Late presenting, contained rupture of the superficial femoral artery following atherectomy and stenting: case report and literature review.

Excisional atherectomy alone or followed by stenting is considered an appropriate treatment strategy for patients with lifestyle-limiting claudication due to obstructive infra-inguinal peripheral arterial disease (Ramaiah et al., J Endovasc Ther 2006;13:592-6021). We present a case of a 69-year-old man with eccentric severely calcified disease of the superficial femoral artery (SFA) treated with excisional atherectomy followed by stenting with an interwoven nitinol stent. The procedure was complicated by extravascular stent migration associated with a contained rupture presenting 30 days after the intervention. The complication was successfully treated with a stent graft. Although rare, pseudoaneurysms have been reported at the site of prior atherectomy; however, this case is the first description of a contained rupture post atherectomy associated with erosion of a nitinol stent into an extra-luminal position. The mechanism and management of this complication are discussed.

Serum neutrophil gelatinase-associated lipocalin (NGAL) in predicting worsening renal function in acute decompensated heart failure.

BACKGROUND: The development of worsening renal function (WRF, defined as creatinine rise >or=0.3mg/dL) occurs frequently in the setting of acute decompensated heart failure (ADHF) and strongly predicts adverse clinical outcomes. Neutrophil gelatinase-associated lipocalin (NGAL) is produced by the nephron in response to tubular epithelial damage and serves as an early marker for acute renal tubular injury. We sought to determine the relationship between admission serum NGAL levels and WRF in the setting of ADHF. METHODS AND RESULTS: We measured serum NGAL levels in 91 patients admitted to the hospital with ADHF. Patients were adjudicated by independent physician into those that did or did not develop WRF over the ensuing 5 days of in-hospital treatment. In our study cohort (68% male, mean age 61+/-15 years, mean left ventricular ejection fraction 31+/-14%), median admission serum NGAL level was 165 ng/mL (interquartile range [IQR] 108-235 ng/mL). Thirty-five patients (38%) developed WRF within the 5-day follow-up. Patients who developed WRF versus those without WRF had significantly higher median admission serum NGAL levels (194 [IQR 150-292] ng/mL vs. 128 [IQR 97-214] ng/mL, P=.001). High serum NGAL levels at admission were associated with greater likelihood of developing WRF (odds ratio: 1.92, 95% confidence interval 1.23-3.12, P=.004). In particular, admission NGAL >or=140 ng/mL had a 7.4-fold increase in risk of developing WRF, with a sensitivity and specificity of 86% and 54%, respectively. CONCLUSIONS: The presence of elevated admission serum NGAL levels is associated with heightened risk of subsequent development of WRF in patients admitted with ADHF.

Recent advances in self-expanding stents for use in the superficial femoral and popliteal arteries.

Significant advances have been made in femoropopliteal stent design and clinical outcomes during the past decade. Initial randomized studies demonstrated superiority of nitinol self-expanding stents to balloon angioplasty for treatment of moderate-length superficial femoral artery stenoses. During longer-term follow-up, first generation nitinol stents were hampered by high rates of stent fracture. A number of newer nitinol stent designs have been developed with improved conformability, greater radial strength and lower rates of long-term stent fracture. These newer stent designs have demonstrated superior primary patency and decreased restenosis for the treatment of moderate-length femoropopliteal lesions relative to historical benchmarks. Recent advances in drug-eluting nitinol stents have also offered treatment options for challenging lesion subsets including very long femoropopliteal lesions and for the treatment of in-stent restenosis. This article reviews recent advances and upcoming research in nitinol self-expanding stent technology for the treatment of superficial femoral and popliteal artery stenosis.

Tolvaptan: the evidence for its therapeutic value in acute heart failure syndrome.

INTRODUCTION: Acute heart failure syndrome (AHFS) is one of the leading causes of hospital admission in the US. Tolvaptan is a vasopressin V(2) receptor antagonist that blocks the effect of arginine vasopressin (AVP) in reabsorbing water from the collecting ducts of the nephrons in congestive heart failure. AIMS: To review the evidence for utilizing tolvaptan in the treatment of AHFS. EVIDENCE REVIEW: Several clinical trials have sought to assess the clinical effects of tolvaptan in heart failure. Compared with placebo, tolvaptan has been shown to reduce bodyweight and improve serum sodium in patients with AHFS without worsening renal function. Tolvaptan appeared to be well tolerated with a good safety profile. It caused a significant reduction in pulmonary capillary wedge pressure compared with placebo, but has yet to demonstrate reversal of cardiac remodeling. A large-scale mortality trial showed no differences in long-term mortality rates between tolvaptan and placebo, although early symptom relief was apparent with tolvaptan and lower diuretic use. PLACE IN THERAPY: Tolvaptan has shown to be safe and effective in treating congestion in AHFS. Free water excretion in fluid-overloaded patients vulnerable to cardiorenal compromise with standard diuretic therapy makes V(2) vasopressin receptor blockade an attractive adjunct to standard medical therapy aimed at reducing congestion in AHFS.