Po-Lin Chen

Malignancy After Heart Transplantation

Background: The purpose of this study was to assess the incidence and type of malignancies after heart transplantation at a medical institute in Taiwan. Methods: From January 1987 to December 2008, a total of 66 patients who survived more than 30 days after transplantation were enrolled in this study. Results: Of the 66 heart transplant recipients, 8 (12.1%) post‐transplant malignancies were diagnosed: 5 post‐ transplant lymphoproliferative diseases (PTLD), 1 prostate cancer, 1 lung cancer, and 1 squamous cell carcinoma of the cheek. The clinical presentations were diverse, and the diagnoses were confirmed by biopsy. Only 1 patient died of PTLD and subsequent multiple organ failure. Conclusion: Cancer is a limiting factor for long‐term survival after heart transplantation. The most common type in this study was PTLD. Early detection and aggressive treatment results in good response and preserves the allograft.

One-year results of transcatheter aortic valve implantation as an alternative treatment for severe aortic stenosis in high-risk patients.

Background: Aortic valve replacement (AVR) remains the gold standard treatment for symptomatic severe aortic stenosis (AS). For the past 10 years, transcatheter aortic valve implantation (TAVI) has been applied in patients with high surgical mortality and morbidity risks. The preliminary results of our TAVI patients are presented in this study. Methods: Ten high‐risk patients with severe AS, for AVR, were referred and accepted for TAVI in the 6 month period from May 2010 to October 2010. The patient age, logistic EuroSCORE, femoral arterial diameter, aorta annulus size, aorta valve area (AVA), mean aortic pressure gradient (MPG), as well as coronary angiography results were all collected. Six patients were treated via the transapical approach in March 2010, whereas the other four were treated with the transfemoral approach, according to their femoral artery diameter and arterial quality. This study focuses on the immediate, 1 month, 3 month, and 1 year results of TAVI. Results: The average age of the 10 patients receiving TAVI was 81.5 years. The mean calculated EuroSCORE was 28.3 ± 7.9%. The mean AVA was 0.61 ± 0.19 cm2. The MPG was 48 ± 16 mmHg. The surgical technical success achieved 100%. There was no reported moderate to severe postoperative paravalvular aortic regurgitation, permanent complete atrioventricular block, major access site complication, or embolic stroke. Chronic renal failure, which necessitated permanent hemodialysis, developed in 10% of the patients. One acute myocardial infarction and one case of pneumonia developed postoperatively. The AVA was increased by 251%, whereas the MPG was decreased by 80% at the 3 month follow‐up. The 30‐day mortality rate was 10%. The all‐cause 1‐year mortality rate was 20%. Conclusion: This new technique and device requires greater caution and needs more practice to accumulate sufficient experience. The studied patients were very fragile, due to old age and multiple comorbidities. Our results are similar to findings of multicenter trials. With careful patient screening and selection, TAVI can be a promising treatment for high‐risk severe AS patients.

Edge Stenosis After Covered Stenting for Long Superficial Femoral Artery Occlusive Disease: Risk Factor Analysis and Prevention With Drug-Coated Balloon Angioplasty:

Purpose: To report a retrospective analysis of risk factors for edge restenosis after Viabahn stent-graft treatment of superficial femoral artery (SFA) occlusive disease and determine any protective effect of drug-coated balloons (DCBs) used at the time of stent-graft implantation. Methods: Between October 2011 and July 2016, 110 patients (mean age 73.3±7.6 years; 78 men) were treated with the Viabahn stent-graft for long SFA occlusions. Thirty-eight (34.5%) patients had DCB reinforcement at the distal edge of the stent-graft. For analysis, the population was divided into groups of no edge stenosis patients (n=88; mean lesion length 22.4±4.2 cm) and edge stenosis patients (n=22; mean lesion length 23.5±5.7 cm). The clinical outcomes, ankle-brachial indices, computed tomography angiography findings, and patency were compared at a minimum of 12 months. Logistic regression analysis was employed to determine risk factors for edge stenosis; the results are presented as the odds ratio (OR) and 95% confidence interval. Results: No differences in clinical or procedural characteristics were identified except the higher incidence of diabetes (p=0.008) and greater need for retrograde access (p=0.033) in the edge stenosis group. DCB reinforcement reduced the incidence of edge stenosis (p=0.021) and target lesion revascularization (TLR; p=0.010) and resulted in a significantly higher 1-year primary patency rate (92.1% vs 76.4%, p=0.042). However, multivariate analysis revealed only poor distal runoff (OR 0.31, 95% CI 0.11 to 0.83, p=0.020) as a predictor of edge stenosis. Conclusion: The risk of edge stenosis after Viabahn implantation was higher in patients with poor distal runoff. DCB reinforcement over the distal edge reduced edge stenosis, decreased 1-year TLR, and improved 1-year primary patency.

Establishing stable innominate access by inserting a body floss wire from the brachial artery to the femoral artery facilitates right carotid artery stenting in Type III arch anatomy

OBJECTIVES In patients with severe carotid artery stenosis, the anatomy of their Type III aortic arch increases the difficulty and complication rates during carotid artery stenting because of its tortuosity and sharp angulation for cannulation as well as the unstable support of the guidewire for shuttle sheath delivery. METHODS We demonstrate a novel technique to overcome these challenges, namely the creation of stable innominate artery access by inserting a through-and-through body floss wire from the right brachial artery to the femoral artery. RESULTS We successfully performed right carotid artery stenting in 3 patients with Type III arch anatomy. All patients received regular outpatient follow-up uneventfully for more than 1 year. CONCLUSIONS This facilitates the procedure of the right carotid artery stenting in patients with Type III aortic arch.

Increase Carotid Flow by Double Sheath Connection Technique to Reduce Cerebral Ischemia for Transcatheter Aortic Valve Implantation through Transcarotid Approach

Purpose: Transcarotid transcatheter aortic valve implantation (TAVI) is one alternative approach if unfavorable femoral access. However, this approach may cause cerebral vascular accidents (CVAs) by temporarily occluding common carotid artery (CCA). The purpose of this study is to develop a new method reducing cerebral ischemia during transcarotid TAVI. Methods: We inserted an 8- and 18-Fr. sheath in CCA with tip toward brain and aortic arch, respectively, and connected their side arms to create a bypass flow. Medtronic CoreValve was then delivered and deployed in position after pre-TAVI balloon dilatation. Results: Three patients received this implantation. There were no CVAs or transient ischemic attacks (TIAs) after the procedure and all patients had been followed up uneventfully for 1 year. Conclusion: Our technique is feasible and potentially reduces stroke in transcarotid TAVI.

Endovascular stenting for end-stage lung cancer patients with superior vena cava syndrome post first-line treatments – A single-center experience and literature review

Background Superior vena cava (SVC) syndrome is a major complication that occurs when a growing lung malignancy compresses the SVC extrinsically. Current treatment options include radiotherapy or chemotherapy to shrink the tumor or endovascular stenting of the SVC to restore flow. Herein, we report a case series treated in a single institution to demonstrate the safety, effectiveness, and outcomes of salvage and primary stenting for malignant SVC obstruction. Methods A total of 12 male patients with malignant superior vena cava obstruction caused by lung cancer underwent SVC stenting from October 2009 to May 2015. Data were reviewed retrospectively, including demographic and clinical characteristics, procedural details, and outcomes. Results Seven patients had received radiotherapy prior to SVC stenting, while the other five patients received stenting as first‐line therapy for SVC syndrome. Only one patient experienced initial symptomatic improvement after radiotherapy, and symptoms of SVC syndrome recurred one year later. Wallstents® (Boston Scientific, Natick MA, USA) were used in all patients. Preoperatively, the mean narrowest SVC diameter measured by CT was 2.16 mm (0–5.5 mm). Technical success was achieved in all patients without complications such as pulmonary embolism, rupture or bleeding. Postoperative mean narrowest SVC diameter measured by CT during follow‐up was 11.17 mm (8–13.5 mm). Symptoms of SVC syndrome such as arm and face swelling and dyspnea improved within 1–5 days in all patients. After median follow‐up duration of 11.5 months, only one patient presented recurrent SVC syndrome due to in‐stent thrombosis two months after stenting. Conclusion Salvage SVC stenting remains a safe and effective treatment for patients with SVC obstruction after failure of radiotherapy and chemotherapy. Primary stenting may be considered at initial presentation of SVC syndrome to improve patients’ quality of life.

A Novel Hybrid Viabahn-assisted Bypass Technique: Extra-arterial Flossing Wiring for Chronic Total Occlusion in Superficial Femoral Artery

Introduction A hybrid Viabahn-assisted bypass (VAB) technique is introduced for revascularizing chronic total occlusion (CTO) in superficial femoral artery (SFA) when bypass surgery is difficult or endovascular intervention fails. Report This technique combines extra-arterial flossing wiring with antegrade-retrograde intervention via traditional open exposure of middle SFA and deploying a Viabahn from the proximal true lumen through the subintimal lumen and extra-arterial space, and back into distal true lumen to restore flow. It only needs a 3–5 cm incision to expose the mid-SFA without clamping or endarterectomy of the SFA. Discussion This hybrid procedure is an alternative technique to improve SFA revascularization in some difficult CTOs.

Comparison of balloon-expandable valves versus self-expandable valves in high-risk patients undergoing transcatheter aortic valve replacement for severe aortic stenosis.

Background Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis (AS) who have a high surgical risk. In Taiwan, this is the first study reporting TAVI outcomes at a single center offering two different transcatheter heart valve technologies via four types of approaches. Our aim was to compare 30‐day and 6‐month Valve Academic Research Consortium‐2 (VARC‐2) outcomes of the two valves. Methods We reported the procedural, 30‐day, and 6‐month VARC‐2 outcomes of high‐risk patients who were consecutively treated with the Medtronic CoreValve (MCV) or with the Edwards SAPIEN valve or SAPIEN XT valve (ESV; Edwards Lifesciences, Irvine, CA, USA) delivered via four types of approaches. Results From May 2010 to December 2013, 30 consecutive patients with severe AS underwent TAVI: 15 patients were treated with the MCV and 15 patients were treated with the ESV. The transfemoral approach was the most frequently used route (13 MCV and 6 ESV), followed by the transapical approach (9 ESV), trans‐subclavian approach (1 MCV), and direct aortic approach (1 MCV). There were no procedural deaths. “Device success” was achieved in 29 (96.7%) patients, and is defined as the absence of procedural mortality, correct positioning of one prosthetic heart valve into the proper anatomical location, and intended performance of the heart valve without moderate or severe regurgitation. The VARC‐2–defined combined safety endpoint at 30 days was comparable between patients treated with the ESV and the MCV (33.3% vs. 20%, respectively; group, p = 0.409). At the 6‐month follow up, the combined efficacy endpoint was not significantly different between the two groups (13.3% in the ESV group vs. 20% in the MCV group; p = 0.624). There was only one (3.3%) patient who required permanent pacemaker implantation. Conclusion For the first time in Taiwan, we have demonstrated that TAVI using either device is complementary and feasible for treating a wide range of patients by using a careful selection of approaches. Favorable overall procedural success rates and 30‐day and 6‐month outcomes were achieved with both devices.

Concomitant Bentall operation plus aortic arch replacement surgery

Background: The Bentall operation is recommended for thoracic aortic dissection or aneurysm involving the aortic root. However, if the lesion extends to the aortic arch, concomitant Bentall operation plus aortic arch replacement (CoBAAR) surgery is required. CoBAAR is challenging because of its complex cardiopulmonary procedure, prolonged cardiopulmonary bypass time, and demanding operative techniques. Therefore, surgical mortality and morbidity rates for CoBAAR are very high. However, the Bentall operation performed as a single procedure may lead to reoperation if the residual aneurysm progresses. Therefore, CoBAAR as a one‐stage surgery can lower the need for reoperation and possible further complications. Methods: Nine patients received CoBAAR during January 2005 to May 2010. Six patients were diagnosed with Sanford type A aortic dissection and three with nondissecting ascending aortic and arch aneurysm. Four patients received a Bentall operation plus hemiarch replacement. The others received a Bentall operation plus total arch replacement along with elephant trunk because of extensive lesions. Results: The in‐hospital mortality was 11.1% (1 patient with total arch replacement). Morbidity included stroke (2 patients), spinal cord injury (1 patient), mechanical ventilation for more than 72 hours (5 patients), and temporary renal dialysis (3 patients). Eight patients survived. Conclusion: CoBAAR is a demanding operative technique requiring complex cardiopulmonary bypass. However, surgeons can perform this procedure on extensive ascending aortic dissection or aneurysm patients, achieving satisfactory results.

Outcome of drug-eluting balloon angioplasty versus endarterectomy in common femoral artery occlusive disease

Objective: Common femoral artery (CFA) occlusive disease remains a debatable site for endovascular therapy, and the outcome of drug‐eluting balloon (DEB) angioplasty in treating CFA occlusive disease is largely unknown. This study compared the efficacy, safety, and short‐term patency rate of DEB angioplasty and femoral endarterectomy for treatment of CFA occlusive disease. Methods: From March 2013 to June 2016, there were 100 patients with symptomatic CFA occlusive disease who were retrospectively reviewed. Forty patients were treated with DEB angioplasty and 60 were treated with femoral endarterectomy. Each patient received regular follow‐up. Patency rate, ankle‐brachial index, target lesion revascularization, and adverse events were assessed. Results: Technical success was 100% in all patients. The DEB group had a lower 1‐year primary patency rate (75.0% vs 96.7%; P = .003), but the secondary patency rate was similar between the two groups (97.5% vs 98.3%; P = 1.000). At 2‐year follow‐up, the primary patency was lower in the DEB group (57.1%) than in the endarterectomy group (94.1%; P = .001), whereas the secondary patency rate had no significant difference (90.5% vs 97.1%; P = 1.000). Both groups had significant improvement in ankle‐brachial index. Freedom from target lesion revascularization was lower in the DEB group both at 1 year (75.0% vs 96.7%; P = .003) and at 2 years (57.1% vs 94.1%; P = .001). There was no significant difference in the incidence of complications and adverse events. Conclusions: Femoral endarterectomy has a better primary patency rate compared with DEB angioplasty in treating CFA occlusive disease without significant increase in complications. In patients not suitable for endarterectomy, DEB angioplasty provides a similar secondary patency rate and could be considered an alternative treatment. Graphical Abstract Figure. No caption available.