Transradial carotid stenting in a patient with bovine arch anatomy

Carotid stenting in difficult arch anatomy can be safely done by transradial route depending upon operator's experience. Left carotid artery stenosis with Bovine arch anatomy can be approached by right arm approach (radial/brachial) easily. In cases with Bovine arch anatomy, left arm approach by modified looping technique is still possible. We report a case of carotid stenting in a patient with bovine arch anatomy using percusurge anchoring technique through left radial approach. © 2010 Wiley‐Liss, Inc.     

Complications of aortic atherosclerosis: Atheroemboli and thromboemboli

Opinion statement Patients with severe aortic atherosclerosis are at high risk for stroke and other embolic complications. Therapy to prevent emboli from aortic plaque is not yet established. Therefore, patients with atherosclerosis or risk factors for embolic disease should be identified and treated aggressively. Aspirin, smoking cessation, and control of blood pressure and glucose are important. Retrospective data in patients with severe aortic plaque support the use of statins to prevent stroke. Iatrogenic embolization can occur as a result of aortic manipulation during invasive vascular procedures or cardiovascular surgery. The risks and benefits of these procedures must be carefully weighed, and alternate approaches should be considered for patients with severe aortic atherosclerosis. For those who require coronary artery bypass graft (CABG) surgery, off-pump CABG is an option. Prophylactic aortic arch atherectomy should not be routinely performed. Aortic filters or stenting have been introduced but have not yet been fully evaluated. For patients who require angiography and have severe descending aortic, aortic arch, or abdominal aortic plaque, it is possible that a brachial (rather than a femoral) approach may avoid embolic complications.     

Hybrid treatment for complex aortic problems combining surgery and stenting in the integrated operating theater

OBJECTIVES: Conventional surgical treatment of complex aortic pathologies involving several thoracoabdominal aortic segments necessitates extended incisions or subsequent surgeries, resulting in significant mortality and morbidity rates. The combination of surgery and simultaneous stenting in the operating theater may reduce the surgical trauma. METHODS: A total of nine patients (62 +/- 10 years, range 44-70) underwent a combined surgical and endovascular treatment of thoracic or thoracoabdominal aortic aneurysms or chronic dissection. Five patients were treated with viscero-renal artery translocation followed by transfemoral stenting of the entire thoracoabdominal aorta. Two patients underwent debranching of the supraaortic vessels followed by immediate transfemoral stenting of the aortic arch, and two patients with a history of an ascending aortic aneurysm repair were treated with open surgical debranching of the supraaortic trunks and repair of the ascending aorta and aortic arch with elephant trunk technique. Preoperatively, magnetic resonance imaging was used to check supraaortic and intracranial vessels as well as the completeness of the Circle of Willisi prior to arch stenting and/or supraaortic vessel surgery. Cerebrospinal fluid drainage and induced mild hypertension have been used for one-step thoracoabdominal aortic stenting. RESULTS: Thirty-day mortality rate and incidence of paraplegia was 0%. There was a single reversible perioperative stroke after aortic arch stenting. One patient required temporary renal replacement therapy using continuous arterio-venous hemofiltration. There was one early reoperation at the superior mesenteric artery after viscero-renal translocation. Four type I endoleaks occurred in three patients requiring two interventions. All patients have been discharged to home. CONCLUSION: The innovative combination of simultaneous conventional surgery and stenting reduces the operative burden for patients with complex aortic pathologies involving several segments of the thoracic and thoracoabdominal aorta. Arch debranching and viscero-renal artery translocation may avoid the use of thoracoabdominal incisions, cardiopulmonary bypass techniques, deep hypothermia, and circulatory arrest.     

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.     

Treatment of iatrogenic aortic dissection by percutaneous stent placement

During elective cardiac catheterization via the right femoral artery, difficulty was encountered advancing the guidewire beyond the aortic arch and the procedure abandoned. The patient later developed back pain and hypotension. A contrast-enhanced spiral computed tomography scan confirmed aortic dissection, extending from an entry point in the external iliac artery to the arch. We hypothesized that the entry site was responsible for filling the dissection in the thoraco-abdominal component. A stent was placed in the iliac artery, occluding the entry point. This is the first report of aortic dissection, a rare complication of angiography, managed by percutaneous stenting of the entry point.     

Vascular remodeling after "successful" repair of coarctation: impact of aortic arch geometry.

OBJECTIVES: This study was designed to investigate the influence of aortic arch geometry on vascular remodeling after anatomically successful repair of coarctation of the aorta (CoA). BACKGROUND: Abnormalities of the precoarctation vasculature are known to occur after CoA repair and appear related to adverse outcomes. The influence of aortic arch geometry on such abnormalities is unknown. METHODS: Sixty-three postcoarctectomy subjects (age 15.9 +/- 6.3 years) were compared with 63 control volunteers. Aortic arch shape was characterized on magnetic resonance imaging using both qualitative classification, identifying 3 subtypes of arch geometry (Gothic, Crenel, Romanesque), and a quantitative index, height/width ratio (H/W) of the aorta. Using ultrasound, we measured carotid artery intima-media thickness (IMT) and stiffness index and distensibility, as well as right brachial artery flow-mediated dilation (FMD) and glyceryl trinitate (GTN)-induced dilatation, to assess the precoarctation vasculature of these subjects. RESULTS: Gothic arch type was associated with higher carotid IMT and stiffness index, lower carotid distensibility (p < 0.001 for all), and lower brachial reactivity (FMD, p < 0.01; GTN response, p < 0.001) compared with Crenel and Romanesque geometries and with control subjects. The height/width ratio was also significantly related to these vascular abnormalities. Even in CoA subjects with Romanesque arch geometry, arterial function and stiffness parameters were significantly impaired compared with control subjects. CONCLUSIONS: In young adult survivors of anatomically successful CoA repair, a gothic-type aortic arch with high H/W is associated with abnormal IMT, higher aortic stiffness index, and impaired arterial reactivity in the pre-CoA vasculature.     

Hybrid procedure of bilateral pulmonary artery banding and bilateral ductal stenting in an infant with aortic atresia and interrupted aortic arch

We report an infant with aortic valve atresia, interrupted aortic arch, ventricular septal defect, confluent pulmonary arteries, bilateral arterial ducts, absent common carotid arteries, and anomalous coronary arteries arising from main pulmonary artery. Hybrid procedure consisting of bilateral pulmonary artery banding and bilateral arterial duct stenting was performed at 4 weeks of age. Hybrid procedure can be an alternative palliative approach in an infant with this complex cardiac anatomy. © 2014 Wiley Periodicals, Inc.     

Endovascular coil embolization of a complex aortic arch pseudoaneurysm following arch stenting

Pseudoaneurysm formation is a life‐threatening complication of thoracic aortic stenting due to the high risk of rupture. When located in the aortic arch, anatomic features may pose difficulties in choosing the optimal treatment strategy. Here, we describe the first poststenting aortic arch pseudoaneurysm treated by endovascular coil embolization. This approach, which we performed in a multidisciplinary setting, may be a feasible alternative in patients not considered suitable for open repair or stent‐grafting. As an acute pseudoaneurysm may develop and rapidly expand during the first days after aortic stenting, early follow‐up imaging is preferable.     

Feasibility of the 3D RCA catheter to engage the brachiocephalic vessels during carotid angiography and stenting

Background : Engagement of the brachiocephalic vessels during carotid angiography is performed using a JR‐4, Vitek, or other catheters with variable success. These catheters require additional training for safe manipulation. In this study, we evaluated the feasibility of using the 3D RCA catheter which requires less manipulation in the aorta, and less training, to engage the brachiocephalic vessels. Methods : We prospectively studied consecutive high‐risk patients undergoing carotid angiography and stenting from August 2005 to March 2009 at our institution. A baseline aortogram was performed to define the arch type in all patients. Engagement of the brachiocephalic vessels was initially attempted using the 3D RCA catheter using the following approach: The 3D RCA catheter is positioned in the ascending aorta beyond the brachiocephalic vessels take off. The natural curve of the catheter usually makes it point cephalad spontaneously in most patients and as it is gently withdrawn it engages the aortic arch vessels without much manipulation. Clinical follow‐up with a neurological exam was performed at one month and six months. Results : A total of 52 patients were enrolled in this study. Baseline demographics and aortic arch types encountered are listed in Table I . The 3D RCA catheter readily engaged the brachiocephalic vessels in 50/52 patients (96.0 %) in our cohort of patients undergoing carotid angiography. Of the 52 patients, 43 subsequently underwent carotid stenting and shuttle sheath placement was facilitated by initial engagement of the relevant common carotid artery with the 3D RCA catheter. There was one transient neurologic complication that resolved by 5 days in a patient that underwent carotid stenting. Conclusions : The 3D RCA catheter can be used with a high success rate to engage the brachiocephalic vessels in all 3 arch types, including a bovine arch during carotid angiography and facilitates shuttle sheath placement for carotid stenting. It requires less manipulation and therefore may be a more operator friendly approach. © 2010 Wiley‐Liss, Inc.     

鼻咽癌放疗后主动脉弓上动脉狭窄血管内支架置入的疗效分析

目的探讨血管内支架置入治疗鼻咽癌放疗后主动脉弓上动脉狭窄病变的疗效。方法回顾性分析8例鼻咽癌放疗后症状性主动脉弓上动脉中重度狭窄行血管内支架置入术患者的临床资料,观察治疗后脑缺血症状的改善情况。通过颈部血管彩色多普勒血流显像随访。结果 8例患者均经全脑DSA证实,主动脉弓上颅外段共有中重度狭窄动脉24处,其中包括颈内动脉11处,颈总动脉2处,椎动脉10处,锁骨下动脉1处。(1)经血管扩张成形及支架置入后,血管腔残余狭窄率平均20%。术后复查头部CT未见出血。术后定期复查颈部血管彩色多普勒血流显像,显示血管形态良好,血流通畅,未见支架内血栓形成及再狭窄,无过度灌注等不良事件发生。(2)随访1年所有患者无再发脑缺血症状,颈部血管彩色多普勒血流显像未发现明显再狭窄。结论血管内支架置入是鼻咽癌放疗后主动脉弓上动脉狭窄可以选择的治疗方法。     

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.     

Contralateral transradial approach for carotid artery stenting: A feasibility study

Background : Carotid artery stenting (CAS) has become an accepted modality of treatment for revascularization of the internal carotid artery (ICA). CAS from femoral approach has got wide acceptance, however, it can be problematic due to access site complication as well as technical difficulties related to peripheral vascular disease and/or anatomical variations of the aortic arch. Small feasibility studies of CAS through ipsilateral transradial approach have been described in the literature. The purpose of the present study is to evaluate the feasibility of contralateral transradial approach as an alternative approach for CAS. Methods : Twenty patients (mean age: 65 ± 5, 17 male) underwent CAS using contralateral transradial approach. All had a CA stenosis greater than 80%. The target common carotid artery (CCA) was initially cannulated via the contralateral radial artery using a 5F Simmons 1 diagnostic catheter or a 5F TIG diagnostic catheter, which was then advanced to the external CA (ECA) over an exchange length of 0.032″ Terumo Glidewire or a 0.025″ Glidewire. Once the catheter was parked in the optimal position in ECA, the wire was removed and was replaced by 0.035″ Amplatz Super stiff Guide wire. Following that, the Simmons 1 or the TIG catheter was removed and 6F Pinnacle Sheath was exchanged and positioned in the distal CCA. CAS was performed using standard techniques with weight‐based heparin for anticoagulation. Results : CAS was successful in 16/20 (80%) patients, including 12/12 (100%) right CA, 4/8 (50%) left CA. Mean interventional time was 40 ± 5 min. The sheath was removed immediately after the procedure. There were no radial access site complications. One patient sustained a transient ischemic attack and recovered completely with complete resolution of symptoms within 1 hr. Median Hospital stay was 3 ± 0.5 days. Angulation of left CCA with the aortic arch was the technical cause of failure in the four unsuccessful cases. Conclusion : CAS using the contralateral transradial approach appears to be safe and technically feasible. The technique may be particularly useful in patients with right ICA lesions because of the favorable right CCA angle with the aortic arch. © 2009 Wiley‐Liss, Inc.     

Left recurrent laryngeal nerve palsy following aortic arch stenting: A case report

BACKGROUND Aortic arch stenting is continuously emerging as a safe and effective option to alleviate aortic arch stenosis and arterial hypertension.CASE SUMMARY We present a 15-year-old girl with aortic arch hypoplasia who had undergone implantation of an uncovered 22 mm Cheatham-Platinum stent due to severe(native) aortic arch stenosis. On follow-up seven months later, she presented a significant re-stenosis of the aortic arch. A second stent(LD Max 26 mm) was implanted and both stents were dilated up to 16 mm. After an initially unremarkable post-interventional course, the patient presented with hoarseness five days after the intervention. MRI and CT scans ruled out an intracranial pathology, as well as thoracic hematoma, arterial dissection, and aneurysm around the intervention site. Laryngoscopy confirmed left vocal fold paresis attributable to an injury to the left recurrent laryngeal nerve(LRLN) during aortic arch stenting, as the nerve loops around the aortic arch in close proximity to the area of the implanted stents. Following a non-invasive therapeutic approach entailing regular speech therapy, the patient recovered and demonstrated no residual clinical symptoms of LRLN palsy after six months.CONCLUSION Left recurrent laryngeal nerve palsy is a rare complication of aortic arch stenting not previously reported.     

Supported percutaneous coronary intervention using a novel 6‐Fr intra‐aortic balloon pump catheter via the brachial artery in a nonagenarian patient with an abdominal aortic aneurysm

Intra‐aortic balloon pump (IABP) counterpulsation is a useful hemodynamic assist device during complex percutaneous coronary intervention (PCI) in patients with poor left ventricular function; however, the presence of an abdominal aortic aneurysm poses a problem, because insertion via the femoral artery may cause distal embolism and aneurysm rupture. A 92‐year‐old man with unstable angina was admitted to our hospital. Coronary angiography revealed chronic total occlusion of the proximal left anterior descending artery and severe stenosis of the left circumflex artery (LCX). The left ventricular ejection fraction was 36%. He also had an infrarenal abdominal aortic aneurysm with a diameter of 55 mm. Supported PCI was performed for the management of the LCX lesion. A novel 6‐Fr IABP catheter was inserted via the left brachial artery. The lesion was successfully dilated, and a 3.0 × 13 mm Cypher® stent was placed. After the PCI procedure, the IABP catheter was retrieved in the catheter laboratory, and the patient was discharged after 7 days. When a femoral approach is contraindicated in PCI, 6‐Fr IABP catheter insertion via the brachial artery is feasible and effective. © 2011 Wiley‐Liss, Inc.     

Gastroepiploic artery graft angiography via brachial approach using a Yumiko catheter.

We report here our initial experience in angiography of gastroepiploic artery (GEA) grafts via a brachial approach using the Yumiko catheter regarding technical aspect. Good-quality GEA angiography was obtained in 12 (86%) of 14 patients using our technique. GEA graft angiography can be performed using the Yumiko catheter via a brachial approach. This technique may be less stressful for patients receiving coronary catheterization, including GEA graft angiography.     

Brachial artery approach for transluminal angioplasty of the internal carotid artery

One possible problem in internal carotid angioplasty is inacessibility of the lesion due to elongation of the aortic arch, the brachiocephalic trunk, or the carotid artery itself. A new approach to performing angioplasty of the right or left internal carotid artery utilizing the brachial artery was used after failure of the transfemoral approach in 5 lesions (4 patients). The common carotid artery was cannulated with preformed 5F catheters. Angioplasty was performed with a conventional balloon dilatation catheter. If required, a Wall stent was implanted to optimize the angiographic result. After failure of the conventional transfemoral technique, the brachial technique permitted successful angioplasty of the ipsilateral internal carotid artery in 4 lesions and the contralateral internal carotid artery in 1 lesion. In 1 patient, a stent was implanted. No complications occurred. The mean stenosis diameter decreased from 77.8 ± 6.3% to 17.8 ± 9.1%. Doppler sonography performed 4–6 months later showed no restenosis. The brachial artery approach seems to be a suitable alternative to the femoral technique. © 1996 Wiley-Liss, Inc.     

Transbrachial intra-aortic balloon pumping for high-risk percutaneous coronary intervention

The beneficial effect of placement of intra-aortic balloon (IAB) pump before revascularization in patients with high-risk coronary anatomy and impaired left ventricular systolic function is documented. However, the conventional insertion of IAB pump via the common femoral artery may be contraindicated or may be even impossible in patients with severe vascular disease. Recently, the percutaneous insertion of IAB via the brachial artery has been shown to be effective and safe in small series of patients with vascular disease undergoing coronary artery bypass surgery. The authors report their experience with a patient with aortobifemoral bypass grafts who underwent successful stenting of a trifurcating distal left main stenosis after placement of a 7.5-Fr IAB pump via the left brachial artery.     

Complete repair of the interrupted aortic arch by an anterior approach. Apropos of 9 cases

Interrupted aortic arch is a duct-dependent heart disease, and this is why the use of prostaglandins E, which keep the ductus arteriosus open to feed the descending aorta, has transformed its formerly sombre prognosis. The authors report the cases of 9 neonates and infants presenting with interrupted aortic arch associated with ventricular septal defect who underwent total repair of the malformations under extracorporeal circulation. Five children were less than 10 years' old. The aortic lesions were of type A in 2 cases (interruption distal to the left subclavian artery) and of type B in 7 cases (interruption between the left carotid and subclavian arteries). In the second group the lesions were of type B1 in 5 cases (without retro-oesophageal right subclavian artery) and of type B2 in 2 cases (right retro-oesophageal artery distal to the interruption). There was one death (11 p. 100). So far, no child has been reoperated upon for residual aortic obstruction or reopened ventricular septal defect. This technique of total repair in one stage, with closure of the ventricular septal defect, seems to be preferable to the two-stage technique in which stage one includes, in addition to aortic arch repair, cerclage of the pulmonary artery, a procedure with numerous disadvantages and a higher overall mortality rate.     

Video‐assisted Thoracoscopic Surgery: Is It a Superior Technique for the Division of Vascular Rings in Children?

Objective. The use of video‐assisted thoracoscopic surgery (VATS) is becoming increasingly common in the treatment of congenital heart defects, particularly for the division of vascular rings. We compare the short‐term outcomes of vascular ring division by VATS as opposed to open thoracotomy and discuss new issues raised by VATS division of vascular rings. Methods. Over a 3‐year period, 47 pediatric patients underwent isolated division of a vascular ring. We reviewed preoperative, operative, and postoperative data. For patients whose vascular ring contained a ligamentous or atretic segment, comparisons were made between operations performed by open thoracotomy and by VATS. Results. For the 47 patients, diagnoses included right aortic arch/aberrant left subclavian artery/left ligamentum arteriosum (25), double aortic arch/right dominant (19), and double aortic arch/left dominant (3). At the time of repair, ages ranged from 1.4 to 207 months (median 15.0) and weights ranged from 2.8 to 54.0 kg (median 11.0). The 29 patients with a vascular ring containing a ligamentous or atretic segment were included in the comparison between open thoracotomy and VATS. This included 25 patients with a right aortic arch, aberrant left subclavian artery, and ligamentum arteriosum, and 4 patients with a right dominant double aortic arch in which the left arch was atretic. Patients with patent rings requiring clamping and oversewing of the vessels were not included in the comparison. Thoracoscopic division was successful in 14/16 (88%) patients. There was no significant difference in the procedure time (P = .48) with the thoracoscopic approach. There were also similar times for intensive care unit stay (P = .25) and total length of hospital stay (P = .22). Conclusions. The division of vascular rings by VATS shows similar outcomes compared with the open thoracotomy approach. It is expected that, with an increase in comfort level and further improvements in technology, the use of VATS can be extended to include patients with other congenital heart defects.