Percutaneous endovascular abdominal aneurysm repair: State-of-the art.

Endovascular repair of abdominal aortic aneurysms emerged initially as an alternative treatment strategy for patients considered to be inoperable or high risk for surgery. The evolution of endovascular techniques has made this technology a safe and less invasive alternative to open surgery for patients with suitable aortic anatomy. This manuscript reviews the current state of the art for endovascular AAA repair techniques, clinical outcomes, guideline recommendations, and future applications.

Left Atrial Appendage Occlusion for Stroke Prevention.

More than 2.3 million adults in the United States have atrial fibrillation (AF), which exposes them to a 5-fold increased risk of stroke. The left atrial appendage (LAA) appears to be the source of thrombus formation in the vast majority of these patients. Anticoagulation significantly reduces the risk of stroke, but often we encounter patients who have absolute or relative contraindication to anticoagulation. Percutaneous LAA exclusion offers an alternative to anticoagulation to decrease the risk of stroke. Three device systems are currently available in the United States. The WATCHMAN® device is the most studied and approved by Food and Drug Administration (FDA) to be used in patients with AF unsuitable for anticoagulation who are at a high risk of stroke. The Amulet® device is currently being used as part of the AMPLATZER® Amulet® LAA Occluder trial, which is a non-inferiority randomized trial comparing the Amulet® to the WATCHMAN® device. The third device in use is the LARIAT®, which is an FDA approved snare and pre-tied stich system. It is used to approximate soft tissue which in this case is the LAA. It is a hybrid system and requires both epicardial and endocardial access. The main obstacle to percutaneous LAA closure is procedural related complications, which can be minimized with optimum operator experience.

Utility of extended cardiac monitoring to detect atrial fibrillation in patients with severe obstructive sleep apnea.

BACKGROUND: The relationship between obstructive sleep apnea (OSA) and increased risk for atrial fibrillation (AF) has been well established in previous studies. The relationship between OSA and silent AF is unknown. We hypothesized that patients with OSA but no known history of AF are at an increased risk for the arrhythmia and may be detectable by prolonged electrocardiogram (ECG) monitoring. In this study, we examined whether 7 days of extended cardiac monitoring with an ECG event recorder is an effective screening tool to detect intermittent, silent AF in patients with severe OSA. METHODS: The study was a prospective observational study. Randomly chosen patients with newly diagnosed severe OSA, apnea-hypopnea index (AHI) ≥ 30, were included. Demographic, medical history, and sleep data were collected. Patients with a history of AF or symptoms of palpitations were excluded from participating. Seven consecutive days of ambulatory ECG event recording (with Model ER920W, eCardio, Houston, TX) were performed prior to the initiation of CPAP treatment. RESULTS: A total of 20 subjects, with a BMI of 38.8 ± 12.2, successfully completed the study. The mean age group was 52.6 ± 12.6 years and mean AHI 63.5 ± 29.2. The majority of subjects (70 %) had no abnormal cardiac rhythms detected. AF lasting for 7 s was seen in one subject, and paroxysmal atrial tachycardia lasting for 3.6 s was seen in another. Clinically relevant AF was not detected in any of the subjects. CONCLUSION: In patients with severe OSA without a known history of AF, 7 days of extended cardiac monitoring with an ECG event recorder did not detect clinically meaningful, silent AF.

Critical evaluation of stents in the peripheral arterial disease of the superficial femoral artery - focus on the paclitaxel eluting stent.

The endovascular management of obstructive disease of the superficial femoral artery (SFA) is challenging due to unique anatomical and biomechanical forces. Obstructive lesions of the SFA make up the largest proportion of lesions leading to symptomatic peripheral arterial disease. Accordingly, endovascular treatment of SFA disease is becoming increasingly common and, in many cases, is the preferred initial therapy. The use of self-expanding nitinol stents have proven superior to percutaneous transluminal balloon angioplasty in the treatment of intermediate length SFA stenosis. However, achieving durable results, as well as attaining adequate therapy for long occlusions typically seen in clinical practice, remains problematic. Newer technologies, such as paclitaxel eluting stents, seem promising in improving outcomes.

Positive pressure for obesity hypoventilation syndrome.

Obesity is increasing world-wide; obesity hypoventilation syndrome (OHS), formerly Pickwickian syndrome, has increased in parallel. Despite its prevalence, OHS has not been studied well, but there is abundant evidence that it is tightly linked with sleep-disordered breathing, most commonly obstructive sleep apnea. This article reviews the pathophysiology of OHS as well as the literature regarding the benefits of treating this disorder with positive airway pressure. We also emphasize that while positive pressure treatments may temporize cardiopulmonary disease progression, simultaneous pursuit of weight reduction is central to long-term management of this condition.