ABSTRACT
Nailfold capillary density is lower in patients with pulmonary arterial hypertension (PAH). It is unclear whether this observation signifies a unique systemic manifestation of PAH, or reflects microcirculatory dysfunction secondary to pulmonary hypertension (PH). Capillary density and loop dimensions were measured by nailfold-capillaroscopy (NC) in 30 PAH (23 idiopathic, or iPAH, 7 hereditary, or hPAH), 17 chronic thromboembolic PH (CTEPH) patients and 48 controls. NC-Measurements were repeated after pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) in CTEPH patients. We examined whether NC-measurements were related to markers of disease severity and predictive of time to clinical worsening (TTCW) as tested by univariate linear/logistic regression and cox-regression analysis, respectively. Capillary density was significantly lower in PAH (7.5 ± 1.1, p < 0.001) and in CTEPH (8.4 ± 1.5, p < 0.001) compared to asymptomatic controls (10.3 ± 1.0 capillaries/mm). Capillary density was similar in iPAH and hPAH and unrelated to hemodynamics in either PAH or CTEPH. A lower capillary density was predictive of clinical worsening in PAH (p 0.05). After normalization of pulmonary artery pressures by PEA or BPA, capillary density remained reduced in CTEPH patients. Capillary loop apex, capillary and venous- and arterial limb diameter were increased in patients with PAH and CTEPH compared to controls. Nailfold capillary density is reduced to a similar extent in iPAH, hPAH and CTEPH. Normalization of hemodynamics by PEA or BPA does not lead to a restoration of capillary density in CTEPH. Capillary dimensions were increased in both patients with PAH and CTEPH. Lower capillary density was predictive of clinical worsening in PAH. Our findings indicate that a loss of peripheral capillaries is not specific to PAH and is not related to the hemodynamic disturbance per se, but that shared mechanisms may account for a simultaneous development of a systemic microangiopathy and pulmonary vascular remodeling.
Subject(s)
Capillaries , Hypertension, Pulmonary , Humans , Female , Male , Middle Aged , Capillaries/pathology , Capillaries/physiopathology , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/etiology , Aged , Biomarkers , Pulmonary Embolism/physiopathology , Pulmonary Embolism/complications , Microscopic Angioscopy/methods , Adult , Pulmonary Arterial Hypertension/physiopathology , Pulmonary Arterial Hypertension/surgery , Endarterectomy/methods , Microvascular Density , Chronic Disease , Nails/blood supply , Case-Control StudiesABSTRACT
BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension with a low incidence. Despite pulmonary endarterectomy(PEA) being the preferred treatment for CTEPH, for patients who failed medical therapy and who are not suitable candidates for PEA, lung transplantation (LT) is still the only effective treatment for end-stage CTEPH; however, there are currently very few reports on the efficacy of LT for CTEPH. METHODS: We retrospectively analyzed the clinical data of seven patients diagnosed with CTEPH between July 2019 and July 2021. The follow-up deadline was March, 2022. RESULTS: The mean age at admission was 54 ± 12 years. The average value of mean pulmonary artery pressure (mPAP) was 40 ± 5 mmHg. The mean preoperative oxygenation index(PaO2/FiO2) was 203 ± 56 mm Hg. After evaluation, one patient underwent left LT and the rest underwent bilateral LT. Three patients received intraoperative veno-venous extracorporeal membrane oxygenation (ECMO) support, and four patients received intraoperative veno-arterial ECMO support. The average postoperative mPAP was 19 ± 4 mmHg. The mean postoperative oxygenation index(PaO2/FiO2) was 388 ± 83 mmHg. There was a significant difference between the preoperative and postoperative mPAP and oxygenation index(PaO2/FiO2). All patients recovered well and were discharged 37 ± 19 days postoperatively. The mean follow-up duration was 19 ± 8 months. There was no recurrence of CTEPH. CONCLUSIONS: LT is an effective treatment for end-stage CTEPH, which can improve cardiopulmonary function and quality of life and prolong survival. Patients who are unable to tolerate PEA should be considered for LT as early as possible when internal medicine failed.
Subject(s)
Hypertension, Pulmonary , Lung Transplantation , Pulmonary Embolism , Humans , Middle Aged , Female , Male , Retrospective Studies , Hypertension, Pulmonary/surgery , Pulmonary Embolism/surgery , Pulmonary Embolism/complications , Adult , Chronic Disease , Treatment Outcome , Extracorporeal Membrane Oxygenation/methods , Aged , Endarterectomy/methodsABSTRACT
PURPOSE: Pulmonary thromboendarterectomy (PTE) is the treatment for patients with chronic thromboembolic disease. In the immediate postoperative period, some patients may still experience life-threatening complications such as reperfusion lung injury, airway bleeding, and persistent pulmonary hypertension with consequent right ventricular dysfunction. These issues may require support with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery or lung transplantation. This study aims to analyze our series of PTEs that require ECMO. METHODS: A descriptive and retrospective analysis of all PTE performed at the Favaloro Foundation University Hospital was conducted between March 2013 and December 2023. RESULTS: A total of 42 patients underwent PTE with a median age of 47 years (interquartile range: 26-76). The incidence of patients with ECMO was 26.6%, of which 53.6% were veno-venous (VV) ECMO. Preoperatively, a low cardiac index (CI), high right and left filling pressures, and high total pulmonary vascular resistances (PVRs) were associated with ECMO with a statistically significant relationship. The hospital mortality was 11.9%, and the mortality in the ECMO group was 45.5%, with a statistically significant relationship. Veno-arterial ECMO has a worse prognosis than VV ECMO. CONCLUSIONS: Preoperatively, a low CI, high right and left filling pressures, and high total PVRs were associated with ECMO after PTE.
Subject(s)
Endarterectomy , Extracorporeal Membrane Oxygenation , Hospital Mortality , Pulmonary Embolism , Humans , Extracorporeal Membrane Oxygenation/mortality , Extracorporeal Membrane Oxygenation/adverse effects , Middle Aged , Endarterectomy/adverse effects , Endarterectomy/mortality , Male , Retrospective Studies , Female , Treatment Outcome , Adult , Aged , Pulmonary Embolism/mortality , Pulmonary Embolism/surgery , Pulmonary Embolism/physiopathology , Time Factors , Risk Factors , Pulmonary Artery/physiopathology , Pulmonary Artery/surgery , Hypertension, Pulmonary/mortality , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/surgeryABSTRACT
BACKGROUND: The purpose of this study was to compare femoropopliteal bypass (FPB) and remote endarterectomy (RE) for long femoropopliteal lesions. METHODS: Single center retrospective propensity matching analysis of the symptomatic patients with long occlusion of the femoro-popliteal segment (>250 mm), who underwent femoro-popliteal bypass above the knee or remote endarterectomy from 2014 to 2020. Primary endpoints: primary patency (PP), secondary patency (SP), target lesion revascularization (TLR). Secondary endpoints: MALE, MACE, clinical improvement and survival. RESULTS: Four hundred patients were divided into two groups: 200 in the FPB group and 200 in the RE group. As a result of propensity score matching, 110 (FPB) and 109 (RE) patients remained. Three-year primary patency rates were 62% for FPB vs. 53% for RE, P=0.16. Secondary patency rates were 84% for FPB vs. 75% for RE, P=0.10. Freedom from TLR were 61% for FPB vs. 71% for RE P=0.21. Survival and amputation-free survival (AFS) also did not differ (93% vs. 94%, P=0.81 and 87% vs. 92%, P=0.19 respectively). Primary patency of the GSV higher than RE (P=0.00) and PTFE (P=0.00). It was established statistically advantages of RE and great saphenous vein (GSV) bypass over a PTFE bypass in SP (P=0.01 P=0.03), TLR (P=0.02 P=0.00) and AFS (P=0.03 P=0.01). CONCLUSIONS: Surgical treatment of long femoropopliteal occlusions with an autovenous bypass or remote endarterectomy showed significantly better results in secondary patency, TLR and AFS than the use of PTFE prostheses. GSV remains the gold standard for femoropopliteal bypass surgery.
Subject(s)
Endarterectomy , Femoral Artery , Peripheral Arterial Disease , Popliteal Artery , Propensity Score , Vascular Patency , Humans , Male , Popliteal Artery/surgery , Popliteal Artery/physiopathology , Femoral Artery/surgery , Femoral Artery/physiopathology , Retrospective Studies , Female , Aged , Endarterectomy/adverse effects , Peripheral Arterial Disease/surgery , Peripheral Arterial Disease/physiopathology , Middle Aged , Treatment Outcome , Limb Salvage , Time Factors , Risk FactorsABSTRACT
Isolated popliteal artery occlusions are rare compared with femoropopliteal occlusive diseases. Although endovascular procedures have gained importance in treatment, conventional surgery remains the gold standard. In this study, we reviewed popliteal endarterectomy and patch plasty using a posterior approach. Fourteen patients who underwent surgery for isolated popliteal artery occlusions were retrospectively examined. Patients were assessed in terms of age, sex, and risk factors, such as accompanying diseases and smoking, surgical method and anesthesia, incision type, preoperative and postoperative pulse examination, ankle-brachial indices, patency, wound infection, postoperative complications, and the treatment applied. Twelve (85.7%) patients were male, and 2 (14.3%) were female. Limb ischemia was critical (ABIâ <â 0.7) in 11 (78.5%) patients. The average duration of postoperative hospitalization was 8â ±â 3.7 days on average, and the average length of follow-up was 17â ±â 3.4 months. Thrombosis and complications requiring secondary intervention did not develop during the early postoperative period. While the patency rate in the first 6 months of follow-up was 100%, it was 92.8% in the 1st year and 85.7% in the 2nd year. Surgical treatment with the posterior approach in isolated popliteal artery lesions is preferred by vascular surgeons as a prioritized treatment method, with a sufficient recanalization rate and low perioperative morbidity and mortality rates. Furthermore, it is promising because it does not prevent below-knee femoropopliteal bypass, which is the subsequent stage of treatment. Moreover, the great saphenous vein was protected, and the acceptable early- and mid-term results were encouraging.
Subject(s)
Endarterectomy , Popliteal Artery , Humans , Popliteal Artery/surgery , Male , Female , Endarterectomy/methods , Retrospective Studies , Aged , Middle Aged , Arterial Occlusive Diseases/surgery , Constriction, Pathologic/surgery , Treatment Outcome , Postoperative Complications/epidemiology , Vascular PatencyABSTRACT
BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disorder with substantial morbidity and mortality, also a disease underdiagnosed and undertreated. It is potentially curable by pulmonary endarterectomy (PEA) in patients with surgically accessible thrombi. Balloon pulmonary angioplasty (BPA) and targeted medical therapy are options for patients with distal lesions or persistent/recurrent pulmonary hypertension after PEA. There is an urgent need to increase the awareness of CTEPH. Qualified CTEPH centers are still quite limited. Baseline characteristics, management pattern and clinical outcome of CTEPH in China needs to be reported. METHODS AND DESIGN: The CHinese reAl-world study to iNvestigate the manaGEment pattern and outcomes of chronic thromboembolic pulmonary hypertension (CHANGE) study is designed to provide the multimodality treatment pattern and clinical outcomes of CTEPH in China. Consecutive patients who are ≥ 14 year-old and diagnosed with CTEPH are enrolled. The diagnosis of CTEPH is confirmed in right heart catheterization and imaging examinations. The multimodality therapeutic strategy, which consists of PEA, BPA and targeted medical therapy, is made by a multidisciplinary team. The blood sample and tissue from PEA are stored in the central biobank for further research. The patients receive regular follow-up every 3 or 6 months for at least 3 years. The primary outcomes include all-cause mortality and changes in functional and hemodynamic parameters from baseline. The secondary outcomes include the proportion of patients experiencing lung transplantation, the proportion of patients experiencing heart and lung transplantation, and changes in health-related quality of life. Up to 31 December 2023, the study has enrolled 1500 eligible patients from 18 expert centers. CONCLUSIONS: As a real-world study, the CHANGE study is expected to increase our understanding of CTEPH, and to fill the gap between guidelines and the clinical practice in the diagnosis, assessment and treatment of patients with CTEPH. REGISTRATION NUMBER IN CLINICALTRIALS.GOV: NCT05311072.
Subject(s)
Angioplasty, Balloon , Endarterectomy , Hypertension, Pulmonary , Pulmonary Embolism , Humans , Hypertension, Pulmonary/therapy , China , Pulmonary Embolism/complications , Pulmonary Embolism/therapy , Chronic Disease , Quality of Life , Treatment Outcome , Female , Combined Modality Therapy , Male , East Asian PeopleABSTRACT
BACKGROUND: Endovascular therapy has become established as a first-line therapy in most arterial regions. However, open vascular surgery (endarterectomy) remains the treatment of choice for common femoral artery (CFA) lesions. The aim of this study is to investigate the acute and mid-term results of directional atherectomy plus drug-coated balloon (DCB) in comparison to endarterectomy in treatment of de novo arteriosclerotic CFA lesions. METHODS: This prospective, randomized, multicenter non-inferiority study will enroll 306 participants with symptomatic (Rutherford category 1 to 5) de novo stenosis of the CFA including the bifurcation. Patients eligible for both treatment groups could be included in this 1:1 randomized trial. Primary efficacy endpoint is patency of the target lesion at 12 months defined as restenosis < 50% without the need of clinically driven target lesion revascularization (cdTLR). Primary safety endpoint is a combined endpoint including death, myocardial infarction, major or minor amputation of the target limb, and peri-procedural complications at 30 days. Secondary endpoints include primary patency of the target lesion at 6 and 24 months, secondary patency, cdTLR 6, 12, and 24 months, change in ankle-brachial index, and Rutherford-Becker class at 6, 12, and 24 months. Limb salvage, change in quality of life measured by Walking Impairment Questionnaire, and major adverse events including death, myocardial infarction, and minor or major amputation of the target limb will be determined at 6, 12, 24, and 36 months. DISCUSSION: Endovascular treatment of CFA lesions is still a matter of debate. Few studies compared modern endovascular therapy methods against the so-called gold standard surgical endarterectomy so far. Based on recent positive results, this study aims to confirm non-inferiority of a "leaving nothing behind" endovascular approach combining directional atherectomy and DCB compared to surgical therapy. TRIAL REGISTRATION: ClinicalTrials.gov NCT02517827.
Subject(s)
Endarterectomy , Femoral Artery , Peripheral Arterial Disease , Vascular Patency , Humans , Angioplasty, Balloon/adverse effects , Angioplasty, Balloon/methods , Angioplasty, Balloon/instrumentation , Atherectomy/adverse effects , Atherectomy/methods , Coated Materials, Biocompatible , Endarterectomy/adverse effects , Endarterectomy/methods , Equivalence Trials as Topic , Femoral Artery/surgery , Limb Salvage , Multicenter Studies as Topic , Peripheral Arterial Disease/therapy , Peripheral Arterial Disease/surgery , Peripheral Arterial Disease/physiopathology , Prospective Studies , Quality of Life , Randomized Controlled Trials as Topic , Time Factors , Treatment Outcome , Vascular Access DevicesABSTRACT
Spontaneous retroperitoneal hematoma (SRH) is a rare complication of anticoagulation therapy. Presentation may vary from limb paresis to hypovolemic shock due to blood loss. The optimal treatment is controversial. It can be managed conservatively or surgically. We report a case of a 73-year-old man presenting with progressively worsening abdominal pain and severe pain radiating to his left lower limb twenty-five days after his pulmonary endarterectomy (PEA) surgery. He was on anticoagulation per our institutional protocol for PEA patients. Investigations revealed a large, spontaneously occurring iliopsoas hematoma. Our patient was treated conservatively, and the SRH stabilised.
Subject(s)
Endarterectomy , Hematoma , Humans , Male , Aged , Endarterectomy/adverse effects , Retroperitoneal Space , Hematoma/etiology , Hematoma/surgery , Pulmonary Artery/surgery , Tomography, X-Ray Computed , Pulmonary Embolism/etiology , Pulmonary Embolism/surgery , Anticoagulants/adverse effects , Anticoagulants/therapeutic use , Postoperative ComplicationsABSTRACT
BACKGROUND: The treatment of pulmonary hypertension (PH) has improved rapidly in recent decades. There is increasing evidence to support the role of early intervention and treatment in affecting clinical outcomes in PH. OBJECTIVES: To assess treatment effects before and after the escalation of specific PH treatments using continuous heart monitoring with a Reveal LINQ loop recorder. METHODS: Patients were compared before and after treatment escalation. Treatment escalation was defined as an additional pulmonary arterial hypertension (PAH) drug, pulmonary endarterectomy, percutaneous balloon angioplasty or bilateral lung transplantation. Specifically, changes in heart rate variability (HRV), heart rate (HR) and physical activity were assessed. RESULTS: In this prospective study, 41 patients (27 with PAH and 14 with chronic thromboembolic pulmonary hypertension (CTEPH)) were enrolled. Among them, 15 (36.6%) patients underwent PH treatment escalation. Prior to escalation, patients were monitored for a median of 100 (range: 68-100) days and after therapy escalation for a median duration of 165 (range: 89-308) days. In the escalation group, there was a significant increase in HRV, physical activity indexed by daytime HR and a significant decrease in nighttime HR assessed at baseline and after treatment escalation in both the PAH and CTEPH groups. This was paralleled by significant improvements in WHO functional class, 6-min walking distance and N-terminal pro-b-type natriuretic peptide. CONCLUSIONS: This is the first study to demonstrate an association between specific PH therapies and changes in HRV, HR nighttime and physical activity. This indicates the potential of continuous monitoring in the evaluation of treatment effects in PH.
Subject(s)
Heart Rate , Hypertension, Pulmonary , Humans , Female , Male , Middle Aged , Prospective Studies , Heart Rate/physiology , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/therapy , Treatment Outcome , Endarterectomy/methods , Aged , Antihypertensive Agents/therapeutic use , Time Factors , Angioplasty, Balloon/methods , Adult , Lung Transplantation , Electrocardiography, Ambulatory/methods , Pulmonary Artery/physiopathologyABSTRACT
Chronic thromboembolic pulmonary hypertension (CTEPH) is classified as group IV pulmonary hypertension, characterized by thrombotic occlusion of the pulmonary arteries leading to vascular stenosis or obstruction, progressive increase in pulmonary vascular resistance and pulmonary arterial pressure, and eventual right heart failure. Unlike other types of pulmonary hypertension, the prognosis of CTEPH can be significantly improved by surgery, vascular intervention, and/or targeted drug therapy. Pulmonary endarterectomy (PEA) is the preferred treatment of choice for CTEPH. However, PEA is an invasive procedure with high operative risks, and is currently only performed in a few centers in China. Balloon pulmonary angioplasty (BPA) is an emerging interventional technique for CTEPH, serving as an alternative for patients who are ineligible for PEA or with residual pulmonary hypertension after PEA. BPA is gaining traction in China, but its widespread adoption is limited due to its complexity, operator skills, and equipment requirements, a lack of standard operating procedures and technical guidance, which limit the further improvement and development of BPA in China. To address this, a multidisciplinary panel of experts was convened to develop the Consensus on the Procedure of Balloon Pulmonary Angioplasty for the Chronic Thromboembolic Pulmonary Hypertension, which fomulates guidelines on BPA procedural qualification, perioperative management, procedural planning, technical approach, and complication prevention, with the aim of providing recommendations and clinical guidance for BPA treatment in CTEPH and standardizing its clinical application in this setting. Summary of recommendations: Recommendation 1: It is recommended that physicians who specialize in pulmonary vascular diseases take the lead in formulating the diagnostic and treatment plans for CTEPH, using a multidisciplinary approach.Recommendation 2: Training in BPA technique is critical; novice operators should undergo standardized operative training with at least 50 procedures under the guidance of experienced physicians before embarking on independent BPA procedures.Recommendation 3: BPA requires catheterization labs, angiography systems, standard vascular interventional devices and consumables, drugs, and emergency equipment.Recommendation 4: Patient selection for BPA should consider cardiac and pulmonary function, coagulation status, and comorbid conditions to determine indications and contraindications, thereby optimizing the timing of the procedure and improving safety.Recommendation 5: In experienced centers, patients deemed likely to benefit from early BPA, based on clinical and imaging features of CTEPH and without elevated D-dimer levels, could bypass standard 3-month anticoagulation therapy.Recommendation 6: BPA is a complex interventional treatment that requires thorough pre-operative assessment and preparation.Recommendation 7: The use of perioperative anticoagulants in BPA requires a comprehensive risk assessment of intraoperative bleeding by the operator for individualized decision making.Recommendation 8: A variety of venous access routes are available for BPA; unless contraindicated, the right femoral vein is usually preferred because of its procedural convenience and reduced radiation exposure.Recommendation 9: For the different types of vascular lesion in CTEPH, treatment of ring-like stenoses, web-like lesions, and subtotal occlusions should be prioritized before addressing complete occlusions and tortuous lesions, in order to reduce complications and improve procedural safety.Recommendation 10: A targeted, incremental balloon dilatation strategy based on vascular lesions is recommended for BPA.Recommendation 11: Intravascular pulmonary artery imaging technologies, such as OCT and IVUS can assist in accurate vessel sizing and confirmation of wire placement in the true vascular lumen. Pressure wires can be used to objectively assess the efficacy of dilatation during BPA.Recommendation 12: Endpoints for BPA treatment should be individually assessed, taking into account improvements in clinical symptoms, hemodynamics, exercise tolerance, and quality of life.Recommendation 13: Post-BPA routine monitoring of vital signs is essential; anticoagulation therapy should be initiated promptly post-procedure in the absence of complications. In cases of intraoperative hemoptysis, postoperative anticoagulation regimen adjustments should be adjusted according to the bleeding severity.Recommendation 14: If reperfusion pulmonary edema occurs during or after BPA, ensure adequate oxygenation, diuresis, and consider non-invasive positive-pressure ventilation if necessary, while severe cases may require early mechanical ventilation assistance or ECMO.Recommendation 15: In cases of intraoperative hemoptysis, temporary balloon occlusion to stop bleeding is recommended, along with protamine to neutralize heparin. Persistent bleeding may warrant the use of gelatin sponges, coil embolization, or covered stent implantation.Recommendation 16: For contrast imaging during BPA, non-ionic, low or iso-osmolar contrast agents are recommended, with hydration status determined by the patient's clinical condition, cardiac and renal function, and intraoperative contrast volume used.
Subject(s)
Angioplasty, Balloon , Hypertension, Pulmonary , Pulmonary Embolism , Humans , Angioplasty, Balloon/methods , Hypertension, Pulmonary/therapy , Hypertension, Pulmonary/etiology , Pulmonary Embolism/therapy , Chronic Disease , Pulmonary Artery/surgery , Endarterectomy/methods , Consensus , ChinaABSTRACT
Chronic thromboembolic pulmonary hypertension (CTEPH) presents as a progressive vascular condition arising from previous episodes of acute pulmonary embolism, contributing to the development of pulmonary hypertension (PH). Pulmonary thromboendarterectomy (PTE) is the gold-standard surgical treatment for CTEPH; however, it may be associated with postoperative sequelae, including atrial arrhythmias (AAs). This comprehensive literature review explores the potential mechanisms for PTE-induced AAs with emphasis on the role of PH-related atrial remodelling and the predisposing factors. The identified preoperative predictors for AAs include advanced age, male gender, elevated resting heart rate, previous AAs, and baseline elevated right atrial pressure. Furthermore, we explore the available data on the association between post-PTE pericardial effusions and the development of AAs. Lastly, we briefly discuss the emerging role of radiomic analysis of epicardial adipose tissue as an imaging biomarker for predicting AAs.
Subject(s)
Endarterectomy , Hypertension, Pulmonary , Pulmonary Embolism , Humans , Endarterectomy/adverse effects , Endarterectomy/methods , Pulmonary Embolism/surgery , Pulmonary Embolism/physiopathology , Hypertension, Pulmonary/surgery , Hypertension, Pulmonary/etiology , Arrhythmias, Cardiac/etiology , Arrhythmias, Cardiac/surgery , Arrhythmias, Cardiac/physiopathology , Postoperative Complications/etiology , Risk Factors , Pulmonary Artery/surgeryABSTRACT
Chronic thromboembolic pulmonary hypertension is a rare form of pulmonary hypertension in patients who have evidence of chronic thromboembolic occlusion of the pulmonary vasculature. Historically, surgical pulmonary thromboendarterectomy has been the treatment of choice. However, with up to 40% of patients deemed inoperable, balloon pulmonary angioplasty has emerged as an additional treatment strategy. Balloon pulmonary angioplasty is a complementary strategy alongside surgical pulmonary thromboendarterectomy and offers the opportunity for pulmonary revascularization in patients who have more distal disease, higher comorbidities, or residual obstruction following operative intervention. This review examines the history of balloon pulmonary angioplasty, highlights its effectiveness, discusses important complications and risk reduction strategies, and emphasizes the importance of centers forming a multidisciplinary team of providers to manage the complexity of patients with chronic thromboembolic pulmonary hypertension.
Subject(s)
Angioplasty, Balloon , Hypertension, Pulmonary , Pulmonary Artery , Pulmonary Embolism , Humans , Pulmonary Embolism/physiopathology , Pulmonary Embolism/therapy , Pulmonary Embolism/surgery , Pulmonary Embolism/complications , Chronic Disease , Treatment Outcome , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/therapy , Hypertension, Pulmonary/diagnosis , Pulmonary Artery/physiopathology , Pulmonary Artery/surgery , Risk Factors , Arterial Pressure , Endarterectomy/adverse effectsABSTRACT
BACKGROUND: Carotid webs are abnormal thin shelf-like or flap-like tissue in the carotid bulb (proximal internal carotid artery). Rarely are carotid webs detected prior to symptoms since routine carotid artery surveillance is not performed in younger individuals without traditional risk factors for carotid disease. The cause and natural history remain unknown. In general, they are not common but should be considered in the differential diagnosis of a patient who presents with ischemic neurologic symptoms. The web can create a flow disturbance, potentiating local thrombus formation, which can embolize producing resulting in cerebral ischemia. Current treatment is to reduce thrombus formation (antithrombotics and/or anticoagulation) or to alter the flow disturbance caused by the web (surgical removal or stent). METHODS: We retrospectively identified all patients presenting with acute ischemic stroke to our Comprehensive Stroke Center that were diagnosed with carotid web from January 2020 to December 2023. Patient demographics, presentation, hospital course including treatment and complications were collected and reported. RESULTS: Fifteen patients presented with carotid web and stroke from 2020 to 2023 and 13 underwent carotid artery stenting or endarterectomy with no periprocedural complications. Most (40%) carotid webs were not primarily identified by the initial radiology interpretation. CONCLUSIONS: We discuss our experience of carotid web and its management as well as review of the current literature.
Subject(s)
Carotid Artery Diseases , Ischemic Stroke , Ischemic Stroke/complications , Carotid Artery Diseases/complications , Carotid Artery Diseases/diagnostic imaging , Carotid Artery Diseases/therapy , Stents , Endarterectomy , Retrospective Studies , Humans , Male , Female , Adult , Middle AgedABSTRACT
El autor de este artículo describe personalmente la técnica de la endarterectomía carotídea clásica con algunos detalles personales que puedan ser de utilidad o de reflexión para el lector.(AU)
The author of this paper personally describes the classical carotid endarterectomy technique with some personaldetails that may be useful or thought-provoking for the reader.(AU)
Subject(s)
Humans , Male , Female , Endarterectomy , Endarterectomy, Carotid , Endarterectomy, Carotid/methods , Endarterectomy, Carotid/standardsABSTRACT
BACKGROUND: Impaired quality of life (QoL) is prevalent among patients with chronic thromboembolic pulmonary hypertension (CTEPH) despite improved survival due to medical advances. We clarified the physical QoL of patients with CTEPH with mildly elevated pulmonary hemodynamics and evaluated its determinants using a database of patients with CTEPH evaluated for hemodynamics during exercise. METHODS: The QoL was measured in 144 patients with CTEPH (age, 66 (58-73) years; men/women, 48/96) with mildly elevated mean pulmonary artery pressure (<30 mm Hg) at rest after treatment with balloon pulmonary angioplasty and/or pulmonary endarterectomy using the Short-Form 36 (SF-36) questionnaire. The enrolled patients were divided into 2 groups: physical component summary (PCS) scores in the SF-36 over 50 as PCS-good and those under 50 as PCS-poor. RESULTS: The median PCS in SF-36 score was 43.4 (IQR 32.4-49.5) points. The PCS-poor group (n = 110) was older and had lower exercise capacity and SaO2 during exercise. PCS scores were correlated with 6-minute walk distance (rs=0.40, p < 0.001), quadriceps strength (rs=0.34, p < 0.001), peak VO2 (rs=0.31, p < 0.001), SaO2 at rest (rs=0.35, p < 0.001) and peak exercise (rs=0.33, p < 0.001), home oxygen therapy usage (rs=-0.28, p = 0.001), and pulmonary vascular resistance at peak exercise (rs=-0.26, p = 0.002). CONCLUSIONS: The impairment of physical QoL was common in patients with CTEPH with improved hemodynamics; exercise capacity, hypoxemia, and hemodynamic status during exercise were related to the physical QoL.
Subject(s)
Endarterectomy , Exercise Test , Hypertension, Pulmonary , Pulmonary Embolism , Quality of Life , Humans , Female , Male , Middle Aged , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/therapy , Hypertension, Pulmonary/etiology , Aged , Pulmonary Embolism/physiopathology , Pulmonary Embolism/complications , Pulmonary Embolism/therapy , Exercise Test/methods , Chronic Disease , Exercise Tolerance/physiology , Retrospective Studies , Angioplasty, Balloon/methodsABSTRACT
Chronic thromboembolic pulmonary hypertension (CTEPH) is a pulmonary vascular disease characterized by an insidious onset, progressive deterioration, and poor prognosis. It is distinguished by the thrombotic organization within the pulmonary arteries, leading to vascular stenosis or occlusion. This results in a progressive increase in pulmonary vascular resistance and pulmonary arterial pressure, ultimately leading to right heart failure. In recent years, balloon pulmonary angioplasty (BPA) has emerged as an effective treatment option for patients ineligible for pulmonary endarterectomy (PEA). However, the use of stents in patients with suboptimal balloon dilation remains controversial. This article describes two cases of chronic thromboembolic pulmonary hypertension (CTEPH) in which balloon angioplasty yielded unsatisfactory results, subsequently leading to stent placement. Following stent implantation, there was improved blood flow, significant reduction in pulmonary arterial pressure, and notable alleviation of patient symptoms. One-year follow-up showed no recurrence of stenosis within the stent, suggesting potential guidance for the use of pulmonary artery stenting as a treatment modality for CTEPH. This report provided new insights into the therapeutic approach for CTEPH.
Subject(s)
Angioplasty, Balloon , Hypertension, Pulmonary , Humans , Hypertension, Pulmonary/etiology , Hypertension, Pulmonary/surgery , Pulmonary Artery/surgery , Constriction, Pathologic , EndarterectomyABSTRACT
Balloon pulmonary angioplasty continues to gain traction as a treatment option for patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. Recent European Society of Cardiology guidelines on pulmonary hypertension now give balloon pulmonary angioplasty a Class 1 recommendation for inoperable and residual chronic thromboembolic pulmonary hypertension. Not surprisingly, chronic thromboembolic pulmonary hypertension centers are rapidly initiating balloon pulmonary angioplasty programs. However, we need a comprehensive, expert consensus document outlining critical concepts, including identifying necessary personnel and expertise, criteria for patient selection, and a standardized approach to preprocedural planning and establishing criteria for evaluating procedural efficacy and safety. Given this lack of standards, the balloon pulmonary angioplasty skill set is learned through peer-to-peer contact and training. This document is a state-of-the-art, comprehensive statement from key thought leaders to address this gap in the current clinical practice of balloon pulmonary angioplasty. We summarize the current status of the procedure and provide a consensus opinion on the role of balloon pulmonary angioplasty in the overall care of patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. We also identify knowledge gaps, provide guidance for new centers interested in initiating balloon pulmonary angioplasty programs, and highlight future directions and research needs for this emerging therapy.
Subject(s)
Angioplasty, Balloon , Hypertension, Pulmonary , Pulmonary Embolism , Thromboembolism , Humans , Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/etiology , Hypertension, Pulmonary/therapy , Pulmonary Embolism/complications , Pulmonary Embolism/therapy , American Heart Association , Chronic Disease , Pulmonary Artery , EndarterectomyABSTRACT
La hipertensión pulmonar tromboembólica crónica (HPTEC) es una forma potencialmente curable de hipertensión pulmonar (HP) que aparece hasta en 3% de los pacientes tras una embolia pulmonar (EP). En estos pacientes, la EP no se resuelve, dando paso a coágulos fibróticos organizados, con el desarrollo de HP precapilar debido a la obstrucción proximal de las arterias pulmonares. También puede desarrollarse una microvasculopatía distal que contribuye al aumento de la resistencia vascular pulmonar (RVP). La ecocardiografía transtorácica (ETT) es la exploración que permite establecer la sospecha de HP. La gammagrafía pulmonar de ventilación-perfusión (V/Q) es la herramienta fundamental en el estudio de los pacientes con sospecha de HPTEC; si es normal, prácticamente la descarta. El cateterismo cardiaco derecho es obligatorio para el diagnóstico. La HPTEC se define como la existencia de síntomas, defectos de perfusión residuales e HP precapilar tras un periodo mínimo de tres meses de anticoagulación. La angiografía pulmonar ayuda a determinar la extensión y la accesibilidad quirúrgica de las lesiones tromboembólicas. Las personas con HPTEC son candidatas a anticoagulación indefinida. La endarterectomía pulmonar es el tratamiento de elección, resultando en una mejoría clínica y hemodinámica significativa. Aproximadamente un 25% de los pacientes presentan HP residual postendarterectomía. La angioplastia pulmonar con balón (APB) es una técnica endovascular dirigida a lesiones más distales, de utilidad para sujetos con HPTEC inoperable o HP persistente/recidivante postendarterectomía. Ambos tipos de pacientes también se pueden beneficiar de tratamiento farmacológico para la HP. Las tres terapias constituyen los pilares de la terapia, que ha evolucionado hacia un enfoque multimodal.(AU)
Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.(AU)
Subject(s)
Humans , Male , Female , Hypertension, Pulmonary/diagnosis , Pulmonary Embolism , Endarterectomy , Angioplasty, Balloon , Risk FactorsABSTRACT
Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by the obstruction of pulmonary arteries secondary to chronic thromboembolism. Pulmonary thromboendarterectomy surgery (PTE) is the main treatment for patients with CTEPH, as it removes the chronic thrombi from the pulmonary arteries. Pulmonary reperfusion syndrome is a common complication of the surgery, which involves the development of pulmonary edema in the area where blood perfusion improves after the surgery. The incidence of this syndrome varies from 8 to 91% depending on the criteria used for diagnosis, and it is one of the most serious complications of pulmonary thromboendarterectomy. In such cases, circulatory support with extracorporeal membrane oxygenation (ECMO) has become a valuable therapeutic modality. We present the case of a 60-year-old woman with a history of acute pulmonary embolism due to deep vein thrombosis of the right pelvic limb who was diagnosed later with CTEPH who was admitted for scheduled surgical treatment involving bilateral PTE. However, during the immediate postoperative period, she developed cardiogenic shock and refractory hypoxemia secondary to pulmonary reperfusion syndrome following the surgical procedure. As a result, she required veno-venous ECMO circulatory support for 6 days, leading to resolution of the pulmonary condition and clinical improvement.
La hipertensión pulmonar tromboembólica crónica (HPTEC) es un subtipo de hipertensión pulmonar caracterizada por la obstrucción de las arterias pulmonares secundaria a tromboembolias crónicas. La cirugía de tromboendarterectomía pulmonar (TEAP) es el tratamiento principal para los pacientes con HPTEC, elimina los trombos crónicos de las arterias pulmonares. El síndrome de reperfusión pulmonar es una complicación común de la cirugía, se trata del desarrollo de edema pulmonar en el área en la que la perfusión sanguínea mejora después de la cirugía. La incidencia del síndrome varía del 8 al 91% según los criterios utilizados para diagnosticarlo y es una de las complicaciones más graves de la tromboendarterectomía pulmonar. En tales casos, el soporte circulatorio con oxigenación por membrana extracorpórea (ECMO) se ha convertido en una valiosa modalidad terapéutica. Presentamos el caso de una paciente de 60 años de edad con antecedente de tromboembolia pulmonar aguda secundaria a trombosis venosa profunda de miembro pélvico derecho a quien durante el seguimiento se realizó el diagnóstico de HPTEC e ingresó de manera programada para tratamiento quirúrgico con realización de TEAP bilateral, sin embargo durante el posquirúrgico inmediato presentó choque cardiogénico e hipoxemia refractaria secundarios a síndrome de reperfusión pulmonar, por lo cual requirió soporte circulatorio con ECMO venovenosa durante seis días, con resolución del cuadro pulmonar y mejoría clínica.
Subject(s)
Endarterectomy , Extracorporeal Membrane Oxygenation , Postoperative Complications , Pulmonary Edema , Pulmonary Embolism , Humans , Female , Extracorporeal Membrane Oxygenation/methods , Endarterectomy/methods , Middle Aged , Pulmonary Edema/etiology , Pulmonary Embolism/etiology , Postoperative Complications/etiology , Hypertension, Pulmonary/etiology , Pulmonary Artery/surgeryABSTRACT
OBJECTIVE: Common femoral endarterectomy (CFE) comprises the current standard-of-care for symptomatic common femoral artery occlusive disease. Although it provides effective inflow revascularization via a single incision, it remains an invasive procedure in an often-frail patient population. The purpose of this retrospective clinical study was to assess the morbidity and mortality of CFE in a contemporary cohort. METHODS: Consecutive CFEs performed at a large, urban hospital were reviewed. Six-month mortality, local complications (hematoma, lymphatic leak, pseudoaneurysm, wound infection, and/or dehiscence), and systemic complications were analyzed using univariate and multivariate analyses. RESULTS: A total of 129 isolated CFEs were performed over 7 years for claudication (36%), rest pain (16%), tissue loss (29%), or acute on chronic limb ischemia (21%). Mean age was 75 ± 9 years, and 68% of patients were male. Comorbidities were prevalent, including coronary artery disease (54%), diabetes (41%), chronic pulmonary disease (25%), and congestive heart failure (22%). The majority of CFEs were performed under general anesthesia (98%) with patch angioplasty using bovine pericardium (73% vs 27% Dacron). Twenty-two patients (17%) sustained local complications following the procedure; their occurrence was significantly associated with obesity (P = .002) but no technical or operative factors. Nineteen patients (15%) sustained serious systemic complications; their occurrence was significantly associated with chronic limb-threatening ischemia (P < .001), and a high American Society of Anesthesiologists (ASA) class (P = .002). By 6 months, 17 patients (13%) had died. Being on dialysis, presenting with chronic limb-threatening ischemia, and being in a high ASA class at the time of operation were all associated with 6-month mortality; a high ASA class at the time of operation was independently predictive of mortality (odds ratio, 3.08; 95% confidence interval, 1.03-9.24; P = .044). CONCLUSIONS: Although commonly performed, CFE is not a benign vascular procedure. Disease presentation, anesthetic risk, and expected longevity play an important role in clinical outcomes. Evolving endovascular approaches to the common femoral artery could serve to reduce morbidity and mortality in the future.