Percutaneous PFO closure for cryptogenic stroke in the setting of a systematic cardiac and neurological screening and a standardised follow-up protocol.

BACKGROUND: There are no uniform workup and follow-up (FU) protocols for patients presenting with cryptogenic embolism (CE) who undergo percutaneous closure of a patent foramen ovale (PFO). METHODS: We prospectively performed a systematic cardiac and neurological FU protocol in all patients who underwent percutaneous PFO closure in order to assess the incidence of subsequent cardiac and neurological adverse events. All patients received dual antiplatelet therapy for 6 months and were systematically included in a 12-month standardised FU protocol including: clinical evaluation-transthoracic and transoesophageal echocardiography, 24-hour Holter monitoring and/or 1-week R-test, and transcranial Doppler. Late FU (>12 months) was performed by reviewing medical records. RESULTS: Over a 10-year period, 221 consecutive patients underwent PFO closure for CE and 217 of them (98%) completed the 12-month FU. Ischaemic event recurrence at 12-month and late FU (mean time 69±35 months, median time 65 months, Q1:38 months, Q3:98 months) was observed in 6 (2.8%) and 3 patients (1.4%), respectively. The initial diagnosis of CE was reconsidered in 17 cases (7.8%), as the clinical and paraclinical FU exams showed possible alternative aetiologies for the initial event: 13 patients (6.0%) presented at least 1 episode of atrial fibrillation, while in 4 cases (1.8%) a non-ischaemic origin of the initial symptoms was identified. CONCLUSIONS: Alternative diagnoses explaining the initial symptoms are rarely detected with an in-depth screening for alternative diagnoses before PFO closure. Despite extensive screening, atrial fibrillation is the most frequently observed alternative aetiology for cryptogenic stroke.

A Randomized Study of SheathLess vs Standard Guiding Catheters for Transradial Percutaneous Coronary Interventions.

BACKGROUND: The small diameter of radial arteries remains a major limitation of the transradial approach for percutaneous coronary intervention (PCI). Sheathless guiding catheters (GCs) might offer an advantage over standard GCs. METHODS: Between 2011 and 2013, we randomized 233 transradial PCIs performed in men with ostial or bifurcation lesions and in all women between standard GC (Medtronic Launcher; Minneapolis, MN) and the SheathLess Eaucath GC (Asahi Intecc, Aichi, Japan). RESULTS: Successful PCI using the transradial approach was not different between the groups (P = 0.74), however the rate of successful transradial PCI with the designated GC (ie, without crossover to the opposing GC) was superior in the SheathLess group compared with the standard GC group (96.5% vs 89.9%; P = 0.047). Safety end point (ie, absence of PCI complication, radial artery occlusion, perforation, pseudoaneurysm, and Early Discharge after Transradial Stenting of Coronary Arteries [EASY] hematoma grade ≥ 2) did not differ between the groups (60.5% in both groups). Mean PCI duration (45.1 minutes vs 45.9 minutes), fluoroscopy (20.1 minutes and 19.9 minutes), and cannulation times (3.6 minutes vs 3.7 minutes), contrast media volume (196 mL vs 187 mL) and conversion to transfemoral approach (1.8% vs 0.8%) were not different between the groups. Patients' subjective assessment revealed less arm pain during navigation of the SheathLess GC (1.9 ± 1.9 vs 4.8 ± 3.6; P < 0.001). Operators graded arm crossability as easier with the SheathLess GC (8.7 ± 1.5 vs 5.1 ± 3.5; P < 0.001). CONCLUSIONS: In selected coronary lesions requiring large-bore catheters in men and in all lesions in women, the SheathLess GC was superior to the standard GC for successful transradial PCI with the designated GC. The SheathLess GC was also associated with easier arm navigation and less patient discomfort.

Platypnea-orthodeoxia syndrome in the elderly treated by percutaneous patent foramen ovale closure: a case series and literature review.

BACKGROUND: Platypnea-orthodeoxia syndrome (POS) is a rare clinical phenomenon, associating normal oxygen saturation in a supine position and arterial hypoxemia in an upright position. This pathology can be secondary to an intracardiac shunt, a pulmonary vascular shunt or a ventilation-perfusion mismatch. Cardiac POS occurs in the presence of a right-to-left cardiac shunt, most commonly through a patent foramen ovale (PFO). METHODS AND RESULTS: From our single-center prospective database of percutaneous PFO closure we identified five patients (4 females, mean age: 77 ± 11 years) out of 224 (2.2%) patients with a PFO who presented with a POS of cardiac origin. Transthoracic and transoesophageal echocardiographic examinations revealed the underlying mechanisms of POS and the diagnosis was confirmed by right-and-left cardiac catheterization (RLC) and by measuring serial blood oxygen saturation in the pulmonary veins and left atrium in supine and upright positions. PFO was associated with atrial septal aneurysm and a persistent prominent Eustachian valve in 3 patients. All patients underwent a successful percutaneous PFO closure without any immediate or subsequent complications (mean follow-up of 24 ± 18 months). Immediately after the procedure, mean arterial oxygen saturation improved from 83% ± 3 to 93% ± 2 in an upright position and symptoms disappeared. CONCLUSION: POS is a rare and under-diagnosed pathology that must be actively investigated in the presence of position-dependent hypoxemia. The diagnostic work-up must exclude other causes of hypoxemia and confirm the intracardiac shunt using either contrast echocardiography or RLC. For cardiac POS, percutaneous PFO closure is a safe and effective technique that immediately relieves orthodeoxia and patient symptoms.

AngioJet rheolytic thrombectomy in patients presenting with high-risk pulmonary embolism and cardiogenic shock: a feasibility pilot study.

AIMS: Pulmonary embolism (PE) associated with haemodynamic instability has exceedingly high mortality. While intravenous thrombolysis is considered the therapy of choice, percutaneous mechanical thrombectomy may represent an alternative treatment. METHODS AND RESULTS: The impact of AngioJet® rheolytic thrombectomy (RT) in PE associated with cardiogenic shock was assessed in a single-centre prospective pilot study. Ten consecutive PE patients in cardiogenic shock were included in the study. Six patients had thrombolysis contraindications, eight were intubated before the RT procedure and six had experienced cardiac arrest prior to the RT procedure. The RT procedure was technically successful in all cases. The Miller index improved from 25 to 20 (p=0.002). The shock index decreased from 1.22 to 0.9 (p=0.129). Thrombolytic agents were administered during or after the procedure in four patients because of progressive clinical deterioration. Seven patients died in the first 24 hours: two from multi-organ failure, one from post-anoxic cerebral oedema, and four from progressive right heart failure. The three survivors had favourable outcomes at one year. CONCLUSIONS: This study suggests that the AngioJet® RT procedure may be safely performed in PE patients with cardiogenic shock. However, despite angiographic and haemodynamic improvements, the procedure does not appear to influence the dismal prognosis of these high-risk patients.

Angioplasty and provisional stent treatment of common femoral artery lesions.

PURPOSE: Isolated atherosclerotic common femoral artery (CFA) disease is a rare cause of symptomatic peripheral arterial disease. Although surgical endarterectomy is considered the therapy of choice, little is known about outcomes of percutaneous treatment. MATERIALS AND METHODS: A prospectively maintained single-center database was retrospectively analyzed for outcomes of consecutive patients undergoing isolated percutaneous revascularization of CFA disease between 1996 and 2007. In all cases, the intended strategy was balloon angioplasty with provisional stent placement in case of poor angioplasty results. Among 516 consecutive procedures involving the CFA, 419 were excluded because of nonatherosclerotic disease (n = 156) or treatment of additional vascular segments during the same procedure (n = 263). Procedural success (ie,<30% residual stenosis), in-hospital vascular complications (major [requiring surgical or percutaneous treatment] or minor [treated conservatively]), and 12-month restenosis and target lesion revascularization (TLR) rates were assessed for the remaining 97 interventions. RESULTS: CFA bifurcation lesions were present in 40 cases (41.2%) and required treatment of the deep femoral artery in 25 (25.8%). Chronic total CFA occlusions accounted for 11 cases (11.3%). Balloon angioplasty was performed in 96 cases (98.9%), and provisional stent placement was necessary in 37 (38.1%). The procedure was successful in 89 cases (91.8%). Minor and major vascular complications at 30 days occurred in three (3.1%) and four (4.1%) cases, respectively. At 12 months, restenosis greater than 50% and TLR were observed in 19.5% and 14.1% of procedures, respectively. CONCLUSIONS: This series shows that isolated CFA lesions may be safely and efficaciously treated with angioplasty and provisional stent placement.

[Role of endovascular therapy in the management of patients with lower extremity atherosclerotic disease according to new European guidelines]. / Rôle du traitement endovasculaire dans l'insuffisance artérielle des membres inférieurs selon les nouvelles directives européennes.

For the first time, the European Society of Cardiology has edited guidelines on the treatment of peripheral artery disease. With respect to the treatment of lower extremity disease, the endovascular approach is recommended in the majority of cases, independently of clinical presentation (claudication or critical limb ischemia) and of lesion complexity (TASC II A-B-C). For very complex lesions (TASC II D) surgery remains preferred. However, the guidelines state that in experienced centers even those lesions may be treated by endovascular means, especially in patients at high risk for surgery.

Guideliner microcatheter to improve back-up support during a complex coronary stenting procedure through a tortuous left internal mammary graft.

Back-up support during percutaneous coronary interventions (PCI) is one of the keys for successful intervention. Extra back-up support guiding catheters, deep intubation, buddy wires, and other more complex techniques are usually used to improve this support. Left anterior descending (LAD) artery PCI through the left internal mammary artery (LIMA) are rarely performed because many operators feel reluctant to instrument a disease-free LIMA graft risking iatrogenic complications by passing wire, balloons, and stents to the diseased distal LAD. Improving back-up support during LIMA-LAD PCIs is often challenging because in this particular setting the distance between the LAD lesion and the guiding catheter is exceedingly long. We report a case of a challenging PCI of the LAD through a patent and disease-free LIMA graft. After multiple failed attempts to cross the LAD lesion with conventional stent deployment techniques, we successfully finished the stenting procedure using the Guideliner microcatheter (Vascular Solutions) as a guiding extension through the LIMA graft. With this case, we illustrate that this microcatheter dramatically improves the back-up support, allowing stent deployment also in very difficult settings as in tortuous LIMA grafts.

Poor responsiveness to antiplatelet drugs in acute coronary syndromes: clinical relevance and management.

Cardiovascular diseases are the most common cause of mortality and morbidity in Western countries, accounting for more than 40% of total mortality. An optimal pharmacological management in these patients is of major importance and antiplatelet agents remain the cornerstone of acute coronary syndrome (ACS) therapy at hospital admission and during percutaneous coronary interventions (PCI). The recently described poor biological responses to aspirin and clopidogrel have been source of major concern, especially in era of drug eluting stent implantation. Indeed, insufficient platelet inhibition at the time of PCI has been consistently associated with an increased risk of complications and recurrence of ischemic events. Despite the lack of uniformly accepted definitions of aspirin and clopidogrel poor response, we sought to describe the current evidence and gaps in knowledge. While trials on the potential benefit of an increased antiplatelet maintenance dose after PCI have shown only marginal benefits, the strengthening of the initial antiplatelet regimens by additional loading doses of clopidogrel, by the administration of glycoprotein IIb/IIIa receptor inhibitors or phosphodiesterase inhibitors might further improve outcomes during ACS and PCI in patients with poor responsiveness to conventional dual antiplatelet therapy. Overall, tailoring the antiplatelet treatment on the basis of the individual biological response improves the short-term outcome after PCI. New and more potent antiplatelet drugs may overcome the clinical consequences of the poor response to antiplatelet agents.

Endovascular treatment of common femoral artery disease: medium-term outcomes of 360 consecutive procedures.

OBJECTIVES: The purpose of this study was to evaluate the technical feasability, safety, and 1-year efficacy of the endovascular treatment of atherosclerotic common femoral artery (CFA) obstructions. BACKGROUND: Atherosclerotic CFA obstruction is a known cause of symptomatic peripheral arterial disease. Although surgical endarterectomy is considered the therapy of choice for this condition, little is known about the percutaneous options. METHODS: Using a prospectively maintained single-center database, we retrospectively analyzed the outcomes of 360 consecutive percutaneous interventions of the CFA for atherosclerotic disease and assessed procedural success, in-hospital complications, and 1-year patency and target lesion revascularization rates. RESULTS: Ninety-seven procedures (26.9%) were isolated CFA interventions, whereas 157 (43.6%) and 152 (42.2%) also involved inflow and outflow vessels, respectively. Bifurcation lesions were present in 140 cases (38.9%), and concomitant treatment of the profunda femoral artery was performed on 93 occasions (25.8%). Chronic total CFA occlusions were recanalized in 60 cases (16.7%). Balloon angioplasty was performed as the primary intervention in virtually all cases (98.6%), whereas stenting was needed for suboptimal angioplasty results in 133 procedures (36.9%). Failures-defined as a final angiographic result with a >30% residual stenosis-were observed on 26 occasions (7.2%). In-hospital major (i.e., requiring surgery) and minor (i.e., treated percutaneously or conservatively) complications occurred in 5 (1.4%) and 18 (5.0%) procedures, respectively. One-year follow-up data were available for 281 patients (87.5%). Restenosis >50% by duplex scanning and target lesion revascularization were observed in 74 of 268 (27.6%) and 64 of 322 (19.9%) procedures, respectively. CONCLUSIONS: This large series suggests that the percutaneous approach may be a valid alternative to surgery for CFA atherosclerotic obstructions.

Late tamponade secondary to aortic root perforation by BioSTAR septal closure device.

We report a patient who presented with pericardial tamponade 9 months after percutaneous closure of a patent foramen ovale using a BioSTAR septal closure device (NMT Medical, Boston, MA). During the operation, bleeding was observed on the posterior aortic root caused by a nonendothelialized strut. The device was explanted, followed by pericardial patch aortoplasty and patch closure of the patent foramen ovale. This report presents a case of late tamponade related to the new-generation bioabsorbable BioSTAR device. Although late complications related with BioSTAR are rare, the presentation may be dramatic. A high index of suspicion and quick intervention is often lifesaving.

Erroneous placement of central venous catheter in the subclavian artery: retrieval and successful hemostasis with a femoral closure device.

Central venous catheter (CVC) placement, even if performed under duplex scan control, may be associated with incidental arterial injury leading to increased morbidity, mortality, and prolonged hospital stay. Erroneous CVC placement in the carotid or subclavian arteries has been usually treated surgically because those puncture sites may not be efficaciously compressed manually. However, surgery in this setting may be challenging because of difficulty of access for the catheters positioned in the subclavian artery and of the risk of cerebrovascular complications for carotid catheters. Recently, several cases have been published, describing the successful endovascular management of iatrogenic arterial injury using different types of vascular closure devices (VCD). However, in this setting, it remains difficult to be completely sure that the VCD has achieved complete hemostasis and that the patient does not subsequently incur in a clinically silent intrathoracic bleeding. We report the case of an erroneous CVC placement in the right subclavian artery successfully retrieved using an Angioseal VCD. The immediate and complete hemostasis at the puncture site was confirmed at angiography.

Retrieval of lost coronary guidewires during challenging percutaneous coronary interventions.

INTRODUCTION: The presence of symptomatic or asymptomatic intravascular/intracardiac foreign body (FB) is underreported in the literature, but it is more commonly encountered in clinical practice. Nowadays, losing a coronary stent or a guidewire has become a rare event. However, due to the constant increase in the total number of worldwide performed coronary interventions (PCI) and especially due to an increase also in the technical difficulties of these procedures (i.e., new devices+complex techniques), this kind of "lost FB complication" may again become clinically relevant. CASE REPORTS: We report two cases where, during challenging PCIs, 0.014-in. guidewires broke, remaining firmly anchored in the coronary tree floating with their proximal part in the aorta. These wires could have been successfully retrieved with a dedicated three-dimensional snare device, which is specifically manufactured for facilitating this kind of retrieval interventions. CONCLUSIONS: Intracoronary lost guidewires, if untreated, may lead to serious cardiovascular complications, suggesting that one should attempt every possible maneuver to retrieve them from the coronary circulation. By describing the peculiarity of the Entrio snare device, we finally suggest that this kind of dedicated three-dimensional snare device is an excellent tool at cardiologists' disposal for retrieving intracardiac and intravascular lost wires.

[Endovascular treatment of below the knee arteries in critical limb ischemia]. / Traitement endovascutaire des artères jambières dans l'ischémie critique des membres inférieurs.

Lower extremity peripheral arterial disease (PAD) may cause claudication or in the late phase critical limb ischemia (CLI). Due to the constant aging of the population and an increased prevalence of diabetes, CLI has become a major clinical concern for every vascular specialist. CLI is defined as the presence of ischemic rest pain or foot ulcers and a hypoperfusion of the foot. In case of CLI, rapid revascularisation is mandatory, and failure may imply lower limb amputation. Thanks to improvement in technique and equipment, endovascular revascularisation is associated with very promising limb salvage rate. In many centers, this minimally invasive approach has become the treatment of choice for the majority of patients with CLI. This review illustrates the different techniques and the data for infra-popliteal endovascular interventions.

[Evaluating the biological efficacy of clopidogrel: genotype or phenotype?]. / Evaluation de l'efficacité biologique du clopidogrel: génotype ou phénotype?

Clopidogrel has a known biological variability that has been consistently associated with recurrence of coronary ischemic events in clinical studies. Among the tests that are currently available, quantification of the phosphorylation status of the vasodilator phosphoprotein (VASP assay) is probably the most specific assay to evaluate the inhibition of the P2Y12 receptor by clopidogrel. A genetic polymorphism of the cytochrome 2C19 has been associated with the biological efficacy of clopidogrel and is also associated with recurrent ischemic events. The VASP assay and the 2C19 genotyping are candidates for the identification of patients at risk; this is the focus of the present review.