Aghiad Al-Kutoubi

The significance of cerebral infarction and atrophy in patients with amaurosis fugax and transient ischemic attacks in relation to internal carotid artery stenosis: A preliminary report

There is a growing appreciation for the high incidence of silent cerebral infarction and cerebral atrophy on CT scans in patients with amaurosis fugax (AF) and hemispheric transient ischemic attacks (TIAs). Seventy patients with AF only (no TIAs), 104 patients with hemispheric TIAs (no AF), 185 patients without focal carotid territory symptoms (i.e., vertebrobasilar TIAs or asymptomatic carotid bruit only), and 129 patients with stroke and good recovery were studied with CT scan and duplex scanning to grade the degree of stenosis of the internal carotid artery (grades: A = normal, B = 0% to 15% stenosis, C = 16% to 49%, D = 50% to 99%, and E = occlusion). In patients with AF, the incidence of infarction increased from 20% in grades A, B, and C to 40% in grade D and 58% in grade E. The incidence of atrophy increased in parallel from 10% in grade A to 30% in grade E. The increased incidence of atrophy with increasing degrees of stenosis was not the result of increasing degrees of stenosis per se, but the associated increase in the incidence of infarction (patients without CT infarcts in grades D and E had 5% and 0% incidence of atrophy). In patients with hemispheric TIAs, the incidence of CT infarction increased from 25% in grades A and B to 48% in grades D and E. The incidence of atrophy did not show a parallel increase. Our findings support the hypothesis that atrophy is associated not only with cerebral infarction but may be causally related.(ABSTRACT TRUNCATED AT 250 WORDS)

ENDOVASCULAR STENTING OF INTERNAL CAROTID ARTERY FALSE ANEURYSM

Internal carotid artery aneurysms are uncommon and are potentially dangerous because they may rupture, thrombose or embolise. 1 Although satisfactory long term results have been reported, ~ surgical resection is technically very difficult especially if the aneurysm is near the base of the skull. 3 We report a case of an internal carotid artery false aneurysm caused by trauma which was successfully managed by endovascular stenting.

Thrombolysis in Arterial Graft Thrombosis

OBJECTIVE to assess the impact of peripheral arterial thrombolysis for vascular graft occlusion. DESIGN Retrospective review. SETTING University Hospital. MATERIALS Thirty-one patients presented with 33 episodes of graft thrombosis. CHIEF OUTCOME MEASURES Successful thrombolysis in terms of total clearance or sufficient clearance to reveal an underlying factor responsible for graft failure. MAIN RESULTS Thrombolysis was successful in seven of 10 suprainguinal grafts (4 of 5 rtPA; 3 of 5 SK). One patient had failed lysis requiring an ilio-femoral graft. Of the seven patients with successful lysis, one required revision of a proximal anastomosis, two required distal anastomotic revisions, and one rethrombosed. Twenty-three thrombosed infrainguinal grafts were managed initially with intraarterial thrombolysis (9rtPA, 14 SK). Of 27 patients surviving at 30 days, seven required major amputation despite aggressive intervention. CONCLUSIONS Thrombosed suprainguinal grafts are amenable to thrombolysis and adjunctive surgery when necessary, with no major haemorrhagic complications. The majority of patients with thrombosed infrainguinal grafts require surgical intervention in order to preserve, or establish long term patency. For polytetrafluoroethylene (PTFE) grafts, thrombolysis was associated with poor success, haemorrhagic complications and a high amputation rate.

Endovascular Treatment of Carotid Dissecting Aneurysms

Background and Purpose: Cervical arterial dissection is a well-recognised cause for acute ischaemic stroke. Dissecting aneurysms commonly occur in the affected vessels contributing to the clinical presentation. Persistence of these aneurysms may provide a source of future embolic events as well as causing local symptoms or even be at risk of spontaneous rupture. Methods: We describe 4 patients with traumatic internal carotid artery (ICA) dissections with aneurysm formation at the skull base. Three of the 4 patients still had carotid aneurysms on follow-up investigations and so underwent endovascular procedures using stenting and coil techniques. The carotid aneurysm resolved spontaneously in the fourth patient. Results: The endovascular procedures resulted in significant reduction or obliteration of the flow within the carotid aneurysms with restoration of the true lumen diameter in the adjacent ICA in all 3 patients. No perioperative complications were experienced except for transient headache in 2 patients. Conclusions: In patients with persistent aneurysms the exact risk of subsequent ischaemic events remains unknown and prospective long-term studies are needed to ascertain this risk. If recurrent stroke rates are found to be high, then carotid stenting (with or without coil insertion) is a feasible invasive approach which could be considered in these patients.

ANGIOPLASTY OF LOWER LIMB ARTERIAL STENOSES UNDER ULTRASOUND GUIDANCE : SINGLE-CENTER EXPERIENCE

PURPOSE To examine the feasibility and utility of ultrasound-guided angioplasty for treating lower limb stenoses. METHODS Duplex ultrasonography was employed to guide 55 balloon dilation procedures (27 iliac, 26 superficial femoral, 1 profunda, and 1 vein graft) with the help of a special ultrasound catheter (EchoMark). Ultrasound was used to determine balloon size, monitor guidewire passage, direct the dilation, and judge procedural success. Angiography was performed prior to the procedure to confirm preprocedural ultrasound findings and afterward to compare with duplex visual and hemodynamic parameters of success (peak systolic velocity ratio < 2.0). RESULTS The balloon size determined from duplex measurements correlated in all cases with sizes selected based on the angiographic image. Guidewire visualization was possible in 95% of the cases. Angioplasty using ultrasound alone was feasible in 84%; inability to obtain a satisfactory image owing to vessel tortuosity, calcification, and bowel gas accounted for the failures. Against the duplex success criterion, initial completion angiograms had an accuracy of 76%, sensitivity of 76%, and specificity of 100%. The additional time for ultrasound guidance averaged 42 +/- 12 minutes for all cases. CONCLUSIONS Our results show that ultrasound guidance is feasible in routine clinical practice. In this series of well-selected cases of arterial stenoses, angioplasty was performed safely using ultrasound guidance alone in over 80% of the cases. Fluoroscopic monitoring is needed when ultrasound visualization is suboptimal.

Restenosis after percutaneous transluminal angioplasty

Abstract Background: Determine the feasibility of studying the natural history of the atherosclerotic plaque following percutaneous transluminal angioplasty (PTA), using duplex scanning. Methods: Twenty-three patients with 40 stenoses (>70% and 2.0 was used to indicate >50% lumen diameter reduction. Results: Thirty stenoses were available for measurement and analysis. Mean reduction in plaque thickness after angioplasty was greater in echolucent plaques (2.33 ± 0.9 mm) than echogenic plaques (0.83 ± 0.6 mm; P 2.0) at 6 months was 12 of 30 (40%) remaining unchanged at 1 year; of the lesions that restenosed, 33% recurred before week 8 and the remainder between weeks 8 and 24, suggesting different mechanisms. During follow-up, all plaques showed “growth”; 2 mm in the remaining 13 (43%; group B). The incidence of restenosis (PSVR >2.0) was 4 of 17 (23%) in group A and 8 of 13 (61%) in group B ( P Conclusion: Duplex scanning provides valuable information on both luminal diameter and plaque thickness; it may be used to study the natural history of plaques following angioplasty and also the effects of therapeutic agents aimed at reducing restenosis.

Transbrachial coil occlusion of the first intercostal branch of an internal mammary artery bypass graft for angina

Percutaneous transbrachial insertion of a metallic coil into the first intercostal branch of the left internal mammary artery resulted in resolution of severe angina in a 60-year-old man who had coronary artery bypass surgery 14 years previously. The diagnosis of coronary artery steal was made clinically. This case illustrates the importance of recognising coronary steal in patients who redevelop angina after coronary artery surgery with the use of an incompletely prepared left internal mammary artery as a conduit. The diagnosis can be made clinically and the condition treated without the need for further surgery.

Peripheral Transluminal Angioplasty under Ultrasound Guidance: Initial Clinical Experience and Prevalence of Lower Limb Lesions Amenable to Ultrasound-Guided Angioplasty

PURPOSE Currently, endovascular techniques require monitoring by radiographic imaging for accurate catheter placement. The aim of this study was first to determine the feasibility of angioplasty under ultrasound guidance using a special catheter system. Based on this outcome, the second goal was to investigate the prevalence of lesions amenable to ultrasound-guided angioplasty. METHODS A balloon catheter system (Echomark) has been developed, which allows accurate catheter guidance by ultrasound imaging. An ultrasound-sensitive piezoelectric sensor positioned in the middle of the balloon portion of the angioplasty catheter is interfaced to an external duplex scanner via the catheter system. The exact position of the balloon relative to the transducer is calculated and reproduced on the screen of the duplex scanner to guide balloon positioning. In the feasibility assessment of the procedure, 16 patients with disabling claudication and rest pain were selected for balloon angioplasty under ultrasound guidance based on arteriographic and hemodynamic lesion criteria of > 50% stenosis with a peak systolic velocity ration > 2.5 in a lesion < 4 cm long that could be imaged by duplex ultrasonography. A fall in the peak systolic velocity ratio below 2.0 was selected for a procedural endpoint corresponding to < 30% residual stenosis on the completion angiogram. In the second part of the study, the prevalence of stenoses amenable to ultrasound-guided angioplasty was studied in 80 patients presenting with symptoms of peripheral arterial disease. RESULTS In the feasibility study, 20 stenoses (5 common iliac, 6 external iliac, and 8 superficial femoral arteries and 1 graft) meeting the inclusion criteria were subjected to ultrasound-guided angioplasty with confirmation by completion angiography. The procedure was possible in 18 (90%) of the 20 stenoses. The two failures occurred in iliac arteries that could not be imaged by duplex scanning due to obesity, bowel gas, and/or vessel wall calcification. In one case, the peak systolic velocity ratio exceeded 2.5 despite a satisfactory control arteriogram; redilation was performed, and the ratio fell below 2.0. In the second part of the study, 21 (26.2%) of the 80 patients had 29 stenoses that were amenable to angioplasty according to angiographic criteria (> 50% stenosis and < 4 cm length). All these stenoses were evaluated with duplex scanning to determine their suitability for angioplasty under ultrasound guidance. Twenty-three (79%) of the 29 lesions selected for angioplasty were well visualized by duplex, and angioplasty would have been possible based on our initial clinical experience. CONCLUSIONS Angioplasty under ultrasound control is a feasible technique for peripheral lesions. Ultrasound allows monitoring of both anatomical and hemodynamic parameters during angioplasty and thus provides a procedural endpoint that correlates to the control angiogram. A large proportion (79%) of stenoses deemed suitable for angioplasty can be well visualized by ultrasound, but obesity, vessel wall calcification, and bowel gas may limit the ability to obtain a satisfactory ultrasound image. Ultrasound-guided angioplasty is a potentially useful procedure that warrants further investigation.

Retrieval of detached coating of a hydrophilic guidewire from the profunda femoris artery using an Amplatz gooseneck snare

We present a case where during accidental puncture of the profunda femoris artery the plastic coating of a hydrophilic guidewire was stripped off against the bevel of a metal needle. This lay coiled in the profunda femoris artery. It was retrieved using an Amplatz gooseneck snare from an ipsilateral antegrade common femoral artery puncture.

Pulmonary artery reconstruction for tuberculosis

A 35-year-old woman underwent reconstruction of her right pulmonary artery for treatment of acquired right pulmonary artery stenosis. The stenosis was secondary to tuberculosis causing both an extrinsic and an intrinsic obstructive component. After her reconstruction, the patient made an uneventful recovery, and perfusion to the right lung was subsequently restored.