Carotid sheath rescue with a distal filter retrieval catheter

Sheath placement prior to carotid artery stenting is usually uncomplicated, and provides sufficient support for the procedure. In certain patients, especially those with unfavorable arch anatomy, tortuous vessels, and heavily calcified lesions, the sheath backs out into the aortic arch with compromise of wire and embolic protection device (EPD) position, and risk of “dragging” the EPD back through the lesion. A novel use of the distal filter retrieval catheter to “rescue” a prolapsed guide sheath is described. Use of the filter retrieval catheter as a “body” to retrack the sheath but not recapturing the deployed filter is a useful technique, since the equipment is already available. This avoided the need to pull a retrieved filter through a severe undilated carotid stenosis, reducing the amount of manipulations needed to reposition the sheath and thus reducing the risk of embolic events. © 2008 Wiley‐Liss, Inc.     

Transradial approach for carotid artery stenting: a feasibility study.

BACKGROUND: Carotid artery stenting (CAS) has become accepted as an alternative to carotid endarterectomy for revascularization of the internal carotid artery (ICA) among high risk patients. CAS from the femoral approach can be problematic due to access site complications as well as technical difficulties related to peripheral vascular disease (PVD) and/or anatomical variations of the aortic arch. The purpose of the present study is to evaluate the feasibility of the radial artery as an alternative approach for CAS. METHODS: Forty-two patients (mean age 71 +/- 1, 26 male) underwent CAS. All had a CA stenosis greater than 80% and comorbid conditions increasing the risk of carotid endarterectomy. The target common carotid artery (CCA) was initially cannulated via the radial artery using a 5F Simmons 1 diagnostic catheter which was then advanced to the external CA (ECA) over an extra support 0.014" coronary guidewire. After removing the coronary guidewire, a 0.035" guidewire was advanced into the ECA, and the Simmons 1 was exchanged for a 5F or 6F shuttle sheath and positioned in the distal CCA. In four patients with a bovine aortic arch, the left CCA was accessed with a 5F Amplatz R2 catheter which was then exchanged for a shuttle sheath over a 0.035" guidewire. CAS was performed using standard techniques with weight-based bivalirudin for anticoagulation. RESULTS: CAS was successful in 35/42 (83%) patients, including 28/29 (97%) right CA, 4/5 (80%) bovine left CA, 7/13 (54%) left CA. Mean interventional time was 30 +/- 3 minutes. The sheath was removed immediately after the procedure. There were no radial access site complications. One patient sustained a stroke 24 hrs after the procedure with complete resolution of symptoms (Mean NIH stroke scale 2.0 +/- 0.3 before, 1.9 +/- 0.3 after). Median hospital stay was 2 +/- 0.6 days. Inadequate catheter support at the origin of the CCA was the technical cause of failure in the seven unsuccessful cases. CONCLUSION: CAS using the transradial approach appears to be safe and technically feasible. The technique may be particularly useful in patients with right ICA lesions and severe PVD or unfavorable arch anatomy, and among patients with a bovine aortic arch.     

Takayasu's arteriopathy with associated occlusion of right coronary artery, brachiocephalic trunk and left subclavian artery and aortic regurgitation. Cardiovascular approach leading to a successful outcome - a case presentation

In a 37 year-old woman with Takayasu's arteriopathy angiography revealed occlusion of right coronary artery (RCA), brachiocephalic trunk and left carotid artery (LCA), as well as aortic regurgitation. She underwent a complex cardiovascular surgery consisting of aortic valve implantation, RCA grafting and implantation of vascular bifurcated graft anastomosed between ascending aorta and brachiocephalic trunk and LCA. The multi-slice computed tomography performed two weeks after the operation revealed preserved grafts patency.     

三分支主动脉弓覆膜支架在Stanford A型主动脉夹层手术中的应用

目的总结三分支主动脉弓覆膜支架治疗StanfordA型主动脉夹层的临床经验。方法正中开胸,股动脉、右房插管转流,不游离主动脉弓及头臂血管,鼻温18℃,停循环,于无名动脉近端2cm部分切开升主动脉,直视下置入三分支主动脉弓覆膜支架于主动脉弓和近端降主动脉及三支头臂血管内,行左颈总动脉、右无名动脉气囊导管选择性脑灌注,吻合支架血管近端与升主动脉人工血管,恢复全身灌注。观察并发症及疗效。出院时和3个月复查CT血管造影（CTA）。结果本组无死亡,手术过程顺利,脑及右上肢停循环6-7min,左上肢及降主动脉停循环25-27min,心肌血运阻断时间81-96min,体外循环时间145-190min。术后64排CTA示1例左锁骨下动脉支架外左侧少量血流流向降主动脉,3个月时消失;术后短暂、轻度精神症状1例;二次开胸止血1例,与血管吻合无关。术后1周及3个月CTA示支架血管位置满意,各头臂血管血流通畅。结论三分支主动脉弓覆膜支架术中置人治疗A型主动脉夹层具有操作简单、并发症少、临床效果好等优点,值得临床推广应用。     

A prospective randomized trial of Novoste right versus Judkins catheters for engagement of the right coronary artery during diagnostic catheterization

There has been little technical advancement in catheter shape for diagnostic cardiac catheterization since the early reports of Sones and colleagues during the development of the procedure. In order to determine the utility of a new catheter that directly, without torque or rotation, engages the right coronary artery (RCA), one hundred patients were randomized between 6Fr standard RCA Judkins (6Fr R4) (Cordis Corporation, Miami, FL, USA) or 6Fr Novoste RCA catheters (Novoste Corporation, Aguadilla, Puerto Rico). Endpoints included the duration of the various aspects of the procedure and a qualitative and quantitative assessment of angiographic quality. The Novoste RCA catheters were associated with statistically decreased times of catheter insertion (42 +/- 37 vs 90 +/- 119 secs), and engagement (31 +/- 35 vs 77 +/- 117 secs), of the right coronary artery as compared to Judkins catheters. Judkins RCA catheters had a significantly higher primary success rate (96%) than the Novoste group (84%, P = 0.045). There was no difference in angiographic quality in either group and no complications occurred during the study. While taller patients (mean 68 in) had increased success with the Novoste catheter, no other clinical, demographic, or anatomical characteristics of the RCA orifice predicted successful engagement and angiography. The direct engagement Novoste RCA catheter is associated with a more expeditious procedure than Judkins catheters when they can engage the RCA orifice. However, Novoste catheters were less successful and required more frequent exchanges to complete the procedure.     

Echocardiographic and Doppler evaluation of the aortic arch and brachiocephalic vessels in cerebral and systemic arteriovenous fistulas

Congenital arteriovenous fistulas presenting in the newborn period pose difficult diagnostic problems and simulate structural heart disease. Angiocardiography, when performed, demonstrates enlarged brachiocephalic vessels and rapid cerebral venous return. The value of echocardiographic imaging and measurement of the aortic arch and brachiocephalic vessels, and evaluation of the Doppler flow profile in these vessels as a means of making a rapid diagnosis of cerebral or thoracic arteriovenous fistula, was therefore assessed in 10 infants with these diagnoses seen over a 4 year period (1983 to 1987). Twenty-nine infants (median age 6 weeks) undergoing two-dimensional echocardiography but with no significant lesions were prospectively selected as controls. Nine of the 10 patients had congestive heart failure at presentation (mean age 2 days). A cranial bruit was heard in three and arteriovenous fistula was suspected in five patients. Aortic arch segments and brachiocephalic vessel dimensions expressed as ratios of the abdominal aorta showed significantly larger values in patients for the ascending aorta (p = 0.01), innominate artery (p less than 0.001), right and left subclavian arteries (p less than 0.001) and left common carotid artery (p less than 0.05). The thoracic descending aorta was, however, significantly smaller in patients (p less than 0.002). Retrograde diastolic Doppler flow in the descending aorta proximal to the ductus arteriosus and anterograde diastolic flow with a mean spectral flow-time integral 27% of systolic were present in patients only, whereas Doppler diastolic flow in brachiocephalic vessels, present in 5 of 29 control infants, was less than 15% of systolic flow and not accompanied by dilation of these vessels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complex carotid stenting using a coronary technique

PURPOSE: To report the utility of a coronary technique to facilitate carotid stenting in patients with difficult arch anatomies. TECHNIQUE: When confronted with challenging arch anatomy that prevents engaging the common carotid artery (CCA) with the guiding sheath using standard techniques, an 8-F left Amplatz guiding catheter (AL1) is placed at the origin of the innominate artery. A 0.014-inch coronary guidewire is advanced into the external carotid artery (ECA), and a small monorail coronary balloon is inflated in a small branch of the ECA. The balloon/guidewire combination facilitates maneuvering a 0.035-inch Amplatz super-stiff guidewire through the ECA and then advancing the guiding catheter into the CCA. CONCLUSION: This anchoring technique can be a helpful method for cannulating the CCA in patients with a complex arch when the ECA is patent.     

症状性颈内动脉起始段狭窄血管内自膨式支架治疗26例

目的探讨血管内自膨式支架技术治疗症状性颈内动脉起始段狭窄的临床效果。 方法对26例患者颈内动脉起始段狭窄的患者行全脑血管造影,依照北美有症状颈动脉内膜切除试验测量标准,判断颈动脉狭窄程度,对狭窄率>50％的患者置入自膨式支架,术中5例行球囊预扩张,3例应用保护装置。结果 26例支架置入均获成功,血管残余狭窄程度<30％。术后随访23例(10-22个月),1例发生再狭窄(狭窄率>55％)。结论 血管内支架成形术是治疗颈动脉狭窄的一种有效方法,至于术后存在的血栓形成、再狭窄等问题还有待于今后进一步研究。     

Safety and effectiveness of the arani curve guiding catheters in Palmaz-Schatz stenting of right coronary artery stenosis

The purpose of this study was to evaluate the safety and efficacy of Arani curve guiding catheters in Palmaz-Schatz stenting of right coronary artery (RCA) stenosis. A total of 15 stents was implanted in 13 right coronary arteries. For stenting of the RCA with marked superior orientation and shepherd's crook configuration of the proximal segment, a catheter with a 75° primary curve was used. A catheter with a 90° primary curve was usually the best choice for stenting of the RCA with slight superior, horizontal, or inferior orientation of the proximal segment. These catheters provided excellent support in 12 of 13 cases (93%) and resulted in successful stent deployment in these patients. There was one dissection which occurred distal to the stent following poststent balloon dilatation, and which required emergency coronary artery bypass graft surgery. There were no complications attributed to these guiding catheters. An extraordinary formation of pseudostenosis occurred in one patient. We conclude that Arani curve guiding catheters provide strong support and are safe and effective in stenting of RCA stenosis. © 1996 Wiley-Liss, Inc.     

Axillary artery access for interventional procedures.

PURPOSE: To evaluate axillary artery access for the interventional treatment of carotid or splanchnic arteries that have angulated takeoff or complex anatomy when larger catheters (up to 9 F) are needed. TECHNIQUE: The axillary artery approach was used to treat the left internal carotid artery (ICA) in 3 patients (2 angulated takeoffs and 1 bovine arch) and a celiac axis aneurysm. An 8-F, 45-cm-long introducer sheath was inserted for the carotid procedures, whereas a 9-F, 90-cm sheath was chosen for the celiac aneurysm. Cerebral protection and stenting were successfully performed in all carotid patients; an 8x40-mm stent-graft was implanted to exclude the celiac artery aneurysm. An 8-F vascular closure device was used in the axillary arteries; hemostasis was immediate, and no hematoma or other complications were recorded in follow-up. CONCLUSIONS: This preliminary experience revisits the axillary approach as an alternative access route for interventional procedures. In association with a vascular closure device, this approach should be considered as a useful and safe option for those interventional procedures in which larger sheaths or catheters are required to cope with difficult arterial anatomies.     

A modified technique for carotid cannulation via the transfemoral approach, during angioplasty and stent placement

We report a modified technique for advancing a catheter or sheath into the right common carotid artery when the aortic arch anatomy is unfavorable.A standard 0.035-inch guidewire is passed into the right subclavian artery, and a diagnostic catheter is threaded over it, deep into the right axillary and brachial artery. This wire is exchanged for a stiffer wire (for example, a super-stiff Amplatz), and the catheter is removed. This stiff wire acts as an anchor and provides enough support for a sheath or a guide catheter to be easily advanced into the right brachiocephalic artery, up to its bifurcation into the subclavian and common carotid arteries. Another wire is then buddy-wired through the guide or sheath into the common carotid artery and is placed in a branch of the external carotid artery. The stiff wire is now slowly withdrawn from the subclavian artery, and as soon as its tip exits the subclavian ostium, the guide or sheath is advanced into the common carotid artery.This simple modification can improve the success rate of carotid cannulation via the femoral approach without increasing procedural risks.     

Effectiveness of a handmade “New Carotid Catheter” in transradial carotid angiography: A comparison with conventional multipurpose catheters

Objective

The incidence and severity of carotid atherosclerosis increases in proportion with coronary artery disease and its severity. A special catheter specifically used for transradial carotid angiography has not yet been marketed. In this study, we investigate the feasibility and safety of our carotid catheter, which was made by reshaping currently available catheters.

Methods

Between 2010 and 2017, a total of 921 patients with indications for carotid angiography were identified after angiographic examinations and included in the study. Carotid angiography was performed in 403 patients (female, n = 161) using the 3.5 JL catheter, while in 518 (female, n = 207) patients, new catheters were employed. The new catheter was shaped like a hook in the laboratory with a heat gun. Demographic information and angiographic data from the patients in both groups were retrospectively analyzed.

Results

The baseline characteristics of both groups were comparable. When compared with the use of a 3.5 JL catheter, right transradial carotid angiographies performed with our new handmade catheter resulted in lesser amounts of opaque material used (55 mL vs 66 mL, P < 0.001) and shorter total fluoroscopy time, (3.60 ± 1.85 min vs 3.14 ± 1.55 min, P < 0.001). The handmade catheter also resulted in a higher success rate of selective visualization (97% vs 40%, P < 0.001). Rates of minor complication were comparable between the two catheters (6.5% vs 6.6% P = 234). Neither permanent damage nor morbidity or mortality was observed in either arm.

Discussion

Currently available catheters and methods are inadequate for routine transradial carotid angiography. For routine transradial carotid angiography, innovatively designed catheters are required. The catheter we developed for transradial carotid angiography was more successful than the conventional catheter in obtaining satisfactory images. High quality images can be obtained with the newly designed catheters.

Conclusion

Transradial carotid angiography can be performed using our newly developed carotid catheter. The carotid arteries of patients with widespread coronary artery disease can be visualized, while asymptomatic patients carrying a high risk of stroke can be treated, preventing potential stroke occurrence. In a larger‐scale comparative study, the favorable contributions of routine use of the new method and a decreased frequency of stroke may be demonstrated.     

Abnormal origin of right coronary artery and use of Tiger catheter through femoral route

BackgroundAbnormal origin of right coronary artery (RCA) is not uncommon. The incidence is .25–.92%. Right Judkin catheter is used universally for engaging right coronary ostium from femoral route. We have tried Tiger catheter from femoral route in abnormal origin of RCA patients. We were successful in cannulating RCA ostium in most of the cases.Materials and methodsWe have studied about 5120 patients over 4 years. We have selected patients from November 2010 to November 2014. Our patients are from two institutions—I.P.G.M.E.R., Kolkata and Burdwan Medical College, West Bengal. Right Judkin 3.5 and 4 were used universally. We have used AL-1,2,3, AR1,2, multipurpose, different guide catheters for cannulating RCA ostium in those cases where we failed to engage by right Judkin catheter. We have used Tiger catheter as a last resort when all endeavor failed.Results and analysisAmong 40 cases of left sinus origin Type A—9, Type B—14, Type C—6, Type D—3, and Type E—8 patients were observed. But 668 cases abnormal origin of RCA were from right coronary sinus only. High take-off origin were 422 cases (8%), low take-off were 132 cases (2.5%), and posterior origin were 114 cases (2%). We could engage right coronary ostium by Tiger catheter in 690 cases (97%). We failed in 23 cases (3%).ConclusionTiger catheter can be used successfully in abnormal RCA origin cases. It is more effective but less risky in comparison to other catheters.     

Catheter Selection for Coronary Angiography and Intervention in Anomalous Right Coronary Arteries

Background: An anomalous origin of the right coronary artery (ARCA) from the left sinus of Valsalva (LSOV) has been reported in 6–27% of patients with coronary anomalies. The unusual location and course of this anomaly poses a technical challenge for the interventionalist. Appropriate guiding catheter selection is critical to ensure successful angiography and percutaneous intervention (PCI). We report our experience in 24 patients with an anomalous RCA originating from the LSOV .
Methods: Twenty-four angiograms of ARCA-LSOV were reviewed by two independent interventionalists with attention to the origin and take off of the RCA within the aortic root. The origin was adjudicated with a scheme based on anatomical landmarks as described—A: origin from the aorta above the sinotubular plane; B: origin just below the ostium of the left coronary artery (LCA); C: origin below the sinotubular plane between the midline and the LCA; D: origin along the midline .
Results: The distribution of various takeoffs of the RCA was as follows: For type A (N = 4) the FL3.0 and FCL3.0 catheters were successful in three and one cases, respectively. For type B (N = 5) the FCL3.0 or 3.5 was successful in four out of the five cases. For type C (N = 9) the VL catheter was successful in eight (VL3.5 = 5:VL 3.0 = 3) cases. The AL catheter was successful in five cases of type D (N = 6) RCAs (AL1 = 3:AL2 = 1:AL3 = 1) .
Conclusions: The classification method and catheter selection provide a useful framework to successfully engage ARCA-LSOV and may reduce contrast and radiation exposure .     

Endovascular revascularization of bald aortic arch for severe cerebral ischemia

Takayasu arteritis is a rare form of chronic, inflammatory arteriopathy affecting the aorta and its major branches. Obstructive lesions of all arch vessels lead to ischemic brain symptoms. There is very limited experience of endovascular revascularization in this situation. We report case of a female patient with potentially life threatening cerebral ischemic symptoms due to extra‐cranial occlusion of all arch arteries. Stent supported angioplasty of brachiocephalic, right common carotid and right subclavian artery was successfully performed. This improved her cerebral blood flow and relieved her severe, disabling neurologic symptoms. © 2013 Wiley Periodicals, Inc.     

Takayasu's disease involving the vessels arising from the arch of the aorta and those of the upper limbs (author's transl)

Lesions localized to the vessels arising from the aortic arch and those in the upper limbs were observed in 72 out of 84 patients with Takayasu's disease. In 54% of these 72 cases, other regions were affected, while only the vessels arising from the arch of the aorta were the site of lesions in the other 46% (isolated axillo-post-vertebral subclavian lesions were present in 14% of cases). Semiological features, long-term complications, and prognosis are discussed. 53 revascularizations were performed in 47 patients without mortality. Surgery is definitely indicated when severe stenosis of the brachiocephalic vessels or the main carotid arteries or their division exists. Revascularization of a subclavian artery stenosis should be limited to cases with ischemia of the upper limb on effort or when a histological diagnosis is required. Controversy exists as to the need for this operation in ectatic forms.     

Primary angioplasty in acute inferior myocardial infarction with anomalous-origin right coronary arteries as infarct-related arteries: focus on anatomic and clinical features, outcomes, selection of guiding catheters and management

BACKGROUND: Inferior wall myocardial infarction caused by obstruction of an anomalous-origin right coronary artery (RCA) is a rare angiographic finding; primary angioplasty to an anomalous-origin RCA has never been reported. METHODS: In 185 patients with acute inferior wall myocardial infarction resulting from RCA occlusion who underwent primary angioplasty, eight patients (4.3%) had anomalous-origin RCAs. RESULTS: Coronary angiography showed that all 8 patients had a dominant RCA. Six patients (75%) had an anomalous-origin RCA arising from the anterior aspect of the ascending aorta above the sinotubular line and the other 2 patients (25%) had an anomalous-origin RCA arising from the left sinus of Valsalva with a separate ostium from the left main coronary artery. The standard Judkins right guiding catheter did not offer adequate support in these patients. In the group of 6 patients, an Amplatz guiding catheter offered good support, while a standard Judkins left guiding catheter was adequate in the other 2 patients. Obstruction of the proximal RCA occurred in 6 patients (75%). Successful reperfusion was achieved in 6 patients (75%), resulting in an uneventful clinical course and long-term survival (mean follow-up, 24.9 +/- 16.5 months). Two patients (25%) had unsuccessful reperfusion and died from cardiogenic shock. CONCLUSIONS: In this small series, anomalous-origin RCAs were the dominant artery and predisposed to atherosclerosis at the proximal portions. We suggest that appropriate guide catheter selection and careful manipulation are essential for the success of revascularization. Complete reperfusion results in an excellent clinical and long-term outcome in patients with anomalous-origin RCAs.     

Procedural outcome and midterm result of carotid stenting in high-risk patients

Carotid endarterectomy is the standard treatment for carotid stenosis, but carotid artery stenting has emerged as a potential alternative. Elective carotid artery stenting was performed in 42 patients aged 42 to 79 years (mean, 67.05 +/- 8.67 years) after ultrasonography, computed tomography, magnetic resonance angiography and a neurological evaluation. There was bilateral carotid stenosis in 23 patients (55%), with > 90% stenosis in 18 vessels. All patients had significant associated coronary lesions. An emboli protection device and self-expanding stents were used. One year later, the patients were evaluated by Doppler sonography and selective angiography. Technical success was achieved in all procedures. During follow-up, 1 (2.4%) patient died from myocardial infarction, 1 underwent coronary artery bypass and 14 (40%) had minor complaints including occasional dizziness. No other neurological events were noted. Restenosis was found in one case, but selective angiography ruled out a significant lesion. One patient suffered embolization, but recovered completely within 24 hours. In 7 (17%) patients with type C arch interruption and a tortuous carotid course, stenting was successful and they had no embolization or restenosis. Carotid artery stenting is recommended in high-risk patients.     

Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels

OBJECTIVES: To compare stenting of aortic arch vessel obstruction with surgical therapy and to establish recommendations for treatment. BACKGROUND: Though surgery has been considered to be the procedure of choice for subclavian and brachiocephalic obstruction, little work has been done to compare it with stenting. METHODS: Eighteen patients with symptomatic aortic arch vessel stenosis or occlusion were treated with stenting, followed by periodic clinical follow-up and noninvasive arterial Doppler studies. Data were compared with the results as shown in a systematic review of a published series of surgery and stenting procedures which included comparison of technical success, complications, mortality and patency. RESULTS: Primary success in our series was 100% with improvement in mean stenosis from 84+/-11% to 1+/-5% and mean arm systolic blood pressure difference from 44+/-16 mm Hg to 3+/-3 mm Hg. There were no major complications (death, stroke, TIA, stent thrombosis or myocardial infarction). At follow-up (mean 17 months), all patients were asymptomatic with 100% primary patency. Literature review demonstrates equivalent patency and complications in the other published series of stenting. In contrast, there was a similar patency but overall incidence of stroke of 3+/-4% and death of 2+/-2% in the published surgical series. CONCLUSIONS: Subclavian or brachiocephalic artery obstruction can be effectively treated by primary stenting or surgery. Comparison of stenting and the surgical experience demonstrates equal effectiveness but fewer complications and suggests that stenting should be considered as first line therapy for subclavian or brachiocephalic obstruction.     

Intravascular ultrasound in patients with suspected aortic dissection: comparison with transesophageal echocardiography]

Thirteen patients with suspected aortic dissection (two women, 11 men, age 61 +/- 10.8 years) underwent transesophageal echocardiography (TEE), intravascular ultrasound (IVUS), angiography, and in part computed tomography (CT). TEE was performed using 3.5 or 3.75 MHz ultrasound transducers. IVUS examination was done using a 6F 20 MHz "rotational-tip" IVUS catheter (Boston Scientific) advanced over a guiding-wire positioned in the ascending aorta by the "side-saddle" technique. In two patients it was not possible to advance the catheter into the abdominal aorta. Of the remaining 11 patients, eight had aortic dissection (six Typ III, one Typ II, and one Typ I, de Bakey classification). Two patients had aortic aneurysms without dissection and one patient had a perforation of the ascending aorta. TEE, CT, and angiography led to the correct diagnosis in all patients, while IVUS failed to provide precise information within the ascending aorta and the aortic arch. Reasons were the limited scanfield of the 20 MHz transducer and the inability to steer and position the IVUS catheter. Contrary to the limited value in the ascending aorta, IVUS could successfully scan the entire descending aorta, including the dissection membrane and the originating vessels, if the max. diameter was less than 4 cm. No adverse effects occurred. Intravascular ultrasound allows to scan the entire aorta in patients with suspected aortic dissection. The current limitations can be solved only by the introduction of steerable and/or low frequency catheters.