Covered Endovascular Reconstruction of Aortic Bifurcation Facilitated by Intravascular Lithotripsy With Shockwave Balloon: A Case Report

Aortoiliac occlusive disease (AIOD) is a specific form of peripheral artery disease (PAD) that affects the infrarenal aorta and iliac arteries. Patients with PAD commonly suffer from intermittent claudication (IC), a condition characterized by cramping pain during or after exercise that is relieved by rest. The first-line therapy for IC involves medical management, foot care, and structured exercise programs while revascularization therapy, which can be endovascular, surgical, or a combination of both, is generally reserved for patients with claudication who do not respond adequately to initial therapies. We present the clinical case of a 58-year-old female with hypertension, dyslipidemia, and a smoking habit who was referred to our hospital (Misericordia Hospital, Grosseto, Italy) due to bilateral IC of the buttocks and thighs. Computed tomography (CT) angiography revealed a 90% tight stenosis of the infrarenal abdominal aorta just above the iliac bifurcation with diffuse calcifications. After a careful evaluation of the patient's condition and anatomical characteristics of the atherosclerotic disease, the vascular team decided to perform covered endovascular reconstruction of aortic bifurcation (CERAB) with previous intravascular lithotripsy (IVL) with shockwave balloon using intravascular ultrasound (IVUS) as guidance, because of severe aortic luminal calcifications. We performed successful CERAB, and the patient was discharged in good clinical condition on the fifth day of hospitalization with an indication to follow optimal medical therapy. At the one-month clinical follow-up, the patient reported the disappearance of claudication with marked improvement in quality of life. This first described case of IVUS-guided IVL-facilitated CERAB demonstrates the efficacy and safety of IVL in calcific aortic disease and shows the usefulness of IVUS as guidance in peripheral calcium debulking procedures

Influence of the Occlusion Site

Background: Previous findings suggest that transient myocardial ischemia and reperfusion may elicit changes in the autonomic balance. In this study, a spectral analysis of heart rate variability was used to assess the modifications of sympathovagal balance induced by coronary angioplasty and their relationship with the occlusion site. Methods: We studied 23 patients (17M, 6F, age 58 ± 10 years) with left anterior descending and 19 patients (15M, 4F, age 56 ± 9 years) with right coronary artery stenosis. Spectral analysis of heart rate variability was performed, by autoregressive model, in basal conditions and during each balloon inflation. At least two inflations of 90–120 seconds were performed in each patient. Results: In patients with left anterior descending artery stenosis, the first occlusion induced marked changes in the autonomic balance, which moved toward a sympathetic predominance. The low frequency component of the spectrum and the low-to-high frequency ratio increased from 59 ± 10 normalized units (NU) to 75 ± 10 NU (P < 0.001) and from 2.4 ± 1.4 to 7.3 ± 4.7 (P < 0.001) respectively, while the high frequency component decreased from 30 ± 11 NU to 14 ± 7 NU (P < 0.001). These changes showed a progressive attenuation during repetitive occlusions, and were significantly correlated with the entity of myocardial ischemia assessed by the ST-segment shift measured on the intracoronary electrocardiographic lead. On the contrary, in patients with right coronary artery stenosis the first occlusion was ineffective with regard to the spectral parameters whereas the third occlusion induced a significant increase in the high frequency component (from 31 ± 9 NU to 41 ± 10 NU, P < 0.01) and decrease in the low-to-high frequency ratio (from 2.1 ± 0.9 to 1.3 ± 0.5, P < 0.05) suggesting a vagal activation. The entity of vagal activation was not correlated with the ST-segment shift. Conclusions: Our data indicate that repetitive coronary occlusions induce significant changes in the autonomic balance. The direction and the time course of these changes are related to the occlusion site

Mechanical Prevention of Distal Embolization During Primary Angioplasty

Background— Effective myocardial reperfusion after primary percutaneous coronary intervention (PCI) may be limited by distal embolization. We tested the safety, feasibility, and efficacy of the FilterWire-Ex (FW), a distal embolic protection device, as an adjunct to primary PCI. Methods and Results— Fifty-three consecutive patients undergoing primary PCI with FW protection were compared with a matched control group treated by primary PCI alone. Successful FW positioning was obtained in 47 patients (89%) without complications. Histological analysis of the content of the last 13 filters showed multiple embolic debris in all cases. FW use was associated with lower postinterventional corrected TIMI frame count (22±14 versus 31±19; P =0.005) and higher occurrence of grade 3 myocardial blush (66% versus 36%; P =0.006) and early ST-segment elevation resolution (80% versus 54%; P= 0.006). At multivariate analysis, FW use was the only independent predictor of early ST-segment elevation resolution and of grade 3 myocardial blush. FW patients showed lower peak creatine kinase-MB release (236±172 versus 333±219 ng/mL; P =0.013) and greater improvement at 30 days in left ventricular wall motion score index (−0.30±0.19 versus −0.18±0.26; P= 0.008) and ejection fraction (+7±4% versus +4±7%; P =0.012). Conclusions— FW use during primary PCI is feasible and safe. Distal embolization prevention appears to exert a beneficial effect on markers of myocardial reperfusion and on left ventricular function improvement at 30 days

Randomized comparison of operator radiation exposure comparing transradial and transfemoral approach for percutaneous coronary procedures: Rationale and design of the minimizing adverse haemorrhagic events by TRansradial access site and systemic implementation of angioX - RAdiation Dose study (RAD-MATRIX)

Background: Radiation absorbed by interventional cardiologists is a frequently under-evaluated important issue. Aim is to compare radiation dose absorbed by interventional cardiologists during percutaneous coronary procedures for acute coronary syndromes comparing transradial and transfemoral access. Methods: The randomized multicentre MATRIX (Minimizing Adverse Haemorrhagic Events by TRansradial Access Site and Systemic Implementation of angioX) trial has been designed to compare the clinical outcome of patients with acute coronary syndromes treated invasively according to the access site (transfemoral vs. transradial) and to the anticoagulant therapy (bivalirudin vs. heparin). Selected experienced interventional cardiologists involved in this study have been equipped with dedicated thermoluminescent dosimeters to evaluate the radiation dose absorbed during transfemoral or right transradial or left transradial access. For each access we evaluate the radiation dose absorbed at wrist, at thorax and at eye level. Consequently the operator is equipped with three sets (transfemoral, right transradial or left transradial access) of three different dosimeters (wrist, thorax and eye dosimet

A Qualitative Exploration of the Use of Contraband Cell Phones in Secured Facilities

Offenders accepting contraband cell phones in secured facilities violate state corrections law, and the possession of these cell phones is a form of risk taking behavior. When offenders continue this risky behavior, it affects their decision making in other domains where they are challenging authorities; and may impact the length of their incarceration. This qualitative phenomenological study examined the lived experience of ex-offenders who had contraband cell phones in secured correctional facilities in order to better understand their reasons for taking risks with contraband cell phones. The theoretical foundation for this study was Trimpop\u27s risk-homeostasis and risk-motivation theories that suggest an individual\u27s behaviors adapt to negotiate between perceived risk and desired risk in order to achieve satisfaction. The research question explored beliefs and perceptions of ex-offenders who chose to accept the risk of using contraband cell phones during their time in secured facilities. Data were collected anonymously through recorded telephone interviews with 8 male adult ex-offenders and analyzed using thematic content analysis. Findings indicated participants felt empowered by possession of cell phones in prison, and it was an acceptable risk to stay connected to family out of concern for loved ones. The study contributes to social change by providing those justice system administrators, and prison managers responsible for prison cell phone policies with more detailed information about the motivations and perspectives of offenders in respect to using contraband cell phones while imprisoned in secured facilities

Atrial fibrillation in the cardiometabolic patient

Prevalence of obesity, metabolic syndrome (MetS) and type 2 diabetes (T2D) is growing alarmingly, and the number of affected people continues to escalate. Such cardiometabolic states exert many deleterious effects on the heart as they are associated with adverse left ventricular (LV) remodeling and, most notably, with a marked increase in the risk of developing atrial fibrillation (AF) and subsequent stroke. Epidemiological studies clearly show a strong association between obesity and AF, with a 4-5% increase in AF risk for every unit increase in BMI. The increased risk of developing AF in cardiometabolic patients is explained by changes in volume status, energy substrate utilization, tissue metabolism and systemic inflammation, all factors promoting elevation in left atrial and systolic blood pressure, LV systo-diastolic dysfunction, with subsequent atrial stretch and "triggers" for AF. In the present review, we critically discuss available evidence on AF risk in the cardiometabolic patient. Specific aspects will be discussed: 1) epidemiology and prognosis of AF in patients with obesity, MetS and T2D; 2) molecular mechanisms involved in the pathophysiology of metabolic cardiomyopathy and left atrial remodeling; 3) advances in medical therapy including weight loss strategies and lifestyle changes; 4) new oral anticoagulants and stroke risk in obese and diabetic patients; 5) effectiveness and safety of AF catheter ablation. Taken together, these novel insights point to the development of new therapeutic strategies to combat the burden of AF in patients with cardiometabolic disturbances

[The DAPT study]

Background. Dopo impianto di stent è raccomandata la duplice terapia antiaggregante allo scopo di prevenire l’insorgenza di complicanze trombotiche, ma restano ancora da chiarire i benefici ed i rischi associati al prolungamento della doppia antiaggregazione oltre i 12 mesi. Metodi. Sono stati arruolati pazienti sottoposti ad angioplastica coronarica con impianto di stent medicato. Dopo 12 mesi di trattamento con tienopiridina (clopidogrel o prasugrel) e aspirina, i pazienti sono stati randomizzati a mantenimento della terapia con tienopiridina o a placebo per altri 18 mesi, in entrambi i casi con prosecuzione del trattamento con aspirina. Gli endpoint co-primari di efficacia erano rappresentati dalla trombosi di stent e dagli eventi avversi maggiori cardio- e cerebrovascolari (un composito di morte, infarto o ictus) nel periodo compreso fra 12 e 30 mesi. L’endpoint primario di sicurezza era costituito dalle emorragie moderate o severe. Risultati. Un totale di 9961 pazienti sono stati randomizzati a prosecuzione della terapia con tienopiridina o a placebo. Il mantenimento della duplice antiaggregazione rispetto al trattamento con placebo è risultato associato ad una riduzione della trombosi di stent (0.4 vs 1.4%; hazard ratio 0.29; intervallo di confidenza [IC] 95% 0.17-0.48; p&lt;0.001) e degli eventi avversi maggiori cardio- e cerebrovascolari (4.3 vs 5.9%; hazard ratio 0.71; IC 95% 0.59-0.85; p&lt;0.001). L’incidenza di infarto miocardico è stata inferiore nel gruppo a doppia antiaggregazione prolungata rispetto a quello trattato con placebo (2.1 vs 4.1%; hazard ratio 0.47; p&lt;0.001). La mortalità da ogni causa è stata del 2.0% nel gruppo a doppia antiaggregazione prolungata e dell’1.5% nel gruppo placebo (hazard ratio 1.36; IC 95% 1.00-1.85; p=0.05). Il tasso di emorragie moderate o severe è risultato più elevato nel gruppo a doppia antiaggregazione prolungata (2.5 vs 1.6%; p=0.001). In entrambi i gruppi è stato osservato un rischio elevato di trombosi di stent e di infarto miocardico nei 3 mesi successivi alla sospensione della duplice terapia antiaggregante. Conclusioni. Dopo impianto di stent medicato, il prolungamento della doppia antiaggregazione oltre i 12 mesi, rispetto alla sola terapia con aspirina, ha determinato una significativa riduzione del rischio di trombosi di stent e di eventi avversi maggiori cardio- e cerebrovascolari ma è risultato associato ad un aumento del rischio emorragico. [N Engl J Med 2014;371:2155-66