Karolina Dzierwa

Zotarolimus-eluting stent for the treatment of recurrent, severe carotid artery in-stent stenosis in the TARGET-CAS population.

Purpose To evaluate the safety and efficacy of a balloon-mounted drug-eluting stent (DES) for recurrent carotid in-stent stenosis (ISS). Methods As part of our targeted carotid artery stenting (TARGET-CAS) protocol, neurological and ultrasound evaluations have been performed at 3, 6, and 12 months and then annually since 2001 in all carotid stent patients. For angiographically-confirmed >70% ISS, balloon angioplasty was performed as a first-line treatment. Recurrent ISS was treated with a 4.0-mm zotarolimus-eluting coronary stent (ZES) that was postdilated according to intravascular ultrasound imaging. Among the 1350 neuroprotected CAS procedures performed between January 2001 and March 2011, there were 7 (0.52%) patients (5 men; ages 51–72 years), all neurologically asymptomatic, with >70% recurrent ISS that occurred at 5 to 11 months after the initial balloon angioplasty treatment for ISS. Results ZES implantation under distal embolic protection was technically successful and uncomplicated. Angiographic stenosis was reduced from 84.6%±7.5% to 10.7%±3.6% (p <0.01). In 5 patients with ZES implanted fully within the self-expanding carotid stent, duplex ultrasound follow-up (mean 17 months, range 6–36) revealed no evidence of restenosis or stent fracture/deformation. In the 2 other patients, the ZES had been implanted for distal edge ISS such that the ZES protruded beyond the original carotid stent. This protruding segment of the ZES demonstrated deformation/kinking in both; in one, this led to symptomatic stent occlusion. Conclusion The use of coronary ZES in the treatment of recurrent carotid ISS is feasible and appears effective provided the ZES is placed entirely within the original stent. Placement of a coronary ZES outside the carotid stent scaffold should be avoided.

Flow reversal for proximal neuroprotection during endovascular management of critical symptomatic carotid artery stenosis coexisting with ipsilateral external carotid artery occlusion.

Purpose: To report the utility of proximal brain protection by flow reversal in endovascular management of critical internal carotid artery (ICA) stenosis coexisting with ipsilateral external carotid artery (iECA) occlusion. Case Report: Four patients with a symptomatic, critical ICA stenosis (in-stent restenosis in one) and iECA occlusion were admitted for carotid artery stenting (CAS). In all cases, the stenosis severity and high-risk lesion morphology precluded the use of filter protection. The “tailored” CAS algorithm indicated that a proximal anti-embolism system should be used to maximize the potential for effective neuroprotection. The flow reversal system, which consists of an independent guiding sheath balloon positioned in the common carotid artery (CCA) and an iECA balloon-wire, was employed, using the CCA balloon only. The system was well-tolerated, and the CAS procedures were uneventful. Conclusion: Due to a unique design with separate CCA and iECA balloons, the flow reversal system can be used for proximal neuroprotection during CAS in severe, symptomatic ICA lesions coexisting with iECA occlusion.

Treatment strategies in severe symptomatic carotid and coronary artery disease

Summary Coexistent carotid artery stenosis (CS) and multivessel coronary artery disease (CAD) is not infrequent. One in 5 patients with multivessel CAD has a severe CS, and CAD incidence reaches 80% in those referred for carotid revascularization. We reviewed treatment strategies for concomitant severe CS and CAD. We performed a literature search (MEDLINE) with terms including carotid artery stenting (CAS), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), stroke, and myocardial infarction (MI). The main therapeutic option for CS-CAD has been (simultaneous or staged) CEA-CABG. This, however, is associated with a high risk of MI (in those with CEA prior to CABG) or stroke (CABG prior to CEA), and the cumulative major adverse event rate (MAE – death, stroke or MI) reaches 10–12%. With increasing adoption of CAS, a sequential strategy of CAS followed by CABG has emerged. Registries (usually single-centre) indicate an MAE rate of ≈7% for CAS followed by CABG (frequently after >30 days, due to double antiplatelet therapy). Recently, 1-stage CAS-CABG has been introduced. This involves different antiplatelet regimens and, in some centers, preferred off-pump CABG, with a cumulative MAE of 1.4–4.5%. No randomized trial comparing different treatment strategies in CS-CAD has been conducted, and thus far reported series are prone to selection/reporting bias. In addition to the established surgical treatment (CEA-CABG, sequential/simultaneous), hybrid revascularization (CAS-CABG) is emerging as a viable therapeutic option. Larger, preferably multi-centre, studies are required before this can become widely applied.

Simultaneous vertebral and subclavian artery stenting

Introduction Vertebrobasilar territory ischemia leads to disabling neurological symptoms and may be caused both by vertebral artery (VA) and subclavian artery (SA) stenosis. The coexisting symptomatic ipsilateral VA and proximal SA stenosis should be considered as a true bifurcation lesion for percutaneous treatment. Aim To evaluate the safety and efficacy of simultaneous angioplasty of vertebral and subclavian stenosis. Material and methods Fifteen patients (age 69.5 years, 46.7% men, all symptomatic from posterior circulation (history of stroke, transient ischemic attack, chronic ischemia symptoms)) were scheduled for simultaneous SA/VA angioplasty. Clinical and duplex ultrasound follow-up was conducted 1, 6 and 12 months after the procedure. Results The technical success rate was 100%. Single balloon-mounted stent angioplasty was performed for all VAs and for 13 (86.7%) SAs. In 4 cases a simultaneous radial and femoral approach was required. The mean North American Symptomatic Carotid Endarterectomy Trial (NASCET) VA stenosis was reduced from 88.7 ±9.7% to 5.7 ±6.8% and SA stenosis from 80 ±12.2% to 11 ±12.3% (p < 0.01). No periprocedural death, stroke, myocardial infarction or transient ischemic attack occurred. During follow-up (range: 6–107 months) in 10 of 15 (66.7%) patients relief of chronic ischemic symptoms was observed. No stroke/TIA occurred. One cardiovascular and 2 non-cardiovascular deaths were recorded. There was 1 symptomatic vertebral and 1 subclavian in-stent restenosis, and 2 cases of asymptomatic VA in-stent occlusion occurred. Conclusions Simultaneous vertebral and subclavian artery stenting is safe and effective. The restenosis rate remains at an acceptable level and it may be treated successfully with drug-eluting balloon angioplasty. In selected patients a dual radial and femoral approach may facilitate the procedure.

Mesh-covered (Roadsaver) stent as a new treatment modality for symptomatic or high-risk carotid stenosis

Introduction Prevention of periprocedural stroke has a crucial role in carotid artery stenting (CAS) procedures. Aim To assess retrospectively 30-day safety and effectiveness of 41 procedures of internal and common carotid artery stenting using the Roadsaver double nitinol layer micromesh stent in 40 non-consecutive patients with symptomatic or high-risk carotid artery stenosis. Material and methods The patients were men (n = 31) and women (n = 9); mean age was 67.8 ±7.9 years. Femoral access was used in 39 cases, whereas radial access was used in 2. Proximal (n = 27) or distal (n = 14) embolic neuroprotection was used. Results The Roadsaver stents (nominal diameter 7, 8 or 9 mm, length 25 or 30 mm) were implanted successfully in all cases. One minor stroke occurred after common carotid artery intubation with a guiding catheter (before stent deployment) and one transient postprocedural ischemic attack (TIA) of the ipsilateral cerebral hemisphere was observed. Internal/common carotid artery stenosis severity was evaluated by duplex Doppler. Maximal peak systolic velocity (PSV) before CAS was in the range: 2.0–7.0 m/s, mean: 3.9 ±1.0 m/s, at 24–48 h after stenting mean PSV was 1.1 ±0.4 m/s (p < 0.05), and at 30 days 1.1 ±0.3 m/s (p < 0.05). Maximal end-diastolic velocity (EDV) was 0.85–3.5 m/s, mean 1.4 ±0.5 m/s, at 24–48 h after stenting mean EDV was 0.3 ±0.1 m/s (p < 0.05), and at 30 days 0.4 ±0.1 m/s (p < 0.05). No restenosis or thrombosis was observed. Angiographic stenosis decreased from 82.9 ±9.1% (range: 61–97%) to 19.3 ±7.3% (range: 0–34%) (p < 0.05). Conclusions The CAS using the Roadsaver stent seems to be safe and effective. Further studies involving larger patient populations and longer follow-up are needed.

Intravenous N-acetylcysteine for the PRevention Of Contrast-induced nephropathy – a prospective, single-center, randomized, placebo-controlled trial. The INPROC trial

Introduction Contrast-induced nephropathy (CIN) is a common clinical problem that is growing in importance as an increasing number of tests and procedures which utilize contrast media (CM) are performed. Aim To evaluate the efficacy of intravenous N-acetylcysteine (NAC) for prevention of CIN after diagnostic and/or interventional procedures requiring CM administration. Material and methods In a prospective, single-center, randomized, placebo-controlled trial the preventive effects of N-acetylcysteine were evaluated in 222 patients undergoing elective angiography and/or angioplasty. Patients were randomly assigned to receive either NAC or placebo. All patients received intravenous hydration with normal saline before and after catheterization. Serum creatinine (SCr) and estimated glomerular filtration rate were assessed at baseline, at 48–72 h and 10–15 days after CM administration. Contrast-induced nephropathy was defined as an increase in SCr of at least 44 µmol/l (0.5 mg/dl) or an increase of ≥ 25% of the baseline value 48–72 h after CM administration. Results Contrast-induced nephropathy occurred in 30 of 222 patients (13.5%): 9 of 108 patients in NAC (8.3%) and 21 of 114 patients in the control group (18.4%; p = 0.0281). The multivariate Cox analysis revealed that elevated SCr at 10–15 days (HR = 2.69; p = 0.018) and baseline SCr level (HR = 1.009; p = 0.015) were independent prognostic variables for adverse events during follow-up. Conclusions Our findings suggest that intravenous NAC along with intravenous hydration may help prevent declining renal function after CM exposure. Elevated SCr level 10–15 days after CM administration was associated with increased risk of adverse events in long-term observation, while elevated SCr within 72 h was not. Measuring SCr at least 10 days after exposure to CM may provide a better outcome measure.

Hybrid one-day coronary artery bypass grafting and carotid artery stenting – cardiac surgeons’ perspective on the procedure’s safety

1Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland 2Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland 3Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland 4Cardiosurgical Students’ Scientific Group, Jagiellonian University Medical College, Krakow, Poland 5Department of Cardiac and Vascular Diseases, John Paul II Hospital, Krakow, Poland

Invasive treatment for carotid fibromuscular dysplasia.

Introduction Fibromuscular dysplasia (FMD) is an infrequent non-inflamatory disease of unknown etiology that affects mainly medium-size arteries. The prevalence of FMD among patients scheduled for endovascular treatment of carotid artery stenosis is unknown. Aim To evaluate the prevalence and treatment options of carotid FMD in patients scheduled for carotid artery stenting (CAS). Material and methods Between Jan 2001 and Dec 2013, 2012 CAS procedures were performed in 1809 patients (66.1% men; age 65.3 ±8.4 years, 49.2% symptomatic). In case of FMD suspicion in Doppler-duplex ultrasound (DUS), computed tomography angiography was performed for aortic arch and extracranial and intracranial artery imaging. For invasive treatment of FMD carotid stenosis, balloon angioplasty was considered first. If the result of balloon angioplasty was not satisfactory (> 30% residual stenosis, dissection), stent placement was scheduled. All patients underwent follow-up DUS and neurological examination 3, 6 and 12 months after angioplasty, then annually. Results There were 7 (0.4%) (4 symptomatic) cases of FMD. The FMD group was younger (47.9 ±7.5 years vs. 67.2 ±8.9 years, p = 0.0001), with higher prevalence of women (71.4% vs. 32.7%, p = 0.0422), a higher rate of dissected lesions (57.1% vs. 4.6%, p = 0.0002) and less severe stenosis (73.4% vs. 83.9%, p = 0.0070) as compared to the non-FMD group. In the non-FMD group the prevalence of coronary artery disease was higher (65.1% vs. 14.3% in FMD group, p = 0.009). All FMD patients underwent successful carotid artery angioplasty with the use of neuroprotection devices. In 4 cases angioplasty was supported by stent implantation. Conclusions Fibromuscular dysplasia is rare among patients referred for CAS. In case of significant FMD carotid stenosis, it may be treated with balloon angioplasty (stent supported if necessary) with optimal immediate and long-term results.

Double filters: a protection technique for high-risk innominate artery angioplasty.

We read with interest the commentary by Guimaraes et al., in which they related a case of protected innominate artery (IA) stenting using left subclavian artery balloon occlusion to divert flow to a single internal carotid artery (ICA) filter, thus protecting both circulations. Typically, embolic protection has not been considered necessary in IA angioplasty; data from a large prospective registry indicated that non-neuroprotected angioplasty for symptomatic IA stenosis can be perform with a very low risk (,1%) of cerebral complications. On the other hand, in the largest series of IA angioplasty, the rate of cerebral ischemic complications was as high as 8%. After witnessing a devastating ipsilateral stroke in a patient undergoing unprotected IA stenting, we began using a dual filter system to protect both circulations during IA stenting in patients at high risk of embolization. We demonstrate the technique in a 67-yearold man with a history of coronary artery disease, hypertension, and hyperlipidemia who was admitted to our clinic with a diagnosis of severe IA and significant left ICA stenoses discovered 2 months earlier after hospitalization for iliac artery angioplasty. At that time, the patient presented with symptoms of transient posterior circulation ischemia, including vertigo, ataxia, and dysarthria, but no symptoms referable to the anterior circulation. The computed tomographic angiography (CTA) performed at the time confirmed a tight (80%) stenosis of the IA caused by fibrous short plaque [92 Hounsfield units (HU)] and a borderline lesion (50%) in the left ICA. On admission, a duplex ultrasound scan recorded a 4.6-m/s increase in peak systolic velocity in the IA and a third degree ‘‘steal syndrome’’ in the right vertebral artery. On neurological examination, the patient’s symptoms included ataxia, dysarthria, and nystagmus. After consultation within our multidisciplinary team, the patient was scheduled for IA angioplasty the next day. On top of continuous low-dose aspirin (75 mg/d) and statin therapy, a 300-mg loading dose of clopidogrel was administrated before the procedure. In the intervention suite, the right femoral artery was punctured, and a 9-F arterial sheath was inserted; 7000 units of unfractionated heparin were administrated to achieve an activated clotting time .250 seconds. A 9-F Judkins right guiding catheter (Cordis Corporation, Bridgewater, NJ, USA) was positioned in the IA ostium. The IA lesion (Figure, A) was crossed with a V-18 Control Wire (Boston Scientific Corp., Natick, MA, USA) that was inserted distally into the right axillary artery. With the use of two HiTorque Balance Middle Weight 0.014-inch coronary wires (Abbott Vascular, Redwood City, CA, USA), two 7-mm3300-cm SpiderFX neuroprotection systems (ev3/Covidien, Mansfield, MA, USA) were advanced and opened in the right ICA and in the right vertebral artery (Figure, B). Lesion predilation was performed with a 4320-mm Ultra-soft SV monorail balloon dilation catheter (Boston Scientific Corp.). Over both neuroprotection wires, a balloonmounted 7316-mm Neptun peripheral stent (Balton, Warsaw, Poland) was positioned (Figure, C) and deployed at the lesion with 12 atmospheres of pressure for 20 seconds; it was postdilated with 14 atmospheres of pressure for 20 seconds. Both neuroprotection systems were retrieved uneventfully. The final angiogram (Figure, D) showed optimal J ENDOVASC THER 2014;21:177–179 177

Transradial approach for carotid artery stenting in a patient with severe peripheral arterial disease

We present a case of a 73-year-old man with critical bilateral internal carotid artery stenosis, recent right-hemisphere stroke and severe peripheral artery disease in whom right internal carotid artery stenting (RICA-CAS) was performed successfully via a right transradial approach.