Kaul Ua

Early and long-term results of subclavian angioplasty in aortoarteritis (Takayasu disease): comparison with atherosclerosis.

AbstractPurpose: To compare the early and long-term outcomes of subclavian artery angioplasty in patients with aortoarteritis and atherosclerosis. Methods: Sixty-one subclavian artery angioplasties were performed in 55 consecutive patients with aortoarteritis (n=32) and atherosclerosis (n=23) between 1986 and 1995. An arch aortogram followed by a selective subclavian artery angiogram was done to profile the site and extent of the lesion, its relation to the vertebral artery, and the distal circulation. Percutaneous transluminal angioplasty (PTA) was performed via the femoral route for 56 stenotic lesions and 5 total occlusions. Results: PTA was successful in 52 (92.8%) stenotic lesions and 3 (60%) total occlusions. Three patients (5.4%) had complications, that could be effectively managed nonsurgically. Compared with atherosclerosis, patients with aortoarteritis were younger (27.4±9.3 years vs 54.5±10.5 years; p<0.001), more often female (75% vs 17.4%; p<0.001), gangrene was uncommon (0% vs 17.4%; p<0.05), and diffuse involvement was seen more often (43.8% vs 4.4%; p<0.001). The luminal diameter stenoses were similar before PTA (88.6±9.7% vs 89.0±9.1%; p=NS). Higher balloon inflation pressure was required to dilate the lesions of aortoarteritis (9.9±4.6 ATM vs 5.5±1.0 ATM; p<0.001). This group had more residual stenosis (15.5±12.4% vs 8.3±9.4%; p<0.05) after PTA. There were no neurological sequelae, even in PTA of prevertebral lesions. On 3–120 months (mean 43.3±28.9 months) follow-up of 40 patients, restenosis was more often observed in patients with aortoarteritis, particularly in those with diffuse arterial narrowing. These lesions could be effectively redilated. Clinical symptoms showed marked improvement after successful angioplasty. Conclusion: Subclavian PTA is safe and can be performed as effectively in aortoarteritis as in atherosclerosis, with good long-term results. Long-term follow-up shows that it provides good symptomatic relief.

Balloon angioplasty for renovascular hypertension in Takayasu's arteritis

Percutaneous transluminal renal angioplasty was performed in 54 consecutive patients with hypertension and renal artery stenosis caused by Takayasus arteritis. Angioplasty was technically successful in 67 (89.3%) of 75 lesions attempted. In these 67 lesions, the degree of stenosis decreased from 88.3 +/- 4.8% to 23.5% +/- 13.6% (p < 0.001) after angioplasty. Following successful angioplasty there was significant improvement in hypertension (p < 0.001) within 48 hours. Patients with bilateral renal artery stenosis had higher systolic blood pressure both before balloon dilatation (p < 0.05) and after balloon dilatation before discharge (p < 0.001), compared with patients with unilateral renal artery stenosis. Three to 70 months (mean 26.4 +/- 10.3 months) after successful angioplasty, blood pressure was reduced to normal or was improved in 93% of patients. Angiographic restudy an average of 14.2 +/- 7.8 months after angioplasty showed restenosis at the same site in 7 of 52 (13.5%) lesions and fresh stenosis in one artery. All these eight lesions were successfully dilated. Further improvement in the luminal diameter was observed in 11 (21.2%) lesions. Late angiographic restudy in seven patients an average of 56.1 +/- 6.3 months after angioplasty showed no restenosis. Our results suggest that balloon angioplasty is safe and highly effective in relieving renal artery stenosis caused by Takayasus arteritis and should be the treatment of choice for renovascular hypertension in this disease.

Balloon angioplasty of the aorta in Takayasu's arteritis : initial and long-term results

Percutaneous transluminal balloon angioplasty for stenosis of the aorta was performed in 36 patients with Takayasus arteritis (age range, 8 to 36 years; mean, 19.1 +/- 7.7 years). Balloon dilatation was successful in 34 patients and resulted in a decrease in the mean peak systolic pressure gradient (PSG) from 75.2 +/- 29.1 mm Hg to 24.8 +/- 19 mm Hg (p less than 0.001) and a mean increase in the diameter of the stenosed segments from 4.5 +/- 2.2 mm to 9.6 +/- 3.8 mm (p less than 0.001). Hemodynamic and angiographic restudy, which was performed in 20 patients at a mean follow-up period of 7.7 +/- 4.1 months (range, 3 to 24 months), showed a further decrease in PSG (greater than or equal to 15 mm Hg) in seven patients (from 40.0 +/- 11.2 mm Hg to 15.7 +/- 10.2 mm Hg; p less than 0.01), no significant change in PSG in 12 patients (17.1 +/- 13.6 mm Hg vs 16.6 +/- 12.7 mm Hg; p = NS), and an increase in PSG from 15 mm Hg to 85 mm Hg in one patient. The patient who showed restenosis underwent successful redilatation. Six patients who underwent late recatheterization and angiography at 36 to 60 months (mean, 43 +/- 9.4 months) show continued relief of stenosis (mean PSG, 8.8 +/- 7.8 mm Hg). Patients with short-segment (less than 4 cm) stenosis experience more relief than patients with long-segment (greater than or equal to 4 cm) stenosis (residual PSG, 18.6 +/- 8.2 mm Hg vs 40 +/- 16 mm Hg; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

SELF- AND BALLOON-EXPANDABLE STENT IMPLANTATION FOR SEVERE NATIVE COARCTATION OF AORTA IN ADULTS

BACKGROUND Balloon angioplasty for native coarctation of the aorta (CoA) in adults, though promising, is sometimes limited by significant residual gradient (>20 mm Hg). Few studies available have reported on use of balloon-expandable stents in such a situation. We evaluated the use of self- and balloon-expandable stents in patients with suboptimal response to balloon angioplasty (BA). METHODS Twenty-one hypertensive patients (age, 18 to 61 years; mean, 28.6 +/- 11.2 years) with native CoA and in whom results of BA were suboptimal (ie, residual peak systolic gradient [PSG] >20 mm Hg) underwent stent implantation. Balloon-expandable Palmaz stents were implanted in 5 patients (group A) and self-expandable nitinol aortic stents in the remaining 16 patients (group B). RESULTS In group A, PSG decreased from 62.8 +/- 10.6 (53 to 80) mm Hg to 28.1 +/- 6.3 (22 to 39) mm Hg after BA. Systolic gradient further decreased to 8.3 +/- 3.9 (2 to 16) mm Hg (P <.001) after implantation of the balloon-expandable Palmaz stent. In group B, PSG decreased from 70.2 +/- 24.6 (40 to 110) mm Hg to 28.4 +/- 9.8 (22 to 42) mm Hg after BA and further reduced to 9.0 +/- 5.5 (4 to 16) mm Hg (P <.001). One of these patients had a nitinol self-expandable stent implanted after a Palmaz stent embolized immediately after deployment. Nitinol stents were easier to deploy and conformed better to aortic anatomy compared with balloon-expandable stents. In group A, the diameter of the coarcted segment increased from 3.8 +/- 0.8 mm to 13.3 +/- 0.8 mm (P <.001) after stent implantation and in group B it increased from 4.5 +/- 1.1 mm to 14.1 +/- 2.1 mm (P <.001). There was no significant difference between the two groups in the PSG and diameter of the coarcted segment before and after stent implantation. With the exception of one case, in which a Palmaz stent embolized, there was no other complication in our series. On follow-up of 12 to 71 months (mean, 40.7 +/- 5.8 months) all the implanted stents remained in their original position and none showed evidence of fracture. Improvement in hypertension was seen in 20 of 21(95.2%) of the patients. On recatheterization and angiography 1.2 +/- 0.6 years after implantation in 19 patients, one patient showed an increase in PSG to 27 mm Hg across the nitinol stent and underwent successful redilation. No increase in gradient was seen in other patients. Beneficial late remodeling was seen in 10 of 14(71.4%) of patients restudied after implantation of self-expandable stent. None of the patients showed aneurysm formation. CONCLUSIONS Stent implantation is safe and effective in improving suboptimal results after BA for CoA. Self-expandable stents were easier to implant, adapted better to the wall of the aorta, and in most patients had similar efficacy in reducing coarctation as balloon-expandable stents.

Long-term results after balloon pulmonary valvuloplasty in adults

Percutaneous balloon pulmonary valvuloplasty for congenital pulmonary valve stenosis was performed in 40 adult patients (aged 18 to 56 years). The duration of follow-up was 24.5 +/- 11.5 months. The peak systolic pressure gradient from the right ventricle to the pulmonary artery decreased from 107 +/- 29 mm Hg to 37 +/- 25 mm Hg immediately after the procedure. On follow-up, gradient obtained either by cardiac catheterization or Doppler echocardiography was 31 +/- 13 mm Hg. In eight patients with residual gradient after valvuloplasty of > 50 mm, the mean peak systolic gradient decreased from 74.5 +/- 18.3 to 33.5 +/- 13.9 mm Hg on follow-up. Thus balloon pulmonary valvuloplasty is a safe and effective procedure for the treatment of adult patients with pulmonic stenosis; there is a tendency for high residual gradients to regress on follow-up.

Endovascular Stenting for Unsuccessful Angioplasty of the Aorta in Aortoarteritis

AbstractPurpose: The efficacy and safety of endovascular stent implantation to correct dissection or a suboptimal result after percutaneous transluminal angioplasty (PTA) was evaluated in patients suffering from aortic stenosis due to aortoarteritis. Methods: Twelve children and young adults [aged (mean±SD) 18.2±8.7 years] underwent stent implantation after PTA of the aorta, seven for obstructive dissection, four for ineffective balloon dilatation, and one for recurrent restenosis. Nine patients underwent implantation of self-expandable stents and three received balloon-expandable Palmaz stents. Results: Stent implantation could be successfully performed in all 12 patients. After stent implantation, the peak systolic pressure gradient decreased from 91±33.5 mmHg to 12.4±12.5 mmHg (p<0.001). The diameter of the stenosed segment increased from 4.6±0.8 mm to 11.1±1.9 mm (p<0.001). The dissection was completely covered in all seven patients with dissection. Except for epigastric pain with vomiting in one patient, there was no complication. On follow-up, over 12–57 months (mean 26.8±10.8 months), 11 patients (91.6%) had marked improvement in their blood pressure. Patients with congestive heart failure and claudication also showed improvement. Repeat catheterization in five patients, between 6–30 months (mean 16.8 ±9.1 months) after stent implantation, showed sustained improvement in four and a fusiform, long segment, intrastent restenosis after 30 months in one child. The stenosis was safely redilated. Conclusion: Endovascular aortic stent implantation is safe and provides good immediate relief in patients with unsatisfactory results after balloon angioplasty. Improvement is sustained in most patients on intermediate-term follow-up.

Percutaneous transluminal angioplasty for stenosis of the aorta due to aortic arteritis in children.

Abstract. Percutaneous transluminal balloon angioplasty for stenosis of the aorta due to aortic arteritis was attempted on 45 lesions in 41 children (age range, 4–14 years; mean, 9.9±4.2 years) presenting with symptoms of hypertension, severe congestive heart failure, and lower limb claudication. Balloon dilatation was technically successful in 38 (92.7%) patients for 41 stenotic lesions (91.1%). The mean peak systolic pressure gradient (PSG) decreased from 71.7 ± 23.9 mmHg to 23.2 ± 17.5 mmHg (p < 0.001) and the diameter of the stenosed segment increased from 3.3 ± 1.1 mm to 7.5 ± 2.2 mm (p < 0.001) immediately after angioplasty. Patients with short-segment (<3 cm) stenosis had a lower residual gradient (17.9 ± 11.1 mmHg vs 30.5 ± 22.6 mmHg; p < 0.05) and a wider diameter of the aorta (8.8 ± 1.1 mm vs 7.5 ± 2.2 mm; p < 0.02) compared to patients with long-segment (≥3 cm) stenosis. Four patients required stent implantation; 2 for flow-limiting dissection, 1 for failure to reduce PSG by >50%, and 1 for recurrent restenosis. There was marked hemodynamic and angiographic improvement in these 4 patients. Hemodynamic and angiographic restudy in 21 of the 41 patients at mean follow-up period of 6.2 ± 4.2 months (range, 3–24 months) showed restenosis in 4 (19%) patients. Restenosis was more common in patients with long-segment stenosis than those with short-segment stenosis (30% vs 9.1%). Late restudy in 8 patients, done at 3–7 years after first restudy, showed no recurrence of aortic narrowing. On clinical follow-up of 38 patients for a mean of 58.8 ± 36.0 months (range, 8–146 months) there was marked improvement in symptoms. Hypertension was cured in 11 (29%), improved in 24 (63%), and persisted in 3 (8%). Six patients with associated severe renal artery stenosis showed further improvement in hypertension after successful renal angioplasty. Severe congestive heart failure improved in 21 (95.4%) of 22 patients. Mean left ventricular ejection fraction improved from 0.32 ± 0.08 to 0.48 ± 0.10 (p < 0.001) at a mean follow-up of 28.7 ± 8.4 months in these patients. Hemodynamic restudy in 10 of these patients showed improvements in left ventricular end-diastolic pressure from a mean 37 ± 9 mmHg (range, 25–55 mmHg) to 16.4 ± 6.2 mmHg (range, 6–25 mmHg) (p < 0.001). Lower limb claudication improved in all 4 patients. Our results suggest that percutaneous transluminal balloon angioplasty in children is safe and highly effective in relieving stenosis of the aorta due to aortic arteritis, with marked clinical improvement, and should be the treatment of choice particularly for discrete stenosis.

Endovascular stent implantation for severe pulmonary artery stenosis in aortoarteritis (Takayasu's arteritis)

Symptomatic pulmonary artery stenosis is a relatively uncommon manifestation of aortoarteritis. We describe a patient of aortoarteritis with severe proximal right pulmonary artery stenosis who presented with dyspnea on exertion and central cyanosis. The pulmonary artery stenosis was successfully relieved by percutaneous transluminal balloon angioplasty and implantation of a balloon‐expandable stent. This resulted in immediate improvement in oxygen saturation, disappearance of cyanosis, relief of dyspnea, and marked improvement in right lung perfusion as demonstrated by pre‐ and postangioplasty technetium lung ventilation‐perfusion scans. The changes in the pulmonary arterial wall morphology were detected precisely by intravascular ultrasound imaging. Catheter Cardiovasc Interv 2004;61:281–285.

Endovascular treatment of aortic rupture during angioplasty for aortic in-stent restenosis in aortoarteritis

Aortic rupture during balloon angioplasty for in‐stent restenosis without attempting to overexpand it is a rarity. We report a case of a young woman with aortoarteritis who had aortic rupture during angioplasty for in‐stent restenosis. The balloon used was of the same diameter as the previously implanted stent and was completely within the stent during inflation. The disruption was successfully treated by percutaneous placement of a self‐expandable endovascular stent graft. Cathet Cardiovasc Intervent 2003;58:103–106.

A constricting band: An unusual cause of incomplete expansion of Amplatzer septal occluder device

Various problems and complications have been reported during transcatheter closure of ostium secundum atrial septal defect with Amplatzer septal occluder. We report an unusual problem that was responsible for incomplete expansion of the waist of the device, not yet reported in world literature. A polyester band in continuation with the polyester mesh was found constricting the waist of the device, which after being cut led to successful redeployment of the device. Catheter Cardiovasc Interv 2004;61:418–421.