Clinical situations requiring radial or brachial access during carotid artery stenting.

INTRODUCTION: Radial or brachial access may be preferred in the case of severe peripheral artery disease (PAD) or difficult aortic arch anatomy during carotid artery stenting (CAS). AIM: To evaluate the clinical conditions indicating potential benefit from non-femoral access as well as feasibility and safety of transradial/transbrachial access (TRA/TBA) as an alternative approach for CAS. MATERIAL AND METHODS: Since 2013, 67 patients (mean age: 70 years old, 44 men, 42% symptomatic) were selected for CAS with the TRA/TBA approach. The composite endpoint was stroke/death/myocardial infarction within 30 days of the procedure and compared to the propensity score matched transfemoral approach (TFA) group. Clinical (including neurological) examination and Doppler ultrasonography were performed before the procedure, at discharge and at 30 days. RESULTS: CAS with TRA/TBA was successful in 63/67 patients. Transfemoral access was not feasible due to PAD in 35 (52.2%) patients, bovine arch in 10 (14.9%), obesity (BMI > 35 kg/m2) in 9 (13.4%), severe degenerative disease of the spine in 7 (10.5%), arch type III in 5 (7.5%) and excessive subclavian stent protrusion in 1 (1.5%) patient. Mean NASCET carotid artery stenosis was reduced from 81% to 9% (p < 0.001). The composite endpoint occurred in 3 (4.8%) cases and it was not statistically significantly different from the matched TFA group (6.3%; p = 0.697). No access site complications requiring surgical intervention or blood transfusion developed. CONCLUSIONS: Transradial and transbrachial CAS may be an effective and safe procedure, and it may constitute a viable alternative to the femoral approach in patients with severe PAD, difficult aortic arch anatomy or obesity.

Carotid artery stenting with Roadsaver stent. Early and four-year results from a single-center registry.

INTRODUCTION: Prevention of peri- and postprocedural complications is still a challenge in carotid artery stenting (CAS). AIM: To assess immediate and long-term safety and effectiveness of CAS using the Roadsaver double-nitinol-layer-micromesh stent. MATERIAL AND METHODS: Since 2014, 298 CAS procedures in 287 non-consecutive patients (203 men, mean age 70.5 ±8.6 years, 100% symptomatic/high risk lesions) have been performed using the Roadsaver stent and proximal (40%) or distal (60%) neuroprotection system. Clinical and neurological examinations as well as duplex ultrasound were completed before CAS, before discharge, at 1, 6 and 12 months, then annually. RESULTS: All CAS procedures were successful. Carotid stenosis was reduced from 84.9 ±9.9% to 11.0 ±9.4% (p < 000.1). In hospital, 1 ipsilateral periprocedural major (0.3%) and 3 minor (1.34%) ischemic strokes occurred, 2 (0.7%) patients died due to a cerebral hemorrhage on day 9 and 21. Three (1.0%) additional ipsilateral minor strokes within 30 consecutive days occurred. Thus, 30-day complications were observed in 9 (3.0%) patients. Two minor strokes were associated with in-stent thrombosis (0.7%). The 4-year follow-up showed 82% overall survival (95% CI: 69-91%) with no significant difference between asymptomatic (77%) and symptomatic patients (97%; p = 0.076). The stroke-free survival was 89% (95% CI: 77-95%), 84% asymptomatic vs. 98% symptomatic (p = 0.187). Seven (2.3%) patients developed > 50% in-stent restenosis. CONCLUSIONS: Carotid artery stenting using the Roadsaver stent for symptomatic patients and high risk lesions showed to be safe and effective, with a low complication rate and acceptable in-stent restenosis risk in 4-year follow-up.

Coexistence and management of abdominal aortic aneurysm and coronary artery disease.

BACKGROUND: Abdominal aortic aneurysm (AAA) and coronary atherosclerosis share common risk factors. In this study, a single-center management experience of patients with a coexistence of AAA and coronary artery disease (CAD) is presented. METHODS: 271 consecutive patients who underwent elective AAA repair were reviewed. Coronary imaging in 118 patients was considered suitable for exploration of AAA coexistence with CAD. RESULTS: Significant coronary stenosis (> 70%) were found in 65.3% of patients. History of cardiac revascularization was present in 26.3% of patients, myocardial infarction (MI) in 31.4%, and 39.8% had both. In a subgroup analysis, prior history of percutaneous coronary intervention (PCI) (OR = 6.9, 95% CI 2.6-18.2, p < 0.001) and patients' age (OR = 1.1, 95% CI 1.0-1.2, p = 0.007) were independent predictors of significant coronary stenosis. Only 52.0% (40/77) of patients with significant coronary stenosis underwent immediate coronary revascularization prior to aneurysm repair: PCI in 32 cases (4 drug-eluting stents and 27 bare metal stents), coronary artery bypass graft in 8 cases. Patients undergoing revascularization prior to surgery had longer mean time from coronary imaging to AAA repair (123.6 vs. 58.1 days, p < 0.001). Patients undergoing coronary artery evaluation prior to AAA repair had shorter median hospitalization (7 [2-70] vs. 7 [3-181] days, p = 0.007) and intensive care unit stay (1 [0-9] vs. 1 [0-70] days, p = 0.014) and also had a lower rate of major adverse cardiovascular events or multiple organ failure (0% vs. 3.9%, p = 0.035). A total of 11.0% of patients had coronary artery aneurysms. CONCLUSIONS: Patients with AAA might benefit from an early coronary artery evaluation strategy.

Determinants of long-term outcome in patients after percutaneous stent-assisted management of symptomatic subclavian or innominate artery stenosis or occlusion.

AIMS: Incidence and determinants of restenosis and adverse events after endovascular management (PTA±stent) of the subclavian/innominate artery (SA/IA) stenosis/occlusion remain unclear due to the relatively short-term follow-up or limited size of prior studies. This large-scale, long-term prospective study investigated safety, efficacy, and prognosis after SA/IA PTA±stent. METHODS AND RESULTS: The study involved 411 consecutive patients with symptomatic SA/IA stenosis/ occlusion; 393 were followed annually after successful PTA±stent for up to 16 (minimum one) years. Primary outcomes were freedom from restenosis and MACCE (cardiovascular death, myocardial infarction, stroke). Angiographic success rate was 99.7% in stenoses and 76.1% in occlusions. The incidence of any periprocedural complication was 4.4% (serious - 1.2%). Symptoms of limb ischaemia, vertebrobasilar insufficiency or angina resolved in 79.1%, decreased in 19.6%. Freedom from restenosis was 82.6% and 77.9% whereas freedom from MACCE was 86.6% and 78.3% at five and 10 years, respectively. MACCE determinants (HR; 95% CI) were previous myocardial infarction (5.36; 2.9-9.91), ischaemic stroke (2.03; 1.12-3.66), hs-CRP (1.04; 1.02-1.07), concurrent atherosclerosis (1.35; 1.00-1.82). Restenosis determinants were implantation of ≥2 stents (2.65; 1.23-5.72), stent diameter (0.45; 0.34-0.59), hs-CRP (1.06; 1.02-1.1), WBC (1.2; 1.07-1.35), age (0.97; 0.94-0.99), concurrent carotid or vertebral disease (1.85; 1.07-3.18), IA intervention (2.28; 1.08-4.84). CONCLUSIONS: This study established long-term durability of stent-assisted PTA of symptomatic SA/IA disease and identified risk factors for restenosis and long-term MACCE. Patients at increased risk might benefit from targeted, intensified prevention measures.

Distal neuroprotection system as option for right subclavian artery ostial recanalization.

We present the case of a 49-year-old woman with neurological symptoms and severe atherosclerosis of aortic arch branches affecting subclavian and carotid arteries. Our patient has a history of transient ischemic attack and recurrent paresthesias of her right arm. We present a double access intervention using a distal embolic neuroprotection device during ostial right subclavian artery recanalization. We recommend that use of an embolic protection device in right subclavian artery ostial recanalization should be considered.

Clinical experience with the use of low molecular weight heparin in orthopaedic treatment of paediatric patients.

BACKGROUND: The objective of the paper is to describe our clinical experience with the use of low molecular weight heparin in children treated due to various orthopaedic conditions. MATERIAL AND METHODS: We have studied the treatment outcomes of 35 patients aged 11 to 18 years who were hospitalized in the Department of Paediatric Orthopaedics and Department of Traumatology and Emergency Medicine of the Medical University of Lublin and were treated with a low molecular weight heparin (LMWH). Short-term prophylaxis was applied in 33 patients during immobilization after such orthopaedic procedures as surgical correction of spine deformity and corrective osteotomy of the femoral and tibial bone. Two children received LMWH therapy after reduction and fixation of femoral bone fractures and long-term immobilization following ankle joint distortion with early-stage venous thromboembolism (VTE). RESULTS: None of the patients who received prophylactic treatment showed the clinical manifestations of thrombosis. The VTE symptoms subsided in children treated with the LMWH. Nadroparin was administered for both short-term prophylaxis and treatment, and was administered in doses proportionate to body weight and without prior determination of anti-factor Xa activity (anti-Xa assay). No side effects were observed. CONCLUSIONS: The use of the LMWH turned out to be effective and safe in thromboprophylaxis in paediatric patients.

Assessment of left ventricle diastolic function in myocardial infarction patients treated with primary angioplasty.

BACKGROUND: More than 5% of patients over the age of 65 have been found to develop heart failure, and over half of them preserve normal left ventricular systolic function. In the last few years, diastolic heart failure has become a serious clinical and epidemiological problem. METHODS: This prospective study was carried out on 99 patients. Patients were evaluated up to three months after primary percutaneous coronary intervention (PCI). Evaluation was performed three times: within the first 24 hours after primary PCI, on day seven after PCI and at three months after PCI. We analyzed the relationship between the severity of left ventricle diastolic dysfunction and atherosclerosis risk factors, infarction site, maximum levels of cardiac biomarkers such as troponin I, CPK and CK-MB, CRP protein levels, angioplasty effectiveness, reperfusion time, TIMI and TMPG grade. RESULTS: Most patients with ST elevation myocardial infarction (STEMI) treated with primary PCI demonstrated left ventricle diastolic dysfunction on the first day of myocardial infarction. Levels of cardiac biomarkers were significantly higher in patients with restrictive filling pattern. The inflammatory response (CRP levels) was found to have an important role in the development of diastolic abnormalities. There was a close relationship between diastolic and systolic function. Average values of left ventricular ejection fraction in patients with restrictive filling pattern were significantly lower than in those with impaired relaxation (44.7 vs. 52.7%; p < 0.001) and normal filling (54.2%; p = 0.002). CONCLUSIONS: More than half of patients with a first STEMI have left ventricle diastolic dysfunction within the first day after PCI, and these abnormalities are still present three months after PCI. Time and effectiveness of reperfusion, CRP level, troponin I, max, CPK max and CK-MB max levels as well as left ventricular ejection fraction have an important influence on the development of diastolic dysfunction. Infarct extension contributes significantly to the process.

[Spontaneous recanalisation of the superficial femoral artery following angioplasty of the femoral artery in a patient with disseminated atherosclerosis--a case report]. / Samoistne udroznienie zamknietej tetnicy udowej powierzchownej u pacjenta z wielonaczyniowa choroba wiencowa i wielopoziomowa miazdzyca tetnic konczyn dolnych po angioplastyce tetnicy udowej z wszczepieniem stentu IntraCoil.

We present a case of a 51-year-old male with multivessel coronary artery disease and disseminated peripheral arterial disease (PAD) who underwent coronary angioplasty, followed by angioplasty with stent implantation of the left superficial iliac artery and right femoral artery. Thirty days later the patient was admitted for elective angioplasty of the previously closed superficial right femoral artery; however, angiography showed that the artery was patent with a residual stenosis which narrowed the vessel lumen by 10%. We believe that spontaneous recanalisation of this artery was caused by multiple factors, including cessation of smoking, physical training, pharmacological therapy and previous angioplasty of the right femoral artery.

[Cardiac tamponade as the first symptom of oesophageal carcinoma -- a case report]. / Tamponada serca jako pierwszy objaw raka przelyku -- opis przypadku.

We present a case of a 56-year-old male who was admitted to our hospital due to cardiac tamponade. A 600 ml of purulent fluid was evacuated from the pericardium. The patient received antibiotics, however, due to recurrent pericardial effusion a pericardial drainage was required. Esophagoscopy and computerised tomography revealed oesophageal carcinoma with oesophago-pericardial fistula.

[Current knowledge on diastolic heart failure]. / Wspólczesne poglady na temat niewydolnosci rozkurczowej lewej komory serca.

Heart failure (HF) is still one of the most common causes of hospitalisation. Originally it was understood as systolic function impairment, but it is prooved that 40 to 50 percent of patients with clinical symptoms of HF have normal systolic function. These data lead to diagnosis of diastolic heart failure (DHF). The diastoly of the left ventricle consists of four stages: isovolumetric relaxation, early mitral inflow, slow mitral inflow and left atrium contraction. Authors have presented definition, epidemiology and basic pathophysiology of DHF. The categories of myocardial and non-myocardial pathogenic mechanisms have also been described. The clinical symptoms that allow to distinguish diastolic from systolic heart failure (SHF) have been pointed. The most common disorders that affect diastolic function like hypertension, coronary artery disease and diabetes have been described. Recent guidelines on therapy in diastolic heart failure have been also presented.

[Difficulties in the differential diagnosis of left ventricular aneurysm -- a case report]. / Trudnosci w róznicowaniu tetniaków lewej komory. Opis przypadku.

Difficulties in the differential diagnosis of left ventricular aneurysm - a case report. A case of a 55-year-old male with a post- infarction left ventricular aneurysm is described. The results of such non-invasive tests as echocardiography, angiography and magnetic resonance did not allow to differentiate between true and false aneurysm. The patient underwent successful surgery which revealed the presence of true left ventricular aneurysm. Difficulties in the differentiation between true aneurysm and pseudoaneurysm are discussed.

[Inhomogeneity of myocardial depolarization and repolarization in patients with chronic ischaemia undergoing coronary angioplasty]. / Zachowanie sie depolaryzacji i repolaryzacji miesnia sercowego w przewleklym niedokrwieniu serca u pacjentów leczonych koronaroplastyka.

AIM: The purpose of the study was to assess selected parameters of myocardial depolarization and repolarization, as well as other SCD risk factors before and after coronary angioplasty (PCI), especially in patients (pts) with increased risk of SCD. METHODS: 50 consecutive pts undergoing successful coronary angioplasty (39 men, 11 women, mean age 54 +/- 9.9 yrs) were included. Before PCI and 19.6 +/- 4.3 days after the procedure parameters of signal averaged ECG, QTd, heart rate variability--HRV, late potentials--LP and ejection fraction (LVEF) were assessed. Pts having at least one of the following: increased QTd (>80 ms), present LP, depressed HRV (SDNN <70 ms), significant ventricular arhythmia--VA (>10/h, >10 couplets/24h, VT), depressed LVEF (40%) were defined as having increased risk of SCD. RESULTS: 38 pts (76%) before PCI had increased risk of SCD. Increased QTd was observed in 46% pts, positive LP in 44% pts, depressed HRV in 20% pts, significant VA was present in 24% pts and depressed LVEF in 30% pts. After PCI there was a significant improvement in parameters of signal averaged ECG, especially in pts with LP present before PCI (QRS decreased from 120.8 +/- 25 to 100.4 +/- 19.4 ms, LAS from 57.3 +/- 23.8 to 37.7 +/- 15.3 ms, RMS40 increased from 9.3 +/- 5.8 to 26.8 +/- 22.1 ms; p < 0.005). In pts with increased risk similar improvement was seen in QT dispersion (decreased from 79.4 +/- 14.4 to 54.9 +/- 17.5 ms; p < 0.0005), in measures of autonomic tone (SDNN increased from 80.8 +/- 17.6 to 109.3 +/- 22.0 ms; p < 0.05) and in LVEF (increased from 45.7 +/- 10.3% to 50.6 +/- 10.9% p < 0.00005). In 15 (30%) patients with depressed LVEF there was no significant improvement in LP, QTd, HRV and VA. CONCLUSIONS: Delayed ventricular activation, inhomogeneous ventricular repolarization, abnormal autonomic control and significant ventricular arrhythmia are common in pts currently undergoing PCI. There is a significant improvement in arrhythmia triggering factors after successful coronary angioplasty, except in pts with depressed LVEF.