Percutaneous coronary intervention for diffuse coronary artery disease

Patients with diffuse coronary artery disease present a significant management problem. It has been proposed that diffuse coronary disease is unsuitable for balloon angioplasty and surgical treatment is not ideal either. We review the evidence that coronary balloon angioplasty is not a suitable treatment for diffuse coronary disease and examine the role of alternative interventional techniques. New techniques including long angioplasty balloon catheters and atherectomy devices have shown promise. If this is confirmed by prospective randomized trials then coronary angioplasty may yet prove an attractive treatment for diffuse coronary disease.     

Endoscopic ultrasound access,therapy, and treatment of gastrointestinal bleeding

The first line of therapy for gastrointestinal bleeding is endoscopic treatment. However, there is a subset of patients in whom standard endoscopic hemostatic treatment fails or is considered unsuitable. Historically, these patients underwent surgical or interventional radiologic procedures to manage the refractory bleed. Endoscopic ultrasound has recently been used to help detect and offer alternative approaches to treatment and potentially improve patient outcome for these difficult-to-treat lesions. This article serves as a review of the novel endoscopic ultrasound techniques used to treat gastrointestinal bleeding.     

Angina abdominalis: duplex ultrasound diagnosis and percutaneous revascularization

Intestinal ischemia is still a challenge for clinicians and requires a close interdisciplinary cooperation between internist, surgeon and radiologist. In the last years the diagnosis and therapy, classically invasive and surgical, was supplemented by duplex ultrasound and percutaneous techniques like angioplasty and stenting. A 56 year-old man from Greece presented with epigastric pain, which was intensified by food ingestion. These symptoms were caused by a stenosis of the superior mesenteric artery, which was diagnosed by duplex sonography and angiography. No blood flow was detected in the inferior mesenteric and the celiac artery. Occlusion of one internal carotid artery made the patient a poor candidate for surgery. Therefore an interventional approach was chosen. A good result was achieved by angioplasty and stent implantation. On the day after the intervention oral food intake was possible without any pain. 18 months after the intervention the patient was free of abdominal symptoms. Therapy of mesenteric ischemia by percutaneous angioplasty and stenting is published only in case-reports and small series. Therefore the indication is mainly restricted to patients with a high risk for a surgical intervention.     

Balloon angioplasty for native coarctation of the aorta

Balloon angioplasty of native coarctations of the aorta is one of the most controversial facets of the pediatric interventional cardiologist's practice. We have evaluated the history and experimental rationale of this technology. Presently accepted techniques are outlined and controversies intrinsic in performance of this procedure are discussed. Acute, short-term, and long-term results are reviewed with particular emphasis on differences in success of the procedure as related to patient age. Common and significant complications are discussed and in some cases compared to analogous surgical complications. Newer technologies and approaches to interventional therapy for coarctation of the aorta are also discussed.     

Carotid Artery Stenosis: Who Should Undergo Surgery and Who Should Undergo Stenting?

Carotid angioplasty and stent implantation is a rapidly evolving treatment option currently under evaluation in several randomized trials. Although this technique needs some special technical skills and knowledge, it is technically simpler than many other interventional procedures. Current data indicate that the results regarding success rate and complication rate may be similar to surgery. It will take years to get the results of the randomized trials that are currently planed or have already started. Unfortunately, the results of these studies will not reflect the state-of-the-art because new stents and new protection devices will become available during these studies. Therefore, in clinical practice the decision has to be made depending on individual patient and lesion characteristics. Patients with concomitant diseases considered to be a risk factor for surgical procedures and patients with contralateral occlusion may be better candidates for angioplasty and stenting. However, patients with diffuse disease of the common carotid artery and patients with difficult vascular access may be better candidates for surgery.     

Prevention of restenosis after coronary angioplasty

PURPOSE OF REVIEW: Despite numerous advances in coronary interventional techniques, the frequent occurrence of restenosis continues to plague interventional cardiology. With the widespread use of drug-eluting stents, there is a need to reexamine critically the roles of the various interventional techniques currently available. RECENT FINDINGS: Drug-eluting stents have dramatically reduced the rates of restenosis and target vessel revascularization in a wide spectrum of patients with varying lesion morphologies. However, when restenosis does occur, it still tends to be dependent on the same factors that predict restenosis with bare metal stenting. The routine use of drug-eluting stents entails high initial costs to the health care system. Debulking as a means to improve outcomes after angioplasty has not lived up to expectations. Gene therapy is rapidly evolving into a viable means to reduce neointimal proliferation after angioplasty. SUMMARY: Careful patient selection and attention to the procedure of stent deployment optimize the results of angioplasty with drug-eluting stents. Because of cost considerations, drug-eluting stents should be used in patients who are expected to have the greatest absolute benefit. In this context, when judiciously used, conventional balloon angioplasty and bare metal stenting still have a definite role in the management of patients with obstructive coronary artery disease.     

Surgical removal of a ruptured, detached angioplasty balloon after popliteal stenting

Balloon catheter entrapment after stent implantation is a potential interventional complication. However, angioplasty balloon disconnection from the catheter shaft and in-stent entrapment is a very uncommon event that could have serious thrombotic or embolic consequences. The management of this event may be interventional or surgical, depending on the patient's status and the position of the balloon inside the vessel. We describe a case of acute lower limb ischemia after popliteal self-expandable stenting, due to loss of the balloon along with a portion of its shaft. Surgical retrieval was accomplished without any further complications.     

Unusual complication of retrograde dissection to the coronary sinus of valsalva during percutaneous revascularization: a single-center experience and literature review

BACKGROUND: While coronary dissection, which is one of the most frequently occurring complications during interventional procedures, has various forms, extensive coronary dissection retrograde to the coronary sinus of Valsalva (CSV) is very rarely observed. METHODS AND RESULTS: Within the last 5 years, we retrospectively reviewed our experience with 4,700 consecutive patients who underwent angioplasty procedures, 7 of whom (0.15%) developed extensive coronary dissection retrograde to the CSV. Six of the seven patients developed retrograde dissection of the right CSV during angioplasty to the right coronary artery. One of the seven patents developed retrograde dissection of the left CSV during angioplasty to the left anterior descending artery. Retrograde dissection, which extended to the ascending aorta in two patients, was observed by transthoracic echocardiography and surgical findings, respectively. Five patients were successfully treated by coronary stenting. However, this complication caused four patients to have acute myocardial infarctions, resulting in emergency surgery for one patient and in-hospital death for another. CONCLUSIONS: Our experience increased our understanding of this very rare complication. However, this complication may be life threatening, and patients in this clinical setting may have a potential risk for acute myocardial infarction, emergency surgery, or even sudden cardiac death. Therefore, it is important to learn how to promptly diagnose and manage this complication.     

Laparoscopic-Assisted Percutaneous Endoscopic Gastrostomy

There are a variety of techniques for gastrostomy tube placement. Endoscopic and radiologic approaches have almost entirely superseded surgical placement. However, an aging population and significant advancements in modern healthcare have resulted in patients with increasingly complex medical issues or postsurgical anatomy. The rising prevalence of obesity has also created technical challenges for proceduralists of many specialties. When patients with these comorbidities develop the need for long-term enteral nutrition and feeding tube placement, standard approaches such as percutaneous endoscopic gastrostomy (PEG) by endoscopists and percutaneous image-guided gastrostomy (PIG) by interventional radiologists may be technically difficult or impossible. For these challenging situations, laparoscopic-assisted PEG (LAPEG) is an alternative option. LAPEG combines the advantages of PEG with direct intraperitoneal visualization, helping ensure a safe tube placement tract free of intervening organs or structures. In this review, we highlight some of the important factors of first-line gastrostomy techniques, with an emphasis on the utility and procedural technique of LAPEG when they are not feasible.     

New approaches to redo-coronary bypass grafting

Patients presenting with recurrent symptoms after coronary artery bypass graft surgery (CABG) continue to be a significant therapeutic challenge for the interventional cardiologist and cardiac surgeon. Percutaneous transcatheter angioplasty and repeat CABG, directed at vein graft degeneration and progression of native atherosclerotic disease, carry substantially worse outcomes than primary procedures. Recent minimally invasive, surgical advances using minimal-access incisions, arterial conduits, and off-pump techniques are demonstrating improved hospital outcomes compared with conventional CABG. These sternotomy-sparing, beating heart surgical approaches combined with recent advances in drug-eluting stents to provide complete revascularization may provide the best cardiac event-free survival for symptomatic CABG patients in the future.     

Image guided percutaneous gastrostomy catheter placement: How we do it safely and efficiently

Gastrostomy tube is an effective and safe long-term feeding access that is welltolerated by patients.The typical placement routes include surgical,endoscopic and interventional radiologic placement.In particular,percutaneous interventional radiologic gastrostomy(PIRG)has increasingly become the preferred method of choice in many practices.Although many PIRG techniques have been developed since the 1980s,there is still a paucity of evidence supporting the choice of a most-optimal PIRG technique.Hence,there is a large variation in institutional approach to PIRG.We are a large,quaternary academic institution with an extensive experience in PIRG.Therefore,we aim to present the“push”PIRG technique utilized in our institution,to review the current literature,to discuss the optimal choice of PIRG technique and to generate further interests in comparison studies.     

Chronic Thromboembolic Pulmonary Hypertension: Evolving Therapeutic Approaches for Operable and Inoperable Disease

Chronic thromboembolic pulmonary hypertension (CTEPH), a rare consequence of an acute pulmonary embolism, is a disease that is underdiagnosed, and surgical pulmonary thromboendarterectomy (PTE) remains the preferred therapy. However, determination of operability is multifactorial and can be challenging. There is growing excitement for the percutaneous treatment of inoperable CTEPH with data from multiple centers around the world showing the clinical feasibility of balloon pulmonary angioplasty. Riociguat remains the only approved medical therapy for CTEPH patients deemed inoperable or with persistent pulmonary hypertension after PTE. We recommend that expert multidisciplinary CTEPH teams be developed at individual institutions. Additionally, optimal and standardized techniques for balloon pulmonary angioplasty need to be developed along with dedicated interventional equipment and appropriate training standards. In the meantime, the percutaneous revascularization option is appropriate for patients deemed inoperable in combination with targeted medical therapy, or those who have failed to benefit from surgery.     

Percutaneous transluminal angioplasty of the inferior right hepatic vein for the treatment of Budd-Chiari syndrome

Budd-Chiari Syndrome is one of the several causes of portal hypertension and is characterised by hepatomegaly, ascites and abdominal pain. The treatment requires either medical or interventional/surgical procedures. A case of Budd-Chiari Syndrome with a membranous web that causes obstruction in the ostium of the inferior right hepatic vein is reported here which was treated by percutaneous transluminal angioplasty (PTA). The patient was asymptomatic and off medication and there was no recurrence after 18-months follow-up.     

Provisional stenting for symptomatic intracranial stenosis using a multidisciplinary approach: acute results, unexpected benefit, and one-year outcome.

Percutaneous techniques have dramatically changed our approach to coronary and peripheral revascularization. Intracranial atherosclerosis is a highly morbid disease; however, techniques for revascularization are still in evolution. The authors comprise a multidisciplinary team of neurologists, neuroradiologists, and interventional cardiologists who have collaborated in treating fifteen patients with symptomatic intracranial stenosis who have failed medical therapy. The acute success rate (100%) and one-year freedom from death and stroke (93.4%) using balloon angioplasty and provisional stenting are encouraging. A surprising observation in this patient cohort was that 53% of patients had improvement or resolution of a deficit that was chronic and presumed to be permanent and irreversible. This type of chronic but reversible deficit is termed "brain angina". The background, rationale for a multidisciplinary team, techniques, and preliminary results of intracranial angioplasty with provisional stenting are presented.     

The place of rotablator for treatment of in-stent restenosis.

In-stent restenosis (ISR) is still a growing problem in interventional cardiology due to the increasing number of stent implantations. Various treatment modalities are available at present. As a non ablative strategy balloon angioplasty is the strategy of choice for focal ISR, while ablative techniques such as directional coronary atherectomy, Excimer laser coronary angioplasty and rotational atherectomy are used preferentially in diffuse restenosis processes. These debulking techniques are optimized by peri-interventional use of intravascular ultrasound and adjunctive balloon angioplasty. Study data comparing different interventional approaches, usually with adjunct balloon angioplasty, have not proven an optimal treatment modality for ISR yet.     

Spontaneous coronary artery dissection on the 10th post-partum day: a case report

Spontaneous coronary artery dissection is a rare cause of myocardial infarction. It most commonly occurs in young women in the peri-partum period. The aetiology remains obscure. The authors describe the case of a 38 year old woman who suffered an inferior wall myocardial infarction on the 10th post-partum day. After failure of thrombolysis, coronary angiography showed dissection of the right coronary artery. An attempted angioplasty was unsuccessful and the patient was treated medically with a favourable clinical outcome. Spontaneous coronary artery dissection should be considered in all young patients without coronary risk factors presenting with acute myocardial ischaemia, especially young women in the peri-partum period. Emergency coronary angiography should be undertaken to establish the diagnosis and orientate appropriate treatment which may be medical, interventional or surgical.     

Therapie der Mitralklappeninsuffizienz

Surgical mitral valve repair has constantly evolved to become the standard of care for severe mitral regurgitation (MR) with superior acute and long-term results compared to valve replacement. Minimally-invasive surgical techniques have been successful in reducing operative trauma while yielding equivalent or even superior results compared to the conventional sternotomy approach. However, due to elevated operative risk a growing proportion of patients are not referred for surgery, especially elderly patients with reduced ventricular function and functional MR who often present with relevant comorbidities. It is for these patients that transcatheter-based therapies may represent an attractive option. While most interventional techniques are still in experimental or early clinical stages of development, relevant clinical experience has been gained with the MitraClip? device. For successful implementation of a patient-centered mitral valve program, integration of surgical and interventional treatment modalities within a heart center is of paramount importance. This is best accomplished by an interdisciplinary dedicated heart team consisting of cardiologists and cardiac surgeons.     

Side effects and complications after hepatic artery embolization in the carcinoid syndrome

Twenty patients with histologically verified carcinoid liver metastases underwent a total of 24 liver artery embolizations by means of interventional radiologic techniques. There were no deaths. The postembolization syndrome, consisting of fever, abdominal pain, nausea, and vomiting, occurred in all the patients. Severe complications were rare, the most serious being multiple hepatic abscesses with septicemia in one patient, septicemia in another, and mild acute pancreatitis in a third. All these three patients recovered without any sequels from the embolization, and none required surgical intervention. The hepatic abscesses were drained percutaneously, guided by ultrasound. Hepatic artery embolization seems justified in patients with disabling symptoms from the carcinoid syndrome, as long as alternative therapy with the same benefit but fewer complications is not available.     

Wire-guided excimer laser coronary angioplasty: instrument selection, lesion characterization, and operator technique

Laser angioplasty has now been successfully performed on over 2,000 patients worldwide. Two systems (Advanced Interventional Systems, and Spectranetics, Corp.) have now received initial approval from the Food and Drug Administration. As with all new interventional techniques designed as an alternative to balloon angioplasty, there are a variety of instrument related issues that merit consideration in terms of patient selection as well as operator technique. While the ultimate role of laser angioplasty in the percutaneous revascularization of coronary artery disease remains to be established with certainty, laser angioplasty is, in fact, being currently used on a widespread basis as an alternative or an adjunct to balloon angioplasty in a large number of centers worldwide. Industry projections suggest that the use of this technique will increase further over the next decade. Accordingly, the purpose of this article is to discuss specific issues regarding instrumentation, native anatomical considerations, operator technique, and complications that relate specifically to the applied use of this technology as it is currently being used.     

Fibromuscular dysplasia of bilateral brachial arteries--a case report and literature review

Fibromuscular dysplasia (FMD) is a noninflammatory, nonatherosclerotic disease of the vascular system, that can affect intima, media, or adventitia. The dysplasia in these layers leads to decrease in the lumen and increased turbulence leading to diminished flow through the affected portion. The treatment of FMD thus far has been either surgical and/or interventional. The authors describe a patient who presented with painful digits and who was found to have bilateral brachial artery FMD and was treated with balloon angioplasty with complete resolution of symptoms.