P2396Stress computed tomographic perfusion improve diagnostic accuracy of coronary computed tomographic angiography in intermediate to high risk patients for coronary artery disease

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Microembolization during carotid artery stenting in patients with high-risk, lipid-rich plaque: A randomized trial of proximal versus distal cerebral protection

Objectives: The goal of this study was to compare the rate of cerebral microembolization during carotid artery stenting (CAS) with proximal versus distal cerebral protection in patients with high-risk, lipid-rich plaque. Background: Cerebral protection with filters partially reduces the cerebral embolization rate during CAS. Proximal protection has been introduced to further decrease embolization risk. Methods: Fifty-three consecutive patients with carotid artery stenosis and lipid-rich plaque were randomized to undergo CAS with proximal protection (MO.MA system, n = 26) or distal protection with a filter (FilterWire EZ, n = 27). Microembolic signals (MES) were assessed by using transcranial Doppler during: 1) lesion wiring; 2) pre-dilation; 3) stent crossing; 4) stent deployment; 5) stent dilation; and 6) device retrieval/deflation. Diffusion-weighted magnetic resonance imaging was conducted before CAS, after 48 h, and after 30 days. Results: Patients in the MO.MA group had higher percentage diameter stenosis (89 \ub1 6% vs. 86 \ub1 5%, p = 0.027) and rate of ulcerated plaque (35% vs. 7.4%; p = 0.019). Compared with use of the FilterWire EZ, MO.MA significantly reduced mean MES counts (p < 0.0001) during lesion crossing (mean 18 [interquartile range (IQR): 11 to 30] vs. 2 [IQR: 0 to 4]), stent crossing (23 [IQR: 11 to 34] vs. 0 [IQR: 0 to 1]), stent deployment (30 [IQR: 9 to 35] vs. 0 [IQR: 0 to 1]), stent dilation (16 [IQR: 8 to 30] vs. 0 [IQR: 0 to 1]), and total MES (93 [IQR: 59 to 136] vs. 16 [IQR: 7 to 36]). The number of patients with MES was higher with the FilterWire EZ versus MO.MA in phases 3 to 5 (100% vs. 27%; p < 0.0001). By multivariate analysis, the type of brain protection was the only independent predictor of total MES number. No significant difference was found in the number of patients with new post-CAS embolic lesion in the MO.MA group (2 of 14, 14%) as compared with the FilterWire EZ group (9 of 21, 42.8%). Conclusions: In patients with high-risk, lipid-rich plaque undergoing CAS, MO.MA led to significantly lower microembolization as assessed by using MES counts. (Carotid Stenting in Patients With High Risk Carotid Stenosis ["Soft Plaque"] [MOMA]; NCT01274676) \ua9 2011 American College of Cardiology Foundation

Progressive growth of coronary aneurysms after bioresorbable vascular scaffold implantation: Successful treatment with OCT-guided exclusion using covered stents

The development and progressive enlargement over time of multiple saccular coronary artery aneurysms (CAA) after implantation of everolimus-eluting stent and bioresorbable vascular scaffolds (BVS) have been reported. CAA was successfully excluded by two overlapped covered stents expanded inside a long metallic drug-eluting stent to avoid dislodgment at the overlap point. Optical coherence tomography (OCT) was repeatedly performed to monitor CAA expansion and to guide treatment through precise measurement of aneurysm length and vessel size at the landing zone. At 10-month follow-up, coronary computed tomography angiography showed persistent CAA exclusion. To the best of our knowledge, this is the first report of this technique to exclude a long CCA segment

Seven-year recurrence of left ventricular apical ballooning

Left ventricular apical ballooning (Tako-tsubo syndrome) is an acute and rapidly reversible dysfunction of the left ventricle, triggered by a profound psychological stress. We describe an interesting case of very late recurrence

Early stent thrombosis after superficial femoral artery stenting successfully treated with transcatheter rheolytic thrombectomy in a patient with reduced aspirin responsiveness

Purpose: To describe a case of early superficial femoral artery (SFA) thrombosis after stenting in an aspirin low-responsive patient successfully treated with percutaneous mechanical thrombectomy. Clinical and interventional summary: Early SFA stent thrombosis occurred in a 65-year-old man treated with multiple stent implantation for chronic total occlusion of the left SFA. The potential cause for thrombosis was a suboptimal PTA [percutaneous transluminal angioplasty] result characterized by no-flow limiting residual linear dissection left untreated and which was associated with low responsiveness to aspirin. Rapid thrombus removal and flow restoration were obtained with the Angiojet Ultra Thrombectomy System (Medrad, Warrendale, PA, USA). Conclusions: Treatment of SFA stent thrombosis should be undertaken with the understanding of the underlying thrombotic causes and the knowledge of the most appropriate therapeutic options. A percutaneous mechanical strategy with the Angiojet Ultra Thrombectomy System may achieve rapid and complete recanalization even in the presence of huge thrombotic burden.&lt;. Learning objective: New devices have been available for huge thrombotic burden management in acute clinical peripheral settings. A few clinical experiences have been described and the case we present shows the safety and efficacy of the rheolytic thrombectomy for femoral stent thrombosis management avoiding bleeding and distal embolization risks

Emergency stenting of totally occluded left main coronary artery in acute myocardial infarction

We report a case of emergency stenting for acute occlusion of the left main coronary artery in the setting of acute myocardial infarction. Although stent implantation allowed prompt revascularization and successful immediate management of this life-threatening condition, subacute stent thrombosis occurred, requiring re-PTCA followed by surgical revascularization. This case suggests that stenting of an acutely occluded left main coronary artery may be a life-saving procedure but should only be used as a bridge to surgery rather than a definitive treatment modality

Large coronary aneurysm complicated by acute myocardial infarction: combined intravascular ultrasound imaging and doppler flow assessment before and after PTFE-covered stent implantation

Although most patients with coronary artery aneurysms are asymptomatic, manifestations of myocardial ischemia may occur. However, the role that a coronary aneurysm may play in impairing arterial flow of an otherwise normal coronary circulation is not completely known. A 64-year-old woman with previous anteroseptal myocardial infarction was found to have a large aneurysm of the proximal left anterior descending (LAD) coronary artery without angiographic evidence of atherosclerotic disease. IVUS evaluation revealed an 18 mm long and 12.2 x 10.8 mm wide aneurysm without atherosclerosis, thrombus or calcification. Pulsed wave Doppler showed significant reduction of LAD flow reserve, which normalized after successful obliteration of the aneurysm with polytetrafluoroethylene (PTFE)-covered stent implantation. Severe in-stent graft restenosis was found at 7-month angiographic and intravascular ultrasound follow-up, which was managed successfully with minimally invasive direct coronary bypass surgery. The patient did well, without symptoms over the following year