Chris J. Hebert

Novel simultaneous combination chemical thrombolysis/rheolytic thrombectomy therapy for acute critical limb ischemia: The power‐pulse spray technique

The novel power‐pulse spray (P‐PS) technique maximizes and combines the advantages and minimizes the disadvantages of both chemical thrombolysis (CT) and rheolytic thrombectomy (RT). Forty‐nine consecutive patients with iliofemoral thrombotic occlusion were treated via P‐PS technique. Using a 6 Fr RT catheter, saline prime was exchanged for thrombolytic solution [group 1, 10–20 mg tenecteplase (TNK)/50 cc saline, n = 25; group 2, 1,000,000 urokinase (UK)/50 cc saline, n = 24]. The outflow port was closed, then the catheter was advanced at 1 mm increments while pulsing lytic agent. After 30‐min lysis time, RT and definitive treatment of the underlying stenosis were performed. Procedure success was 23/25 (92%) and 22/24 (91.6%) for group 1 and 2, respectively. The mean total procedure time was 72 and 75 min in group 1 and 2, respectively. Thirty‐day limb salvage was 91% in both groups. There were no major surgical complications. The P‐PS technique is safe and effective using either UK or TNK, offering several potential advantages over monotherapy, including more rapid revascularization, decreases systemic lytic exposure and bleeding complications while facilitating both CT and RT capacity and efficacy. Catheter Cardiovasc Interv 2004;63:512–522.

Intraoperative innominate and common carotid intervention combined with carotid endarterectomy: a "true" endovascular surgical approach.

Purpose: To report the technique of carotid endarterectomy (CEA) combined with retrograde balloon angioplasty and stenting of proximal “tandem” lesions in the supra-aortic trunk. Technique: Intraoperative techniques in 34 patients with 23 left common carotid artery (CCA) and 11 innominate artery lesions included general anesthesia, low-dose dextran, prosthetic patching, selective shunting, 8-F sheath entry into the native CCA before the CEA, manual CCA sizing, and balloon-expandable stent placement after predilation. The technique has a high procedural success rate (97%) and appears durable. Over a mean 34-month follow-up, 2 >70% ostial CCA restenoses were found at 24 months. Conclusions: Intraoperative innominate or left CCA balloon angioplasty/stenting combined with carotid endarterectomy is safe, effective, and durable.

Targeted Renal Therapy and Contrast-Induced Nephropathy during Endovascular Abdominal Aortic Aneurysm Repair: Results of a Feasibility Pilot Trial

Purpose: To evaluate the feasibility of targeted renal therapy (TRT) to decrease the rate of contrast-induced nephropathy (CIN) during endovascular aortic aneurysm repair (EVAR) in patients at risk for CIN. Methods: A prospective nonrandomized analysis of TRT was performed in 10 high-risk patients (8 men; median age 66.5 years, range 56–80) with pre-existing renal insufficiency. TRT involved high-dose intrarenal artery infusions of fenoldopam (FEN), a short acting selective dopamine-1 agonist and renal arteriolar vasodilator, delivered percutaneously via a left brachial access using the 5-F Benephit PV Infusion System during EVAR. Results: There were no device-related complications. TRT infusion duration ranged from 3.5 to 6.0 hours (median 4.5). Median contrast dosage was 120 mL (range 50–200). At 24 and 72 hours after EVAR, creatinine clearance (CrCl) had improved in 7 (70%) patients, remained unchanged in 2 (20%), and declined >25% in 1 (10%); the latter returned to baseline on day 5. At 30 days, 7 (70%) patients had improved CrCl and 3 (30%) remained unchanged. Conclusion: TRT is feasible during EVAR in high-risk patients. Further investigation is warranted to determine the safety and efficacy of TRT in preserving renal function during EVAR.

24-Carat Gold, 14-Carat Gold, or Platinum Standards in the Treatment of Critical Limb Ischemia: Bypass Surgery or Endovascular Intervention?

Critical limb ischemia (CLI) remains a poorly understood, rarely reported, and inconsistently treated major global healthcare epidemic. The incidence in the US is estimated at 1% of the population aged 50 years and older and at approximately double that rate in the over-70 age group. These frequencies are expected to increase significantly with the aging population and the expected increase in diabetes. Within 1 year of being diagnosed with CLI, 40% to 50% of the now 20 million US diabetics will experience an amputation, and 20% to 25% will die. The estimate for treating CLI in the US alone is

Continuous Tenecteplase Infusion Combined with Peri/Postprocedural Platelet Glycoprotein IIb/IIIa Inhibition in Peripheral Arterial Thrombolysis: Initial Safety and Feasibility Experience

10 to

Critical limb ischemia: a global epidemic. A critical analysis of current treatment unmasks the clinical and economic costs of CLI

20 billion per year, but just a 25% reduction in amputations could save

Bivalirudin as a foundation anticoagulant in peripheral vascular disease: a safe and feasible alternative for renal and iliac interventions.

2.9 to

Nitinol Stent Fractures in the SFA The biomechanical forces exerted on the SFA provide a "stiff " challenge to endovascular stenting.

3.0 billion annually. Infrainguinal bypass surgery (IBS) utilizing autogenous saphenous vein has been considered the “24-carat gold standard” treatment for CLI, but over the last decade, endovascular therapy has emerged to seriously challenge IBS, which has created considerable controversy. Despite an overall lack of “hard” level I data, many interventionists are questioning the role of IBS as a first-line CLI therapy or are at least now considering IBS a “tainted” gold standard (“14-carat”). This review will examine the available evidence, but there should be no doubt regarding the huge global clinical and economic impact of CLI and amputations.

Novel Treatment Strategy for Leg and Sternal Wound Complications After Coronary Artery Bypass Graft Surgery: Bioengineered Apligraf

Purpose: To evaluate a continuous-infusion protocol for peripheral arterial thrombolysis using tenecteplase (TNK), with regard to the technique, dosing, infusion times, and clinical outcomes. Methods: Between November 1999 and July 2002, 48 patients (30 men; mean age 68.5±11.9 years) presented with acute limb ischemia (ALI) owing to iliofemoral arterial thrombosis, which was treated with continuous TNK infusion (either 0.50 mg/h [n=22, group A] or 0.25 mg/h [n=26, group B]). All patients received periprocedural heparin (500 U/h) and peri and postprocedural tirofiban for 6 to 12 hours. Follow-up included ankle-brachial index and duplex ultrasound at baseline, 1 month, and 6 months. The variables retrospectively analyzed included total infusion time, total TNK dose, fibrinogen analysis, clinical and thrombolysis outcomes, and complications. Results: The overall clinical procedural success was 95.8%. Complete (>95%) lysis was observed in 35 (73%) patients; overall mean infusion time was 7.5 hours, and overall mean TNK dose was 4.8 mg. No deaths, intracranial bleeding, or embolic events occurred in either group. Of the 8 (16.7%) complications, 5 (10.4%) were major: 1 femoral repair (group A), 2 >5-cm nonsurgical hematomas (1 in each group), and 2 gastrointestinal hemorrhages (1 in each group). The 3 (6.3%) minor complications were minor hematomas (2 in group A and 1 in group B). The 30-day and 14-month mean limb salvage rates were 95.8% (46/48) and 89.6% (43/48), respectively. Conclusions: Continuous TNK infusion (0.25–0.50 mg/h) is a safe and feasible treatment for continuous pharmacological thrombolysis in ALI, potentially offering decreased infusion times and bleeding complications, as well as improved outcomes.