[Management of access site vascular complications in transcatheter aortic valve implantation]. / Gestione delle complicanze vascolari del sito di accesso nell'impianto transcatetere di valvola aortica.

Since its advent, transcatheter aortic valve implantation (TAVI) has experienced a continuous expansion, thanks to extraordinary clinical results and to the dramatic increase of safety, enabled by improvements of prosthesis and delivery systems, refinement of implantation techniques, increasing operator experience, and use of computed tomography scan for procedural planning. However, complications rates are still not negligible. As vascular complications, and, particularly, access-related complications are among the most frequent adverse events, all TAVI operators should know how to prevent and how to manage those potentially catastrophic situations. Here we provide an overview of the most frequent access site vascular complications and the respective treatment options.

An Unusual Case of Aortic-Right Atrium Fistula: A Diagnostic and Therapeutic Challenge.

An aorta-to-right atrium (RA) fistula is an anomalous communication between the ascending or descending thoracic aorta and the RA. In this report, we describe a case of an idiopathic aortic root-to-RA fistula occasionally found during a coronary angiography performed in a young patient admitted for acute chest pain with evidence of multivessel coronary artery disease. The anatomical peculiarity of this fistulous communication is that it gave origin to collateral vessels furnishing the inferolateral wall of the left ventricle. The case represented a diagnostic and therapeutic challenge that required a multimodality imaging and a multidisciplinary team approach.

Does optimal lesion preparation reduce the amount of acute recoil of the Absorbe BVS? Insights from a real-world population.

OBJECTIVES: To evaluate the acute recoil of the ABSORB bioabsorbable vascular scaffold (BVS) and its relationship with procedural characteristics in a real world population. BACKGROUND: In vivo acute recoil of the BVS was evaluated in selected patients. METHODS: Acute recoil was studied with videodensitometry in a consecutive series of patients treated by means of a BVS, and the results were compared with those obtained in subjects receiving an everolimus-eluting stent (EES). Recoil was defined as the difference between the mean diameter of the fully expanded balloon on which the device was mounted (or the mean diameter of the post-dilatation balloon), and the mean luminal diameter of the treated segment immediately after the final inflation. RESULTS: Recoil was assessed in 106 lesions treated with a BVS and 71 treated with an EES. The absolute and percent recoil of the BVS were significantly greater (0.32 ± 0.16 mm and 10% ± 5% vs. 0.17 ± 0.07 and 5% ± 3%; P < 0.001). Multiple regression analysis showed that BVS use was associated with acute recoil (ß = 0.477; P<0.001). Suboptimal lesion preparation (residual stenosis after balloon angioplasty >20%) (ß = 0.217; P = 0.027) and a small vessel reference diameter (ß = 0.335; P = 0.002) were associated with increased BVS but not EES recoil. CONCLUSIONS: In unselected patients, the acute recoil of the BVS was significantly greater than that of the metal EES. In the BVS group, residual stenosis after predilatation correlated with percent recoil, and so optimal lesion preparation seems to be mandatory in order to maximize the mechanical properties of the scaffold.

Pioneer re-entry device for iliac chronic total occlusion: truly a paradigm shift.

The number of percutaneous revascularization procedures performed for symptomatic peripheral arterial disease has significantly increased over the past several years. Traditionally, the use of percutaneous techniques were limited to certain anatomic subsets, such as stenosis or focal occlusions, with surgical treatment preferred for more extensive disease. More recently, endovascular specialists are facing the challenge of peripheral chronic total occlusions. Furthermore, unlike the coronary circulation, these occlusions are often very long and associated with other features of complexity such as severe calcifications. One of the primary issues concerning these lesions is the ability to safely achieve initial angiographic success. This article focus indeed on the Pioneer catheter, a new lumen re-entry device exploiting intravascular ultrasound imaging that was used in a case of totally occluded left common iliac artery with favorable results. The details of this technique, and how this catheter helped in re-entering the true lumen at the aortic bifurcation after subintimal dissection, are thoroughly discussed.

Capture and repositioning of third-generation migrated abdominal endovascular graft by bilateral femoral wire externalization and pulling by "horse-riding" technique followed by balloon EVG stabilization.

Endovascular aneurysm repair is becoming the treatment of choice for elderly patients bearing abdominal aortic aneurysms with particular anatomical characteristics. Endovascular grafts are usually oversized to achieve sealing and minimize graft migration, the likelihood of which is also reduced by fixation hooks and barbs in the newer generation grafts. Yet, upward migration of the prosthesis, potentially compromising flow to renal and splanchnic vessels, may still occur acutely and requires timely management. We describe a patient with abdominal aortic aneurysm in whom proximal migration of an endovascular graft occurred, leading to renal and mesenteric artery obstruction, which was successfully managed by means of capturing and repositioning the device with a "horse-riding" technique followed by balloon stabilization of the graft to reduce the risk of re-dislodgment during controlateral leg insertion.

The impact of an eccentric intravascular ImageWire during coronary optical coherence tomography imaging.

AIMS: Optical coherence tomography (OCT) provides high-resolution imaging which enables characterisation of atherosclerosis and vascular response to injury, but to ensure optimal analysis, one must realise potential sources of image distortion. We designed a series of analyses, using coronary stents as a model, to investigate the influence of wire position on OCT-derived vascular images. METHODS AND RESULTS: The study evaluated intracoronary OCT images from the Cardialysis-Cleveland University Hospitals Cardiovascular Imaging Core Laboratories database. Intracoronary OCT images were acquired with the M2 system (LightLab Imaging Inc., Westford, MA, USA) and analysed using a customised software. Wire concentric index (WCI) was calculated as "wire-lumen distance/lumen radius". Lumen, stent, and strut contours were defined and 360 chords (1 degree increments) were placed radially between the lumen and stent contours. Strut length was defined by the number of chords spanned by each strut. Strut level thickness (SLT) was measured with each chord. SLT variability ([Max-Min SLT]/number of chords per strut) was calculated. Lumen measurements were performed with optimal calibration and repeated with ±1% changes from optimal Z-offset. The hemisphere containing an eccentric wire had shorter strut reflections (5.0±1.6° vs. 6.6±2.1°, p<0.001) compared to the opposite hemisphere. Eccentric wires depicted 84% of the struts as non-parallel to the luminal surface (>10% SLT variability). Changing Z-offset by 1% resulted in a non-uniform shrinkage or expansion of the luminal contour in images generated from eccentric wires, but not from concentric wires. CONCLUSIONS: Eccentric intraluminal position of the OCT ImageWire occurs frequently and affects calibration and interpretation of images, including length, orientation and visibility of vessel wall structures.

Randomized clinical trial on short-time compression with Kaolin-filled pad: a new strategy to avoid early bleeding and subacute radial artery occlusion after percutaneous coronary intervention.

BACKGROUND: Despite the increasing use of transradial techniques for cardiac percutaneous procedures, none of the strategies commonly utilized for hemostasis has been able to reduce the occurrence of radial artery occlusion (RAO). The aim of this study was to evaluate the occurrence of 24-hour RAO and the rate of bleeding of a novel hemostatic device for radial closure after percutaneous interventions, in adjunct to short-time compression. METHODS: Once the radial access was obtained, patients were randomized to 3 different strategies of radial closure: a short compression with the QuikClot® Interventional™ pad (Z-Medica Corporation, Wallingford, CT, USA) (15 minutes, group 1), a short compression (15 minutes, group 2), and a conventional prolonged compression (2 hours, group 3) both without QuikClot® utilization. RESULTS: Fifty patients in group 1, 20 in group 2, and 50 in group 3 were enrolled. The three groups were homogenous for baseline and procedural characteristics. None of patients in group 1 developed RAO, 1 (5%) occurred in group 2, and 5 (10%) in group 3 (P = 0.05). Active bleeding after compression removal occurred in 10 patients (20%) in group 1, 18 (90%) in group 2, and 1 (2%) in group 3 (P < 0.001). Among patients in group 1, at univariate analysis, the predictors of acute bleeding resulted in chronic therapy with clopidogrel (Odds Ratio 28.78, 95% Confidence Intervals 4.79-172.82, P < 0.001) and high levels of activated clotting time (ACT) at the time of sheath removal (OR 1.02, 95% CI 1.00-1.03, P = 0.009). At ROC analysis, the cutoff value of ACT for the risk of bleeding with a sensitivity of 80% and specificity of 75% was 287 seconds. CONCLUSIONS: Early sheet removal and short-time compression with QuikClot® Interventional™ can reduce the rate of RAO after diagnostic or interventional procedures especially in patients not on double antiplatelet therapy.

Mehran contrast-induced nephropathy risk score predicts short- and long-term clinical outcomes in patients with ST-elevation-myocardial infarction.

BACKGROUND: The Mehran Risk Score (MRS) has been demonstrated to be clinically useful for prediction of contrast-induced nephropathy (CIN) after nonurgent percutaneous coronary intervention. We aim to validate the MRS in the setting of Primary percutaneous coronary intervention for prediction of both CIN and short- and long-term clinical outcomes. METHODS AND RESULTS: We assigned 891 consecutive patients with ST-elevation-myocardial infarction undergoing primary percutaneous coronary intervention to 4 groups of risk of CIN (RC) according to MRS (low, medium, high, and very high risk). We evaluated CIN, death, and major cardiovascular and cerebrovascular events after 25 months' mean follow-up. At multivariable analysis, mortality in very high-risk group was more than 10-fold higher (hazard ratio [HR], 10.11; 95% confidence interval [CI], 4.83 to 21.1; P<0.001) when compared with the low-risk group and was also increased in the high-risk group (HR, 6.31; 95% CI, 3.28 to 12.14; P<0.001) and medium-risk group (HR, 3.18; 95% CI, 1.83 to 5.51; P<0.001). Similarly, an increasing effect was seen across MRS strata for major cardiovascular and cerebrovascular events both in the very high-risk group (HR, 3.79; 95% CI, 2.27 to 6.6.32; P<0.001), high-risk group (HR, 1.90; 95% CI, 1.31 to 2.75; P=0.001), and medium-risk group (HR, 1.42; 95% CI, 1.10 to 1.85; P=0.007). In addition, the HR for rehospitalization increased with the increasing RC groups (HR, 3.32; 95%CI, 1.96 to 5.63; P<0.001; HR, 3.11; 95% CI, 1.35 to 7.20; P=0.008; HR, 7.73; 95% CI, 2.97 to 20.10; P<0.001, respectively). The odds ratio for CIN was 2.84 (95% CI, 1.16 to 6.92; P=0.021) in the very high RC group, 1.33 (95% CI, 0.68 to 2.61; P=0.398) in the high RC group, and 1.10 (95% CI, 0.67 to 1.79; P=0.699) in the medium RC group, as compared with the lower one. CONCLUSIONS: The MRS may be applied in the primary angioplasty setting population and is able to predict CIN and to stratify patients for poor clinical outcomes both in the short- and long-term follow-up.

Strut coverage and vessel wall response to a new-generation paclitaxel-eluting stent with an ultrathin biodegradable abluminal polymer: Optical Coherence Tomography Drug-Eluting Stent Investigation (OCTDESI).

BACKGROUND: Polymer-coated drug-eluting stents are effective in preventing restenosis but have been associated with delayed healing and incomplete strut coverage. It is unknown whether paclitaxel-eluting stents (PES) with minimal biodegradable abluminal coating enhances strut coverage while preventing neointimal hyperplasia. Using optical coherence tomography (OCT) as a primary imaging modality, we assessed the proportion of uncovered struts at 6-month follow-up in PES coated with durable versus ultrathin (<1 microm) biodegradable abluminal polymers. METHODS AND RESULTS: In this pilot trial, 60 patients with de novo lesions (< or =25 mm) in native coronary vessels were randomly assigned to receive either TAXUS Liberté PES or JACTAX PES, a Liberté stent with polymer deposited abluminally as microdots (JACTAX HD: 9.2 microg each of polymer and paclitaxel per 16-mm stent; JACTAX LD: 5 microg each). OCT follow-up occurred at 6 months with clinical follow-up through 1 year. The primary end point was percent uncovered struts by OCT. An independent core laboratory blinded to stent assignment analyzed images. The 6-month rate of uncovered struts per patient was 5.3+/-14.7% for TAXUS Liberté, 7.0+/-12.2% for JACTAX HD, and 4.6+/-7.3% for JACTAX LD (P=0.81); percent malapposed struts was 1.4+/-4.4%, 0.8+/-1.9%, and 1.1+/-2.8%, respectively (P=0.86). Strut-level intimal thickness was 0.20+/-0.10, 0.22+/-0.15, and 0.24+/-0.15 mm (P=0.64); percent volume obstruction by OCT was 22.2+/-12.8, 22.5+/-16.2, and 25.8+/-15.2 (P=0.69). There were no deaths, Q-wave myocardial infarctions, or stent thromboses through 1 year. CONCLUSIONS: JACTAX PES with an ultrathin microdot biodegradable abluminal polymer did not result in improved strut coverage at 6 months compared with TAXUS Liberté. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00776204.

Long-term outcomes in patients undergoing percutaneous coronary intervention with drug-eluting stents.

Drug-eluting stents substantially reduce restenosis compared with bare-metal stents and represent a significant advance in percutaneous coronary interventions. Accordingly, drug-eluting stents have been rapidly adopted into practice and are currently used in the vast majority of complex percutaneous coronary procedures. However, in the last 2 years, concerns have been raised regarding their long-term safety, especially regarding the risk of late and very-late stent thrombosis. Delayed endothelial coverage after drug-eluting stent implantation is thought to prolong the window of vulnerability to stent thrombosis, which requires a prolonged dual antiplatelet therapy. Recent registry studies and meta-analyses seem to have provided reassuring results regarding the long-term rates of death and myocardial infarction associated with the use of drug-eluting stents compared with bare-metal stents. However, data are not consistent and concerns remain.

Evaluation of flow in the left anterior descending coronary artery but not in the left internal mammary artery graft predicts significant stenosis of the arterial conduit.

OBJECTIVES: The purpose of this study was to evaluate which Doppler-derived flow index best predicts new distal left anterior descending coronary artery (LAD) stenosis in patients with left internal mammary artery (LIMA) graft. BACKGROUND: The LIMA flow measurement has been proposed to assess graft function, but it may be misleading in case of new distal LAD stenosis and/or competitive flow from native LAD. Distal LAD coronary flow reserve (CFR: hyperemic/baseline peak flow velocity ratio) may be more appropriate. METHODS: The LIMA and distal LAD flow was measured by transthoracic Doppler echocardiography in 96 patients undergoing diagnostic/therapeutic coronary angiography, 7 +/- 4 years after cardiac bypass surgery. The LIMA flow indexes (systolic-to-diastolic peak velocity ratio [SDPVr] >1, diastolic time velocity integral fraction [DTVIf] <0.5, and CFR <2) and LAD CFR <2 were used to predict > or =70% new LAD stenosis. RESULTS: The LAD CFR <2 predicted new LAD stenosis, found in 21 of 77 patients without competitive flow from native LAD, with significantly higher diagnostic accuracy (98%) than LIMA flow indexes (SDPVr >1 = 61%, DTVIf <0.5 = 69%, and CFR <2 = 72%). The LIMA flow indexes were abnormal in 17 of 19 patients with competitive graft flow, but only 5 had graft restriction, and none had significant LAD stenosis. In a multivariate model of new distal LAD stenosis prediction, competitive flow from native LAD reduced the predictive role of LIMA but not of LAD CFR. CONCLUSIONS: In patients without competitive flow from native LAD, LAD CFR is more accurate for the detection of LAD stenosis than LIMA CFR. In patients with competitive graft flow, abnormal LIMA flow patterns and blunted LIMA CFR do not reflect downstream LAD flow as LAD CFR does.