Catheter‐based therapy for acute ischemic stroke: A national unmet need

Early reperfusion therapy for acute stroke, similar to acute myocardial infarction, has the best opportunity to reduce morbidity and mortality. Treatment options include intravenous (IV) thrombolysis therapy and/or catheter‐based therapy (CBT). Catheter‐based therapies include local intra‐arterial thrombolysis, mechanical thrombectomy, and angioplasty techniques. Intravenous thrombolysis is limited to the first three hours after symptom onset, which excludes many patients with disabling stroke deficits. Catheter‐based therapy is effective up to seven hours after onset, but availability is limited by the lack of neurointerventionalists available around the clock to provide this care. To increase the number of providers for acute stroke reperfusion therapy, we have formed a multidisciplinary team to take advantage of cardiologists' carotid stent placement experience to provide continuous coverage for emergency reperfusion therapy. We present two cases of acute stroke treated with CBT by interventional cardiologists. © 2008 Wiley‐Liss, Inc.     

Acute stroke intervention for acute embolic procedural strokes performed by cardiologists

Acute ischemic stroke is a feared complication during cardiovascular procedures associated with high morbidity and mortality if not immediately recognized and treated. We conducted a review of cases at our center where patients experienced an acute, procedure-related ischemic stroke and underwent immediate endovascular stroke treatment by the interventional cardiologists trained in acute endovascular stroke intervention. Baseline demographics, procedural and follow-up data were collected. Three patients were identified in whom the percutaneous procedure (peripheral arterial intervention, transapical NeoChord [NeoChord Inc, Minnesota, USA] implantation and transcatheter aortic valve implantation, respectively) was complicated by an acute embolic ischemic stroke. In all cases, cerebral vessel re-canalization was technically successful with thrombolysis in cerebral infarction (TICI) IIB/III flow. Follow-up computed tomography scans showed no infarct demarcation, oedema or intracranial hemorrhage. One patient survived with no neurological symptoms at 6-month follow-up whereas the two other patients died of unrelated intensive care complications and decompensated heart failure. We conclude that endovascular stroke treatment during cardiovascular interventions can be performed by interventional cardiologists with appropriate training. It offers the unique opportunity to treat cerebral embolization in a time-efficient manner, potentially improving morbidity and mortality of affected patients.     

Multivessel peripheral revascularization for acute stroke intervention: Successful M2 bifurcation stenting and the growing case for comprehensive endovascular interventional training

A comprehensive endovascular skill set is desirable and key to successful intervention in the patient with complex cardiovascular disease. Acute stroke intervention is the next frontier for the endovascular specialist. We report a case of acute stroke intervention in a patient with severe peripheral vascular disease performed by interventional cardiologists with peripheral endovascular skills that clearly demonstrates the new paradigm of global revascularization. © 2010 Wiley‐Liss, Inc.     

Elective percutaneous intervention for intracranial atherosclerotic stenoses by interventional cardiologists

Background : Current “best” medical therapy with anti‐platelet and/or anti‐thrombotic agents for symptomatic atherosclerotic intracranial (IC) disease is associated with high recurrence. IC catheter‐based therapy (CBT) using balloon angioplasty with or without stent placement is an option for patients who have failed medical therapy. We sought to examine the outcomes of CBT for patients with symptomatic IC arterial disease managed by experienced interventional cardiologists. Methods : We retrospectively studied 89 consecutive symptomatic patients with 99 significant (≥70% diameter) IC arterial stenoses who underwent CBT. CBT was performed by experienced interventional cardiologists with the consultative support of a neurovascular team. The primary endpoint was stroke and vascular death. Results : Procedure success was achieved in 96/99 (97%) lesions and percent diameter stenosis was reduced from 91% ± 7.5% preprocedure to 19% ± 15% postprocedure (P < 0.001). The rate of in‐hospital periprocedural stroke and all death was 3%. The primary endpoint of stroke and vascular death rate at 1 year was 5.7% (5/88) and at 2 years was 13.5% (11/81). The 2‐year all‐cause mortality was 11.3% (10/88). Conclusions : For patients with symptomatic IC arterial stenosis who have failed medical therapy or are considered very high risk for stroke, CBT performed by experienced interventional cardiologists is safe and offers both high procedural success rates and excellent clinical outcomes at 1 year. CBT is an attractive option for this high‐risk patient population considering the expected 12–15% rate of recurrent stroke at 1 year. © 2012 Wiley Periodicals, Inc.     

Renal artery aneurysm treatment with coil embolization.

Renal artery aneurysm is a rare condition, but its incidence has increased through discovery because of improved imaging techniques. However, a therapeutic approach for renal artery aneurysm has not been established. We report the case of a 58-year-old female who had developed hypertension at 52 years of age and was under oral medication for this condition. In a medical check-up, a right renal artery aneurysm of 10 mm in diameter was detected by computed tomography (CT). Renal function was normal and there were no abnormalities in urinalysis; therefore, the patient was observed as an outpatient. Abdominal CT performed 9 months later revealed a saccular renal artery aneurysm of 15 mm in diameter with partial wall calcification and mild mural thrombus. Selective right renal arteriography detected a tumor with calcification, but no renal arterial stenosis or renal arteriovenous fistula. Since the aneurysm had enlarged, catheter treatment was selected to reduce the risk of rupture. A 6-Fr guide catheter was inserted into the right renal artery and the tip of a microcoil catheter was advanced into the aneurysm, which was then embolized with 12 microcoils. The absence of the aneurysm was confirmed using right renal arteriography. No complications occurred during or after embolization, and selective right renal arteriography performed 3 months later showed no change in the coil position or blood flow in the aneurysm, suggesting a good postoperative course. Our results suggest that this approach may generally be applicable for renal artery aneurysms, depending on the shape, size, and location of the aneurysm.     

Endovenous therapy for deep venous thrombosis: The TORPEDO trial

Objectives. We compared the efficacy and safety of percutaneous endovenous intervention (PEVI) plus anticoagulation with anticoagulation alone in the reduction of venous thromboembolism (VTE) and post‐thrombotic syndrome (PTS) in acute proximal deep venous thrombosis (DVT). Background. Recurrent VTE and PTS are common complications of DVT. There are no randomized trials investigating the efficacy of PEVI in the reduction of the above complications. Methods. Patients with symptomatic proximal DVT were randomized to receive PEVI plus anticoagulation or anticoagulation alone. Anticoagulation consisted of intravenous unfractionated heparin or subcutaneous low‐molecular weight heparin plus warfarin. PEVI consisted of one or more of a combination of thrombectomy, balloon venoplasty, stenting, or local low‐dose thrombolytic therapy. Results. At 6 months follow‐up, recurrent VTE developed in 2 of 88 patients of the PEVI plus anticoagulation group versus 12 of 81of the anticoagulation‐alone group (2.3% vs. 14.8%, P = 0.003). PTS developed in 3 of 88 patients of the PEVI plus anticoagulation Group and 22 of 81 of the anticoagulation‐alone group (3.4% vs. 27.2%, P < 0.001). Conclusions. In patients with symptomatic proximal DVT, PEVI plus anticoagulation may be superior to anticoagulation—alone in the reduction of VTE and PTS at 6 months. © 2010 Wiley‐Liss, Inc.     

Radiation‐induced peripheral artery disease

Radiation therapy is a cause of cardiovascular morbidity and mortality. This is due to the significant degree of atherosclerosis seen in the vessels in the vicinity of the area being irradiated. Radiation‐induced peripheral arterial disease is increasingly being recognized as large populations of cancer patients survive longer, yet it is a problem that is often under reported. Although it has most commonly been associated with carotid artery disease, all vascular beds are prone to this form of injury. The injury is accelerated by usual risk factors for atherosclerosis. Developing a healthy lifestyle, dietary prudence and the aggressive treatment of hypertension, diabetes mellitus, and dyslipidemia should all be encouraged in this patient population. When revascularization strategies are warranted, the percutaneous approach may be superior to open surgery as technical difficulties may arise in the fibrotic, scarred tissue. Stenting with distal embolic protection devices should be considered as the treatment of choice for patients with radiation‐induced carotid artery disease. Several reports also suggest good results with balloon angioplasty with or without stenting in the case of radiation‐induced renal, iliac, and femoral artery disease. Lifelong antiplatelet therapy may be appropriate. © 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.     

Rheolytic thrombectomy in patients with massive and submassive acute pulmonary embolism

Objectives : To appraise the impact of AngioJet rheolytic thrombectomy (RT) on angiographic and clinical endpoints in patients with acute pulmonary embolism (PE). Background : The management of patients with acute PE and hemodynamic compromise, based mainly on anticoagulant and thrombolytic therapies, is challenging and still suboptimal in many patients. In such a setting, mechanical removal of thrombus from pulmonary circulation holds the promise of significant clinical benefits, albeit remains under debate. Methods : We retrospectively report on 51 patients referred to our catheterization laboratory and treated with AngioJet RT. Patients were classified according to the degree of hemodynamic compromise (shock, hypotension, and right ventricular dysfunction) to explore thoroughly the degree of angiographic pulmonary involvement (angiographic massive PE was defined as the presence of a Miller index ≥ 17) and the impact on angiographic (obstruction, perfusion, and Miller indexes) and clinical (all‐cause death, recurrence of PE, bleeding, renal failure, and severe thrombocytopenia) endpoints of AngioJet RT. Results : Angiographic massive PE was present in all patients with shock, whereas patients with right ventricular dysfunction and hypotension showed a similar substantial pulmonary vascular bed involvement. Technical success was obtained in 92.2% of patients, with a significant improvement in obstruction, perfusion and Miller indexes in each subgroup (all P < 0.0001). Four patients reported major bleedings and eight (15.7%) died in‐hospital. Laboratory experience was significantly associated to a lower rate of major bleedings. All survivors were alive at long‐term follow‐up (35.5 ± 21.7 months) except three who expired due to cancer and acute myocardial infarction. Conclusions : In experienced hands AngioJet RT can be operated safely and effectively in most patients with acute PE, either massive or submassive, and substantial involvement of pulmonary vascular bed. © 2009 Wiley‐Liss, Inc.     

心血管介入医师在急性缺血性卒中处理中的地位与作用

卒中是中老年人致死、致残的主要原因之一.在美国,卒中是仅次于心脏病和癌症,位居第3的致死原因.据估计,美国每年有近80万人发生卒中,其中近90%为缺血性.在缺血性卒中之中,有70%～80%由直径较大的脑血管闭塞所致~([1]).流行病学资料显示,我国每年新发卒中患者在200万以上,每年约有150万人死于卒中.在卒中后存活的患者中,约有3/4患者遗留不同程度的残疾,给社会和家庭带来了沉重的经济和精神负担.     

心血管介入医师在急性缺血性卒中处理中的地位与作用

卒中是中老年人致死、致残的主要原因之一.在美国,卒中是仅次于心脏病和癌症,位居第3的致死原因.据估计,美国每年有近80万人发生卒中,其中近90%为缺血性.在缺血性卒中之中,有70%～80%由直径较大的脑血管闭塞所致~([1]).流行病学资料显示,我国每年新发卒中患者在200万以上,每年约有150万人死于卒中.在卒中后存活的患者中,约有3/4患者遗留不同程度的残疾,给社会和家庭带来了沉重的经济和精神负担.     

心血管介入医师在急性缺血性卒中处理中的地位与作用

卒中是中老年人致死、致残的主要原因之一.在美国,卒中是仅次于心脏病和癌症,位居第3的致死原因.据估计,美国每年有近80万人发生卒中,其中近90%为缺血性.在缺血性卒中之中,有70%～80%由直径较大的脑血管闭塞所致~([1]).流行病学资料显示,我国每年新发卒中患者在200万以上,每年约有150万人死于卒中.在卒中后存活的患者中,约有3/4患者遗留不同程度的残疾,给社会和家庭带来了沉重的经济和精神负担.     

Utilization of an aspiration thrombectomy catheter (Pronto) to treat acute atherothrombotic embolization during percutaneous revascularization of the lower extremity

Acute limb ischemia is typically a surgical emergency and can occur secondary to distal embolization during catheter‐based percutaneous revascularization. We present a case of acute atherothrombotic embolization to the left lower extremity after stenting of the left proximal popliteal and anterior tibial arteries. This was successfully treated with the use of the coronary aspiration thrombectomy device Pronto (Vascular Solutions, Minneapolis, MN) resulting in flow restoration. © 2008 Wiley‐Liss, Inc.     

Single center experience with percutaneous endovascular repair of superior vena cava syndrome

Objectives : To demonstrate short‐term effectiveness and long‐term efficacy of percutaneous transluminal angioplasty (PTA) with or without adjunctive therapy in treatment of superior vena cava syndrome (SVCS). Background : Recently, PTA with or without adjunctive therapy has evolved as first‐line therapy for SVCS. Despite growing evidence for PTA with or without adjunctive therapy, there are little data reflecting its short‐ and long‐term outcomes. Methods : We retrospectively reviewed 14 consecutive patients undergoing PTA with or without adjunctive therapy for SVCS, between July 2001 and September 2009. Results : A total of 14 patients (nine women; mean age, 49 ± 15 years) with SVCS underwent attempted PTA with or without adjunctive therapy. Causes of SVCS were indwelling catheters or pacemaker wires (n = 5), idiopathic (n = 5), thoracic outlet syndrome (n = 2), and cancer‐related thrombosis (n = 2). Obstruction of the SVC involved inflow branches in 86% of patients (n = 12). PTA with or without adjunctive therapy was attempted in all 14 patients and was angiographically successful in 93% (n = 13). PTA and stenting was performed in eight (57%) patients; three (21%) patients had PTA with thrombectomy/thrombolysis; one (7%) patient had PTA alone; and one (7%) patient had thrombectomy/thrombolysis alone. Symptom relief was seen in 86% (n = 12), and initial patency was 90%. There were no procedural complications. Mean follow‐up was 12 months, and no deaths were reported. In the 11 (79%) patients with follow‐up imaging, nine (82%) patients showed patency and two (18%) had residual symptoms, with one patient undergoing surgery. Conclusions : PTA with adjunctive endovascular stent therapy for SVCS is safe and effective at giving both rapid and sustained symptom relief. © 2011 Wiley‐Liss, Inc.     

Acute cerebral rescue during carotid artery stenting: A stroke of good fortune?

Major stroke is a potentially devastating complication of carotid artery revascularization. Carotid artery stenting, unlike endarterectomy, offers the opportunity to attenuate this complication by allowing for the instantaneous detection and early endovascular treatment of neurologic defects complicating the procedure. We report a case that highlights the utility of aggressive endovascular cerebral rescue during a carotid artery stent procedure. © 2008 Wiley‐Liss, Inc.     

Carotid artery stent placement is safe in the very elderly (≥80 years)

Background: Carotid artery stent (CAS) placement is an alternative to carotid endarterectomy (CEA) for stroke prevention. Clinical adoption of CAS depends on its safety and efficacy compared to CEA. There are conflicting reports in the literature regarding the safety of CAS in the elderly. To address these safety concerns, we report our single‐center 13‐year CAS experience in very elderly (≥80 years of age) patients. Methods: Between 1994 and 2007, 816 CAS procedures were performed at the Ochsner Clinic Foundation. Very elderly patients, those ≥80 years of age, accounted for 126 (15%) of all CAS procedures. Independent neurologic examination was performed before and after the CAS procedure. Results: The average patient age was 82.9 ± 2.9 years. Almost one‐half (44%) were women and 40% were symptomatic from their carotid stenoses. One‐third of the elderly patients met anatomic criteria for high surgical risk as their indication for CAS. The procedural success rate was 100% with embolic protection devices used in 50%. The 30‐day major adverse coronary or cerebral events (MACCE) rate was 2.7% (n = 3) with all events occurring in the symptomatic patient group [death = 0.9% (n = 1), myocardial infarction = 0%, major (disabling) stroke = 0.9% (n = 1), and minor stroke = 0.9% (n = 1)]. Conclusion: Elderly patients, ≥80 years of age, may undergo successful CAS with a very low adverse event rate as determined by an independent neurological examination. We believe that careful case selection and experienced operators were keys to our success. © 2008 Wiley‐Liss, Inc.     

Minimally invasive transradial intervention using sheathless standard guiding catheters

Objectives : We evaluated a sheathless transradial technique for interventions using standard five and six French nonhydrophilic guiding catheters. Background : Miniaturization of transradial interventions may serve to improve patient comfort and reduce the risk of access‐site complications. Guiding catheters carry an outer diameter approximately 2 Fr sizes smaller than their corresponding introducer sheaths. Methods : We identified consecutive patients who underwent transradial intervention between August 2010 and December 2010 using 5 or 6 Fr guides with a sheathless technique. Results : A total of 11 patients were identified (mean age 70.7 ± 10.9 years; 73% male). Single coronary intervention was performed in 10 patients and renal artery intervention in one. Right radial access and 6 Fr guide catheters were used in the majority (each 73%). Five techniques were used to create an inner dilator as the taper. Four of these inner tapers (standard diagnostic catheters, hydrophilic diagnostic catheters, long sheath dilators and guide extensions) enabled successful sheathless guide insertion in all 10 patients attempted. One technique (a partially inflated angioplasty balloon protruding from the guide) attempted in one patient was unsuccessful. All interventional procedures were successful, there were no radial artery access‐site complications and in no case was cross‐over to femoral artery access‐site required. Conclusion : Sheathless transradial intervention using standard 5 and 6 Fr guiding catheters is a safe and effective method for treatment of coronary and peripheral vascular lesions. © 2011 Wiley Periodicals, Inc.     

Interventional stroke therapy: current state of the art and needs assessment.

The primary therapeutic strategy for ischemic stroke, as for MI patients, is early reperfusion. Improvement in stroke treatment will require dedicated stroke centers to emulate MI quality indicators such as minimizing the "door-to-balloon time". A critical element in achieving this goal will be organizing the existing multidisciplinary pool of carotid interventionalists to provide the endovascular component of the acute care for ischemic stroke patients.     

The CAPTURE registry: predictors of outcomes in carotid artery stenting with embolic protection for high surgical risk patients in the early post-approval setting.

BACKGROUND: The use of carotid artery stenting with embolic protection has been practiced for over a decade in the United States, and increasingly so since carotid stenting received FDA approval in 2004. While there have been attempts at establishing predictors of outcomes in carotid artery stenting, they have generally been limited to single center experiences and/or multicenter retrospective surveys. This report examines predictors of outcomes in carotid stenting in the earliest and largest prospective multicenter neurologist-adjudicated experience in the United States post device approval. METHODS: The Carotid Acculink/Accunet Post-Approval Trial to Uncover Unanticipated or Rare Events (CAPTURE) is a prospective, multi-center registry conducted to assess outcomes of carotid artery stenting (CAS) in the noninvestigational setting following device approval for high surgical risk patients (symptomatic with > or =50% stenosis; asymptomatic > or =80% stenosis). A neurologist examined the patients before the procedure, at 24 hr and 30-days post-procedure. The primary endpoint was a composite of death, any stroke, or myocardial infarction within 30-days post-procedure. Strokes and neurological events suspected to be strokes were adjudicated by an independent Clinical Events Adjudication Committee (CEAC) using prespecified definitions. Logistic regression analysis was performed to determine clinical, procedural, and anatomic predictors of endpoint outcomes. RESULTS: Three thousand five hundred patients were enrolled at 144 sites by 353 physicians of varying specialty backgrounds and CAS experience. The 30-day primary endpoint event rate of death, stroke and MI was 6.3% [95% CI: 5.5-7.1%], and the rate of major stroke and death 2.9% [95% CI: 2.4-3.5]. Predictors of adverse outcomes included age, symptomatic patients, predilation prior to embolic protection device placement, time from symptoms to CAS procedure, and the use of multiple stents. CONCLUSIONS: In general, carotid stenting is performed safely in patients with severe stenosis at high surgical risk, with best outcomes in younger asymptomatic patients. However, there are certain patient and procedural characteristics that are associated with poorer outcomes. In these patients, the risk of stenting should be considered vis-à-vis both the anticipated benefit as well as the alternative surgical and medical options.     

Percutaneous retrieval of fractured bird's nest IVC filter penetrating into aorta

Inferior vena cava filters can provide lifesaving protections in patients with recurrent venous thromboembolic disease that are not candidates for anticoagulation. They are, however, associated with short‐ and long‐term complications necessitating frequent follow‐up. The authors report, in this article, a case of migration of Bird's Nest filter strut into the descending aorta and its percutaneous retrieval by snaring and capture. This case also underscores the trend to use retrievable filters to avoid longer‐term complications. © 2012 Wiley Periodicals, Inc.