On Topaz

Aspirin Desensitization/Challenge in 3 Patients With Unstable Angina

Aspirin sensitivity is relatively frequent and can be a major problem in patients who need percutaneous coronary intervention and stenting with subsequent dual antiplatelet therapy. Desensitization is often the therapy in these patients, but this can prolong the time to revascularization significantly. Rapid oral aspirin desensitization protocols have been described since 2000. However, data are lacking on the optimal strategy for aspirin desensitization and determining which patients are mostly benefited from this desensitization. The authors describe the use of a Wong-modified protocol in 3 patients who had known aspirin sensitivity and who had unstable angina and an indication for percutaneous coronary intervention.

Origin of a common trunk for the inferior phrenic arteries from the right renal artery: a new anatomic vascular variant with clinical implications

The inferior phrenic arteries constitute a pair of important vessels, supplying multiple organs including the diaphragm, adrenal glands, esophagus, stomach, liver, inferior vena cava, and retroperitoneum. The vast majority (80-90%) of inferior phrenic arteries originate as separate vessels with near equal frequency from either the abdominal aorta or the celiac trunk. Infrequently, the right and left inferior phrenic arteries can arise in the form of a common trunk from the aorta or from the celiac trunk. We herein present three patients with a new anatomic vascular variant: a common trunk of the inferior phrenic arteries arising from the right renal artery. In one case, the left inferior phrenic branch of the common trunk provided collaterals connecting with a supra-diaphragmatic branch of the left internal mammary artery and in another with the lateral wall of the pericardium. Angiographic identification of a common trunk for the inferior phrenic arteries arising from the right renal artery is important for proper diagnosis and clinical management. The presence of this unique vascular variant can impact revascularization of the renal arteries.

Utilization of excimer laser debulking for critical lesions unsuitable for standard renal angioplasty

The energy emitted by ultraviolet laser is avidly absorbed in atherosclerotic plaques. Conceptually, it could be applied for debulking of selected atherosclerotic renal artery stenoses. We describe early experience with revascularization of critical renal artery lesions deemed unsuitable for standard renal angioplasty. Institutional Review Board permission to conduct the data analysis was obtained.

Bypass Graft Stent Fracture Leading to Saphenous Vein Graft Pseudoaneurysm

An 83-year-old man, with a history of coronary artery bypass graft surgery 19 years before presentation and subsequent percutaneous coronary intervention to saphenous vein graft with placement of a paclitaxel drug-eluting stent 16 years later, presented with a 2-week history of fevers, productive cough, and pleuritic chest pain. He was found to have leukocytosis and chest x-ray evidence of pneumonia with a widened mediastinum. He was admitted for treatment of protracted pneumonia. He had a borderline elevated troponin I, which, in the absence of anginal pain, was thought to be secondary to demand ischemia. A chest radiograph obtained at admission showed bilateral pleural effusions, a right lower lobe infiltrate, and a widened …

Revascularization of the impenetrable CTO—In support of enhanced antegrade approach

The pathologic build-up of various tissue constituents within coronary chronic total occlusions (CTOs) well explains the notorious technical difficulties encountered during PCI of these formidable targets [1]. Their content includes tightly capped atherosclerotic plaque, necrotic core, cholesterol, calcium, and thrombus. Extracellular matrix, which contains proteoglycans, is commonly found in CTOs of less than 1-year-old. Advanced age of CTO increases the size of the fibrocalcific content [1] and leads to development of microvessels consisting of intraluminal recanalization channels [2]. These microscopic vessels provide a potential anatomic route for antegrade or retrograde guidewire crossing through the obstructive lesion. Intriguingly, 49% of angiographic CTOs are, in fact, less than 99% occluded when histologically examined [3]. Thus, the microchannels become a key component that determines either success or failure of revascularization efforts. The retrograde approach for CTO recanalization and various accompanying modifications were developed to overcome the remarkable resistance of the proximal cap of the plaque to antegrade entry. Since the distal cap is oftentimes softer than the proximal cap, it frequently yields to retrograde penetration. Thus, the retrograde approach has recently gained recognition enjoying a growing popularity [4] and certain hype. Quite impressive to the observing eye, technically demanding and considerably satisfying when accomplished, this approach is yet far from perfect. Generally, the retrograde approach requires more equipment, is associated with prolonged procedure time, and oftentimes leads to marked exposure of patients and operators to radiation [5]. Furthermore, it necessitates multiple modifying steps for equipment passage along the tortuous anatomic route, each step in turn increases the associated risk of vascular complications. Information regarding long term outcomes and adverse effects of the retrograde recanalization and a meaningful comparision to the antegrade approach are lacking. Consequently, judging from the opinion of experts attempting to sound ‘‘trendy’’ during discussions held in high flying conferences, and according to reports in over enthusiastic papers, the traditional antegrade approach seems ‘‘less sophisticated’’ or even ‘‘outdated technique.’’ That is wrong. In this issue of CCI, in a well-documented case [6], Christ and Glogar from the Medical University of Vienna describe their method of modified enhanced antegrade PCI technique, which was developed to overcome two consecutive technical failures of PCI of a CTO in the left anterior descending artery. The first of these attempts was obtained antegradelly followed by unsuccessful retrograde approach. The technique of Christ and Glogan is based on antegrade guidewire access through a microcatheter. The microcatheter is anchored by an inflated balloon, which is a modification that enables finding of an entry point and enhances probing and pushability of the navigating guidewire. The authors correctly denote that the retrograde technique and its variations are accompanied by considerable technical challenges and by a not so low complications rate. Therefore, conceptually and practically, any improvement of known antegrade techniques is a desired development. In fact, antegrade penetration with a microcatheter has been previously described by Carlino et al [7]. They incorporated antegrade microinjections of contrast immediately distal to the cap of the CTO. This is done to identify and enlarge the CTOs microvessles, thus again, creating passage for successful crossing with a floppy guidewire. With lingering concerns over the fact that procedural success rates for CTO have not improved substantially over time during the stent era [8], the need to develop new technologies [9]and improved devices for ante-

Stenting for renal artery stenosis: Effects of contested data on opposing management strategies†

Clinical tempers frequently flair and convictions vociferously expressed when the markedly controversial issue of optimal treatment of renal artery stenosis (RAS) is debated. Feeding the differences in opinions is a wealth of fragmented and contested data. The meritorious article by Kalra et al. appearing in this issue [1] stands for recognition as it renews the management focus on one important subgroup of RAS patients, namely those with associated chronic kidney disease (CKD). The authors sought to investigate whether differences in outcomes after revascularization compared to medical treatment might be observed in RAS patients if stratified by the CKD status. This prospective study consisted of two cohorts from the United Kingdom and Germany, which enrolled 908 patients. The investigators conducted a meticulous evaluation of the patients precisely analyzing a large data set. Despite certain shortcomings of the study such as the untraditional design (recognized first and foremost by the investigators themselves), the findings are of significant interest and potential impact. The outcomes of this investigation demonstrate that percutaneous endovascular interventions (PEI) can improve renal function in advanced CKD, and revascularization can provide a survival advantage for the treated patients. From a clinical perspective, the threat of significant RAS progression toward severe renal dysfunction and permanent dialysis is a major concern [2]. Noteworthy, even a moderate angiographic RAS of 50–60% is associated with a 12% cumulative incidence of renal atrophy and a 28% cumulative incidence of disease progression over just 2-year period [3]. Whether an ‘‘incidental’’ angiographic finding or not, atherosclerotic RAS exerts a major impact on patient survival [4,5]. Over the last two decades, a significant paradigm shift took place with PEI replacing surgery as the preferred revascularization approach for RAS. On the surface, there should be no controversy concerning PEI for RAS because it can achieve a success rate as high as 95–98%, <5% major complications and 10% restenosis rate [6,7]. Excellent results with stenting can be achieved even in critical and complex RAS lesions [8]. However, PEI is far from a universally accepted strategy for RAS [9,10], and the incorporation of certain technical components is controversial. Namely, the decision to use filter protection devices versus no protection is particularly contentious. Critics of interventions point to the (too few) published randomized clinical trials, citing insufficient evidence of significant improvement in blood pressure, preservation of kidney function or reduction of CHF following stenting [11]. Some conservative management proponents state categorically that in contrast to PEI ‘‘advances in medical therapy continue to improve outcomes on these RAS patients’’ [12]. Yet criticism of the conservative management view is valid because a pattern of deficient scientific process can be found in studies that report no benefit for stenting. Instances of poor selection criteria for patients’ enrollment, and even, at times, sheer misinterpretation of results occur. For example, in one controversial study comparing medical therapy to balloon angioplasty [13] no less than 44% of the RAS patients who failed medical therapy crossed over to the revascularization treatment arm, yet the successful results were not attributed to the invasive modality. In another recent multicenter study whose goal was to prospectively compare stenting versus medical therapy [14], nonsignificant RAS lesions of <70% were treated unnecessarily via stenting, the translesion gradient was not measured and an unacceptable high technical fail-