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1.
Pan Afr Med J ; 42: 122, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36060853

RESUMO

Aneurysms of the tibial arteries are rare, and they most commonly occur due to trauma of the lower extremities. Acquired arteriovenous fistulas of the tibial arteries are a recognized complication of trauma of the lower extremity and they are related to the mechanism of the injury. Although the natural history of stable arteriovenous fistula is relatively benign, the aneurysms of the tibial arteries should be repaired with autologous vein bypass grafts, if there is distal ischemia. Endovascular repair has been reported as an effective alternative treatment for traumatic tibial artery aneurysms. The case of a 60-year-old male with the rare combination of a tibial artery aneurysm and traumatic arteriovenous fistula of the left lower extremity is reported in view of its rarity and the modern holistic endovascular approach used for treatment. A covered stent graft in the anterior tibial artery was used for the treatment of both the aneurysm and the arteriovenous fistula. The patient was discharged under dual antiplatelet treatment for three months, continued by clopidogrel as monotherapy. At the six-month follow-up, the patient has restored palpable peripheral pulses and no sign of recurrence or complication was recognized. A total endovascular approach can be an effective treatment for these complicated traumatic aneurysms.


Assuntos
Aneurisma , Fístula Arteriovenosa , Lesões do Sistema Vascular , Aneurisma/complicações , Aneurisma/cirurgia , Fístula Arteriovenosa/etiologia , Fístula Arteriovenosa/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Stents/efeitos adversos , Artérias da Tíbia , Lesões do Sistema Vascular/cirurgia
2.
Neurol India ; 70(4): 1407-1411, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36076636

RESUMO

Background: In patients with acute ischemic stroke with large vessel occlusion, various angiographic features are important in patient selection and predicting outcome. Objective: We evaluated angiographic features like collaterals, clot burden score, angiographic recanalization, number of passes, and intracranial atherosclerotic disease (ICAD) with the functional outcome at 90 days. Materials and Methods: This was a retrospective analysis of prospectively collected data of 163 patients with acute ischemic stroke with large vessel occlusion who underwent mechanical thrombectomy within 24 hours of symptom onset. Angiographic data were reviewed blinded to clinical data. The outcome was defined as modified Rankin scale (mRS) at 90 days (good outcome mRS ≤2). Results: The median age of patients was 60 years and 34.4% were females. The median National Institutes of Health Stroke Scale (NIHSS) and Alberta Stroke Programme Early CT Score (ASPECTS) at admission were 17 and 6, respectively. On bivariate analysis, ASPECTS was >6, clot burden score was ≥7, recanalization of TICI was ≥2b, absence of ICAD, showed a positive correlation with the good outcome at 90 days (P-values of 0.003, 0.0001, and 0.03, respectively). Multiple attempts of device passes were associated with poor recanalization (P = 0.001) and it was seen more in ICAD patients. On multivariate analysis, independent predictors of poor outcome were clot burden score <7 (P = 0.043) and TICI score <2b (P = 0.048). Out of 41 patients (26%) with ICAD, 29 had a poor outcome at 90 days. Conclusion: Lower clot burden and less degree of recanalization were associated with poor outcome in acute ischemic stroke due to Large vessel occlusion (LVO). The presence of ICAD also predicted poor outcome.


Assuntos
Isquemia Encefálica , AVC Isquêmico , Acidente Vascular Cerebral , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Isquemia Encefálica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents/efeitos adversos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Resultado do Tratamento
3.
Neurol India ; 70(4): 1487-1491, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36076648

RESUMO

Background: Rapid neurological recovery from subacute to chronic ischemic stroke in subset of patients following carotid revascularization was observed. Objective: Retrospective analysis of data of the patients who had shown rapid recovery from subacute to chronic ischemic stroke following revascularization by Carotid stenting. Materials and Methods: We retrospectively analyzed pooled data from our carotid stenting patients done during January 2009 to January 2020.The inclusion criterion of the study was patients with rapid recovery within 24 h following revascularization by carotid stenting. There were total of 12 such patients. There were 8 males and 4 females. Apart from NIHSS, stroke severity was measured on MRI by ASPECTS score and cognitive function by MMSE. Each of these patients has undergone Carotid Stenting with distal protection for high-grade stenosis. Results: All of these 12 patients had Prestenting ASPECTS score ranging 8-10. Prestenting NIHSS score was ranging from 6-12 with an average of 8. Postprocedure NIHSS score was decreased to a range of 0-4 with average of 3.Prestenting MMSE was ranging 14-20 with an average of 18 score which turned into Post-stenting MMSE scale ranging 24-28 with an average of 26.Each of these patients shows decrease in NIHSS score by at least 50% in 24h to be called rapid recovery or Lazarus phenomenon. Additionally, they show significant improvement in cognitive function on MMSE scale. Conclusion: Rapid recovery from subacute to chronic ischemic stroke following revascularization by Carotid Stenting is potentially feasible in subset of patient who has mild to moderate deficit but high ASPECTS score.


Assuntos
Estenose das Carótidas , Endarterectomia das Carótidas , AVC Isquêmico , Acidente Vascular Cerebral , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Stents , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Resultado do Tratamento
4.
Neurol India ; 70(4): 1506-1511, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36076651

RESUMO

Background: The transvenous endovascular approach has become an optimal method for the treatment of cerebrovascular diseases. This procedure might cause iatrogenic damage to the chordae willisii (CW) in the straight sinus. However, little literature has been found to support this hypothesis. Objective: To investigate the possible damage of CW in the straight sinus during a transvenous endovascular procedure. Materials and Methods: The features of the CW from 38 cadaveric heads were observed via an endoscope mimicking a mechanical thrombectomy procedure in the straight sinus. Endoscopic observation and light microscopy examination were used to assess the damage of the CW throughout the procedure. Results: Valve-like lamellae and longitudinal lamellae were found predominantly in the posterior portion of the straight sinus. Trabeculae were present in both the anterior and posterior portions of the straight sinus. Samples treated with a stent had a significantly higher rate of Grade 1 damage during the eight procedures compared with samples treated with a balloon (P = 0.02). The incidence of damage to the CW surface was higher in the stent group than in the balloon group (P = 0.00). The use of stent or balloon did not increase the rate of CW damage during repeated experiments. Conclusions: The stent or balloon navigation through the straight sinus can cause minor damage to the CW. Frequent uses of retrograde navigation through the straight sinus do not seem to increase the possibility of damage to CW.


Assuntos
Cavidades Cranianas , Procedimentos Endovasculares , Humanos , Stents
5.
J Invasive Cardiol ; 34(9): E690-E691, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36076323

RESUMO

A 44-year-old man with history of D-transposition of the great arteries status post Mustard repair with pulmonary baffle obstruction was referred for further management. Cardiac computed tomography demonstrated calcific stenosis of the pulmonary venous baffle (PVB) outflow and right heart catheterization demonstrated elevated superior vena cava, pulmonary artery, and pulmonary capillary wedge pressures. A course of treatment is described demonstrating the challenges and potential complications of hybrid PVB stenting in a patient with challenging anatomy.


Assuntos
Transposição das Grandes Artérias , Transposição dos Grandes Vasos , Adulto , Transposição das Grandes Artérias/efeitos adversos , Transposição das Grandes Artérias/métodos , Humanos , Masculino , Complicações Pós-Operatórias/etiologia , Stents/efeitos adversos , Transposição dos Grandes Vasos/cirurgia , Veia Cava Superior
6.
J Invasive Cardiol ; 34(9): E692-E693, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36076324

RESUMO

A 67-year-old male presented with non-ST-segment elevation myocardial infarction. Angiography showed severe restenosis within the previously (before 2 years) implanted 2 stents (3 x 24 mm) in the right coronary artery. Severe calcification was evident angiographically and after multiple dilations with noncompliant balloons, the focal underexpansion of the stent remained. A 3-mm x 12-mm intravascular lithotripsy balloon was used and after the third series of 10 pulses, full expansion of the stent was observed. Postdilation of the stenosis with noncompliant and drug-eluting balloons was accompanied by excellent angiographical result with no residual stenosis. The patient was discharged free of symptoms and remains uneventful with no complications. The case demonstrates the feasibility of intravascular lithotripsy in acute coronary syndromes related to stent underexpansion due to severe calcification that is refractory to other conventional techniques.


Assuntos
Síndrome Coronariana Aguda , Angioplastia Coronária com Balão , Litotripsia , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/cirurgia , Idoso , Angioplastia Coronária com Balão/métodos , Constrição Patológica , Angiografia Coronária , Humanos , Masculino , Stents , Resultado do Tratamento
7.
J Invasive Cardiol ; 34(9): E694-E695, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36076325

RESUMO

A 59-year-old female was admitted for non-ST-segment elevation myocardial infarction and Killip class 3 heart failure with a left ventricular ejection fraction of 30%. Coronary angiogram showed moderate to severe stenosis over the ostial-proximal left anterior descending artery with minor disease over the left circumflex artery and right coronary artery. We describe a complication encountered where a protruding stent was weakened and elongated during our attempts to remove it, risking possible breakage, stent embolization, and long stent protrusion inside the aorta. We then describe treatment with what we call the alpha-loop snaring technique, which, to our knowledge, is the first report describing this novel approach, which can salvage a failing snaring attempt of a completely deployed and dislodged coronary stent.


Assuntos
Infarto do Miocárdio sem Supradesnível do Segmento ST , Função Ventricular Esquerda , Aorta , Angiografia Coronária , Feminino , Humanos , Pessoa de Meia-Idade , Stents , Volume Sistólico
10.
Heart Surg Forum ; 25(4): E540-E544, 2022 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-36052898

RESUMO

BACKGROUND: Total arch replacement (TAR) and the frozen elephant trunk (FET) routinely are performed to treat aortic dissection. When aortic dissection combines with the aberrant right subclavian artery (aRSA), routine TAR+FET will occlude the ostium of aRSA. But there is no consensus regarding the optimal surgical strategy to revascularize the aRSA. We seek an uncomplicated and less time-intensive way to reconstruct the aRSA. METHODS: From July 2020 to April 2022, six patients with aortic dissection and aRSA underwent TAR+FET and intraoperative fenestration on the descending trunk. The mean age of the patients was 51.7 (SD 16.2; range 30.0-72.0). TAR+FET was performed via a median sternotomy and under cardiopulmonary bypass (CPB) and moderate hypothermic circulatory arrest (HCA). A fenestra of descending trunk was made intraoperative. RESULTS: There was no operative death in hospital and follow up. The average aortic cross-clamp time, SACP time, and lower body circulatory arrest time was 138.8 (SD 22.5; range 103.0-156.0) min and 28.3 (SD 3.9; range 25.0-35.0) min. Bleeding, neurological deficit, visceral ischemia, injury to the spinal cord, or organ dysfunction was not observed. Follow-up CTA showed the blood flow of aRSA was patent in all patients. CONCLUSION: TAR+FET and intraoperative fenestration on the descending trunk is an efficacious approach. It also reduces the difficulty of reconstruction the aRSA in aortic dissection patients.


Assuntos
Aneurisma Dissecante , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Anormalidades Cardiovasculares , Aneurisma Dissecante/diagnóstico , Aneurisma Dissecante/cirurgia , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/cirurgia , Anormalidades Cardiovasculares/cirurgia , Humanos , Estudos Retrospectivos , Stents , Artéria Subclávia/anormalidades , Resultado do Tratamento
11.
Heart Surg Forum ; 25(4): E483-E488, 2022 Jul 07.
Artigo em Inglês | MEDLINE | ID: mdl-36052917

RESUMO

OBJECTIVE: The preoperative aortic hemodynamic data of patients with Stanford type B aortic dissection were obtained by computer fluid dynamics (CFD). Then we explored the relationship between hemodynamic data and short-term residual pseudolumen after thoracic endovascular aortic repair (TEVAR) and predict the latter through the former. METHODS: We collected the relevant data of 53 patients who underwent TEVAR in our hospital. They were divided into the A group (residual false lumen group) and B group (closed false lumen group), according to whether there was a residual false cavity around the stent recently after TEVAR. Three-dimensional reconstruction and CFD analysis of the thoracic and abdominal aorta was performed by DSCTA before the operation to obtain the aortic wall shear stress (WSS) and maximum blood flow velocity of the true and false lumen at the entrance, middle point of the long axis, and distal decompression port at the peak time of ventricular systolic velocity. Through the statistical analysis, we further studied the predictive value of hemodynamic data for residual pseudolumen. RESULTS: There was no significant difference in age, male, preoperative and postoperative thoracic and abdominal aorta DSCTA interval, history of hypertension, history of diabetes, smoking, Pt and APTT at admission between the two groups (P > 0.05). The blood flow velocity and shear stress at the entrance of the false lumen and the distal decompression port in the two groups were statistically significant (P < 0.05), while the other hemodynamic indexes were not statistically significant (P > 0.05). Binary logistic regression analysis further showed that the shear stress of the false lumen at the level of the distal decompression port (OR = 1.73, P = 0.01) was an independent risk factor for the residual false lumen around the stent in the early stage after TEVAR. The ROC curve analysis showed that the AUC area of the ROC curve corresponding to the shear stress of the false cavity at the level of the distal decompression port was 0.83, the best cross-sectional value was 9.49pa, and the sensitivity and specificity were 84.60% and 72.50%. CONCLUSIONS: The residual pseudolumen after TEVAR is related to the hemodynamic factors in the aorta before TEVAR. Preoperative hemodynamic data also have good predictive value. When the shear stress of the false lumen at the level of the distal decompression port is greater than 9.49pa, the probability of residual false lumen around the stent during the perioperative period significantly increases.


Assuntos
Aneurisma Dissecante , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma Dissecante/diagnóstico , Aneurisma Dissecante/cirurgia , Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/cirurgia , Computadores , Estudos Transversais , Procedimentos Endovasculares/métodos , Hemodinâmica , Humanos , Hidrodinâmica , Masculino , Estudos Retrospectivos , Stents , Resultado do Tratamento
12.
Heart Surg Forum ; 25(4): E616-E620, 2022 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-36052920

RESUMO

BACKGROUND: After proximal aortic surgery, total arch replacement (TAR) may again be needed because of recurrent dissection or aneurysm. This paper analyzed the relevant data of this technology with hopes of improving cognition and treatment. METHODS: There were a total of 60 eligible cases of secondary TAR after proximal aortic surgery in our center from 2010 to 2020. The primary surgical procedures included aortic valve replacement (AVR), ascending aortic replacement, Bentall, hemi-arch replacement, and thoracic endovascular aortic repair (TEVAR). The data were analyzed using the IBM SPSS Statistics 23.0 for Windows™ and presented as the mean ± standard deviations and direct frequencies, as appropriate. RESULTS: The interval between two operations was 44.8±53.6 months, 24 cases (40%) underwent emergency operation, the recurrence of type A dissection included 51 cases, accounting for 85% of the causes of total arch re-replacement. In the second surgical procedures, the ascending + TAR + stented elephant trunk (SET) implantation accounted for 75.0%. The overall surgical success rate was 98.3%. Postoperative respiratory complications were the most common, including infection, pneumothorax and hemothorax in 21 cases (35.6%). The second most common complication was acute kidney injury (AKI) in six cases (10.2%), and neurological complications took place in three cases (5.1%). The 30-day mortality rate was 15.3% and the 1-, 3- and 5-year survival rates were 96.0%, 84.0%, and 76.0%, respectively. CONCLUSIONS: The recurrence of dissection is the main cause of TAR after proximal aortic surgery, followed by aneurysm and the resurgical criteria for aneurysm needs to be unified. In addition to TAR, SET also is widely used. Despite high early mortality, its long-term prognosis is acceptable.


Assuntos
Aneurisma Dissecante , Aneurisma da Aorta Torácica , Implante de Prótese Vascular , Procedimentos Endovasculares , Aneurisma Dissecante/complicações , Aneurisma Dissecante/diagnóstico , Aneurisma Dissecante/cirurgia , Aorta/cirurgia , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Humanos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Stents/efeitos adversos , Resultado do Tratamento
13.
World J Pediatr Congenit Heart Surg ; 13(5): 637-644, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36053106

RESUMO

Decision-making for biventricular repair (BVR) or univentricular palliation is challenging in neonates with hypoplastic left heart complex (HLHC). Hybrid strategy can be used successfully to achieve BVR in some of these patients. Between June 1998 and January 2022, 342 patients with a diagnosis of HLHS/variants, ductal-dependent lower body circulation with two ventricles, or HLHC with borderline left ventricle (LV) underwent initial bilateral pulmonary artery banding and ductal stenting in our institution. Among these 342 patients, 224 patients were defined as HLHS/variants and underwent univentricular palliation. 118 patients were determined to have borderline LV and hypoplastic left ventricular structures (HLHC, n = 48) or ductal-dependent lower body circulation with two ventricles (n = 70) considered suitable for BVR. 48 patients had multilevel obstructions including both aortic and mitral valve hypoplasia, aortic arch hypoplasia, and borderline LV. These were considered to have HLHC. These 48 HLHC patients are the subject of this report. Neonatal hybrid palliation at a median age of seven days was performed in 48 patients and 46 patients underwent BVR at a median age of 156 days. In 46 patients who underwent BVR, hospital mortality was not observed. The median follow-up was 66 months, with no late mortality. Heart transplant-free survival at 5, 10, and 15 years was 95.7%. 12 patients (26%) required reoperation and 9 (19.5%) required catheter reinterventions. Hybrid palliation may increase the chances for biventricular circulation in patients with borderline LV and small left-sided structures. Giessen hybrid approach as a left ventricular recruitment strategy achieves excellent early and long-term results.


Assuntos
Coartação Aórtica , Cardiopatias Congênitas , Síndrome do Coração Esquerdo Hipoplásico , Coartação Aórtica/cirurgia , Ventrículos do Coração/anormalidades , Humanos , Recém-Nascido , Stents
14.
Adv Surg ; 56(1): 305-319, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-36096574

RESUMO

Fenestrated-branched endovascular aortic repair (FB-EVAR) has gained widespread acceptance in patients with complex aortic aneurysms. It has evolved from an alternative to treat elderly and higher risk patients to the first line of treatment in most patients with suitable anatomy, independent of the clinical risk. Currently, these devices are available off-the-shelf (ready to use) and tailored to the patient anatomy with the options of fenestrated, branched and mixed fenestrated, and branched designs. Reports from single and multicenter experiences and systematic reviews have shown lower mortality and morbidity for FB-EVAR compared with historical results of open surgical repair. The main advantages are noted on mortality, respiratory complications, acute kidney injury, and length of hospital stay. The purpose of this article is to review the advances in the endovascular repair of complex aortic aneurysms exploring the indications for treatment, preoperative evaluation, patient selection, device design, and implantation technique.


Assuntos
Aneurisma da Aorta Torácica , Aneurisma Aórtico , Implante de Prótese Vascular , Procedimentos Endovasculares , Idoso , Aneurisma Aórtico/complicações , Aneurisma Aórtico/cirurgia , Aneurisma da Aorta Torácica/complicações , Aneurisma da Aorta Torácica/cirurgia , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/métodos , Humanos , Estudos Multicêntricos como Assunto , Complicações Pós-Operatórias/etiologia , Desenho de Prótese , Fatores de Risco , Stents/efeitos adversos , Resultado do Tratamento
15.
Zhonghua Xin Xue Guan Bing Za Zhi ; 50(9): 895-899, 2022 Sep 24.
Artigo em Chinês | MEDLINE | ID: mdl-36096707

RESUMO

Objective: To investigate the safety and efficacy of dual guiding catheter kissing technique (DCK) in the treatment of stent partly dislodgement in coronary artery. Methods: The study retrospectively involved 6 hospitalized patients with coronary artery stent partly dislodgement during PCI at The First Affiliated Hospital of Zhengzhou University from February 2016 to June 2019, DCK was used in these patients. We observe the success rate of stent retrieval, success rate of PCI, incidence of complications and major adverse cardiovascular events in 1 year follow up. Results: 6 patients were involved, of which 3 are male, ages range 49 to 68 years old, 4 patients are diagnosed with unstable angina, the other two are stable angina. All the partially disloged stents in the 6 patients were successfully removed from coronary artery. Except for 1 patient who refused coronary artery stenting again, the other 5 patients were successfully implanted coronary artery stenting. No serious complications occurred, no patients died and no major adverse cardiovascular events happened during 1 year follow up. Conclusions: DCK is safe and effective to remove partially dislodged stent in coronary artery.


Assuntos
Angioplastia Coronária com Balão , Intervenção Coronária Percutânea , Idoso , Angina Instável , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/métodos , Cateteres , Vasos Coronários/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents/efeitos adversos
16.
Catheter Cardiovasc Interv ; 100(3): 367-368, 2022 09.
Artigo em Inglês | MEDLINE | ID: mdl-36084192

RESUMO

In this issue of Catheterization and Cardiovascular Interventions, Farag et al. reported their experience comparing patients with acute coronary syndrome versus stable angina patients who were turned down for bypass surgery and subsequently treated with coronary stenting (1).


Assuntos
Angioplastia Coronária com Balão , Ponte de Artéria Coronária/efeitos adversos , Humanos , Stents , Resultado do Tratamento
17.
BMC Neurol ; 22(1): 351, 2022 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-36109690

RESUMO

BACKGROUND: Cerebral vasospasm (CVS) is a leading cause of morbidity and mortality in patients after aneurysmal subarachnoid hemorrhage (aSAH). Endovascular treatment, including intraarterial infusion of drugs with vasodilation effects, and balloon- and stentriever angioplasty, are helpful but may achieve only short-term effects. There is a clinical need for long-lasting treatment of refractory recurrent vasospasm. We report our experience in stent implantation as a treatment for recurrent severe post-SAH vasospasm. METHODS: A retrospective analysis of our institutional database of 883 patients with SAH, managed between January 2010 and December 2021, was performed. Six patients were identified as having received intracranial stenting in the context of post-SAH cerebral vasospasm. All patients were initially treated with intra-arterial infusion of nimodipine and/or milrinone. Self-expanding intracranial stents were implanted during endovascular aneurysm treatment to enable access despite impaired perfusion (Group 1) or as a bail-out strategy after failed intraarterial drug infusion or mechanical treatment (Group 2). All stented patients received dual antiplatelet therapy (DAPT) for 6 months. RESULTS: Nine vessels in six patients with severe post-SAH vasospasm were stented. The stents were deployed in 16 vessel segments. All attempted implantations were technically successful. All patients demonstrated radiographic and clinical improvement of the vessel narrowing. No recurrent vasospasm or permanent vessel occlusion of the stented vessels was encountered. A thrombus formation in a Group 1 patient resolved under 4 mg eptifibatide IA infusion. During long-term angiographic follow-up, neither in-stent stenosis nor stent occlusion was found. CONCLUSIONS: Endovascular implantation of self-expanding stents is a potential ultima ratio strategy for patients with severe refractory post-SAH cerebral vasospasm. Stents with reduced thrombogenicity (avoiding DAPT) and bioabsorbable self-expanding stents might further advance this concept.


Assuntos
Aneurisma da Aorta Abdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Vasoespasmo Intracraniano , Aneurisma da Aorta Abdominal/complicações , Implante de Prótese Vascular/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Eptifibatida/uso terapêutico , Seguimentos , Humanos , Milrinona/uso terapêutico , Nimodipina/uso terapêutico , Inibidores da Agregação Plaquetária/uso terapêutico , Estudos Retrospectivos , Stents/efeitos adversos , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/terapia
18.
JAMA Netw Open ; 5(9): e2231944, 2022 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-36112371

RESUMO

Importance: A transcarotid artery revascularization (TCAR) device was approved by the US Food and Drug Administration in 2015 for carotid revascularization in patients at high risk for stroke, cranial nerve injury, or major cardiac event. It is unclear how the introduction of TCAR has changed the use of carotid endarterectomy (CEA) and transfemoral carotid artery stenting (TFCAS). Objective: To quantify the temporal changes in the operative approach to carotid revascularization (CEA vs TFCAS vs TCAR), and to identify patient and disease characteristics commonly associated with each approach. Design, Setting, and Participants: This retrospective cohort study obtained data from the Vascular Quality Initiative database from January 1, 2015, to December 31, 2019. Patients with carotid artery stenosis who underwent CEA, TFCAS, or TCAR were included. Data were analyzed from January to April 2022. Exposures: Month and year of surgery as well as patient risk status. Main Outcomes and Measures: Number and proportion of carotid revascularization procedures by operative approach. Results: A total of 108 676 patients (mean [SD] age 56.6 [12.5] years; 66 684 men [61.4%]) were included in the analysis. The most common operative approach overall was CEA (n = 81 508 [75.0%]), followed by TFCAS (n = 15 578 [14.3%]) and TCAR (n = 11 590 [10.7%]). The number of procedures increased over the study period (16 754 in 2015 vs 27 269 in 2019; P < .001). In 2015, CEA was used in 84.9% of all cases, followed by TFCAS (14.4%) and TCAR (0.8%). In 2019, CEA was used in 64.8% of cases, followed by TCAR (21.9%) and TFCAS (13.3%). The proportional use of CEA decreased by 5.0% (95% CI, -7.4% to -2.6%) per year, and TCAR use increased by 5.3% (95% CI, 2.3%-8.3%) per year. Among patients at high risk, the change was greater: CEA use decreased by 7.8% (95% CI, -11.9% to -3.8%) per year, TFCAS decreased by 4.8% (95% CI, -9.5% to -0.14%) per year, and TCAR increased by 12.6% (95% CI, 7.1%-18.1%) per year. Multinomial logistic regression showed that patient risk status was the most important characteristic associated with TCAR compared with CEA (relative risk ratio, 36.10; 95% CI, 29.24-44.66; P < .001) and TFCAS (relative risk ratio, 14.10; 95% CI, 11.86-16.66; P < .001). Linear regression revealed no association between year of surgery and in-hospital myocardial infarction, stroke, or mortality. Conclusions and Relevance: Results of this study indicate that TCAR has become the dominant carotid revascularization approach, surpassing TFCAS and CEA in patients at high risk for stroke, cranial nerve injury, or cardiovascular events. Patient high-risk status was the main characteristic associated with a stenting approach, highlighting the perceived importance of carotid stenting therapies in this patient population.


Assuntos
Estenose das Carótidas , Endarterectomia das Carótidas , Acidente Vascular Cerebral , Artérias Carótidas , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
19.
Am J Case Rep ; 23: e937598, 2022 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-36114659

RESUMO

BACKGROUND Coronary stent dislodgement is rare but carries serious complications like thrombosis, myocardial infarction, disruption of the systemic circulation, and coronary dissection, which can lead to sudden death. Thus, rapid evaluation and intervention are needed to restore blood flow to vital organs. CASE REPORT A 46-year-old woman with no relevant past medical history except for smoking, presented to the Emergency Department (ED) with left-sided chest pain. The physical exam was unremarkable. EKG showed ST segment elevation, and troponin was 4.03. She underwent cardiac catheterization, which showed 100% occlusion of the left anterior descending coronary artery (LAD). A drug-eluting stent (DES) was placed. Later, she had chest pain similar to the initial episode. EKG showed 1-mm elevation at ST segment in leads V1 and V2 and T wave inversion in leads V2, V3, V4, and V5. She underwent a repeat heart catheterization, which revealed a dissection in the middle LAD distal to the initial stent placement. She was treated with another stent overlapping the proximal stent. While attempting to cross the proximal stent, the stent came off the balloon, slipped from the wire, and went down into the descending aorta. CONCLUSIONS Coronary artery stent dislodgement is a rare event that can lead to significant complications during PCI. Patient restlessness and small-sized, severely angulated, and previously stented coronary arteries are associated risk factors. The main treatment option is stent retrieval, either surgically or using other available techniques. If retrieval of the stent is impossible, crushing it against the blood vessel wall could be considered.


Assuntos
Stents Farmacológicos , Intervenção Coronária Percutânea , Dor no Peito/etiologia , Vasos Coronários , Stents Farmacológicos/efeitos adversos , Feminino , Humanos , Pessoa de Meia-Idade , Intervenção Coronária Percutânea/efeitos adversos , Stents/efeitos adversos , Troponina
20.
Lancet Neurol ; 21(10): 877-888, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-36115360

RESUMO

BACKGROUND: The optimal treatment for patients with asymptomatic carotid artery stenosis is under debate. Since best medical treatment (BMT) has improved over time, the benefit of carotid endarterectomy (CEA) or carotid artery stenting (CAS) is unclear. Randomised data comparing the effect of CEA and CAS versus BMT alone are absent. We aimed to directly compare CEA plus BMT with CAS plus BMT and both with BMT only. METHODS: SPACE-2 was a multicentre, randomised, controlled trial at 36 study centres in Austria, Germany, and Switzerland. We enrolled participants aged 50-85 years with asymptomatic carotid artery stenosis at the distal common carotid artery or the extracranial internal carotid artery of at least 70%, according to European Carotid Surgery Trial criteria. Initially designed as a three-arm trial including one group for BMT alone (with a randomised allocation ratio of 2·9:2·9:1), the SPACE-2 study design was amended (due to slow recruitment) to become two substudies with two arms each comparing CEA plus BMT with BMT alone (SPACE-2a) and CAS plus BMT with BMT alone (SPACE-2b); in each case in a 1:1 randomisation. Participants and clinicians were not masked to allocation. The primary efficacy endpoint was the cumulative incidence of any stroke or death from any cause within 30 days or any ipsilateral ischaemic stroke within 5 years. The primary safety endpoint was any stroke or death from any cause within 30 days after CEA or CAS. The primary analysis was by intention-to treat, which included all randomly assigned patients in SPACE-2, SPACE-2a, and SPACE-2b, analysed using meta-analysis of individual patient data. We did two-step hierarchical testing to first show superiority of CEA and CAS to BMT alone then to assess non-inferiority of CAS to CEA. Originally, we planned to recruit 3640 patients; however, the study had to be stopped prematurely due to insufficient recruitment. This report presents the primary analysis at 5-year follow-up. This trial is registered with ISRCTN, number ISRCTN78592017. FINDINGS: 513 patients across SPACE-2, SPACE-2a, and SPACE-2b were recruited and surveyed between July 9, 2009, and Dec 12, 2019, of whom 203 (40%) were allocated to CEA plus BMT, 197 (38%) to CAS plus BMT, and 113 (22%) to BMT alone. Median follow-up was 59·9 months (IQR 46·6-60·0). The cumulative incidence of any stroke or death from any cause within 30 days or any ipsilateral ischaemic stroke within 5 years (primary efficacy endpoint) was 2·5% (95% CI 1·0-5·8) with CEA plus BMT, 4·4% (2·2-8·6) with CAS plus BMT, and 3·1% (1·0-9·4) with BMT alone. Cox proportional-hazard testing showed no difference in risk for the primary efficacy endpoint for CEA plus BMT versus BMT alone (hazard ratio [HR] 0·93, 95% CI 0·22-3·91; p=0·93) or for CAS plus BMT versus BMT alone (1·55, 0·41-5·85; p=0·52). Superiority of CEA or CAS to BMT was not shown, therefore non-inferiority testing was not done. In both the CEA group and the CAS group, five strokes and no deaths occurred in the 30-day period after the procedure. During the 5-year follow-up period, three ipsilateral strokes occurred in both the CAS plus BMT and BMT alone group, with none in the CEA plus BMT group. INTERPRETATION: CEA plus BMT or CAS plus BMT were not found to be superior to BMT alone regarding risk of any stroke or death within 30 days or ipsilateral stroke during the 5-year observation period. Because of the small sample size, results should be interpreted with caution. FUNDING: German Federal Ministry of Education and Research (BMBF) and German Research Foundation (DFG).


Assuntos
Isquemia Encefálica , Estenose das Carótidas , Endarterectomia das Carótidas , AVC Isquêmico , Acidente Vascular Cerebral , Isquemia Encefálica/complicações , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Endarterectomia das Carótidas/métodos , Humanos , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Stents/efeitos adversos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
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