Jean-François Dorval

The Benefits Conferred by Radial Access for Cardiac Catheterization Are Offset by a Paradoxical Increase in the Rate of Vascular Access Site Complications With Femoral Access : The Campeau Radial Paradox

OBJECTIVES The purpose of this study was to assess whether the benefits conferred by radial access (RA) at an individual level are offset by a proportionally greater incidence of vascular access site complications (VASC) at a population level when femoral access (FA) is performed. BACKGROUND The recent widespread adoption of RA for cardiac catheterization has been associated with increased rates of VASCs when FA is attempted. METHODS Logistic regression was used to calculate the adjusted VASC rate in a contemporary cohort of consecutive patients (2006 to 2008) where both RA and FA were used, and compared it with the adjusted VASC rate observed in a historical control cohort (1996 to 1998) where only FA was used. We calculated the adjusted attributable risk to estimate the proportion of VASC attributable to the introduction of RA in FA patients of the contemporary cohort. RESULTS A total of 17,059 patients were included. At a population level, the VASC rate was higher in the overall contemporary cohort compared with the historical cohort (adjusted rates: 2.91% vs. 1.98%; odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.17 to 1.89; p = 0.001). In the contemporary cohort, RA patients experienced fewer VASC than FA patients (adjusted rates: 1.44% vs. 4.19%; OR: 0.33, 95% CI: 0.23 to 0.48; p < 0.001). We observed a higher VASC rate in FA patients in the contemporary cohort compared with the historical cohort (adjusted rates: 4.19% vs. 1.98%; OR: 2.16, 95% CI: 1.67 to 2.81; p < 0.001). This finding was consistent for both diagnostic and therapeutic catheterizations separately. The proportion of VASCs attributable to RA in the contemporary FA patients was estimated at 52.7%. CONCLUSIONS In a contemporary population where both RA and FA were used, the safety benefit associated with RA is offset by a paradoxical increase in VASCs among FA patients. The existence of this radial paradox should be taken into consideration, especially among trainees and default radial operators.

Percutaneous endoluminal arterial cryoenergy improves vascular remodelling after angioplasty

This study aimed to investigate the effect of percutaneous endoluminal arterial cryoenergy immediately after balloon angioplasty on vascular remodeling. Restenosis, the main complication after coronary artery angioplasty, is a complex phenomenon in which vascular remodeling plays a prominent role. Observations of reduced scarring in freeze-induced wounds suggest potential value for cryoenergy in the prevention of restenosis. Juvenile swine underwent a first oversized balloon injury in both carotid arteries (CA) (3 injury sites/artery) and a second injury at day 14. At that time, one CA was randomly assigned to endoluminal cryoenergy of the sequential segments (proximal, medial, distal) at -15 degrees C, -30 degrees C, and -50 degrees C for 120 sec, and the other CA was used as control. Animals were sacrificed 28 days after the second procedure. Compared with intact reference segments, angioplasty reduced both the luminal (LA) and the external elastic lamina (EEL) areas from 6.66+/-0.59 to 3.13+/-0.54 mm(2) (p<0.05) and from 8.81+/-0.81 to 6.48+/-0.52 mm(2) (p<0.05), respectively. Cryoenergy, at the temperature with maximal benefits (-50 degrees C), caused a temperature-related protection, as the LA was maintained (6.79+/-0.89 versus 7.18+/-0.78 mm(2) for reference) and the EEL area increased from 9.12+/-0.78 to 12.98+/-1.07 mm(2), p<0.05. Moreover, cryoenergy increased the density of collagen III (p<0.05) which correlated with the maintenance of the LA (r=0.8045, p<0.009). Cryoenergy prevents late luminal loss after double-injury angioplasty by improving vascular remodeling, and is an interesting new therapeutic approach for the prevention of restenosis after angioplasty. The increased synthesis of collagen III appears to be involved in this phenomenon and could be a potential method of stabilizing the vulnerable plaque.

Efficacy of a balloon-expandable vascular access system in transfemoral TAVI patients

Vascular complications (VC) are a serious and frequent complication of transfemoral transcatheter aortic valve implantation (TAVI) and result in increased morbidity and mortality. It has been suggested that newly developed vascular sheaths may increase the ability to perform transfemoral TAVI in patients with normal and access‐limiting peripheral artery disease (PAD) and reduce vascular complications. Aims: We sought to assess the safety and efficacy of the 19 French (F) SoloPath balloon‐expandable transfemoral vascular access system in patients who underwent transfemoral TAVI at our center between 2011 and 2014. Methods and results: Single‐center retrospective study of 90 patients who underwent transfemoral TAVI with the use of the SoloPath sheath. Patients were categorized into two groups according to a sheath to femoral artery ratio (SFAR) of less than or equal to 1.05, or greater than 1.05. Overall, the incidence of major bleeding complications was low, 4.4%. No significant differences were found in technical or procedural success rates (100% in both groups and 100% vs. 91.3; P = 0.09; respectively), total vascular complications (20.8 vs. 21.7; P = 0.92) or total bleeding complications (20.8 vs. 30.4; P = 0.36 between those with SFAR greater or less than 1.05. Conclusions: The use of the SoloPath balloon‐expandable sheath is feasible and safe even in patients with SFAR > 1.05, showing no increased vascular or bleeding complications compared to patients with larger vascular access.

Endovascular Cryotherapy Accentuates the Accumulation of the Fibrillar Collagen Types I and III after Percutaneous Transluminal Angioplasty in Pigs

Purpose: To investigate the effect of endovascular cryotherapy (Cryo) on the density of collagen types I (CI) and III (CIII), which are involved in the dynamic modulation of extracellular matrix (ECM) after percutaneous transluminal angioplasty (PTA). Methods: Twenty-one juvenile farm swine and 10 miniswine underwent PTA of the femoral arteries with and without Cryo (–50°C for 2 minutes). Quantitative angiography, histomorphometry, and quantification of CI and CIII were performed at 1 week (n=7), 1 month (n=7), 3 months (n=7), and 6 months (n=10). Results: PTA decreased the minimal luminal diameter (MLD) (range 3.48±0.18 to 4.2±0.39 mm) compared to baseline values (range 3.67±0.15 to 4.59±0.23 mm), but the application of Cryo maintained the MLDs at preprocedural levels (range 3.88±0.31 to 4.58±0.21 mm). At the time of sacrifice, the MLDs were similar in PTA and Cryo-treated arteries, but the external elastic lamina was significantly greater after Cryo application (range 10.17±0.54 to 14.34±0.76 mm2) than after PTA (range 8.69±0.70 to 11.77±0.73 mm2, p<0.05). Cryo did not alter the luminal area or prevent neointimal growth. A time-dependent increase of both CI and CIII was observed as early as 1 week after PTA, peaking at 3 months, and declining thereafter. Cryo accentuated this increase at all time points. Conclusion: The application of Cryo accentuates the accumulation of CI and CIII in PTA-treated femoral arteries. This effect may be of clinical relevance in the stabilization of peripheral atherosclerotic plaque.

Results of a multimodal approach for the management of aortic coarctation and its complications in adults

OBJECTIVES We aimed to assess the results of various tailored management strategies for adults with coarctation in our centre. METHODS We reviewed all adults patients treated for aortic caorctation between January 2000 and December 2015 in our institution. The primary end point was a composite of death, perioperative stroke, paraplegia, need for unplanned reoperation or occurrence of pseudoaneurysm during the follow-up. The mean follow-up was 82 ± 5 months. RESULTS Sixty-three adults were treated for a native coarctation (n = 34), a recurrent coarctation (n = 14) or aneurysmal complication (n = 15). Mean age of the patients was 42 ± 1.7 years. All but 1 patient with native coarctation (33/34, 97%) and recurrent coarctation (13/14, 93%) underwent endovascular repair and 10 (67%) patients with aneurysmal complications were treated surgically. Freedom from the primary composite end point was 94, 84 and 81% at 1, 5 and 10 years, respectively, without difference between the 3 indication groups (P = 0.96). CONCLUSIONS A tailored management strategy is necessary to provide good results for the treatment of adults with aortic coarctation. Thus, centres that are involved in the care of this complex pathology should be able to propose a multimodal approach, either endovascular or surgical depending on patients characteristics and anatomic features.

Management of a spontaneous renal capsule hematoma following cardiac catheterization involving use of a platelet glycoprotein IIb/IIIa inhibitor: A case report

We describe the case of a 64‐year‐old woman who experienced a left renal sub‐capsular hematoma following complex percutaneous coronary intervention. The hemorrhage was arrested by balloon inflation followed by coil embolization. Final thrombosis around the coil was achieved by an infusion of a small amount of thrombin.

Clinical outcomes of bioresorbable vascular scaffold to treat all-comer patients. Are patients with acute coronary syndrome better candidate for bioresorbable vascular scaffold?

BACKGROUND Scaffold thromboses (ST) and adverse events and have been associated with bioresorbable vascular scaffolds (BVS) at long-term, but their mechanism remains unclear. We sought to evaluate patient and lesion characteristics associated with mid- to long-term outcomes in patients treated with BVS. METHODS This is an observational single-center, single-arm, retrospective study evaluating the performance of BVS in an all-comer population, including complex lesions (chronic total occlusions, long lesions), small vessels, and acute coronary syndromes (ACS). RESULTS From May 2013 to June 2015, we included 482 patients (580 lesions) that were treated with BVS implantation including 71.2% treated for ACS in the present analysis. Mean follow-up period was 816.2 ± 242.6 days. The primary endpoint was device oriented cardiac events (DOCE), defined as a composite of target-lesion revascularization (TLR), ST, target vessel myocardial infarction (TVMI) and cardiac death. Using Kaplan-Meier methods, the DOCE and ST rates at 36 months were 9.4% and 2.3%, respectively. No ST occurred between 2 and 3 years and ST occurred after 3 years, in one patient. Using multivariate analysis, ACS was the only significant predictor of lower rates of DOCE (p = 0.04, HR: 0.47, 95% CI: 0.23-0.96). CONCLUSIONS In this large all-comers real-world cohort, lesions treated with BVS had non-negligible rates of DOCE and ST, in line with previous published randomized trials. The occurrence of very late event was very low after 24 months. ACS patients had lower rates of DOCE.

Long-term outcomes of bioresorbable vascular scaffold in ST-elevation myocardial infarction

Abstract Background: Bioresorbable vascular scaffolds (BVS) implantation in selected patients with stable angina has been demonstrated feasible and safe. However, limited data are currently available on long-term outcomes after BVS implantation for ST-elevation myocardial infarction (STEMI). Therefore, we sought to assess the safety, efficacy and long-term results of BVS implantation in STEMI patients. Methods: Retrospective review of all STEMI patients treated with the Absorb® BVS (Abbott Vascular, Santa Clara, CA) or conventional drug eluting stent (DES) between 1 April 2013 and 30 March 2014. Primary outcomes were procedural success, device thrombosis and device-oriented composite endpoint (DOCE) including cardiac death, target vessel myocardial infarction and target lesion revascularization. The study included 54 BVS patients and 121 DES patients. Results: Patients were slightly younger in the BVS group (60 vs. 63 years old, p = .03). Other baseline characteristics were comparable between the two groups. Procedural success was achieved in all patients. Median follow-up was 901 days and 849 days for BVS and DES patients, respectively (p = .01). The cumulative incidence of DOCE was not significantly different between the BVS and DES groups (7.5% vs. 9.1%, hazard ratio [HR]: 0.74 [95% confidence interval (CI): 0.26–2.2], p = NS). Rate of probable/definite device thrombosis were not statistically different between both groups (3.7% vs. 3.3%, p = NS). Conclusions: The results of this single-centre retrospective study, one of the first assessing long-term safety and efficacy of BVS in STEMI, seems reassuring with similar long-term results as compared with patients treated with conventional DES.

Bioresorbable vascular scaffold to treat in‐stent restenosis: Single‐center experience

AIMS The management of patients with in-stent restenosis (ISR) is still a major clinical challenge even in the era of drug-eluting stents (DES). Recent studies have demonstrated acceptable clinical outcomes for the everolimus-eluting bioresorbable vascular scaffold (BVS) ABSORB™ in patients with stable coronary artery disease but data are scarce on its use in patients with ISR. We report the long-term results of our preliminary experience with this novel approach at our institution. METHODS AND RESULTS We investigated the safety and efficacy of BVS implantation to treat ISR. 34 consecutive patients (37 lesions) underwent PCI for ISR with BVS implantation between May 2013 and June 2015 at our institution and were included in the current analysis. Follow-up was available in 91.9% of the patients. Mean follow-up period was 801.9 ± 179 days. One patient had definite scaffold thrombosis (ScT) 2 months after stent implantation which was treated with DES. Five patients (six lesions) experienced target lesion revascularization (TLR). The composite endpoint rate of TLR, ScT, myocardial infarction, and death occured in 6/37 lesions at follow-up (16.2%). CONCLUSIONS These real-world data using BVS in patients with ISR demonstrates that ISR treatment with ABSORB™ BVS is feasible but could have slightly higher target lesion failure rates as compared to DES. This proof of concept could be hypothesis-generating for larger randomized controlled studies.

Everolimus-eluting bioresorbable vascular scaffold implantation to treat saphenous vein graft disease, single-center initial experience

AIMS Recent studies have shown favorable outcomes with everolimus-eluting bioresorbable vascular scaffold (BVS) in patients with stable coronary artery disease. Data on the use of BVS in saphenous vein graft disease (SVG) is currently lacking. METHODS AND RESULTS A total of 10 consecutive patients (13 lesions, including 6 in-stent restenosis) who underwent BVS for SVG disease between May 2013 and June 2015 at a tertiary care institution were included. Median follow-up period was 874 (720-926) days. One patient had scaffold thrombosis (ScT) 15 months after implantation, which was treated medically. Another patient had target lesion revascularization (TLR) in two different lesions, where BVS was used to treat in-stent restenosis. The composite endpoint of TLR, ScT, target vessel myocardial infarction, and cardiac death, was reached in two patients CONCLUSIONS: This first real-world data on the use of the ABSORB™ BVS in patients with SVG disease shows that its implantation is technically feasible. The observed rate of target lesion revascularization was similar to those observed with drug-eluting stents in similar settings. Larger studies are required to better define the optimal use of BVS to treat SVG disease.