Tibioperoneal (outflow lesion) angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: five-year follow-up.

BACKGROUND: In a prospective, nonrandomized, consecutive series of tibioperoneal vessel angioplasty (TPVA), critical limb ischemia (CLI) patients' data were analyzed with regard to immediate and follow-up success. METHODS AND RESULTS: TPVA was successful in 270 of 284 critically ischemic limbs (95%), with 167 limbs (59%) requiring dilatation of 333 ipsilateral inflow obstructions to access and successfully dilate 486 of 529 (92%) tibioperoneal lesions. A clinical success (relief of rest pain or improvement of lower-extremity blood flow) was attained in 270 limbs at risk (95%). Clinical 5-year follow-up of 215 of 221 successful CLI patients (97%) with 266 successfully revascularized limbs revealed that bypass surgery occurred in 8% and significant amputations in 9% of limbs; 91% of the limbs were salvaged. The cohort's probability of survival was 56%: 58% for Fontaine class III and 33% for class IV patients. Class III compared with class IV patients had significantly (P<0.05) fewer surgical bypasses (3% versus 16%) and amputations: above-knee, 1% versus 4%; below-knee, 3% versus 12%; and transmetatarsal, <1% versus 21%. CONCLUSIONS: TPVA, often in combination with inflow lesions, is an effective primary treatment for critical limb ischemia. The poor cumulative survival reflects the existence of severe comorbidities, which could potentially be affected by aggressive and effective cardiovascular diagnostic and therapeutic strategies.

Percutaneous coronary intervention in the current era compared with 1985-1986: the National Heart, Lung, and Blood Institute Registries.

BACKGROUND: Although refinements have occurred in coronary angioplasty over the past decade, little is known about whether these changes have affected outcomes. METHODS AND RESULTS: Baseline features and in-hospital and 1-year outcomes of 1559 consecutive patients in the 1997-1998 Dynamic Registry who were having first coronary intervention were compared with 2431 patients in the 1985-1986 National Heart, Lung, and Blood Institute Registry. Compared with patients in the 1985-1986 Registry, Dynamic Registry patients were older (mean age, 62 versus 58 years; P:<0.001) and more often female (32.1% versus 25.5%; P:<0.001). In the Dynamic Registry, procedures were more often performed for acute myocardial infarction (22.9% versus 9.9%; P:<0.001) and treated lesions were more severe (84.5% versus 82.5% diameter reduction; P:<0.001), thrombotic (22.1% versus 11.3%; P:<0.001) or calcified (29.5% versus 10.8%; P:<0.001). Stents were used in 70.5% of Dynamic Registry patients, whereas 1985-1986 patients received balloon angioplasty alone. Procedural success was higher in the Dynamic Registry (92.0% versus 81.8%; P:<0.001) and the rate of in-hospital death, myocardial infarction, and emergency coronary bypass surgery combined was lower (4.9% versus 7.9%; P:=0.001) than in the 1985-1986 Registry. The 1-year rate for CABG was lower in the Dynamic Registry (6.9% versus 12.6%; P:<0.001). CONCLUSIONS: Although Dynamic Registry patients had more unstable and complex coronary disease than those in the 1985-1986 Registry, their rate of procedural success was higher whereas rates of complications and subsequent CABG were lower. Results of percutaneous coronary intervention have improved substantially over the past decade.

Global experience in cervical carotid artery stent placement.

The purpose of this article is to review and update the current status of carotid artery stent placement in the world. Surveys to major interventional centers in Europe, North and South America, and Asia were initially completed in June 1997. Subsequent information from these 24 centers in addition to 12 new centers has been obtained to update the information. The survey asked the various questions regarding the patients enrolled, procedure techniques, and results of carotid stenting, including complications and restenosis. The total number of endovascular carotid stent procedures that have been performed worldwide to date included 5,210 procedures involving 4,757 patients. There was a technical success of 98.4% with 5,129 carotid arteries treated. Complications that occurred during the carotid stent placement or within a 30-day period following placement were recorded. Overall, there were 134 transient ischemic attacks (TIAs) for a rate of 2.82%. Based on the total patient population, there were 129 minor strokes with a rate of occurrence of 2.72%. The total number of major strokes was 71 for a rate of 1.49%. There were 41 deaths within a 30-day postprocedure period resulting in a mortality rate of 0.86%. The combined minor and major strokes and procedure-related death rate was 5.07%. Restenosis rates of carotid stenting have been 1.99% and 3.46% at 6 and 12 months, respectively. The rate of neurologic events after stent placement has been 1.42% at 6-12-month follow-up. Endovascular stent treatment of carotid artery atherosclerotic disease is growing as an alternative for vascular surgery, especially for patients that are high risk for standard carotid endarterectomy. The periprocedure risks for major and minor strokes and death are generally acceptable at this early stage of development and have not changed significantly since the first survey results. Cathet. Cardiovasc. Intervent. 50:160-167, 2000.

Transseptal guidewire stabilization facilitates stent-graft deployment for persistent proximal ascending aortic dissection.

PURPOSE: To report endovascular repair of a DeBakey type I ascending aortic dissection. CASE REPORT: Five months after aortocoronary bypass grafting, a 56-year-old woman demonstrated a persistent ascending aortic type I dissection whose entry tear proximal to the innominate artery spiraled down the descending thoracic aorta into the iliofemoral arteries. Repair was facilitated with a guidewire passed through a transseptal sheath in the right femoral vein. The guidewire traversed the right and left atria and the left ventricle and then exited into the ascending aorta and was exteriorized through the right femoral artery. A right brachial catheter aided contrast visualization of the innominate artery. Adenosine-induced elective cardiac arrest promoted precise placement of a customized polyester-covered balloon-expandable stent, which closed the aortic rent. CONCLUSIONS: A transseptal approach enables the guidewire to follow the curvature of the aortic arch, providing precise control of the stent-graft delivery system. This case illustrates the applicability of endovascular techniques to repair ascending aortic pathologies using readily available techniques, equipment, and drugs.

Catheter-based techniques for closure of coronary fistulae.

This study details different methodologies of percutaneous closure of arteriosystemic and arteriovenous coronary fistula. Seven patients underwent transcatheter intervention of 10 fistulas, with 7 fistulas successfully closed: 6 with embolic coil devices and 1 with a covered stent obstructing the fistula ostium. The major complication encountered was one death as a result of device recoil into a major epicardial vessel. Percutaneous transcatheter closure of coronary fistulas appears to be simple, facile, and effective. However, device recoil into an undesired arterial segment, while irritating in a noncoronary arterial tree, may be catastrophic when occurring in an epicardial coronary artery.

In vivo crushing of an aortic stent enables endovascular repair of a large infrarenal aortic pseudoaneurysm.

PURPOSE: To report an unusual approach to endovascular exclusion of a large aortic pseudoaneurysm. METHODS AND RESULTS: A 63-year-old male had an unsuccessful endovascular repair of an aortic anastomotic pseudoaneurysm that left an expanded, uncovered Palmaz stent lying obliquely within the aorta. After nearly 3 years, the pseudoaneurysm enlarged to 7 cm, and the patient became symptomatic. Repair of the pseudoaneurysm was accomplished by crushing the indwelling stent to allow placement of a stent-graft. CONCLUSIONS: Malpositioned stents that are hindering an endoluminal procedure may be crushed against the arterial wall in vivo to facilitate passage of endovascular instruments or devices.

The acute outcome of tibioperoneal vessel angioplasty in 417 cases with claudication and critical limb ischemia.

A non-randomized, consecutive series of 417 first procedure tibioperoneal vessel angioplasty (TPVA) cases were analyzed to determine if angioplasty were an alternative revascularization technique for critical limb ischemia (CLI) and claudicants patients. TPVA was performed on 312 patients (70% male; age 66 +/- 10 years) with success attained in 406/417 cases (96%) of 605/657 lesions (92%): [461/469 stenoses (98%) and 144/188 occlusions (77%) *(P < 0.05)]. Claudication and CLI patients had similar rates of success. In claudication patients clinical success was 130/133 (98%); lesion success was 197/208 (92%); stenosis was 148/151 (98%); and occlusion was 49/57 (86%). In CLI patients clinical success was 270/284 (95%); lesion success was 408/449 (91%); stenosis was 313/318 (98%); and occlusion was 95/131 (73%). We conclude that TPVA is an effective revascularization technique for obstructed tibioperoneal vessels, with excellent success in stenotic (98%) and reasonable results in occluded vessels (77%). These data demonstrate TPVA effectiveness in CLI patients and in carefully selected claudicants with appropriate indications (severe, lifestyle limiting claudication) and readily amenable anatomy, and TPVA for CLI patients appears to be an effective revascularization technique.

Catheter therapy for fontan baffle obstruction and leak, using an endovascular covered stent.

A 6 1/2-year-old (weight 20 kg) patient was found to have significant cavo-atrial obstruction and significant right-to-left shunt via multiple large fenestrations in the baffle, with oxygen saturation of 81% 3 1/2 yr after a fenestrated Fontan operation. In one session, this patient had undergone placement of a Palmaz stent at the cavo-atrial narrowing in order to increase anterograde venous return into the pulmonary artery. This was unsuccessful in improving the oxygen saturation because of the large leak in the baffle. Therefore, at a second catheterization session, two telescoping dacron-covered experimental vascular self-expanding stents were placed from the right atrial origin (distal to the hepatic veins) into the pulmonary artery connection delineated by the Palmaz stent, with complete reconstruction of the baffle and improvement in oxygen saturation to 95%.

Four-year follow-up of Palmaz-Schatz stent revascularization as treatment for atherosclerotic renal artery stenosis.

BACKGROUND: Stent revascularization is perceived as superior to balloon angioplasty and surgical revascularization, but the paucity of stent publications precludes even historical comparison with surgical data. METHODS AND RESULTS: Palmaz-Schatz stent revascularization of renal artery stenosis was successfully performed on 163 consecutive patients for poorly controlled hypertension or preservation of renal function. Of these, 145 were eligible for > or =6-month clinical follow-up of the effect of the procedure on renal function, blood pressure control, number of antihypertensive medications, and survival. At 4 years, systolic and diastolic blood pressures significantly decreased (from 166+/-26 to 148+/-22 mm Hg and from 86+/-14 to 80+/-11 mm Hg, respectively; P<0.05), and blood pressure control was more facile in approximately half of the patients. Creatinine decreased or remained stable in approximately two thirds of the patients. The cumulative probability of survival was 74+/-4% at 3 years, with few deaths related to end-stage renal disease. Survival was good in patients with normal (92+/-4%) baseline renal function, fair (74+/-7%) in those with mildly impaired renal function, and poor (52+/-7%) in patients with elevated baseline creatinine levels (> or =2.0 mg/dL). The combination of impaired renal function and bilateral disease adversely affected survival. CONCLUSIONS: Renal artery stent revascularization in the presence of normal or mildly impaired renal function had a beneficial effect on blood pressure control and a nondeleterious effect on renal function. Survival was adversely affected by renal dysfunction despite adequate revascularization. Early diagnosis and adequate revascularization before the onset of renal dysfunction could beneficially affect blood pressure control, preserve or prevent deterioration of renal function, and improve patient survival.

Stent revascularization for atherosclerotic renal artery stenosis. 1-year clinical follow-up.

Patients who had undergone stent revascularization of renal artery stenosis for poorly controlled hypertension, preservation of renal function, or both were monitored to assess the procedure's effect upon subsequent renal function and blood pressure control. At 1-year follow-up, systolic and diastolic blood pressures had significantly decreased (166 +/- 26 to 156 +/- 25 mmHg and 86 +/- 14 to 80 +/- 13 mmHg, respectively; P < 0.05), and creatinine levels decreased or remained stable in approximately two thirds of the patients. Renal artery stent revascularization appears to have a beneficial effect upon blood pressure control and a nondeleterious effect upon renal function in the majority of patients.

Current global status of carotid artery stent placement.

Our purpose was to review the current status of carotid artery stent placement throughout the world. Surveys were sent to major interventional centers in Europe, North and South America, and Asia. Information from peer-reviewed journals was also included and supplemented the survey. The survey asked various questions regarding the patients enrolled, procedure techniques, and results of carotid stenting, including complications and restenosis. Of the centers which were sent surveys, 24 responded. The total number of endovascular carotid stent procedures that have been performed worldwide to date included 2,048 cases, with a technical success of 98.6%. Complications that occurred during carotid stent placement or within a 30-day period following placement were recorded. Overall, there were 63 minor strokes, with a rate of occurrence of 3.08%. The total number of major strokes was 27, for a rate of 1.32%. There were 28 deaths within a 30-day postprocedure period, resulting in a mortality rate of 1.37%. Restenosis rates of carotid stenting have been 4.80% at 6 mo. Endovascular stent treatment of carotid artery atherosclerotic disease is growing as an alternative to vascular surgery, especially for patients that are at high risk for standard carotid endarterectomy. The periprocedural risks for major and minor strokes and death are generally acceptable at this early stage of development.

Stent deployment resolves a petrous carotid artery angioplasty dissection.

A patient with a symptomatic petrous carotid artery stenosis underwent balloon angioplasty, which was complicated by a flow-limiting dissection. The problem was resolved by deploying a balloon-expandable coronary stent. The patient suffered no neurologic deficit, was discharged within 12 hours, and was asymptomatic at last follow-up, 5 months after the procedure, without warfarin therapy. This therapeutic option may prove useful as a means to correct endovascular procedural complications.

Palmaz stent compression in patients following carotid artery stenting.

UNLABELLED: Carotid artery stenting is being investigated as a therapeutic strategy for the management of bifurcation stenosis. Palmaz stents were deployed successfully in the carotid arteries of 112 patients using high-pressure balloon inflations. In 11 out of 70 patients who came for 6-mo follow-up angiography, a stent collapse was noted. Carotid ultrasound was able to detect stent collapse in only two patients at follow-up. Only one patient who had collapse of stent along its entire length was symptomatic at follow-up. Repeat balloon angioplasty was performed in 5 patients, 3 of whom had a Wallstents deployed within the Palmaz stent. CONCLUSION: Stent collapse was observed in a significant number of Palmaz stents within 6 mo of placement in the carotid arteries. These observations should influence the choice of stents for the treatment of extracranial carotid disease.

Coronary blood flow velocities during rotational atherectomy.

This study was designed to evaluate the alterations in doppler derived coronary blood flow velocities and flow reserve following rotational ablation. Changes in doppler derived coronary blood flow velocity variables have been valuable in assessing the physiological outcome following coronary balloon angioplasty. Rotational ablation's mechanism of plaque removal could alter distal vascular bed characteristics, and, as a result, intracoronary blood flow velocities and the coronary flow reserve. A 12-MHz doppler guidewire recorded intracoronary phasic velocities and coronary flow reserve (as assessed by the hyperemic response to adenosine [12-18 mcg intracoronary]) in 28 patients, before and after rotational ablation of 30 lesions. Adjunctive balloon angioplasty was performed in 27 of 28 patients (96%). Rotational ablation and adjunctive balloon angioplasty successfully reduced the lesion diameter (87 +/- 9% to 14 +/- 11%; P < 0.001). A significant increase in the mean distal average peak velocity (25 +/- 13 cm/sec, before; 47 +/- 22 cm/sec, after; P < 0.001), and decrease in the proximal to distal average peak velocity ratio, (2.1 +/- 1.3; to 1.2 +/- 0.4; P = 0.002) was recorded. The mean distal diastolic to systolic velocity ratio (before, 1.4 +/- 0.7; after, 1.6 +/- 0.8; P = 0.44) and the coronary flow reserve (before, 1.6 +/- 0.6; after, 1.5 +/- 0.5; P = 0.34) did not increase despite increases in distal velocities, following successful intervention. Doppler derived distal coronary blood flow velocities increased following rotational ablation and adjunctive balloon angioplasty, with resolution of transstenotic velocity gradient. Changes in distal phasic velocity pattern and coronary flow reserve, immediately after the intervention, were not useful in the assessment of the functional outcome and may be related to abnormalities in distal vascular bed vasoreactivity produced by rotational ablation.

Evaluation of endovascular abdominal aortic aneurysm repair: anatomical classification, procedural success, clinical assessment, and data collection.

PURPOSE: To detail a methodology for evaluation of endovascular abdominal aortic aneurysm (AAA) repair that has been achieved through consensus of an international multidisciplinary team of investigators. METHODS: This schema features an anatomical classification for AAAs, a definition of procedural success, and a procedure for clinical assessment, as well as the necessary data collection forms. Patient data include demographics, procedural and clinical success, complications, and follow-up. Procedural details can be related to anatomic situations, comorbid processes, devices, and effective aneurysmal exclusion. RESULTS: These data would allow assessment of the procedures, physician learning curves, procedural indications, techniques, methodologies, the relationship of indications to success and complications, devices and subsequent graft patency, and aneurysmal exclusion. CONCLUSIONS: The use of this standardized data collection system could enable physicians and industry to better understand endovascular AAA repair and ultimately improve patient care.