Staged hybrid treatment of complex ascending aortic and distal aortic arch pseudoaneurysm after repair of aortic coarctation.

A 49-year-old operated for aortic coartaction patient presented with thoracic and ascending aortic aneurysm. He was asymptomatic. Angio-magnetic resonance nuclear scan and angiography revealed an ascending aortic aneurysm (5.2 cm), bicuspid aortic valve, 6-cm proximal descending aortic pseudoaneurysm at the site of the previous operation with involvement of the left subclavian artery. Restenosis at the original site of coarctation and aortic arch hypoplasia distally to the brachiocefalic trunk was also found. The operation performed was a "modified Bentall - De Bono". The pseudoaneurysm was not accessible through median sternotomy due to the massive lung adhesions following the previous surgery. The left common carotid artery was explanted from the aortic arch and connected with a graft to the ascending aortic conduit. A proximal neck suitable for landing zone of the endovascular stent-graft was then established. The postoperative course was uneventful. After two weeks, the patient was readmitted. The exclusion of the thoracic descending aortic pseudoaneurysm by endovascular implantation of the stent-graft prosthesis was performed. The left subclavian artery was excluded because left vertebral artery was closed. The patient did not develop hand claudicatio. The procedure was successful.

Can IVUS-virtual histology improve outcomes of percutaneous carotid treatment?

Several previous studies focusing on comparison between outcomes of carotid artery stenting (CAS) and carotid endoarterectomy (CEA) have put forward conflicting results about the non-inferiority of CAS compared to CEA. Likely outcomes after CAS have been greatly limited by incomplete knowledge of atherosclerotic carotid pathology and probably inappropriate patient selection criteria. In the current practice, only the degree of lumen obstruction is indication to an invasive treatment (CEA or CAS) in symptomatic or asymptomatic patients, but it has been recently demonstrated that histology of carotid plaques also plays a major role. Indeed, plaque morphology and composition seem to influence more importantly outcomes of CAS than those of CEA. Angiography is a poor diagnostic tool to detect the severity and composition of atherosclerotic lesions. Virtual histology (VH) is a new technology incorporated in the latest intravascular ultrasound (IVUS) equipment that allows a validated histological characterization of plaques by performing a spectral, objective and highly-reproducible analysis of the radiofrequency and amplitude data of the ultrasound waves that cross different tissues. This manuscript reports authors' experience with the use of IVUS-VH during CAS. This new technology, by characterizing morphology, extension and histology of carotid plaque, seems to provide important information for confirming percentage of carotid stenosis and judging its embolic potential, tailoring the procedure and guiding the choice of stent and finally for checking stent apposition and complete covering of vulnerable plaques. According to authors' opinion IVUS-VH has the potential to optimize patients' and lesions' selection criteria for CAS in order to improve its outcomes.

Setting up of a multicentric European registry dealing with type B dissections in chronic and acute phases with thoracic EndoFit devices.

AIM: This registry aims at evaluating the use and efficacy of the EndoFit stent graft (LeMaitre Vascular, Burlington MA, USA) for the treatment of acute and chronic aortic type B dissections. METHODS: Indications for treatment are: recurrent pain, persistent hypertension, serious organ malperfusion in patients with acute or subacute type B aortic dissection and progression of aneurysm size despite maximal medical therapy in patient with chronic type B dissection. Exclusion criteria are: age under 18 years old, pregnancy, coagulopathy or bleeding disorders, connective tissue disease. Straight or tapered EndoFit stent graft will be used in acute or chronical dissection respectively. RESULTS: The primary endpoint is the assessment of the safety and the efficacy of the EndoFit Thoracic Endoluminal Stent Graft in the exclusion of the thoracic aortic false lumen in acute and chronic type B aortic dissections. The assessment includes: technical success, thrombosis of the thoracic false lumen at 6 months, rate of aorto-enteric, aorto-esophageal and aorto-bronchial fistula, serious adverse events including death, stroke, paraplegia, myocardial infarction, multi-organ failure and renal insufficiency. Secondary endpoints are: the technical feasibility of device implantation in 2 different shapes (straight for acute dissection and tapered for chronic dissection), the technical feasibility of endovascular placement of tapered grafts in vessels of different size and shape, the integrity of the device fabric and wire structure, the occurrence of device migration, the patient's neurological, cardiac and cardiovascular status, the blood flow supply to abdominal and visceral organs arteries and any secondary intervention including stentgraft extension, coiling or surgical conversion. One hundred patients enrolled have been defined to allow reliable findings and results. CONCLUSION: The DEDICATED is the first prospective data collection registry focusing on the role of tapered stentgrafts in chronic aortic dissection and their efficacy in excluding the dissected thoracic false lumen.

Endovascular treatment of penetrating aortic ulcers: mid-term results.

OBJECTIVES: The aim of this study was to evaluate mid-term results of endovascular treatment of penetrating aortic ulcers. METHODS: Between February 2000 and November 2006, 18 consecutive patients underwent endovascular treatment of the descending thoracic aorta (N=16) and abdominal infrarenal aorta (N=2) for penetrating aortic ulcer, in a single University Hospital. Data were prospectively collected and retrospectively analyzed. Mean follow-up was 41 months (range 4 to 77 months). RESULTS: Technical success was achieved in all patients. No perioperative deaths occurred. No conversion to open repair or secondary procedures were required. Two patients died in the follow-up period for reasons not related to penetrating aortic ulcers. One type II endoleak was observed. It was still present, unchanged, twelve months after the procedure. CONCLUSION: Endovascular treatment of penetrating aortic ulcers of the descending thoracic and infrarenal aorta were safe and effective in the mid-term in this small series of patients.

Coronary artery fistulas: clinical consequences and methods of closure. A literature review.

Coronary fistulas are uncommon anomalies of congenital and rarely iatrogenic etiology. Their clinical significance is mainly dependent on the severity of the left-to-right shunt they are responsible for. Symptoms, high-flow shunting and the occurrence of complications, only partially related to the magnitude of the shunt, are the main indications for their closure, especially in the adult population. Pediatric patients, even asymptomatic but presenting with electrocardiographic or chest X-ray abnormalities, should be treated in order to avoid the long-term complications related to the presence of the fistula. Treatment of adult asymptomatic patients with non-significant shunting is still a matter of debate. Surgery and direct epicardial or endocardial ligation were traditionally viewed as the main therapeutic method for the closure of coronary fistulas. Progress in the techniques of endoluminal intervention has led to fistula embolization using different devices including coils, balloons and chemicals. The success rate is good and the procedure-related morbidity acceptable.

Plasma levels of metalloproteinases-3 and -9 as markers of successful abdominal aortic aneurysm exclusion after endovascular graft treatment.

BACKGROUND: Structural alterations of aortic wall resulting from degradation of matrix proteins by matrix metalloproteinases (MMPs) characterize abdominal aortic aneurysms (AAAs). No studies have compared circulating levels of MMPs after endovascular graft (EVG) exclusion in comparison with open surgical repair (OSR) in patients affected by AAA. METHODS AND RESULTS: An abdominal angiography and CT scan were performed in all patients at the time of enrollment. A spiral CT scan was performed at 6 months to detect presence of endoleaks. MMP-3 and MMP-9 levels were measured before EVG (n=30) and OSR (n=15) treatments and at 1, 3, and 6 months of follow-up by a sandwich ELISA technique. Healthy volunteers (n=10) were used as control subjects. Immunohistochemical staining for MMP-9 and MMP-3 was performed on tissue samples from surgical cases. Both MMP-9 and MMP-3 mean basal levels were significantly higher in patients affected by AAA than in control subjects (32.3+/-20.7 ng/mL for EVG and 28+/-9.9 ng/mL for OSR versus 8.9+/-2.5 ng/mL, 2P<0.05; 18.3+/-9.7 ng/mL and 26.7+/-10.8 ng/mL versus 8.2+/-5.3 ng/mL, 2P<0.001). In the OSR group, both MMP-9 and MMP-3 mean levels decreased after surgery (28+/-9.9 ng/mL at basal versus 14.7+/-6.6 ng/mL at 6 months, 2P<0.001; 26.7+/-10.8 versus 12+/-5.3 ng/mL; 2P<0.001). In the EVG group, a statistically significant difference at 6-month follow-up in MMP-9 and MMP-3 mean plasma values was detected in patients who had endoleakage in comparison with patients without endoleakage (44.3+/-20.7 versus 14.6+/-7.0 ng/mL, 2P<0.005; 25+/-11.5 versus 10.3+/-5.4 ng/mL, 2P<0.005). CONCLUSIONS: After EVG exclusion, MMP-9 and MMP-3 levels decreased to a level similar to that of patients undergoing OSR. In addition, a lack of decrease in MMP levels after EVG exclusion may help in identifying patients who will have endoleakage and consequent aneurysm expansion caused by continuous sac pressurization during follow-up.

Nonbiodegradable expanded polytetrafluoroethylene-covered stent implantation in porcine peripheral arteries: histologic evaluation of vascular wall response compared with uncoated stents.

PURPOSE: To test the vascular wall response to an expanded polytetrafluoroethylene-covered stent, compared with conventional stenting, up to 6 months after deployment in the vascular district of a swine model. METHODS: Fourteen minipigs underwent implantation of expanded polytetrafluoroethylene-covered stents (CS) and bare stents (BS) in five peripheral arteries. Animals were killed at different time points (from 1 to 180 days). Histopathologic assessment by morphologic and morphometric analysis and by scanning electron microscopy (SEM) were used to assess the incorporation characteristics and re-endothelialization extent of the two types of stents. RESULTS: A total of 70 stents (14 CS and 14 BS in the renal arteries; 28 CS in the iliac arteries, and 14 CS in the aorta) were implanted. Microscopic examination confirmed the absence of occlusive thrombi in both the CS and BS groups. Microthrombi were observed in 10 of 13 CS (77% of cases) and in four of four BS (100% of cases, p < 0.05). Inflammation was mild in 69% of segments in which a CS was implanted and in 74% of segments in which a BS was implanted (p = NS), while a severe inflammatory reaction was observed in 6% of CS segments and in 8% of BS segments (p = NS). No differences were detected at the long-term analysis between neointimal thickness in CS compared with BS segments (0.46 +/- 0.18 mm vs 0.42 +/- 0.26 mm at 90 days and 0.36 +/- 0.08 mm vs 0.35 +/- 0.04 mm at 180 days; p = NS, respectively). At SEM analysis, re-endothelization was evident 15 days after the implant in both CS and BS starting from the stent edges. CONCLUSION: CS implantation did not elicit a more severe thrombotic deposition compared with that of BS. A similar inflammatory reaction of the arterial wall was present in the two stent groups 3 and 6 months following the implant. In addition, CS implantation did not stimulate excessive neointimal formation when compared with BS.

[Percutaneous treatment of peripheral obstructive arteriopathy: the reasons for a choice]. / Il trattamento percutaneo delle arteriopatie ostruttive periferiche: i perché di una scelta.

Progressive aging of the Italian population is a relevant fact and this increases the occurrence of peripheral vascular disease in this subset of the population. At the same time, due to the national demographic decline, more and more aged people are going to live on their own. In this category the problem of self-caring is becoming highly relevant considering that only 12-13% of patients who had a limb amputation will walk with an artificial leg. This implies relevant social costs which are somewhat hidden because of their distribution in society (hospital, home care, individuals). Undoubtedly, there will be a dramatic reduction in the quality of life for these people. New technological progress and the development of new treatment modalities in the last decade have had a profound impact on the care of these patients. The role of peripheral vessel arteriography as a gold standard for the final evaluation of the disease and for the possibility of endovascular treatment has been widely accepted. Percutaneous transluminal intervention has proven to be more efficient economically with less morbidity and mortality than traditional vascular surgery, mainly in the limb salvage subgroup of patients. Health organization authorities should take these changes into account and modify their attitude towards the treatment of this pathology in order to provide better care for patients and to better allocate the economical resources of the National Health System.

The role of central fat distribution in coronary artery disease in obesity: comparison of nondiabetic obese, diabetic obese, and normal weight subjects.

OBJECTIVE: To investigate the degree of coronary artery disease (CAD) in relation to obesity and fat distribution in obese patients with normal glucose tolerance, in comparison with CAD of diabetic obese patients and of normal weight subjects with CAD. DESIGN: Patients listed for coronary angiography with different body mass index (BMI) with or without diabetes: study of the correlation between severity of coronary damage and fat distribution. SUBJECTS: 92 patients subdivided into: 30 normal glucose tolerant obese (BMI 31.7+/-0.5, aged 53+/-1.7 y), 28 type 2 diabetic obese (BMI 30.7+/-0. 3, aged 57+/-1.2 y), and 34 normal weight patients (BMI 23.1+/-0.3, aged 54+/-1.7 y). MEASUREMENTS: CAD assessed by angiography and evaluated according to the method of Gensini. Fat mass and fat distribution assessed by bioelectrical impedance and anthropometry. Clinical, biochemical and hormonal variables, as well as smoking habits and alcohol intake. RESULTS: The angiographic coronary scores were similar in nondiabetic obese and in diabetic obese patients, and were significantly higher than those of normal weight subjects. In the entire population coronary score correlated with indices of abdominal fat distribution. In the stepwise analysis of each group separately, waist hip ratio (WHR) correlated with coronary score only in normal weight nondiabetic patients. CAD was inversely associated with BMI only in nondiabetic obese patients. CONCLUSION: CAD of obese patients: 1) is similar to that of diabetic obese patients; 2) is more severe than that of normal weight individuals; and 3) is inversely correlated with BMI. CAD appears to be associated with WHR, not with BMI, only in nondiabetic patients with normal body weight. On the contrary, CAD of diabetic obese patients is unrelated to BMI and parameters of fat distribution, but is associated with smoking habits.

Treatment of a coronary aneurysm with a new polytetrafluoethylene-coated stent: a case report.

A 43-year-old man underwent implantation of a PTFE-covered stent to exclude an aneurysm in an aorto-coronary venous bypass graft. A successful aneurysm closure was achieved after high-pressure stent expansion and no intimal hyperplasia was observed within the PTFE-covered stent segment in the angiogram performed 9 months later. The technical characteristics and indications of this new coronary prosthesis are discussed based on the authors' recent experience in 63 patients.

Percutaneous treatment of iliac aneurysms and pseudoaneurysms with Cragg Endopro System 1 stent-grafts.

PURPOSE: To evaluate the feasibility and short-term follow-up results of treating iliac aneurysms by the Cragg Endopro System 1 stent-graft. METHODS: Nine lesions (two pseudoaneurysms and seven atherosclerotic aneurysms) were treated in eight patients by percutaneous implantation of a total of 10 stent-grafts. The procedure was followed by anticoagulation with heparin for 6 days, then antiplatelet therapy. Follow-up was by color Doppler ultrasound scan at 2 days and 3 months after the procedure for all patients, and by venous digital subtraction angiography and/or angio-CT up to 12 months later for four patients. RESULTS: Initial clinical success rate was 100% and there were two minor complications. In one case the delivery system was faulty resulting in failure to deploy the stent-graft. An additional device had to be used. At 3-12 months all prostheses were patent but one patient (12.5%) had a minimal pergraft leak. CONCLUSION: Percutaneous stent-grafting with this device is a safe and efficacious treatment of iliac artery aneurysms.

Dobutamine stress echocardiography for the identification of multivessel coronary artery disease after uncomplicated myocardial infarction: the importance of test end-point.

Our aim was to verify whether the sensitivity of pharmachological stress echocardiography for multivessel disease after acute myocardial infarction may be improved by a more aggressive protocol, i.e. not considering the appearance of the first wall motion abnormality as the absolute end-point if it occurs in the infarcted area without clinical or instrumental markers of extensive ischemia or left ventricular dysfunction. One-hundred twenty-one consecutive patients (age 32-71 years) prospectively underwent dobutamine-atropine stress echo (dobutamine infusion up to 40 micrograms/kg/min with additional atropine 1 mg) 11.8 +/- 4.8 days after uncomplicated myocardial infarction and coronary angiography within 6 weeks. Criteria for stopping the test were: significant ST depression or elevation, typical chest pain, major arrhythmias and left ventricular dysfunction. The test was considered as positive if a deterioration of basal wall motion pattern was observed: it was defined homozonally positive (the deterioration occurred in the myocardial area fed by the culprit vessel) or heterozonally positive (the deterioration occurred in a different vascular area). A coronary stenosis > 70% of vessel lumen was defined as critical. Thirty-four patients showed a negative test result. Among the 87 patients with positive test, 65 had no further wall motion deterioration from the first-induced wall motion abnormality (WMA) to peak test (Group A), whereas nine patients showed further homozonal (Group B) and 13 further heterozonal (Group C) asynergies. Sensitivity, specificity and accuracy of dobutamine stress echocardiography for multivessel disease were, respectively, 63%, 96% and 82% using the first-induced wall motion abnormality as test end-point, whilst they were 84% (P < 0.01), 93% and 89% according to the aggressive approach previously described. Dobutamine stress time of patients with multivessel disease was higher in Groups B and C (13.1 +/- 3.6 min) than in Group A (9.8 +/- 3.7 min, P < 0.01) and, finally, the mean obstruction of non-culprit vessel was higher in Group A (62.2%) than in Group C (47.4%, P < 0.05). No major complications were found. We conclude that the sensitivity of dobutamine stress echocardiography for multivessel disease following recent myocardial infarction is critically dependent on the test end-point. It may be improved by a more aggressive approach capable to identify less severe heterozonal coronary lesions.

Once daily felodipine in preventing ergonovine-induced myocardial ischaemia in Prinzmetal's variant angina.

The efficacy of extended-release felodipine in preventing ergonovine-induced myocardial ischaemia was assessed in 14 patients (12 male, two female, aged 56 +/- 7 years) with Prinzmetal's variant angina. Four of the patients had normal coronary arteries, eight had one-vessel and two had two-vessel disease. The ergonovine test was performed once in basal conditions and twice 5 days after beginning the oral administration of felodipine 20 mg o.d., 4 and 24 h after the last administration. During a continuous 6-lead ECG recording, ergonovine was injected at doses of 25, 50, 100, 200, and 400 micrograms at 5 min intervals. Blood samples for felodipine plasma concentrations were drawn at the time of the tests. The basal ergonovine test was positive in all 14 patients (seven with anterior and seven with inferior ST segment elevation > 0.1 mV) at a mean ergonovine dose of 162 +/- 138 micrograms. The test was repeated 4 h after the last felodipine administration and was negative in 13 patients (93%), but 24 h after the last drug administration, eight patients (57%) had a positive test response (five with anterior, three with inferior ST segment elevation) at a higher ergonovine dose than at baseline (150 vs 97 micrograms, P = 0.042). The only differences between patients with a negative and a positive test were the mean values of the left ventricular end-diastolic pressure (9.3 vs 14.9 mmHg, P = 0.002) and the ergonovine doses used in the baseline tests (250 vs 97 micrograms, P = 0.034).(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous closure of interatrial defect using the buttoned double-disk prosthesis]. / Chiusura percutanea del difetto interatriale mediante protesi doppio disco a bottone.

BACKGROUND: Surgical repair is the procedure of choice for atrial septal defect correction. Even though surgical mortality is low (< 1%), morbidity is significant (anesthesia, thoracotomy, cardiopulmonary bypass, longer hospitalization and intensive care unit monitoring). Transcatheter methods to occlude atrial septal defects have been in development during the last two decades. We report our experience in Italy with the Sideris buttoned double-disk device. METHODS: From March 1992 to April 1993, 14 patients aged 20 months to 52 years, weight 10 to 82 kg, underwent transcatheter atrial septal defect occlusion with the Sideris buttoned device. The buttoned device is a miniaturized two disk device introduced through small venous sheaths (8-9 F). The diameter of atrial septal defects by echocardiography varied between 9 and 23 mm, while the balloon stretched diameter of the defects varied between 13 and 24 mm. The devices selected were 19 +/- 4 mm larger than the stretched diameter of the defect, but less than the total length of the septum (33-56 mm) by echo. RESULTS: Pulmonary-to-systemic flow ratio varied between 1.5 to 4.0. Mean pulmonary artery pressure varied between 10 and 24 mmHg (mean value 17 +/- 3.5 mm Hg). The relationship between different atrial septal defect measurements (echo, shunt flow, stretched diameter) was statistically analysed: transthoracic echo diameter had a good correlation with the balloon stretched diameter (r = 0.63, p < 0.001). The atrial septal defect was occluded in 12 patients (86% success rate). There was one early "unbuttoning" which was surgically corrected with success. The other patient underwent surgical correction 3 months later because of unsuitability for transcatheter closure. Minimal residual shunt detected by color flow mapping at 1 month follow-up was seen in 4 patients (33%). No complications occurred in any of our patients. CONCLUSIONS: This initial experience with the Sideris buttoned double-disk device demonstrated that transcatheter closure of atrial septal defect is feasible and effective. It can be accomplished through small introducing sheaths. Further clinical trials are justified. This method could become the procedure of choice for the correction of small ASDs.

Iopamidol in cardioangiography: a retrospective, multicenter study. Part I. Adult patients.

To evaluate the occurrence of complications during diagnostic or interventional catheterization a retrospective analysis of catheterization procedures in 12 Italian laboratories using the nonionic contrast medium (CM) iopamidol (370 mgI/ml) was performed. Data obtained on 26,219 patients greater than or equal to 14 years are presented. The overall complication rate was 1.89% (485/26,219). The overall mortality rate was 0.1% (27/26,219). Procedure related complications were 389 (1.48%) and CM related complications were 106 (0.4%). No death was attributed to CM. Ventricular fibrillation (VF) rate was 0.11% comparable to the low rate observed with nonionic CM in other studies and less than the rate observed in surveys concerning the use of ionic CM. Fifty-seven thrombotic events were recorded (0.22%), a rate comparable with other surveys with ionic and nonionic CM. The total complication rate (6.1%), the rates of coronary occlusion (1.34%), myocardial infarction (0.37%) and urgent coronary artery by-pass grafting (0.5%) in 1,348 coronary angioplasties were lower than those recorded in previous surveys. These data confirm a good tolerability and no increased risk of VF and thrombotic events with iopamidol in cardiac catheterization.

Iopamidol in cardioangiography: a retrospective, multicentre study. Part II. Paediatric patients.

To evaluate the complication rate in paediatric cardioangiography with the nonionic contrast medium iopamidol data on 8,166 procedures were retrospectively collected in 12 centres. The overall complication rate was 3.78% (309/8,166). 3.44% were related to the procedure, and 0.34% to the contrast medium. The mortality rate varied with age. It was higher in patients less than 2 months (0.38%) than in patients greater than 2 months-2 years (0.06%) and in patients older than 2 years (0.03%). The total complication rate was higher than the one observed in a similar retrospective analysis performed in adult patients (1.89%). This difference is probably due to higher risk conditions of the younger patients. However the contrast medium related complication rate (0.34% vs 0.4%) and the mortality rate (0.11% vs 0.1%) were comparable, confirming the good tolerability of iopamidol in cardiac catheterisation also in paediatric patients.