Gustavo Lev

Transcatheter aortic valve implantation without balloon predilation: A single-center pilot experience

To assess the results of transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve prosthesis (Medtronic, Minneapolis, MN), without balloon predilation, in high‐risk patients with degenerated severe aortic stenosis.

Improvement in executive function after unilateral carotid artery stenting for severe asymptomatic stenosis

OBJECT Executive functions are crucial for organizing and integrating cognitive processes. While some studies have assessed the effect of carotid artery stenting (CAS) on cognitive functioning, results have been conflicting. The object of this study was to assess the effect of CAS on cognitive status, with special interest on executive functions, among patients with severe asymptomatic internal carotid artery (ICA) stenosis. METHODS The authors prospectively assessed the neuropsychological status of 20 patients with unilateral asymptomatic extracranial ICA stenosis of 60% or more by using a comprehensive assessment battery focused on executive functions before and after CAS. Individual raw scores on neuropsychological tests were converted into z scores by normalizing for age, sex, and years of education. The authors compared baseline and 3-month postoperative neuropsychological scores by using Wilcoxon signed-rank tests. RESULTS The mean preoperative cognitive performance was within normal ranges on all variables. All patients underwent a successful CAS procedure. Executive function scores improved after CAS, relative to baseline performance as follows: set shifting (Trail-Making Test Part B: -0.75 ± 1.43 vs -1.2 ± 1.48, p = 0.003) and processing speed (digit symbol coding: -0.66 ± 0.85 vs -0.97 ± 0.82, p = 0.035; and symbol search: -0.24 ± 1.32 vs -0.56 ± 0.77, p = 0.049). The benefit of CAS for working memory was marginally significant (digit span backward: -0.41 ± 0.61 vs -0.58 ± 0.76, p = 0.052). Both verbal (immediate Rey Auditory Verbal Learning Test: 0.35 ± 1.04 vs -0.22 ± 0.82, p = 0.011) and visual (delayed Rey-Osterrieth Complex Figure: 0.27 ± 1.26 vs -0.22 ± 1.01, p = 0.024) memory improved after CAS. CONCLUSIONS The authors found a beneficial effect on executive function and memory 3 months after CAS among their prospective cohort of consecutive patients with unilateral and asymptomatic ICA stenosis of 60% or more.

Initial Experience With Transradial Access for Carotid Artery Stenting

We report our experience using transradial access (TRA) for carotid artery stenting (CAS). Eighty-eight patients underwent CAS using a nonfemoral approach, 79 of them by TRA. Carotid artery stenting was performed using standard techniques with a long hydrophilic sheath. Mean age was 69.5 years. A total of 46 patients were symptomatic and 34 were asymptomatic. Transradial access and procedural success were achieved in 98.8% and 96.6% of the cases, respectively. There were no deaths, myocardial infarction, or radial access site complications. In all, 2 patients sustained a stroke, 1 hemorrhage, and 1 ischemia. Carotid artery stenting using TRA was safe and technically feasible.

Angioplasty for Treatment of Isolated Below-the-Knee Arterial Stenosis in Patients With Critical Limb Ischemia

Objective: To report our experience in patients with critical limb ischemia (CLI) due to isolated below-the-knee (BTK) arterial lesions. Methods: Between 1992 and 2009, we performed 2747 peripheral angioplasties, while 2.8% (78 of 2747) were only BTK and were included in the present study. Results: Mean age was 70.2 ± 11 years, 58.4% had diabetic, 85.7% were smokers, and 20.8% had chronic renal failure. Baseline Rutherford class: 50 patients with class IV and 27 with class V to VI. Angiographic and clinical success were 97.4% and 90.91%, respectively. At 30 days, there were no deaths, 2 patients had acute vessel closure and 2 major amputation. At long-term follow-up (22.4 ± 9.6 months), there were 7 unrelated deaths (10%), 5 amputations (7.1%), 3 reinterventions (4.2%), while 16 patients remained symptomatic. Overall amputation and amputation plus claudication-free survival were 90% and 70%, respectively. Conclusion: Endovascular treatment of BTK lesions represents a safe and effective treatment option to patients with CLI.

Safety and feasibility of balloon-expandable stent implantation for the treatment of type I endoleaks following endovascular aortic abdominal aneurysm repair.

AIMS The occurrence of type I endoleaks represent an ominous sign after endovascular aneurysms repair (EVAR). We report our experience using balloon-expandable stents (BES) for the treatment of proximal Type I endoleaks at five high-volume hospitals in Argentina. METHODS AND RESULTS Of 1,395 patients who underwent EVAR, we retrospectively collected data of 29 (2%) consecutive patients who underwent additional BES to repair proximal type I endoleaks. The mean age was 75.8 years old (range 63-87) and 93% were male. A hostile anatomy was found in 89.6% of the cases. BES oversize (balloon/neck diameter ration ≥ 30%) was frequent (69%); whereas, BES/prosthesis diameter ratio was less than 1 in 79% of the cases. Complete and partial sealing was obtained 72 and 28% of the cases, respectively. There were no immediate or late surgical conversion or major complications related with stent implantation. At a median time follow-up of 14.9 months (25-75% interquartiles: 4.5-17.5 months), there were no cardiovascular deaths, evidence of aneurysm sac enlargement or need for re-intervention. CONCLUSIONS Our preliminary results suggest that BES implantation for the treatment of proximal type I endoleaks is feasible and safe with favourable mid-term results and may preclude the need for surgical conversion.

Clinical Outcome After Saphenous Vein Stenting With Taxus Liberté Stent Results From the OLYMPIA Registry (TAXUS Liberté Postapproval Global Program)

We evaluated the incidence of clinical events after implantation of the TAXUS Liberté paclitaxel-eluting stent in saphenous vein graft (SVG) lesions in an unselected patient population. The OLYMPIA (TAXUS Liberté Post-Approval Global Registry) program gathered data on 21 954 patients receiving at least 1 TAXUS Liberté stent, including 345 patients with SVG lesions. All cardiac events were monitored with independent adjudication of end points. Patients enrolled at procedure started with no mandated inclusion/exclusion criteria. In SVG-OLYMPIA (n = 345), baseline comorbidities/complex disease were more frequent than the rest of the OLYMPIA (n = 21 560). SVG-OLYMPIA had similar cardiac death, target vessel revascularization, and definitive stent thrombosis rates than the rest of OLYMPIA. Despite higher baseline risk, the SVG-OLYMPIA had similar 12-month clinical outcome than the rest of the OLYMPIA registry, confirming the safety and efficacy of the TAXUS Liberté stent in this high-risk group.

Percutaneous repair of left ventricular pseudoaneurysm after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) represents a viable therapeutic option in patients with severe symptomatic aortic valve stenosis. The development of a left ventricular pseudoaneurysm (LVP) represents an infrequent but potentially catastrophic complication after transapical TAVR. In this case report, we present a patient undergoing TAVR through subclavian access which had an LVP and underwent successful percutaneous closure.

Estratégia híbrida combinando angioplastia carotídea e cirurgia cardiovascular

BACKGROUND: Carotid lesions are observed in 8% to 14% of cardiovascular surgery candidates and increase the risk of perioperative stroke. This is particularly important in patients with coronary disease and/or severe valve disease who are not candidate to revascularization procedures at different time points. We assessed the results of a hybrid strategy, where carotid angioplasty and cardiovascular surgery were performed sequentially with an interval of a few hours. METHOD: Carotid lesions > 70% in symptomatic patients and > 80% in asymptomatic patients were treated. Acetylsalicylic acid was administered prior to carotid stenting and heparin was administered at the time of the procedure. Once the percutaneous intervention was over, patients were transferred to the surgery room to carry out the cardiovascular procedure. Clopidogrel was administered 8 hours after the end of the surgery. RESULTS: Forty-three consecutive patients were included and treated with the hybrid strategy. Male patients (81%) were prevalent, with mean age of 70.5 ± 8.5 years, and 25.6% were diabetic. A cerebral protection system was used in 42 patients and stents were implanted in all of them. Coronary artery bypass graft (CABG) was performed in 20 patients, CABG + aortic valve replacement (AVR) in 18, CABG + ascending aorta repair in 1, CABG + mitral valve annuloplasty in 1, CABG + mitral valve replacement (MVR) in 1, AVR in 1 and MVR in 1. Hospital results showed 4 deaths (2 due to multiple organ failure, 1 due to heart failure and 1 to bleeding), 1 case of perioperative acute myocardial infarction and no strokes. Late follow-up was performed in all of the patients at 25 ± 15 months. After hospital discharge, there were two deaths not related to the percutaneous or surgical procedures and no neurological events. CONCLUSION: A hybrid strategy combining carotid stenting and cardiovascular surgery is feasible and safe with an acceptable complication rate. It may be a good option in clinically unstable patients, however, further studies with a large number of patients are required to reproduce our findings.