Miloslav Spacek

Carotid artery stenting without post-dilation.

INTRODUCTION The aim of this study is to report the feasibility, safety, and 1-year restenosis rate of carotid artery stenting (CAS) without post-dilation. METHODS Between April 2006 and November 2009, 254 consecutive patients (68.7 ± 8.5 years old, 31% symptomatic) underwent 308 CAS procedures with the intention of avoiding post-dilation (eligibility criteria were stenosis of less than 30% after stent placement with no overt signs of calcification). Comparison and analysis of mid-term clinical outcomes and restenosis rates of CAS with or without post-dilation was performed retrospectively. RESULTS Overall, 27 patients (study group) were eligible for treatment without post-dilation. No significant difference in adverse events was found between the study and control group. In the study group, 2 transient ischemic attacks (7.4%) occurred immediately after the procedure and no other neurological complications were reported during the 30-day, 6-month, and 1-year follow-ups (3 patients died from causes unrelated to the procedure). Two asymptomatic restenosis cases were diagnosed in the study group within the first 12-months after the procedure compared to 16 significant restenosis cases diagnosed in the control group (7.4% vs 5.7%, NS). All of them were successfully treated with repeated intervention. CONCLUSION We suggest that CAS without post-dilation is feasible and probably safe with a low rate of cerebrovascular events and restenosis in a selected group of patients. We also suggest that CAS with postdeployment stenosis of less than 20% and without overt signs of severe calcification might be performed without post-dilation.

Carotid artery stenting – current status of the procedure

Surgical carotid endarterectomy (CEA) was long considered the standard approach for the treatment of atherosclerotic carotid artery disease. This was based on results of several randomized trials demonstrating its effectiveness over the best medical therapy. In the past two decades, patients identified high-risk for surgery were offered carotid artery stenting (CAS) as a less invasive option. Despite its initial limitations, CAS has evolved into an elaborate method currently considered to be equivalent and in selected patients even preferable to CEA. However, outcomes of both procedures are highly operator dependent and a simple stratifying method to prioritize CAS, CEA or medical therapy only has not yet been proposed. In addition, recently published randomized trials highlighted the importance of proper patient selection and rigorous training contributing to low absolute rates of (procedural) adverse events. This review discusses the history and evidence for carotid revascularization and briefly presents technical aspects and innovations in CAS.

Echocardiographic detection of myocardial crypts in hypertrophic cardiomyopathy: a first report in phenotype-positive patient

A 39-year-old patient with hypertrophic cardiomyopathy (HCM) and past medical history of surgical myectomy (requiring permanent pacemaker insertion for post-procedural atrio-ventricular block) was referred to our institution following episode of unexplained syncope. Transthoracic echocardiography (TTE) showed severe biventricular hypertrophy with septal thickness of 28 mm ( Panel A , area of previous myectomy marked by asterisk), only mild systolic …

Comparison of Carotid Artery Stenting in Patients With Single Versus Bilateral Carotid Artery Disease and Factors Affecting Midterm Outcome

BACKGROUND Carotid artery stenting (CAS) is the method of choice for carotid artery revascularization of patients at high risk for carotid endarterectomy. In this study, we compared the midterm results of CAS in patients with unilateral versus bilateral carotid artery disease. METHODS AND RESULTS This is a retrospective analysis of 1-year outcome of 273 consecutive patients in whom 342 CAS procedures were performed. The incidence of periprocedural transient ischemic attacks (TIAs) differed significantly (8% vs. 1%; p = 0.01) among patients with and without bilateral internal carotid disease, and a tendency to a lower occurrence of early adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction) was subsequently shown (11% vs. 5%; p = 0.12). At 1-year follow-up, there was a high incidence of adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction, restenosis) in patients with bilateral carotid artery disease (40% vs. 14%; p < 0.01), which was mainly driven by a higher incidence of death, periprocedural TIA, and restenosis (p ≤ 0.02 for all). According to multivariate analysis, the independent predictors of midterm adverse events were left ventricular dysfunction, male gender, bilateral carotid artery disease, renal insufficiency, cerebral symptoms within the last 6 months before the intervention, and low-density lipoprotein cholesterol level. CONCLUSIONS At midterm follow-up, patients with bilateral carotid artery disease treated by CAS have significantly more adverse events than those with unilateral disease.

Early Opening of Dormant Septal Collaterals During Alcohol Septal Ablation: A Possible Hazard of Remote Necrosis

Alcohol septal ablation has become a common method to relieve left ventricular outflow track gradient in selected patients with hypertrophic obstructive cardiomyopathy. There is only limited knowledge regarding inadvertent remote (nontarget) myocardial necrosis caused by septal collateral recruitment. Herein we describe a case of unexpected contrast medium leakage through newly opened septal collateral circulation immediately after low-dose ethanol injection suggesting that angiographic inspection of collateral recruitment is necessary in all cases of repeat ethanol injection.

Comparison of mid-term outcomes of carotid artery stenting for moderate versus critical stenosis

Introduction Little is known about the prognosis of moderate versus critical carotid stenosis treated by carotid artery stenting (CAS). Material and methods This was a retrospective analysis of a single-centre registry including 271 consecutive patients (69 ±9 years, 87% at high risk for surgery), in whom 308 procedures were performed. The study included both symptomatic (≥ 50% carotid artery stenosis) and asymptomatic (≥ 70% carotid artery stenosis) patients. The primary endpoint was the rate of adverse events during follow-up (range 1-48 months), defined as all-cause death or stroke. Results We treated 115 critical and 193 moderate stenoses and implanted 318 stents (56% with closed cell design). Embolic protection systems were used in 296 cases (96%). The technical success rate was 98.2% in the critical stenoses group and 99% in the moderate group (NS). During follow-up, the incidence of the primary endpoint was 12.9% (13 pts) in the critical stenoses group and 14.7% (25 pts) in the moderate stenoses group (estimated 3-year freedom from death/stroke was 0.844 vs. 0.812; log-rank test p = 0.983). Left ventricular ejection fraction < 40%, significant contralateral carotid artery occlusion or stenosis and renal insufficiency were identified as significant predictors of the primary endpoint (p < 0.03). Conclusions Carotid artery stenting with embolic protection systems in patients at high risk for carotid endarterectomy is safe. Patients with initially moderate and critical stenoses have an identical mid-term prognosis with regard to death and stroke.

The role of near-infrared spectroscopy in the detection of vulnerable atherosclerotic plaques

Coronary artery disease is the leading cause of mortality worldwide. Most acute coronary syndromes are caused by a rupture of a vulnerable atherosclerotic plaque which can be characterized by a lipid-rich necrotic core with an overlying thin fibrous cap. Many vulnerable plaques can cause angiographically mild stenoses due to positive remodelling, which is why the extent of coronary artery disease may be seriously underestimated. In recent years, we have witnessed a paradigm shift in interventional cardiology. We no longer focus solely on the degree of stenosis; rather, we seek to determine the true extent of atherosclerotic disease. We seek to identify high-risk plaques for improvement in risk stratification of patients and prevention. Several imaging methods have been developed for this purpose. Intracoronary near-infrared spectroscopy is one of the most promising. Here, we discuss the possible applications of this diagnostic method and provide a comprehensive overview of the current knowledge.

Microembolization following balloon deflation during proximally protected carotid artery stenting—A potential focus of procedure improvement?

We have read with interest the recently published article by Nikas et al. [1] on periprocedural adverse events (PAEs) of carotid artery stenting (CAS) with use of the GORE Flow Reversal System. In light of this data, we would like to share our own single-center experience with transcranial doppler monitoring (TCD) during proximally protected CAS using MO.MA Cerebral Protectin Device. At first, however, several important points should be emphasized.

Letters to Editor Bovine arch

Bovine aortic arch refers to the most common variant of aortic arch branching in humans. This configuration can be found in approximately 27% of the population and can be further divided into 2 subtypes. In the less usual subtype (7%, Figure 1 – panel A), the innominate artery (usually 1-2.5 cm long) trifurcates into the left common carotid artery, the right common carotid artery and the right subclavian artery, while the more usual subtype (although angiographically less apparent) can be described as the common origin of the innominate artery and the left common carotid artery and can be found in approximately 20% of the population (Figure 1 – panel B). Both of the subtypes occur more commonly in blacks compared with whites [2]. Although the term “bovine arch” evokes resemblance with the aortic arch branching configuration found in cattle, the “true bovine arch” (Figure 1 – panel C) found in cattle bears no resemblance to any of the common aortic arch variations found in humans. Paradoxically, the bovine arch is considered a norm in rodents and beasts of prey, and it was its angiographic appearance from which its name was derived (Figure 2). Nevertheless, it is of great importance for physicians to be familiar with the knowledge of aortic arch branching variations, especially in the field of carotid interventions. In particular, when the left internal carotid artery is the target artery for carotid artery stenting and the procedure is performed via the femoral artery, passage of the sheath through the bovine arch is around an acute angle and can become very challenging. It is now evident that gaining access to the target vessel plays a key role in carotid artery stenting. Bovine arch, elongation, angulation or calcification of the aortic arch, and stenosis at the origin of branching vessels are the greatest predictors of difficult access, and cumulate in older patients. This must be taken into consideration especially in the light of the recently published Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) [3], which revealed a significantly higher proportion of cerebrovascular events during carotid angioplasty and stenting in octogenarians compared to younger patients. However, carotid artery stenting should be performed in high-volume centres that have good experience with “complex carotid interventions” and documented low periprocedural stroke and death rates. Corresponding author: Prof. MUDr. Josef Veselka CSc, FESC, FSCAI, FICA Department of Cardiology Cardiovascular Center Motol University Hospital V úvalu 84, 150 06, Prague 5 Czech Republic Phone: +420224434901 Fax: +420224434920 E-mail: veselka.josef@ seznam.cz Letter to Editor

First-in-man near-infrared spectroscopy proof of lipid-core embolization during carotid artery stenting

Intravascular near-infrared spectroscopy (NIRS), which has been used in over 5,000 patients to identify the lipid-core plaques (LCP) that cause coronary events, may also assist in the characterization of the carotid atherosclerotic lesions predisposing to stroke. To our knowledge, this is the first report of the use of NIRS in a patient undergoing carotid artery stenting (CAS).