Relationship of walking impairment and ankle-brachial index assessments with peripheral arterial translesional pressure gradients.

BACKGROUND: The relationship of peripheral arterial mean translesional pressure gradient (TLG) to presenting symptom, functional impairment, and initial noninvasive ABI assessments has never been established. OBJECTIVES: To evaluate the association between TLG, severity of walking impairment, rest and exercise ankle-brachial indices (ABI). METHODS: TLG in 19 patients presenting with claudication and single superficial femoral artery lesion were measured invasively. TLG was measured at rest and post-hyperemia induction with intra-arterial adenosine (100 and 200 µg), nitroglycerin (100 and 200 µg), and after 3 minutes of ipsilateral calf cuff pressure inflation-deflation sequence. For each patient, a walking impairment questionnaire (WIQ) was completed and rest and exercise ABI were measured prior to TLG assessment. RESULTS: Mean age was 60 ± 6 years, 89% were men. Mean WIQ score was 4817 ± 3549, mean rest and exercise ABI were 0.79 ± 0.14 and 0.59 ± 0.17, respectively, and mean exercise duration was 6.3 ± 3.4 minutes. TLG with 100 µg of adenosine strongly correlates with WIQ score (r = -0.723); rest ABI (r = -0.748); exercise ABI (r = -0.888), exercise duration (r = -0.711), and percent angiographic stenosis (r = -0.818), respectively (p < 0.01 for all). TLG with adenosine 200 µg, nitroglycerin 100 and 200 µg and after cuff inflation-deflation also demonstrated significant correlation. Receiver operator curve analysis demonstrated that a TLG > or = 11 mmHg post 100 µg adenosine administration had 71.43% sensitivity and 100% specificity for identifying patients with disease defining state of exercise ABI < or = 0.70. CONCLUSION: This study validates the utility of invasive TLG measurements using vasodilation for determining the functional and hemodynamic significance of superficial femoral artery lesions.

"Bilateral knuckle" technique and Stingray re-entry system for retrograde chronic total occlusion intervention.

We report a novel technique for retrograde chronic total occlusion intervention, in which the lesion is crossed by forming and advancing a "knuckle" in both the antegrade and retrograde guidewire, followed by reentry in the true lumen by using the Stingray re-entry system.

Comparison of characteristics and outcomes of patients undergoing saphenous vein graft stenting who were or were not enrolled in the stenting of saphenous vein grafts randomized controlled trial.

OBJECTIVE: We sought to compare the characteristics and outcomes of patients who were enrolled versus those who were not enrolled in the Stenting of Saphenous Vein Grafts (SOS) randomized controlled trial. METHODS AND RESULTS: We identified all patients who underwent saphenous vein graft stenting during the SOS Trial enrollment period (May 2005 and October 2007) at our institution. Baseline characteristics and clinical outcomes were compared between patients who were versus those who were not enrolled in SOS. Of the 97 patients who underwent saphenous vein graft stenting during the study period, 62 patients (64%) were enrolled in SOS. In the enrolled group, 62 patients with 91 lesions were randomized to a bare metal stent (BMS) (n = 39) or paclitaxel-eluting stent (n = 41). In the nonenrolled group, 35 patients with 44 lesions received a drug-eluting stent (DES) (n = 27) or BMS (n = 8). During a median follow-up period of 2.66 years, nonenrolled patients had higher mortality (31.4% vs 14.5%, P = 0.039), but lower rates of myocardial infarction (5.7% vs 32.3%, P = 0.005) and target vessel failure (37% vs 61.3%, P = 0.023). Overall, patients who received DES had lower incidence of myocardial infarction, target lesion revascularization, target vessel failure and major adverse cardiac events, and similar mortality compared with the BMS group. CONCLUSIONS: Compared with nonenrolled patients, those who were enrolled in SOS had lower mortality. Patients receiving DES had better outcomes than those receiving BMS in both groups.

Use of the venture wire control catheter for subintimal coronary dissection and reentry in chronic total occlusions.

Antegrade wiring of chronic total occlusions (CTO) may fail due to subintimal wire entry and inability to reenter the true lumen. We report the use of the Venture wire control catheter to reenter the true lumen after subintimal entry in a long right coronary artery CTO.

Analysis of saphenous vein graft lesion composition using near-infrared spectroscopy and intravascular ultrasonography with virtual histology.

OBJECTIVE: To examine the composition of saphenous vein graft (SVG) lesions using two novel modalities, near-infrared spectroscopy (NIRS) and intravascular ultrasonography with virtual histology (IVUS-VH). METHODS: We performed NIRS and IVUS-VH imaging of 23 SVGs in 21 patients undergoing clinically-indicated angiography. RESULTS: Mean patient and SVG age was 66±7 and 10±7 years, respectively. SVG lesion location was aorto-ostial in 8 (35%), body in 13 (57%) and distal anastomotic in 2 (9%). Compared to anastomotic lesions, body lesions had larger mean lumen area (6.4±1.8 mm2 vs. 4.2±6.4 mm2, P=0.02) but similar mean plaque burden (73±5% vs. 70±10%, P=0.66). A NIRS lipid core plaque was identified in 9 of 13 body lesions vs. 1 of 10 anastomotic lesions (69% vs. 10%, P=0.005). SVG body lesions had higher lipid core burden index (LCBI) compared to anastomotic lesions (184±76 vs. 49±54, P<0.001). By IVUS-VH, SVG lesions had high % necrotic core (28±10%) and % dense calcium (13±10%), without any significant difference between body and anastomotic sites. Older SVG age was associated with higher lesion and vessel LCBI (r=0.76 and r=0.64, respectively, P<0.001), but was not associated with IVUS-VH determined plaque composition. Higher HDL-cholesterol was associated with lower lesion LCBI (r=-0.43, P=0.04). CONCLUSIONS: NIRS-measured lipid core plaque in SVGs increases with increasing SVG age and is infrequent in anastomotic lesions. No association was found between IVUS-VH plaque composition measurements and SVG lesion location or age.

Contemporary use of embolic protection devices in saphenous vein graft interventions: Insights from the stenting of saphenous vein grafts trial.

BACKGROUND: We sought to evaluate the contemporary use of embolic protection devices (EPDs) in saphenous vein graft (SVG) interventions. METHODS: We examined EPD use in the stenting of saphenous vein grafts (SOS) trial, in which 80 patients with 112 lesions in 88 SVGs were randomized to a bare metal stent (39 patients, 43 grafts, and 55 lesions) or paclitaxel-eluting stent (41 patients, 45 grafts, and 57 lesions). RESULTS: An EPD was used in 60 of 112 lesions (54%). A Filterwire (Boston Scientific) was used in 70% of EPD-treated lesions, Spider (ev3, Plymouth, Minnesota) in 12%, Proxis (St. Jude, Minneapolis, Minnesota) in 12%, and Guardwire (Medtronic, Santa Rosa, California) in 7%. Of the remaining 52 lesions, an EPD was not utilized in 13 lesions (25%) because the lesion was near the distal anastomosis, in 14 lesions (27%) because of an ostial location, in one lesion (2%) because of small SVG size, in two in-stent restenosis lesions (4%) because of low distal embolization risk, and in 22 lesions (42%) because of operator's preference even though use of an EPD was feasible. Procedural success was achieved in 77 patients (96%); in one patient a Filterwire was entrapped requiring emergency coronary bypass graft surgery and two patients had acute stent thrombosis. CONCLUSION: In spite of their proven efficacy, EPDs were utilized in approximately half of SVG interventions in the SOS trial. Availability of a proximal protection device could allow protection of approximately 25% of unprotected lesions, yet operator discretion appears to be the major determinant of EPD use.

Amplatzer vascular plugs for occlusion of a left internal mammary artery graft anastomosed to the anterior interventricular vein.

The authors present a case of left internal mammary artery graft anastomosis to the anterior interventricular vein leading to congestive heart failure. The patient underwent successful left main stenting using an Impella left ventricular assist device and left internal mammary graft occlusion using two Amplatzer vascular plugs.