Optimal Minimal Stent Area and Impact of Stent Underexpansion in Left Main Up-Front 2-Stent Strategy.

BACKGROUND: We previously reported the use of minimal stent area to predict angiographic in-stent restenosis after drug-eluting stent implantation for unprotected left main (LM) disease. We aimed to evaluate the optimal minimal stent area criteria for up-front LM 2-stenting based on long-term clinical outcomes. METHODS: We identified 292 consecutive patients with LM bifurcation stenosis who were treated using the crush technique. The final minimal stent area was measured in the ostial left anterior descending artery (LAD), ostial left circumflex artery (LCX), and distal LM. The primary outcome was 5-year major adverse cardiac events, including all-cause death, myocardial infarction, and target lesion revascularization. RESULTS: The minimal stent area cutoff values that best predicted the 5-year major adverse cardiac events were 11.8 mm2 for distal LM (area under the curve, 0.57; P=0.15), 8.3 mm2 for LAD ostium (area under the curve, 0.62; P=0.02), and 5.7 mm2 for LCX ostium (area under the curve, 0.64; P=0.01). Using these criteria, the risk of 5-year major adverse cardiac events was significantly associated with stent underexpansion in the LAD ostium (hazard ratio, 3.14; [95% CI, 1.23-8.06]; P=0.02) and LCX ostium (hazard ratio, 2.60 [95% CI, 1.11-6.07]; P=0.03) but not in the distal LM (hazard ratio, 0.81 [95% CI, 0.34-1.91]; P=0.63). Patients with stent underexpansion in both ostial LAD and LCX had a significantly higher rate of 5-year major adverse cardiac events than those with no or 1 underexpanded stent of either ostium (P<0.01). CONCLUSIONS: Stent underexpansion in the LAD and LCX ostium was significantly associated with long-term outcomes in patients who underwent up-front 2-stenting for LM bifurcation stenosis.

Intravascular ultrasonography assisted carotid artery stenting for treatment of carotid stenosis: Two case reports.

BACKGROUND: Digital subtraction angiography (DSA), the gold standard of cerebrovascular disease diagnosis, is limited in its diagnostic ability to evaluate arterial diameter. Intravascular ultrasonography (IVUS) has advantages in assessing stenosis and plaque nature and improves the evaluation and effectiveness of carotid artery stenting (CAS). CASE SUMMARY: Case 1: A 65-year-old man presented with a five-year history of bilateral lower limb weakness due to stroke. Physical examination showed decreased strength (5-/5) in both lower limbs. Carotid artery ultrasound, magnetic resonance angiography, and computed tomography angiography (CTA) showed a right proximal internal carotid artery (ICA) stenosis (70%-99%), acute cerebral infarction, and severe right ICA stenosis, respectively. We performed IVUS-assisted CAS to measure the stenosis and detected a low-risk plaque at the site of stenosis prior to stent implantation. Post-stent balloon dilatation was performed and postoperative IVUS demonstrated successful expansion and adherence. CTA six months postoperatively showed no significant increase in in-stent stenosis. Case 2: A 36-year-old man was admitted with a right common carotid artery (CCA) dissection detected by ultrasound. Physical examination showed no positive neurological signs. Carotid ultrasound and CTA showed lumen dilation in the proximal CCA with an intima-like structure and bulging in the proximal segment of the right CCA with strip-like low-density shadow (dissection or carotid web). IVUS-assisted DSA confirmed right CCA dissection. CAS was performed and intraoperative IVUS suggested a large residual false lumen. Post-stent balloon dilatation was performed reducing the false lumen. DSA three months postoperatively indicated good stent expansion with mild stenosis. CONCLUSION: IVUS aids decision-making during CAS by accurately assessing carotid artery wall lesions and plaque nature preoperatively, dissection and stenosis morphology intraoperatively, and visualizing and confirming CAS postoperatively.

Revascularization Options for Left Main Disease: What Clinicians Need to Know.

PURPOSE OF REVIEW: Left main disease represents the highest-risk lesion subset of coronary artery disease and is associated with adverse cardiovascular events. Accordingly, we aim to understand how the significance of left main disease is assessed by different modalities, followed by a review of management options in current era. RECENT FINDINGS: Invasive coronary angiogram remains the gold standard for assessment of left main disease, but intracoronary imaging or physiological testing is indicated for angiographically equivocal disease. Revascularization by either coronary artery bypass surgery or percutaneous coronary intervention is strongly recommended, which have been compared by six randomized trials, as well as recent meta-analyses. Surgical revascularization remains the preferred mode of revascularization, especially in patients with high lesion complexity and left ventricular dysfunction. Randomized studies are needed to understand if current-generation stents with the use of intracoronary imaging and improved medical therapy could match outcomes with surgical revascularization.

Comparison between internal jugular vein access using midline catheter and peripheral intravenous access during cardiopulmonary resuscitation in adults.

Objectives: Vascular access is an important procedure for drug administration during the resuscitation of a patient with cardiac arrest; however, it can be challenging under emergent conditions. This study aimed to investigate the efficiency of ultrasound-guided internal jugular venous access using a midline catheter versus peripheral intravenous access during cardiopulmonary resuscitation. Methods: This was a prospective single-center observational study among patients who received cardiopulmonary resuscitation. The primary outcomes were the success rate of first attempt and the time taken for vascular access via the internal jugular and peripheral veins. We also measured the diameter of the internal jugular and peripheral veins at the access point and the distance from the access point to the heart. Results: In all, 20 patients were included in the study. Internal jugular and peripheral venous access had a first-attempt success rate of 85% and 65%, respectively (p = 0.152). The time to access the internal jugular and peripheral veins was 46.4 ± 40.5 s and 28.8 ± 14.7 s, respectively (p = 0.081). The diameter of the internal jugular and peripheral veins was 10.8 ± 2.6 mm and 2.8 ± 0.8 mm, respectively (p < 0.001). The distance from the vascular access point to the heart was 20.3 ± 4.7 cm and 48.8 ± 13.1 cm for the internal jugular and peripheral veins, respectively (p < 0.001). Conclusions: There was a trend toward higher success rates in the internal jugular vein rather than the peripheral intravenous approach, which was not statistically significant.

Case report: Non-thrombotic iliac vein lesion: an unusual cause of unilateral leg swelling in a patient with endometrial carcinoma.

81-year-old female presented with subacute right lower extremity edema due to iliac vein compression by a markedly enlarged external iliac lymph node later identified as newly relapsed metastatic endometrial carcinoma. The patient underwent a full evaluation of the iliac vein lesion and cancer and had an intravenous stent placed with complete resolution of symptoms post-procedure.

Human Basilar Arterial Plaque Detected by Near-Infrared Spectroscopy: Clinical Image.

A patient in their 70s presented with weakness of the left limb and aphasia. Left vertebral angiography showed acute basilar artery occlusion. After mechanical thrombectomy, basilar artery trunk stenosis was evident and catheter-based near-infrared spectroscopy (NIRS) showed lipid-rich atherosclerotic plaque extending to almost 220° of the vessel circumference in the culprit lesion. Loading doses of dual antiplatelet therapy and aggressive medical treatment were started because additional intervention might have increased risk of plaque protrusion and thrombotic reocclusion. The patient presented with minor stroke caused by restenosis of the basilar artery 4 months later; balloon angioplasty and stenting were performed without thromboembolic complications. The patient was discharged without any new neurologic deficits. NIRS visualizes the distribution of lipids in the culprit lesion and the plaque burden of residual stenosis, identifies mechanisms of in situ thrombosis, and provides suggestions for the timing of additional interventions.

MORPHOMETRIC AND MORPHOLOGICAL ASSESSMENT OF CORONARY ARTERIES WITH INTRAVASCULAR ULTRASOUND.

OBJECTIVE: The aim: To perform a morphometric assessment of the coronary arteries ostia by intravascular ultrasound with morphological evaluation among the Ukrainian population. PATIENTS AND METHODS: Materials and methods: Intravascular images of the ostia of the right (48%) and left (52%) coronary arteries with the minimum diameter, maximum diameter, mean diameter and lumen area were analyzed. An intravascular ultrasound procedure was performed before percutaneous intervention. RESULTS: Results: A total of 25 IVUS examinations were collected from patients of both sexes and the same ages: 61,27±10,24 for males and females 68±5,83 (p=0.64).The left coronary artery (LCA) ostium assessment was performed in 13 (52%) cases: 8 men and 5 women (32% and 20%, respectively). The right coronary artery (RCA) ostium assessment was performed in 12 (48%) cases: 7 men and 5 women (28% and 20%, respectively). The maximal diameter of the coronary artery ostia was higher in men (5.95±0.66mm) than in women (4.82±0.34mm) (p<0.0001). In men, the maximal diameter of the RCA was higher than in the LCA (6.4±0.40mm and 5.56±0.60mm, respectively). The same differences were found in the mean diameter and lumen area (p<0.05). In women, the minimum diameter, mean diameter, maximum diameter and lumen area of the RCA were higher than LCA but without statistically signi#cant di"erences. The anatomic precondition explains the observed changes in echogenicity. CONCLUSION: Conclusions: IVUS analysis shows signi#cantly higher parameters of the minimum diameter, mean diameter, maximum diameter and lumen area in men than in women among the Ukrainian population. Therefore, morphological evaluation is crucial in the interpretation of intracoronary images.

Endovascular Management of Combined Symptomatic Spontaneous Isolated Renal and Celiac Arterial Dissection: A Case Report.

PURPOSE: To report a unique entity and its management that occurred at our facility: combined spontaneous isolated renal and celiac arterial dissection (SIRCAD) with resultant renal and gastrointestinal symptoms. CASE REPORT: A 50-year-old man with no past medical history presented with a 4 day history of nausea, intermittent stabbing epigastric pain, right flank pain, and uncontrolled hypertension. After full physical examination and imaging studies, the diagnosis of SIRCAD was established and confirmed. Selective right renal artery catheterization revealed dissection limited to the main trunk, and after careful selective hand-injection and successful cannulation of the distal renal artery branches through the true lumen assisted by intravascular ultrasound, a balloon expandable covered stent (6 mm in diameter and 60 mm in length) was deployed in the main renal artery. The same steps were performed for management of the celiac artery dissection. The patient was treated with clopidogrel 75 mg for 6 weeks and lifetime aspirin. A week after the procedure, his symptoms completely resolved. CONCLUSION: The pathology of SIRCAD in the absence of other vascular dissections is extremely rare, which speaks for the necessity of reporting this case and highlights the great role of evolving imaging modalities in the diagnosis and management of such cases. CLINICAL IMPACT: Symptomatic combined spontaneous isolated renal and celiac arterial dissection (SIRCAD) remain rare despite the increased frequency of reports on asymptomatic dissections. The etiology of SIRCAD is not precisely defined. Moreover, treatment of SIRCAD remains controversial with only a few cases of percutaneous interventional treatment are reported in the literature.

Intravascular Ultrasonography (IVUS)-A Tool for Imaging the Eustachian Tube?

The Eustachian tube (ET) has a key role in the pathogenesis of otitis media. Until now, there has been a lack of meaningful imaging methods to investigate the ET and its surrounding tissue. The aim of the current study was to investigate the possibilities of imaging the ET using Intravascular Ultrasonography (IVUS). ETs from sheep were scanned ex vivo and in vivo with different IVUS probes. In addition to native ETs, water was also used to improve coupling. Scans were subsequently compared with histological sections and a 3D model of the ET. In addition, ETs with a stenosis induced by a hyaluronic acid depot, after stent insertion, and during lower jaw movement were examined. The IVUS catheter was inserted into the ET lumen without any problems or injuries in all cases. The surrounding structures of the ET were identified in the ultrasound image. In addition, a change in size of the ET lumen due to movement was observed, and the position of the stent and the depot of hyaluronic acid could be examined. With the use of IVUS, a non-invasive possibility to examine the ET over its course with the adjacent structures as well as after different treatments is presented.

Advances in the development of biodegradable coronary stents: A translational perspective.

Implantation of cardiovascular stents is an important therapeutic method to treat coronary artery diseases. Bare-metal and drug-eluting stents show promising clinical outcomes, however, their permanent presence may create complications. In recent years, numerous preclinical and clinical trials have evaluated the properties of bioresorbable stents, including polymer and magnesium-based stents. Three-dimensional (3D) printed-shape-memory polymeric materials enable the self-deployment of stents and provide a novel approach for individualized treatment. Novel bioresorbable metallic stents such as iron- and zinc-based stents have also been investigated and refined. However, the development of novel bioresorbable stents accompanied by clinical translation remains time-consuming and challenging. This review comprehensively summarizes the development of bioresorbable stents based on their preclinical/clinical trials and highlights translational research as well as novel technologies for stents (e.g., bioresorbable electronic stents integrated with biosensors). These findings are expected to inspire the design of novel stents and optimization approaches to improve the efficacy of treatments for cardiovascular diseases.

Successful percutaneous transluminal renal angioplasty with multimodality imaging guidance for a juvenile patient with renovascular hypertension due to fibromuscular dysplasia.

Percutaneous transluminal renal angioplasty (PTRA) is an effective treatment for renovascular hypertension due to fibromuscular dysplasia (FMD). PTRA for renovascular FMD is performed with only balloons based on the consensus that stent kinking and fracture have been reported in cases of PTRA using stents for FMD. Therefore, it is important to avoid procedural complications, such as flow-limiting dissection or arterial rupture, in PTRA for renovascular FMD.We present a case of a juvenile patient who presented with renovascular hypertension due to FMD. Angiography revealed focal stenosis of the right renal artery, and the pressure wire showed a resting distal coronary to aortic pressure ratio (Pd/Pa) of 0.83. Intravascular ultrasound (IVUS) showed an intima-media complex that could not be qualitatively assessed. Optical coherence tomography (OCT) showed intimal fibroplasia and medial hyperplasia with areas of low intensity. Based on the OCT images, balloon angioplasty was performed using a semi-compliant balloon. After balloon angioplasty, IVUS and OCT revealed luminal expansion with mild residual stenosis, and the Pd/Pa ratio was 0.99. We decided not to increase the balloon size to avoid vascular injuries. In conclusion, PTRA with only balloon can be safely performed for FMD under the guidance of multimodal imaging, using IVUS, OCT, and a pressure wire. Learning objectives: This report describes successful percutaneous transluminal renal angioplasty (PTRA) for a juvenile patient with renovascular hypertension due to fibromuscular dysplasia (FMD) under the guidance of multimodal imaging, using intravascular ultrasound (IVUS), optical coherence tomography (OCT), and a pressure wire. When IVUS for FMD cannot assess the culprit lesion qualitatively, OCT could be effective in performing angioplasty with only balloon, without significant vascular injuries. A pressure wire can show the endpoint of PTRA and help avoid increasing the balloon size to prevent significant vascular injuries.

Underlying mechanisms of saphenous vein graft stenosis after coronary artery bypass caused by clipping of the side branches: an experimental study.

Background: Saphenous veins are regular bypass conduits selected in non-left anterior descending artery (LAD) coronary artery bypass graft (CABG) surgery. Despite the technical errors, acute thrombosis, intimal hyperplasia and arteriosclerosis which could lead to saphenous vein graft (SVG) failure, the metal-clipping-related SVG failure is unique and rare. This study was conducted to investigate the clinical and underlying mechanisms of the metal-clipping-related SVG failure. Methods: We collected 6 typical cases of the metal-clipping-related SVG failure in 41 patients who were diagnosed graft stenosis by coronary angiograph after CABG in the Department of Cardiology, Beijing Anzhen Hospital, from January 2020 to September 2021. Furthermore, we built an in vitro model to verify the identical intravascular ultrasound (IVUS) pattern of metal clip. Results: There were 6 in 41 cases of SVG stenosis caused by clipping of the side branches. We found that the stenosis of SVG caused by metal clipping mostly occurred at the corner and multipole clipping points. In this situation, great resistance could be felt when pushing the instruments through the stenosis and crystallized cholesterol was rarely caught by the distal protection device. We verified the similar IVUS pattern of metal clip at the side-branches of SVG in vitro. Conclusions: The metal-clipping-related stenosis may lead to SVG failure. The stenosis of SVG caused by metal clipping mostly occurred at the corner and multipole clipping points. IVUS showed great modality for clarification.

HbA1c, Coronary atheroma progression and cardiovascular outcomes.

BACKGROUND AND AIMS: We tested the hypothesis that on-treatment HbA1c levels independently associate with coronary atheroma progression and major adverse cardiovascular events (MACE: death, myocardial infarction, cerebrovascular accident, coronary revascularization, or hospitalization for unstable angina) rates. METHODS: We performed a post-hoc pooled analysis of data from seven prospective, randomized trials involving serial coronary intravascular ultrasonography (IVUS). The percent atheroma volume (PAV) was calculated as the proportion of the entire vessel wall occupied by atherosclerotic plaque. Using multivariable mixed modeling, we determined the association of on-treatment HbA1c with annualized change in PAV. Cox proportional hazard models were used to assess the association of HbA1c with incidence of MACE. RESULTS: Among 3,312 patients (mean age 58.6±9years, 28.4%women) average on-treatment HbA1c was 6.2±1.1%. Overall, there was no net significant annualized change in PAV (0.12±0.19%, p = 0.52). In a fully adjusted multivariable analysis (following adjustment of age, sex, body mass index, systolic blood pressure, smoking, low- and high-density lipoprotein cholesterol, triglyceride levels, peripheral vascular disease, trial, region, and baseline PAV), higher on-treatment HbA1c levels were independently associated with annualized changes in PAV [beta-estimate (95% confidence interval): 0.13(0.08, 0.19), p < 0.001]. On-treatment HbA1c levels were independently associated with MACE [hazard ratio (95% confidence interval): 1.13(1.04, 1.23), p = 0.005]. CONCLUSIONS: Independent of achieved cardiovascular risk factor control, greater HbA1c levels significantly associate with coronary atheroma progression rates and clinical outcomes. These results support the notion of a direct, specific effect of glycemic control upon coronary atheroma and atherosclerotic events, supporting the rationale of therapies designed to directly modulate it.

A Case of Intraprocedural Plaque Protrusion during Carotid Artery Stenting Using the Stent-in-Stent Technique for Carotid Artery Stenosis with Unstable Plaque.

Objective: Carotid artery stenting (CAS) using the stent-in-stent technique was reported to prevent intraprocedural plaque protrusion (PP) in patients with carotid artery stenosis with unstable plaque. We report a case of intraoperative PP after CAS despite the use of stent-in-stent technique. Case Presentation: A 63-year-old man presented with rapid progression of right carotid artery stenosis with unstable plaque during follow-up and was admitted to undergo CAS. Under local anesthesia with Mo.Ma Ultra and FilterWire EZ protection, CAS was performed using the stent-in-stent technique. The first 8 mm × 29 mm Carotid Wallstent (CWS) was placed. The second CWS (6 mm × 22 mm) was placed in a stent-in-stent manner to match the stenotic lesion, and conservative postdilation was performed. Then the third CWS (6 mm × 22 mm) was added due to the presence of PP on intravascular ultrasonography (IVUS). No postoperative neurological abnormalities were found, and no new high-signal areas were observed on diffusion-weighted MRI the day after surgery. The patient was discharged without postoperative complications. No stroke and restenosis were observed at 3 months after CAS. Conclusion: PP can occur even with stent-in-stent technique, suggesting the importance of diagnosis by IVUS.

Feasibility study of cumulative sum (CUSUM) analysis as a competency assessment tool for ultrasound-guided venous access procedures.

PURPOSE: Typically, physician training programs use a self-reported case-log competency assessment that does not measure procedure success or objectively assess competency. Cumulative sum (CUSUM) analysis could provide objective assessments of competency and progress over the training period. Our study objective was to determine the feasibility of CUSUM analysis to assess competency of ultrasound-guided peripheral intravenous (USG-PIV) line placement in pediatric anesthesiology fellows. METHODS: We applied a CUSUM analysis to assess competency in USG-PIV placement in three consecutive pediatric anesthesia fellowship classes. After a didactic and hands-on training session, fellows placed a USG-PIV line and self-reported the outcomes via a web-based application. Fellows were deemed competent if the CUSUM curve crossed two consecutive boundary lines from above. RESULTS: Twenty-nine fellows reported 1,388 USG-PIV attempts, with 74% success. Most fellows (26/29; 90%) achieved competency by the end of the fellowship. Two fellows identified in the mid-year CUSUM as not progressing towards competency achieved competency after targeted interventions. Fellows achieving competency (11/29 vs 25/29; odds ratio, 15; 95% confidence interval [CI], 1.98 to 113.56; P = 0.01) and attempts needed to achieve competency (19 vs 11; mean difference, 8.5; 95% CI, 3.3 to 13.7; P = 0.002) were significantly lower in younger patients and significantly higher in older patients. CONCLUSION: Our study showed that CUSUM can be used to assess competence in USG-PIV procedures performed by pediatric anesthesia fellows and to identify learners not progressing toward competency in procedural skills. Ultrasound-guided venous access required more attempts to achieve competency in younger patients.

RéSUMé: OBJECTIF: En règle générale, les programmes de formation des médecins se fondent sur une évaluation autodéclarée des compétences dans un registre des cas qui ne mesure pas la réussite de l'intervention et n'évalue pas objectivement la compétence. L'analyse du cumul des écarts (CUSUM - pour CUmulative SUM) pourrait fournir des évaluations objectives des compétences et des progrès au cours de la période de formation. L'objectif de notre étude était de déterminer la faisabilité d'une analyse CUSUM pour évaluer la compétence pour le positionnement du cathéter intraveineux périphérique échoguidé (CIP-écho) des fellows en anesthésiologie pédiatrique. MéTHODE: Nous avons appliqué une analyse CUSUM pour évaluer la compétence pour le positionnement du CIP-écho de trois classes consécutives de fellows en anesthésie pédiatrique. Après une séance de formation didactique et pratique, les fellows ont placé un cathéter CIP-écho et ont déclaré eux-même les résultats via une application Web. Les fellows étaient jugés compétents si la courbe CUSUM franchissait deux lignes de démarcation consécutives à partir du haut. RéSULTATS: Vingt-neuf fellows ont rapporté 1388 tentatives de CIP-écho, avec un taux de réussite de 74 %. La plupart des fellows (26/29; 90 %) ont acquis la compétence à la fin de leur fellowship. Deux fellows identifiés dans l'analyse CUSUM de mi-année comme ne progressant pas vers la compétence sont parvenus à l'acquérir après des interventions ciblées. Les fellows acquérant cette compétence (11/29 vs 25/29; rapport de cotes, 15; intervalle de confiance [IC] à 95 %, 1,98 à 113,56; P = 0,01) et les tentatives nécessaires pour acquérir la compétence (19 vs 11; différence moyenne, 8,5; IC 95 %, 3,3 à 13,7; P = 0,002) étaient significativement plus basses avec des patients plus jeunes et significativement plus élevés chez les patients plus âgés. CONCLUSION: Notre étude a montré qu'une analyse CUSUM pouvait être utilisée pour évaluer la compétence pour les procédures de CIP-écho réalisées par des fellows en anesthésie pédiatrique et pour identifier les apprenants qui ne progressent pas vers la compétence en habiletés opératoires. L'accès veineux échoguidé a nécessité davantage de tentatives pour atteindre la compétence chez les patients plus jeunes.

Fenestration Using a Novel Cutting Balloon for Acute Vessel Occlusion Secondary to Intramural Hematoma Following Stent Implantation.

Intramural hematoma after percutaneous coronary angioplasty is associated with adverse events and requires immediate bail out; however, the optimal treatment approach has not yet been established. Herein, we describe a case of coronary occlusion due to an intramural hematoma following stent implantation in the mid left anterior descending (LAD) coronary artery. Intravascular ultrasound revealed a massive intramural hematoma from the distal edge of the stent to the distal segment of the LAD, and the true lumen was completely compressed. By performing fenestration with a Wolverine™ Cutting Balloon™ (Boston Scientific, Massachusetts, United States), we were able to bail out without additional stenting. In conclusion, a cutting balloon with improved crossability can be an effective management strategy for intramural hematoma.