Renal artery aneurysm endovascular repair.

A 68-year-old woman with a left renal artery aneurysm underwent successful endovascular repair with the use of a commercial type self-expanding stent-graft. Complete aneurysm exclusion was achieved after stent-graft expansion. A side branch vessel was occluded after stent-placement, resulting in a small upper lobe renal perfusion defect. There were no other complications. The aneurysm remained excluded and its greatest diameter has been reduced from 2.6 cm to 1.95 cm, 10 months after treatment. Renal function remained normal.     

Percutaneous transradial artery approach for femoro- popliteal artery intervention in the current era in Japan

The percutaneous transradial artery approach for coronary angiography and intervention has been recognized as a safe and effective method, however, it is limited for endovascular therapy (EVT) for femoro-popliteal artery because of lack of devices with longer shaft. Herein, we report two EVT cases for superficial femoral artery disease treated with a long shaft balloon through the radial artery. Although femoro-popliteal artery intervention with this approach has several limits for available devices and technical issues, it is effective for particular patients who are impossible in EVT with femoral artery approach.     

Management of spontaneous coronary artery dissection in the primary percutaneous coronary intervention era

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndromes. The increasing use of early angiography in the primary percutaneous coronary intervention (PPCI) era has led to earlier identification of patients with SCAD and may encourage an increased use of percutaneous revascularization strategies in this population. However, the pathophysiology of SCAD is distinct from the usually stenotic atherosclerotic plaque-rupture events responsible for most ST-elevation and non-ST-elevation myocardial infarctions, but our approach to managing these patients utilizes largely the same medical and revascularization therapies used in conventional acute coronary syndromes. This review examines the literature on SCAD and contemporary management issues.     

Renal artery aneurysm: An endovascular treatment for a rare cause of hypertension

Renal artery aneurysms are a rare cause of secondary hypertension. Endovascular treatment with a polytetrafluoroethylene (PTFE)-coated stent can exclude aneurysms and treat hypertension. We report the case of a 23-year-old man with hypertension diagnosed three years earlier and in whom renal angiography revealed three aneurysms involving the right renal artery. A covered stent was implanted, resulting in successful exclusion of the aneurysm. Ten months after the procedure the patient is asymptomatic and with normal blood pressure without antihypertensive therapy.     

Application of endovascular pure electrocoagulation in the management of coronary artery perforation during percutaneous coronary intervention

Coronary artery perforation(CAP)during percutaneous coronary intervention(PCI)is a serious complication associ- ated with significant morbidity and mortality.It...     

Renal artery stenosis: epidemiology, clinical manifestation, and percutaneous endovascular therapy

Renal artery stenosis may cause or deteriorate arterial hypertension and/or renal insufficiency. Technical improvements of diagnostic and interventional endovascular tools have lead to a more widespread use of endoluminal renal artery revascularization and extension of the indications for this type of therapy. Since the first renal artery angioplasties performed by Felix Mahler and Andreas Grüntzig in 1978, numerous single-center studies have reported the beneficial effect of percutaneous transluminal renal angioplasty, and since the early 1990's stenting of renal artery stenosis caused either by atherosclerosis or by fibromuscular dysplasia. This article summarizes the impact of technical improvements of endovascular tools on interventional techniques during the last decade and gives an overview concerning the clinical impact of renal artery revascularization. Despite the absence of sufficient randomized studies, there is nonetheless evidence that stenting of hemodynamically relevant atherosclerotic renal artery stenosis has an impact on blood pressure control, renal function, and left ventricular hypertrophy.     

Rescue percutaneous coronary intervention early after coronary artery bypass grafting in the drug-eluting stent era

Ten patients underwent rescue percutaneous coronary intervention for myocardial infarction or ischemia soon after coronary artery bypass grafting, and 6 received drug-eluting stents (DESs). Outcomes were limited primarily by bleeding events. There was 1 episode of DES thrombosis after antiplatelet therapy was discontinued due to gastrointestinal hemorrhage. Rescue percutaneous coronary intervention is a feasible approach to reestablish coronary perfusion in the perioperative period, but DESs should be used only after appropriate risk stratification for potential bleeding complications that may require the withdrawal of antiplatelet therapy.     

Successful urgent endovascular surgery for symptomatic subclavian artery aneurysmal compression of the trachea.

The purpose of this study is to report the progress of a patient who entered the hospital with symptomatic tracheal compression from a large right subclavian artery aneurysm that was treated with a self-expanding stent graft. The patient was at increased risk for traditional surgery, thus endovascular isolation of the aneurysm was felt to be reasonable. A flexible self-expanding stent graft was placed via a brachial artery cutdown and common femoral access without complication. The symptoms improved and the patient remained asymptomatic at 2-year follow-up with serial CT scan confirmation of aneurysm regression. This unusual case illustrates that endovascular decompression of an aneurysm may have some benefit in alleviating subacute symptoms of extrinsic encroachment into other vital structures. Technical and clinical success was achieved with the stent graft deployment and this seems to be a reasonable alternative to surgery in such patients.     

Low-dose protamine to facilitate earlier sheath removal from the femoral artery after peripheral endovascular intervention

Objectives: This study aimed to evaluate the safety of low‐dose protamine administration to facilitate earlier vascular sheath removal. Background: Vascular access complications are the most common cause of postprocedural morbidity in patients undergoing peripheral endovascular intervention (PEI). Prolonged manual compression and closure devices do not eliminate these complications. Methods: A consecutive series of 166 patients who underwent PEI were retrospectively compared to an all‐comers control group of 136 patients who did not receive protamine. The study population received an intravenous dose of protamine based upon the dose of heparin received and the length of the procedure. The arterial sheath was removed when activated clotting time was less than 220 seconds. Primary end‐points included bleeding complications, comprised of groin hematomas and retroperitoneal bleeding, and vascular complications, comprised of pseudoaneurysms, access vessel thrombosis, and arteriovenous fistula formation. Results: The study population on average was older than the control group (71 vs. 67 years) and had a higher incidence of hypercholesterolemia (89.8% vs. 76.5%, P = 0.002). The average dose of protamine was 1.9 ± 0.83 mg, with a total dose of heparin of 5371 ± 1327 units. The time until sheath removal was 8.9 ± 8.6 minutes in the protamine group versus 188 ± 118 minutes in the control group (P < 0.001). There were no episodes of protamine anaphylaxis or adverse reactions. The access site complication rate between the 2 groups was statistically insignificant. Conclusions: This strategy offers an inexpensive, safe, and reliable method to achieve hemostasis and facilitate earlier sheath removal in patients undergoing PEI. (J Interven Cardiol 2011;24:278–284)     

Prophylactic endovascular management of peripheral artery disease in elderly candidates prior to cardiac surgery

Background and objectives Peripheral vascular disease (PVD) is a major risk factor in candidates for cardiac surgery and can impact morbidity and mortality in the perioperative and follow-up period. Elderly patients with PVD may benefit from endovascular treatment prior to cardiac surgery. We sought to assess the common clinical settings requiring prophylactic endovascular treatment before coronary surgery in elderly patients, the results, and the mid-term impact on subsequent revascularization. Methods Between November 2002 and June 2006, 37 patients (25 males, mean age 79.9±8.3 years, mean serum creatinine 1.9±0.6 mg/dl) underwent endovascular repair of PVD before cardiac surgery. For each patient, diagnostic methods, indications for intervention, types of interventions, procedural success, and complications were recorded. Results Four clinical settings were identified: renal artery stenting prior to coronary surgery (7 patients), iliac artery angioplasty and stenting (10 patients) in order to facilitate aortic balloon pump insertion after surgery, subclavian artery angioplasty and stenting prior to utilization of ipsilateral arterial conduits bypass surgery (5 patients), and carotid artery stenting before coronary surgery (15 patients). Technical success was achieved in all patients (100%); complications included brachial artery occlusion (1 patient), minor stroke (2 patients), contrast nephropathy (1 patient), and minor bleeding at the puncture site (3 patients). All patients underwent successful coronary or valvular surgery; no patients died in the perioperative period. After a mean follow-up of 26.6±3.1 months, all patients are alive and free from anginal symptoms or valvular dysfunction without clinical or Doppler ultrasonography evidence of restenosis of the implanted peripheral vascular stents. Conclusions It is not unusual for elderly patients who are candidates for cardiac surgery to require endovascular intervention for significant PVD prior to coronary bypass or valvular surgery. The results showed a low complication rate. The cardiologists have a fundamental role, not only in the diagnosis of peripheral vascular stenosis, which was seen frequently in patients with significant CAD, but also in the appropriate endovascular management of these high-risk patients.     

Cardiac events after non-cardiac surgery in patients with previous coronary intervention in the drug-eluting stent era

The peri-operative risk for patients with coronary drug-eluting stents (DES) who subsequently have non-cardiac surgery (NCS) is unclear. We performed this retrospective study of all patients in our institution who had coronary intervention and subsequent NCS from 2003 through December 2008 to evaluate the incidence of major adverse cardiac events (MACE) in patients who received DES compared to those who received bare-metal stents (BMS) or had percutaneous transluminal coronary angioplasty (PTCA) during the same time period. The main outcome measures were 30-day post-operative myocardial infarction, stent thrombosis, target vessel revascularization (TVR) and cardiac death. During the 6-year study period, 1,770 coronary interventions were performed and 238 patients subsequently had NCS in 8 days to 49 months. Eighteen patients had PTCA, 79 BMS and 141 DES. Acute myocardial infarction occurred in 1 patient who had PTCA, 2 who had BMS and 14 who had DES (p = 0.10). Stent thrombosis occurred in 6 patients who had DES and none who had BMS (p = 0.09). Seven patients who had DES had TVR compared to 1 patient who had BMS and none who had PTCA (p = 0.41). Cardiac mortality occurred in 2 patients who had DES and none who had PTCA or BMS (p = 0.35). In conclusion, the 30-day MACE in patients who received coronary DES and undergone NCS were not significantly different compared to those who received BMS or had PTCA only, with a trend toward higher stent thrombosis in the DES group.     

Increasing endovascular intervention for claudication: impact on vascular surgery resident training.

PURPOSE: To audit the caseloads of vascular surgery residents in the management of disabling claudication and assess the influence of endovascular procedures on overall operative experience. METHODS: A retrospective review was conducted of vascular surgery resident experience in the open and endovascular management of lower limb claudication during two 3-year periods (January 2000 to December 2002 and January 2003 to December 2005). The time periods differed with regard to number of surgical faculty with advanced endovascular skills (3 in the first period and 4 in the second) and the availability of portable operating room angiography equipment. RESULTS: During the 6-year period, the operative logs of vascular surgery residents indicated participation in 283 procedures [170 (60%) open surgical interventions, including 146 suprainguinal procedures] performed for claudication. The number of procedures increased by 62% (p<0.05) from the first period (n=108) to the second (n=175). Endovascular intervention to treat aortoiliac occlusive disease increased 4-fold (14 versus 56 interventions, p=0.01) compared to a decrease in open (bypass grafting, endarterectomy) surgical repair (45 to 31 procedures, p=0.22). The greatest change in resident experience was in endovascular intervention of infrainguinal occlusive disease: the case volume increased from 4 to 39 procedures (p=0.07) during the 2 time intervals. By contrast, the number of open surgical bypass procedures was similar (45 versus 49) in each 3-year period. CONCLUSION: An audit of resident experience demonstrated intervention for claudication has increased during the past 6 years. The increased operative experience reflects more endovascular treatment (atherectomy, angioplasty, stent-graft placement) of femoropopliteal and aortoiliac occlusive disease, but no decrease in open surgical operative experience for claudication. This increase in endovascular intervention may be related to a decrease in the threshold for intervention.