Piotr Paluszek

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.

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.

New endovascular techniques for treatment of life-threatening Takayasu arteritis

Takayasu arteritis (TA) is a medium-size and large artery vasculitis of unknown aetiology affecting mainly the aorta and its major branches, usually in young female patients. Histopathology reveals adventitial thickening, focal lymphocytic infiltration of the tunica media and intimal hyperplasia leading to artery stenosis/occlusion. Less commonly media degeneration presents as aneurysmal dilatation [1]. Clinical symptoms arise from systemic inflammation and local vascular complications. Neurological manifestation of the disease includes headache, dizziness, visual disturbance, transient ischemic attack (TIA) and stroke [2]. Takayasu arteritis may be associated with premature mortality among young patients. Mortality is significant (3–11%) and varies according to geographical location and management strategy. The most frequently reported causes of death include stroke, myocardial infarction, congestive cardiac failure, and peri- and postoperative complications. The majority of patients (23%) are unable to work, and about 60% are limited in everyday activities [3, 4].

Transradial approach for vertebral artery stenting.

Introductuion Symptomatic severe vertebral artery (VA) stenosis may be treated safely with stent supported angioplasty via femoral access. There is limited clinical data on transradial approach for VA angioplasty in case of peripheral artery disease. Aim To evaluate the safety and efficacy of transradial angioplasty of symptomatic VA stenosis. Material and methods Fifteen patients (age 66 ±7.4 years, 73% men, with VA > 80% stenosis, 11 right-side, all symptomatic from posterior circulation (history of stroke, TIA, or chronic ischaemia symptoms)) with peripheral artery disease (PAD) or unsuccessful attempt via femoral approach were scheduled for VA angioplasty by radial access. Clinical and duplex ultrasound (DUS) follow-up were performed before discharge and 1, 12, and 24 months after VA angioplasty. Results The technical success rate was 100%. In all cases VA angioplasty was performed with the use of single balloon-mounted stent (9 bare metal stents, 6 drug-eluting stents). The mean NASCET VA stenosis was reduced from 85.3% to 5.3% (p < 0.001). No periprocedural death, stroke, myocardial infarction, or transient ischaemic attack occurred. During 24-months follow-up, in 12 of 15 patients chronic ischaemia symptoms release was observed, and no new acute ischaemic neurological symptoms were diagnosed in all patients. One patient died 20 months after intervention from unknown causes. There was one symptomatic borderline VA in-stent stenosis 12 months after angioplasty. Conclusions Transradial VA stenting may be a very effective and safe procedure, and it may constitute an alternative to the femoral approach in patients with symptomatic VA stenosis.

Transradial carotid artery stenting with the use of a novel integrated embolic protection technology (RCD code: I‑1B.O)

We present the case of a 79‑year‑old woman with critical right internal carotid artery stenosis in whom carotid artery stenting was performed via a right radial artery approach with the use of a novel integrated embolic protection technology- Paladin System® (Contego Medical). JRCD 2018; 3 (7): 239–242

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.