James S. Jenkins

Infrapopliteal drug-eluting stents for chronic limb ischemia

Objective: We report our experience with the elective placement of below‐knee, drug‐eluting stents in patients with chronic limb ischemia. Background: Infrapopliteal percutaneous transluminal angioplasty has been associated with a lower rate of procedural success and high rate of restenosis because of the small size of the tibial vessels and the prevalence of calcified and diffuse atherosclerotic disease. Prior published data reports 3‐year patency rates below 25%. Bare metal stents have been reported in bailout situations. Drug‐eluting stents have markedly reduced restenosis compared to bare metal stents in the coronary vasculature, but there is little data supporting the use of these devices below the knee. Methods: Elective placement of drug‐eluting stents in infrapopliteal lesions was performed on 10 patients with severe (≥Fontaine Stage IIb) claudication (n = 1) or limb‐threatening ischemia (n = 9) (rest pain, nonhealing ulcers and gangrene). Results: A total of 17 drug‐eluting stents were electively placed in 12 below‐knee arteries in 10 patients, resulting in an average of 1.7 ± 0.7 stents per patient. The mean lesion length was 24.8 ± 10.9 mm, the mean total stent length was 38.3 ± 19.1 mm, and the mean nominal stent diameter was 2.8 ± 0.3 mm. One patient required target vessel revascularization (TVR) at 3 weeks because of stent thrombosis. TVR was 10% at 12.4 ± 6.5 months of follow‐up. Clinically driven angiography in three different patients was performed at 4, 15, and 16 months and confirmed drug‐eluting stent patency in each case. Conclusions: The use of below‐knee drug‐eluting stents is feasible and appears to be safe in our small series of complex infrapopliteal lesions causing chronic limb ischemia. The occurrence of a single case of stent thrombosis warrants continued observation in this cohort. Prospective clinical trials will be necessary to confirm the benefits and justify the costs of this strategy for treating patients with infrapopliteal culprit lesions and chronic limb ischemia.

Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach.

Compared with recent advances in treatment of serious cardiovascular diseases, such as myocardial infarction and stroke, the treatment and outcome of acute pulmonary embolism (PE) have remained relatively unchanged over the last few decades. This has prompted several experts to call for the formation of multidisciplinary PE response teams with a more proactive approach to the treatment of PE. In the current document, we discuss the formation of such teams and describe the available treatment options beyond anticoagulation, with a focus on the interventional approach. Acknowledging the paucity of data to support widespread adoption of such techniques, we call for the collection of outcomes data in multicenter registries and support for randomized trials to evaluate interventional treatments in patients with high-risk PE.

A randomized trial of intravenous N-acetylcysteine to prevent contrast induced nephropathy in acute coronary syndromes

Background: Pharmacokinetic data suggests that the intravenous form of n‐acetylcysteine (NAC) may be more effective than the oral formulation in preventing contrast induced nephropathy (CIN). NAC owing to its anti‐oxidant properties might be beneficial for patients with acute coronary syndromes (ACS) who are at increased risk for CIN. The aim of this prospective randomized, single‐center, double‐blind, placebo controlled trial (NCT00939913) was to assess the effect of high‐dose intravenous NAC on CIN in ACS patients undergoing coronary angiography and/or percutaneous coronary intervention (PCI). Methods: We randomized 398 ACS patients scheduled for diagnostic angiography ± PCI to an intravenous regimen of high‐dose NAC (1,200 mg bolus followed by 200 mg/hr for 24 hr; n = 206) or placebo (n = 192). The primary end‐point was incidence of CIN defined as an increase in serum creatinine concentration ≥25% above the baseline level within 72 hr of the administration of intravenous contrast. Results: There was no difference found for the primary end point with CIN in 16% of the NAC group and in 13% of the placebo group (p = 0.40). Change in serum cystatin‐C, a sensitive marker for renal function, was 0.046 ± 0.204 in the NAC group and 0.002 ± 0.260 in the control group (p = 0.07). Conclusion: In ACS patients undergoing angiography ± PCI, high‐dose intravenous NAC failed to reduce the incidence of CIN.

Comparison of Cutting Balloon Angioplasty and Percutaneous Balloon Angioplasty of Arteriovenous Fistula Stenosis: A Meta‐Analysis and Systematic Review of Randomized Clinical Trials

BACKGROUND Hemodialysis (HD) access failure is a common cause of increased morbidity and healthcare cost in patients with end stage renal disease (ESRD). Percutaneous balloon angioplasty has been used to treat hemodialysis access stenosis but is complicated by a high rate of restenosis. Percutaneous cutting balloon (PCB) angioplasty is an alternative approach that has shown to reduce restenosis. OBJECTIVES The aim of the study is to assess the safety and efficacy of PCB angioplasty in comparison with conventional and high-pressure balloon angioplasty in the treatment of hemodialysis access site stenosis. METHODS We searched PubMed, EMBASE and the Cochrane Central register of controlled trials (CENTRAL) databases through August 2014 and selected studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We included all randomized clinical trials with a head-to-head comparison between PCB and conventional or high-pressure balloon angioplasty RESULTS Three studies with 1034 participants (age 60.7 (±12.9) years and 50.1% males) with 525 in PCB and 509 in control arm were included in the analysis. The immediate procedural success rate was not significantly different in the PCB angioplasty and control arm respectively, (87.2% vs. 83.7% RD -0.02; 95%CI -0.06 to 0.01; P = 0.38). The six-month target lesion patency was significantly higher in the PCB angioplasty arm (67.2% vs. 55.6% RD 0.12; 95%CI 0.05-0.19; P < 0.05) with number needed to treat (NNT) of 9. The device related complications were not statistically significant between groups (RD 0.03; 95%CI -0.02 to 0.07; P = 0.26). CONCLUSIONS PCB angioplasty is effective in treatment of hemodialysis access stenosis, with significantly higher six-month patency compared to balloon angioplasty.

CILOSTAZOL INCREASES PATENCY AND DECREASES ADVERSE OUTCOMES IN PATIENTS SUBMITTED TO PERCUTANEOUS FEMOROPOPLITEAL STENT REVASCULARIZATION: A RANDOMIZED CONTROLLED TRIALS META-ANALYSIS

Cilostazol is an oral antiplatelet agent currently indicated for the treatment of intermittent claudication. There is some evidence that it may reduce femoropopliteal stent restenosis after percutaneous intervention. We searched PubMed, Scopus, and Cochrane databases from 1966 through September