Zastosowanie systemu proksymalnej protekcji mózgowej Mono Mo.MA w leczeniu świeżej niedrożności tętnicy kręgowej

Głównym ograniczeniem zabiegów przezskórnej rewaskularyzacji tętnic kręgowych jest zjawisko embolizacji okołozabiegowej do tętnic mózgowych zaopatrujących tylny krąg unaczynienia mózgu i ryzyko wystąpienia udaru mózgu. Opisano zabieg skutecznej rekanalizacji tętnicy kręgowej u chorego z obustronną niedrożnością tętnic kręgowych i objawami niedokrwienia mózgu z wykorzystaniem nowego systemu protekcji mózgowej Mono Mo.Ma i czasowym odwróceniem przepływu w tętnicy kręgowej.The major concern in performing percutaneous procedures for the treatment of vertebrobasilar obstructive disease is the risk of embolic phenomena. We describe the successful treatment of a symptomatic patient with bilateral vertebrobasilar disease utilizing a new proximal protection device, Mono Mo.Ma

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

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

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

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

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