Free-Cell Area Impact on Stroke Prevention in Asymptomatic Patients Undergoing Carotid Artery Stenting: The "Carotid Artery sTenting And CeLl-area Impact on Stroke and Major Adverse events" (CATACLISMA) Multicenter Registry.

PURPOSE: The study investigated the association between cell-stent area and cerebrovascular events incidence in asymptomatic patients undergoing carotid artery stenting (CAS). MATERIALS AND METHODS: This is an observational, retrospective, multicenter, cohort study. Between 2012 and 2022, all patients undergoing primary CAS for severe asymptomatic carotid artery stenosis were evaluated. Three groups were defined on the basis of the cell area (open cell, OC; closed cell, CC; double layer, DL). Periprocedural primary outcomes were 30-day stroke, mortality, myocardial infarction (MI), and major adverse event (MAE, stroke/mortality composite outcome) rates. Follow-up primary outcomes included overall survival, stroke-free survival (SFS), freedom from ipsilateral stroke (FFiS), and freedom from stroke-related mortality (FF-SRM). Data were analyzed at short-term (1 year) and mid-term (2.5 years) period. RESULTS: A total of 1096 CAS were considered (787 men, 71.8%, median age = 74 years). Technical success was achieved in 99.5% procedures. Periprocedural 30-day stroke rate was 1.5% (OC: 1.1%, CC: 2.3%, DL: 1%, p=0.27), mortality was 0.7% (OC: 1.1%, CC: 0.3%, DL: 0.5%, p=0.35), and no MI was recorded. The MAE rate was 2.1% (OC: 2%, CC: 2.6%, DL: 1.5%, p=0.66). Median follow-up was 46 months. At 1 and 2.5 years, estimated overall survival was 96.1% and 91% (p=0.41), SFS was 99.1% and 98.2% (p=0.007, CC stroke rates 2.9% and 4.2% at timepoints), FFiS was 99.4% and 99% (p=0.014, CC FFiS rates 1.7% and 2.6% at timepoints) and FF-SRM was 99.5% and 99% (p=0.28). During follow-up, no stroke events occurred in DL group. CC design showed higher rates of any (4.2%) and ipsilateral stroke (2.6%) within 2.5 years. CONCLUSION: In asymptomatic patients undergoing CAS, the contemporary overall stroke incidence is 1.5%. No statistical differences were observed in terms of 30-day stroke incidence among groups. The closed free-cell area showed higher rates of any and ipsilateral stroke within 2.5 years. The DL stents may offer the best available performances in terms of mid-term stroke prevention. CLINICAL IMPACT: The study analyzed the contemporary results of carotid artery stenting (CAS) focusing on the impact of cell-stent area on peri- and post-operative cerebrovascular events in a multicenter real-world experience. In asymptomatic patients undergoing CAS the contemporary overall stroke incidence is 1.5%. No statistical differences were observed in terms of 30-day stroke incidence among groups. The closed free-cell area showed higher rates of any and ipsilateral stroke within 2.5 years. DL stents may offer the best available performances in terms of mid-term stroke prevention.

The PONTE (PDTA FOR INTEGRATED FOLLOW-UP TERRITORY HOSPITAL OF THE PATIENT WITH CARDIAC HEART FAILURE) (BRIDGE) Heart Failure project: increased adherence to guideline-recommended therapies through web-based shared clinical database.

The aim of this study was to evaluate the effects on the adherence of drug prescription to the guideline recommendations of a chronic care model based on the close interaction between hospital and local healthcare district cardiologists through a shared web-based database. From 2018 to 2021, patients hospitalized for an episode of acute decompensated heart failure (HF) (de novo or worsening) in cardiology wards from the healthcare district of Bari, Italy, were enrolled. The follow-up programme was based on a first visit after discharge within 1 month; patients were therefore addressed to the local health district cardiologist outpatient clinics when not requiring further invasive investigations and haemodynamically stable and followed-up with at least one visit every 6 months. In order to share in-hospital patients' data with outpatient clinics, at discharge, they were entered in a web-based database accessible for all cardiologists and centres participating in the Ponte Project. The group of patients affected by HF with reduced ejection fraction (HFrEF) were considered for the analyses. Drug prescription rates at 1-year follow-up were analysed as endpoint, as well as the re-admission for HF worsening. Out of 1200 HF patients enrolled in the project until December 2021, 56% were affected by HFrEF. At 1-year follow-up, 91% of patients were assuming beta-blockers, 86% mineralocorticoid receptor antagonists, 98% angiotensin-converting enzyme inhibitors/angiotensin receptor antagonists/neprilysin angiotensin receptor antagonists, and 13% ARNI. Compared to patients enrolled before 2020, ARNI prescription increased in 2021 (60% vs. 13%, respectively, P < 0.001). In 30% of patients, ARNI were prescribed before hospital discharge. Furthermore, in 10% of the population (most diabetics), sodium-glucose cotransporter 2 inhibitors were also prescribed. The implementation of the PONTE project was associated with an improved adherence to guidelines recommendations.

Prognostic risk factors for loss of patency after femoropopliteal bailout stenting with dual-component stent: results from the TIGRIS Italian Multicenter Registry.

PURPOSE: To identify the risk factors associated with patency loss after bailout stenting with third-generation hybrid heparin-bonded nitinol stent of the femoropopliteal segment. METHODS: Prospective, multicenter, single-arm registry including 156 patients (50 females, mean age 72 ± 11 years) subjected, from February 2017 to December 2018, to provisional stenting with Gore Tigris vascular stent of the distal superficial femoral artery, with or without involvement of the popliteal artery, in 9 different centers. The 194 lesions, with Rutherford score ≥ 3, were stented in case of recoil, dissection or residual stenosis not responding to percutaneous trans-luminal angioplasty (PTA). The follow-up (FU) was performed with clinical evaluation and duplex ultrasound (DUS) at 1, 6 and 12 months. RESULTS: The primary patency rate was 99(95%CI 98-100)% at 1 month, 86(80-92)% at 6 months and 81(74-88)% at-12 months. After patency loss, 13/23 (56.5%) patients were re-treated, yielding a primary assisted patency of 91(86-96)% at 6 months and 88(82-94)% at 12 months and a secondary patency of 94(90-98)% at 6 months and 90(84-95)% at 12 months. Rutherford score ≥ 4 (p = 0.03) and previous severe treatments (p = 0.01) were identified as risk factors for early patency loss during FU. The involvement of the popliteal artery was not an independent risk factor for loss of patency. CONCLUSIONS: The bailout stenting of the femoropopliteal segment with third-generation nitinol stents is a safe and effective option in case of recoil, dissection or residual stenosis not responding to PTA. Critical limb ischemia and history of previous major treatment at the same level are significant prognostic factors for patency loss during FU.

Biventricular thrombosis in biventricular stress(takotsubo)-cardiomyopathy.

Endo-ventricular thrombosis represents a possible clinical complication of stress(takotsubo)-cardiomyopathy (SC). Depressed ventricular systolic ventricular function, localized left ventricular (LV) dyskinesis, but also an increased pro-thrombotic state induced by catecholamine surge may facilitate the occurrence of endovascular thrombosis in SC. SC, however, may also present as right ventricular (RV) dysfunction or even as biventricular ballooning. Ventricular thrombosis may therefore theoretically occur in either ventricles or both. We report the case of an 88-year old woman, with vascular dementia and depression, admitted for abdominal pain, diarrhea, and rectal bleeding. Unexpectedly, electrocardiogram showed induced QT-prolongation with diffuse negative T-waves, while echocardiogram severe LV dysfunction (ejection fraction 35%), but also RV dysfunction and biventricular thrombosis. The diagnosis was therefore biventricular SC complicated by biventricular thrombosis; LV recovered after 10 days. When SC presents with a biventricular involvement, a careful assessment of either ventricular cavities should be therefore recommended to exclude the presence of (bi)ventricular thrombosis. It remains unresolved whether biventricular SC may represent a condition at higher risk of ventricular thrombosis.

Infected pseudoaneurysm after carotid endarterectomy: mismatch between clinical presentation and origin.

Pseudoaneurysm after carotid endarterectomy (CEA) is a rare complication, with an incidence lower than 1%. Infection as a cause of carotid pseudoaneurysm is uncommon, and is mostly caused by staphylococci. An 81-year-old woman, treated with right carotid endarterectomy 7 years earlier, presented with a diagnosis of right carotid pseudoaneurysm. The patient was neurologically asymptomatic; clinical status, laboratory, and imaging findings were negative for infection. She was referred to surgical treatment consisting of patch excision and a carotid polytetrafluoroethylene bypass grafting. During intervention a purulent fluid collection was discovered, and therefore an inverted great saphenous vein carotid bypass was performed. The postoperative course was normal. Microbiological examination on the purulent fluid collection and excised patch showed the presence of Staphylococcus epidermidis. Carotid pseudoaneurysms after CEA often arise in asymptomatic patients. Despite this common clinical presentation, an infective origin must always be taken into account before any intervention is planned.

Blunt abdominal aortic disruption (BAAD) in shear fracture of the adult thoraco-lumbar spine: case report and literature review.

To present a rare case of association of abdominal aorta rupture and flexion-distraction fracture of thoracolumbar spine and to review the literature on this condition. In non-penetrating abdominal traumatic injuries with flexion-distraction fractures of the thoracolumbar spine, rupture of the abdominal aorta is an extremely rare occurrence but its outcome is potentially lethal. This association of skeletal and vascular lesions mainly affects young patients and involves the thoraco-lumbar junction and the portion of the aorta that lies in front of it. The authors analyze the pertinent literature and describe a case, operated in two sittings, of a traumatic lesion of the aorta attributable to a fracture of L1, focusing on mechanism of damage, diagnosis and surgical treatment. At 2-year follow-up examination, there were no neurological deficits. A review of the pertinent literature has shown that mortality can be reduced by a meticulous clinical and radiological work-up for a correct diagnosis followed by surgical repair of any damaged vessels. The possibility of performing a rapid diagnosis by means of total-body CT-scan plus CT-angiography allows repair of vascular damage, stabilization of the patient's hemodynamic conditions and, subsequently, surgical treatment of the vertebral fracture.

ST-depression in right precordial leads with inferior STEMI and occluded right coronary artery: intertwined anatomy and ischemic areas.

Right coronary artery (RCA) occlusion in inferior acute myocardial infarction is usually heralded by ST-elevation both in inferior and in right precordial leads. We report the case of a 68-year-old male, who presented marked ST-elevation in inferior leads, mirrored by ST-depression in anterior-septal and lateral leads. Right precordial lead electrocardiogram unexpectedly showed ST-depression V1R-V5R leads. Coronary angiography showed mid-left anterior descending (LAD) coronary near-complete occlusion with distal wrapping LAD. Left circumflex artery was not occluded, while RCA was occluded mid tract. The patient was treated with coronary angioplasty on RCA and LAD. Absence of ST-elevation in right precordial leads may be presumably explained by the presence of a large ischemic area distal to mid-LAD near-occlusive stenosis and of a long-wrapping LAD. Complex coronary anatomy and intertwined ischemic areas may underlie apparently discording electrocardiograms.

Kounis syndrome following canned tuna fish ingestion.

Kounis syndrome (KS) is a complex of cardiovascular symptoms and signs following either allergy or hypersensitivity and anaphylactic or anaphylactoid insults. We report the case of 57-year-old man, with hypertension and history of allergy, referred for facial rash and palpitations appeared after consumption of canned tuna fish. Suddenly, the patient collapsed: electrocardiogram showed ST-elevation in inferior leads. The patient was transferred from the spoke emergency room for coronary angio, which did not show any sign of coronary atherosclerosis. A transient coronary spasm was therefore hypothesized and the final diagnosis was KS. To the best of our knowledge, this is one of the first cases of KS following the ingestion of tuna fish. KS secondary to food allergy has also been reported, and shellfish ingestion has been considered as one of the most active KS inducer foods. Canned tuna fish too is well known as an allergy inducer. Tuna fish allergy should be considered, however, within the context of scombroid food poisoning, also called histamine fish poisoning. Fish with high levels of free histidine, the enzyme substrate converted to histamine by bacterial histidine decarboxylase, are those most often implicated in scombroid poisoning. Inflammatory mediators such as histamine constitute the pathophysiologic basis of Kounis hypersensitivity-associated acute coronary syndrome. Patients with coronary risk factors, allergic reaction after food ingestion, and suspected scombroid poisoning should be therefore carefully monitored for a prompt diagnosis of possible coronary complications.

Subacute stent thrombosis and stress-induced cardiomyopathy: trigger or consequence?

Stress-induced cardiomyopathy or Takotsubo cardiomyopathy (TCM) is a unique syndrome, characterized by transient left ventricular (LV) apical ballooning without significant coronary arteries stenosis, affecting mainly menopausal women. We present the case of a 70 year old woman with subacute stent thrombosis (ST) at the level of the right coronary artery and transient apical ballooning with normal flow of left and circumflex coronary arteries. TCM is frequently associated with emotional stress, but to date no case of ST triggering TCM have been reported.

Factors influencing outcome after open surgical repair of juxtarenal abdominal aortic aneurysms.

The purpose of this study was to seek factors predicting outcome after open surgical repair of juxtarenal abdominal aortic aneurysms (AAAs). From a series of 733 patients treated for AAAs, 92 patients underwent elective conventional open repair with suprarenal clamping. We assessed postoperative cardiorespiratory and renal morbidity and mortality and survival at 1, 3, and 5 years. One patient (1.1%) died after an acute myocardial infarction. Postoperative complications including myocardial infarction and renal failure arose in 22 patients (23.9%). Significant predicting factors of renal failure were a preoperative creatinine clearance < or = 40 mL/min (p = .03) and female sex (p = .004). Kaplan-Meier survival analysis showed an overall survival rate of 98.9% at 1 year and 88.6% at 3 and 5 years. In patients carefully selected by preoperative imaging criteria to undergo open juxtarenal AAA repair, appropriate intraoperative management guarantees a good immediate postoperative outcome.

[Screening for abdominal aortic aneurysm during transthoracic echocardiography. A prospective study in 1202 consecutive patients at high risk: incidence, correlation with risk factors, feasibility, diagnostic accuracy, and increase in echocardiography time]. / Ricerca dell'aneurisma dell'aorta addominale durante ecocardiografia transtoracica. Studio prospettico su 1202 pazienti consecutivi ad alto rischio: incidenza, correlazione con i fattori di rischio, fattibilità, accuratezza, tempo medio aggiuntivo.

BACKGROUND: The rupture of abdominal aortic aneurysm is a pathology with a high mortality risk. Conversely, the study of the abdominal aorta is not routinely included in the echocardiography protocol, although it can be performed quickly and easily for screening of the aneurysm. The aim of this study was to evaluate screening of abdominal aortic aneurysm at the end of each echocardiographic exam performed at our laboratory. METHODS: From March 2002 to October 2003, 1202 patients aged > 40 years were studied at our echo-lab. After the first 4 months of screening, only patients at high risk were screened, namely men > 65 or < 65 years and women > 65 years with at least one risk factor for ischemic heart disease. We evaluated feasibility, diagnostic accuracy, incidence in the study population, interobserver variability, the correlation with risk factors for ischemic heart disease and the increase in total echocardiography time. RESULTS: The mean aortic diameter was 19.08 +/- 5.98 mm and feasibility was very high (95.6%). We found 62 unknown aneurysms and 20 localized aortic dilatations (incidence of 5.6 and 1.7%, respectively); the incidence of both of them was 9.1 in men and 1.6 in women. Multivariate analysis revealed male gender, older age and other arterial district pathologies as independent risk factors. The interobserver concordance was excellent as well as diagnostic accuracy. The mean time increase in routine echocardiography was 33.8 +/- 18.6 s. CONCLUSIONS: The abdominal aortic study at the end of a routine echocardiography, in patients at risk of aortic pathology because of age or other risk factors, is a simple and accurate method for screening of abdominal aortic aneurysm. It showed a very low cost, also due to the short-time increase in routine echocardiography.

Matrix metalloproteinase 9 activity in patients before and after endovascular or surgical repair of abdominal aortic aneurysms.

The objective of this prospective study was to assess matrix metalloproteinase 9 (MMP-9) activity in patients undergoing open surgery or endovascular repair of abdominal aortic aneurysms (AAAs), comparing changes in plasma levels in the two groups. We studied 12 patients after conventional open surgery and 9 patients after endovascular aneurysm repair. MMP-9 was assayed in plasma at baseline and 1 week and 1 month thereafter. Preoperative MMP-9 levels were similar in the two groups (41.7 +/- 19.1 vs 44.4 +/- 24.6 ng/mL; p = not significant). Assessment 1 week later showed that MMP levels in both repair groups had increased. In the open surgery group, they increased significantly (59.7 +/- 16.8 ng/mL; p < .05) but not in the endovascular group (49.3 +/- 32.4 ng/mL). One month later, MMP-9 levels decreased in both groups but not significantly (to 32.6 +/- 24.6 ng/mL for open surgery repair and to 34.7 +/- 23.5 ng/mL for endovascular repair). At 1 month after repair, MMP-9 levels decreased significantly only in smokers, whereas in nonsmokers, they did not (from 46.9 +/- 22.1 to 31.7 +/- 21.5 ng/mL in smokers [p < .05] vs from 34.7 +/- 17.4 to 37.1 +/- 28.9 ng/mL in nonsmokers). This study confirms that enzyme secretion changes during the postoperative course. The differing patterns of MMP-9 expression prevent us from reaching definitive conclusions about the use of MMP-9 as a marker during early postprocedural follow-up. An important matter to clarify is the role of MMP-9 in long-term follow-up, especially after endovascular AAA repairs.