aspiration catheter and the other for distal placement of balloon trap to prevent distal embolization while managing a case of coronary stent thrombosis to improve the angiographic outcome in this scenario.

377 Optimal timing for percutaneous coronary interventions in patients undergoing TAVI

Aims PCI timing in patients undergoing TAVI is still controversial, with most cases treated before TAVI, because of concerns about potential ischaemic complications during valve replacement. This study aims to compare procedural and in-hospital outcomes in patients undergoing PCI before or after TAVI. Methods and results Patients undergoing TAVI and PCI from 2010 to 2021 at Verona University Hospital were included. High-risk PCI were defined when performed in unprotected left main, proximal left anterior descending, proximal dominant right coronary artery or in 3-vessel disease. The primary endpoint was the cumulative incidence of any TAVI procedural complication and in-hospital adverse events (VARC-3 criteria). 129/940 TAVI patients underwent PCI was performed before TAVI in 33.4% of cases. Most patients (76.4%) were at high-risk. The primary endpoint occurred in 30.2% PCI pre-TAVI vs. 23.3% post-TAVI (HR: 0.72; 95% CI: 0.26–2.86; P = 0.671); and in 37.9% vs. 18.5% respectively, among high-risk PCI (HR: 1.62; 95% CI: 0.86–3.76; P = 0.102). At 24 months, MACCE-free survival was comparable (PCI pre-TAVI 91.7% vs. post-TAVI 97.5%, HR: 0.88, 95% CI: 0.13–4.77, P = 0.765). Conclusions PCI performed after TAVI does not expose patients to higher risks of peri-procedural or long-term complications when compared with pre-TAVI procedures, even in presence of high-risk lesions. 377 FigureAn example of post-TAVI high risk PCI. Pre-TAVI coronary angiography showed ostial left main critical lesion (A). After Symetis Aortic valve deployment, balloon angioplasty and stent implantation were performed (B and C) with good final angiographic result (D).

Rotatripsy: synergistic effects of complementary technologies: a case report

Background Percutaneous coronary intervention (PCI) to calcified coronary lesions (CCLs) remains one of the most complex procedures. Latest modality to modify calcium, intravascular lithotripsy (IVL), has shown good safety and efficacy in preliminary research. However, it may be associated with acute complications, and as standalone therapy, is not sufficient for all CCLs. Case summary Eighty-two-year-old man, known case of coronary artery disease and multiple comorbidities, presented with worsening angina of 1 month duration. Coronary angiography revealed heavily calcified triple vessel disease with critical distal left main (LM) involvement. Owing to high surgical risk, he was offered intravascular ultrasound (IVUS) guided PCI with intra-aortic balloon support. While the diffuse, circumferential calcified lesions in LM and left anterior descending (LAD) artery were modified with rotablation (RA) followed by IVL with 3.5 and 3.0 mm balloons; ostial-proximal lesion in left circumflex (LCX) artery was treated with 3.0 mm IVL balloon as a standalone therapy. During second cycle of shockwave therapy in LCX, the 3.0 mm IVL balloon ruptured with type C dissection extending upto LM ostium which required emergent LM bifurcation stenting. We had a good angiographic result which was confirmed with IVUS. Discussion ntravascular lithotripsy and RA are complementary technologies in treating CCLs. Rotablation with a relatively small-sized burr is safe and can favourably modify superficial calcium which helps in smooth delivery of IVL balloon and ensures safe shockwave therapy, if required. Unselected upfront use of IVL without intravascular imaging may be associated with complications as described in this case.

A rare case of post-traumatic high-flow priapism requiring endovascular salvage with bilateral superselective microcoil embolization

Post-traumatic high-flow priapism is a rare occurrence, with potentially debilitating long-term erectile dysfunction if left unaddressed. Even rarer, however, is for the priapism symptoms to be caused by a single cavernosal arterial pseudoaneurysm, with feeding vessels from the distal branched vessels of ‘both’ the left and right internal pudendal arteries. To the best of our knowledge, we present the first documented case of endovascular salvage utilizing superselective microcoil embolization in the treatment of high-flow priapism caused by a singular pseudoaneurysm with bilateral inflow. Timing of symptoms, interpretation of imaging, multidisciplinary discussions, procedural risk, arterial anatomy and choice of embolic agent were all careful considerations in this case. Following embolization, this young gentleman ultimately had a successful angiographic result, normalization of his cavernosal artery peak systolic velocity on ultrasound and a full return to normal erectile function by 6 months.

Plakkmodifikáció a 21. században – az első magyar tapasztalatok az intravascularis lithoplasticával

Összefoglaló. A nagy mésztartalmú plakkok által okozott szűkületek percutan intervenciója az esetek egy részében a jelenleg széles körben elérhető megoldások alkalmazásával technikailag nem kivitelezhető. A procedurális sikertelenség vezető oka a meszes laesiók kalciumtartalom miatti fokozott ellenállása a ballonos dilatációkkal szemben, mely lehetetlenné teszi a szükséges sztentek levezetését is. Az ilyen laesiók mésztartalmának csökkentését célzó hagyományos plakkmodifikációs eljárások – mint a rotablatio, a vágó- és ultranagy nyomású ballonok – sem jelentenek megoldást minden esetben, különösen az érfal átmérőjének legalább 50%-át elérő, akár körkörösen jelen lévő meszesedés fennállása esetén. A közelmúltban éppen ezen laesiók mésztartalmának feltördelésére, így a sztentek deponálásának elősegítésére kifejlesztett módszert a szakirodalom intravascularis lithoplastica néven említi. A jelen közleményben a Klinikánkon eddig 4 beteg rendkívül meszes laesióinak jó angiológiai eredményű ellátása során az eszközzel szerzett tapasztalatokat foglaljuk össze. A végeredményt tekintve az intravascularis lithoplastica ígéretes új intervenciós lehetőség a masszívan meszes coronarialaesiók ellátására. Orv Hetil. 2021; 162(2): 69–73. Summary. Percutaneous intervention of stenoses caused by highly calcified plaques utilizing the currently widely available methods is not possible due to technical difficulties in several cases. Increased resistance of calcified plaques against balloon dilation due to their calcium content plays a leading role in procedural failure, as stent crossing becomes impossible as well. Classical methods of plaque modification for debulking the calcification of such lesions – such as rotablation, cutting and ultra-high pressure non-compliant balloons – do not resolve this issue, especially when calcification exceeds 50% of the vessel diameter. A new method, referred to as intravascular lithoplasty in the literature, has recently been developed to break the calcium and thus promote stent deployment in such lesions. In our current work, we summarize the experience gathered with this method during the treatment of extremely calcified lesions of 4 patients with good angiographic result. As a conclusion, intravascular lithoplasty is a promising new interventional method in the treatment of massively calcified coronary lesions. Orv Hetil. 2021; 162(2): 69–73.

Thrombolysis in Cerebral Infarction 2b Reperfusions

In patients undergoing mechanical thrombectomy, achieving complete (Thrombolysis in Cerebral Infarction 3) rather than incomplete successful reperfusion (Thrombolysis in Cerebral Infarction 2b) is associated with better functional outcome. Despite technical improvements, incomplete reperfusion remains the final angiographic result in 40% of patients according to recent trials. As most incomplete reperfusions are caused by distal vessel occlusions, they are potentially amenable to rescue strategies. While observational data suggest a net benefit of up to 20% in functional independence of incomplete versus complete reperfusions, the net benefit of secondary improvement from Thrombolysis in Cerebral Infarction 2b to 3 reperfusion might differ due to lengthier procedures and delayed reperfusion. Current strategies to tackle distal vessel occlusions consist of distal (microcatheter) aspiration, small adjustable stent retrievers, and administration of intra-arterial thrombolytics. While there are promising reports evaluating those techniques, all available studies show relevant limitations in terms of selection bias, single-center design, or nonconsecutive patient inclusion. Besides an assessment of risks associated with rescue maneuvers, we advocate that the decision-making process should also include a consideration of potential outcomes if complete reperfusion would successfully be achieved. These include (1) a futile angiographic improvement (hypoperfused territory is already infarcted), (2) an unnecessary angiographic improvement (the patient would not have developed infarction if no rescue maneuver was performed), and (3) a successful rescue maneuver with clinical benefit. Currently there is paucity of data on how these scenarios can be predicted and the decision whether to treat or to stop in a patient with incomplete reperfusion involves many unknowns. To advance the status quo, we outline current knowledge gaps and avenues of potential research regarding this clinically important question.

First-in-man experience of the Versi Retriever in acute ischemic stroke

ObjectiveTo describe our initial experience with the Versi Retriever for mechanical thrombectomy in patients with acute ischemic stroke.MethodsThis study is a single-center, single-arm, first-in-man registry under institutional review board control to evaluate the efficacy and safety of the new stent retriever, the Versi Retriever. Patients with acute ischemic stroke were consecutively enrolled between September and November 2017. The clinical and procedural data were retrospectively analyzed. The angiographic result after the procedure was self-graded based on the Thrombolysis in Cerebral Infarction (TICI) scale by each operator.ResultsEleven patients with a mean age of 69.4 years were treated with the Versi Retriever. Median National Institutes of Health Stroke Scale score on admission was 16 (IQR 10–34). The occluded vessel was located in the anterior circulation in 81.8%. Revascularization rates of TICI 2b–3 and TICI 3 at final angiogram were achieved in 100% and 63.6%, respectively. A favorable functional outcome (modified Rankin Scale 0–2) at 90 days was obtained in 72.7%. No symptomatic intracranial hemorrhage occurred and no procedure-related complication was observed.ConclusionsOur initial experience suggests that the Versi Retriever is a safe and effective stent retriever for mechanical thrombectomy in patients with acute ischemic stroke.Clinical trial registrationNCT03366818

Treatment Strategy of a Patient With a Brain Arteriovenous Malformation and Cranial Dural Fistula: 2-Dimensional Operative Video

We present the case of a 56-yr-old right-handed male, after informed consent was obtained, who presented with acute confusion and agitation, on the background of a remote history of an uncomplicated resection of a left parietal grade 2 glioma. Imaging revealed a large, acute right temporal intracerebral hemorrhage (ICH). Standard vascular workup for the cause of the ICH included catheter angiography. No direct cause of the hemorrhage was revealed; however, a high grade parasagittal dural arteriovenous fistula (DAVF) with cortical venous reflux was noted close to the prior craniotomy site. The venous reflux was towards the left hemisphere, but it was hypothesized that similar reflux on the right side may have been present and was not presently evident due to thrombosis. The DAVF was embolized by endovascular means, followed by evacuation of the hematoma. Follow-up angiogram 7 mo later revealed a high-flow, right superior temporal cortical arteriovenous malformation (AVM). The DAVF unfortunately had also progressed. Endovascular occlusion of both lesions was attempted but was not successful. Subsequently, microsurgical resection for both the vascular malformations was performed with careful pre- and intraoperative planning to obtain a successful clinical and angiographic result. In this video, we summarize diagnostic and therapeutic nuances that have broad implications for the workup of ICH and the strategic management of a unique scenario involving a brain AVM and high-grade cranial dural fistula in the same patient. Prior to each procedure, informed consent was obtained from the patient, which includes consent for publication.

Republished: Unexpected early radiographic findings associated with a ruptured blister-like carotid wall aneurysm

A 33-year-old man presented with aneurysmal subarachnoid hemorrhage from a ruptured, blister-type sidewall internal carotid artery (ICA) aneurysm. Balloon-assisted coiling was performed with residual neck. He subsequently developed severe vasospasm requiring intra-arterial therapies on multiple occasions, during which it was noted that despite widespread vasospasm, a focal segment of the ICA at the site of the aneurysm showed no significant spasm, suggesting underlying vessel abnormality. He was discharged without deficit and scheduled for flow diversion given concern over this potentially pathologic segment of vessel. At time of scheduled flow diversion 6 weeks later, a de novo unstable-appearing 6 mm stalk-like pseudoaneurysm was identified in this segment. Both aneurysms and the diseased vessel were successfully treated with Pipeline stenting, with excellent clinical and angiographic result. This case highlights the need for close angiographic follow-up when there is a heterogeneous vasospastic response in arterial segments adjacent to a ruptured aneurysm.