The feasibility of a novel method to remove circumferentially ruptured balloons during ultrasound-guided percutaneous transluminal angioplasty for arteriovenous dialysis access.

OBJECTIVE: Angioplasty balloon rupture is a rare complication during percutaneous transluminal angioplasty (PTA). Conventional approach to retrieve circumferentially ruptured balloons is open surgery. This study examined the feasibility of a novel approach which can remove ruptured balloon during PTA in vascular access. METHODS: This retrospective study analyzed 35 patients of a total 6465 patients that underwent ultrasound-guided PTA with a circumferential balloon rupture from February 2016 and August 2023. The patients underwent surgery (Group I, n = 13) or the novel method (Group II, n = 22) for balloon retrieval. Kaplan-Meier curve was used to assess the primary patency rates of the two groups. RESULT: The total incidence of circumferential balloon rupture was 0.5% in our center. Balloon retrieval was successful in both groups with no complications except one case had an infection in the surgical wound. Kaplan-Meier curve analysis showed that the post-intervention primary patency rates of the two methods were not significantly different (p > 0.05). There was a significant difference between pre-operation and post-operation brachial arterial flow (p < 0.001). CONCLUSION: The feasibility of the novel technique for retrieval of circumferential ruptured balloons during ultrasound-guided PTA is validated. The technique enables less invasive retrieval and continuation of PTA.

Patency and factors related to patency after percutaneous transluminal angioplasty for inflow arterial stenosis in native arteriovenous fistula dysfunction: a single-center retrospective study.

Controversy still exists regarding how much the inflow arterial percutaneous transluminal angioplasty (PTA) contributed to maintaining fistula function for hemodialysis. We aimed to analyze patency and risk factors after inflow arterial PTA. Hemodialysis patients with inflow arterial primary stenosis who were admitted to our institution from January 2017 to December 2022 were examined. One group had arterial-venous fistula with inflow artery stenosis alone (AVF + iAS) and another group had AVF with inflow artery stenosis and any vein stenosis (AVF + iAS + VS). The characteristics of patients, stenotic lesions, and PTA procedures were recorded. Kaplan-Meier analysis was used to compare primary patency, assisted primary patency, and secondary patency in the two groups. Cox proportional hazard analysis was used to identify risk factors associated with patency. We examined 213 patients, 53 in the AVF + iAS group (51 radial arterial stenosis and 2 ulnar arterial stenosis) and 160 in the AVF + iAS + VS group (159 radial arterial stenosis and 1 ulnar arterial stenosis). Kaplan-Meier analysis indicated the AVF + iAS group had better primary patency and assisted primary patency (both P < 0.05), but the groups had similar secondary patency. Cox proportional hazard analysis indicated that none of the analyzed clinical and biochemical indexes had clinically meaningful effects on primary patency, assisted primary patency, or secondary patency in either group. The patency and safety after PTA for inflow arterial stenosis were satisfactory, and none of the examined risk factors had a major clinical impact on patency. We recommend PTA as treatment for inflow stenosis of an AVF.

Case Report: A case of rapamycin-eluting stent for the treatment of refractory stenosis of arteriovenous fistula stenosis.

For patients with repeated stenosis of autologous arteriovenous fistula, percutaneous transluminal angioplasty (PTA) or bare metal stent placement had limited efficacy. Rapamycin was reported to inhibit neointimal hyperplasia and keep blood vessels patent. In this study, we reported a case with refractory stenosis, i.e., a short duration of patency maintenance after each repeated PTA, which was treated with a rapamycin-eluting stent (RES). The RES extended the patency duration from 4 to 5 months on average to 14 months. The stent was used to maintain dialysis for over 30 months. RES may be an effective way to treat refractory stenosis and salvage limited vascular resources.

One Puncture, Two Solutions: Simultaneous Carotid and Iliac Artery Stenting.

An 81-year-old man with asymptomatic severe carotid artery stenosis and symptomatic iliac artery stenosis underwent simultaneous carotid artery stenting (CAS) and iliac artery percutaneous transluminal angioplasty and stenting. The procedure involved transfemoral access, balloon angioplasty, and stenting of the right iliac artery, followed by CAS of the right carotid artery. Similar procedures were performed later on the left iliac and carotid arteries. The patient was discharged with no neurological deficits and remained asymptomatic at a six-month follow-up. Simultaneous CAS and iliac artery stenting were feasible and effective in patients with concurrent severe carotid and iliac artery stenosis, providing a comprehensive revascularization strategy for patients with complex atherosclerotic disease.

Frequent use of percutaneous transluminal angioplasty is not associated with reduced vascular access recreation in a longitudinal ecology study.

The frequency of percutaneous transluminal angioplasty (PTA) procedures has substantially increased, but its effect on vascular access recreation (VAR) remains inconclusive. We conducted a population-based retrospective analysis of Taiwan hemodialysis (HD) centers from 2004 to 2012. Data was accumulated into center-level characteristics, including patients' demographics, baseline characteristics, PTA procedures, and VAR. Center-level characteristics were summarized annually using appropriate measures. A mixed model assessed the association between PTA frequency and VAR rates, considering within-center correlation and adjusting for potential confounders. A total of 82,005 patients (mean age 62.7 ± 13.9 years, 50.5% male, 48.5% with diabetes mellitus) from 820 HD centers were analyzed. From 2004 to 2012, PTA frequency significantly increased from 1.24 to 3.23 per 1000 HD sessions, while VAR rates did not decline as expected (0.5-0.8 per 1000 HD sessions). Compared with the HD centers of infrequent use of PTA (annual lowest quartile, range 0.39-1.20 per 1000 HD sessions), the ones of frequent use (annual highest quartile, range 2.52-5.10 per 1000 HD sessions) didn't have lower VAR (range 0.54-0.99 vs. 0.50-0.91 per 1000 HD sessions, respectively). After controlling the potential confounders, the HD centers' PTA rates were not significantly associated with lower VAR rates (- 2.6, 95% confidence interval: - 30.3; 25.0, p = 0.85). Frequent use of PTA does not seem to improve VA patency at the center level, with no significant association identified with lower VAR. The indication of PTA in daily practice should be re-evaluated in terms of its efficiency in lowering VAR.

Comparative evaluation of local and downstream responses in two commercially available paclitaxel-coated balloons in healthy peripheral arteries of a swine model.

OBJECTIVE: To investigate the local, downstream, and systemic effects of 2 different paclitaxel-coated balloons. DESIGN: Preclinical study in healthy peripheral arteries of a swine model, with randomized allocation of the distribution of the devices: the test paclitaxel-coated balloon (PCB) (LuminorⓇ), a control PCB (IN.PACTⓇ), and a plain angioplasty balloon (OceanusⓇ), considering single (1×) and overlapping (3×) doses with simple blind histologic analysis. METHODS: Twenty animals underwent balloon angioplasty at 1× or 3× doses in the external and internal branches of both femoral arteries and were followed-up for 28 days. Postprocedural and follow-up angiography were carried out. Comprehensive necropsy and histology were used to evaluate the local, downstream and systemic effects. RESULTS: Angioplasty was successfully carried out in all animals. Significant protocol deviations appeared in 3 arteries (treated with Oceanus®) without clinical relevance. Those samples were excluded from the analysis. All the animals survived the follow-up period without major clinical issues. Local signs of drug toxicity were less marked with Luminor® than IN.PACT® at 1× dose, including endothelial loss (P = .0828), intima/media inflammation (P = .0004), transmural medial smooth muscle cell (SMC) loss (P = .0016), wall thickness loss (P = .0141), presence of fibrin in the vascular wall (P = .0054), and adventitial inflammation (P = .0080). A similar pattern was observed at the 3× dose for endothelial loss (P = .0011), intima/media inflammation (P < .0001), circumferential SMC loss (P = .0004), medial SMC replacement with proteoglycans (P = .0014), fibrin (P = .0034), and collagen content (P = .0205). Downstream vascular histologic changes were mild although more prevalent in the IN.PACT® 3× group (P = .006). No systemic effects of toxicity were detected in any of the samples analyzed. CONCLUSION: Luminor® showed better healing pattern (lower inflammation, and endothelial and muscular loss) than IN.PACT® balloon. The effect was evident at single and triple doses. The prevalence of downstream lesions, albeit low, was higher with the triple dose of IN.PACT® compared with Luminor®.

Impact of Peripheral Angioplasty on Wound Oxygenation and Healing in Patients with Chronic Limb-Threatening Ischemia Measured by Near-Infrared Spectroscopy.

Managing chronic limb-threatening ischemia (CLTI) is challenging due to difficulties in assessing tissue oxygen saturation in ulcers. Near-infrared spectroscopy (NIRS) is a non-invasive method for measuring tissue oxygen saturation (StO2). This study evaluated the effects of endovascular treatment (EVT) on StO2 and wound healing in CLTI patients, comparing NIRS to standard ankle-brachial index (ABI) measurements. Using the Duesseldorf PTA Registry, 43 CLTI patients were analyzed: 27 underwent EVT, and 16 received conservative treatment. ABI assessed macrocirculation, while NIRS measured wound, wound area, and mean foot StO2 at baseline, post-EVT, and four-month follow-up. Wound severity was classified by wound area and wound, ischemia, and foot infection (WIfI) score. Wound StO2 increased significantly (median (interquartile range (IQR)), 38 (49.3) to 60 (34.5)%, p = 0.004), as did wound area StO2 (median (IQR), 70.9 (21.6) to 72.8 (18.3)%, p < 0.001), with no significant changes in the control group by four-month follow-up. Wound area decreased significantly after EVT (mean ± SD, 343.1 ± 267.8 to 178.1 ± 268.5 mm2, p = 0.01) but not in the control group. Changes in wound StO2, wound area StO2, and WIfI score correlated with wound area reduction, unlike ABI. This small exploratory study shows that NIRS-measured StO2 improvements after EVT correlate with reduced wound area and WIfI scores, highlighting NIRS as a potential enhancement for CLTI wound management in addition to ABI.

Assessment of Sonographic Parameters for Predicting Primary Patency Rate in Hemodialysis Patients With Venous Valve-Related Stenosis.

OBJECTIVES: Ultrasonography is more frequently used in patients with arteriovenous fistula (AVF) stenosis. The aim of this study is to use sonographic parameters for predicting primary patency in hemodialysis patients with venous valve-related stenosis (VVRS) who are treated by ultrasound-guided percutaneous transluminal angioplasty (PTA). METHODS: A total of 229 VVRS patients who underwent PTA between January 2017 and December 2021 were enrolled. Clinical characteristics were retrospectively collected. Sonographic parameters were measured both before and after PTA. Univariate and multivariate Cox analyses were performed to identify independent factors associated with primary patency rate. RESULTS: All measured sonographic parameters improved after PTA compared to before PTA. Before PTA, the diameter of VVRS > 1.0 mm, age ≤ 57 years, and body mass index (BMI) > 21.57 kg/m2 were associated with better outcomes. While the diameter of radial artery, proximal radial artery close to the anastomosis, brachial artery, the flow volume of brachial artery, the length and peak velocity (PV) of the VVRS, and the diameter and PV after the VVRS had no association with the primary patency rate. After PTA, only patients with a diameter of VVRS > 4.0 mm had favorable outcome. In addition, patients with a gain of diameter of VVRS > 2.4 mm after PTA had a trend of better outcomes. CONCLUSIONS: The diameter of VVRS before and after PTA could be served as markers to predict primary patency rate and second patency rate in AVF patients with VVRS. The gain of diameter of VVRS could also be a potential marker. CLINICAL IMPACT: Using simple markers of sonographic parameters, we could quickly identify patients with a higher risk of restenosis. These patients should be followed more closely in case of restenosis at early. It is also beneficial to the prevention of thrombosis. These measures help to preserve more valuable vascular for a long-term dialysis. Additionally, the physician should pay more attention on the dialysis-related complications in these risky patients, such as hemodialysis-related hypotension.

"Wire kissing technique" and "externalization and pull-through technique" for treating chronic total occlusion in hemodialysis vascular access: A case report.

The construction and utilization of dependable vascular access are essential for hemodialysis. Despite its importance, complications with vascular access are common, significantly impacting patient morbidity and mortality. This report presents a novel approach to treating chronic total occlusion (CTO) in hemodialysis vascular access using the "wire kissing technique" an "externalization and pull-through technique." An 82-year-old woman on hemodialysis had a thrombotic obstruction in her cephalic vein, which conventional methods failed to address. The wire kissing technique allowed the meeting of antegrade and retrograde wires within the CTO lesion, stabilizing the wire and facilitating balloon passage. The externalization and pull-through technique further enabled the balloon to cross the rigid CTO lesion, successfully completing percutaneous transluminal angioplasty (PTA). Post-procedure ultrasonography showed significant improvements in flow volume and resistance index. These techniques, commonly used in coronary and femoral arteries, have not been previously reported for dialysis vascular access. This case highlights a novel and effective solution for overcoming technical difficulties in crossing CTO lesions, potentially improving outcomes in vascular access for hemodialysis patients.

Prevalence and Management of Venous Rupture Following Percutaneous Transluminal Angioplasty in Dysfunctional Arteriovenous Access: A Comparative Study of Primary Patency Rates with Non-Ruptured Access Circuits.

Purpose: This study aims to evaluate the incidence and management of venous ruptures after percutaneous transluminal angioplasty (PTA) for dysfunctional arteriovenous (AV) access. Materials and Methods: From January 1998 to December 2015, 13506 PTA, mechanical thrombectomy, and thrombolysis procedures were performed in 6732 patients. The venous rupture rate following PTA was obtained, and access circuit primary patency (ACPP) was compared according to the etiology (PTA, thrombotic occlusion, and treatment type) of the venous rupture present. Results: Venous rupture developed in 604 of the 13506 procedures. Venous ruptures were more frequent in female, AV graft cases, and in cases accompanied by thrombosis. Balloon tamponade was performed in 604 rupture cases, and stents were deployed in 119 cases where contrast extravasation and flow stasis persisted. ACPP was significantly better in the non-ruptured AV access circuits than in the ruptured group. However, AV access type and thrombosis was not associated with primary patency. In ruptured cases, ACPP is 8.4 months for prolonged balloon tamponade and 11.2 months for bare-metal stent insertion, showing statistically significant difference. Conclusion: Balloon tamponade and bare-metal stent placement are effective treatment for PTA-induced venous ruptures. In particular, stent placement showed a similar ACPP to that of non-ruptured AV access circuits.

Percutaneous Transluminal Angioplasty Alleviate Pediatric Postthrombotic Syndrome: A Case Report and Literature Review.

PURPOSE: Postthrombotic syndrome (PTS) is one of the long-term sequelae of deep vein thrombosis (DVT), and effective symptom management in pediatric PTS remains a challenge, with interventional therapy rarely explored in this population. We present a successful case of interventional treatment pediatric PTS, resulting in a remarkable amelioration of her symptoms. CASE REPORT: This case features a 6-year-old girl diagnosed with hyperinsulinemia, leading to a hypoglycemic coma. Following a mini-pancreatic partial pancreatectomy, she required further intensive care in the pediatric intensive care unit. It was during this period that left lower extremity DVT was identified, prompting warfarin anticoagulation therapy. During the anticoagulation period, she had several bleeding events and was switched to anticoagulation with low molecular heparin. One month later, the left common iliac vein and external iliac vein was found to be completely occluded. Over time, she experienced a gradual onset of lower limb swelling and pain, which, after 6 months, was accompanied by perineal edema and venous claudication. As a result, she underwent successful percutaneous transluminal angioplasty. In addition, the anticoagulation regimen was adjusted to rivaroxaban. At the 8-month follow-up, we observed significantly improvement in her postoperative lower extremity swelling and symptoms related to venous occlusion had completely disappeared. Moreover, vascular imaging confirmed improvement in stenosis and uninterrupted blood flow. CONCLUSIONS: In our review of pediatric PTS studies, we observed limited options to alleviate symptoms, and interventional treatments have not been reported. Our case study, demonstrating the safe and effective use of percutaneous transluminal angioplasty, helps to illuminate this area and alleviate pediatric PTS symptoms. CLINICAL IMPACT: This case validates the efficacy and safety of using percutaneous transluminal angioplasty (PTA) for the treatment of postthrombotic syndrome (PTS) in pediatric patients. This interventional approach offers significant symptomatic relief and improves quality of life, especially in cases where traditional anticoagulation therapies fail or lead to complications. The successful case presented emphasizes the necessity of considering endovascular interventions for children with moderate to severe PTS, particularly when conservative management is ineffective. This research underscores the potential for PTA to be adopted in clinical practice, offering a promising new approach for managing pediatric PTS.

Novel use of a stent retriever as a distal filler protection device for prevention of secondary embolization.

Distal embolus due to mechanical thrombectomy is a frequent complication and directly results in a poor prognosis. Therefore, it is important to decrease distal embolus as much as possible in mechanical thrombectomy. EmboTrap III may be useful as a filter to prevent distal embolus in patients with a large volume of thrombus. Here, we report the results of one suggestive case and we also provide experimental data from a vessel model. The patient was a 78-year-old female who was admitted to hospital as an emergency case with chief complaints including dysarthria and left hemiplegia, including facial paralysis. She was diagnosed as large vessel occlusion-acute ischemic stroke with right tandem lesions by workup and underwent mechanical thrombectomy. A large volume of secondary thrombus due to flow stasis was assumed based around the occlusion site, and worsening of neurological symptoms was a concern due to distal embolus caused by recanalization of the cervical internal carotid artery. The SEIMLESS technique was performed under distal protection using EmboTrap III. There was no distal embolus or deterioration of neurological symptoms, and a good prognosis was achieved. This outcome suggests that PTA under distal protection using EmboTrap III may be useful for prevention of distal embolus.

Outcomes of Noncompliant Balloons in the Treatment of Lower Extremity Chronic Limb Threatening Ischemia: A Prospective Study.

PURPOSE: This is a prospective study to investigate the clinical outcomes of using noncompliant balloons in lower limb angioplasty for chronic limb threatening ischemia (CLTI). MATERIALS AND METHODS: This is a prospective single-center cohort study performed at a local tertiary hospital in Singapore. Consecutive patients who underwent lower limb angioplasty for CLTI using a noncompliant balloon catheter were enrolled if they were aged 40 years and above, presented with CLTI Rutherford grade 4 to 6, and had TASC C or D lesions in the lower limb vessels that were at least 100mm in length. Patient demographics, Rutherford grading, lesion characteristics, complications, and follow-up data were collected and analyzed. The primary outcomes were 30-day freedom from major adverse events, amputation-free survival (AFS) at 12 months, and freedom from clinically driven target lesion revascularization (cdTLR) at 12 months. Secondary outcomes included clinical success and target lesion primary patency (TLPP) at 12 months. Amputation-free survival, freedom from cdTLR, and TLPP were calculated by Kaplan-Meier analysis. RESULTS: From May 2020 to December 2021, 50 patients (50 limbs) were enrolled. 43 (86%) patients had diabetes mellitus, while 12 patients (24%) had end-stage renal failure. 85 lesions were treated, including 59 (69.4%) below-the-knee (BTK) lesions. All the lesions were TASC C (n=45, 52.9%) or TASC D (n=40, 47.1%) lesions. Mean lesion length was 231.4±116.2mm. Technical success rate was 96.5%. No patients were lost to follow-up. Median follow-up duration was 282 days (IQR: 31-390 days). One patient died on day 26 due to an acute myocardial infarction. Two patients had groin hematomas postprocedure, both of which were treated conservatively. AFS, freedom from cdTLR, and TLPP at 12 months postprocedure was 70.0% (95% confidence interval [CI]: 58.4%-83.9%), 90.1% (95% CI: 83.4%-97.4%), and 61.1% (95% CI: 50.7%-73.6%), respectively. CONCLUSION: Early results have shown that the use of a high-pressure, noncompliant balloon is effective in lower limb angioplasty for CLTI in a highly challenging group of patients with a high prevalence of long BTK disease. Good vessel patency and limb salvage rates can be achieved, with a low complication rate. We await more long-term outcomes on vessel patency. CLINICAL IMPACT: There are many devices in the market for use in lower limb angioplasty. However, many of them come with an increased financial cost, procedural time and procedural difficulty. We report our prospective results with the exclusive use of a high pressure, non-compliant balloon, in a challening group of patients with a high prevalence of diabetes and end stage renal failure, achieving amputation free surival at 6 and 12 months post-procedure of 84.0% and 70.0% respectively. The use of non-compliant balloon is technically easy and does not add additional steps compared to a standard POBA procedure, thus limiting costs. We believe this article can be a push factor for clinicians to consider the use of these high pressure, non-compliant balloons in their patient care.

Percutaneous transluminal angioplasty of femoropopliteal veins for treatment of post-thrombotic syndrome.

Background: Controversy persists concerning the endovascular treatment of the post-thrombotic syndrome (PTS), particularly if femoropopliteal veins are involved. Methods: We screened consecutive patients with PTS who underwent percutaneous transluminal angioplasty (PTA) of femoropopliteal veins using posterior tibial or popliteal vein access who had at least 3-month follow-up. Our assessment included the evaluation of primary and secondary patency of the treated segments by Doppler ultrasound (DUS) and clinical outcomes measured by the change in Villalta score as well as ulcer healing. Results: Among 29 patients, 8 (27.7%) were women and the mean (SD) age was 53.3 (13.6) years. Posterior tibial vein and popliteal access were used in 26 (89.7%) and 3 patients (10.3%), respectively. 13 (44.8%) patients had prior (n = 11, 37.9%) or concomitant (n = 9, 31.0%) endovascular treatment of the iliac or common femoral veins. At a median follow-up of 395 days (Q1: 205-Q3: 756 days), primary patency of femoropopliteal veins was 79.3% (95% CI 64.6-94.1%) and secondary patency was 82.8% (95% CI, 69.0-96.5%). The percentage of patients with moderate or severe PTS according to the Villalta score decreased from baseline to last follow-up from 34.5% to 18.5% and from 31% to 14.8%, respectively (p<0.003). Overall, the mean (SD) Villalta score decreased from 11.5 (1.7) to 8.0 (1.7) (p<0.0001). Postprocedural complete ulcer healing occurred in 4 out of 5 (80%) patients. Two (6.9%) patients developed new ulcers. No major bleeding, pulmonary embolism, stroke, or death occurred. Conclusion: PTA of femoropopliteal veins via posterior tibial or popliteal vein access appears to improve the severity of PTS with acceptable patency rates.

Percutaneous Transluminal Angioplasty for Atherosclerotic Stenosis of Vertebral Artery Origin.

Background: In patients with vertebral artery origin (VAO) stenosis and concomitant stenoses of other cerebral feeding arteries, data on the risk of percutaneous transluminal angioplasty (PTA) alone and with stent placement (PTAS) for VAO stenosis are limited. We aimed to determine how the presence of polystenotic lesions in other cerebral feeding arteries and concomitant carotid artery stenting (CAS) affect the periprocedural risk and long-term effect of PTA/S for atherosclerotic VAO stenosis. Methods: In a retrospective descriptive study, consecutive patients treated with PTA/S for ≥70% VAO stenosis were divided into groups with isolated VAO stenosis and multiple stenoses. We investigated the rate of periprocedural complications in the first 72 h and the risk of restenosis and ischemic stroke (IS)/transient ischemic attack (TIA) during the follow-up period. Results: In a set of 66 patients aged 66.1 ± 9.1 years, polystenotic lesions were present in 56 (84.8%) patients. 21 (31.8%) patients underwent endovascular treatment for stenosis of one or more other arteries in addition to VAO stenosis (15 underwent CAS). During the periprocedural period, no patient suffered from an IS or died, and, in the polystenotic group with concomitant CAS, there was one case of TIA (1.6%). During a mean follow-up period of 36 months, we identified 8 cases (16.3%) of ≥50% asymptomatic VA restenosis, and, in the polystenotic group, 4 (8.9%) cases of IS. Conclusion: The presence of severe polystenotic lesions or concomitant CAS had no adverse effect on the overall low periprocedural risk of PTA/S of VAO stenosis or the risk of restenosis during the follow-up period.

Delayed Displacement of Enterprise Stent in Treating Symptomatic Intracranial Atherosclerotic Stenosis: A Case Report.

A 53-year-old patient was admitted to the stroke unit with sudden onset of weakness on the left side and dysarthria. This patient had been diagnosed with symptomatic intracerebral artery stenosis two months previously and had been administered dual oral antiplatelet agents and an aggressive dose of atorvastatin. The patient underwent percutaneous transluminal angioplasty and stenting two weeks after admission. Interventional treatment was technically successful when a self-expandable Enterprise stent was used. She was followed up for 2 years after discharge, without any cerebrovascular incidents. Repeat CTA revealed delayed displacement of the Enterprise stent and a discussion was had.

Asymptomatic Complete Spiral Stent Fracture in Subclavian Artery with Progressive Restenosis in the Early Postoperative Period: A Case Report.

Objective: Stent fractures may be a risk factor for delayed restenosis, but it is difficult to diagnose asymptomatic stent fractures in the subclavian artery (SCA). We report a rare case of percutaneous transluminal angioplasty and stenting (PTAS) for SCA stenosis with asymptomatic severe stent fracture that showed progressive in-stent stenosis in the early postoperative period. Case Presentation: A 70-year-old woman presented with left arm claudication. Magnetic resonance imaging at the time of admission showed SCA stenosis with severe calcification. Because of the left subclavian steal phenomenon on ultrasonography of the left vertebral artery, she underwent PTAS using a balloon-expandable stainless stent. Ultrasonography the day after treatment showed appropriate stent placement. Computed tomography angiography (CTA) 30 days after PTAS showed an asymptomatic complete spiral stent fracture at the mid-portion of the stent. The in-stent stenosis then gradually progressed on follow-up ultrasonography at the site of the stent fracture. Nine months after the first PTAS, a second PTAS using a self-expandable nitinol stent was performed because the peak systolic velocity exceeded 300 cm/s on Doppler ultrasound. Two years after the second PTAS, no neurological symptoms and no stent deformation were observed. Conclusion: PTAS with a balloon-expandable stainless stent for SCA stenosis with severe calcification may lead to stent fracture. In the case of severe stent fracture, careful follow-up may be needed for the detection of asymptomatic in-stent stenosis in the early postoperative period.

Predicting postoperative delirium after percutaneous transluminal angioplasty and stenting in patients with intracranial atherosclerotic stenosis.

OBJECTIVE: Known as a major surgical complication, postoperative delirium (POD) has not been well studied in patients with intracranial atherosclerotic stenosis (ICAS). This study aimed to investigate the correlation between perioperative clinical characteristics and the occurrence of POD. METHODS: Patients' demographic characteristics and perioperative testing data were collected. Binary logistic regression was conducted for assessing related risk factors. A nomogram was developed to predict the occurrence of POD after percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAS. RESULTS: The occurrence of POD in this study was 30.67%. Among all the clinical and laboratory characteristics in patients, age (OR = 1.234, 95%CI = 1.004-1.517, p = 0.046), gender (OR = 5.676, 95%CI = 1.028-31.334, p = 0.046), preoperative MMSE scores (OR = 2.298, 95%CI = 1.005-5.259, p = 0.049), the degree of stenosis (OR = 6.294, 95%CI = 1.043-37.974, p = 0.045), operating time (OR = 1.088, 95%CI = 1.023-1.157, p = 0.006), and HbA1c levels (OR = 2.226, 95%CI = 1.199-4.130, p = 0.011) were the independent risk factors. CONCLUSION: Male patients with advanced-age, lower preoperative MMSE scores, severe stenosis, longer operating time, and higher HbA1c levels are closely related to POD after PTAS. Fully perioperative assessments may play an important role in predicting the occurrence of POD.

Assessing the Suitability of CHA2DS2-VASc for Predicting Adverse Limb Events and Cardiovascular Outcomes in Peripheral Artery Disease Patients with Percutaneous Transluminal Angioplasty: A Retrospective Cohort Study.

Patients with peripheral artery disease (PAD) are at high risk of major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs). CHA2DS2-VASc is a prognostic score for atrial fibrillation stroke risk; however, no study has evaluated its predictive ability for MALEs and MACEs in PAD patients who underwent percutaneous transluminal angioplasty. We conducted a retrospective cohort study on patients from Taiwan with PAD. The patients were stratified into four risk groups based on their modified CHA2DS2-VASc score. Cox proportional hazard models, 10-fold cross-validation, and receiver operating characteristic (ROC) analyses were utilized to evaluate the predictive ability of CHA2DS2-VASc for MALEs, MACEs, and MALEs + MACEs. Kaplan-Meier analysis estimated the survival probability of the risk groups. CHA2DS2-VASc was found to be a significant predictor of MACEs (hazard ratio (HR) 3.52 (95% confidence interval (95% CI) 1.00-12.12; p = 0.048), HR 4.18 (95% CI 1.19-14.36; p = 0.023), and HR 5.08 (95% CI 1.49-17.36; p = 0.009), for moderate-, high-, and very high-risk groups, respectively), while for MALEs and MALEs + MACEs, significance was achieved only for the high-risk group using a univariate model. For the multivariate adjusted model, the score was found to be a significant predictor of MACEs for only the very high-risk group, with an HR of 4.67 (95% CI 1.03-21.09; p = 0.045). The score demonstrated an AUC > 0.8, good discrimination (c-index > 0.8), and good calibration for predicting MACEs. However, it failed to achieve good performance for predicting MALEs and MALEs + MACEs. Based on all of the findings, CHA2DS2-VASc could potentially serve as a risk stratification score for predicting MACEs in patients with PAD, but it failed to qualify as a good predictor for MALEs.