Aneurysmal dilatation of medium caliber arteries in Turner syndrome.

Turner syndrome is the most common chromosomal abnormality in female subjects, affecting 1 in 2000 live births. The condition is associated with a generalized vasculopathy as well as congenital cardiac and other defects. We report aneurysmal dilation of medium caliber arteries involving the celiac axis and coronary vessels in two women with Turner syndrome.

Beware of the B(e)all valve: mistaken valve identity, 30-year survival, and valve replacement.

Effective management of patients after the implantation of mechanical cardiac valves includes correct recognition of each valve and its related complications. Herein, we present the case of a patient who had undergone implantation of a floating-disc Beall-Surgitool mitral valve in 1976 and developed multiple valve-related complications. Over 30 years and in multiple medical centers, the device was mistakenly assumed to be a "ball" valve. The correct identification of the prosthesis led to the recognition of valvular failure, and the patient underwent its replacement with an On-X bileaflet carbon valve. Pathologic and microscopic examination of the explanted Beall valve showed massive pannus formation that extended over the sewing cuff on the atrial and ventricular side, preventing complete disc closure; disrupted fabric coating of the sewing ring, with exposure of the underlying metal; and a marked inflammatory reaction. We report one of the longest intervals on record between the implantation and replacement of a Beall-Surgitool valve.

Origin of a common trunk for the inferior phrenic arteries from the right renal artery: a new anatomic vascular variant with clinical implications.

The inferior phrenic arteries constitute a pair of important vessels, supplying multiple organs including the diaphragm, adrenal glands, esophagus, stomach, liver, inferior vena cava, and retroperitoneum. The vast majority (80-90%) of inferior phrenic arteries originate as separate vessels with near equal frequency from either the abdominal aorta or the celiac trunk. Infrequently, the right and left inferior phrenic arteries can arise in the form of a common trunk from the aorta or from the celiac trunk. We herein present three patients with a new anatomic vascular variant: a common trunk of the inferior phrenic arteries arising from the right renal artery. In one case, the left inferior phrenic branch of the common trunk provided collaterals connecting with a supra-diaphragmatic branch of the left internal mammary artery and in another with the lateral wall of the pericardium. Angiographic identification of a common trunk for the inferior phrenic arteries arising from the right renal artery is important for proper diagnosis and clinical management. The presence of this unique vascular variant can impact revascularization of the renal arteries.

Utilization of excimer laser debulking for critical lesions unsuitable for standard renal angioplasty.

BACKGROUND: The energy emitted by ultraviolet laser is avidly absorbed in atherosclerotic plaques. Conceptually, it could be applied for debulking of selected atherosclerotic renal artery stenoses. We describe early experience with revascularization of critical renal artery lesions deemed unsuitable for standard renal angioplasty. Institutional Review Board permission to conduct the data analysis was obtained. METHODS: Among 130 percutaneous renal artery interventions with balloon angioplasty and adjunct stenting, there were 12 (9%) patients who underwent laser debulking prior to stenting. These patients presented with critical (95+/-3.5% stenoses) lesions (11 de novo, 1 stent restenosis) deemed unsuitable for standard renal angioplasty because of marked eccentricity and presence of thrombus. Indications for intervention included preservation of kidney function, treatment of uncontrolled hypertension, management of congestive heart failure, and treatment of unstable angina. Blood pressure and estimated glomerular filtration rate (eGFR) were measured pre- and 3 weeks post-intervention. RESULTS: A baseline angiographic stenosis of 95+/-3.5% was reduced to 50+/-13% with laser debulking. There were no laser-induced complications. Post-stenting the angiographic residual stenosis was 0%. The mean gradient across the lesions was reduced from baseline 85+/-40 to 0 mmHg. A normal post-intervention antegrade renal flow was observed in all patients. Baseline mean systolic BP of 178+/-20 mmHg decreased to 132+/-12 mmHg (P<0.0001) and mean diastolic pressure of 85+/-16 mmHg reduced to 71+/-9 mmHg (P = 0.01). A pre-intervention mean eGFR of 47.7+/-19 ml/min/1.73 m(2) increased to 56+/-20.4 ml/min/1.73 m(2) (P = 0.05) post-procedure. The interventions were not associated with major renal or cardiac adverse events. During follow-up one patient developed transient contrast-induced nephropathy. CONCLUSIONS: Debulking of select renal artery stenoses with laser angioplasty followed by adjunct stenting is feasible. Further prospective, randomized studies will be required to explore the role of debulking and laser angioplasty in renal artery revascularization.

Excimer laser debulking for percutaneous coronary intervention in left main coronary artery disease.

Excimer laser has been successfully applied to complex atherosclerotic plaques in acute coronary syndromes; however, its role in debulking in left main coronary artery disease has not been fully explored. Details of a series of 20 patients who underwent excimer laser revascularization of a spectrum of left main coronary artery lesions are presented. Twenty symptomatic patients who received excimer laser debulking were examined for procedural outcome and follow up results. The left main coronary artery was characterized as protected, semi-protected, poorly protected, or unprotected, depending on the presence or absence of patent bypass grafts to the left anterior descending (LAD) and circumflex (CX) arteries. A fully protected left main coronary artery (LMCA) was present in only 20% of the patients. The target lesions included 11(55%) distal LMCA stenoses, six (30%) ostial stenoses, and one (5%) mid-portion lesions. Two (10%) patients had in-stent re-stenosis of the entire length of the LMCA. Small (0.7 mm-1.4 mm) excimer laser catheters were mostly used. A relatively high number of laser energy pulses (1,334 +/- 643) were required to achieve adequate debulking. Successful LMCA intervention was performed in 19 (95%) patients, while in-hospital complications occurred in only one (5%) patient. Subacute/late stent thrombosis developed 3 months after the procedure in one patient, and two patients died from non-cardiac causes during follow-up. Lesions in LMCAs can be revascularized in selected patients by laser debulking and adjunct stenting. Inadequate protection by bypass grafts and decreased left ventricular function do not contradict utilization of excimer laser. Small laser catheters and high energy levels are required during laser debulking of stenoses of left main coronary arteries.