Transcoronary Gradients of Mechanosensitive MicroRNAs as Predictors of Collateral Development in Chronic Total Occlusion.

Background and Objectives: In this present study, we investigated the impact of mechanosensitive microRNAs (mechano-miRs) on the collateral development in 126 chronic total occlusion (CTO) patients, selected from 810 undergoing angiography. Materials and Methods: We quantified the collateral blood supply using the collateral flow index (CFI) and assessed the transcoronary mechano-miR gradients. Results: The patients with favorable collaterals had higher CFI values (0.45 ± 0.02) than those with poor collaterals (0.38 ± 0.03, p < 0.001). Significant differences in transcoronary gradients were found for miR-10a, miR-19a, miR-21, miR-23b, miR-26a, miR-92a, miR-126, miR-130a, miR-663, and let7d (p < 0.05). miR-26a and miR-21 showed strong positive correlations with the CFI (r = 0.715 and r = 0.663, respectively), while let7d and miR-663 were negatively correlated (r = -0.684 and r = -0.604, respectively). The correlations between cytokine gradients and mechano-miR gradients were also significant, including Transforming Growth Factor Beta with miR-126 (r = 0.673, p < 0.001) and Vascular Endothelial Growth Factor with miR-10a (r = 0.602, p = 0.002). A regression analysis highlighted the hemoglobin level, smoking, beta-blocker use, miR-26a, and miR-663 as significant CFI determinants, indicating their roles in modulating the collateral vessel development. Conclusions: These findings suggest mechanosensitive microRNAs as predictive biomarkers for collateral circulation, offering new therapeutic perspectives for CTO patients.

A novel troubleshooting technique for below-the-knee artery occlusions with proximal cap ambiguity: Transpedal Retrograde Wire Just Marker Technique.

BACKGROUND: Chronic total occlusions with ambiguous proximal caps pose a challenging problem in below-the-knee artery endovascular interventions. CASE REPORT: We defined a new technique for antegrade puncture and penetration of an ambiguous proximal cap in a 52-year old male patient with a non-healing wound on his right forefoot. Anterior tibial artery (ATA) was determined as the target vessel; however, its origin and course could not be determined. A retrograde guidewire (Asahi Gladius 0.018 inch, Asahi Intecc) was advanced into the distal ATA via transpedal loop following pedal loop angioplasty. This guidewire was advanced through and parked to the tibioperoneal trunk with a small distal loop at the tip. While the looped wire was held in its position as a marker for ATA ostium, a second guidewire (Asahi Gladius 0.018 inch, Asahi Intecc) with the guidance of 4F vertebral catheter (Vert Catheter, Merit Medical) successfully penetrated the ambiguous cap and subsequent target vessel revascularization was achieved with 2.5/150 mm peripheral balloon angioplasty catheter (Minerva SC 0.018 inch, BrosMed Medical). CONCLUSION: Transpedal Retrograde Wire Just Marker Technique is a novel and practical technique which can be used in chronic total occlusions of below-the-knee arteries with ambiguous proximal caps.

Efficacy of Transpedal Retrograde Approach in Endovascular Treatment of Patients With Buerger's Disease.

BACKGROUND: Endovascular treatment of Buerger's disease is challenging, which usually impedes antegrade revascularization options. We aimed to evaluate the effectiveness of transpedal retrograde approach in patients with Buerger's disease with ambiguous proximal caps and/or previously failed endovascular intervention via antegrade approach. METHODS: Eighteen patients with the diagnosis of Buerger's disease who had previously failed antegrade endovascular interventions and/or ambiguous proximal caps were enrolled. Baseline demographic characteristics, severity of critical limb-threatening ischemia, wound scores, postprocedural pedal loop scores, and recovery or amputation rates were recorded. RESULTS: The patients presented with ischemic rest pain (n = 5, Rutherford stage 4), ischemic ulcers with minor tissue loss (n = 8, Rutherford stage 5), and severe ischemic ulcers or gangrene with major tissue loss (n = 5, Rutherford stage 6). Preprocedural wound score according to Saint Elian Wound Score System (SEWSS) was 15.72 ± 5.05. Retrograde transpedal puncture was achieved with an 89% success rate. Postintervention angiographic success rate was 100%. Postintervention Rutherford stage improved compared with preprocedural Rutherford stages (P<.01). In addition, the average SEWSS score decreased significantly after the interventions (P<.001). Postprocedural pedal loop score was found to be associated with SEWSS scores and amputation rates. CONCLUSIONS: Transpedal retrograde approach is a technically feasible and potentially effective treatment modality for Buerger's disease and may be considered as a first-line treatment option in the treatment of limb salvage, especially when proximal caps of target vessels are ambiguous or antegrade approach is unsuccessful.

A randomized trial comparing left distal radial versus femoral approach for coronary artery bypass graft angiography: a pilot study.

BACKGROUND: Left distal transradial angiography (ldTRA) is a new technique for radial coronary angiography and may be an alternative to conventional transfemoral angiography (TFA) in patients who had previously undergone coronary artery bypass graft (CABG) surgery. In this study we compared ldTRA with TFA in patients who had undergone CABG surgery in terms of procedural details. METHODS: Fifty-seven consecutive patients with history of previous CABG among 459 patients who were admitted to coronary angiography unit (elective and acute coronary syndromes) in our center between October 2019 and February 2020 were included in the study. Consecutive patients were randomized to ldTRA (34 patients) and TFA (23 patients) group. The difference in total procedure times was defined as primary endpoint. The difference in sheat times, fluoroscopy times, contrast volume used and radiation exposure were designated as secondary endpoints. Post angiographic complications were compared between two groups. RESULTS: Out of 34 patients, successful distal radial access was obtained in 25 patients (74%). Baseline demographics, contrast use and radiation exposure were similar between groups. Sheath times in ldTRA was significantly longer (P<0.001), but total procedure times were not different (18.4±7.8 vs. 14.6±6.1, P=0.07). Non-standard angiographic equipment usage was significantly higher in ldTRA procedures (80% vs. 13%, P<0.001). There was no major bleeding in neither of groups, and three minor bleedings in FA group (0% vs.13%, P=0.10). CONCLUSIONS: ldTRA in patients with a palpable pulse and successful access might be used successfully for angiography in patient with previous CABG even early in an operator's experience.

Percutaneous angioplasty in the treatment of thrombosed hemodialysis fistulas: A single-center experience with 1 year of follow-up.

OBJECTIVE: Thrombosis of a hemodialysis arteriovenous fistula (AVF) is a serious complication that needs urgent treatment. Most cases are treated surgically, but recently, endovascular strategies have become a viable alternative. This study is an evaluation of the success and patency rate of percutaneous balloon angioplasty of thrombosed hemodialysis fistulas using a drug-coated balloon (DCB) contrasted with a standard balloon (SB). METHODS: The data of 33 patients with a thrombosed native hemodialysis AVF treated percutaneously in a tertiary care center were analyzed retrospectively. Success of the procedure was defined as restoration of flow with less than 30% residual stenosis and resumption of dialysis through the hemodialysis AVF. The success rate of the procedure and the patency rate at 1, 6, and 12 months were evaluated. The effect on patency of a DCB was compared to that of a SB. RESULTS: Twenty-five radiocephalic and 8 brachiocephalic thrombosed hemodialysis AVFs were treated during the study period. Flow was restored in 23 thrombosed fistulas, a success rate of 69.7%. The patency rate of successfully treated fistulas was 95.6% at 1 month, 76.1% at 6 months, and 57.9% at 12 months. Ten of the 23 re-established AVFs were treated with a DCB and the remainder were treated with a SB. The patency of the fistulas treated with a DCB was similar to that of a SB at 1 month (100% vs 92.3%, respectively; p=0.393). The patency rate of a DCB was greater than that of a SB at 6 months (88.9% vs 66.7%, respectively; p=0.258) and 12 months (75% vs 45.4%, respectively; p=0.219). CONCLUSION: Percutaneous intervention for thrombosed hemodialysis AVFs is a safe, minimally invasive, and effective procedure. There was a positive trend in the patency rate of patients treated with a DCB at 6 and 12 months compared with a SB.

[Turkish Cardiology Association Consensus Report: COVID-19 Pandemic and Cardiovascular Diseases (May 13, 2020)]. / Türk Kardiyoloji Dernegi Uzlasi Raporu: COVID-19 Pandemisi ve Kardiyovasküler Hastaliklar Konusunda Bilinmesi Gerekenler (13 Mayis 2020).

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

The relationship between serum asymmetric dimethylarginine levels and radial artery spasm.

OBJECTIVE: The use of the radial approach in coronary angiography or percutaneous coronary intervention has increased owing to its advantages over the femoral approach such as rapid patient mobilization and improved patient comfort. However, radial artery spasm (RAS) that occurs during the procedure is a crucial factor in transradial approach failure and access site switch. Asymmetric dimethylarginine (ADMA) is a naturally occurring, modified amino acid that inhibits nitric oxide (NO) production. High ADMA levels may reduce arterial elasticity especially in small arteries like the radial artery. This study aimed to evaluate the relationship between ADMA levels and RAS in radial artery access. METHODS: This study included 155 patients (89 males and 66 females) who underwent transradial coronary angiography between January 2016 and June 2016. The ADMA level in the plasma was determined using a quantitative sandwich enzyme immunoassay technique. RESULTS: RAS was observed in 16 of the 155 patients (10.1%). The RAS was found to be more frequent in female patients (17.9% for women vs. 4.4% for men, p=0.019). The plasma concentration of ADMA in the RAS group was significantly higher than that in the control group [22.1 ng/mL (12.1-37.8) vs. 9.2 ng/mL (5.9-14.8), p<0.001]. Moreover, the plasma concentration of ADMA was significantly higher in patients with RAS among female patients [20.4 ng/mL (12.1-44.9) vs. 9.9 ng/mL (6.2-16.6); p=0.002] and among male patients [25.2 ng/mL (13.7-35.4) vs. 8.2 ng/mL (5.9-12.8); p=0.007]. Binary logistic regression analysis of all patients showed that ADMA concentration was the only predictor for RAS (odds ratio=1.142; 95% confidence interval=1.061-1.228; p<0.001). CONCLUSION: It was found that the ADMA concentration of the patients in the RAS group was elevated compared to that of controls. The findings indicated that elevated ADMA concentrations could predict RAS that may occur.

[Consensus Report from Turkish Society of Cardiology: COVID-19 and Cardiovascular Diseases. What cardiologists should know. (25th March 2020)]. / Türk Kardiyoloji Dernegi Uzlasi Raporu: COVID-19 Pandemisi ve Kardiyovasküler Hastaliklar Konusunda Bilinmesi Gerekenler (25 Mart 2020).

In December 2019, in the city of Wuhan, in the Hubei province of China, treatment-resistant cases of pneumonia emerged and spread rapidly for reasons unknown. A new strain of coronavirus (severe acute respiratory syndrome coronavirus-2 [SARS-CoV-2]) was identified and caused the first pandemic of the 21st century. The virus was officially detected in our country on March 11, 2020, and the number of cases increased rapidly; the virus was isolated in 670 patients within 10 days. The rapid increase in the number of patients has required our physicians to learn to protect both the public and themselves when treating patients with this highly infectious disease. The group most affected by the outbreak and with the highest mortality rate is elderly patients with known cardiovascular disease. Therefore, it is necessary for cardiology specialists to take an active role in combating the epidemic. The aim of this article is to make a brief assessment of current information regarding the management of cardiovascular patients affected by COVID-19 and to provide practical suggestions to cardiology specialists about problems and questions they have frequently encountered.

Percutaneous Coronary Intervention for Chronic Total Occlusion versus Percutaneous Coronary Intervention for Non-Complex Coronary Lesions: Is There a Different Impact on Thyroid Function?

OBJECTIVE: This study assessed whether high levels of iodide administered during percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) differentially influenced thyroid function compared to PCI for non-complex coronary lesions. SUBJECTS AND METHODS: A total of 615 patients were enrolled in the study; 205 underwent elective PCI for CTO lesions (Group I) and 410 underwent elective PCI for non-complex lesions including non-CTO, non-bifurcation, non-calcified, and non-tortuous lesions (Group II). Patients were monitored for development of incidental thyroid dysfunction between 1 and 6 months after PCI. RESULTS: The patients in Group I were administered a median of 255 mL of contrast medium during PCI for CTO; a median of 80 mL was administered to the patients in Group II during non-complex PCI (p =0.001). Ten (5.4%) of the 186 euthyroid patients in Group I and 19 (5%) of the 379 eu-thyroid patients in Group II developed subclinical hyper-thyroidism (p = 0.854). However, 7 (50%) of the 14 subclinical hyperthyroid patients in Group I and only 3 (12%) of the 25 subclinical hyperthyroid patients in Group II developed overt hyperthyroidism (p = 0.019). CONCLUSION: In euthyroid patients, PCI for coronary CTO lesions did not increase the risk for subclinical hyperthyroidism when compared to PCI for non-complex coronary lesions. However, in patients with subclinical hyperthyroidism at baseline, PCI for coronary CTO lesions significantly increased the development of overt hyperthyroidism when compared to PCI for non-complex coronary lesions.

Is trans-radial approach related to an increased risk of radiation exposure in patients who underwent diagnostic coronary angiography or percutaneous coronary intervention? (The SAKARYA study).

OBJECTIVE: It is still debatable whether diagnostic coronary angiography (CA) or percutaneous coronary interventions (PCIs) increase radiation exposure when performed via radial approach as compared to femoral approach. This question was investigated in this study by comparison of dose-area product (DAP), reference air kerma (RAK), and fluoroscopy time (FT) among radial and femoral approaches. METHODS: All coronary procedures between November 2015 and November 2017 were assessed; and 4215 coronary procedures were enrolled in the study. Patients with bifurcation, chronic total occlusion, cardiogenic shock, or prior coronary artery bypass surgery were excluded. These 4215 procedures were evaluated for three different categories: diagnostic CA (Group I), PCI in patients with stable angina (Group II), and PCI in patients with ACS (Group III). RESULTS: Age was significantly higher in the femoral arm of all groups. Among patients in the radial arm of Groups I and II, males were over-represented. Therefore, a multiple linear regression analysis with stepwise method was performed. After adjusting these clinical confounders, there was no significant difference with regard to DAP, RAK, and FT between femoral and radial access in Group I. In contrast, PCI via radial access was significantly associated with increased DAP, RAK, and FT in Groups II and III. CONCLUSION: In spite of an increased experience with trans-radial approach, PCI of coronary lesions via radial route was associated with a relatively small but significant radiation exposure in our study. Compared to femoral access, diagnostic CA via radial access was not related to an increased radiation exposure.

Percutaneous endovascular therapy for symptomatic chronic total occlusion of the left subclavian artery.

INTRODUCTION: Percutaneous endovascular therapy is an accepted and preferred procedure for symptomatic subclavian artery disease. However, the technical feasibility and effectiveness of treating chronic total occlusion of the subclavian artery with this approach is uncertain. We aimed to evaluate the initial and mid-term results of endovascular therapy for patients with symptomatic chronic total occlusion of the left subclavian artery. METHODS: Consecutive patients who underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery between January 2010 and February 2014 were included. RESULTS: Overall, 16 patients (10 male, 6 female; mean age 56 ± 13 years) underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery. 6 (37.5%) had arm claudication, 8 (50.0%) had vertebrobasilar insufficiency and 2 (12.5%) had coronary steal. 18 balloon-expandable stents were implanted in 15 patients. Central luminal passage was not achieved in one patient because of the subintimal position of the guidewire (procedural success rate 93.8%). There were no procedure-related complications. Mean preprocedural and postprocedural systolic blood pressure differences between the upper extremities were 37 ± 13 (range 25-60) mmHg and 11 ± 9 (range 5-38) mmHg, respectively; the improvement was statistically significant. Outpatient follow-up revealed one asymptomatic restenosis at two years. The patency rate at two years was 93.3%. CONCLUSION: Balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery is safe and effective, with good acute success rate and mid-term patency. Prospective randomised studies on larger patient populations would provide more precise results.

Cutaneous analgesia before transradial access for coronary intervention to prevent radial artery spasm.

AIM: Transradial access (TRA) for coronary intervention is increasingly used in current clinical practice. The aim of the present study was to evaluate the hypothesis that cutaneous analgesia before TRA for coronary intervention at a puncture site 30 minutes before puncture can reduce patient discomfort and the incidence of radial artery spasm (RAS). METHODS: Patients (n=104) undergoing planned coronary interventions using TRA were prospectively randomized to receive either 1 mL of 1% lidocaine subcutaneously (n=52) (control group) or subcutaneous lidocaine plus 5% lidocaine cream (n=52) cutaneously 30 minutes before puncture (treatment group). The primary endpoint was angiographically or clinically confirmed RAS. Secondary endpoints were the occurrence of patient discomfort in the forearm during the procedure and access-site crossover to the femoral artery. Patient discomfort was quantified with a visual analogue scale (VAS) score. RESULTS: Fifty-two patients in the treatment group (60.5±9.4 years of age and 16 female) and 52 patients in the control group (60.4±9.7 years of age and 16 female) were included in the final analysis. Radial artery spasm occurrence decreased in the treatment group compared to the control group (26.9% vs 9.6%; p=0.04) accompanied by a VAS score of 3.7±1.8 in the treatment group and 4.9±2.0 in the control group; p=0.02. The access site crossover rate did not differ between the groups (7.6% vs 21.1%; p=0.09). CONCLUSION: Cutaneous analgesia before TRA for coronary interventions is associated with a substantial reduction in the RAS and the procedure-related level of patient discomfort.

Comparison of closed-cell and hybrid-cell stent designs in carotid artery stenting: clinical and procedural outcomes.

INTRODUCTION: Carotid artery stenting (CAS) is a promising alternative to surgery in high-risk patients. However, the impact of stent cell design on outcomes in CAS is a matter of continued debate. AIM: To compare the periprocedural and clinical outcomes of different stent designs for CAS with distal protection devices. MATERIAL AND METHODS: All CAS procedures with both closed- and hybrid-cell stents performed at our institution between February 2010 and December 2015 were analyzed retrospectively. Adverse events were defined as death, major stroke, minor stroke, transient ischemic attack and myocardial infarction. Periprocedural and 30-day adverse events and internal carotid artery (ICA) vasospasm rates were compared between the closed-cell and hybrid-cell stent groups. RESULTS: The study included 234 patients comprising 146 patients with a closed-cell stent (Xact stent, Abbott Vascular) (mean age: 68.5 ±8.6; 67.1% male) and 88 patients with a hybrid-cell stent (Cristallo Ideale, Medtronic) (mean age: 67.2 ±12.8; 68.2% male). There was no significant difference between the groups with respect to periprocedural or 30-day adverse event rates. While there was no difference in terms of tortuosity index between the groups, there was a higher procedural ICA vasospasm rate in the closed-cell stent group (35 patients, 23%) compared with the hybrid-cell stent group (10 patients, 11%) (p = 0.017). CONCLUSIONS: The results of this study showed no significant difference in the clinical adverse event rates after CAS between the closed-cell stent group and the hybrid-cell stent group. However, procedural ICA vasospasm was more common in the closed-cell stent group.

Endovascular Treatment of Renal Artery Stenosis due to Fibromuscular Dysplasia - Is Stent Implantation Underused in this Circumstance?

Fibromuscular dysplasia (FMD) is a nonatherosclerotic and noninflammatory arterial disease that commonly affects the renal and carotid arteries. The primary target in treating patients with renal artery FMD is the control of blood pressure in order to prevent end-organ damage, which can be caused by poorly controlled hypertension. Invasive endovascular treatment should be taken into consideration both when hypertension cannot be controlled with medication. According to current opinion, hypertension attributed to renal artery FMD is often successfully treated solely with percutaneous renal balloon angioplasty (PRBA), with no requirement for stent implantation under most circumstances. However, an FMD recurrence after PRBA occurs frequently in these patients.