Absent right common carotid artery with stenting of symptomatic internal carotid artery stenosis.

Absent common carotid artery with independent origin of internal and external carotid arteries from the subclavian artery is a rare but recognized phenomenon. We describe one such case with an associated symptomatic proximal high-grade stenosis of the right internal carotid artery. The abnormal carotid anatomy was not initially well appreciated, resulting in a failed surgical exploration and subsequent successful endovascular carotid stenting. To our knowledge, this is the first reported case of carotid stent in a right internal carotid artery originating from the subclavian artery.

Assessment of reverse flow as a means of cerebral protection during carotid artery stent placement with diffusion-weighted and transcranial Doppler imaging.

PURPOSE: To assess the effectiveness of flow reversal as an alternative means of cerebral protection by using transcranial Doppler recordings and diffusion-weighted imaging (DWI) as surrogate markers of brain injury. MATERIALS AND METHODS: Eighteen patients with symptomatic carotid artery disease were recruited. Magnetic resonance imaging was performed before the intervention and at 3 and 24 hours and 30 days after the intervention to detect new ischemic lesions with DWI. Transcranial Doppler recordings were made during the procedure to assess for microembolic signals (MESs). Data were compared against data from a historical control cohort of patients who underwent CAS placement with or without filter protection (n = 15 each) under the same protocol in a different study. RESULTS: There were fewer periprocedural new lesions on DWI in the reverse-flow cohort compared with the historical control cohort with filter protection (P = .084). Reverse flow revealed significantly fewer MESs during the whole procedure compared with the filter-protected group (P = .01) but not the unprotected group (P = .55). There was a marked decrease in MES counts for reverse flow protection during the embologenic stages of the procedure (P = .004). CONCLUSIONS: Use of the reverse flow device was associated with fewer overall lesions on DWI and proportionately fewer positive scans compared with the use of filter-type devices (P = .08, not significant). Transcranial Doppler recordings demonstrated a significant reduction in embolization to the brain during carotid artery stent placement with the use of reverse-flow cerebral protection.

Filter-protected versus unprotected carotid artery stenting: a randomised trial.

BACKGROUND: Our aim was to determine whether filter protection reduces embolisation to the brain during carotid artery stenting (CAS). METHODS: Thirty patients with symptomatic carotid artery stenosis > or =70% (North American Symptomatic Carotid Endarterectomy Trial) were randomly assigned to filter-protected or unprotected CAS. Diffusion-weighted magnetic resonance imaging (DWI) of the brain was performed before and at 3 time points after CAS. In a subset of patients, high-intensity transient signals on transcranial Doppler (TCD) were recorded with categorisation of emboli. Data were independently reviewed off-site. RESULTS: There were no significant differences in mean age, proportion of octogenarians or presenting symptoms between the groups. On procedural DWI (1-3 and 24 h after stenting), there were 7/24 (29%) and 4/22 (18%) new lesions in protected and unprotected patients respectively (p = 0.38). At 30 days there were 9/33 (26%) and 4/33 (12%) lesions in protected and unprotected patients, respectively (p = 0.1). On TCD there were significantly more signals in total as well as particulate emboli during filter-protected CAS (426.5 and 251.3) than during unprotected CAS (165.2 and 92) - p = 0.01 and 0.03, respectively. CONCLUSIONS: Filter-protected CAS is associated with an increase in new lesions on DWI and significantly higher rates of total and particulate microembolisation on TCD than unprotected CAS. The clinical significance of these findings requires further study.

Long-Term Evaluation of Percutaneous Groin Access for EVAR.

BACKGROUND: Percutaneous endovascular aneurysm repair (PEVAR) has been shown to have high success rates, shorter operating times and length of stay compared to open access. However, there exists a lack of long-term follow-up data on these patients, and questions remain regarding longer-term outcomes. This study aims to assess the long-term complications and evolution of accessed vessels post-PEVAR. METHODS: Sixty-one cases of bilateral PEVAR (122 groins) with > 36 months follow-up were analysed. Vessel diameter, calcification, dissection, lymphocele, pseudoaneurysm and thrombus formation were reviewed at 30th day and at the most recent follow-up CT. Notes were reviewed for groin infections, haematomas and nerve injury. Complications were considered 'major' if they required intervention or treatment. RESULTS: Mean follow-up time from procedure to most recent scan was 49.9 months. There were no major short- or long-term complications. The early complication rate was 9.8%, with six pseudoaneurysms, four dissections, one thrombus, one nerve injury and no lymphoceles, haematomas or groin infections. The long-term complication rate was 0.8%, with only one pseudoaneurysm. The remainder of early complications resolved naturally without intervention. Accessed vessel showed significantly (P ≤ 0.05) increased diameter and calcification between 30th day and last follow-up scan. CONCLUSION: This study provides the largest clinical cohort and the longest mean follow-up time reported in the literature and demonstrates the long-term safety of PEVAR. PEVAR has a very low long-term complication rate, without any major complications in our cohort. The accessed common femoral arteries do not show stenosis or thrombosis. Minor short-term complications appear to gradually resolve without intervention. Larger multi-centre studies are recommended.

Is there any benefit from staged carotid and coronary revascularization using carotid stents? A single-center experience highlights the need for a randomized controlled trial.

BACKGROUND AND PURPOSE: To assess the benefits of carotid artery stenting before coronary artery bypass surgery to reduce the risk of stroke occurring during the cardiac procedure. METHODS: A prospective cohort study was performed in patients undergoing carotid artery stenting before coronary artery bypass surgery, or combined bypass and valve replacement procedures, to assess the procedures effectiveness in stroke prevention. Outcome measures including 30-day post stenting and cardiac surgery neurological complication and all-cause mortality rates were assessed. RESULTS: A total of 52 patients were included. Two patients underwent aortic valve replacements at the same time as coronary revascularization. No neurological complications occurred because of the stenting procedure. One cardiac death not related to coronary artery bypass surgery occurred in the 30-day follow-up period for the stent procedure. An additional 6 (11.5%) outcome events (3 strokes and 3 deaths) occurred in the 30-day follow-up period after the cardiac procedure. Three patients died of cardiac causes while awaiting their cardiac bypass procedure. CONCLUSIONS: Our results are comparable to those in patients that undergo staged or combined carotid endarterectomy before cardiac surgery. Our small cohort study adds to the limited world literature on the subject but is not sufficiently powered to recommend alterations in practice.

Renal artery sympathetic denervation: observations from the UK experience.

BACKGROUND: Renal denervation (RDN) may lower blood pressure (BP); however, it is unclear whether medication changes may be confounding results. Furthermore, limited data exist on pattern of ambulatory blood pressure (ABP) response-particularly in those prescribed aldosterone antagonists at the time of RDN. METHODS: We examined all patients treated with RDN for treatment-resistant hypertension in 18 UK centres. RESULTS: Results from 253 patients treated with five technologies are shown. Pre-procedural mean office BP (OBP) was 185/102 mmHg (SD 26/19; n = 253) and mean daytime ABP was 170/98 mmHg (SD 22/16; n = 186). Median number of antihypertensive drugs was 5.0: 96 % ACEi/ARB; 86 % thiazide/loop diuretic and 55 % aldosterone antagonist. OBP, available in 90 % at 11 months follow-up, was 163/93 mmHg (reduction of 22/9 mmHg). ABP, available in 70 % at 8.5 months follow-up, was 158/91 mmHg (fall of 12/7 mmHg). Mean drug changes post RDN were: 0.36 drugs added, 0.91 withdrawn. Dose changes appeared neutral. Quartile analysis by starting ABP showed mean reductions in systolic ABP after RDN of: 0.4; 6.5; 14.5 and 22.1 mmHg, respectively (p < 0.001 for trend). Use of aldosterone antagonist did not predict response (p > 0.2). CONCLUSION: In 253 patients treated with RDN, office BP fell by 22/9 mmHg. Ambulatory BP fell by 12/7 mmHg, though little response was seen in the lowermost quartile of starting blood pressure. Fall in BP was not explained by medication changes and aldosterone antagonist use did not affect response.

Multicenter evaluation of carotid artery stenting with a filter protection system.

OBJECTIVES: The aim of this study was to evaluate the feasibility and safety of carotid artery stenting (CAS) with a filter protection system. BACKGROUND: Neurologic events linked to the embolization of particulate matter to the cerebral circulation may complicate CAS. Strategies designed to capture embolic particles during carotid intervention are being evaluated for their efficacy in reducing the risk of these events. METHODS: Between September 1999 and July 2001, a total of 162 patients (164 hemispheres) underwent CAS with filter protection (NeuroShield, MedNova Ltd., Galway, Ireland) according to prospective protocols evaluating the filter system at three institutions. RESULTS: Angiographic success was achieved in 162 of the procedures (99%) and filter placement was successful in 154 (94%) procedures. Carotid access was unsuccessful in two cases (1%) and filter placement in eight cases (5%). Of the latter, five procedures were completed with no protection and three were completed using alternative protection devices. On an intention-to-treat basis, the overall combined 30-day rate of all-stroke and death was 2% (four events: two minor strokes and two deaths). This includes one minor stroke in a patient with failed filter placement and CAS completed without protection. There was one cardiac arrhythmic death and one death from hyperperfusion-related intracerebral hemorrhage. There were no major embolic strokes. CONCLUSIONS: Carotid artery stenting with filter protection is technically feasible and safe. Early clinical outcomes appear to be favorable and need to be confirmed in a larger comparative study.

Short-term changes in cerebral microhemodynamics after carotid stenting.

BACKGROUND AND PURPOSE: The cerebral hemodynamic sequelae of interventions in patients with severe internal carotid artery (ICA) stenoses are not fully understood. In this study, we sought to determine the immediate changes in cerebral perfusion characteristics, determined by MR imaging in patients who have undergone unilateral transluminal angioplasty and stent placement. METHODS: Eleven patients with symptomatic high-grade ICA stenosis underwent MR imaging within 4 hours before and within 3 hours after carotid stent placement. First-pass gadolinium-enhanced imaging of perfusion was performed by using a gradient-recalled echo-planar technique. Localized relative cerebral blood volume (rCBV) and bolus first-moment transit time (TT(FM)) were calculated for different vascular territories (middle, anterior, and posterior cerebral arteries) in each hemisphere. RESULTS: Significantly longer TT(FM) (P <.005) was observed in the symptomatic territory of the middle cerebral artery before intervention. After intervention, TT(FM) remained significantly longer in this territory (P <.05). However, the magnitude of the interhemispheric asymmetry had declined significantly (50-60% reduction; P <.05). No significant differences or changes in rCBV were identified between hemispheres, between images, or in areas of unilateral leptomeningeal enhancement after intervention. CONCLUSION: MR can demonstrate short-term partial resolution of timing asymmetry in interhemispheric perfusion after angioplasty and stent insertion for severe stenosis of the ICA.

Long-term results of carotid artery stents to manage symptomatic carotid artery stenosis and factors that affect outcome.

BACKGROUND: Limited data are available about the long-term outcomes of the use of carotid artery stents in symptomatic patients and the impact of patient variables on the durability of endovascular carotid procedures. Outcome data previously reported from registry series mix symptomatic and asymptomatic patients. We present analysis of long-term follow-up, with independent neurological assessment, for patients with symptomatic high-grade carotid lesions undergoing stenting to identify patients at risk of recurrence. METHODS AND RESULTS: Prospectively collected data on 563 carotid stenting procedures in a single center were analyzed. Univariate and multivariate techniques were used to identify risk groups and beneficial technical adaptations. Ipsilateral stroke rates for all patients were 4.8%, 7.0%, and 9.5% at 30 days, 1 year, and 4 years, respectively. The rates improved to 2.7%, 4.1%, and 4.5% when patients were treated with optimal therapy. Retinal events had a lower risk of long-term recurrent ipsilateral stroke (hazard ratio=0.228, CI=0.082 to 0.632, P=0.004) than cerebral events. A recurrent or residual stenosis of >50% had a statistically significant effect on long-term stroke recurrence in multivariate analysis (hazard ratio=2.187, CI=1.173 to 4.078, P=0.014). CONCLUSIONS: Patients with retinal presentations are a lower risk group to treat. Residual stenosis or restenosis >50% has a statistically significant trend to an increased risk of recurrence for ipsilateral stroke in the long term in this population. In our patients, a combination of procedural modifications and pharmacological changes seems to improve outcomes.

Successful angiographic embolisation of bleeding into the chest wall after chest drain insertion.

Peripheral arterial injuries after blunt or penetrating trauma commonly follow injuries to adjacent soft tissue and bone. The traditional approach to these injuries is by open exploration, with identification and ligation of the bleeding vessel. We describe the case of a type II respiratory failure patient who had an enormous pectoral muscle haematoma following chest drain insertion, in whom the bleeding was only controlled by angiographic embolisation following failure of surgical exploration.

Embolization of a hemorrhoid following 18 hours of life-threatening bleeding.

Hemorrhoids usually do not pose diagnostic difficulties and they rarely cause massive bleeding. We report a case of massive rectal bleeding over 18 h needing 22 U blood transfusion treated by superselective transcatheter coil embolization 12 h following operative treatment performed in a different hospital. Diagnostic angiography with a view to superselective embolization, following failure of sigmoidoscopy to localize and treat the cause of hemorrhage, might act as a life-saving treatment in massive rectal bleeding, obviating the need for repeated endoscopy or emergency surgery.

Endofibrosis of iliac arteries in high-performance athletes: diagnostic approach and minimally invasive endovascular treatment.

The aim of this article is to report our experience in the diagnosis of two cases of iliac artery endofibrosis or arteriopathy, a rare entity occurring in high-performance athletes, presenting with intermittent claudication (right-sided in both) after maximal exercise. External iliac artery endofibrosis or arteriopathy is a likely diagnosis in competitive athletes free of cardiovascular risk factors who present with leg claudication. Arteriography and a papaverine-assisted mean pressure gradient across the iliac arteries of more than 10 mmHg is a useful diagnostic approach. Moreover, balloon angioplasty of the iliac artery in that patient, in whom a pressure gradient was detected, resulted in symptomatic relief for 2 months followed by mild symptom recurrence. Thus, although balloon angioplasty is feasible and safe, it might not be adequate to treat this entity and, thus, its value remains undefined.

Stent implantation for acute iliac artery occlusions: initial experience.

PURPOSE: Treatment options for acute occlusion of the iliac arteries include surgical thrombectomy, surgical bypass, and endovascular interventions such as thrombolysis and mechanical thrombectomy with or without adjunctive angioplasty or stent implantation. Acute lesions are not usually treated by stent implantation for fear of distal embolism. The purpose of this study was to retrospectively review a single-center experience of primary iliac stent implantation for acute ischemia secondary to acute thrombosis. MATERIALS AND METHODS: Between April 2004 and August 2005, seven patients (five men and two women; mean age, 69.9 y; range, 53-93 y) underwent iliac stent implantation for the acute onset (within 12 days before presentation) of ipsilateral ischemic symptoms. Diagnostic angiography revealed occlusion of the common and external iliac arteries (n = 3) or external iliac artery (n = 4). Patients with rest pain (n = 6) were treated with unfractionated heparin. RESULTS: All acute occlusions were traversed by the guide wire with relative ease. Recanalization with stent implantation was successful in all cases without distal embolization. Five patients showed noticeable clinical improvement. Two elderly patients with isolated patent profunda segments with no demonstrable distal runoff vessels did not have long-term clinical improvement despite successful iliac recanalization. CONCLUSIONS: This small case series suggests that primary stent implantation for acute iliac occlusions with a patent common femoral artery under intravenous heparin protection may be a reasonable endovascular alternative to thrombolysis for patients who cannot tolerate the time delay to achieve thrombolysis or who have contraindications to thrombolysis. The safety of this technique may be comparable to that of primary stent implantation for chronic occlusions, but larger series would be necessary to confirm this.

Protected carotid stenting: safety and efficacy of the MedNova NeuroShield filter.

OBJECTIVE: Neuroprotection during carotid stenting has the potential to reduce procedural atheroembolic sequelae. We report the United Kingdom experience of NeuroShield (MedNova Ltd, Horsham, West Sussex, United Kingdom). METHODS: We performed a prospective cohort analysis of 50 consecutive patients (50 lesions) in a regional vascular tertiary referral center (catchment area one million) that provides an institutional service for the short term. The subjects were all the patients referred for carotid stenting after preassessment by a multidisciplinary team. All the patients underwent pretreatment with antiplatelet agents. Forty-two patients had atherosclerotic stenosis of the carotid bifurcation between 70% and 95% (with North American Symptomatic Carotid Endarterectomy Trial criteria). Six patients had restenosis after endarterectomy. Two had previous local radiotherapy. Forty-two patients were symptomatic (amaurosis fugax/central retinal artery occlusion in 11 cases, and hemispheric transient ischemic attack/cerebrovascular accident in 31 cases). Eight patients were asymptomatic with bilateral high-grade stenoses, with six cases before coronary artery bypass grafting. The intervention performed was protected primary carotid stenting. Outcome measures were procedural atheroembolic events, including all-stroke and death rates up to 30 days, and analysis of retrieved debris in a subset of 11 cases. RESULTS: The technical success rate was 50/50 (100%) for stenting and 49/50 (98%) for filter placement/retrieval. Technical complications comprised nonsymptomatic spasm at the filter site (flow limiting in two cases and non-flow limiting in five cases). Procedural events were one minor stroke (patient fully recovered within 48 hours) in a complex clinical setting and one ventricular fibrillation arrest in a patient before coronary artery bypass grafting who was resuscitated without neurologic event. At 30 days, the death or major disability from stroke rate was 2/50 (4%). No cases were atheroembolic. The all-stroke/death rate was 3/50 (6%). The two deaths were the result of a fatal hemorrhagic stroke that occurred at 4 days and was thought to be caused by reperfusion and a perforated ventricle caused by a temporary pacing wire. One femoral pseudoaneurysm followed failed closure device deployment and required percutaneous thrombin injection. The mean particle number per patient was 12 (range, 0 to 41). The mean particle diameter was 284.9 microm(range, 31 to 1430 microm). The mean ellipsoid volume load was 0.1602 mm(3) (range, 0.0005 to 0.1968 mm(3)). CONCLUSION: Carotid stenting protected with NeuroShield is safe. The filter traps embolic debris liberated during the procedure.

Placement of a retrievable Günther Tulip filter in the superior vena cava for upper extremity deep venous thrombosis.

A retrievable Günther Tulip caval filter (William Cook, Europe) was successfully placed and retrieved in the superior vena cava for upper extremity deep venous thrombosis in a 56-year-old woman. Bilateral subclavian and internal jugular venous thromboses thought secondary to placement of multiple central venous catheters were present. There have been reports of the use of permanent Greenfield filters and a single case report of a temporary filter in the superior vena cava. As far as we are aware this is the first reported placement and successful retrieval of a filter in these circumstances.

Neurological outcomes after carotid stenting protected with the NeuroShield filter compared to unprotected stenting.

PURPOSE: To compare outcomes for two nonrandomized cohorts of patients with high-grade carotid disease who underwent either unprotected carotid stenting or stent implantation protected by the NeuroShield filter. METHODS: Under this protocol, symptomatic patients with carotid stenoses >70% or asymptomatic patients with bilateral carotid stenoses who were being evaluated for coronary artery bypass grafting were eligible for carotid stenting. Between December 1998 and November 2001, 75 consecutive patients (57 men; median age 67 years range 45-85) underwent carotid stenting without cerebral protection; concurrently, 75 carotid stent procedures protected with the NeuroShield filter were performed in 73 patients (51 men; median age 66 years, range 47-83). A neurologist reviewed all patients before and after treatment. The groups were comparable for age, sex, and symptoms, but the protected group had a higher proportion of postsurgical restenoses (14.7% versus 1.3%; p=0.003). Outcome measures included death and neurological events at 24 hours and 30 days. RESULTS: There were minor technical difficulties in 12 of the protected group, but none were clinically relevant. The procedural all-stroke/death rates in the unprotected versus protected groups, respectively, were 5.3% (4/75) and 2.7% (2/75; p=0.681), while the disabling stroke/death rates were 4% (3/75) and 1.3% (1/75; p=0.620). At 30 days, the all-stroke/death rates were 10.7% (8/75) in the unprotected group and 4.0% (3/75) in the protected group (p=0.117); the death/major-disability-from-stroke rates were 6.7% (5/75) and 2.7% (2/75), respectively (p=0.442). CONCLUSIONS: Filter-related complications are well tolerated. Neuroprotection devices have the potential to reduce the procedural neurological event rate. Larger series and/or randomized trials are required for further evaluation.

Outpatient vascular intervention: a two-year experience.

PURPOSE: To retrospectively analyze the outcome of a range of interventional vascular procedures performed on outpatients. METHODS: Suitability for outpatient procedures was assessed according to agreed protocols. An episode was defined as any procedure/s through a single access site at one attendance. Retrospective case-note review was performed. RESULTS: There were 693 outpatient episodes between April 1998 and May 2000 (290 interventional, and 403 diagnostic procedures), comprising 25% (693/2,769) of the total workload. Follow-up is available in 214; 38 of these were transfers from outlying hospitals and were excluded from analysis. One hundred and seventy-six were true outpatients. There were 98 iliac and 46 femoropopliteal interventions, 2 aortic stents, 1 renal and 5 upper-limb angioplasties (PTAs), 5 embolizations, 8 Hickman lines, 1 line stripping, 3 atherectomies, 1 dialysis-graft PTA and 6 bypass-graft PTAs. Sixty-eight closure devices were used. Twelve patients were converted to inpatients (6.8%, 12/176). The readmission rate was 3.4% (6/176). The reattendance rate was 1.1% (2/176), both subsequently attending for outpatient duplex ultrasound examination to exclude pseudoaneurysm. The major complication rate was 3.4% and the delayed major complication rate was 1.7%. CONCLUSION: Outpatient vascular intervention is safe with appropriate protocols and with careful patient selection. Local vascular services benefit from the release of inpatient beds.

Angioplasty or stenting in adult coarctation of the aorta? A retrospective single center analysis over a decade.

For over 11 years, endovascular treatment by angioplasty (PTA) alone or stenting of adult coarctation at a single center was evaluated. We retrospectively reviewed 28 consecutive patients (31 interventions), median age 25 years, treated between 1991 and 2002, 20 of whom had native coarctation. Thirteen patients had PTA alone (16 procedures) (10 "kissing balloon" angioplasty comprising 12 interventions, and 3 single balloon angioplasty comprising 4 interventions) and 15 patients were stented (15 procedures), including 6 secondary and 9 primary stents. There were no procedural or 30-day complications. For the whole group, the median follow-up was 6.6 years (range 1-10 years). In the PTA group, median follow-up was 9 years (range 3-10) and in the stenting group it was 3 years (range 1-5). There were 9 restenoses in the PTA group (6 after "kissing balloons" and 3 after single balloon) comprising 56% of the angioplasties (9/16 procedures). There was 1 restenosis in the stenting group diagnosed at computed tomography (CT). The patient was clinically well. For the whole group there were significant reductions in systolic blood pressure (BP) (p = 0.0003), diastolic BP (p = 0.004) and number of drugs per patient (p = 0.045) at latest follow-up post-treatment. Five patients discontinued therapy. Analysis of the groups revealed that the reduction of systolic and diastolic BP and number of drugs did not reach statistical significance in the PTA group but were significant in the stent group. The endovascular management of adult coarctation is safe. Stents may be more effective than PTA alone but longer-term follow-up of stents is required.