Andrea Pacchioni

Risk of brain injury during diagnostic coronary angiography: Comparison between right and left radial approach

OBJECTIVES To assess the incidence of silent cerebral embolization when using the transradial approach for diagnostic coronary angiography (DCA). BACKGROUND Compared to other vascular access sites, the right transradial approach (RTA) could reduce the amount of brain emboli by avoiding mechanical trauma to the aortic wall caused by catheters and wire, whereas it increases manipulation of catheters in the ascending aorta and has a higher risk of direct embolization into the right common carotid artery. A recent study showed an increased incidence of microembolic signals (MES) in RTA compared to femoral. However, left transradial approach (LTA) has never been assessed. METHODS 40 patients with suspected coronary artery disease were randomized to DCA via RTA (n=20) or LTA (n=20) with contemporaneous bilateral transcranial Doppler monitoring. RESULTS MES were detected in all patients, with a significantly higher rate in the RTA group (median 61, interquartile range (IQR) 47-105, vs 48, IQR 31-60, p=0.035). MES generated during procedures needing >2 catheters (n=8), are higher than those detected during procedures performed with 2 catheters (n=32, 102, IQR 70-108, vs 48, IQR 33-60, p=0.001). At multivariate analysis increasing number of catheters was the only independent predictor of high incidence of MES (OR 16.4, 95% CI 1.23-219.9, p=0.034, -2LL=26.7). CONCLUSIONS LTA has a lower risk of brain embolization because of the lower number of catheter exchange maneuvers. Since the degree of brain embolism depends on the magnitude of mechanical manipulation, catheter changes should be minimized to reduce the risk of cerebral embolization.

Early and Long-Term Outcomes After Combined Percutaneous Revascularization in Patients With Carotid and Coronary Artery Stenoses

OBJECTIVES This study sought to evaluate the 30-day and long-term clinical outcomes of patients with carotid obstructive disease (COD) and concomitant coronary artery disease (CAD) undergoing a combined percutaneous revascularization, in 4 high-volume centers skilled for the treatment of multilevel vascular disease. BACKGROUND The optimal management of patients with COD and concomitant CAD remains controversial. A variety of therapeutic strategies, including coronary artery bypass grafting, alone or in combination with carotid artery revascularization, have been reported. METHODS Between January 2006 and April 2010, 239 consecutive patients with COD (symptomatic carotid stenosis in 20.5%) and concomitant CAD were treated with staged or simultaneous carotid artery stenting and percutaneous coronary intervention, and enrolled in this prospective registry. The primary endpoint was the incidence of major cardiac and cerebrovascular events, including any death, myocardial infarction, or stroke occurring between the first revascularization procedure and 30 days after treatment of the second vascular territory affected. RESULTS The incidence of the primary endpoint at 30 days was 4.2% (95% confidence interval [CI]: 2.02 to 7.56). The rate of death, myocardial infarction, and stroke at long-term follow-up (median 520 days) was 4.2%, 2.1%, and 3.8%, respectively. At long-term follow-up, patients with previous cardiovascular disease had significantly higher rates of major cardiac and cerebrovascular events than did patients with a first clinical episode (17% vs. 6%, hazard ratio: 3.34; 95% CI: 1.46 to 7.63; p = 0.004). CONCLUSIONS In patients with COD and concomitant CAD, a combined percutaneous treatment compares favorably with previous surgical or hybrid experiences. Such strategy may be particularly suited to complex patients at high surgical risk.

Coil embolization for distal left main aneurysm: A new approach to coronary artery aneurysm treatment†

Coronary artery aneurysm is an uncommon disease, whose natural history and therapeutic approach are still controversial: medical therapy, surgical revascularization with or without aneurysm ligation or excision, and endovascular exclusion with membrane covered stents are all accepted and viable options, according to anatomic characteristics. Intracranial aneurysms are adequately treated by means of coil embolization, an option that, to our knowledge, has never been tested in coronary interventions. We report the first case of a coronary aneurysm involving the distal left main and the proximal left anterior descending artery treated with “stent‐assisted” coil embolization.

Prediction of Cardiovascular Events by Inflammatory Markers in Patients Undergoing Carotid Stenting

OBJECTIVE To assess whether inflammatory markers predict atherosclerotic disease activity after carotid treatment in patients with severe carotid stenosis and nonsignificant coronary artery disease undergoing carotid stenting. PATIENTS AND METHODS From March 1, 2004, to September 30, 2005, a total of 55 consecutive patients (mean ± SD age, 69±8.3 years; 26 men) with severe carotid stenosis and nonsignificant coronary artery disease were treated with carotid stent implantation. Patients were followed up for a period of 5 years for the occurrence of cardiovascular events. RESULTS A significant correlation between quantitative analysis of debris entrapped in the filters and inflammatory markers was found. Moreover, the number of particles per filter, the total particles area, and the mean particle axis per filter were significantly higher in patients with clinical events at the follow-up compared with patients without events (87 vs 32, P=.006; 50,118.7 vs 17,782, P=.002; 33.9 vs 30.2, P=.03). At 5-year follow-up we recorded cardiovascular or neurologic events in 11 of the 55 patients (20%). Higher preprocedural levels of high-sensitivity C-reactive protein, interleukin 6 soluble receptor, and interleukin 6 were significantly associated with clinical events at follow-up (P<.001, P=.05, and P=.02, respectively). In particular high-sensitivity C-reactive protein measured at 24 and 48 hours after carotid stenting showed a significant correlation with clinical events (P=.001). Also preprocedural intracellular adhesion molecule 1 and circulating vascular cell adhesion molecule 1 blood concentrations were significantly correlated with a worse prognosis at follow-up (P=.04 and P=.03, respectively). CONCLUSION In patients with severe carotid stenosis and nonsignificant coronary artery disease, inflammation is associated with atherosclerotic disease activity and a worse prognosis. Interleukin 6, interleukin 6 soluble receptor, intracellular adhesion molecule 1, vascular cell adhesion molecule 1, and high-sensitivity C-reactive protein levels at baseline and 24 and 48 hours after carotid stenting are predictive of neurologic and cardiovascular events at follow-up.

A higher body mass index is associated with reduced prevalence of unstable atherosclerotic plaque: A possible explanation of the obesity paradox

infarction. Although rare data reported that there is significant benefit even if the ischemic time is shorter than 6 h, that benefit will be significantly higher in the existence of longer ischemic time [4]. Another issue is infusion time of the stem cells. The days between the 2nd and the 7th are reported as the best time period for the benefit theoretically [5], because that is the time in which the inflammatory cytokines have increased, cell adhesion and migration have been at the highest levels, and the matrix collagen synthesis has not increased yet, the first day may also be better because the trials have shown more benefit in this period if the total ischemic time is longer than 6 h [6] (Fig. 1). In conclusion, if the individuals who had total ischemic time longer than 6 h, and baseline LVEF lower than 45% on the first day for the stem cell infusion after MI are selected, the benefit will be higher. So we think that these points should be considered in the future studies. References

Arrhythmogenic right ventricular dysplasia/cardiomyopathy presenting as ST-segment elevation myocardial infarction: A case report

Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is often challenging due to differing clinical presentations and unpredictable progression of the disease. We report a case of ARVD/C that presented as cardiac arrest in an 18-year-old male while playing soccer. The electrocardiographic features after resuscitation were typical of anterior ST-segment elevation acute myocardial infarction, and the patient was initially managed accordingly. Importantly, an urgent coronary angiogram revealed completely normal coronary arteries. ARVD/C was first suspected following an echocardiogram, and was later confirmed by cardiac magnetic resonance. One month before the event, the patient had been evaluated for ventricular extrasystoles and an abnormal resting electrocardiogram, however ARVD/C was ruled out because of the presence of only two minor diagnostic criteria (T-wave inversion in anterior precordial leads in the absence of right bundle branch block and more than 1000 ventricular extrasystoles during 24-h Holter monitoring). In consequence, physical activity was not forbidden. In conclusion, this case report enforces the need for a strict prohibition of physical activity and serial evaluation of individuals with only minor diagnostic criteria for ARVD/C, for lacking sensibility of Task Force diagnostic criteria.

Optical coherence tomography assessment of newgeneration mesh-covered stents after carotid stenting

AIMS The aim of this study was to identify the findings (by optical coherence tomography [OCT]) after carotid artery stenting (CAS) with two different types of new-generation mesh-covered stent. METHODS AND RESULTS Sixteen consecutive patients undergoing CAS with mesh-covered stents and highdefinition OCT image acquisition were enrolled in the study. Cross-sectional OCT images for the presence of strut malapposition (SM) and plaque prolapse (PP) were evaluated using a proximal or distal embolic protection device (EPD). CGuard stents were used in 11 patients (68.8%) and RoadSaver stents in five (31.2%). With OCT analysis, the incidence of SM was 20.5% for CGuard vs. 26.8% for RoadSaver, p=0.26, and the incidence of PP was 10.8% for CGuard vs. 20.7% for RoadSaver, p=0.05. No neurological complications (stroke/TIA) occurred during the procedural and post-procedural periods. CONCLUSIONS The OCT findings of two different types of mesh-covered stent after CAS were obtained safely. Our work indicates that current mesh-covered carotid stents may show differences in SM and PP. The effect of stent design and implantation technique on OCT findings post CAS, and their relation to longterm clinical outcomes, require further evaluation.

Simultaneous patent foramen ovale and left atrial appendage closure.

To the Editor A 73-year-old man with permanent atrial fibrillation was referred to our institution following a new cerebral transient ischemic attack (TIA), 1 month after the first episode, despite full anticoagulation therapy with international normalized ratio (INR) levels in normal range. His family history and physical examination were normal. He had a history of rheumatoid arthritis and recent upper gastrointestinal bleeding due to gastric erosions and esophagitis with progressive anemia. The vascular Doppler ultrasound study was normal. Hypercoagulability was not present. Transesophageal echocardiography (TEE) showed a patent foramen ovale (PFO), without septal aneurysm, with a small shunt visible with color Doppler and a significant passage of microbubbles during the Valsalva maneuver. The left atrial appendage (LAA) was also visualized and was free of thrombus.

Drug-coated balloon: Long-term outcome from a real world three-center experience.

OBJECTIVES In-stent restenosis (ISR) and diffuse small vessel disease still represent challenging subsets for percutaneous coronary interventions, also in the new-generation DES era. We aim at reporting on the long-term clinical outcome of drug-coated balloons (DCB) in all-comers population. METHODS Consecutive patients treated with DCB between January 2011 and December 2014 were retrospectively studied in three centers of northern Italy. The measured end-points were cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and major adverse cardiac events (MACE) defined as combination of cardiac death, MI, and TLR. RESULTS We included 143 patients. Of the 167 lesions treated, 41 (24.5%) were de novo lesions in small coronary vessels (<2.5 mm) and 126 (75.4%) were ISR. Among ISR lesions, 78.5% were DES-ISR, 32.5% were focal, 15.8% multifocal, 30.1% diffuse, 18.2% proliferative, and 3.1% were total occlusions. Procedural success was achieved in 94.6% of cases. Overall survival free from MACEs was 91.6% at 12 months, and 75.3% at 48 months, with a total of 3 cardiac deaths, 8 MI, and 27 TLR. No thrombotic event occurred in the treated segments. There were no differences in MACESs between the ISR and de novo lesions groups. At multivariate analysis, acute coronary syndromes, previous MI, previous surgical revascularization, peripheral arterial disease and diabetes were independent predictors of MACEs at long-term follow-up. CONCLUSIONS DCB proved a valid revascularization strategy in an all-comers population of patients with ISR and de novo lesions in small vessels, with an acceptable rate of cardiac events up to 48 months follow-up.

Difficult Cases and Complications from the Catheterization Laboratory: Case 2

Transcatheter aortic valve implantation (TAVI) is now becoming an alternative therapy to surgical aortic valve replacement (SAVR) for the patient with high surgical risk. Preprocedural complications are still frequent, and they include not only vascular but also severe life-threatening complications such as stroke, heat block, coronary obstruction, improper prosthesis positioning, cardiac perforation, mitral valve injury, and annulus or aortic root rupture. Among these severe complications, annulus and aortic root rupture will induce catastrophic outcomes [1].