Patient Characteristics Can Influence the Incidence of Perioperative Microemboli during Carotid Artery Interventions

Purpose. Perioperative cerebral microembolization demonstrated on diffusion-weighted MRI (DWI) can occur following carotid endarterectomy (CEA) and carotid artery stenting (CAS). We sought to explore potential risk factors for this in the large patient cohort. Methods. We reviewed a 6-year consecutive patient cohort that received either CEA or CAS, and perioperative DWI evaluations. Results. 303 patients were reviewed, and 56 (19.4%) patients were found to have perioperative microemboli. The incidence was higher among patients who received CAS (P < 0.001). Hypertension (P = 0.03), smoking (P = 0.001), and a history of transient ischemic attacks (P = 0.04) were risk factors for microembolization. The risk was higher among CEA patients with obesity (P = 0.05), and among CAS patients with coronary artery disease (P = 0.03). Conclusion. Specific patient populations are likely more prone to develop perioperative cerebral microemboli following carotid intervention. Continued risk stratification may help decrease future perioperative cerebral microembolization rates.

Heparin-Bonded Viabahn and Drug-Eluting Bare Metal Zilver (PTX) Sandwich Stents in Femoral Chronic Total Occlusion: A Retrospective Review of Mid-Term and Long-Term Outcomes

Articles describe a retrospective cohort study to assess the feasibility of reducing neointimal hyperplasia following interventions in chronic total occlusive peripheral vascular disease. The “sandwich” technique implemented is a novel modified angioplasty technique that combines heparin-bonded (Viabahn) stents with drug-eluting stents (Zilver PTX) deployed during arterial recanalisation. A review of 46 cases underwent this procedure at our institution as a limb saving procedure is conducted to determine mid-long-term patency outcomes and identify any subsequent interventions. Followup demonstrates favourable mid-long-term patency in 50% of TASC-C cases. No documented postprocedural complications were noted with unrelated observed mortality rates in either TASC-C or TASC-D subgroups. An observed advantage could be gained by using this new stenting technique via the subintimal recanalisation route. Albeit not statistically significant, type II diabetics and patients on aspiring had better sustained patency angioplasties. The sandwich technique has been shown to effectively offer symptoms relief and reduce total duration of hospital stay. Study findings support the need to evaluate the long-term efficacy through a larger longitudinal prospective study. However, to overcome the encountered study limitations, a well-structured methodology for comparison with conventional angioplasty techniques is essential to assess the synergetic potential of the sandwich technique.

Clinical Significance and Prognostic Value of Preoperative Angiographic Assessment in Infrainguinal Arterial Reconstructions

Objective. To assess the practical implementation of the modified Schwierz T. system for angiographic scoring of the arteries below the distal anastomosis (run-off) after infrainguinal reconstructions. Methods. We used the modified Schweierz T. score, which is readily practically applied in each patient for assessment of the run-off segment, independently from the planned level of distal anastomosis. 97 consequently treated patients who underwent infrainguinal arterial reconstructions were followed up during a 12-month period, and we retrospectively compared the results of two groups—48 of failed and 49 of patent bypasses; as for the long term patency there were some discrepancies with the expected good results. Measurements of the flow volume were performed below distal anastomoses in peripheral bypass operations with flowmeter VeriQ, Medistim, Oslo, Norway. Flowmetry was performed before and after a 5-minute infusion of Prostavasin or Ilomedin, causing peripheral vasodilatation. The resulting values were averaged and compared to the beforehand calculated according to the Schwierz score minimal expected flow. Results. Schwierz score gives orientation immediately after the reconstruction about the early patency of the bypass. Control angiographies and revisions in cases with inadequate minute blood flow identify some mistakes, the correction of which (if possible) in one operation time improves the results and the early patency. 9% of the failed bypasses in the first month had blood flow above the expected and 37% of the failed bypasses in the eighth month had flow above the expected. Mismatch in the patent bypasses was observed in 6%, probably due to subjective underestimation of some collateral vessels. Conclusion. Quantification of the distal flow is very important. The suggested model of assessment must determine as exactly as possible minimal flow to be reached at the end of the operation. We consider the preoperative angiographically calculated expected blood flow, good additional criteria for the quality of the newly constructed bypass. Intraoperative registration of low blood flow has the significance of screening for further assessment through intraoperative arteriography for the morphological identification of the cause. Having in mind the subjective nature of the angiographic scoring system and its dependence on the quality of the image, we consider the preoperative angiographic estimated expected volume of flow referring to the early patency adequate and inappropriate for long term prediction, but useful as an accessory orientation measurement of the state of the run-off arteries and the result of the surgery.

Pregnancy-Associated Plasma Protein-A Levels and Coronary Angiographic Features in Acute Coronary Syndrome Patients

Background. Pregnancy-associated plasma protein-A (PAPP-A) is a biomarker of plaque rupture, associated with adverse cardiac events in acute coronary syndromes (ACSs) patients. Aim. To identify coronary angiographic (CA) features related to PAPP-A level elevation in ACSs patients. Methods. Forty ACSs patients were enrolled in this prospective cohort study (level of evidence: III-prognostic). Serum samples for PAPP-A quantitation were obtained upon coronary care unit admission. All patients underwent CA and coronary intervention within 6 hours of sampling. Results. Mean age of the study cohort was 57 ± 11 years, (males: 55%, n=22). Patients with ST-segment elevation myocardial infarction (35%, n=14) showed significantly higher serum PAPP-A level (11.8 ± 2 µg/mL), compared to non-ST-segment elevation myocardial infarction (15%, n=6) and unstable angina (50%, n=20) patients (11 ± 2.6 µg/mL and 8.7 ± 2.3 µg/mL, resp., P<0.001). Higher PAPP-A levels were significantly associated with complex culprit lesion morphology (11.8 ± 2 µg/mL for type C lesions, 9.7± 2.5 µg/mL and 7.3 ± 3.5 µg/mL for type B and type A lesions, resp., P<0.001), while no relationship to number of diseased coronaries. Conclusion. Higher PAPP-A levels in ACSs patients are associated with unfavorable coronary anatomy and complex angiographic plaque features.

Medium-Term Results of Treatment for Complicated Acute Type B Dissection: A Spanish Experience in a Single Centre

Objective. To analyze and evaluate medium-term results obtained in endovascular treatment of complicated type B dissection. Methods. Prospective registry and retrospective analysis of the dissections treated with endoprosthesis in 1998 and 2010. Comorbidity, clinical presentation, anatomical characteristics, and evolution were recorded. Actuarial analysis was conducted for survival, follow-up and survival free of endoleaks, and free of reintervention due to relapse and/or progression. Results. Eighteen (18) patients were treated (14 male : 4 female), with a median age of 53 years (range 29–80). Their main symptoms were acute pain in 16 cases and hypertensive crisis in 15. The indications were 10 dissections not controlled by medication, 4 aneurysm dissecans, 2 acute lower limb ischemias, and 2 Type A progressions. Median 1.7 devices were used (range 1–4). Coverage of left subclavian artery was required in 3 cases, and of subclavian and left carotid artery in other 2 cases. There was a 100% technical success. Median follow-up was 43.1 months (1.5–127 range). There were two deaths caused by multiorganic failure, early mortality of 0%, and hospital mortality of 11%. There was a case of Type I Endoleak and 5 cases which required a new intervention due to relapse and/or progression. Cumulative survival at 30 months was 88%; follow-up free of endoleaks at 36 months was 91%. Follow-up free of progression/relapse at 12 months was 88%. Conclusion. Endovascular treatment of complicated type B acute dissection is an effective therapy for this condition, with a low associated mortality and with acceptable survival.

Study of the Influence of Upper Extremities Variation on Transradial Success

Background. To investigate whether the presence of arterial anomalies in upper limb arteries can influence the success rate of transradial coronary angiography. Methods. retrograde transarterial sheath injection was done in patients with transradial coronary angiography. Arterial anomalies in the upper limb are evaluated in these patients. There are ten brachial (5.4%), 7 radial (4/2%), 5 subclavian (3%), and 3 brachiocephalic arteries (1.8%). There also were 4 loops in ulnar artery (2.4%) and one in radial (0.6%). Except cannulation time (), there were associations between anomalies and other times () and contrast volume used (). Anomalies did not have any effect on procedural success rate and just in one patient because of subclavian loop,procedure changed to femoral approach (). Discussion. Patients without upper extremities anomalies in comparison with patients with anomalies had significantly shorter periods for angiographic time, catheterization time, and fluoroscopic time. We recommend femoral catheterization instead of radial catheterization in patients with upper extremities anomalies.

Anticoagulation for Atrial Fibrillation: Is This the End of Warfarin? Not Just Yet

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Its prevalence is known to increase with age and with an aging population AF is likely to become even more common. Although sometimes patients with AF remain asymptomatic, it is now recognized that AF is far from “benign” conferring a significant risk increase in morbidity and mortality. Restoration of sinus rhythm and rate-limiting medication help with symptoms; however, anticoagulation remains essential in reducing thromboembolic risk. The uptake of appropriate anticoagulation with vitamin K antagonists has increased significantly in the last few decades and this review will analyze whether the new oral anticoagulants might prove to be even more effective than existing vitamin K antagonists.

Fibrous Cap Smooth Muscle Cells in Atherosclerotic Coronary Arteries Do Not Express Pluripotent Stem Cell Markers

Rupture of the coronary artery fibrous cap is a common cause of myocardial infarction, and bone marrow derived cells could play a role in preventing plaque rupture. It is currently unknown whether smooth muscle cells within coronary artery fibrous cap formation are of mature phenotype. Objective. To characterize cells expressing bone marrow stem cells of embryonic type (ESC) markers in coronary artery fibrous cap formation. Design. New Zealand White rabbits were fed a diet supplemented with 0.5% cholesterol + 1% methionine + 5% peanut oil for 4 weeks and then a normal diet for 9 weeks. The left main coronary artery was excised from the heart, processed for paraffin and immunohistochemistry was performed by standard techniques. Results. Oct-4, SSEA 1, 3, and 4 were all present within in atherosclerotic plaque core, codistributed with RAM-11, and were sparingly found in the fibrous cap, but TRA-1-60 and TRA-1-81 positive cells were scarce. Core but not fibrous cap smooth muscle (SMCα actin+) cells also showed codistribution with ESC markers. Conclusions. These results suggest that smooth muscle cells present in the fibrous cap do not express ESC markers, indicative of a mature cell.