Spontaneous Coronary Artery Dissection in a 35 Year-Old Woman with Systemic Lupus Erythematosus Successfully Treated by Angioplasty

Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute myocardial ischaemia with complex pathophysiology; it has been associated with several conditions such as atherosclerosis, connective tissue disorders and the peripartum period. SCAD has exceptionally been reported (three published cases) in patients with systemic lupus erythematosus (SLE). In this work, we report the original case of a 35 year-old woman with a known history of SLE who presented with an acute coronary syndrome caused by an extensive dissection of the left anterior descending artery (LAD) and the diagonal and who was successfully treated by an intravascular ultrasound (IVUS)-guided percutaneous angioplasty.     

Incidence of and factors associated with achieving target lipid levels in patients with peripheral arterial disease

BACKGROUND: Patients with peripheral arterial disease (PAD) have increased mortality compared with patients without PAD. Coronary artery disease (CAD) accounts for almost 75% of deaths in PAD patients. Studies suggest that PAD is underdiagnosed and atherosclerotic risk factors undertreated when compared with CAD. OBJECTIVE: To determine whether cholesterol guidelines are being met in patients with PAD and to determine whether any independent factors increase the likelihood of reaching goal low-density lipoprotein (LDL). DESIGN: A retrospective chart review of subjects diagnosed with PAD in 2001 at 2 Veterans Affairs Medical Centers. MEASUREMENTS: Univariate analysis compares baseline characteristics between those reaching goal and those who do not. Multivariate logistic regression analysis identified predictors of meeting LDL goal among PAD patients. RESULTS: Of 315 patients, 62% reached goal LDL. Those more likely to reach goal were older, had hypertension, and a history of CAD and stroke. Positive predictors of LDL goal were age and CAD, while smoking was a negative predictor. CONCLUSION: The majority of veterans with PAD received lipid-lowering medication and achieve goal LDL, but they are more likely to do so if they are older than 70 and have a history of CAD.     

New endovascular technique for thrombus in the non‐stenting zone—the Grab a Clot and Hold ON “(GACHON) technique”: Case report

It is difficult to treat a thrombotic embolism in the common femoral artery or popliteal artery (POP A), i.e., the non‐stenting zone. We report a new technique for the treatment of thrombotic embolism in the non‐stenting zone using a self‐expandable nitinol stent. Case 1 had an external iliac artery (EIA) occlusion that occurred over several months. A self‐expandable nitinol stent was placed in the right EIA lesion via a retrograde approach using a distal 9‐Fr balloon protection guide catheter in the right femoral artery. A thrombotic embolism occurred at the balloon protection site. It was too big to be removed using an aspiration catheter; therefore, we attempted removal with a self‐expandable stent. Using a crossover approach, we delivered a nitinol self‐expandable stent to the distal site of the thrombus, opened the tip of the stent, and pulled it up to the proximal site. Finally, we “grabbed a clot,” moved it to the stenting zone, and “held on” the vessel wall without occurrence of a distal embolism. We named this the “GACHON technique.” Case 2 underwent endovascular therapy for an acute thrombotic embolism in POP A after thoracic endovascular aortic repair for dissection. This thrombus was too big to aspirate, and we successfully treated it using the “GACHON technique.” The “GACHON technique” may be considered as a choice of treatment for a thrombotic embolism in the non‐stenting zone. © 2016 Wiley Periodicals, Inc.     

Embolization of an Aberrant Right Subclavian Artery Aneurysm with Amplatzer Vascular Plug without Bypass

Aberrant right subclavian artery (ARSA) aneurysms are rare, but the risk of rupture and thromboembolism is high, with a postrupture mortality rate of 50%. Open surgical repair of ARSA aneurysms usually requires thoracotomy and aortic grafting, which can be contraindicated in high-risk patients with multiple comorbidities. Endovascular repair of ARSA aneurysms has been reported, with or without adjunctive surgical bypass. We report a case of an 80-year-old woman resenting with an asymptomatic 4 cm ARSA aneurysm who underwent a completely endovascular treatment of the aneurysm using an Amplatzer vascular plug II (St. Jude Medical Inc., St. Paul, MN).     

Efficacy and safety of argatroban in patients with heparin induced thrombocytopenia undergoing endovascular intervention for peripheral arterial disease

Objectives: This study aimed to evaluate the efficacy and safety of argatroban during percutaneous interventions for peripheral arterial disease (PAD). Background: Endovascular interventions are commonly used in patients with peripheral arterial disease. Heparin is routinely administered during these procedures, but cannot be used in patients with a history of heparin‐induced thrombocytopenia (HIT). Argatroban is an approved direct thrombin inhibitor for treatment of patients with HIT. There are currently few data on the efficacy and safety of argatroban during endovascular interventions for PAD. Methods: Patients who underwent endovascular interventions for PAD on argatroban between 2002 and 2005 were identified from out database. Efficacy was evaluated using a composite of death, urgent revascularization, and amputation, while safety was assessed by TIMI major bleeding during the index hospitalization. Results: A total of 48 patients undergoing lower extremity revascularization on argatroban were identified. Thirty two of these patients (67%) had antibody‐confirmed HIT and the other 16 (33%) had suspected HIT. A mean dose of argatroban was 173.5 ± 143 μg/kg bolus, followed by a 10.7 ± 9.64 μg/kg/min infusion during the procedure. Twelve patients (25%) met the composite end point (two deaths, one urgent revascularization, nine amputations because of progressive peripheral arterial disease). TIMI major bleeding occurred in three (6%) patients. Conclusion: In patients with confirmed or suspected HIT undergoing endovascular intervention for PAD, argatroban appears to be effective and safe. A larger study is warranted to confirm these findings from a single center. © 2008 Wiley‐Liss, Inc.     

Medial-to-lateral plantar loop technique for retrograde transcollateral recanalization of the lateral plantar artery in patients with type 3 plantar arch

A 89-year-old male presented with severe untreatable pain and ischemic non-healing ulcer in the left forefoot. The pre-procedural angiograms showed multiple stenosis of the superficial femoral and popliteal arteries, occlusion of anterior tibial artery, tibio-peroneal trunk (TTP) and distal posterior tibial artery (PTA), stenosis of the peroneal artery, and the patency of the medial plantar artery (MPA) as a single pedal artery, with very poor perfusion of the lateral aspect of the forefoot. The TTP and PTA were recanalized, and balloon angioplasty of superficial femoral artery and popliteal artery and peroneal artery was carried out. After unsuccessful antegrade attempts, the lateral plantar artery (LPA) was retrogradely recanalized performing the medial-to-lateral plantar loop, navigating from the deep branch of MPA to the plantar arch and reentering back in the common plantar artery through the LPA. Balloon angioplasty of LPA was performed though the retrograde and antegrade route. When the MPA is the single pedal artery, and the antegrade recanalization of the dorsalis pedis artery (DPA) and the LPA is not possible, the medial-to-lateral plantar loop is a feasible technique to recanalize the LPA retrogradely through the plantar arch.     

A Review of the Role of Anticoagulation in the Treatment of Peripheral Arterial Disease

Peripheral arterial disease (PAD) is a major medical/surgical problem associated with high risk for coronary heart disease (CHD). Anticoagulation plays a significant role in the management of the PAD patient. However, evidence-based medicine supports only select anticoagulants, mainly antiplatelet agents. The available anticoagulant classes, their individual medications, and the mechanisms of action are described. Dextran 40, platelet glycoprotein (GP) IIb/IIIa receptor antagonists, direct thrombin (factor IIa, FIIa) inhibitors, and factor Xa (FXa) inhibitors do not, at this juncture, appear to have a significant role to play in the PAD patient. Aspirin has been used in PAD patients for a few decades, as has warfarin, but the role of warfarin is very limited. An attempt has been made to place each medication and its function in context all the way to the present with oral direct thrombin (FIIa) and FXa inhibitors described. These inhibitors may ultimately play an, as yet, undefined role in PAD. Specific use of anticoagulants in PAD patients is described and aspirin still stands out as a fundamental therapy. The thienopyridines, especially clopidogrel, have their established place and there is some evidence for benefit from the use of clopidogrel in dual therapy with aspirin. Dipyridamole, especially with aspirin as dual therapy, and cilostazol also have their evidence-based niches. The main role played by warfarin is for the patient with a vein graft in the arterial circulation. Heparin retains significant procedural importance. For now, Class I, Level of Evidence A center around aspirin for the PAD patient with clopidogrel, an alternative agent.     

Echocardiographic Evaluation of External Iliac Artery Doppler Waveform in Patients with Coronary Artery Disease

Visual interpretation of the Doppler waveform in the common femoral or distal external iliac artery (EIA) was reported to be useful in screening for proximal peripheral artery occlusive disease (PAOD) in patients with lower limb ischemia. Commonly patients with coronary artery disease (CAD) referred for echocardiography have coexistent arterial pathology. Therefore, we decided to study whether echocardiographic evaluation of the distal EIA flow can be useful for detection of PAOD in patients with CAD. We studied 150 consecutive patients (pts) with CAD referred for echocardiography. At the end of an echocardiographic examination, evaluation of the flow in the distal EIA with an echocardiographic probe was performed. The Doppler waveform was classified as normal—with early diastolic flow reversal or abnormal–without early diastolic flow reversal. Echocardiographic findings were compared in a blinded fashion with the results of the ankle brachial index measurements (ABI). Based on the ABI ≤ 0.9, peripheral artery disease was diagnosed in 54 pts (36%) and abnormal external iliac Doppler waveform was found in 27 pts (18%). Sensitivity of abnormal external iliac Doppler waveform in predicting PAOD was 48%, specificity 99%, positive predictive value (PPV) 96%, and negative predictive value 77%. Peripheral arterial occlusive disease is common in patients with CAD referred for echocardiographic study. Echocardiographic assessment of distal EIA Doppler waveform has low sensitivity, but high specificity and high PPV in the diagnosis of peripheral arterial occlusive disease.     

Association of the Prognosis of Ankle-brachial Index Improvement One Year Following Endovascular Therapy in Patients with Peripheral Artery Disease: Data from the I-PAD NAGANO Registry

Objective Despite reports on the effects of ankle-brachial index (ABI) improvement following endovascular therapy (EVT) on the limb prognosis, studies evaluating cardiovascular events are limited. We investigated whether or not ABI improvement 1 year following EVT was associated with cardiovascular events. Methods The I-PAD NAGANO registry is an observational multicenter cohort study that enrolled 337 patients with peripheral artery disease (PAD) who underwent EVT between August 2015 and July 2016. From this cohort, we identified 232 patients whose ABI data 1 year following EVT were available, after excluding patients with critical limb ischemia. We divided the patients into two groups according to the degree of ABI improvement 1 year following EVT (ΔABI) - the ΔABI <0.15 group and the ΔABI ≥0.15 group - and compared the outcomes. The primary endpoint was major adverse cardiovascular events (MACEs), including all - cause death, myocardial infarction (MI), and stroke. The secondary endpoints were major adverse limb events (MALEs), defined as a composite of target lesion revascularization and major amputation, all - cause death, MI, and stroke. The median follow-up period was 3.3 years. Results The incidence of MACEs was significantly higher in the ΔABI <0.15 group than in the ΔABI ≥0.15 group (ΔABI <0.15 vs. ΔABI ≥0.15, 25.8% vs. 11.9%, log-rank p=0.036), as was the incidence of stroke (14.1% vs. 2.2%, log-rank p=0.016). A Cox regression analysis revealed that ΔABI ≥0.15 was significantly associated with fewer MACEs (hazard ratio 0.38, 95% confidence interval 0.17-0.83, p=0.016). Conclusion An increase in ABI ≥0.15 at 1 year following EVT was a predictor of reduced MACEs.     

Case Report and Review of Literature: Late Retrograde Type A Aortic Dissection With Rupture after Repair of Type B Aortic Dissection with a GORE TAG Endovascular Prosthesis

Acute aortic dissection is the most common catastrophic condition of the aorta. Treatment options include open surgery and thoracic endovascular aortic reconstruction (TEVAR). We present a late Type A dissection as a complication of the management of descending aortic dissections with TEVAR and a review of the literature. TEVAR of the thoracic aorta is a viable treatment option for the management of complicated descending thoracic aortic dissections. Careful patient selection is necessary as medical therapy successfully treats the majority of uncomplicated Type B dissections. TEVAR should be reserved for patients with complicated Type B dissections or those who fail nonoperative management. Close postoperative monitoring is necessary when TEVAR is performed and should be accompanied by lifelong surveillance. A high level of suspicion is important to identify retrograde Type A dissections in these patients given its rarity and the ambiguity of its clinical presentation.     

Percutaneous endoluminal anatomical bypass for patients with external iliac artery occlusion after failed conventional endovascular recanalization

Endovascular therapy, an established first‐line treatment for isolated iliac artery (IA) occlusion (IAO), may be of limited use in challenging lesions. We describe a novel percutaneous endoluminal anatomical bypass (PEApass) technique for uncrossable external IA (EIA) occlusion. A 70‐year‐old man on hemodialysis with a history of colostomy presented with chronic limb‐threatening ischemia due to a left EIA with below‐the‐knee occlusions. During a previous colostomy, the left EIA was accidentally ligated. Conventional endovascular recanalization for the ligated EIA failed, and a femoral‐femoral bypass and below‐knee angioplasty were performed as alternative therapy. Two weeks later, surgical site infection developed at both anastomosis sites. PEApass was performed prior to removing the infected graft. An arteriovenous fistula (AVF) in the distal location was created using a re‐entry device, and its proximal location was created using a 0.014‐in. penetration guidewire, which was snared on the inside of the iliac vein (IV) using a retrograde snare. The proximal and distal sections of the IA were connected using an 8.0‐mm × 100‐mm stent graft implanted through the IV. A final angiogram indicated that flow to the occluded IA was completely restored without complications. Following the PEApass, the infected graft was removed. Complete wound healing was achieved within approximately 1 month. This innovative PEApass procedure is feasible and could be an alternative procedure for patients with uncrossable IAO.