Balázs Berta

A randomised comparison of transradial and transfemoral approach for carotid artery stenting: RADCAR (RADial access for CARotid artery stenting) study

AIMS Limited data exist on radial access in carotid artery stenting. This multicentre prospective randomised study was performed to compare the outcome and complication rates of transradial and transfemoral carotid artery stenting. METHODS AND RESULTS The clinical and angiographic data of 260 consecutive patients with high risk for carotid endarterectomy, treated between 2010 and 2012 by carotid stenting with cerebral protection, were evaluated. Patients were randomised to transradial (n=130) or transfemoral (n=130) groups and several parameters were evaluated. Primary combined endpoint: major adverse cardiac and cerebral events, rate of access-site complications. Secondary endpoints: angiographic outcome of the procedure, fluoroscopy time and X-ray dose, procedural time, crossover rate to another puncture site and hospitalisation in days. Procedural success was achieved in all 260 patients (100%), the crossover rate was 10% in the TR and 1.5% in the TF group (p<0.05). A major access-site complication was encountered in one patient (0.9%) in the TR group and in one patient (0.8%) in the TF group (p=ns). The incidence of major adverse cardiac and cerebral events was 0.9% in the TR and 0.8% in the TF group (p=ns). Procedure time (1,620 [1,230-2,100] vs. 1,500 [1,080-2,100] sec, p=ns) and fluoroscopy time (540 [411-735] vs. 501 [378-702] sec, p=ns) were not significantly different, but the radiation dose was significantly higher in the TR group (195 [129-274] vs. 148 [102-237] Gy*cm2, p<0.05) by per-protocol analysis. Hospitalisation days were significantly lower in the TR group (1.17±0.40 vs. 1.25±0.45, p<0.05). By intention-to-treat analysis there was a significantly higher radiation dose in the TR group (195 [130-288] vs. 150 [104-241], p<0.05), but no difference in major events (0.9 vs. 0.8, p=ns) and length of hospitalisation in days (1.4±2.6 vs. 1.25±0.45, p=ns). CONCLUSIONS The transradial approach for carotid artery stenting is safe and efficacious; however, the crossover rate is higher with transradial access. There are no differences in the total procedure duration and fluoroscopy time between the two approaches but the radiation dose is significantly higher in the radial group, and the hospitalisation is shorter with the use of transradial access by per-protocol analysis. By evaluating the patient data according to intention-to-treat analysis we found no difference in major adverse events and hospitalisation. In both groups, vascular complications rarely occurred.

Transpedal access after failed anterograde recanalization of complex below-the-knee and femoropoliteal occlusions in critical limb ischemia

Successful angioplasty is one of the main factor of limb salvage during critical limb ischemia. In complex femoropopliteal to infrapopliteal occlusions, an anterograde recanalization attempt can fail in up to 20% of the cases. The purpose of this dual center pilot study was to evaluate the acute success and clinical impact of retrograde transpedal access for retrograde below‐the‐knee and femoropopliteal chronic total occlusions after failed anterograde attempt and to access the late complications at the puncture site.

Transradial and transulnar access for iliac artery interventions using sheathless guiding systems: A feasibility study

Our aim was to evaluate the acute success and complication rates of the transradial and transulnar access for iliac artery stenting using sheathless guiding systems.

Factors associated with deferred lesion failure following fractional flow reserve assessment in patients with diabetes mellitus

To explore the predictors of deferred lesion failure (DLF) in patients with diabetes mellitus (DM) and lesions with a fractional flow reserve (FFR) >0.80 and to examine whether a predictive relationship between negative FFR values (>0.80–1.00) and DLF exists.

Allen's test in patients with peripheral artery disease

IntroductionTransradial (TR) approach for coronary and peripheral angiography has become a popular technique. The Allen’s test (AT) could be used to determine the presence of collateral flow in the hand. Recently, angiographic background of modified AT was evaluated, but patients with peripherial arterial disease (PAD) were excluded in these studies. Therefore, the present study was designed to assess reliability of AT in patients with symptomatic PAD.MethodsThe present study comprised 92 symptomatic patients with PAD (Rutherford class 2–6). Perfusion of the hand was assessed with AT before outpatient peripheral angiography.ResultsSignificant RA stenosis (n=6, 12.5%) and UA stenosis (n=26, 54.2%) were found in 30 patients with positive AT (62.5%). In patients with negative AT, only UA showed significant stenoses (n=6, 13.6%). Thirty-eight patients with positive AT had anatomic abnormality in the forearm arteries or in the palmar arch (79.2%). Anatomic abnormality in the forearm arteries or in the palmar arch could be detected in 15 cases with negative AT (34.1%, p<0.0001). Conclusions. In the presence of an abnormal AT and concommitant PAD, the use of RA for peripheral or coronary catheterization and angioplasty is not recommended.

A krónikus kritikus végtagischaemia invazív kezelésének hosszú távú eredményei

INTRODUCTION AND AIM Surgical tibial bypass for critical limb ischemia is associated with significant morbidity, mortality, and graft failure, whereas percutaneous angioplasty and stenting has promising results. The objective of this study was the investigation of the long term results of below-knee percutaneous angioplasty for restoring straight inline arterial flow in patients with critical limb ischemia. METHOD The clinical and angiographic data of 281 consecutive patients with critical limb ischemia treated by PTA between 2008 and 2011 was evaluated in a prospective register. The aim of the revascularization was to achieve a straight inline flow to the wound with balloon angioplasty. Stent implantation was done in the case of recoil and flow limiting dissection. Primary end points were clinical success (relief of resting pain, healing of ulceration, limb survival) and major adverse events (death, myocardial infarction, major unplanned amputation, need for surgical revascularization, or major bleeding). Secondary end points were the angiographic result of the intervention, procedural data and consumption of angioplasty equipment. The impact of diabetic leg syndrome and the result of the angioplasty on the limb salvage was also investigated. We have analysed the impact of major amputation on long term mortality. RESULTS Mean age of patients was 72.5 ± 10.6 years and the follow-up period was 40.8 ± 9.7 months. Technical success was reached in 255 (90.7%) of the patients: 255 limbs straight inline flow with good angiographic result was restored to at least one tibial vessel. Balloon angioplasty, stent implantation and rotational atherectomy was performed in 278 (98.9%), 74 (26.3%) and 2 patients (0.7%). From clinical end points the rest pain was ceased in 56.6%, the ulcer and the gangrena was healed in 73.5% and 46.5%. The long term limb survival was 73.5%; 65.8% in diabetic and 89.6% in non-diabetic leg syndrome (p = 0.001). The major adverse events at long-term follow-up occured in 122 (43.8%) patients. Death occured in 57 (20.3%) of the patients during the long-term follow-up: 38 (13.5%) vs. 19 (6.8%) in diabetic vs. non-diabetic leg subgroup, respectively (p = 0.932). Long-term limb saving occured in 72.3% vs. 84.6% of the patients dependening the procedure was successful or unsuccessful (p = 0.225). CONCLUSION Below-knee stent angioplasty for critical limb ischemia results in good clinical outcome, but the major adverse event rate is high. Diabetes mellitus is associated with a high rate of mortality and amputation. Orv. Hetil., 2017, 158(11), 418-425.

Association between VEGF Gene Polymorphisms and In-Stent Restenosis after Coronary Intervention Treated with Bare Metal Stent

Background. In-stent restenosis (ISR) is the gradual narrowing of the vessel lumen after coronary stent implantation due to the increase in vascular smooth muscle cell proliferation. Vascular endothelial growth factor (VEGF) protein plays an important role in this process. Our aim was to analyze the association of single nucleotide polymorphisms of the VEGF gene (rs2010963 and rs6999447) with the occurrence of ISR after coronary artery bare metal stent (BMS) implantation. Methods. 205 patients with a history of BMS implantation and a repeated coronarography were prospectively enrolled. Patients were assigned to diffuse restenosis group (n = 105) and control group (n = 100) and VEGF genotypes were determined. Results. Diffuse ISR was significantly more frequently observed in patients with homozygous normal genotype of rs2010963 polymorphism, and this polymorphism was independently associated with diffuse ISR. Conclusions. RS2010963 is associated with higher incidence of development of diffuse coronary ISR in patients treated with BMS implantation.

High rate of in-stent restenosis after coronary intervention in carriers of the mutant mannose-binding lectin allele

BackgroundIn-stent restenosis occurs in 10–30% of patients following bare metal stent (BMS) implantation and has various risk factors. Mannose-binding lectin (MBL) is known to have effect on the progression of atherosclerosis. Single nucleotide polymorphisms (SNP) of the MBL2 gene intron 1 (codon 52, 54, 57) are known to modulate the bioavailability of the MBL protein. Our aim was to identify the association of these polymorphisms of the MBL gene in the occurrence of in-stent restenosis after coronary artery bare metal stent implantation.MethodsIn a non-randomized prospective study venous blood samples were collected after recoronarography from 225 patients with prior BMS implantation. Patients were assigned to diffuse restenosis group and control group based on the result of the coronarography. MBL genotypes were determined using quantitative real-time PCR. Proportion of different genotypes was compared and adjusted with traditional risk factors using multivariate logistic regression.ResultsAverage follow-up time was 1.0 (+ − 1.4) year in the diffuse restenosis group (N = 117) and 2.7 (+ − 2.5) years in the control group (N = 108). The age, gender distribution and risk status was not different between study groups. Proportion of the MBL variant genotype was 26.8% (29 vs. 79 normal homozygous) in the control group and 39.3% (46 vs. 71 normal homozygous) in the restenosis group (p = 0.04). In multivariate analysis the mutant allele was an independent risk factor (OR = 1.96, p = 0.03) of in-stent restenosis.ConclusionsMBL polymorphisms are associated with higher incidence of development of coronary in-stent restenosis. The attenuated protein function in the mutant allelic genotype may represent the underlying mechanism.

Personalized surgical repair of left ventricular aneurysm with computer-assisted ventricular engineering †

OBJECTIVES Although circular ventricular resection techniques are the gold standard of left ventricular (LV) restoration, these techniques can lead to suboptimal results. Postoperative systolic resection can be inadequate, because it must be planned on a heart stopped in diastole. Low cardiac output due to insufficient LV volume results in a potentially unstable condition, and cannot be corrected. Our aim was to find a preoperative method to minimize risk and maximize outcome with ventricular restoration. METHODS We created a novel method combining surgery with gadolinium-enhanced magnetic resonance to construct a preoperative 3D systolic heart model. The model was utilized to determine resection points that could be intraoperatively used. According to our calculations with the predetermined resection line, the calculated percentage reduction in LV volume was above 30%, and LV volumes were predicted above normal values; thus, performing the operation using these resection points is likely to be safe and effective. We had a mixed, real-life patient group: mitral insufficiency or pulmonary hypertension were not exclusion criteria. RESULTS Forty-one procedures (12 concomitant mitral valve plasty) were done on consecutive patients in a single-centre experience. The incidence rate of major adverse clinical events was 32% postoperatively (n = 13). Control MRI showed a significant improvement in ejection fraction (18.3 ± 4.3 vs 31.3 ± 3.3; P = 0.04). All patients improved their New York Heart Association (NYHA) class postoperatively (40 patients NYHA III/IV versus 40 NYHA I/II). During long-term follow-up, 1 patient died due to end-stage heart failure. CONCLUSIONS Using this model, we were able to find the optimal resection line providing an excellent postoperative result, thus minimizing the risk of low cardiac output syndrome.

Successful surgical restoration of a giant immature left ventricular aneurysm with computer assisted ventricle engineering

Abstract Background: Although circular ventricle resection techniques are the gold standard of left ventricle restoration, these techniques can lead to suboptimal results. Postoperative systolic resection line can be inadequate, as it must be planned on a heart stopped in diastole. The impaired geometry and contractility may lead to increased short- and long-term mortality. Moreover, postoperative low cardiac output due to insufficient left ventricular volume results in a potentially unstable condition, and cannot be corrected. Our aim was to find a preoperative method to minimize risk and maximize outcome with left ventricle restoration. Methods: We have created a novel method combining surgery with modern imaging techniques to construct a preoperative 3D systolic heart model. The model was utilized to determine resection could be intraoperatively used to create the new left ventricle. Results: The computer assisted ventricle engineering technique is described step by step through a successful aneurysmec...