Zastosowanie nowego systemu protekcji dystalnej (FiberNet®) podczas angioplastyki pomostów żylnych

Percutaneous intervention in saphenous vein grafts is associated with a high risk of distal embolisation by plaque material, ‘no flow’ phenomenon and clinical complications such as myocardial infarction or death. According to randomised trial evidence, intervention in a degenerated vein graft should be performed using an embolic protection device (EPD), since this strategy significantly reduces periprocedural and 30 day adverse event rate. FiberNet® is a novel distal protection system with unique characteristics of a low crossing profile (0.031’’ for vessel size 3.5–5 mm), ‘cotton wool’-like three dimensional design and a small pore size (40 µm). The FiberNet® does not require a separate delivery sheath and self-achieves its optimal apposition to the vessel wall; the EPD system also contains a dedicated aspiration catheter. We present the use of FiberNet® in a 77 year-old patient who had undergone coronary artery bypass grafting 20 years ago and currently presented with CCS class III angina due to a significant stenosis of the saphenous vein graft to the marginal branch. The procedure involved the use of a novel mesh-covered stent (MGuard®) designed to ‘trap’ the plaque material between the stent and the vessel wall. It was technically successful and clinically uncomplicated, and the patient remains well six months later

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

Intravenous N-acetylcysteine for the PRevention Of Contrast-induced nephropathy : a prospective, single-center, randomized, placebo-controlled trial : the INPROC trial

Introduction: Contrast-induced nephropathy (CIN) is a common clinical problem that is growing in importance as an increasing number of tests and procedures which utilize contrast media (CM) are performed. Aim: To evaluate the efficacy of intravenous N-acetylcysteine (NAC) for prevention of CIN after diagnostic and/or interventional procedures requiring CM administration. Material and methods: In a prospective, single-center, randomized, placebo-controlled trial the preventive effects of N-acetylcysteine were evaluated in 222 patients undergoing elective angiography and/or angioplasty. Patients were randomly assigned to receive either NAC or placebo. All patients received intravenous hydration with normal saline before and after catheterization. Serum creatinine (SCr) and estimated glomerular filtration rate were assessed at baseline, at 48–72 h and 10–15 days after CM administration. Contrast-induced nephropathy was defined as an increase in SCr of at least 44 μmol/l (0.5 mg/dl) or an increase of ≥ 25% of the baseline value 48–72 h after CM administration. Results: Contrast-induced nephropathy occurred in 30 of 222 patients (13.5%): 9 of 108 patients in NAC (8.3%) and 21 of 114 patients in the control group (18.4%; p = 0.0281). The multivariate Cox analysis revealed that elevated SCr at 10–15 days (HR = 2.69; p = 0.018) and baseline SCr level (HR = 1.009; p = 0.015) were independent prognostic variables for adverse events during follow-up. Conclusions: Our findings suggest that intravenous NAC along with intravenous hydration may help prevent declining renal function after CM exposure. Elevated SCr level 10–15 days after CM administration was associated with increased risk of adverse events in long-term observation, while elevated SCr within 72 h was not. Measuring SCr at least 10 days after exposure to CM may provide a better outcome measure

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

Wewnątrznaczyniowe leczenie objawowych zwężeń proksymalnych odcinków tętnic kręgowych

Two vertebral arteries, basilar artery and their branches create posterior circulation system. This system provides blood supply to the brainstem, thalamus, cerebellum and parts of the temporal and occipital lobes. Ischemic strokes account for about 70–80% of all strokes and posterior circulation strokes accounts for about 20–30% of them. Symptomatic vertebral artery stenosis is a well-known risk factor for vertebrobasilar (VB) stroke. Clinical symptoms of VB ischaemia are very heterogenous due to wide area of vascular supply. Among patients after posterior circulation stroke, vertebral artery stenosis &gt; 50% occurs in 20% of the patients and in 9% is the main cause of stroke. First line treatment consists of risk factors modification and pharmacotherapy. Patients who fail medical management are considered for interventional therapy — either surgical or endovascular. First case of vertebral artery balloon angioplasty was reported in 1981, nowadays vertebral artery stenting is the routine treatment option, described in ESC guidelines in 2011. Vertebral artery stenting is safe and is associated with low percentage of complications. Drug-eluting stents at the ostial vertebral location may reduce in-stent restenosis rate comparing to bare-metal stents, but the results from literature are not conclusive. High restenosis rate after vertebral artery stenting remains a concern, however it could be succesfully treated with reangioplasty in vast majority of cases.Tętnice kręgowe, powstająca z ich połączenia tętnica podstawna oraz ich gałęzie stanowią tylny krąg unaczynienia (TKU). Odpowiada on za dostarczenie krwi do pnia mózgu, tylnej części wzgórza, móżdżku, części płatów skroniowych i potylicznych. Udary niedokrwienne stanowią około 70–80% przypadków wszystkich udarów mózgu, natomiast udary z TKU stanowią około 20–30% wszystkich udarów niedokrwiennych mózgu. Objawowe zwężenie tętnicy kręgowej jest powszechnie uznaną przyczyną udaru z TKU. W populacji osób z przebytym udarem z TKU, zwężenie tętnicy kręgowej &gt; 50% stwierdza się u 20% chorych, z czego u 9% jest to główna przyczyna udaru. Obraz kliniczny niedokrwienia kręgowo-podstawnego jest bardzo różnorodny z powodu rozległego obszaru unaczynienia. Leczeniem pierwszego rzutu jest modyfikacja czynników ryzyka oraz farmakoterapia. Chorzy, u których leczenie zachowawcze nie przynosi zadowalających efektów, są kwalifikowani do leczenia interwencyjnego — metodami chirurgicznymi lub wewnątrznaczyniowymi. Pierwszy zabieg angioplastyki balonowej tętnicy kręgowej opisano w 1981 roku; obecnie standardem są zabiegi angioplastyki z implantacją stentu, co ujęto w wytycznych European Society of Cardiology (ESC) z 2011 roku. Stenty powlekane lekiem antymitotycznym mogą zmniejszać odsetek nawrotu zwężenia w stencie implantowanym do ujścia tętnicy kręgowej w porównaniu do klasycznych stentów metalowych, choć dane z literatury nie są jednoznaczne. Duży odsetek nawrotu zwężenia w stencie w tętnicy kręgowej pozostaje problemem, niemniej w większości przypadków chorzy mogą być skutecznie leczeni zabiegiem ponownej angioplastyki

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

Zastosowanie zapinek naczyniowych AngioSeal w kontroli miejscowej hemostazy w przezskórnych interwencjach obwodowych z dostępu kaniulą 6–9 F przez tętnicę udową

Wstęp: Miejscowe powikłania dostępu naczyniowego przez tętnicę udową po zabiegach na tętnicach obwodowych istotnie zwiększają chorobowość okołozabiegową, wydłużają czas hospitalizacji oraz mogą się przyczyniać do zwiększonej śmiertelności okołozabiegowej. Cel: Ocena skuteczności stosowania zapinek naczyniowych AngioSeal® w redukcji liczby miejscowych powikłań dostępu naczyniowego, skracaniu czasu do uruchomienia i czasu hospitalizacji po przezskórnych interwencjach w naczyniach obwodowych. Materiał i metody: Do standardowej kompresji manualnej (manual compression – MC) vs zapinki AngioSeal® (AS, 6 F i 8 F odpowiednio dla dostępu kaniulą 6–7 F i 8–9 F) zrandomizowano (1 : 1) 201 chorych w wieku 48–87 lat (średnio 66,9 ±8 lat, 59,2% mężczyzn) poddawanych przezskórnej angioplastyce tętnic obwodowych (szyjnej wewnętrznej, szyjnej wspólnej, kręgowej, biodrowej lub udowej, podobojczykowej, nerkowej, pnia ramienno-głowowego, pomostu szyjno-podobojczykowego). U 7 chorych zrandomizowanych do grupy AS (7,1%) nie było warunków anatomicznych do założenia zapinki naczyniowej. Kaniule 8–9 F zastosowano w 73,6% zabiegów w grupie MC vs w 72,5% zabiegów w grupie AS (p = 0,986). Wyniki: Łącznie ostre niedokrwienie kończyny, tętniak rzekomy, rozległy krwiak podskórny, przetoka tętniczo-żylna wystąpiły istotnie częściej w grupie MC niż w AS (18,2% vs 6,6%, p = 0,019), po kaniulacji 8–9 F (19,7% MC vs 7,6% AS) (p = 0,035). Po zabiegu chorzy z AS byli uruchomieni po 1–12 godzinach (średnia: 2,90 ±2,4), a MC 8,6–19,3 godziny (średnia: 14,18 ±2,28) (p < 0,001). Dziewięciu pacjentów z AS (9,9%) wymagało dodatkowo opatrunku uciskowego przez 6–12 godzin. Chorych z grupy MC wypisano ze szpitala 24–240 godzin po zabiegu (średnia: 68,1 ±34,08) vs AS po 24–72 godzinach (średnia: 33,6 ±14,16) (p = 0,001). Wnioski: Zamknięcie dostępu naczyniowego zapinkami naczyniowymi AngioSeal® 6 F i 8 F po przezskórnych interwencjach na tętnicach obwodowych przez tętnicę udową po kaniulacji 6–9 F jest bezpieczne, zmniejsza ryzyko wystąpienia powikłań miejscowych oraz skraca czas unieruchomienia i hospitalizacji.Background: Complications related to the femoral access substantially contribute to peri-procedural morbidity and mortality. Aim: To evaluate whether the use of a collagen plug as a vascular access closure device (AngioSeal®, AS) influences complications related to the femoral access and duration of hospitalization for peripheral endovascular interventions. Material and methods: Two hundred and one consecutive patients (59.2% male, age 48-87 years) undergoing angioplasty/stenting of the internal carotid, common carotid, vertebral, subclavian, renal, iliac/femoral, innominate artery or cervical-subclavian bypass were randomized (1 : 1 ratio) prior to the intervention to standard manual compression (MC) or AS (6 F or 8 F device used for femoral access with 6-7 F or 8-9 F sheaths respectively). Results: Manual compression was used in 110 patients and AS in 91 patients. There was no difference in the use of 8-9 F and 6-7 F sheats between the two per treatment groups (72.5% vs. 73.6% and 27.5% vs. 26.2%, respectively). Large subcutaneous haematoma, arteriovenous fistula, pseudoaneurysm or femoral artery occlusion requiring surgery occurred in 13.8% MC vs. 4.0% AS for 6-7 F sheaths (p = 0.36) and in 19.7% MC vs. 7.6% AS for 8-9 F sheaths (p = 0.035). Total access site complication rate was 18.2% for MC and 6.6% for AS (p = 0.019). Nine patients with AS (9.9%) required an additional compression dressing (≤ 12 h). Overall, AS patients were mobilized earlier (2.9 ±2.4 h vs. 14.2 ±2.8 h, p = 0.001) and discharged home earlier after the intervention (33.6 ±14.16 h vs. 68.1 ±34.08 h, p = 0.001). Conclusions: The use of the AngioSeal® device for femoral access closure during peripheral interventions (AngioSeal® 8 F for 8-9 F sheath and AngioSeal® 6 F for 6-7 F sheath) significantly reduces the access site complication rate and allows earlier patient mobilization and discharge from hospital

Invasive treatment for carotid fibromuscular dysplasia

Introduction: Fibromuscular dysplasia (FMD) is an infrequent non-inflamatory disease of unknown etiology that affects mainly medium-size arteries. The prevalence of FMD among patients scheduled for endovascular treatment of carotid artery stenosis is unknown. Aim: To evaluate the prevalence and treatment options of carotid FMD in patients scheduled for carotid artery stenting (CAS). Material and methods: Between Jan 2001 and Dec 2013, 2012 CAS procedures were performed in 1809 patients (66.1% men; age 65.3 ±8.4 years, 49.2% symptomatic). In case of FMD suspicion in Doppler-duplex ultrasound (DUS), computed tomography angiography was performed for aortic arch and extracranial and intracranial artery imaging. For invasive treatment of FMD carotid stenosis, balloon angioplasty was considered first. If the result of balloon angioplasty was not satisfactory (> 30% residual stenosis, dissection), stent placement was scheduled. All patients underwent follow-up DUS and neurological examination 3, 6 and 12 months after angioplasty, then annually. Results: There were 7 (0.4%) (4 symptomatic) cases of FMD. The FMD group was younger (47.9 ±7.5 years vs. 67.2 ±8.9 years, p = 0.0001), with higher prevalence of women (71.4% vs. 32.7%, p = 0.0422), a higher rate of dissected lesions (57.1% vs. 4.6%, p = 0.0002) and less severe stenosis (73.4% vs. 83.9%, p = 0.0070) as compared to the non-FMD group. In the non-FMD group the prevalence of coronary artery disease was higher (65.1% vs. 14.3% in FMD group, p = 0.009). All FMD patients underwent successful carotid artery angioplasty with the use of neuroprotection devices. In 4 cases angioplasty was supported by stent implantation. Conclusions: Fibromuscular dysplasia is rare among patients referred for CAS. In case of significant FMD carotid stenosis, it may be treated with balloon angioplasty (stent supported if necessary) with optimal immediate and long-term results