Subexpansión de stent tratado con balón de Shockwave / Use of a Shockwave balloon to treat insufficient stent expansion

La calcificación coronaria afecta negativamente los resultados de las intervenciones coronarias al impedir el cruce, lograr una buena aposición y expansión del stent; puede alterar el polímero y la cinética de liberación del fármaco. La subexpansión del stent se asocia a trombosis posterior del stent y/o necesidad de nueva revascularización de la lesión. Existen distintas técnicas para modificar el calcio de las arterias coronarias como los balones no complacientes (BNC), balones modificadores de placa y tecnologías de ateroablación como la aterectomia rotacional, orbital y láser. Todas con complicaciones y limitaciones. La litotripsia intracoronaria es una tecnología nueva, que mediante la emisión de ondas de choque acústicas es capaz de fracturar el calcio coronario profundo mejorando la distensibilidad de la arteria coronaria, lo que permite una adecuada expansión del stent. En esta oportunidad presentamos el caso de un stent subexpandido debido a una lesión muy calcificada de la arteria coronaria derecha (ACD) tratada con un catéter de Shockwave IVL (Shockwave Medical, Santa Clara, California).

Coronary calcification negatively affects the results of coronary interventions by preventing crossing, achieving good apposition and expansion of the stent; it may alter the polymer and the kinetics of drug release. Stent underexpansion is associated with subsequent stent thrombosis and/or the need for new revascularization of the lesion. There are different techniques to modify the calcium of the coronary arteries such as non-compliant balloons (NCB), plaque-modifying balloons and atheroablation technologies such as rotational, orbital and laser atherectomy. All with complications and limitations. Intracoronary lithotripsy is a new technology that, through the emission of acoustic shock waves, is capable of fracturing deep coronary calcium, improving compliance of the coronary artery, which allows adequate expansion of the stent. On this occasion, we present the case of an underexpanded stent due to a highly calcified lesion of the right coronary artery (RCA) treated with a Shockwave IVL catheter (Shockwave Medical, Santa Clara, California).

Chemical Angioplasty with Nitroglycerin for Vasospasm after Subarachnoid Hemorrhage: Case Series and Review

Introduction Vasospasm is a common and potentially devastating complication in patients with subarachnoid hemorrhage, causing high morbidity and mortality. There is no effective and consistent way to prevent or treat cerebral vasospasm capable of altering the morbidity and mortality of this complication. Animal and human studies have attempted to show improvement in aneurysmal vasospasm. Some sought their prevention; others, the treatment of already installed vasospasm. Some achieved only angiographic improvement without clinical correlation, others achieved both, but with ephemeral duration or at the expense of very harmful associated effects. Endovascular techniques allow immediate and aggressive treatment of cerebral vasospasm and include methods such as mechanical and chemical angioplasty. These methods have risks and benefits. Objectives To analyze the results of chemical angioplasty using nitroglycerin (GTN). In addition, to performa comprehensive review and analysis of aneurysmal vasospasm. Methods We describe our series of 77 patients treated for 8 years with angioplasty for vasospasm, either mechanical (with balloon), chemical (with GTN) or both. Results Eleven patients received only balloon; 37 received only GTN; 29 received both. Forty-four patients (70.1%) evolved with delayed cerebral ischemia and 19 died (mortality of 24.7%). Two deaths were causally related to the rupture of the vessel by the balloon. The only predictors of poor outcome were the need for external ventricular drainage in the first hours of admission, and isolated mechanical angioplasty. Conclusions Balloon angioplasty has excellent results, but it is restricted to proximal vessels and is not without complications. Chemical angioplasty using nitroglycerin has reasonable but short-lived results and further research is needed about it. It is restricted to vasospasm angioplasties only in hospitals, like ours, where better and more potent vasodilator agents are not available.

Resultados en el corto y mediano plazo del tratamiento endovascular en la enfermedad arterial obstructiva infrapoplítea en pacientes con isquemia crítica de una extremidad / Short to midterm results after endovascular approach in critical limb isquemia in patients with below-the-knee arterial disease

Resumen Objetivo: Mostrar los resultados en el corto y mediano plazo del tratamiento endovascular de angioplastia transluminal percutánea (ATP) con balón en pacientes en estado de isquemia crítica por enfermedad arterial obstructiva infrapoplítea. Materiales y Método: Estudio descriptivo, observacional, retrospectivo. Se incluyeron los pacientes hospitalizados entre 2009 y 2018 por isquemia crítica Fontaine III o IV sometidos a una ATP del territorio infrapoplíteo. Se observó como objetivos primarios la preservación de la extremidad afectada y la mortalidad posoperatoria a un año plazo, y como objetivos secundarios los procedimientos adicionales en pacientes con lesiones o necrosis distales, estadía hospitalaria, complicaciones posoperatorias y necesidad de reintervención. Resultados: Se incluyeron 42 pacientes con un promedio de edad de 66 años (46-82), con importantes comorbilidades. Un 83,3% ingresó en etapa Fontaine IV. En 16 casos se realizó una angioplastia percutánea en más de una arteria. No se colocó stents. Se presentaron complicaciones en 3 pacientes, 2 requirieron una amputación mayor y en otro se debió efectuar un nuevo procedimiento endovascular de rescate. La estadía hospitalaria promedio fue 22 días. No hubo mortalidad precoz posprocedimiento. La mortalidad global a un año fue 9,5%. A todos los pacientes en etapa Fontaine IV se les efectuó algún procedimiento adicional, a 31 una amputación menor, 3 cerraron sus lesiones por segunda intención y en otro se realizó un injerto dermo-epidérmico. De los 35 pacientes con seguimiento, 77% preservó su extremidad a un año. Conclusión: La reparación endovascular mediante una angioplastia percutánea en estos casos es un procedimiento seguro y tiene una alta tasa de preservación de la extremidad inicial a un año de seguimiento.

Aim: Show initial and midterms results of endovascular Percutaneous Transluminal Angioplasty (PTA) in critical limb isquemia (CLI) patients caused by below-the-knee arterial disease. Materials and Method: Observational, descriptive and retrospective study. 42 CLI patients admitted in our hospital from 2009 until 2018 with Fontaine III or IV treated by PTA in infrapopliteal arteries were analyzed, collecting demographic, clinical and surgical characteristics, additional procedures in Fontaine IV, hospital stay, postoperative complications, need of reintervention, limb preservation and mortality with one year follow-up after procedure. Results: 42 patients, average age 66 year-old (46-82), with significant comorbidities. Fontaine IV stage patients were 83.3%. In 16 cases more than one artery was intervened. No stent revascularization was performed. Complications occurred in 3 patients, 2 required major amputation and an urgent endovascular reintervention was required in another. Average hospital stay was 22 days with no post-operative mortality. One-year global mortality was 9.5 One-year follow-up in 35 patients shows that 77% preserved their limb. Conclusión: Percutaneous transluminal angioplasty procedure in this patients has a high rate of limb preservation in a one-year follow-up. There was no post-operative mortality.

Comparison of standard balloon and drug-coated balloon angioplasty in patients with the below-the-knee peripheral artery disease

SUMMARY OBJECTIVE: The objective of this study was to compare the interventions of percutaneous transluminal drug-coated balloon angioplasty (DCB PTA) and standard PTA in the treatment of patients with the below-the-knee peripheral artery disease (BTK PAD). METHODS: Overall, 196 patients (113 males and 83 females; mean age: 63.56±11.94 years; 45-83 years) were treated with PTA for BTK PAD between June 2014 and March 2019. RESULT: Standard PTA (group 1; 96 patients) and DCB PTA (group 2; 100 patients) results were analyzed and compared retrospectively. No statistically significant difference was found between the mean ages of group 1 and 2 patients (p=0.371, p>0.05). Demographic and clinical data were compared and no any statistically significant differences was found between the two groups. Comparing in terms of the iliac lesion, there was no statistically significant difference between the two groups. However, a statistically significant difference was found between the two groups in terms of frequency of popliteal lesions (p=0.001; p<0.05). There was not a statistically significant difference between the two groups in terms of other lesions. In addition, limb salvage rates were 82.0% (18 amputations) and 65.6% (33 amputations) in the drug-release balloon group and the naked balloon group, at the end of 1 year, respectively. No distal embolism, limb-threatening ischemia, and mortality were observed in any patients. CONCLUSIONS: Based on this study, patients in the DCB group had significantly higher rates of primary patency as compared with the other patients.

Síndrome de Budd-Chiari por obstrução da via de saída da veia hepática por membrana: tratamento percutâneo por angioplastia com balão / Budd-Chiari syndrome due to hepatic venous web outflow obstruction: percutaneous treatment with balloon angioplasty

Resumo A síndrome de Budd-Chiari é uma doença venosa hepática rara, mais incidente em adultos jovens, podendo se apresentar na forma aguda, subaguda ou crônica, o que resulta em hipertensão portal. O tratamento tradicional consiste em técnicas de trombólise e de shunts portossistêmicos intra-hepáticos, como pontes para o transplante hepático. Recentemente, técnicas de angioplastia com balão ou stents têm sido relatadas para o tratamento dessa afecção. Neste artigo, é relatado e discutido um caso de síndrome de Budd-Chiari por obstrução membranosa da via de saída da veia supra-hepática com trombose da veia hepática média em uma paciente de 24 anos. O tratamento estabelecido foi a angioplastia transjugular com balão, que obteve resultados satisfatórios e boa evolução clínica.

Abstract The Budd-Chiari syndrome is a rare hepatic venous disease. It is more prevalent in young adults and may present in acute, subacute, or chronic forms, causing portal hypertension. Traditional treatment consists of thrombolysis techniques and transjugular intrahepatic portosystemic shunt, as a bridge to liver transplantation. Recently, use of balloon or stent angioplasty techniques has been reported for treatment of this condition. In this article, we report and discuss a case of BCS by membranous obstruction in the hepatic vein outflow tract, with middle hepatic vein thrombosis, in a 24-year-old patient. The treatment chosen and employed was transjugular balloon angioplasty, which achieved satisfactory results and good clinical evolution.

Endovascular repair of a penetrating axillary artery injury

Abstract We report a 16-year-old boy who sustained a gunshot injury on his upper left side of the chest that resulted in an injury to the left axillary artery and was treated with endovascular repair. An endovascular repair has been increasingly accepted for the management of hemorrhage in critically ill trauma patients; using covered endovascular stents provides an alternative modality for both controlling hemorrhage and preserving flow.

Angioplastía con balón para el tratamiento de la hipertensión arterial pulmonar por enfermedad tromboembólica crónica. Resultados hemodinámicos y clínicos inmediatos / Balloon pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension

Background: Balloon pulmonary angioplasty (BPA) is a therapeutic alternative for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Aim: To report the initial experience with the "refined BPA technique" with the use of intravascular images. Patients and Methods: Between June 2015 and June 2016 we selected fourteen patients with CTEPH who were considered candidates for BPA. Lesions targeted for treatment were further analyzed using intravascular imaging with optical frequency domain imaging (OFDI). We report the immediate hemodynamic results and four weeks of follow-up of the first eight patients of this series. Results: We performed 16 BPA in eight patients aged 61 ± 14 years (88% women). Mean pulmonary artery pressure (PAPm) was 48.6 ± 5.8 mmHg. Success was achieved in seven patients (88%). A mean of 2.3 segments per patient were intervened in 11 sessions (1.6 sessions/ patient). Only one patient developed lung reperfusion injury. No mortality was associated with the procedure. After the last BPA session, PAPm decreased to 37.4 ± 8.6 mmHg (p=0.02). Pulmonary vascular resistance (RVP) decreased from 858,6 ± 377,0 at baseline to 516,6 ± 323,3 Dynes/sec/cm−5 (p<0.01) and the cardiac index increased from 2.4±0.6 at baseline to 2.8±0.3 L/min/m2 (p=0.01). At 4 weeks after the last BPA, WHO functional class improved from 3.3±0.5 to 2.5±0.5 (p<0,01) and six minutes walking distance from 331±92 to 451±149 m (p=0.01). Conclusions: BPA guided by OFDI for the treatment of inoperable CTEPH patients is a safe alternative with excellent immediate hemodynamic and clinical results.

Angioplastia percutánea con balón en hipertensión pulmonar tromboembólica crónica / Percutaneous balloon angioplasty for treatment of chronic thromboembolic pulmonary hypertension

La hipertensión pulmonar tromboembólica crónica se caracteriza por la presencia de material trombótico organizado dentro de las arterias pulmonares que genera elevación de la resistencia vascular pulmonar, insuficiencia cardíaca derecha y, eventualmente, la muerte. El tratamiento de elección es la tromboendarterectomía pulmonar, que suele ser curativa si la obstrucción es proximal. En algunos casos este tratamiento no es posible y surge como alternativa la angioplastia pulmonar con balón (APB), que está generando creciente interés. Se presentan tres casos de pacientes con hipertensión pulmonar tromboembólica a los que por diferentes circunstancias no pudo tratarse con tromboendarterectomía y se realizó APB comprobándose, en los tres casos, mejoría de la clase funcional, prueba de la caminata de seis minutos, además de parámetros hemodinámicos y angiográficos.

Chronic thromboembolic pulmonary hypertension is characterized by the presence of organized thrombotic material in the pulmonary arteries which causes elevation of the pulmonary vascular resistance, right heart failure, and death if not treated. Pulmonary thromboendarterectomy is the treatment of choice and can be curative when the obstruction is proximal. There are cases in which this therapy is not possible, and pulmonary angioplasty is a therapeutic alternative of growing interest. We present our experience with three patients diagnosed with chronic thromboembolic pulmonary hypertension in whom pulmonary endarterectomy was not possible and pulmonary angioplasty was performed. All patients showed improvement of functional class, six-minute walk distance, and hemodynamic as well as angiographic parameters.

Tratamento da recidiva de reestenose intra-stent renal por angioplastia com balão farmacológico / Drug-coated balloon used to treat in-stent restenosis of the renal artery

Nos últimos anos, balões farmacológicos surgiram como promissora alternativa terapêutica em intervenções endovasculares. Com essa tecnologia, transferem-se drogas antiproliferativas à parede arterial, sem a necessidade de implante metálico para liberação. Descreve-se o caso de um paciente com uma segunda recidiva de reestenose intra-stent renal tratada por angioplastia com balão coberto por droga, com boa evolução clínica caracterizada por adequado controle pressórico e redução de classes e dosagem dos anti-hipertensivos. Os resultados obtidos com balões farmacológicos em outros territórios e esta experiência isolada podem contribuir como sugestão para o uso desses dispositivos na reestenose intra-stent renal, com resultados iniciais satisfatórios

During recent years, drug-coated balloons (DCBs) have emerged as a promising therapeutic option. DCBs directly transfer antiproliferative drugs to the arterial wall in order to decrease myointimal hyperplasia. We describe a case of de novo renal artery in-stent restenosis (ISR) treated with drug-coated balloon angioplasty with acceptable short-term results, achieving blood pressure control using fewer antihypertensive agents. The experience and results obtained with DCBs in other territories could suggest and justify use of this technology in renal artery ISR

O uso do balão com paclitaxel no tratamento da reestenose intra-stent no segmento fêmoro-poplíteo / Use of paclitaxel-coated balloon to treat in-stent restenosis in femoropopliteal segments

Resumo Contexto A reestenose intra-stent por hiperplasia miointimal pós-angioplastia é uma intercorrência frequente e que limita a perviedade do procedimento a longo prazo. A terapia com balões revestidos de droga com ação antiproliferativa pode ser uma alternativa no tratamento dessa complicação. Objetivos Demonstrar eficácia e as complicações (óbito, grandes amputações, etc.) do balão farmacológico no tratamento da reestenose intra-stent de segmento femoropoplíteo. Métodos Estudo de coorte retrospectivo de 32 pacientes consecutivos tratados entre os anos de 2012 e 2016, submetidos a terapia de reestenose intra-stent de segmento femoropoplíteo com angioplastia com balão farmacológico revestido com paclitaxel. A taxa de sucesso foi mensurada pela ocorrência de sucesso do procedimento e reestenose inferior a 50% em avaliação por eco-Doppler colorido 30, 90 e 180 dias após o procedimento. Resultados Quatro pacientes (12,5%) apresentaram reestenose superior a 50%, sendo um (3,1%) após 90 dias e três (9,4%) após 180 dias, conferindo uma taxa de sucesso de 87,5% ao procedimento. Após 180 dias, todos os pacientes referiam melhora ou cessação dos sinais e/ou sintomas apresentados antes do procedimento. Não houve óbitos, e complicações ocorreram apenas em dois casos, no pós-operatório imediato. Conclusões Os resultados a curto prazo da terapia com balão farmacológico são promissores, com redução na taxa de reestenose e baixo índice de complicações. Ainda precisam ser apresentados estudos demonstrando os efeitos a longo prazo dessa terapia, assim como seu impacto econômico quando comparada a outros procedimentos.

Abstract Background In-stent restenosis due to myointimal hyperplasia after angioplasty is common and limits long-term patency. Treatments using balloons coated with antiproliferative drugs may offer an alternative option for this pathology. Objectives To demonstrate the efficacy and complications (death, major amputations, etc.) of drug-coated balloons for treatment of in-stent restenosis in femoropopliteal segments. Methods This was a retrospective cohort study of 32 consecutive patients treated between 2012 and 2016 who underwent treatment to correct in-stent restenosis in the femoropopliteal segment using paclitaxel-coated balloons. The success rate was measured in terms of technical success and restenosis of less than 50% on Doppler ultrasonography at 30, 90, and 180 days after the procedure. Results Four patients (12.5%) exhibited restenosis greater than 50%, one (3.1%) after 90 days and three (9.4%) after 180 days, equating to a success rate of 87.5% of procedures, and by 180 days all patients experienced improvement or cessation of the signs and/or symptoms they had presented prior to the procedure. There were no deaths and complications occurred in just 2 cases in the immediate postoperative period. Conclusions Short-term results are promising, with reductions in the magnitude of restenosis and a low rate of complications. Further studies are needed that can demonstrate the long-term effects and the economic impacts in comparison to other procedures.

Carotid artery stenting in the context of endovascular treatment of acute ischemic stroke / Angioplastia com stent de carótida no contexto do tratamento endovascular do acidente vascular cerebral isquêmico agudo

ABSTRACT Mechanical thrombectomy as an adjunctive to intravenous thrombolysis is now the standard treatment for acute ischemic stroke (AIS) due to large vessel occlusions. However, the best management of acute carotid tandem occlusions (CTO) remains controversial. Method Twenty patients underwent endovascular treatment of acute CTO. The primary endpoint was the composite rate of complete or partial recanalization without a symptomatic intracranial hemorrhage (sICH). Secondary endpoints were recanalization times, procedure times, and clinical outcomes at three months. Results The primary endpoint was reached in 17 (85%) patients. Recanalization rate was reached in 90% of patients (19/20) and sICH rate was 5% (1/20). At the 3-month follow-up we obtained a mRS ≤ 2 rate of 35% (7/20) and a mortality rate of 20% (4/20). Conclusion Carotid angioplasty stenting and endovascular treatment of AIS due to CTO appears effective with an acceptable rate of sICH.

RESUMO Trombectomia mecânica com stentrievers associada a trombólise endovenosa com rTPA é o tratamento padrão-ouro do acidente vascular cerebral isquêmico agudo (AVCi) devido à oclusões de grandes vasos. No entanto, a melhor estratégia terapêutica para oclusões carotídeas combinadas ainda permanece controversa. Método Vinte paciente receberam tratamento endovascular. O desfecho primário foi a taxa de recanalização completa sem sangramento intracraniano sintomático. Os desfechos secundários foram os tempos de recanalização, duração dos procedimentos e desfechos clínicos em 3 meses. Resultados O desfecho primário foi alcançado em 17 (85%) pacientes. A taxa de recanalização foi de 90% (19/20) e a taxa de HIS foi de 5% (1/20). Em três meses, foi obtido bom desfecho neurológico em 35% (7/20) dos pacientes e a mortalidade foi de 20% (4/20). Conclusão A angioplastia com stent de carotída associada ao tratamento endovascular para oclusões combinadas agudas de carótida parece ser efetiva sem um aumento de HIS.

High-pressure balloon assessment of pelviureteric junction prior to laparoscopic "vascular hitch"

ABSTRACT Aim To assess if calibration of the ureteropelvic junction (UPJ) using a high-pressure balloon inflated at the UPJ level in patients with suspected crossing vessels (CV) could differentiate between intrinsic and extrinsic stenosis prior to laparoscopic vascular hitch (VH). Materials and Methods We reviewed patients with UPJO diagnosed at childhood or adolescence without previous evidence of antenatal or infant hydronephrosis (10 patients). By cystoscopy, a high-pressure balloon is sited at the UPJ and the balloon inflated to 8-12 atm under radiological screening. We considered intrinsic PUJO to be present where a ‘waist’ was observed at the PUJ on inflation of the balloon and a laparoscopic dismembered pyeloplasty is performed When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. Patients with absence of intrinsic PUJ stenosis documented with this method are included for the study. Results Six patients presented pure extrinsic stenosis. The mean age at presentation was 10.8 years. Mean duration of surgery was 99 min and mean hospital stay was 24 hours in all cases. We found no intraoperative or postoperative complications. All children remain symptoms free at a mean follow up of 14 months. Ultrasound and renogram improved in all cases. Conclusion When no ‘waist’ is observed we considered this to represent extrinsic stenosis and a laparoscopic VH was performed. In these patients, laparoscopic transposition of lower pole crossing vessels (‘vascular hitch’) may be a safe and reliable surgical technique.

Aterectomia rotacional em artérias com calcificação extrema ou falha em dilatação prévia: aspectos técnicos e evolução tardia após intervenção coronária percutânea / Rotational atherectomy in arteries with extreme calcification or previous failed dilation: technical aspects and late outcomes after percutaneous coronary intervention

A aterectomia rotacional com incorporação de novas estratégias ablativas tem sido proposta para o preparo de lesões extremamente calcificadas. Entretanto, pouco se conhece a respeito da adoçãodessas novas estratégias na prática contemporânea e sobre a evolução tardia dos pacientes submetidos aesse tratamento. Objetivamos avaliar os aspectos técnicos da aterectomia e a evolução tardia dos pacientesquanto à ocorrência de eventos cardiovasculares adversos maiores (ECAM). Métodos: Estudo retrospectivo e unicêntrico, incluindo todos os pacientes submetidos à aterectomiarotacional como parte do tratamento de lesões coronárias com calcificação extrema ou falha de dilataçãoem procedimento prévio, no período de julho de 2012 a novembro de 2014. Foram definidos como ECAM: óbito, infarto agudo do miocárdio com onda Q ou nova revascularização do vaso-alvo.Resultados: Foram submetidos à aterectomia 29 pacientes com idade média de 69,5 ± 7,6 anos. A médiada relação oliva/vaso foi de 0,54 ± 0,07; a velocidade de rotação inicial adotada foi de 161.000 ± 13.928 e a taxa de utilização de cutting balloon pós-aterectomia foi de 45,1%. Sucesso angiográfico foi obtido em todos os procedimentos. Na evolução tardia, a mediana de tempo de seguimento foi de 13,2 meses (intervalo interquartil: 4,0 a 17,4 meses). Foram registrados um óbito por causa não cardíaca e duas novas revascularizações do vaso-alvo. A média do tempo de sobrevivência livre de ECAM foi de 29,7 ± 2,1 meses.Conclusões: A aterectomia rotacional contemporânea incorporou estratégias menos agressivas de ablação,com elevada taxa de sucesso imediato e baixa ocorrência de ECAM na evolução tardia...

Rotational atherectomy with new ablative strategies have been proposed for the treatment of extremely calcified lesions prior to stent implantation. Nevertheless, few data are available about the adoption of these new strategies in contemporary practice and about late outcomes of patients undergoing this therapy. Methods: From July 2012 to November 2014, a retrospective single center registry was conducted, including all patients undergoing rotational atherectomy as part of the treatment of coronary arteries with heavy calcification or previous failed dilation. We evaluated technical aspects of atherectomy and late outcomes of patients for the occurrence of major adverse cardiovascular events (MACE), defined as death, Q-wave myocardial infarction or repeat target vessel revascularization.Results: Twenty-nine patients with a mean age of 69.5 ± 7.6 years, underwent atherectomy. The averageburr-to-artery ratio was 0.54 ± 0.07, the initial rotational speed was 161.000 ± 13.928 and the rate of cuttingballoon utilization after atherectomy was 45.1%. Angiographic success was achieved in all procedures. The median follow-up time was 13.2 months (IQ: 4.0-17.4) and there were three events: 1 death of non cardiac cause and 2 new target vessel revascularizations. The mean MACE-free survival time was 29.7 ± 2.1 months. Conclusions: Contemporary rotational atherectomy incorporates less aggressive strategies of ablation with high rates of acute success and low occurrence of major adverse cardiovascular events during late follow-up...

Cateter balão farmacológico no tratamento da reestenose coronariana intra-stent / Pharmacological balloon catheter in the treatment of intra-stent coronary restenosis

CONTEXTO: A incorporação do cateter balão farmacológico para a reestenose intra-stent foi avaliada num primeiro momento em 2013 quando a CONITEC deliberou por sua não incorporação até que o stent farmacológico fosse avaliado para tratamento da mesma doença. Com a incorporação do stent farmacológico no SUS por meio da Portaria SCTIE/MS nº 29 de 28 de agosto de 2014, uma nova demanda para incorporação do cateter balão farmacológico foi apresentada. A reestenose intra-stent ocorre pela hiperplasia mio-intimal excessiva, reobstruindo a luz do vaso coronariano. Os tratamentos existentes no SUS para essa doença consistem na angioplastia através de cateter balão comum (não farmacológico), intervenção cirúrgica para revascularização e implantes de stent convencional e, agora também, de stent farmacológico. EVIDÊNCIAS CIENTÍFICAS: As evidências científicas parecem indicar que o uso do cateter balão farmacológico pode reduzir a perda tardia de luz no vaso e o risco de eventos adversos cardíacos maiores quando comparado com a angioplastia com balão comum, possuindo resultados semelhantes quando comparado ao implante de stents farmacológicos. CONSIDERAÇÕES FINAIS: A evidência atualmente disponível sobre eficácia e segurança do cateter balão farmacológico para tratamento da reestenose intra-stent é baseada em revisão sistemática e estudos clínicos randomizados. Na revisão sistemática de Indermuehle et al.19 os dados indicam redução do risco de eventos adversos cardíacos maiores impulsionado principalmente por uma menor necessidade revascularização da lesão alvo. O risco de mortalidade também é reduzido em comparação à angioplastia com cateter balão comum. No tratamento da ISR comum, o cateter balão farmacológico mostrou-se superior ao balão de angioplastia comum e ao stent comum. Comparado ao stent farmacológico, os resultados foram semelhantes com a vantagem de o cateter balão farmacológico evitar o acúmulo de múltiplas camadas de stents, mas com a desvantagem de possuir um custo unitário bem mais elevado que o valor atual do stent farmacológico no SUS. DELIBERAÇÃO FINAL: Os membros da CONITEC presentes na reunião do plenário do dia 02/07/2015 deliberaram, por unanimidade, ratificar a recomendação de não incorporar o cateter balão farmacológico no tratamento da reestenose intra-stent. DECISÃO: Foi publicada a portaria nº 35, de 27 de julho de 2015, da decisão de não incorporar o cateter balão farmacológico para o tratamento de pacientes com reestenose coronariana intra-stent no âmbito do Sistema Único de Saúde - SUS. Publicação no DOU nº 141 de 27 de julho de 2015. DECISÃO: A PORTARIA Nº 35, de 24 de julho de 2015 - Torna pública a decisão de não incorporar o cateter balão farmacológico para o tratamento de pacientes com reestenose coronariana intra-stent no âmbito do Sistema Único de Saúde - SUS.

Dorsal-Plantar Loop Technique Using Chronic Total Occlusion Devices via Anterior Tibial Artery

The effectiveness of below-the-knee (BTK) percutaneous transluminal angioplasty to obtain successful revascularization in patients with critical limb ischemia has been well established, and many of these patients with chronic lower-extremity disease have been treated by endovascular intervention as the firstline treatment. Dorsal-plantaer loop technique is one of the new BTK interventional techiniques, and includes recanalization of both pedal and plantar arteries and their anatomical anastomoses. This method generally needs two approaches simultaneously, including antegrade and retrograde. In this report, however, we describe a case in which dorsal-plantar loop technique with only one antegrade approach, using chronic total occlusion devices via anterior tibial artery, was used to successfully recanalize BTK arteries. We think that this new technique, which may represent a safe and feasible endovascular option to avoid more invasive, time-consuming, and riskier surgical procedures, especially in end-stage renal disease and diabetes, should be considered whenever the foot is at risk, and results of above-the-ankle percutaneous transluminal angioplasty remain unsatisfactory or insufficient to achieve limb salvage.

Cateter balão farmacológico no tratamento da reestenose coronariana intra-stent / Pharmacological balloon catheter in the treatment of intra-stent coronary restenosis

CONTEXTO: A reestenose intra-stent ocorre pela hiperplasia mio-intimal excessiva, reobstruindo a luz do vaso. O tratamento existente no SUS consiste na angioplastia através de cateter balão comum, stent não farmacológico e intervenção cirúrgica para revascularização. Considerando que o stent é um dispositivo que passou a ser universalmente utilizado no tratamento da doença arterial coronariana, a reestenose intra-stent surge como um problema desafiador na cardiologia intervencionista. Considerando o número de internações no SUS por doenças isquêmicas do coração e o número de angioplastias com colocação de stents realizadas, pode-se estimar mais de 60 mil procedimentos deste tipo a cada ano. A literatura demonstra que a reestenose intra-stent pode ocorrer em aproximadamente 20% destes procedimentos quando utilizado o stent não farmacológico. A TECNOLOGIA: O cateter balão farmacológico SeQuent® Please é um cateter balão libertador de fármaco para o tratamento de vasos coronários. O fármaco está inserido numa matriz degradável e fisiologicamente inerte, tendo como componente principal a iopromida. Possui revestimento ativo farmacológico localizado na superfície do balão, que contém 3µg de paclitaxel por mm2. O paclitaxel é uma droga quimioterápica potente prescrita em tratamentos de neoplasia que interfere o processo de divisão celular. EVIDÊNCIAS CIENTÍFICAS: As evidências científicas parecem indicar que a aplicação do cateter balão farmacológico pode ser um tratamento promissor para a reestenose intra-stent, reduzindo a perda tardia de luz no vaso e o risco para eventos adversos cardíacos maiores quando comparado com a angioplastia com balão convencional, e possuindo resultados semelhantes quando comparado à implantação de stents farmacológicos. CONSIDERAÇÕES FINAIS: A evidência atualmente disponível sobre eficácia e segurança do Cateter Balão Farmacológico SeQuent Please para tratamento da reestenose intra-stent é baseada em revisão sistemática e estudos clínicos randomizados, com grau de recomendação 1A e nível de evidência A. Neste sentido, os resultados apresentados pelos referidos estudos sugerem que o uso do cateter balão farmacológico é uma alternativa eficaz no tratamento da reestenose intra-stent. DELIBERAÇÃO FINAL: Os membros da CONITEC presentes na 20º reunião ordinária, realizada nos dias 06/11 e 07/11/2013, deliberaram, por unanimidade, por recomendar a não incorporação do cateter balão farmacológico no tratamento da reestenose coronariana intra-stent. Foi assinado o Registro de Deliberação nº 71/2013. DECISÃO: PORTARIA Nº 3, de 29 de janeiro de 2014 - Torna pública a decisão de não incorporar o cateter balão farmacológico no tratamento da reestenose coronariana intra-stent no Sistema Único de Saúde - SUS.

Treatment of symptomatic vertebrobasilar artery stenosis with stent-assistant angioplasty in the elderly

OBJECTIVE: To study the efficacy, safety, and feasibility of stent-assistant angioplasty (SAA) in the treatment of symptomatic vertebrobasilar artery stenosis in the elderly. METHODS: SAA was performed in 26 elderly patients with symptomatic vertebrobasilar artery stenosis. The success rate, perioperative complications, and long-term effectiveness were evaluated. RESULTS: A total of 29 balloon expandable stents were implanted in these patients. The success ratio was 100%. The degree of stenosis decreased from 81.3 ± 8.8% to 3.7 ± 3.6% (p < 0.01). Complications were absent during the perioperative period. Follow-up was performed for seven to 36 months (median: 21.9 months). Two patients developed the recurrent symptoms of vertebrobasilar artery stenosis, and no cerebral ischemic events were noted in the remaining patients, suggesting a favorable outcome. CONCLUSION: SAA is a safe and effective strategy for the treatment of symptomatic vertebrobasilar artery stenosis in the elderly.

El acceso vascular sigue siendo un problema a resolver / Vascular access is still an unresolved problem

El acceso vascular para el tratamiento endovascular de los aneurismas de aorta puede ser una limitante o una causa grave de morbilidad o mortalidad. La presunción, la posibilidad de realizarmaniobras adyuvantes o la combinación con cirugía abierta pueden ser determinantes al momento de planear o finalizar el procedimiento. Se describen una variedad de procedimientos utilizados para modificar la anatomía desfavorable de las arterias ilíacas. La angioplastía con dilatadores o balón, la utilización de ciertas guías y accesos o la realización de conductos pueden ser claves al momento de realizar la cirugía.

O acesso vascular para o tratamento endovascular dos aneurismas da aorta pode ser uma limitante ou uma causa grave de morbilidade ou mortalidade. Como presunção, a possibilidade derealizar manobras adjuvantes ou a combinação com cirurgia aberta podem ser determinantes no momento de planejar ou finalizar o procedimento. Descrevem-se uma variedade de procedimentos utilizados para modificar a anatomia desfavorável das artérias ilíacas. A angioplastia com dilatadores ou balão, a utilização de certas guias e acessos ou a realização de canais podem ser fundamentais no momento de realizar a cirurgia.

The vascular access in the treatment of aortic aneurysms may be a limiting factor or a severe cause of morbidity and mortality. The possibility of carrying out adjuvant procedures or combiningthem with open surgery may be determining factors at the moment of planning or completing the procedure. A series of procedures used to modify the unfavourable anatomy of the iliac arteries are here in described. Dilator or balloon angioplasty, the use of certain guidewires and routes of access or the carrying out of conduits may be key at the moment of carrying out the surgery.