Carotid artery stenting: first consensus document of the ICCS-SPREAD Joint Committee.

BACKGROUND AND PURPOSE: The prevention of stroke and the correct treatment of carotid artery stenosis represent today a major debate in cardiovascular medicine. Beside carotid endarterectomy, carotid angioplasty and stenting is becoming more widely performed for the treatment of severe carotid obstructive disease, and is now accepted as a less invasive technique that may provide an alternative for selected patients, particularly those with significant comorbidities. An Italian multidisciplinary task force, in which converged the most representative scientific societies involved in carotid treatment, was created to provide neurologists, radiologist, cardiologists, vascular surgeons, and all those involved in prevention and treatment of carotid disease with a simple, clear and updated evidence-based consensus document. SUMMARY OF REVIEW: This First Consensus Document of the ICCS (Italian Consensus Carotid Stenting)/SPREAD group addressed the main issues related to methodology, definition of symptomatic and asymptomatic carotid stenosis, indication and procedures for carotid artery stenting, including the use of devices for preventing procedural embolic complications. Special attention was paid to credentials and competency for physicians qualifications to perform vascular angioplasty and stent placement, including training, acceptable complication rates and certification. CONCLUSIONS: As any guideline or consensus statement, also this document is valid as long as the evidence on which it is based remains up-to-date. In such a fast-evolving field of medicine as the management of carotid stenosis, it is mandatory to stimulate a continuous and fruitful discussion among all the professionals involved in this very evolutionary field.

Endocardial defibrillation lead extraction: an unusual case of entrapment.

Spurious discharges due to late insulation break in an IS-1 pacing/sensing connector prompted ICD lead removal in 65-year-old man. The tip of the lead was easily freed and pulled back into the SVC by the superior approach. After that, the lead became trapped. The distal part of the lead was caught and easily withdrawn by inferior approach. Superior venous angiography showed extravascular location of the entrapped part of the lead due to the unintentional percutaneous puncture of the innominate vein after piercing the subclavian vein. It may be desirable to use contrast venography before intervention of extraction to ensure venous patency and lead location.

Technique and timing in contrast-enhanced MR angiography.

The purpose of this paper is to illustrate the fundamentals of contrast-enhanced MR angiography, its recent advances and future prospects. The factors influencing contrast-enhanced MR angiography are identified. The main acquisition and timing techniques are described with emphasis on their advantages and drawbacks.

MR angiography of the carotid arteries: parameters affecting image quality.

RATIONALE AND OBJECTIVES: This study was performed to evaluate the relationship between dose levels of contrast medium and image quality in magnetic resonance (MR) angiography of the carotid arteries with fluoroscopically monitored, manually triggered, elliptically ordered image acquisitions. MATERIALS AND METHODS: Twenty-five patients with clinical indications for angiography of the carotid arteries were examined with MR at 1.5 T by using a fluoroscopically monitored, manually triggered, elliptically ordered pulse sequence with the administration of one of three different volumes of gadolinium-based contrast medium. The signal intensities of the vessel lumen and the surrounding tissues were measured in single partitions at the origin of the common carotid artery, the carotid bifurcation, and the intracranial internal carotid arteries. The contrast-to-noise ratio in these regions of interest also was measured. Maximum intensity projection image quality was appraised for blurring, artifacts, venous enhancement, background suppression, and contrast medium distribution. RESULTS: No artifacts or venous enhancement was observed. The position of the fluoroscopic section affected the distribution of contrast medium along the vessel, as evidenced by the difference between the contrast-to-noise ratio at the origin of the common carotid artery and the ratio at the carotid bifurcation and the intracranial internal carotid arteries (P < .01). The contrast medium dose administered was strongly correlated with image quality (r = 0.90). CONCLUSION: Contrast medium dose is related to image quality in MR angiography of the carotid arteries performed with elliptical ordering, fluoroscopic monitoring, and manual triggering.

Magnetic resonance angiography with elliptical ordering and fluoroscopic triggering of the renal arteries.

PURPOSE: To evaluate centric ordered MR angiography with fluoroscopic triggering of renal artery disease. MATERIAL AND METHODS: 21 patients underwent MR-Angiography with a fluoroscopically triggered centric ordered sequence. The fluoroscopic trigger was obtained with the parameters that follow: TR/TE/TI: 1000/1.7/500 ms; NEX 1; MTX 141 x 256; SL 10mm; AT 0.83 s. The angiographic sequence was obtained with a CareBolus sequence (TR/TE: 3.9/1.5 ms; NEX 1; MTX 176 x 512; SL 1.1 mm; AT ~20s) after the intra-venous injection of 18 ml of Gd-BOPTA 0.5M followed by saline solution at a rate of 2.5 ml.s-1. Contrast-to-noise ratio (CNR) was obtained at the origin of the renal arteries. Statistical analysis was performed considering image quality, contrast media dose and the CNR. RESULTS: Ringing artifacts never occurred. The collaboration of the patient and the use of the earphones are critical to avoid motion artifacts. Renal veins have never been visualized. High CNR were noticed. CONCLUSIONS: This technique allows a more efficient use of the contrast media. MRA with centric ordering and fluoroscopic triggering allows an optimal and easy assessment of the renal arteries.