Christopher Bajzer

Multimodal Therapy for the Treatment of Severe Ischemic Stroke Combining GPIIb/IIIa Antagonists and Angioplasty After Failure of Thrombolysis

Background and Purpose— Intraarterial and intravenous thrombolysis are often ineffective for the treatment of acute ischemic stroke and are associated with a significant risk of intracranial hemorrhage (ICH). Multimodal rescue therapy combining mechanical disruption and platelet GPIIb/IIIa receptor antagonists may improve recanalization. Methods— Patients who did not recanalize with thrombolysis were treated with GPIIb/IIIa antagonists, angioplasty, or an embolectomy device. Treatment was individualized based on vascular anatomy, stroke mechanism, patient status, and symptom duration. Results— Twelve patients were treated within 3.8±2.2 hours. The mean National Institutes of Health Stroke Scale (NIHSS) score was 19.4±4.1. Six patients had carotid terminus occlusion, whereas 5 had middle cerebral artery and 1 had basilar artery occlusion. The average doses of intraarterial tPA and reteplase were 17.1±8.6 mg and 2±0.6 units, respectively. All patients received either an intravenous or intraarterial abciximab bolus (mean 11.8±5.8mg) and heparin (mean 3278±1716U). Eleven were treated with angioplasty and 4 had mechanical embolectomy or stenting. Complete (8) or partial (3) recanalization was achieved in 11 cases. There was only one (8.3%) symptomatic hemorrhage. Patients had a favorable outcome at discharge (mean NIHSS 8.9±8.7) and 6 (50%) had an NIHSS ≤4 at discharge. Conclusions— Multimodal rescue therapy was effective at recanalizing occluded cerebral vessels that failed thrombolysis without an excess risk of ICH.

Intracranial Angioplasty and Stenting in the Awake Patient

Background and Purpose. Endovascular treatment for intracranial atherosclerosis is evolving, but complications remain an issue. Most interventions are performed under general anesthesia, preventing intraprocedural clinical evaluations. We describe our approach to intracranial angioplasty and stenting, using local rather than general anesthesia, and intraprocedural neurological assessment.

A Direct Comparison of Early and Late Outcomes With Three Approaches to Carotid Revascularization and Open Heart Surgery

OBJECTIVES The aim of this study was a comparison of risk-adjusted outcomes of 3 approaches to carotid revascularization in the open heart surgery (OHS) population. BACKGROUND Without randomized clinical trials, the best approach to managing coexisting severe carotid and coronary disease remains uncertain. Staged carotid endarterectomy (CEA) followed by OHS or combined CEA and OHS are commonly used. A recent alternative is carotid artery stenting (CAS). METHODS From 1997 to 2009, 350 patients underwent carotid revascularization within 90 days before OHS at a tertiary center: 45 staged CEA-OHS, 195 combined CEA-OHS, and 110 staged CAS-OHS. The primary composite endpoint was all-cause death, stroke, and myocardial infarction (MI). Staged CAS-OHS patients had higher prevalence of previous stroke (p = 0.03) and underwent more complex OHS. Therefore, the propensity score adjusted multiphase hazard function models with modulated renewal to account for staging, and competing risks were used. RESULTS Using propensity analysis, staged CAS-OHS and combined CEA-OHS had similar early hazard phase composite outcomes, whereas staged CEA-OHS incurred the highest risk driven by interstage MI. Subsequently, staged CAS-OHS patients experienced significantly fewer late hazard phase events compared with both staged CEA-OHS (adjusted hazard ratio: 0.33; 95% confidence interval: 0.15 to 0.77; p = 0.01) and combined CEA-OHS (adjusted hazard ratio: 0.35; 95% confidence interval: 0.18 to 0.70; p = 0.003). CONCLUSIONS Staged CAS-OHS and combined CEA-OHS are associated with a similar risk of death, stroke, or MI in the short term, with both being better than staged CEA-OHS. However, the outcomes significantly favor staged CAS-OHS after the first year.

Tricuspid valve surgery and intraoperative echocardiography: Factors affecting survival, clinical outcome, and echocardiographic success

BACKGROUND The impact of echocardiographic-guided treatment on outcome after tricuspid valve (TV) surgery is not well defined. OBJECTIVES The purpose of this study was to determine clinical and echocardiographic factors associated with adverse outcomes after TV surgery and determine the role of intraoperative echo (IOE) in facilitating successful outcomes after TV surgery. METHODS Four hundred and one patients (279 females, mean age 60 years) underwent TV surgery and other concomitant cardiac surgery at a single institution and were followed clinically and by echocardiography during a 10-year period. RESULTS Decreased survival after TV surgery was associated with: preoperative increased New York Heart Association (NYHA) functional classification (relative risk [RR]=2.02), increased left ventricular dysfunction by echocardiography (RR=1.28), and use of a TV replacement strategy (RR=2.92). Decreased event-free survival after TV surgery was associated with concomitant coronary artery bypass grafting (RR=2.97). Late echocardiographic failure (3 to 4+ tricuspid valve regurgitation [TR]) after TV surgery was associated with increased severity of TR on preoperative echocardiogram (odds ratio [OR]=1.91). Decreased late echocardiographic failure after TV surgery was associated with the use of a TV annuloplasty ring with a repair strategy (OR=0.40). The surgical plan was altered at the time of surgery to insure a successful outcome in 32 (10%) of 335 patients based on IOE findings. CONCLUSIONS Adverse outcomes after TV surgery can be predicted by several preoperative clinical and echocardiographic variables. IOE is useful in improving immediate, but not late, outcomes after TV surgery.

Cause of Death Within 30 Days of Percutaneous Coronary Intervention in an Era of Mandatory Outcome Reporting

OBJECTIVES This study sought to ascertain causes of death and the incidence of percutaneous coronary intervention (PCI)-related mortality within 30 days. BACKGROUND Public reporting of 30-day mortality after PCI without clearly identifying the cause may result in operator risk avoidance and affect hospital reputation and reimbursements. Death certificates, utilized by previous reports, have poor correlation with actual cause of death and may be inadequate for public reporting. METHODS All patients who died within 30 days of a PCI from January 2009 to April 2011 at a tertiary care center were included. Causes of death were identified through detailed chart review using Academic Research Consortium consensus guidelines and compared with reported death certificates. The causes of death were divided into cardiac and noncardiac and PCI and non-PCI-related categories. RESULTS Of the 4,078 PCI, 81 deaths (2%) occurred within 30 days. Of these, 58% died of cardiac and 42% of noncardiac causes. However, only 42% of 30-day deaths were attributed to PCI-related complications. Patients with non-PCI-related, compared with PCI-related, death presented with a higher incidence of cardiogenic shock (15 of 47 [32%] vs. 2 of 34 [6%]; p < 0.01) and cardiac arrest (19 of 47 [40%] vs. 1 of 34 [3%]; p < 0.01). Death certificates had only 58% accuracy (95% confidence interval: 45% to 72%) for classifying patients as experiencing cardiac versus noncardiac death. CONCLUSIONS Less than one-half of 30-day deaths are attributed to a PCI-related complication. Death certificates are inaccurate and do not report PCI-related deaths, which may represent a better marker of PCI quality.

Real-world bare metal stenting: Identification of patients at low or very low risk of 9-month coronary revascularization

The high cost of drug‐eluting stents (DESs) has made identification of patients who are at low risk for subsequent revascularization after treatment with bare metal stents (BMSs) highly desirable. Previous reports from randomized trials suffer from biases induced by restricted entry criteria and protocol‐mandated angiographic follow‐up. Between 1994 and 2001, 5,239 consecutive BMS patients, excluding those with coil stents, technical failure, brachytherapy, staged procedure, or stent thrombosis within 30 days, were prospectively identified from a large single‐center tertiary‐referral‐center prospective registry for long‐term follow‐up. We sought to identify characteristics of patients with very low (≤ 4%) or low (4–10%) likelihood of coronary revascularization 9 months after BMS. Nine‐month clinical follow‐up was obtained in 98.2% of patients. Coronary revascularization was required in 13.4% and did not differ significantly by stent type. On the basis of multivariate analysis identifying 11 independent correlates and previous reports, 20 potential low‐risk patient and lesion groups (228 ± 356 patients/groups) were identified (e.g, patients with all of the following: native vessel, de novo, reference diameter ≥ 3.5 mm, lesion length < 5 mm, no diabetes, not ostial in location). Actual and model‐based outcomes were analyzed. No group had both predicted and observed 9‐month revascularization ≤ 4% (very low risk). Conversely, 19 of 20 groups had a predicted and observed revascularization rate of 4–10% (low risk). In the real‐world setting, the need for intermediate‐term revascularization after BMS may be lower than expected, but it may be very difficult to identify patients at very low risk. Conversely, if the benefits of DESs are attenuated in routine practice, many groups of patients treated with BMSs may have nearly comparable results. Catheter Cardiovasc Interv 2004;63:135–140.

Leukocyte Count Predicts Microembolic Doppler Signals During Carotid Stenting A Link Between Inflammation and Embolization

Background and Purpose— Protected stenting has emerged as a safe and effective alternative to endarterectomy for the treatment of carotid stenosis in patients at high operative risk. Distal microembolization occurs invariably during carotid stenting. Little is known about the relationship between systemic inflammation and embolization during carotid stenting. Methods— We examined 43 consecutive patients who underwent carotid stenting with simultaneous transcranial Doppler (TCD) monitoring of the ipsilateral middle cerebral artery. Embolization was quantified by measuring microembolic signals (MES) on TCD. Preprocedure leukocyte counts were related to MES. Results— In unadjusted analyses, preprocedure leukocyte count was positively correlated with total procedural MES (r2= 0.16; P=0.008). After considering age, gender, comorbidities, concomitant medical therapies, and the use of emboli prevention devices, increasing leukocyte count (&bgr;=35 for each 1000/&mgr;L increment; P=0.018) remained a significant and independent predictor of embolization (model-adjusted r2=0.365; P=0.0005). Conclusions— Increasing preprocedure leukocyte count independently predicted more frequent MES during carotid stenting. These data suggest that systemic inflammation may influence the degree of procedural embolization.

Feasibility of simultaneous bilateral carotid artery stenting

Due to the progressive aging of the population, severe bilateral carotid stenosis has become a more frequent condition. On occasion, simultaneous revascularization may be appropriate. There is increased evidence that for these high‐risk patients, a percutaneous revascularization may be the best approach. However, there are concerns that simultaneous bilateral carotid stenting may be associated with cerebral hyperperfusion, excessive bradycardia, and hypotension. We report a series of 10 consecutive patients who underwent simultaneous bilateral carotid stenting. All of these patients were not deemed to be surgical candidates due to high‐risk comorbidities. All but one of the lesions were successfully stented. There were no procedural deaths, myocardial infarctions, or strokes. Thus, among carefully selected patients, simultaneous bilateral carotid artery stenting is a promising, technically feasible option. Catheter Cardiovasc Interv 2004;61:437–442.

Utility of IVUS-guided transaccess catheter in the treatment of long chronic total occlusion of the superficial femoral artery

Failure to reenter the true lumen distal to an occlusion is the most frequent cause of failure of the technique of subintimal angioplasty. We report the utility of an IVUS‐guided TransAccess catheter in overcoming this problem in the treatment of two patients with long chronic total occlusion of the superficial femoral artery. Catheter Cardiovasc Interv 2004;62:237–243.

Renal artery end-diastolic velocity and renal artery resistance index as predictors of outcome after renal stenting

T have been numerous reports on renal angioplasty and stenting that have opposing results and opinions. Long-term hypertension may cause nephrosclerosis or glomerulosclerosis, and increase vascular resistance. Treatment of the renal artery is unlikely to improve perfusion in patients with increased microvascular resistance, and such patients are unlikely to obtain clinical benefit. Radermacher et al demonstrated that a renal artery resistance index (RI) has good predictive value in identifying patients who are unlikely to benefit from renal revascularization. In this study, we evaluated whether renal artery peak systolic (PSV) and end-diastolic (EDV) velocities and the renal artery RI can predict outcomes after renal artery stenting. • • • Patients treated for renal artery stenosis between August 2000 and February 2001 were identified from a comprehensive database of all peripheral procedures at our institution (Cleveland Clinic Foundation, Cleveland, Ohio). Seventeen patients with renal artery stenosis underwent stenting with a 100% procedural success rate (Figure 1) and underwent complete preprocedural ultrasound study. Clinical indication for renal stenting was medically refractory or difficult to treat hypertension. Clinical follow-up was systematically obtained by chart review for outpatient visit evaluation and telephone interview by physicians. All patients had a follow-up of 30 days. Renal ultrasound was performed using B-mode ultrasound guidance (ATL HDI 5000, Phillips Corporation), and a C5-2 curved array transducer (Phillips Corporation, Bothell, Washington). The PSV and the EDV were measured and the dimensionless RI was calculated as: