Giant coronary artery aneurysm of the left main treated with a covered stent: a case report.

Background: Coronary artery aneurysms (CAAs) of the left main represent a small subset of coronary artery disease and are associated with cardiovascular death. Because of its rare entity, large data are lacking and therefore treatment guidelines are missing. Case summary: We describe a case of a 56-year-old female with a past medical history of spontaneous dissection of the distal descending left artery (LAD) 6 years before. She presented to our hospital with a non-ST elevation myocardial infarction and a coronary angiogram showed a giant saccular aneurysm of the shaft of the left main coronary artery (LMCA). Given the risk of rupture and distal embolization, the heart team decided to go for a percutaneous approach. Based on a pre-interventional 3D reconstructed CT scan and guided by intravascular ultrasound, the aneurysm was successfully excluded with a 5 mm papyrus-covered stent. At 3-month and 1-year follow-up, the patient is still asymptomatic and repeat angiographies showed full exclusion of the aneurysm and the absence of restenosis in the covered stent. Discussion: We describe the successful percutaneous IVUS-guided treatment of a giant LMCA shaft coronary aneurysm with a papyrus-covered stent with an excellent 1-year angiographic follow-up showing no residual filling of the aneurysm and no stent restenosis.

One-year clinical and computed tomography follow-up after implantation of bioresorbable vascular scaffolds in patients with coronary chronic total occlusions.

OBJECTIVES: To assess the safety and efficacy of everolimus-eluting bioresorbable scaffolds (BRS) in the treatment of chronic total occlusions (CTO) using noninvasive multislice computed tomography (MSCT) angiography at one-year follow-up. BACKGROUND: Current evidence regarding the safety and efficacy of BRS for the percutaneous treatment of CTO is limited. METHODS: Between September 2013 and January 2016, patients who received one or more ABSORB BRSs were included at three centers. MSCT (including quantitative analysis) and clinical follow-up were performed at one year. RESULTS: Forty-one CTO patients were included. Mean age was 60 ± 11 years and the majority was male (83%). Average Japanese CTO (J-CTO) score was 0.9 ± 0.9. Seventy-one BRS were implanted in total with, on average, 1.7 ± 0.8 scaffolds/patient, and a total length of 43 ± 20 mm and diameter of 3.1 ± 0.4 mm. One noncardiac death took place. MSCT angiography was performed in 34 (83%) patients: all scaffolds were patent, except in one patient, in whom a patent target vessel was present on subsequent diagnostic angiography. MSCT quality was sufficient for quantitative analyses in 27 patients (46 scaffolds): median reference versus scaffold minimal lumen diameter and minimal lumen area were measured, and showed a small difference of 0.1 mm (-0.2-0.4) (lumen diameter stenosis = 3.0%) and 0.5 mm2 (-1.0-2.0) (lumen area stenosis = 4.2%). CONCLUSIONS: The low number of events and high patency rate at 1 year are encouraging the further use of the ABSORB scaffold for CTOs with low J-CTO score. Noninvasive MSCT angiography is a valid tool to assess scaffold patency, although its image resolution limits the use for quantitative measurements.

Global myocardial oedema in advanced decompensated heart failure.

AIMS: To use cardiac magnetic resonance (CMR) imaging with quantitative T2 mapping as surrogate for myocardial water content in patients with advanced decompensated heart failure (ADHF), compare these values with T2-values observed in chronic heart failure, and evaluate the change with decongestive therapy. METHODS AND RESULTS: Volumetric CMR measurements and quantitative T2 mapping were performed in 18 consecutive ADHF patients with clinical signs of volume overload. Eleven patients with stable heart failure were used as controls. Vasodilator therapy and diuretics were administered to achieve a pulmonary arterial wedge pressure (PAWP) of <18 mmHg and central venous pressure (CVP) of <12 mmHg, after which CMR was repeated. ADHF patients (62 ± 12 years; 89% male; left ventricular ejection fraction 23 ± 8%) presented with low cardiac index (2.08 ± 0.59 L/min/m2), high PAWP (25 ± 7 mmHg), and high CVP (14 ± 5 mmHg). After decongestion, the patients had a significant increase in cardiac index (+0.41 ± 0.53 L/min/m2; P = 0.005) and decreases in both PAWP (-9 ± 6 mmHg; P < 0.001) and CVP (-6 ± 5 mmHg; P < 0.001). At baseline, global left ventricular T2-values were higher in ADHF patients compared with controls (59.5 ± 4.6 vs. 54.7 ± 2.2 ms, respectively; P = 0.001). After decongestion, T2-values fell significantly to 55.9 ± 5.1 ms (P = 0.001), comparable with controls (P = 0.580). In contrast, psoas muscle T2-values were similar at baseline (38.6 ± 4.4 ms) vs. after decongestion (37.8 ± 4.8 ms; P = 0.397). Each 1 ms decrease in global left ventricular T2-value during decongestion was associated with a 1.14 ± 0.40 mmHg decrease in PAWP (P = 0.013), after correction for age and gender. CONCLUSION: Patients presenting with ADHF and volume overload have increased global left ventricular-but not psoas muscle-T2-values, which decrease with successful decongestion. Relief of myocardial oedema correlates with haemodynamic unloading.

CT volumetry of lumbar vertebral bodies in patients with hypoplasia L5 and bilateral spondylolysis and in normal controls.

INTRODUCTION: To examine the feasibility and results of calculating the volume of lumbar vertebral bodies in normal patients and patients with suspected hypoplasia of L5. METHODS: Lumbar multi-detector CT was performed in 38 patients with bilateral spondylolysis and hypoplasia of L5 and in 38 normal patients. Lumbar vertebral body volume of L3, L4 and L5 was measured by CT volumetry with a semi-automated program, created with MeVisLab. RESULTS: In the control group, the average vertebral body volume (in cubic centimeters) of L3 was 35.93 (±7.33), 36.34 (±7.13) for L4 and 34.63 (±6.88) for L5. In patients with suspected hypoplasia L5 the average body volume (in cubic centimeters) of L3 was 36.85 (±7.37), 36.90 (±6.99) for L4 and 33.14 (±6.57) for L5. The difference in mean vertebral body volume for L3, L4 and L5 between both groups was statistically not significant. However, there was a statistically significant difference of the ratio L5/L4 (P < 0.001) between both groups: the mean ratio L5/L4 in the control group was 95.3 ± 3.9%, the ratio for the hypoplastic L5 group was 89.9 ± 6.3%. CONCLUSIONS: There was no significant difference in the vertebral body volume for L3, L4 and L5 between both groups due to inter-patient variability. However, the relation between the body volume of L5 and L4 is significantly different between both groups. The volume of the vertebral body of L5 proved to be on average 10.2% smaller than the volume of L4 in the group with hypoplasia L5 versus 4.7% in the control group.

Prospective study comparing different indirect methods to measure portal pressure.

PURPOSE: To compare the accuracy of wedged hepatic venous pressure (WHVP) measurement with use of an end-hole catheter or an occlusion-balloon catheter versus direct portal pressure (PP) measurement in patients with cirrhosis with sinusoidal portal hypertension and to investigate the factors that affect the results of these indirect measurements. MATERIALS AND METHODS: In a cohort of 174 patients with cirrhosis referred for transjugular intrahepatic portosystemic shunt creation, indirect PP was measured with an end-hole catheter and an occlusion-balloon catheter placed in the right hepatic vein. Direct PP was measured by a pigtail catheter in the main branch of the portal vein. RESULTS: PP was more accurately estimated by the occlusion-balloon technique: mean WHVP measurements were 25.5 mm Hg ± 7.9 and 30.6 mm Hg ± 13.9, respectively, for the occlusion-balloon and end-hole catheter techniques, and the direct PP measurement was 25.0 mm Hg ± 7.0. The median absolute differences between direct and the indirect methods were 6.0 mm Hg with the end-hole catheter and 2.0 mm Hg with the occlusion-balloon catheter (P < .0001, signed-rank test). Relative to direct PP measurements, the occlusion-balloon technique overestimated pressures in cases of higher Model for End-Stage Liver Disease (MELD) scores (Spearman ρ = -0.24; P = .0005). CONCLUSIONS: Compared with direct PP measurements, agreement was clearly higher for indirect WHVP measurement with occlusion-balloon catheters versus end-hole catheters. However, in patients with a high MELD score, there was an overestimation of PP with the occlusion-balloon method.

Outcome of proximal internal iliac artery coil embolization prior to stent-graft extension in patients previously treated by endovascular aortic repair.

PURPOSE: To assess the safety, feasibility, and effectiveness of coil embolization of the proximal internal iliac artery (IIA) before stent-graft extension in patients previously treated by endovascular aortic repair (EVAR). MATERIALS AND METHODS: Over a period of 9 years, 16 ipsilateral, proximal IIA coil embolization procedures were performed before stent-graft extension in 13 patients previously treated by a modular aortic stent graft. Indication for coil embolization and concomitant stent-graft extension were secondary (ie, late) distal type I endoleak (n = 9) and late onset of an isolated common iliac artery aneurysm (n = 7) as a result of increasing dilation of a common iliac artery during follow-up after EVAR; mean common iliac artery diameter before coil embolization was 26.1 mm (range, 15-35 mm). Clinical and radiologic follow-up (mean, 39 months; range, 6-102 months) was done in accordance with an established registry. RESULTS: All procedures were successful except for one performed with 0.035-inch coils. Clinically, buttock claudication was noted in five of 13 patients (38%). No type II endoleak occurred through the coil-embolized internal iliac arteries. The mean common iliac artery diameter at 6-month follow-up was 23.0 mm (range, 14-30 mm; P = .0005). CONCLUSIONS: Ipsilateral coil or microcoil embolization of the proximal IIA before stent-graft extension in patients previously treated by an aortic stent graft seems to be safe and feasible, with favorable outcomes after a mean follow-up of 39 months.