Microsurgery versus embolization: different risk factors for short- and long- term outcomes of patients with ruptured aneurysms

Purpose: To evaluate the risk factors for poor outcomes after surgical and endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods: Patients with ≥ 18-years of age and aSAH were included, while patients who died within 12 h of admission or lost follow-up were excluded. All participants underwent standardized clinical and radiological assessment on admission and were reassessed at discharge and at 6-months follow-up using the Glasgow Outcome Scale (GOS). Results: Death at discharge was associated with female gender, anterior communication artery (ACoA) aneurysm location and presence of atherosclerotic plaque in the surgical group, and with age in the endovascular group. Both groups had clinical condition on follow-up associated with mFisher score on admission and hypertension. GOS on follow-up was also associated with presence of atherosclerotic plaque and multiple aneurysms in surgical group, and with age in endovascular group. Conclusions: Subjects treated surgically are prone to unfavorable outcomes if atherosclerotic plaques and multiple aneurysms are present. In patients with endovascular treatment, age was the main predictor of clinical outcome.

Eficacia y seguridad del Láser Coronario en el tratamiento percutáneo de lesiones coronarias complejas / Efficacy and safety of Coronary Laser in the percutaneous treatment of complex coronary lesions

INTRODUCCIÓN: La enfermedad cardiovascular es en Europa la causa de aproximadamente de un tercio de todas las muertes en personas mayores de 35 años. Una gran parte de esta carga de enfermedad es debida a la enfermedad coronaria. El incremento de la esperanza de vida y el envejecimiento poblacional, permite prever un aumento considerable de la incidencia del síndrome coronario agudo (SCA) durante las próximas tres o cuatro décadas. En el diagnóstico y tratamiento de la enfermedad coronaria, la coronario grafía con contraste (CGC) es una pieza central y la revascularización con técnicas percutáneas (ICP) es la forma de tratamiento más frecuente y ofre cemuy buenos resultados en la mayoría de las lesiónes coronarias. Los objetivos de la ICP son la dilatación de la estenosis y la colocación de un stent y requiere, la mayoría de las veces, una actuación previa sobre la placa de ateroma. Existen lesiones coronarias complejas que requieren intervenciones para modificar la placa de ateroma durante el ICP; para ello se emplean, entre otras la ater

Cardiovascular disease in Europe is the cause of approximately one third of all deaths in people over 35 years of age. A large part of this disease burden is due to coronary heart disease. The increase in life expectancy and popula tion aging make it possible to prevent a considerable increase in the inciden ce of acute coronary syndrome (ACS) during the next three or four decades. In the diagnosis and treatment of coronary disease, contrast-enhanced coronary angiography (CGC) is a central piece and revascularization with percutaneous techniques (PCI) is the most frequent form of treatment, offe ring very good results in most coronary lesions. The objectives of PCI are dilation of the stenosis and placement of a stent, and most of the time they require prior action on the atherosclerotic plaque. There are complex coronary lesions that require emergencies to mo dify the atherosclerotic plaque during PCI, for which láser atherectomy is used, among others. Whenever it was possible for the data to be synthesized in the form of a meta-analysis with the help of the Review Manager 5.3 tool, when a poo led analysis was not possible, the results of the different studies were shown individually. AIMS: The objective of this report is to analyze the effectiveness and safety of the use of the coronary láser in the modification of the atherosclerotic plaque within the PCI procedure in different complex scenarios. METHODS: After defining the research questions and assessing the importance of each of them, several bibliographic search strategies were defined for different databases. The searches were mainly aimed at knowing the effectiveness and safety, according to the questions asked. These searches were designed to maximize sensitivity in order to obtain the broadest spectrum of publica tions for each of the clinical situations. Evidence synthesis was performed using the GRADE methodology and the GRADE-Pro tool. Where possible, data from different papers were pooled in meta-analyses with the help of the Review manager v5.2 package, where data from individual papers were shown when not possible. The results and conclusions were agreed upon by all the authors. RESULTS: Given that coronary láser is a complementary technique used in various cli nical situations in the PCI procedure to favorably modify the plaque (or the thrombus in the case of ACS) and achieve revascularization through the subsequent implantation of a stent, the report on the use of láser in the di fferent clinical situations in which it can be useful. Question 1 (Insurmountable or indilatable lesions). An uncrossable lesion was defined as one in which it was impossible to advance through with a microcatheter or a low-profile balloon, even though it was possible to traver se with a guidewire. After the search, five publications were identified that communicated results of case series and that described, almost all, results of the acute period, none of them presented results of a control group. In the analyzed studies, favorable and consistent results have been found between the works, at the same time the adverse results are not very frequent; however, the studies were performed with small samples and neither angiographic nor evolution results were shown. Question 2 (Patients with an indication for PCI in acute coronary syndro me). To resolve this question, it was decided to use controlled studies whose objective was to determine the efficacy or effectiveness of the EXCIMER láser. After an exhaustive process, 3 studies were selected and included in a meta-analysis. All studies evaluate the success of the procedure, defined in a variable way, although a joint estimate of the effect of the EXCIMER láser can be made, showing that patients in the control group suffer a small increased risk of not achieving success RR=1.13 [CI95% 1.03 to 1.25]. Outco mes related to recovery of coronary flow were also evaluated. It seems that patients in the control group could have a higher risk of negative outcome, although it does not reach statistical significance. Regarding complications, their presentation is very similar between both treatment arms, so the risk estimate is practically null RR=0.98 [95% CI 0.52 to 1.84] Question 3 (Patients with an indication for PCI in in-stent restenosis) The search for published evidence allowed us to identify five publications with a controlled case series design that described the results of the intervention in terms of reperfusion, procedure safety and clinical results at more than 6 months. The degree of confidence in terms of the GRADE methodology offered by this evidence is low. No statistically significant differences could be demonstrated in angiographic success (defined as less than 50% residual stenosis obtained after the procedure in the absence of major cardiac com plications) RR=1.02 [CI95% 0.96; 1.07]. A difference could be demonstrated in the proportions of presence of residual stenosis -3.77% [CI95% -7.00%; -0.53%] and no effect was shown on the maximum luminal diameter of the target segment 0.08mm [CI95% -0.02; 0.19] I2 3%. Regarding safety, no sta tistically significant results were shown in two variables analyzed related to the safety of the intervention: hospital discharge without complications and the need for urgent surgery for coronary revascularization. It has also not been possible to demonstrate significant associations between the interven tion performed on the patients and the clinical results during the deferred follow-up (mean follow-up close to 225 days): death, need for coronary in tervention and myocardial infarction. Question 4 (Patients with an indication for PCI due to stent underexpan sion). It was not possible to identify SR or CT whose objective was to eva luate the efficacy, effectiveness or safety of EXCIMER láser compared to the usual procedure (PCI with conventional balloon dilation), for this reason it was decided to identify observational studies that included or did not in clude a control group, although other types of studies were also reviewed. After the selection process, 3 articles were used to answer this question, all of them showed results from small series of cases without a control group. The study of the outcomes is not homogeneous among the three works: the most common of the reports is the proportion of post-procedure stenosis whose reported weighted average is 20.37% [CI95% 11.07%; 33.92%]. The description of the outcomes related to the safety of the procedure is une ven among the three studies, the most commonly described are: AMI 3.6% [95% CI 0.63%; 17.71%] death 0% [CI95% 0% ; 7.86%], myocardial infarc tion 4.2% [CI95% 1.17% ; 14.25%] and coronary perforation 3.8% [CI95% 0.68% ; 18.89%]. Regarding deferred outcomes, beyond the post-procedure period, the different follow-up times and modalities are also described in a very scattered manner: thus, death was calculated as a weighted average of 9.25% [CI95% 4.02%; 19.91%] with mean follow-ups in the range of 3-6 months. The need for deferred revascularization of the treated lesion could be estimated at 3.7% [CI95% 1.02%; 12.53%]. However, the confidence that the included studies allow for the resolu tion of the question is very weak. Question 5: (Patients with an indication for PCI in the saphenous vein graft). After the search, 2 publications were selected: one of them describes the results of an observational study in which patients who required surgery on saphenous vein grafts, excluding patients with recent infarction or elevated CPK-MB, systolic function less than 30% and use planning of a DPD (distal protection device), with the aim of reducing embolic complications in this subgroup of high-risk lesions; the other study included patients with non-ST segment elevation acute coronary syndrome who required saphenous vein graft surgery. Both are controlled observational studies and the degree of confidence they offer is very low. In the study conducted on patients without ACS, the group whose incompetent saphenous vein grafts were treated with láser did not show a significant difference in the rate of restoration of flow, or in graft dissection or perforation, or in other undesirable events, in com parison with rates reported in patients treated without the involvement of EXCIMER láser. In the observational study of conducted on patients with non-ST elevation ACS who underwent DPD or ELCA-assisted PCI. It was not possible to demonstrate significant differences for any of the outcomes studied: reestablishment of flow, periprocedural AMI, and other immediate outcomes after the intervention. Unfortunately, no results are offered for a term greater than 30 days and it is necessary to point out that the evidence provided in this clinical situation is indirect, insofar as this study was not designed to evaluate the efficacy of coronary láser in this clinical situation KEY POINTS Coronary láser could be an effective and safe technique in the percutaneous treatment of complex coronary lesions, although the available evidence does not allow firm conclusions to be drawn on its effectiveness compared to the usual PCI techniques and other techniques proposed for the treatment of atherosclerotic plaque. or the thrombus in the usual technique was insuffi cient to achieve adequate coronary flow. The láser usage scenarios described in the literature usually overlap. In this report, the possible effectiveness has been evaluated in non-crossable and undilatable lesions, stent restenosis, under-expanded stents, calcified lesions, chronic occlusions, acute coronary syndrome and saphenous vein grafts. Higher quality randomized and observational studies are needed to as sess the efficacy and safety of the technique by comparing it with available alternative therapies and evaluating its longer-term results.

Carotid artery stenting has similar outcomes in men and women / Implante de stent na artéria carótida tem desfechos semelhantes em homens e mulheres

Abstract Background The aim of carotid interventions is to prevent cerebrovascular events. Endovascular treatment (carotid-artery-stenting/CAS) has become established as an alternative to open surgery in some cases. Historically, female sex has been considered as a perioperative risk factor, however, there are few studies regarding this hypothesis when it comes to CAS. Objectives To analyze the CAS results in our center adjusted by sex. Methods A retrospective cohort study was designed, including patients with carotid atheromatosis operated at a single center from January 2016 to June 2019. Our objective was to compare cardiovascular risk, including myocardial infarction, stroke, and mortality, by sex. Follow-up rates of stent patency, restenosis, stroke, myocardial infarction, and death were reported. Results 71 interventions were performed in 50 men (70.42%) and 21 women (29.57%). Mean age was 70.50 ± 10.72 years for men and 73.62 ± 11.78 years for women. Cardiovascular risk factors did not differ significantly between sexes. Mean follow-up was 11.28 ± 11.28 months. There were no significant differences in neurological events during follow-up. No adverse cardiological events were detected at any time. Regarding the mortality rate, during medium-term follow up there were 2 neurological related deaths with no significant differences between sexes (p=0.8432). Neither sex had higher rated of restenosis during long term follow-up (5.63% vs. 1.41%, p = 0.9693) or reoperation (1.41% vs. 1.41%, p = 0.4971). All procedures remained patent (<50% restenosis). Conclusions Despite the limitations of our study, CAS is a therapeutic option that is as effective and safe in women as in men. No sex differences were observed.

Resumo Contexto As intervenções carotídeas visam prevenir eventos cerebrovasculares. O tratamento endovascular (implante de stent na artéria carótida) se estabeleceu como uma alternativa à cirurgia aberta em alguns casos. Historicamente, o sexo feminino é considerado um fator de risco perioperatório, mas há poucos estudos abordando essa hipótese em casos de stent de carótida. Objetivos Analisar os resultados do CAS em nosso centro ajustados por sexo. Métodos Este estudo de coorte retrospectivo incluiu pacientes com ateromatose carotídea operados em um centro de janeiro de 2016 a junho de 2019. Nosso objetivo foi comparar o risco cardiovascular, incluindo infarto do miocárdio, acidente vascular cerebral e mortalidade, de acordo com o sexo. No seguimento, foram descritos patência do stent, reestenose, acidente vascular cerebral, infarto do miocárdio e morte. Resultados Setenta e uma intervenções foram realizadas: 50 homens (70,42%) e 21 mulheres (29,57%). A média de idade foi de 70,50 ± 10,72 anos nos homens e 73,62 ± 11,78 anos nas mulheres. Os fatores de risco cardiovascular não diferiram significativamente entre os sexos. A média de seguimento foi de 11,28 ± 11,28 meses. Durante o seguimento, não houve diferenças significativas nos eventos neurológicos. Nenhum evento cardiológico adverso foi detectado. Quanto à taxa de mortalidade, durante o seguimento de médio prazo ocorreram 2 óbitos neurológicos sem diferenças significativas entre os sexos (p = 0,8432). Não foi observada maior taxa de reestenose no seguimento de longo prazo (5,63% vs. 1,41%, p = 0,9693) ou de reoperação (1,41% vs. 1,41%, p = 0,4971) ao comparar os dois sexos. Todos os procedimentos permaneceram pérvios (< 50% de reestenose). Conclusões Apesar das limitações deste estudo, o stent de carótida em mulheres é uma opção terapêutica tão eficaz e segura quanto em homens. Nenhuma diferença foi observada entre os sexos.

Histology of atherosclerotic plaque from coronary arteries of deceased patients after coronary artery bypass graft surgery. / Histología de la placa de ateroma en arterias coronarias de fallecidos después de una revascularización miocárdica quirúrgica.

BACKGROUND AND AIM: Ischaemic heart disease is an important health problem. The characteristics of atherosclerotic plaques determine patient outcome. The aim of this study was to determine the histological grade of coronary atherosclerotic lesions in deceased patients after coronary artery bypass graft surgery, and to identify the complications of the severe plaques. METHOD: A descriptive, cross-sectional, prospective study was carried out on 21 anatomical pieces of deceased patients over a period of 3 years. The epicardial coronary arteries were sectioned transversally every 1cm, and the odd numbered fragments and the regions of the anastomosis with the grafts were selected. They were embedded in paraffin, stained with haematoxylin-eosin, and the histological slides were studied using an Olympus BHM microscope. RESULTS: An age over 50 years (85.7%), male gender (81.0%), and smoking (66.7%) predominated. Peri-operative infarction (38.1%) and cardiogenic shock (33.3%) were the main direct causes of death. The majority of the grafts were of venous origin (64.6%), and 149 lesions were detected, of which 116 (77.8%) were severe plaques, and 47.4% of them were located in the left anterior descending artery. The large majority (81.9%) of the lesions were located in the arterial segments proximal to the graft. A total of 255 histological complications were detected in the severe plaques, with 75.0% showing calcification. Hypertensive patients had more plaques with more complications, but no statistically significant association was found between these variables. CONCLUSIONS: Severe plaques predominated, mostly located in the proximal segments of the coronary arteries, and the left anterior descending was the most affected artery. Calcification was the most observed complication in the severe plaques.

Serial volumetric assessment of coronary fibroatheroma by optical frequency domain imaging: insights from the TROFI trial.

Aims: Coronary lesions precursors of acute events remain elusive, since they undergo continuous changes and their temporal changes are not very well-characterized. In natural history studies, optical frequency domain imaging (OFDI) has been used only to assess fibroatheromas as a 2D structure and sometimes in a single frame fashion. We aim at describing the serial volumetric modifications of the fibrous cap (FC) of the fibroatheromas as determined by OFDI over a 6-month follow-up period. Methods and results: In 49 patients, OFDI investigation was performed following treatment of culprit lesion and at 6-month follow-up in patients with ST-segment elevation myocardial infarction (STEMI). A fully automatic volumetric quantification of FC was done in all lipid-containing frames of non-culprit lesions in the infarct related artery. These lesions were matched at baseline and 6-month follow-up. A total of 58 non-culprit lipid rich lesions (34 TCFAs and 24 thick-cap fibroatheroma [ThCFA]) were found in 34 patients at baseline. Overall, there was a FC volume decrease of 1.57 (Inter-quartile Range [IQR] -4.13 to 0.54) mm3 at 6-months. 27% of the lesions changed their phenotype over time (TCFA or ThCFA). TCFAs that became ThCFAs at follow-up had smaller mean and maximal FC as compared with lesions that remained TCFAs (P = 0.01 for both). Conclusions: Non-culprit fibroatheromas located in the infarct related artery of patients with STEMI had a volumetric reduction of the FC after 6-month follow-up. Quantitative FC assessment was able to differentiate high-risk lesions that became ThCFAs. There was a considerable change of plaque phenotype (TCFAs or ThCFAs) over time.

Tomografía de coherencia óptica: Bases y aplicaciones de una nueva técnica de imagen intravascular

La angiografía es la técnica de referencia para el diagnóstico de la enfermedad arte rial coronaria. Sin embargo, la mayoría de los síndromes coronarios agudos involucran lesiones angiográficamente no significativas. Es también la técnica de elección para guiar la implantación de prótesis endovasculares y su seguimiento. La tomografía de coherencia óptica es una técnica de imagen interferométrica que penetra en los tejidos alrededor de 2-3 mm y ofrece una alta resolución axial. Es capaz de distinguir diferentes tipos de tejido, como fibroso, lipídico, necrótico o calcificado, reconoce características de las placas de ateroma que se han asociado con progresión rápida de la lesión y eventos clínicos adversos, como la delgada capa de fibroateroma, el espesor de la capa fibrosa, la infiltración de macrófagos y la formación de trombos. En la actualidad, existe un creciente interés en el valor de la tomografía de coherencia óptica en el área de intervención coronaria, donde la técnica ofrece ventajas significativas sobre las técnicas intravasculares de diagnóstico convencionales, como la ecografía intravascular. Su alta resolución permite reconocer las complicaciones periprocedimiento, como microdisección, malaposición e hiperplasia neointimal, haciendo de esta herramienta una de las técnicas más prometedoras en el diagnóstico intravascular.

Coronary angiography is the reference technique for the diagnosis of coronary disease. However, the majority of acute coronary syndromes involve angiographically non- significant lesions. It is also the technique of choice for guiding the implantation of endovascular prostheses and their later monitoring. Optical coherence tomography is an interferometric imaging technique that penetrates tissue approximately 2-3 mm and provides axial and lateral resolution. It is able to distinguish different tissue types, such as fibrous, lipid-rich, necrotic, or calcified tissue. Optical coherence tomography is able to recognize a variety of features of athe- rosclerotic plaques that have been associated with rapid lesion progression and clinical events, such as thin cap fibroatheroma, fibrous cap thickness, dense macrophage infiltration, and thrombus formation. Currently, there is growing interest in the value of optical coherence tomography in the area of coronary intervention, where the technique offers significant advantages over more widespread intravascular diagnostic techniques such as intravascular ultrasound. Its higher resolution permits to recognize periprocedural complications, such as microdissection of the coronary artery, stent malapposition, and neointimal hiperplasia, making this tool one of the most promising techniques in the intravascular diagnosis.

[Optical coherence tomography. Bases and applications of a new intravascular imaging technique]. / Tomografía de coherencia óptica. Bases y aplicaciones de una nueva técnica de imagen intravascular.

Coronary angiography is the reference technique for the diagnosis of coronary disease. However, the majority of acute coronary syndromes involve angiographically non-significant lesions. It is also the technique of choice for guiding the implantation of endovascular prostheses and their later monitoring. Optical coherence tomography is an interferometric imaging technique that penetrates tissue approximately 2-3mm and provides axial and lateral resolution. It is able to distinguish different tissue types, such as fibrous, lipid-rich, necrotic, or calcified tissue. Optical coherence tomography is able to recognize a variety of features of atherosclerotic plaques that have been associated with rapid lesion progression and clinical events, such as thin cap fibroatheroma, fibrous cap thickness, dense macrophage infiltration, and thrombus formation. Currently, there is growing interest in the value of optical coherence tomography in the area of coronary intervention, where the technique offers significant advantages over more widespread intravascular diagnostic techniques such as intravascular ultrasound. Its higher resolution permits to recognize periprocedural complications, such as microdissection of the coronary artery, stent malapposition, and neointimal hyperplasia, making this tool one of the most promising techniques in the intravascular diagnosis.

Detection of TCD4+ subsets in human carotid atheroma.

Activated TCD4(+) cells are detected in human atherosclerotic plaques which indicate their participation in disease progression and destabilization. Among these cells, IFN-γ-producing T cells (TH1) are recognized as having a pro-atherogenic role. Recently, the IL-17-producing T helper lineage of cells (TH17) has been identified in atherosclerotic lesions. They have been linked to atheroma development through the production of pro-inflammatory mediators present in these lesions. Furthermore, IL-22 producing TCD4(+) cells (TH22) have been identified in the atheromatous environment, but their presence and function has not been investigated. The aim of this study was to analyze the immune response mediated by pro-inflammatory subtypes of TCD4(+) cells in atheromatous lesions. Atherosclerotic plaques of 57 patients with critical stenosis of carotid submitted to endarterectomy were evaluated. Three carotid fragments from organ donors were used as control. mRNA analysis showed expression of TH1 (IFN-γ, T-bet, IL-2, IL-12p35, TNF-α and IL-18); TH2 (GATA-3); TH17 (IL-17A, IL-17RA, Rorγt, TGF-ß, IL-6, IL-1ß, IL-23p19, CCL20, CCR4 and CCR6) and TH22 (IL-22 and Ahr) related markers. Asymptomatic patients showed higher expression of mRNA of IL-10, TGF-ß, CCR4 and GATA-3 when compared to symptomatic ones. Immunohistochemistry analysis showed higher levels of IL-23, TGF-ß, IL-1ß and IL-18 in macrophages and foam cells in unstable lesions compared to stable and control ones. In vitro stimulation of atheroma cells induced IL-17 and IFN-γ production. Finally we were able to detect, the following subpopulations of TCD3(+) cells: TCD4(+) IFN-γ(+), TCD4(+)IL-17(+), TCD4(+)IL-4(+), TCD4(+)IL-22(+) and double positive cells (IFN-γ/IL-17(+), IFN-γ/IL-22(+) or IL-17/IL-22(+)). Our results showed the presence of distinct TCD4(+) cells subsets in human carotid lesions and suggest that interactions among them may contribute to the atheroma progression and destabilization.