Adverse reactions after intravascular iodinated contrast media administration and their management.

Endovascular interventions and diagnostic examinations using iodinated contrast media (ICM) are standard of care in current vascular medicine. Although ICM use is generally considered safe, it may be associated with adverse reactions, vary from minor disturbances to rare, but severe life-threatening complications. This position paper of European Society of Vascular Medicine integrates current knowledge and summarizes the key information related to the use of intravascular ICM, serving as recommendation on prevention and management of acute, late, and very late adverse reactions. It should help the health professionals in all fields of vascular medicine to make decisions in daily practice for safe use of contrast media.

Benefits and Challenges of Drug-Coated Balloons in Peripheral Artery Disease: From Molecular Mechanisms to Clinical Practice.

Multiple clinical trials have reported favorable outcomes after drug-coated balloon therapy for peripheral artery disease in above-the-knee and below-the-knee lesions and in both de novo and in-stent restenosis. However, there are still insufficient data to identify and tackle the risk factors associated with a higher risk of restenosis, which is the primary concern for patients who are treated with an endovascular approach. A modern armamentarium, which includes improved lesion preparation techniques such as plaque modification balloons, mechanical atherectomy, intravascular lithotripsy, and imaging, is crucial for obtaining better long-term clinical outcomes. Moreover, a better understanding of the molecular properties of drug-coated balloons has led to improved devices that could tackle the shortcomings of previous generations. This comprehensive review focuses on drug-coated balloon technology as a tool to treat peripheral artery disease and the effects of the molecular mechanisms involved in preventing vascular restenosis.

Intravascular ultrasound insights into the unstable features of the coronary atherosclerotic plaques: A systematic review and meta-analysis.

BACKGROUND: There is a lack of a comprehensive picture of plaque geometry and composition of unstable atherosclerotic lesions as observed with intravascular ultrasound techniques. We analysed through a systematic review with meta-analysis 39 characteristics of atherosclerotic plaques in three scenarios involving culprit and non-culprit lesions from acute coronary syndromes vs stable angina pectoris patients, and culprit vs non-culprit lesions in acute coronary syndromes patients. METHODS: A systematic search of PubMed and EMBASE, from inception to April 2020 was performed. The combined odds ratios or mean differences of all IVUS characteristics were calculated with random-effects models. RESULTS: Twenty-eight studies involving 5434 subjects, and 5618 lesions were included. Culprit lesions in acute coronary syndromes have larger plaque areas and remodeling indexes (MD = 0.13 [0.08; 0.17], p < 0.001) and contained larger necrotic cores (MD = 0.67 (95% CI 0.19;1.15), p = 0.006) that stable angina culprit lesions. In acute patients, culprit plaques were also more remodeled, had larger necrotic cores and had more frequently a Thin-Cap Fibroatheroma morphology (OR = 1.79 (95% CI 1.21; 2.65), p = 0.004) than non-culprit lesions. Non-culprit lesions in acute syndromes were more often ruptured (OR = 2.25 (95% CI:1.05; 4.82), p = 0.037) or Thin-Cap Fibroatheromas than in stable angina. CONCLUSION: Culprit lesions from acute coronary patients are larger, more positively remodeled and contained more lipids as compared to stable angina lesions or non-culprit in acute patients. Non culprit lesions are also more often complicated or vulnerable in acute than stable patients.

Management of chronic peripheral artery disease patients with indication for endovascular revascularization.

With an increasing global burden of patients with chronic peripheral artery disease (PAD) the safe and effective provision of lower limb revascularisation is a growing medical need. Endovascular procedures for the treatment of PAD have become a crucial cornerstone of modern vascular medicine, and the first line revascularisation approach if technically feasible and taking patient choice into consideration. With the increasing age of patients with PAD and the increasing number of comorbidities open vascular surgery is also often not feasible. We outline a framework of key messages, endorsed by the board of the European Society of Vascular Medicine for pre-, peri- and post procedural management of patients requiring endovascular arterial procedures of the lower limbs. These key messages emphasize the important and increasing role of interventional vascular physicians.

Aneurysms and dissections - What is new in the literature of 2019/2020 - a European Society of Vascular Medicine annual review.

More than 6,000 publications were found in PubMed concerning aneurysms and dissections, including those Epub ahead of print in 2019, printed in 2020. Among those publications 327 were selected and considered of particular interest.

New Predictors of Early and Late Outcomes after Primary Percutaneous Coronary Intervention in Patients with ST-Segment Elevation Myocardial Infarction and Unprotected Left Main Coronary Artery Culprit Lesion.

OBJECTIVES: The study evaluated the correlation between baseline SYNTAX Score, Residual SYNTAX Score, and SYNTAX Revascularization Index and long-term outcomes in ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) on an unprotected left main coronary artery lesion (UPLMCA). BACKGROUND: Previous studies on primary PCI in UPLMCA have identified cardiogenic shock, TIMI 0/1 flow, and cardiac arrest, as prognostic factors of an unfavourable outcome, but the complexity of coronary artery disease and the extent of revascularization have not been thoroughly investigated in these high-risk patients. METHODS: 30-day, 1-year, and long-term outcomes were analyzed in a cohort of retrospectively selected, 81 consecutive patients with STEMI, and primary PCI on UPLMCA. RESULTS: Cardiogenic shock (p=0.001), age (p=0.008), baseline SYNTAX Score II (p=0.006), and SYNTAX Revascularization Index (p=0.046) were independent mortality predictors at one-year follow-up. Besides cardiogenic shock (HR 3.28, p<0.001), TIMI 0/1 flow (HR 2.17, p=0.021) and age (HR 1.03, p=0.006), baseline SYNTAX Score II (HR 1.06, p=0.006), residual SYNTAX Score (HR 1.03, p=0.041), and SYNTAX Revascularization Index (HR 0.9, p=0.011) were independent predictors of mortality at three years of follow-up. In patients with TIMI 0/1 flow, the presence of Rentrop collaterals was an independent predictor for long-term survival (HR 0.24; p=0.049). CONCLUSIONS: In this study, the complexity of coronary artery disease and the extent of revascularization represent independent mortality predictors at long-term follow-up.

Urgent need to clarify the definition of chronic critical limb ischemia - a position paper from the European Society for Vascular Medicine.

Chronic critical lower limb ischemia (CLI) has been defined as ischemia that endangers the leg. An attempt was made to give a precise definition of CLI, based on clinical and hemodynamic data (Second European Consensus). CLI may be easily defined from a clinical point of view as rest pain of the distal foot or gangrene or ulceration. It is probably useful to add leg ulcers of other origin which do not heal because of severe ischemia, and to consider the impact of frailty on adverse outcome. From a hemodynamic viewpoint there is no consensus and most of the existing classifications are not based upon evidence. We should thus propose a definition and then validate it in a prospective cohort in order to define the patients at major risk of amputation, and also to define the categories of patients whose prognosis is improved by revascularisation. From today's available data, it seems clear that the patients with a systolic toe pressure (STP) below 30 mmHg must be revascularised whenever possible. However other patients with clinically suspected CLI and STP above 30 mmHg must be evaluated and treated in specialised vascular units and revascularisation has to be discussed on a case by case basis, taking into account other data such as the WiFi classification for ulcers.In conclusion, many useful but at times contradictory definitions of CLI have been suggested. Only a few have taken into account evidence, and none have been validated prospectively. This paper aims to address this and to give notice that a CLI registry within Europe will be set up to prospectively validate, or not, the previous and suggested definitions of CLI.

Antithrombotic treatment in peripheral artery disease.

This review treats antithrombotic use for peripheral arterial disease (PAD). In asymptomatic patients, there are no scientific data to support single antiplatelet therapy (SAPT) for primary prophylaxis. In symptomatic PAD, SAPT with aspirin or clopidogrel is indicated. The efficacy of aspirin is controversial. Clopidogrel may be preferred over aspirin. Ticagrelor is not superior to clopidogrel in reducing major adverse cardiovascular events and major adverse limb events, but lowers the risk of ischaemic stroke. In symptomatic PAD, dual antiplatelet therapy (DAPT) with clopidogrel and aspirin does not provide benefit over SAPT with aspirin alone and is associated with increased risk of major bleeding. DAPT with ticagrelor 60 mg b. i. d. and aspirin provides a significant major adverse cardiovascular events reduction in symptomatic PAD patients and may be considered in PAD patients with prior myocardial infarction. The use of a new thrombin receptor antagonist, vorapaxar, on top of SAPT or DAPT with aspirin and/or clopidogrel, reduces the risk of acute limb ischaemia and peripheral artery revascularization in patients with symptomatic PAD, at the cost of an increased risk for bleeding. Rivaroxaban (2.5 mg b. i. d.) plus aspirin (100 mg daily) is the first antithrombotic association that proved significant benefit for PAD patients, in terms of strong endpoints - total mortality and cardiovascular mortality. Therefore, this association shows the strongest evidence for secondary prevention of symptomatic PAD patients. In PAD patients undergoing percutaneous peripheral interventions, at least four weeks of DAPT with aspirin and clopidogrel is recommended after infrainguinal stent implantation. Stenting below-the-knee arteries is often followed by a longer period of DAPT, but no specific evidence is available. Anticoagulation is mandatory to prevent arterial occlusion during radial or brachial invasive procedures. The strategy includes use of unfractioned heparin, bivalirudin or enoxaparin. Vitamin K antagonists may be considered after autologous vein infrainguinal bypass.

ESVM guidelines - the diagnosis and management of Raynaud's phenomenon.

Regarding the clinical diagnosis of Raynaud's phenomenon and its associated conditions, investigations and treatment are substantial, and yet no international consensus has been published regarding the medical management of patients presenting with this condition. Most knowledge on this topic derives from epidemiological surveys and observational studies; few randomized studies are available, almost all relating to drug treatment, and thus these guidelines were developed as an expert consensus document to aid in the diagnosis and management of Raynaud's phenomenon. This consensus document starts with a clarification about the definition and terminology of Raynaud's phenomenon and covers the differential and aetiological diagnoses as well as the symptomatic treatment.

A 2024 scientific update on the clinical performance of drug-coated balloons.

Continuous advances in the field of interventional cardiology have led to the development of drug-coated balloons (DCB). These represent a promising device for overcoming the well-known limitations of traditional metallic stents, which are associated with a persistent yearly increased risk of adverse events. This technology has the ability to homogeneously transfer the drug into the vessel wall in the absence of a permanent prosthesis implanted in the coronary vessel. Robust data support the use of DCB for the treatment of in-stent restenosis, but there is also currently growing evidence from long-term follow-up of large randomised clinical trials regarding the use of these devices in other scenarios, such as de novo small and large vessel disease, complex bifurcations, and diffuse coronary disease. Other critical clinical settings such as diabetes mellitus, high bleeding risk patients and acute coronary syndromes could be approached in the upcoming future by using DCB, alone or as part of a blended strategy in combination with drug-eluting stents. There have been important scientific and technical advances in the DCB field in recent years. The purpose of this paper is to review the most current data regarding the use of DCB, including the mid- and long-term follow-up reports on the safety and efficacy of this novel strategy in different clinical and angiographic scenarios.

A case report of Ebstein's anomaly-Gerbode defect dyad: is there room for another anomaly in the same patient?

Background: Ebstein's anomaly is a rare congenital heart disease characterized by apical displacement of the septal and posterior tricuspid valve leaflets. It is commonly associated with other defects such as patent foramen ovale or accessory atrioventricular pathways. Case summary: We describe a case of an Ebstein anomaly diagnosed in an adult in his 50s in association with a septal defect between the left ventricle and right atrium (Gerbode defect). The diagnosis was confirmed on magnetic resonance imaging. A third anomaly was noted on coronary angiography, consisting of an aberrant origin of the right coronary artery from the left sinus of Valsalva. The patient was paucisymptomatic until he developed typical atrial flutter. Catheter ablation was employed after first arrhythmia recurrence and the patient is to date in good clinical condition. Conclusion: The association of Ebstein's anomaly-Gerbode defect is extremely rare, and to our knowledge, this is the first case that presents in addition an anomalous coronary artery. Both structural defects were without haemodynamic significance, and there was no proof of myocardial ischaemia. As the case illustrates, congenital disorders, even when in conjunction, can have a silent clinical course and multimodality imaging is sometimes necessary for a complete and final diagnosis.

Portable microfluidic plasmonic chip for fast real-time cardiac troponin I biomarker thermoplasmonic detection.

Acute myocardial infarction is one of the most serious cardiovascular pathologies, impacting patients' long-term outcomes and health systems worldwide. Significant effort is directed toward the development of biosensing technologies, which are able to efficiently and accurately detect an early rise of cardiac troponin levels, the gold standard in detecting myocardial injury. In this context, this work aims to develop a microfluidic plasmonic chip for the fast and accurate real-time detection of the cardiac troponin I biomarker (cTnI) via three complementary detection techniques using portable equipment. Furthermore, the study focuses on providing a better understanding of the thermoplasmonic biosensing mechanism taking advantage of the intrinsic photothermal properties of gold nanoparticles. Specifically, a plasmonic nanoplatform based on immobilized gold nanobipyramids was fabricated, exhibiting optical and thermoplasmonic properties that promote, based on a sandwich-like immunoassay, the "proof-of-concept" multimodal detection of cTnI via localized surface plasmon resonance, surface enhanced Raman spectroscopy and thermoplasmonic effects under simulated conditions. Furthermore, after the integration of the plasmonic nanoplatform in a microfluidic channel, the determination of cTnI in 16 real plasma samples was successfully realized via thermoplasmonic detection. The results are compared with a conventional high-sensitivity enzyme-linked immunosorbent clinical assay (ELISA), showing high sensitivity (75%) and specificity (100%) as well as fast response features (5 minutes). Thus, the proposed portable and miniaturized microfluidic plasmonic chip is successfully validated for clinical applications and transferred to clinical settings for the early diagnosis of cardiac diseases, leading towards the progress of personalized medicine.

A Review Paper on Optical Coherence Tomography Evaluation of Coronary Calcification Pattern: Is It Relevant Today?

The process of coronary calcification represents one of the numerous pathophysiological mechanisms involved in the atherosclerosis continuum. Optical coherence tomography (OCT) represents an ideal imaging modality to assess plaque components, especially calcium. Different calcification patterns have been contemporarily described in both early stages and advanced atherosclerosis. Microcalcifications and spotty calcifications correlate positively with macrophage burden and inflammatory markers and are more frequently found in the superficial layers of ruptured plaques in acute coronary syndrome patients. More compact, extensive calcification may reflect a later stage of the disease and was traditionally associated with plaque stability. Nevertheless, a small number of culprit coronary lesions demonstrates the presence of dense calcified plaques. The purpose of the current paper is to review the most recent OCT data on coronary calcification and the interrelation between calcification pattern and plaque vulnerability. How different calcified plaques influence treatment strategies and associated prognostic implications is of great interest.

Ultrasonography for the optimal selection of patients suitable for single session arteriography and endovascular revascularization in severe peripheral artery disease.

AIMS: Peripheral artery disease (PAD) represents a high burden on the healthcare and social assistance systems. Revascularization reduces symptoms, amputation rate and increases the chances of social reintegration. Our aim was to evaluate the benefits of vascular duplex ultrasonography (DUS) for identifying patients suitable for direct percutaneous transluminal angioplasty (PTA) without the need for a prior angiography. MATERIAL AND METHODS: We included in the study 251 patients with PAD evaluated by DUS. Depending on the DUS findings the patients were split in two groups: group I, 143 patients (57%), in which selective angiography and direct PTA was performed and group 2, 108 patients (43%), in which invasive arteriography was considered necessary prior to a decision for revascularization. Results: The first group had a similar success rate (92.3% vs. 86.1%; p=0.111), but with a reduction in radioscopy time (minutes) (17.2 vs. 20.8; p=0.013), iodine contrast volume (ml) (190 vs. 227.5; p<0.001), days of hospitalization (4 vs. 7; p<0.001) and by 44.75% (p<0.001) of hospitalization costs when compared to the second group. CONCLUSIONS: DUS allows the optimal selection of patients who can benefit from direct PTA. This strategy has a high success rate, with a significant decrease in radioscopy exposure time, volume of iodine contrast needed, duration and hospitalization costs, when compared to arteriography and PTA in two different sessions.

Correlation between Ultrasound Peak Systolic Velocity and Angiography for Grading Internal Carotid Artery Stenosis.

(1) Background: The success of carotid revascularization depends on the accurate grading of carotid stenoses. Therefore, it is important for every vascular center to establish its protocols for the same. In this study, we aimed to determine the peak systolic velocity (PSV) thresholds that can predict moderate and severe internal carotid artery (ICA) stenoses. (2) Methods: To achieve this, we enrolled patients who underwent both duplex ultrasound (DUS) and invasive carotid artery digital subtraction angiography (DSA). The degree of ICA stenosis was assessed using the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST) protocols. The PSV thresholds were determined using receiver operating characteristic (ROC) curves. (3) Results: Our study included 47 stenoses, and we found that the PSV cut-off for predicting ≥70% NASCET ICA stenoses was 200 cm/s (sensitivity 90.32%, specificity 93.75%). However, PSV did not correlate significantly with ≥50% NASCET ICA stenoses. On the other hand, the optimal PSV threshold for predicting ≥80% ECST ICA stenoses was 180 cm/s (sensitivity 100%, specificity 81.82%). (4) Conclusions: Based on our findings, we concluded that PSV is a good and simple marker for the identification of severe stenoses. We found that PSV values correlate significantly with severe NASCET and ECST stenoses, with 200 cm/s and 180 cm/s PSV thresholds. However, PSV was not reliable with moderate NASCET stenoses. In such cases, complementary imaging should be used.

Peripheral Artery Disease Ultrasound Assessment in Predicting the Severity of Coronary Artery Disease.

Atherosclerosis in a progressive disease that is systemic in nature, and hence the simultaneous presentation of coronary artery disease (CAD) and peripheral artery disease (PAD) is not uncommon. As clinically manifested PAD is associated with worse cardiovascular outcomes, the timely identification of subclinical atherosclerosis seems of utmost importance. Ultrasonography (US) is an ideal imaging modality for assessing PAD that is easy to use, accurate, widely available and avoids unnecessary exposure to radiation. Several US parameters have been proposed in the assessment of PAD, with varying prognostic usefulness, depending on disease location. The aim of this review is to summarize the most important evidence available on the association between US-detected atherosclerosis in different vascular sites and the presence and severity of CAD, as well as the impact of the early detection of PAD on the outcomes of patients presenting with CAD.

Outcomes after stenting of renal artery stenosis in patients with high-risk clinical features.

BACKGROUND: In patients with renal artery stenosis, revascularization was seen as a mean to improve outcomes, but large studies failed to show significant benefit in general population. However, data on benefits of renal artery stenting in patients with high-risk features, such as rapidly declining renal function and cardiac destabilization syndromes, are limited, as they were excluded from trials. In this descriptive study, we aimed to evaluate short- and long-term outcomes in high-risk patients with renal artery stenosis, treated by angioplasty and stenting. We have retrospectively interrogated our local databases for renal artery percutaneous interventions; patients at high-risk (rapidly declining renal function; stable chronic renal failure and bilateral renal artery disease; severe hypertensive crisis) were selected for the current analysis. RESULTS: Of 30 patients undergoing renal artery stenting, 18 patients were deemed "high-risk." On short term, good in-hospital control of hypertension and cardiac stabilization were obtained in all patients. Renal function improved significantly only in patients admitted with rapidly declining renal function, with significant creatinine level fall from median 3.98 mg/dL to 2.02 mg/dL, p = 0.023. However, for the whole group, creatinine change was non-significant (- 0.12 mg/dL, p = NS). On the long term, five patients (27.8%) ended-up on chronic hemodialysis and six patients died (33.3%) after a median of 20 months. No death occurred during the first year after the procedure. CONCLUSIONS: Percutaneous procedures are feasible and safe in patients with high-risk renal artery stenosis, especially in those with rapidly declining renal function, probably saving some of them from the immediate need for renal replacement therapy, but long-term results are negatively influenced by the precarious general and cardio-vascular status of these patients and by the pre-existing significant renal parenchymal disease, non-related to the renal artery stenosis.

Vascular Diseases: Etiologic, Diagnostic, Prognostic, and Therapeutic Research.

The impacts of vascular diseases (VD) include increased morbidity and mortality, which are related to factors such as population aging, socio-economics, or an increasing prevalence of risk factors, e [...].