O uso do balão com paclitaxel no tratamento da reestenose intra-stent no segmento fêmoro-poplíteo / Use of paclitaxel-coated balloon to treat in-stent restenosis in femoropopliteal segments

Resumo Contexto A reestenose intra-stent por hiperplasia miointimal pós-angioplastia é uma intercorrência frequente e que limita a perviedade do procedimento a longo prazo. A terapia com balões revestidos de droga com ação antiproliferativa pode ser uma alternativa no tratamento dessa complicação. Objetivos Demonstrar eficácia e as complicações (óbito, grandes amputações, etc.) do balão farmacológico no tratamento da reestenose intra-stent de segmento femoropoplíteo. Métodos Estudo de coorte retrospectivo de 32 pacientes consecutivos tratados entre os anos de 2012 e 2016, submetidos a terapia de reestenose intra-stent de segmento femoropoplíteo com angioplastia com balão farmacológico revestido com paclitaxel. A taxa de sucesso foi mensurada pela ocorrência de sucesso do procedimento e reestenose inferior a 50% em avaliação por eco-Doppler colorido 30, 90 e 180 dias após o procedimento. Resultados Quatro pacientes (12,5%) apresentaram reestenose superior a 50%, sendo um (3,1%) após 90 dias e três (9,4%) após 180 dias, conferindo uma taxa de sucesso de 87,5% ao procedimento. Após 180 dias, todos os pacientes referiam melhora ou cessação dos sinais e/ou sintomas apresentados antes do procedimento. Não houve óbitos, e complicações ocorreram apenas em dois casos, no pós-operatório imediato. Conclusões Os resultados a curto prazo da terapia com balão farmacológico são promissores, com redução na taxa de reestenose e baixo índice de complicações. Ainda precisam ser apresentados estudos demonstrando os efeitos a longo prazo dessa terapia, assim como seu impacto econômico quando comparada a outros procedimentos.

Abstract Background In-stent restenosis due to myointimal hyperplasia after angioplasty is common and limits long-term patency. Treatments using balloons coated with antiproliferative drugs may offer an alternative option for this pathology. Objectives To demonstrate the efficacy and complications (death, major amputations, etc.) of drug-coated balloons for treatment of in-stent restenosis in femoropopliteal segments. Methods This was a retrospective cohort study of 32 consecutive patients treated between 2012 and 2016 who underwent treatment to correct in-stent restenosis in the femoropopliteal segment using paclitaxel-coated balloons. The success rate was measured in terms of technical success and restenosis of less than 50% on Doppler ultrasonography at 30, 90, and 180 days after the procedure. Results Four patients (12.5%) exhibited restenosis greater than 50%, one (3.1%) after 90 days and three (9.4%) after 180 days, equating to a success rate of 87.5% of procedures, and by 180 days all patients experienced improvement or cessation of the signs and/or symptoms they had presented prior to the procedure. There were no deaths and complications occurred in just 2 cases in the immediate postoperative period. Conclusions Short-term results are promising, with reductions in the magnitude of restenosis and a low rate of complications. Further studies are needed that can demonstrate the long-term effects and the economic impacts in comparison to other procedures.

Efficacy of a Modified Pharmacomechanical Thrombolysis Technique for Endovascular Treatment of Thrombosed Prosthetic Arteriovenous Grafts

OBJECTIVE: We applied a modified pharmacomechanical thrombolysis (PMT) technique to endovascular treatment of thrombosed arteriovenous (AV) grafts without the use of any mechanical thrombectomy devices. The aim of this study was to evaluate the efficacy of the PMT technique in the treatment of thrombosed AV grafts by analyzing the long-term patency. MATERIALS AND METHODS: Eighty-two patients with thrombosed AV grafts were treated with the PMT technique. AV graft surveillance to detect failing/failed access was followed by endovascular treatment. RESULTS: The technical and clinical success rates were 95% and 95%, respectively. The total number of thrombolysis sessions was 279. A post-intervention primary patency rate was 45% and 22% at 12 and 24 months, respectively. The secondary patency rate was 96% and 91% at 12 and 24 months, respectively. No major complications were noticed. CONCLUSION: The modified PMT technique is effective in endovascular treatment of thrombosed AV grafts.

Percutaneous Intervention in Axillary Loop-Configured Arteriovenous Grafts for Chronic Hemodialysis Patients

OBJECTIVE: The purpose of this study was to evaluate the fistulographic features of malfunctioning axillary loop-configured arteriovenous grafts and the efficacy of percutaneous interventions in failed axillary loop-configured arteriovenous grafts. MATERIALS AND METHODS: Ten patients with axillary loop-configured arteriovenous grafts were referred for evaluation of graft patency or upper arm swelling. Fistulography and percutaneous intervention, including thrombolysis, percutaneous transluminal angioplasty and stent placement, were performed. Statistical analysis of the procedure success rate and the primary and secondary patency rates was done. RESULTS: Four patients had graft related and subclavian venous stenosis, two patients had graft related stenosis and another four patients had subclavian venous stenosis only. Sixteen sessions of interventional procedures were performed in eight patients (average: 2 sessions / patient) until the end of follow-up. An interventional procedure was not done in two patients with central venous stenosis. The overall procedure success rate was 69% (11 of 16 sessions). The post-intervention primary and secondary patency rates were 50% and 63% at three months, 38% and 63% at six months and 25% and 63% at one year, respectively. CONCLUSION: Dysfunctional axillary loop-configured arteriovenous grafts almost always had subclavian venous and graft-related stenosis. Interventional treatments are helpful to overcome this and these treatments are expected to play a major role in restoring and maintaining the axillary loop-configured arteriovenous loop grafts.

Success rate of szabo technique in ostial coronary Pci. techniques, anagiographic and IVUS findings

Percutaneous coronary intervention [PCI] in ostial coronary artery lesions has been technically difficult because it should be done with precise stent placement in ostium and absence of side branch compromise. The Szabo technique consists of side branch wiring through most proximal stent strut as well as main branch wiring through stent lumen. The side branch wire or anchor wire prevents stent advancement beyond ostial segment and makes possible the accurate stent implantation in ostitum. The purpose of this study is to evaluate the feasibility and success rate of Szabo technique analyzing technical, angiographic and IVUS [Intravascular Ultrashonography] findings success rate. We analysed retrospectively in our cath lab, 13 PCIs in 13 patients with a significant lesion at a coronary artery ostium which was treated percutaneously using Szabo technique. The procedure was defined as technically successful if there was neither stent loss nor second guide wire pull back during stent advancement. A successful procedure from angiographic point of view was defined as a precise stent implantation at ostium without side branch compromise. We defined also successful procedure from IVUS point of view consisting of accurate stent placement in ostium without proximal protrusion and without any stent uncovered area. Of a total of 13 patients with 10 [76.9%] males, 46.2% had diabetes, 69.2% hypertension, 53.8% bypercholesterolemia and 23.1% were smoker or former smoker. They aged from 37-81 years with a mean age of 63 +/- 11 years. In 11 [84.6%] patients 6F and in 2 [15.4%] patients 7F sheathless guiding catheter [Asahi Intecc co; LTD. Japan] were used. The access was radial in 12 [92.3%] and femoral in 1 [7.7%]. The culprit vessel was left anterior descending [LAD] in 9 [69.2%], right coronary artery [RCA] 2 [15.4%],circumflex- obtuse marginal [LCX-OM] 1[7.7%], and posterior descending [PDA] 1[7.7%]. In 9 [69.2%] IVUS was performed through culprit vessel and in 2 [15.4%] IVUS was done also in side branch after stent implantation. In 11 [84.6%] the procedure was technically successful. Among technically successful patients all [100%] had angiographic success. IVUS examination of culprit vessel showed accurate stent placement in ostium 7[77.8%] and slight stent proximal protrusion in 2 patients [22.2%]. This study shows that Szabo technique is safe and feasible for PCI in ostial coronary artery lesions with a high angiographic success rate. In a high percentage of cases the accurate position of stent in ostium can be confirmed by IVUS

Metallic Stent Placement in Hemodialysis Graft Patients after Insufficient Balloon Dilation

OBJECTIVE: We wanted to report our experience of metallic stent placement after insufficient balloon dilation in graft hemodialysis patients. MATERIALS AND METHODS: Twenty-three patients (13 loop grafts in the forearm and 10 straight grafts in the upper arm) underwent metallic stent placement due to insufficient flow after urokinase thrombolysis and balloon dilation. The indications for metallic stent deployment included 1) recoil and/or kinked venous stenosis in 21 patients (venous anastomosis: 17 patients, peripheral outflow vein: four patients); and 2) major vascular rupture in two patients. Metallic stents 8-10mm in diameter and 40-80 mm in length were used. Of them, eight stents were deployed across the elbow crease. Access patency was determined by clinical follow-up and the overall rates were calculated by Kaplan-Meier survival analysis. RESULTS: No procedure-related complications (stent fracture or central migration) were encountered except for a delayed Wallstent shortening/migration at the venous anastomosis, which resulted in early access failure. The overall primary and secondary patency rates (+/- standard error) of all the vascular accesses in our 23 patients at 3, 6, 12 and 24 months were 69% +/- 9 and 88% +/- 6, 41% +/- 10 and 88% +/- 6, 30% +/- 10 and 77% +/- 10, and 12% +/- 8 and 61% +/- 13, respectively. For the forearm and upper-arm grafts, the primary and secondary patency rates were 51% +/- 16 and 86% +/- 13 vs 45% +/- 15 and 73%+/-13 at 6 months, and 25% +/- 15 and 71% +/- 17 vs 23% +/- 17 and 73% +/- 13 at 12 months (p = .346 and .224), respectively. CONCLUSION: Metallic stent placement is a safe and effective means for treating peripheral venous lesions in dialysis graft patients after insufficient balloon dilation. No statistically difference in the patency rates between the forearm and upper-arm patient groups was seen.

Seroma following modified Blalock-Taussig shunt resulting in subsequent occlusion of the shunt which was opened by balloon angioplasty.

We report the case of a 9-year-old boy with tetralogy of Fallot who had undergone left modified Blalock Taussig shunt. The patient developed seroma around the shunt which was excised surgically. The patient developed total occlusion of the shunt post-operatively with clinical deterioration. We used emergency percutaneous angioplasty to successfully treat the patient.

Resultados do Registro Brasileiro CENIC com o implante primário de stents ou da angioplastia com baläo para o tratamento de oclusöes agudas de enxertos de veias de safena / The use of primary stenting or balloon percutaneous transluminal coronary angioplasty for the treatment of acutely occluded saphenous vein grafts. Results from the Brazilian National Registry - CENIC

OBJECTIVE: We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS: Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS: During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3 percent) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47 percent) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION: Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment

Técnica de trombectomía con catéter Hydrolyser / Intravascular thrombectomic technique with the Hydrolyser catheter

El catéter de trombectomía tipo "Hydrolyser" es un dispositivo que sirve para extraer los trombos agudos y subagudos alojados en venas, arterias y prótesis vasculares, como alternativa o complemento del tratamiento endovascular mediante medicamentos trombolíticos. Se presentan los hallazgos y la experiencia inicial con un paciente con diagnóstico de síndrome de vena cava superiror secundario a fibrosis residual de origen fímico, manejado con este nuevo método

By Pass carotido-axilar: tratamiento percutáneo de estenosis distal / Carotid to axillary artery by pass percutaneous treatment of distal stenosis

Se analiza el caso de una paciente de sexo femenino, que presentaba una lesión estenosante a nivel de la anastomosis distal de un by pass carotido-axilar. Consultó por claudicación de miembro superior izquierdo, mareos y dos episodios de pérdida de conocimiento. Se constata una estenosis significativa en la anastomosis distal de un by pass carotido-axilar realizado dieciocho meses antes. Se realizó una angioplastía percutánea con stenting, recuperando la paciente su clase funcional y estado neurológico. Se destaca el rol de la angioplastía con uso de stent para el tratamiento de la enfermedad estenosante de un procedimiento quirúrgico realizado previamente

Revascularización de accesos vasculares para hemodiálisis crónica: resultados inmediatos y seguimiento a mediano plazo / Revascularization of vascular accesses for chronica hemodialysis

La hemodiálisis, uno de los tratamientos supletorios de la insuficiencia renal crónica, implica la depuración sanguínea periódica, a través de un acceso vascular (AV). La principal complicación de los AV son la estenosis y la obstrucción. El objetivo del presente trabajo es presentar nuestra experiencia en el tratamiento percutáneo de las disfunciones de los AV. Entre enero de 1993 y julio de 1995, se trataron por angioplastia (ATP), trombolisis (T-LIS) y trongoaspiración (T-ASP), 34 pacientes con insuficiencia en sus AV para hemodiálisis crónica. De éstos, 19 eran portadores de estenosis y 15 con oclusión del AV. El tratamiento percutáneo de las disfunciones de los AV es el procedimiento de elección ya que ofrece muy buenos resultados. Realizado precozmente, en etapa de estenosis, ofrece mejores resultados que aquellos con oclusión, mejorando significativamente su sobrevida

Revascularización percutánea en accesos vasculares para hemodiálisis / Percutaneous revascularization in vascular access for hemodialysis

Se trataron por angioplastia percutánea transluminal, trombolisis y/o tromboaspiración, veinticinco pacientes con insuficiencia en sus accesos vasculares para hemodiálisis crónica. Fueron éxitos iniciales 11 (85 por ciento) de 13 pacientes portadores de estenosis y 6 (50 por ciento) de 12 portadores de oclusiones del acceso vascular. En tres pacientes (3 oclusiones) se produjo reestenosis del acceso vascular requiriendo un segundo procedimiento de revascularización por angioplastia en un plazo medio de 4 meses (rango 2 - 8 meses). En los 13 pacientes portadores de estenosis la tasa de permeabilidad fue de 75 por ciento a los 6 meses, de 75 por ciento al año y del 75 por ciento a los 2 años. En los 12 pacientes portadores de oclusiones las tasas de permeabilidad fueron de 42 por ciento, 15 por ciento y 15 por ciento respectivamente. El tratamiento de las estenosis de accesos vasculares es el procedimiento de elección, realizándolo precozmente previene la oclusión del mismo mejorando significativamente su sobrevida