Multi-center experience with intravascular lithotripsy for treatment of severe calcification during transcarotid artery revascularization for high-risk patients.

OBJECTIVE: Transcarotid artery revascularization (TCAR) offers a safe alternative to carotid endarterectomy (CEA), but severe calcification is currently considered a contraindication in carotid artery stenting. This study aims to describe the safety and effectiveness of TCAR with intravascular lithotripsy (IVL) in patients with traditionally prohibitive calcific disease. METHODS: All consecutive patients who underwent TCAR+IVL from 2018-2022 at nine institutions were identified. IVL was combined with pre-dilatation angioplasty to treat calcified vessels before stent deployment. The primary outcome was a new ipsilateral stroke within 30 days. Secondary outcomes included any new ipsilateral neurologic event (stroke/transient ischemic attack [TIA]) at 30 days, technical success, and <30% residual stenosis. RESULTS: Fifty-eight patients (62% male; mean age, 78 ± 6.6 years) underwent TCAR+IVL, with 22 (38%) for symptomatic disease. Fifty-seven patients (98%) met high-risk anatomical or physiologic criteria for CEA. Forty-seven patients had severely calcific lesions. Fourteen patients (30%) had isolated eccentric plaque, 20 patients (43%) had isolated circumferential plaque, and 13 (27%) had eccentric and circumferential calcification. Mean procedure and flow reversal times were 87 ± 27 minutes and 25 ± 14 minutes. The median number of lithotripsy pulses per case was 90 (range, 30-330), and mean contrast usage was 29 mL. No patients had electroencephalogram changes or new deficits observed intraoperatively. Technical success was achieved in 100% of cases, with 98% having <30% residual stenosis on completion angiography. One patient had an in-hospital post-procedural stroke (1.72%). Four patients total had any new ipsilateral neurologic event (stroke/TIA) within 30 days for an overall rate of 6.8%. One TIA and one stroke occurred during the index hospitalization, and two TIAs occurred after discharge. Preoperative mean stenosis in patients with any postoperative neurologic event was 93% (vs 86% in non-stroke/TIA patients; P = .32), and chronic renal insufficiency was higher in patients who had a new neurologic event (75% vs 17%; P = .005). No differences were observed in calcium, procedural, or patient characteristics between the two groups. The mean follow-up was 132 days (range, 19-520 days). Three stents developed recurrent stenosis (5%) on follow-up duplex; the remainder were patent without issue. There were no reported interventions for recurrent stenosis during the study period. CONCLUSIONS: IVL sufficiently remodels calcified carotid arteries to facilitate TCAR effectively in patients with traditionally prohibitive calcific disease. One patient (1.7%) suffered a stroke within 30 days, although four patients (6.8%) sustained any new neurological event (stroke/TIA). These results raise concerns about the risks of TCAR+IVL and whether it is an appropriate strategy for patients who could potentially undergo CEA.

Long-term complications of inferior vena cava filters.

Anticoagulation is the cornerstone for the treatment of deep venous thrombosis and pulmonary embolism. On occasion, this is not possible because of bleeding complications or, rarely, breakthrough pulmonary embolism associated with this treatment method. The development of vena cava interruption in the 1970s was a critical advance in the treatment of these patients. Placement of inferior vena cava (IVC) filters has been steadily increasing since their introduction. Nonetheless, the incidence of complications associated with placement of these devices is largely unknown. Most of the evidence regarding IVC filter complications relies on case reports, with scarce data coming from larger randomized controlled trials. We aimed to present a summary addressing long-term complications of IVC filters as published in recent articles addressing problems such as IVC thrombosis and IVC filter migration, perforation, fracture, embolization, and tilting. We performed a PubMed search and Google Scholar search using different combinations of "long term," "complications," "IVC filter," and "vena cava filter." We reviewed the available English publications and reported the findings in this summary.

Posterior tibial vein aneurysm presenting as tarsal tunnel syndrome.

Tarsal tunnel syndrome is a compressive neuropathy of the posterior tibial nerve within the tarsal tunnel. Its etiology varies, including space occupying lesions, trauma, inflammation, anatomic deformity, iatrogenic injury, and idiopathic and systemic causes. Herein, we describe a 46-year-old man who presented with left foot pain. Work up revealed a venous aneurysm impinging on the posterior tibial nerve. Following resection of the aneurysm and lysis of the nerve, his symptoms were alleviated. Review of the literature reveals an association between venous disease and tarsal tunnel syndrome; however, this report represents the first case of venous aneurysm causing symptomatic compression of the nerve.

Chronic mesenteric ischemia after partial coverage of the celiac artery during TEVAR, case report, and review of the literature.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has emerged as a safe and effective alternative to open surgery for treatment of thoracic aortic aneurysms. It has recently been reported that stent-graft coverage of the celiac artery (CA) during TEVAR is associated with a low risk of acute mesenteric ischemia. However, the long-term effect of CA coverage on foregut perfusion is unknown. Here, we report the case of a patient who underwent TEVAR with partial coverage of the CA and subsequently developed symptoms of chronic mesenteric ischemia (CMI). She was successfully treated with CA stent placement. METHODS: Preoperative imaging included computed tomography (CT) angiography of the abdomen and conventional aortogram of a redo-TEVAR, revealing near complete coverage of the CA orifice. Endovascular repair was done using a 7 mm × 20 mm biliary balloon-expandable stent (Cook Medical Inc, Bloomington, IN). A review of the current literature for this rare problem was performed. RESULTS: Completion arteriography demonstrated successful revascularization of the CA without evidence of endoleak. Postoperatively, the abdominal pain was alleviated with early improved diet tolerance and weight gain. Follow-up CT at 6 month demonstrated widely patent CA. A PubMed review showed no reported cases of CMI secondary to CA coverage during TEVAR in the literature. CONCLUSIONS: CMI may develop with coverage of the CA during TEVAR. When other causes of abdominal pain and weight loss have been ruled out, revascularization of the CA can help alleviate the symptoms.

Venous cystic adventitial disease of the common femoral vein.

Venous adventitial cystic disease is a rare condition with few reports previously described. We report the case of a 39-year-old female who presented with left lower extremity edema, acutely exacerbated by exercise. Imaging revealed a hypoechoic mass posterior to her left common femoral vein. Open surgical excision and evacuation was performed with resolution of symptoms within 24 hours. A review of the literature is discussed, along with presentation, diagnosis, treatment, and pathology of this intriguing condition.