Paweł Latacz

Endovascular treatment for chronic cerebrospinal venous insufficiency: is the procedure safe?

Objectives The aim of this report is to assess the safety of endovascular treatment for chronic cerebrospinal venous insufficiency (CCSVI). Although balloon angioplasty and stenting seem to be safe procedures, there are currently no data on the treatment of a large group of patients with this vascular pathology. Methods A total of 564 endovascular procedures (balloon angioplasty or, if this procedure failed, stenting) were performed during 344 interventions in 331 CCSVI patients with associated multiple sclerosis. Results Balloon angioplasty alone was performed in 192 cases (55.8%), whereas the stenting of at least one vein was required in the remaining 152 cases (44.2%). There were no major complications (severe bleeding, venous thrombosis, stent migration or injury to the nerves) related to the procedure, except for thrombotic occlusion of the stent in two cases (1.2% of stenting procedures) and surgical opening of femoral vein to remove angioplastic balloon in one case (0.3% of procedures). Minor complications included occasional technical problems (2.4% of procedures): difficulty removing the angioplastic balloon or problems with proper placement of stent, and other medical events (2.1% of procedures): local bleeding from the groin, minor gastrointestinal bleeding or cardiac arrhythmia. Conclusions The procedures appeared to be safe and well tolerated by the patients, regardless of the actual impact of the endovascular treatments for venous pathology on the clinical course of multiple sclerosis, which warrants long-term follow-up.

Diagnostic accuracy of current sonographic criteria for the detection of outflow abnormalities in the internal jugular veins

Objectives: This study was aimed at evaluation of the diagnostic value of Doppler sonography for the assessment of abnormalities in the internal jugular veins (IJVs). Method: One hundred and sixteen IJVs were assessed in 58 patients with associated multiple sclerosis. Findings of Doppler sonography were compared with results of the reference test: catheter venography. Results: At least one positive extracranial sonographic criterion suggesting venous abnormality was found in 92.2% of the assessed veins. Yet, sensitivity, specificity, positive and negative predictive values of sonography were low: 93.4%, 12.0%, 79.4% and 33.3% for at least one positive criterion, and for at least two positive criteria: 29.3%, 75.0%, 81.8% and 21.7%, respectively. Conclusions: Our research has shown that currently used extracranial sonographic criteria for the detection of obstructive venous abnormalities in the IJVs are of limited diagnostic value. For the time being, diagnosis of this vascular pathology should be given using catheter venography.

Multiple sclerosis, an unlikely cause of chronic cerebrospinal venous insufficiency: retrospective analysis of catheter venography.

Objectives It is unknown if a relationship exists between multiple sclerosis and chronic cerebrospinal venous insufficiency and if this venous pathology is a causal factor for multiple sclerosis or is a product of a neurological disease. Even so, one should expect that if multiple sclerosis were the cause for venous lesions, then patients with an extended history of the disease would present with a more severe venous pathology. Design Retrospective analysis of catheter venography of the azygous and internal jugular veins, and duration of clinical history of the disease in multiple sclerosis patients. Setting Mono-profile specialist hospital. Participants 353 multiple sclerosis patients, with duration of the disease: 0.5-41 years (median: 10 years). Main outcome measures We performed statistical analysis of the correlations between the duration of multiple sclerosis and the degree and number of venous lesions revealed using catheter venography. Results We observed weak, statistically insignificant correlations between the severity of chronic cerebrospinal venous insufficiency and the duration of multiple sclerosis. For the cumulated scores of venous lesions, Spearman and Kendalls tau correlation coefficients were 0.03 and 0.02, respectively; for maximal scores of venous lesions, coefficients were 0.06 and 0.05, while for the number of diseased veins they were 0.007 and 0.006, respectively. Consequently, this analysis did not yield any data supporting the idea that MS is the cause of venous lesions. Conclusion The results of our survey indicated that venous malformations are most likely congenital, and multiple sclerosis had no significant impact on the development of venous pathology.

Transient ST-segment elevation in lead aVR associated with tako-tsubo cardiomyopathy

ST-segment elevation in lead aVR in patients with angina at rest can be related to transmural ischemia of the basal part of the interventricular septum, frequently due to left main or multivessel coronary disease. However, this electrocardiographic (ECG) sign may also occur in other clinical conditions manifesting by acute chest pain. We present a case of a 76-year-old Caucasian woman with transient ST-segment elevation in lead aVR associated with tako-tsubo cardiomyopathy. Our report seems to confirm the hypothesis about the role of reversible myocardial ischemia involving the basal part of the interventricular septum in the pathogenesis of tako-tsubo cardiomyopathy. In conclusion, ST-segment elevation in lead aVR in patients with a clinical presentation of acute coronary syndrome may be not related to coronary artery disease. Tako-tsubo cardiomyopathy should be considered among the causes of ST-segment elevation in lead aVR in patients with angina at rest. Further studies are needed to evaluate the occurrence and importance of this ECG sign in patients with tako-tsubo cardiomyopathy.

Ergotamine-induced cardiovascular toxicity: mechanisms and clinical significance.

concluded that an acute elevation of pulmonary capillary wedge pressure does not limit exercise capacity in CHF. In other words a patient could have a very high PCWP but a relatively good oxygen uptake. According to this Fink et al. did not found an improvement of ventilatory efficiency by acute lowering of filling pressures [9]. Our data confirm that the acute cardiac output response is the main central hemodynamic determinant of exercise capacity and not acute pressure changes. Central cardiac pressures derived from PACmeasurements cannot be deduced from the results of a CPX test and may add independent information during the evaluation of heart failure patients. We hypothesize that a subgroup of patients for example with a disparity between symptoms and results of non-invasive tests may profit from PAC procedures. A prospective study on the impact on prognosis of different non-invasive and invasive hemodynamic tests in patients with severe heart failure is warranted.

Patient- and lesion-tailored algorithm of endovascular treatment for arterial occlusive disease of extracranial arteries supplying the brain: safety of the treatment at 30-day follow-up

Introduction Although surgical endarterectomy remains the treatment of choice for carotid artery stenosis, stenting plays an important role as an alternative treatment modality, especially in high-risk patients. The actual safety profile associated with stenting procedures is probably better than that reported by randomized controlled trials. Aim To assess the safety of stent implantations in extracranial arteries supplying the brain, and also to identify risk factors associated with this procedure. Material and methods This was a post hoc analysis, with 30-day follow-up. We analyzed the results of treatment of 372 patients who underwent 408 procedures, 197 such procedures in asymptomatic, and 211 in symptomatic individuals. Stenting procedures were performed using a technique and armamentarium which were tailored to the type and anatomy of lesions. Results There were 6 (1.5%) strokes, including 2 (0.5%) major strokes, 1 ipsi- and 1 contralateral, and 4 (1.0%) minor strokes. In asymptomatic patients there was 1 (0.3%) minor stroke. Transient ischemic attacks occurred in 5 (1.2%) patients. There were 2 (0.5%) non-STEMI myocardial infarctions and 2 (0.5%) non-stroke related fatalities. Risk factors of these adverse events were diabetes mellitus, lesions localized in a tortuous segment of the artery, embolic material in the filter and bilateral stenoses of carotid arteries. Additional risk factors in asymptomatic patients were renal impairment and advanced coronary artery disease; and in symptomatic patients, grade 3 arterial hypertension, dislipidemia, cigarette smoking and lesions requiring predilatation. Conclusions Stenting procedures of extracranial arteries supplying the brain, which are tailored to the type and anatomy of lesions, seem to be relatively safe.

Optimal interventional treatment in a patient with occlusion of the brachiocephalic trunk and left subclavian artery with “double” steal syndrome

Subclavian steal syndrome, which comprises reversal of flow in the ipsilateral vertebral artery with stenosis or occlusion of the subclavian artery (SA) or brachiocephalic trunk (BCT), was first described by Contorni in 1960 [1]. This clinical syndrome manifests with the signs and symptoms of vertebrobasilar insufficiency, but can also be asymptomatic. This paper describes a step-by-step technique of complex endovascular treatment for a double steal syndrome caused by occlusions of the BCT and the left SA, associated with stenosis of the left internal carotid artery (ICA) and reversed flow in the left external carotid artery (ECA).

Treatment of high- and intermediate-risk pulmonary embolism using the AngioJet percutaneous mechanical thrombectomy system in patients with contraindications for thrombolytic treatment – a pilot study

Introduction Intravenous thrombolysis is the treatment of choice in patients presenting with high- and intermediate-risk pulmonary embolism. The role of percutaneous mechanical pulmonary thrombectomy (PMPT) is not fully established, although selected patients can be managed with this method. Aim This open-label single-centre prospective pilot study was aimed at assessing the feasibility of PMPT for the treatment of severe pulmonary embolism in a Polish hospital. We also evaluated the safety and efficacy of such management. Material and methods We managed 7 patients, aged 52.7 ±16.6 years, presenting with high- and intermediate-risk pulmonary embolism (4 patients with class 5 and one patient with class 4 of the Pulmonary Embolism Severity Index), with occlusion of at least 2 lobar arteries and contraindications for thrombolysis. Percutaneous mechanical pulmonary thrombectomy was performed using the AngioJet system. Results It was possible to introduce the thrombectomy system to the pulmonary arteries in all patients. The procedure was successful in 6 patients (technical success rate: 85.7%). Two (28.6%) patients died during the hospital stay, one patient with unsuccessful thrombectomy and the other due to pneumonia. In all survivors control echocardiography demonstrated normalised function of the right ventricle. Also, dyspnoea disappeared and blood gas parameters normalised. There was no recurrent thromboembolism during 3–14 months of follow-up. Conclusions In the Polish setting, in selected patients, management of high- and intermediate-risk pulmonary embolism with PMPT is technically feasible. Such treatment is relatively safe and effective. It can be an alternative to standard management, especially in patients with contraindications for fibrinolysis or surgical embolectomy.

Early results of endovascular treatment of patients with bilateral stenoses of the internal carotid arteries using proximal protection systems at 30-day follow-up

BACKGROUND Although surgical endarterectomy remains the treatment of choice for carotid artery stenosis, carotid artery stenting (CAS) with use of proximal protection systems (PPS) plays an very important role as alternative treatment modality, especially in patients with critical, symptomatic lesions. This study was single-centre study to evaluate the technical and clinical success of proximal protection devices as the first choice for embolic protection in symptomatic and asymptomatic carotid stenosis in patients with bilateral, advanced lesions of carotid arteries (bilateral stenoses or stenosis and occlusion). METHODS This was a post hoc analysis, with 30-day follow up. We analyzed results of treatment of 38 patients who underwent 38 CAS with PPS, 17 such procedures in asymptomatic (group A), and 21 in symptomatic individuals (group B). The GORE® Flow Reversal System (W.L. Gore, Flagstaff, AZ, USA) was used in 2 patients, and the Mo.Ma Ultra device (Medtronic, Minneapolis, MN, USA) in 36 patients. Mean age was 68±7 years, 65% percent of patient were male. RESULTS There were no procedural and during 30-day follow-up neurologic events. Intolerance of occlusion system occurred in 4 patients (11%) in both groups with any later symptoms. Risk factors of this adverse event comprised: lesions of the left internal carotid lesion and coexisiting diabetes mellitus. CONCLUSIONS CAS in high risk patients with bilateral lesions of carotid arteries with the use of PPS seems to be a relatively very safe procedure.

Safety and efficacy of endovascular treatment for carotid artery stenoses using proximal protection systems: 30-day follow-up

Introduction. Although surgical endarterectomy remains the treatment of choice for carotid artery stenosis, carotid artery stenting (CAS) with use of proximal protection systems (PPS) plays an important role as alternative treatment modality, especially in high risk patients. This study was aimed at the assessment of safety of CAS with use of the PPS and also at identification of risk factors associated with this procedure. Material and methods. This was a post hoc analysis, with 30-day follow-up. We analysed results of treatment of 94 patients who underwent 97 CAS with PPS, 47 such procedures in asymptomatic, and 50 in symptomatic individuals. Results. There were 0 strokes during 30-day follow-up. Transient ischaemic attacks occurred in 2 patients (2%) in symptomatic group. Risk factors of these adverse events comprised: tortuosity of the managed artery, chronic obstructive pulmonary disease, long lesion of the internal carotid artery and history of myocardial infarction. Conclusions. CAS with the use of PPS seems to be a relatively very safe procedure in high risk patients.