Use of covered stents and endograft as a rescue treatment in a patient with a complex form of recurrent aortic coarctation.

We report our experience with one patient with recurrent coarctation and aneurysm degeneration treated endoluminally. A novel technique was used combining balloon-expandable with self-expandable endografts. The balloon-expandable component expanded the area of stenosis and also created a neck to allow the implantation of the self-expandable endograft to exclude the aneurysm. Mismatch of diameters was solved with the creation of a new proximal neck, in which the distal end was progressively expanded to reach the appropriate diameter to implant the self-expandable endograft inside. Expansion of the narrow stenosis and complete exclusion of the aneurysm was achieved without a residual pressure gradient.

Heme oxygenase-1 is expressed in carotid atherosclerotic plaques infected by Helicobacter pylori and is more prevalent in asymptomatic subjects.

BACKGROUND AND PURPOSE: It is not well established what are the features, if any, that distinguish symptomatic from asymptomatic carotid atherosclerotic plaques. Inducible heme oxygenase-1 (HO-1) is a component of cellular defense mechanisms against oxidative stress. We aimed to assess the presence of Helicobacter pylori (H pylori) and the expression of HO-1 in carotid atherosclerotic plaques of patients with and without prior neurologic symptoms attributable to the operated artery. METHODS: We examined 25 symptomatic and 23 asymptomatic carotid atherosclerotic plaques removed during endarterectomy and 7 normal carotid arteries obtained at autopsy. We investigated the presence of H pylori DNA in the vessel wall and performed immunohistochemical detection of HO-1. RESULTS: H pylori DNA was present in 28 plaques and HO-1 was expressed in 30 plaques. HO-1 was found in 27 H pylori-positive specimens but in only 3 H pylori-negative specimens (P<0.001). All 7 normal carotid arteries were negative for both H pylori and HO-1. Although 82% of asymptomatic specimens were positive for H pylori and 87% for HO-1, only 36% of symptomatic specimens were positive for both H pylori and HO-1 (P<0.01). CONCLUSIONS: This study suggests a strong association between H pylori infection and expression of HO-1 in carotid atherosclerotic plaques. There was a substantial prevalence of these features in specimens obtained from asymptomatic subjects.

Cerebral protection during carotid stenting using flow reversal.

BACKGROUND: Carotid angioplasty and stenting can be used in stroke prevention in high-risk patients. As embolic complications can occur during carotid angioplasty and stenting, a device was developed to protect from cerebral embolization. METHODS: Between September 1999 and May 2002, carotid angioplasty and stenting was performed in 100 patients (84 men; mean age, 69.2 years) with symptomatic (26%) or asymptomatic (74%) severe carotid artery stenosis. Wallstents were used in all cases with selective pre-dilatation. Cerebral protection devices (Parodi Anti-Emboli System [PAES], ArteriA, San Francisco, Calif) were used in all patients. All patients were evaluated by a neurologist, both before and after the procedure. According to the criteria set forth by the large trials, the occurrence of minor, major or fatal stroke and myocardial infarction (end points) within 30 days and follow-up were determined as end points. Data were collected prospectively. RESULTS: The overall perioperative stroke and death rate was 3% (1 noncorresponding minor stroke, 1 hemorrhagic stroke, and 1 cardiac event). Four patients developed postoperative transient neurologic events (three related to hemodynamic instability and the fourth due to postoperative embolization). The overall technical success rate for carotid angioplasty (protection device placed in position percutaneously) was 99%. CONCLUSION: The efficacy and safety of carotid angioplasty and stenting with PAES are confirmed. This innovative protection device may prevent the debris released by angioplasty from entering the cerebral circulation. Further investigation is warranted.

Atherosclerotic plaque rupture and intraplaque hemorrhage do not correlate with symptoms in carotid artery stenosis.

OBJECTIVE: Previously we failed to demonstrate a correlation between plaque type and symptoms in 165 carotid endarterectomy specimens. The purpose of this study was to analyze the relation between the anatomy of the carotid plaques and the presence of symptoms in 281 carotid endarterectomy specimens. METHODS: The patients were 213 men (mean age, 68 years) and 68 women (mean age, 68.7 years), with symptomatic disease (n = 133) or asymptomatic disease (n = 148). Specimens were processed for histologic analysis and immunohistochemistry. RESULTS: Plaques were categorized as complicated or noncomplicated, and ruptured or nonruptured. Risk factors could not be correlated with any pathologic or immunohistochemical findings or between plaque type and clinical symptoms. CONCLUSIONS: Almost 70% of plaque specimens demonstrated thrombus, intraplaque hemorrhage, or both. Thrombosis was observed in one fourth of specimens, and intraplaque hemorrhage in almost two thirds of specimens. Sixty four percent of plaques demonstrated neovascularization. It was not possible to demonstrate that complicated plaques (plaque rupture, thrombosis, intraplaque hemorrhage) are associated with symptoms, and it appears that such plaques may occur at any time, irrespective of symptoms.

Long-term outcome after aortic endovascular repair: the Buenos Aires experience.

Long-term (5 years) outcome of 30 patients whose aneurysm was excluded using the Parodi endograft (PE) was assessed. Thirty patients with a mean follow-up of 59 months were the basis of the analysis. Additionally, 100 consecutive patients treated with the Vanguard Endograft (VE) were followed up for 28 months (range, 7 to 56 months). Results were analyzed and both groups compared. There were no late failures related to the loss of the integrity of the device in the PE group. Aorto aortic systems showed distal neck dilatation in high proportion of patients (80%). Aorto-uni-iliac endograft was successful in 80% of the patients. Only one late type I endoleak developed in a patient in whom the proximal stent was placed far from the renal arteries and in contact with thrombus. Also, persistent type II endoleaks were the cause of failure. No neck dilatation was noted. In the VE group, most of the failures were device related.

"Seat belt and air bag" technique for cerebral protection during carotid stenting.

PURPOSE: To present a 2-device technique for cerebral protection during carotid stenting of the internal carotid artery (ICA) in patients with high-grade lesions, contralateral occlusion, and/or an aberrant or nonfunctioning circle of Willis. TECHNIQUE: A reverse flow system (Parodi Anti-Embolism System [PAES]) is first placed with a 260-cm exchange wire in the common carotid artery 3 cm below the carotid bifurcation. Flow reversal is obtained by inflating the balloons in the external and common carotid arteries. Via an external connector, a guidewire and E-Trap filter are delivered to the distal ICA with active suction from a syringe on the PAES catheter. Once the filter is above the stenosis, the reversed flow is discontinued, and the procedure proceeds under cerebral protection with the filter. CONCLUSIONS: The combination of 2 existing cerebral protection devices could, at least in theory, achieve what neither of them could independently. The "seat belt and air bag" approach may represent the ideal means of treating ICA stenoses in patients with a non-functioning circle of Willis.

Tratamiento endovascular de un aneurisma de aorta abdominal en un paciente trasplantado renal / Endovascular treatment of abdominal aortic aneurysm in a patient with a kidney implant

Se presenta el caso clínico de un paciente portador de un aneurisma de aorta abdominal infrarrenal a quien se le practicó hace 11 años un trasplante renal por insuficiencia renal crónica causada por enfermedad renal poliquística. Debido a los riesgos para el homoinjerto renal, de un clampeo aórtico o de la suspensión de la inmunosupresión para la cirugía convencional, es que se optó por la terapéutica endovascular de este aneurisma, implantándose un dispositivo modular aórtico Corvita tipo "B", con dos ramas ilíacas depositadas en las arterias ilíacas comunes derecha e izquierda. Se analizan las ventajas de este procedimiento para el caso en particular siendo, a nuestro entender, una indicación precisa de terapéutica endovascular asociada a aneurismas de aorta abdominal. No se ha logrado hallar en la literatura cita bibliográfica alguna referente a un caso clínico como el que aquí se presenta

Tratamiento endovascular de un aneurisma de aorta abdominal en un paciente trasplantado renal / Endovascular treatment of abdominal aortic aneurysm in a patient with a kidney implant

Se presenta el caso clínico de un paciente portador de un aneurisma de aorta abdominal infrarrenal a quien se le practicó hace 11 años un trasplante renal por insuficiencia renal crónica causada por enfermedad renal poliquística. Debido a los riesgos para el homoinjerto renal, de un clampeo aórtico o de la suspensión de la inmunosupresión para la cirugía convencional, es que se optó por la terapéutica endovascular de este aneurisma, implantándose un dispositivo modular aórtico Corvita tipo "B", con dos ramas ilíacas depositadas en las arterias ilíacas comunes derecha e izquierda. Se analizan las ventajas de este procedimiento para el caso en particular siendo, a nuestro entender, una indicación precisa de terapéutica endovascular asociada a aneurismas de aorta abdominal. No se ha logrado hallar en la literatura cita bibliográfica alguna referente a un caso clínico como el que aquí se presenta (AU)

Tratamiento endoluminal de los aneurismas de aorta / Intraluminal treatment in abdominal aortic aneurysms

Debido al aumento de la población añosa, los cirujanos vasculares se encuentran con mayor frecuencia con pacientes portadores de aneurismas de aorta abdominal que tienen múltiples y severas enfermedades asociadas. El presente estudio se refiere a la experiencia animal y a los primeros casos clínicos de un nuevo tratamiento de los aneurismas que es la inserción retrógrada de una prótesis vascular fijada a "stends" metálicos que se implantan a través de un balón que al inflarse expande al "stends" y lo fija a la pared aórtica. En el trabajo experimental se crearon aneurismas de aorta en perros reemplazando la aorta infrarrenal con una prótesis de dacron en forma de aneurisma; después de cuatro semanas se excluye el aneurisma desde la luz implantando desde la arteria femoral, en forma retrógrada la combinación de "stend" y prótesis. Desde setiembre de 1990 se implantaron 6 pacientes. Un paciente debió ser operado después de implantar la prótesis demasiado alejada de las arterias renales. Todos los pacientes evolucionaron favorablemente

Tratamiento endoluminal de los aneurismas de aorta / Intraluminal treatment in abdominal aortic aneurysms

Debido al aumento de la población añosa, los cirujanos vasculares se encuentran con mayor frecuencia con pacientes portadores de aneurismas de aorta abdominal que tienen múltiples y severas enfermedades asociadas. El presente estudio se refiere a la experiencia animal y a los primeros casos clínicos de un nuevo tratamiento de los aneurismas que es la inserción retrógrada de una prótesis vascular fijada a "stends" metálicos que se implantan a través de un balón que al inflarse expande al "stends" y lo fija a la pared aórtica. En el trabajo experimental se crearon aneurismas de aorta en perros reemplazando la aorta infrarrenal con una prótesis de dacron en forma de aneurisma; después de cuatro semanas se excluye el aneurisma desde la luz implantando desde la arteria femoral, en forma retrógrada la combinación de "stend" y prótesis. Desde setiembre de 1990 se implantaron 6 pacientes. Un paciente debió ser operado después de implantar la prótesis demasiado alejada de las arterias renales. Todos los pacientes evolucionaron favorablemente