Zvonimir Krajcer

Coronary artery disease in hypertrophic cardiomyopathy

Abstract Frequently, patients with hypertrophic cardiomyopathy (HC) have chest pain suggestive of angina pectoris, with the electrocardiogram resembling that of myocardial infarction. 1–3 Atherosclerotic coronary artery disease (CAD) causing angina pectoris and myocardial infarction in HC is being reported with increasing frequency. 4 Myocardial infarction also has been noted to occur with normal coronary arteries. 5 We present our results on the incidence and importance of CAD in 85 consecutive patients with HC who also underwent coronary arteriography.

Closure of Large Percutaneous Access Sites Using the Prostar XL Percutaneous Vascular Surgery Device

Purpose: To report early experience using a vascular closure device following endovascular aortic aneurysmal repair in which large-bore sheaths are used. Technique: A 10F Prostar XL Percutaneous Vascular Surgery device is used to deploy sutures around sheath entry sites up to 16F. At the completion of the procedure, the sutures are tied with a sliding knot to ensure adequate hemostasis. Conclusions: Maintaining the minimal invasiveness of the percutaneous approach to aortic endografting reduces patient discomfort and permits earlier ambulation and hospital discharge. Initial success seems to be maintained at 1 month, however, longer follow-up will be required.

Progression of hypertrophic cardiomyopathy into a hypokinetic left ventricle: Higher incidence in patients with midventricular obstruction

The development of segmental or generalized left ventricular hypokinesia is an unusual occurrence in patients with hypertrophic cardiomyopathy. To determine the incidence and possible pathophysiologic mechanisms responsible for this process, the serial clinical and laboratory data of 62 patients with the diagnosis of hypertrophic cardiomyopathy were analyzed. During a mean follow-up period of 8 years (range 2 to 21), 5 patients (Group A) developed left ventricular hypokinesia, whereas the remaining 57 patients (Group B) continued to exhibit the clinical and laboratory findings of hypertrophic cardiomyopathy. Three patients developed a dilated left ventricle with generalized hypokinesia; two other patients had segmental left ventricular wall motion abnormalities. None of these five patients who developed left ventricular hypokinesia had fixed coronary artery disease. The mean age, sex, mean duration of follow-up, presence of coronary myocardial bridges and angina pectoris, and an interventricular gradient were all similar in Groups A and B. Midventricular obliteration was seen in 4 (80%) of the 5 patients in Group A and in 4 (7%) of the 57 patients in Group B (p less than 0.001). Findings from this study reveal that segmental or generalized left ventricular hypokinesia can develop in patients with hypertrophic cardiomyopathy in the absence of fixed coronary artery disease. Such hypokinesia can occur after an acute myocardial infarction or it can develop gradually without clinical or electrocardiographic evidence of infarction. Patients with the mid-ventricular obliteration variant of hypertrophic cardiomyopathy are at a higher risk of developing segmental or diffuse left ventricular hypokinesia.

Percutaneous Access and Closure of Femoral Artery Access Sites Associated with Endoluminal Repair of Abdominal Aortic Aneurysms

Purpose: To report longer follow-up and further experience using the Prostar XL Percutaneous Vascular Surgery (PVS) device for access and closure of large bore femoral artery access sites during endovascular repair of abdominal aortic aneurysms (AAAs). Methods: One hundred forty-four patients (128 men; mean age 72 years, range 56–89) undergoing endovascular AAA repair had percutaneous access and closure of their 16-F femoral artery access sites using a 10-F PVS device. The first 54 patients were enrolled in the phase III trial of the AneuRx stent-graft for AAA treatment. Results: The femoral artery access site was successfully closed in 136 (94.4%) patients, with only 8 patients in whom adequate hemostasis could not be obtained. One-month follow-up was available in 144 patients, 6-month in 100, and 1-year in 59. No groin or lower extremity complications have been observed in any patient who had successful closure of the femoral artery access site. Conclusions: Large-bore femoral artery access sites can be percutaneously repaired using this device, which minimizes the invasiveness of the endograft procedure.

Percutaneous Repair of Abdominal Aortic Aneurysms Using the AneuRx Stent Graft and the Percutaneous Vascular Surgery Device

Endovascular exclusion of abdominal aortic aneurysms (AAAs) was developed in an effort to treat patients who were at high risk for complications following standard surgical repair. Stent grafts used for endovascular repair of AAAs require the use of large‐bore sheaths and surgical exposure of the common femoral arteries (CFAs). To decrease the invasiveness of AAA repair, we attempted to perform the procedure percutaneously utilizing the Prostar XL Percutaneous Vascular Surgery Device and the preclose technique. Thirty patients underwent an attempted percutaneous AAA repair. These patients were followed prospectively to assess the success of the procedure. Twenty‐eight patients (93%) had successful percutaneous repair of both CFA access sites. One patient had inadequate hemostasis of the 22 Fr CFA entry site and one patient had inadequate hemostasis of the 16 Fr CFA entry site. Both of these CFA sites underwent open surgical repair. The rate of successful repair of the 22 Fr CFA access site was 29 of 30 (96%); for the 16 Fr CFA access site, 29 of 30 (96%). No in‐hospital groin complications were seen. The procedure time was 105 ± 21 min. The estimated blood loss was 90.6 ± 50 cc. The hemoglobin loss was 1.54 ± 0.89 mg/dL and the hematocrit loss was 5.04% ± 2.8%. Complete percutaneous endoluminal AAA repair is feasible using the preclose technique. CFAs with sheaths up to 22 Fr can be safely and successfully accessed and repaired percutaneously using this technique. This method provides secure hemostasis and reduces the invasiveness of procedures requiring large‐bore sheaths. Cathet Cardiovasc Intervent 2002;55:281–287.

Predictors of carotid stent restenosis

Objectives: We sought to determine the predictors of restenosis after carotid artery stenting and report alternatives for its management. Background: Carotid artery stenting has been increasingly accepted as an alternative to carotid endarterectomy (CEA). Predictors of carotid stent restenosis have not been firmly established, and management of restenotic lesions can be challenging. Methods: A retrospective, single‐center review was conducted of 399 carotid stent procedures in 363 patients over 9 years, with a mean follow‐up of 24 months (range 6–99 months). Clinical variables included age, gender, symptoms, hypertension, diabetes, tobacco use, renal insufficiency, coronary artery disease, hyperlipidemia, peripheral vascular disease, history of CEA, and history of neck radiation (XRT). Angiographic variables included reference vessel diameter, lesion length, poststenting residual stenosis, stent diameter, type of stent, and number of stents. Results: Overall, restenosis occurred in 15 patients (3.8%). However, the restenosis occurred in 7 of 35 (20%) patients who had previous XRT, 6 of 57 (10.5%) patients who had previous CEA, and 2 of 9 (22%) patients who previously had both CEA and XRT. The only analyzed variables that were significantly associated with an increased risk of restenosis were previous CEA (OR 4.28, P = 0.008) or XRT (OR 11.3, P ≤≤ 0.0001). Restenosis was most often asymptomatic and detected at routine ultrasound follow‐up. Restenotic lesions were successfully treated in 11/11 cases with angioplasty (27%) or stenting (73%). Four patients that are asymptomatic are being monitored closely with ultrasound. No patients required surgical therapy for restenosis. Conclusions: Restenosis after carotid stenting is uncommon; however, patients with previous CEA or XRT are at increased risk. Restenotic lesions may be safely treated with further percutaneous interventions.

Wallgraft Endoprosthesis for the Percutaneous Treatment of Femoral and Popliteal Artery Aneurysms

Purpose: To evaluate the safety and efficacy of the Wallgraft Endoprosthesis for the treatment of femoropopliteal artery aneurysms. Methods: From October 1997 to April 2000, 17 patients (13 men; mean age 73.5 ± 7.1 years) with 7 femoral and 13 popliteal artery aneurysms underwent percutaneous aneurysm exclusion using the Wallgraft Endoprosthesis as part of a larger clinical trial. The mean aneurysm diameters were 37.6 ± 12.9 mm and 22.3 ± 8.7 mm, respectively. Results: Acute procedural success was 100% for femoral aneurysms and 92.3% (12/13) in the popliteal artery owing to one endoleak that resolved after 1 month. There were no complications, and the mean length of stay was 2.2 ± 3.8 days. Six-month and 1-year aneurysm exclusion rates were 100% for both locations, but 4 (31%) popliteal stent-grafts thrombosed in follow-up. Three were recanalized, but the fourth underwent bypass grafting after 3 thrombotic episodes. The 1-year primary and secondary patency rates were both 100% for the femoral aneurysms and 69% and 92%, respectively, for popliteal repairs. No procedure or device-related deaths occurred. Conclusions: Treatment of aneurysms in the femoropopliteal segment appears to be safe and effective with the Wallgraft Endoprosthesis, although longer follow-up in a larger patient group will be needed to determine this techniques potential versus surgical repair.

Endovascular Exclusion of Popliteal Artery Aneurysms with Stent-Grafts: A Prospective Single-Center Experience

Purpose: To determine the safety and efficacy of percutaneous treatment for popliteal artery aneurysms (PAA) using self-expanding stent-grafts. Methods: From October 2000 through September 2007, 29 patients (27 men; mean age 68±6 years, range 54–88) underwent endovascular exclusion of 33 PAAs. All had symptoms of claudication, and all were atherosclerotic in origin. Four patients presented with popliteal venous thrombosis. Twenty-eight of the treated PAAs had associated mural thrombus. The mean aneurysm diameter was 34.3± 13.3 mm and the mean lesion length was 98.6±102.1 mm. Results: All PAAs were successfully excluded from the arterial circulation using 59 stent-grafts (15 Wallgraft and 44 Viabahn). The average number of stent-grafts implanted was 1.9±0.4 (range 1–3); the mean length of covered vessel (per lesion) was 198.6±105.3 mm. There were no device-associated complications or deaths. Over an average follow-up of 35.4±32.1 months (range 6–120), the primary and secondary patency rates, respectively, were 93.9% and 100% at 6 months, 93.9% and 96.9% at 1 year, and 87.5% and 96.8% at 2 years. At 4.5 years, primary and secondary patency rates were 84.8% and 96.8%, respectively. No endoleaks, aneurysm rupture, thromboembolism, or limb loss occurred at follow-up. Conclusion: Stent-graft exclusion of PAAs is safe and effective, yielding primary and secondary patency rates comparable to surgical repair. In spite of encouraging results in this study, further larger studies are warranted to reconfirm our observations.

Preliminary results of endovascular abdominal aortic aneurysm exclusion with the AneuRx stent-graft.

OBJECTIVES This study evaluated the clinical effectiveness of the Medtronic AneuRx stent-graft in patients with infrarenal abdominal aortic aneurysms (AAAs) who were treated in an endovascular suite. BACKGROUND The use of endovascular stent-graft prosthesis for the treatment of AAAs is receiving increasing attention as an alternative to standard surgical repair. Endovascular treatment of AAAs offers the potential to avoid the significant morbidity and mortality associated with surgical repair. METHODS In this series, 215 patients have undergone AAA exclusion with the AneuRx stent-graft. Six-month follow-up is available in 132 patients; one-year follow-up is available in 84 and two-year follow-up in 22. RESULTS Of the patients, one hundred ninety-two (89%) were male; 87% had hypertension, and 58.6% were American Society of Anesthesiologists grade IV or higher. The procedural success was 99.5%; we were unable to place the device in one patient. There was no procedural or one-month mortality. There were no acute conversions to surgical repair. One patient had a non-Q-wave myocardial infarction 24 h after the procedure. Endoleaks were present in 82 patients (42%) at discharge, 15 patients (11.3%) at six months and 10 patients (11.9%) at one year. Twenty-two patients had a secondary procedure for endoleak repair of which three were conversions to surgical repair. Twelve late deaths have occurred, none due to device failure or AAA rupture. Mean hospital stay was 1.9 days. CONCLUSIONS These results reveal that infrarenal AAAs can be safely and successfully treated in an endovascular suite with the AneuRx stent-graft. Further follow-up is needed to determine the long-term efficacy of endoluminal treatment to prevent rupture and death due to AAAs.

Successful endoluminal repair of a popliteal artery aneurysm using the Wallgraft endoprosthesis.

Purpose: To describe the first application of the Wallgraft endovascular prosthesis to aneurysm exclusion in the popliteal artery. Methods and Results: A 61-year-old man was admitted to our institution with a popliteal artery aneurysm complicated by associated popliteal vein compression, deep venous thrombosis, and pulmonary embolism. The endovascular procedure was performed percutaneously with local anesthesia using a low-profile, covered stent (Wallgraft Endoprosthesis). The aneurysm was successfully excluded from the arterial circulation, and there were no postprocedural complications. Follow-up evaluation with appropriate imaging at 10 months revealed no endoleaks. Conclusions: This initial result indicates that percutaneous deployment of the Wallgraft endoprosthesis, with its smaller diameter and flexible design, may offer significant advantages over currently available devices for repair of popliteal artery aneurysms. This method obviates the need for general anesthesia or surgical exposure, which is particularly beneficial in patients with comorbid illnesses.