Carotid angioplasty and stenting: treatment of postcarotid endarterectomy restenosis is at least as safe as primary stenosis treatment.

OBJECTIVES: This study compared transcranial Doppler (TCD) imaging and outcomes of carotid angioplasty and stenting (CAS) in stenosis after carotid endarterectomy (CEA) vs primary atherosclerotic stenoses. METHODS: A prospectively accumulated database of 812 CAS procedures was analyzed retrospectively. Two groups were created. Group 1 had 72 restenoses at a mean of 71 months (range, 5-245 months) after initial CEA. Group 2 had 740 primary stenoses. Clinical end points were cerebral ischemic events and death. TCD end points were numbers of isolated microemboli and microembolic showers during five procedural phases. RESULTS: Groups 1 and 2 were evenly matched for demographic data: median age, 70 vs 71 years; 44 (61%) vs 525 men (71%); 14 (19%) vs 147 symptomatic (20%). Seven (0.9%) deaths and 10 major (1.2%) and 21 minor (2.6%) strokes occurred in group 2 (P = .049). Mean (standard deviation) numbers of isolated microemboli for groups 1 vs 2 were wiring, 37.0 (31.1) vs 50.4 (52.6); predilation, 14.8 (18.7) vs 21.7 (21.8); stent placement, 58.6 (31.1) vs 64.7 (38.8); postdilation, 20.4 (16.5) vs 27.2 (34.9), cerebral protection device (CPD) use, 44.2 (30.2) vs 37.5 (36.8); total, 134.8 (68.7) vs 175.3 (113.8). Microembolic showers: wiring, 1.7 (4.5) vs 2.2 (6.4); predilation, 2.1 (4.1) vs 3.3 (5.8); stent placement, 21.5 (22.0) vs 26.9 (25.1); postdilation, 5.3 (15.7) vs 5.0 (8.1); CPD use, 5.8 (6.9) vs 6.2 (8.9); total, 30.4 (36.0) vs 39.6 (35.0). TCD data for CPD use vs without for isolated emboli: wiring, 53.2 (45.1) vs 44.3 (51.7); predilation, 24.7 (20.2) vs 18.2 (22.5); stent placement, 77.5 (34.8) vs 53.5 (37.3); postdilation, 33.6 (36.6) vs 20.7 (21.8); CPD use, 38.3 (36.6) vs 0; total, 222.5 (113.8) vs 132.3 (89.1). Showers: wiring, 2.4 (6.6) vs 1.9 (5.8); predilation, 4.2 (6.4) vs 2.4 (5.0); stent placement, 38.9 (25.8) vs 16.2 (18.7); post-dilation, 7.0 (11.2) vs 3.4 (6.4); CPD use, 6.3 (8.9) vs 0; total, 58.4 (37.7) vs 23.3 (23.1). P = .01 for showers during wiring and P < .001 for all other variables. After correction for the difference in CPD use between groups 1 and 2 (17 out of 72 [24%] vs 369 out of 740 [50%]), no statistically significant differences remained in numbers of isolated emboli and embolic showers in the procedural phases or for the entire procedure. No statistically significant differences were found when TCD-detected microembolic load for early (<3 years between CEA and CAS) and late (>5 years) restenoses were compared. CONCLUSIONS: CAS for restenosis after CEA has a complication rate lower than primary CAS. The time interval between CEA and CAS did not influence micro embolic load.

Grading of pulmonary right-to-left shunt with transthoracic contrast echocardiography: does it predict the indication for embolotherapy?

RATIONALE: Pulmonary arteriovenous malformations (PAVMs) are associated with severe neurologic complications in patients with hereditary hemorrhagic telangiectasia (HHT). Therefore, screening is warranted. Transthoracic contrast echocardiography (TTCE) can effectively detect a pulmonary right-to-left shunt (RLS). OBJECTIVES: To determine prospectively the predictive value of TTCE grading to detect PAVMs on high-resolution CT (HRCT) scans of the chest and the indication for embolotherapy. METHODS: Three hundred seventeen patients, referred for possible HHT, were screened for PAVMs. Patients who underwent both chest HRCT scanning and TTCE were included in the study (n = 281). For the purposes of this study we used a 3-point grading scale, and shunt grades 3 and 4 according to the classification model of Barzilai et al were combined. Embolotherapy was performed of all PAVMs judged large enough for treatment. RESULTS: Echocardiographic criteria for a pulmonary RLS were present in 105 patients (41%) [mean (+/- SD) age, 43.7 +/- 15.7 years; female gender, 63%]. Chest HRCT scan findings were positive in 55 patients (52%) in this group. The positive predictive value of shunt grade for the presence of PAVMs on chest HRCT scans was 22.9% for grade 1 (n = 35), 34.8% for grade 2 (n = 23), and 83.0% for grade 3 (n = 47), respectively. None of the patients with PAVMs seen on chest HRCT scans and a TTCE grade 1 (n = 8) or 2 (n = 8) were candidates for embolotherapy. Of 39 patients with TTCE grade 3 and PAVMs seen on chest HRCT scans, 26 patients (67%) underwent embolotherapy. CONCLUSION: An increased echocardiographic shunt grade correlates with an increased probability of PAVMs seen on chest HRCT scans. Only patients with a TTCE grade 3 displayed PAVMs on chest HRCT scans that were large enough for embolotherapy.

Superselective coil embolization of arterial esophageal hemorrhage.

The authors report a case of arterial esophageal bleeding resistant to endoscopic hemostasis in a patient in critical condition after complicated gastrointestinal and pulmonary surgery. Unfit for surgery, the patient's massive hemorrhage was successfully treated with superselective coil embolization of the afferent esophageal branch of the thoracic aorta. In patients with severe arterial bleeding of the esophagus, percutaneous superselective arterial coil embolization may be feasible for control of hemorrhage.

Carotid angioplasty and stenting for postendarterectomy stenosis: long-term follow-up.

BACKGROUND: Carotid angioplasty and stenting (CAS) for recurrent stenosis after carotid endarterectomy (CEA) has been proposed as an alternative to redo CEA. Although early results are encouraging, the extended durability remains unknown. We present the long-term surveillance results of CAS for post-CEA restenosis. METHODS: Between 1998 and 2004, 57 CAS procedures were performed in 55 patients (36 men) with a mean age of 70 years. The mean interval between CEA and CAS was 83 months (range, 6 to 245). Nine patients (16%) were symptomatic. RESULTS: CAS was performed successfully in all patients. No deaths or strokes occurred. A periprocedural transient ischemic attack (TIA) occurred in two patients. During a mean follow-up of 36 months (range, 12 to 72 months), two patients exhibited ipsilateral cerebral symptoms (1 TIA, 1 minor stroke). In 11 patients (19%), in-stent restenosis (> or =50%) was detected post-CAS at month 3 (n = 3), 12 (n = 3), 24 (n = 2), 36 (n = 1), 48 (n = 1), and 60 (n = 1). The cumulative rates of in-stent restenosis-free survival at 1, 2, 3, and 4 years were 93%, 85%, 82%, and 76%, respectively. Redo procedures were performed in six patients, three each received repeat angioplasty and repeat CEA with stent removal. The cumulative rates of freedom from reintervention at 1, 2, 3, and 4 years were 96%, 94%, 90%, and 84%, respectively. CONCLUSION: Carotid angioplasty and stenting for recurrent stenosis after CEA can be performed with a low incidence of periprocedural complications with durable protection from stroke. The rate of in-stent recurrent stenosis is high, however, and does not only occur early after CAS but is an ongoing process.

Acute leg ischemia: the dark side of a percutaneous femoral artery closure device.

The use of femoral artery closure devices to obtain hemostasis after percutaneous catheterization has become widespread because of their proven feasibility in combination with patient-related advantages. Since 2002 more than 6,500 patients have undergone either diagnostic angiography or therapeutic intervention via the femoral route with an Angioseal closure device in our hospital. We were faced with six cases of limb-threatening complications, which are described here. Most (5/6) complications were of obstructive origin due to traumatic dissection or occlusion of the artery mainly caused by malpositioning of the device. Recommendations are made in order to prevent or successfully overcome this certainly increasing problem in the vascular field.

Dutch iliac stent trial: long-term results in patients randomized for primary or selective stent placement.

PURPOSE: To determine long-term results of the prospective Dutch Iliac Stent Trial. MATERIALS AND METHODS: The study protocol was approved by local institutional review boards. All patients gave written informed consent. Two hundred seventy-nine patients (201 men, 78 women; mean age, 58 years) with iliac artery disease were randomly assigned to undergo primary stent placement (143 patients) or percutaneous transluminal angioplasty (PTA) with selective stent placement in cases in which the residual mean pressure gradient was greater than 10 mm Hg across the treated site (136 patients). Before and at 3, 12, and 24 months and 5-8 years after treatment, all patients underwent assessment, which included duplex ultrasonography (US), ankle-brachial index (ABI) measurement, Fontaine classification of symptoms, and completion of the Rand 36-Item Health survey for quality-of-life assessment. Treatment was considered successful for symptoms if symptoms increased at least one Fontaine grade, for ABI if ABI increased more than 0.10, for patency if peak systolic velocity ratio at duplex US was less than 2.5, and for quality of life if the RAND 36-Item Health Survey score increased more than 15 points. Effects of both treatments on symptoms, quality of life, patency, and ABI were compared by using survival analyses. RESULTS: Patients who underwent PTA and selective stent placement had better improvement of symptoms (hazard ratio [HR], 0.8; 95% confidence limits [CLs]: 0.6, 1.0) than did patients treated with primary stent placement, whereas ABI (HR, 0.9; 95% CLs: 0.7, 1.3), iliac patency (HR, 1.3; 95% CLs: 0.8, 2.1), and score for quality of life for nine survey dimensions did not support a difference between treatment groups. CONCLUSION: Patients treated with PTA and selective stent placement in the iliac artery had a better outcome for symptomatic success compared with patients treated with primary stent placement, whereas data about iliac patency, ABI, and quality of life did not support a difference between groups.