Proximal protection in recanalization of totally occluded saphenous vein grafts in acute coronary syndrome.

Percutaneous treatment of old, degenerated saphenous vein grafts (SVG) is associated with a high likelihood of major adverse cardiac events. When an acute coronary syndrome (ACS) develops in a patient with old SVG, fresh thrombus may superimpose on an old, degenerative atheroma: a sudden increase in the athero-thrombotic burden ensues with consequent, frequent total occlusion of the lumen. In this scenario, transluminal recanalization of the graft is usually associated with the highest chance of distal embolization and no-reflow and positioning of an embolic protection device (EPD) is almost mandatory. However, distal EPD are difficult to place when the vessel is totally occluded and do not completely avoid distal embolization. We report two cases of totally occluded SVG in patients admitted for ACS that were recanalized with the aid of a proximal EPD system with angiographic and clinical success.

[Late structural discontinuity and migration of a bioabsorbable scaffold in a saphenous vein graft]. / Discontinuità tardiva e migrazione di uno scaffold bioassorbibile in un graft venoso: a proposito di un caso e di quanto noto in letteratura.

The use of bioresorbable vascular scaffolds (BVS) has many important and potentially useful features, on both pathophysiological and clinical grounds, for the treatment of native coronary artery stenosis. These advantages are less well established when BVS are employed in saphenous vein graft disease. We here describe a peculiar behavior of a previously (6 months) implanted BVS in a degenerated saphenous vein graft during treatment of an in-stent restenosis in a patient suffering from unstable angina. This BVS particular performance seems to suggest that different pathophysiological and anatomical conditions may play a relevant role in affecting the results of transluminal vascular therapy.

Drug-eluting stent use after coronary atherectomy: results from a multicentre experience - The ROTALINK I study.

AIMS: Until now, there is no medium- to long-term clinical evidence of the best treatment after rotational atherectomy. METHODS: From the databases of seven high-volume centres, years 2005-2010, we retrospectively analysed the long-term outcome of patients who had undergone rotational atherectomy followed by plain-balloon angioplasty or implantation of drug-eluting stent (DES) or bare metal stent (BMS). Primary endpoint was the incidence of major adverse cardiovascular events (MACE: death, myocardial infarction, target-lesion-revascularization) at longest available follow-up. RESULTS: In this registry, we enrolled 1397 patients with 1605 lesions, followed for 28.4 ±â€Š21 months. DES-treated patients were more frequently diabetic, had more lesions treated and received a higher number of stents. In-hospital MACEs were significantly higher in DES patients (7.6 vs. 2.6 vs. 2.9%, respectively, P = 0.0001 for both), mainly due to a higher incidence of myocardial infarction (6.4 vs. 1.2 vs. 2.1%, P = 0.0001). The 2-year follow-up showed a significantly lower incidence of MACE in DES patients (15.1 vs. 24.2 vs. 20.8%, P = 0.001 for both), driven by a lower incidence of target-lesion revascularization (8 vs. 14.6 vs. 13.9%, P = 0.002). Myocardial infarction rate was lower in the DES group as well (0.4 vs. 3.1% in BMS, P = 0.001). At multivariate analysis, BMS implantation and balloon angioplasty were independent predictors of long-term MACE. DES implantation was associated with a lower risk of long-term myocardial infarction [hazard ratio 0.15, 95% confidence interval (95% CI) 0.04-0.67] and target-lesion revascularization (hazard ratio 0.42, 95% CI 0.21-0.82). Male sex and DES use were independent predictors of the absence of MACE. CONCLUSION: After rotational atherectomy, DES implantation appears to be a preferable strategy, as it is associated with lower long-term MACE, despite an unexpected increase in periprocedural myocardial infarction.

The treatment of carotid artery bifurcation stenoses with systematic stenting: experience of first 100 consecutive cardiological procedures.

Carotid endarterectomy still represents the gold standard treatment of carotid artery bifurcation stenosis but percutaneous angioplasty with stenting is rapidly growing as a non-invasive alternative. In this paper we report the results of systematic application of carotid stenting performed in a cardiological setting, particularly as regards clinical management of patients and technical approach. One-hundred (100) procedures of carotid artery stenting (CAS) on 94 consecutive patients, both symptomatic and asymptomatic, with a carotid stenosis > 70%, were performed over a period of 30 months. The technical approach was directly derived from coronary angioplasty with use of large lumen guiding catheters, 0.014 in. intravascular guidewires and distal protection devices usually employed in coronary interventions. In 3 cases, a post-carotid endarterectomy restenosis and in 97 cases, a de-novo lesion, were treated respectively; in 71 cases, the degree of stenosis was 71-89% and in 29 cases, 90-99%. Cerebral protection was obtained with a distal to the lesion endovascular filter in 63 cases. Immediate technical success, i.e. residual stenosis of the treated vessel < 30% and no significant pathologic acceleration of blood flow (< 1.5 m/sec) at the Doppler ultrasound evaluation, was achieved in all procedures (100%). Ninety-six (96) procedures were totally uncomplicated; in-hospital cerebral complications were 1 TIA, 2 minor and 1 major strokes; at 30-day follow-up one additional major stroke occurred. Despite a particularly high incidence of comorbidities, neither unfavorable cardiological complications nor neurologic deaths were reported. Systematic CAS is a feasible treatment of the carotid artery bifurcation stenosis with high procedural success and low perioperative and short term complications. Its performance in a cardiological setting can combine satisfying procedural results and potentially successful handling of cardiovascular complications.

Percutaneous treatment of early occlusion of a complex arterial coronary graft: a case report.

The internal mammary arteries are now widely used for surgical myocardial revascularization. Because of its excellent long-term patency rates, re-do surgery is rarely requested and transluminal percutaneous angioplasty of these arterial grafts is still relatively infrequent. This procedure is performed mainly at the distal anastomotic site but also at the origin of the vessel from the subclavian artery, frequently just to treat a local traumatic dissection due to the catheter. We here report the case of a successful angioplasty and stenting of the body of the graft for an early total occlusion of a complex, bifurcated arterial bypass to the left coronary system.

[Stress-induced transient left ventricular apical ballooning]. / Un caso di sindrome "tako-tsubo-like" da stress.

Transient left ventricular apical ballooning is a quite rare clinical event mostly described in the Japanese population. It is also known as tako-tsubo-like syndrome due to the peculiar shape on endsystolic left ventriculogram which is like a tako-tsubo, an ancient device used for trapping octopuses in the Japanese sea. The clinical features of this cardiomyopathy, which mimicked an acute coronary syndrome in an Italian 78-year-old man, are described. Acute left ventricular dysfunction with the typical left ventriculogram and normal epicardial coronary arteries followed an acute emotional and physical stress: the patient felt off his boat, while lifted well up above the water of a great Italian lake during routinary servicing, with consequent chest and head traumas. The combination of emotional and physical stress with the dive in the lake cold water could have caused a brisk and marked increase in catecholamines with possible direct myocardial injury. The occurrence of a rare case of a Japanese cardiomyopathy, also mentioned by a device used in sea-fishing, in an Italian patient following an accidental dive in a lake, appears at least peculiar.

[Indications for percutaneous myocardial revascularization]. / Indicazioni alla rivascolarizzazione coronarica percutanea.

Indications and timing of myocardial revascularization procedures are discussed based on the case of a 78-year-old woman suffering from effort angina due to three-vessel coronary artery disease with normal left ventricular function. At present, atherosclerotic patients have a relatively long history of their disease, so that physicians should organize therapeutic strategies resulting from a right trade-off between guidelines of international scientific societies and the peculiar clinical requirements of the individual patient in the particular stage of his/her disease. This kind of tailored therapy may result from a multidisciplinary approach (heart team), which should involve many specialists as comorbidities and frailty of the patients are numerous and significant.