Gary A. Chaisson

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.

New approach to preoperative vascular exclusion for carotid body tumor.

We report a new approach to preoperative vascular exclusion of a carotid body tumor. Before surgery, covered stents were placed in the external carotid artery, resulting in vascular exclusion of the tumor. Subsequent surgical excision was uneventful, with operative blood loss less than 200 mL and no neurologic complications postoperatively. This technique deserves further consideration as a reasonable alternative to conventional embolization.

Management of the coronary-subclavian steal syndrome with balloon angioplasty. A case report and review of the literature.

A fifty-two-year-old woman with angina pectoris due to coronary-subclavian steal syndrome through a left internal mammary artery graft placed distal to a left anterior descending artery stenosis is presented. Retrograde flow through the mammary artery graft due to severe left subclavian stenosis was observed angiographically. Accordingly, left subclavian balloon angioplasty was performed, restoring normal antegrade flow through the internal mammary artery graft and resulting in resolution of the patients symptoms. The patient was subsequently discharged with no evidence of angina. Carotid- subclavian bypass surgery was avoided, reducing patient discomfort, procedural risk, and expense.

Strategies in infrapopliteal intervention: improving outcomes in challenging patients.

Achieving safe and effective outcomes in patients with infrapopliteal disease is a significant challenge to those treating this difficult anatomic subset of peripheral arterial disease. Patients with infrapopliteal disease typically present with critical limb ischemia (CLI), have high incidence of diabetes mellitus, and are often elderly with multiple comorbid conditions. There is a paucity of data from randomized controlled trials and thus little evidence-based guidance regarding endovascular management of infrapopliteal arterial disease as demonstrated by the lack of recommendations in current ACC/AHA guidelines and the TransAtlantic Intersocietal Consensus statement specifically addressing this anatomic disease subset. Critical limb ischemia is defined as limb pain that occurs at rest or impending limb loss that is caused by severe compromise of blood flow to the affected extremity. The term “critical limb ischemia” should be used for all patients with chronic ischemic rest pain, ulcers, or gangrene attributable to objectively proven arterial occlusive disease. Nearly half of the patients with CLI will need revascularization and among those who have unreconstructable disease, approximately 40% will require major amputation.1 Patients with critical limb ischemia usually have multilevel, multisegmental infrapopliteal disease with frequent involvement of the superficial

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

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.

Exclusion of an isolated iliac artery aneurysm using a bifurcated endograft following failed covered stent exclusion

Endovascular exclusion with covered stents is an alternative to surgical repair of iliac artery aneurysms (IAAs). We report a case where covered stent implantation failed to exclude an IAA, as demonstrated by persistent endoleak. The aneurysm was successfully excluded with a bifurcated aortoiliac endograft. This option should be considered for endovascular treatment of IAAs. Catheter Cardiovasc Interv 2004;61:306–309.