PFO "angioplasty": The preparation of a very stiff and long tunnel for device closure.

INTRODUCTION: Patent foramen ovale (PFO) closure is a widely performed procedure. Understanding the anatomy is mandatory in order to perform the procedure successfully. The degree of overlap between the septum primum and secundum is called the tunnel. In particular, long and stiff tunnels may prevent the correct positioning of devices that have a fixed distance between the right and left atrial discs. PATIENTS AND METHODS: We evaluated retrospectively 361 patients with PFO closure between January 2012 and June 2014 in our institution and were treated due to previous history of ischemic stroke. By TEE, the overlap between septum primum and secundum is usually better seen on the bicaval view that is obtained at 75-90° midesophageal views. Tunnel length and PFO opening were measured. Twelve subjects (median age 35 years; range 30-58 years; three females) showed a long (median 22 mm; range 15-32 mm) and rigid tunnel (median opening 2 mm; range 1-4 mm). RESULTS: Angioplasty of the tunnel was performed by using peripheral angioplasty balloons with a length ranging from 4 to 8 cm and a diameter between 8 and 12 mm. After angioplasty, the tunnel appeared shorter (12 mm; range 8-16 mm) and less rigid (median opening 8 mm; range 7-12 mm). The following devices were implanted: 25 mm Amplatzer PFO occluder in three patients; 25 mm Gore septal occluder in nine subjects. Median fluoroscopy time was 8 min (range 6-10 min). No complications occurred. At a median follow-up of 12 months (range 2-18 months), no problems occurred and all subjects but one (trivial residual shunting) showed a complete closure. CONCLUSIONS: Angioplasty of a PFO rigid and stiff tunnel is a feasible and safe option. © 2016 Wiley Periodicals, Inc.

Percutaneous treatment of aortic isthmus atresia: use of radiofrequency perforation and covered stents.

BACKGROUND: Limited data exists in the literature concerning the percutaneous treatment of complete aortic isthmus atresia. PATIENTS AND METHODS: Between January 2007 and November 2010, 40 subjects underwent percutaneous treatment of aortic coarctation in our catheterization laboratory. Four out of 40 had aortic isthmus atresia with complete interruption. Median age at procedure was 48 years (range, 32-63 years). All subjects had history of arterial systemic hypertension refractory to medical treatment. Two subjects had a previous history of haemorrhagic stroke. All procedures were performed under general anesthesia and orotracheal intubation. In each case radial and femoral artery access was obtained. A radiofrequency (RF) system (Baylis MedComp Inc, Montreal, Canada) consisting of a Nykanen 0.024'' RFguidewire and coaxial microcatheter were used to perforate and cross the atretic segment. A guidewire was then snared and an artero-arterial circuit created. The area was predilated by using coronary angioplasty balloons. A 12 Fr Mullins long sheath was advanced and an E-PTFE covered 8Zig Cheatham-Platinum stent implanted. Patients were monitored in hospital for 48-72 hr. Follow-up was performed at 1, 3, 6, 12 months, and yearly thereafter. RESULTS: Percutaneous recanalization of the atretic segment was performed successfully in all subjects. Mean fluoroscopy and procedure times were 30 ± 6 and 90 ± 15 min, respectively. After implantation, the gradient decreased significantly (prestent: mean value 52.25 mm Hg [range 33-70 mm Hg] versus post stent: mean value 3 mm Hg [range, 0-10 mm Hg] [P < 0.0001]). The stents were placed in the correct position in all subjects and no immediate complications occurred. During a mean follow-up of 19 months (2-41 months), there were no significant complication. All subjects had arterial systemic blood pressure within the normal range. In two out of four patients single agent antihypertensive drug therapy was needed. The first patient in our series was treated conservatively and needed further stent dilation with a second procedure approach, eight months after the initial stent implantation, performed without incident. CONCLUSIONS: Our data show that use of radiofrequency energy perforation and covered CP stent implantation is a safe, effective, and promising tool for treatment of complete aortic isthmus atresia.

Aortic coarctation complicated by wall aneurysm: the role of covered stents.

OBJECTIVES: To evaluate the management of aneurysms associated with aortic coarctation by covered stent deployment. BACKGROUND: Aortic aneurysm formation complicating aortic coarctation carries a risk of rupture with high mortality rate. Surgical repair has a significant mortality and may be associated with central nervous system injury, including paraplegia. Transcatheter intervention alternatively carries a risk of aneurysmal rupture. METHODS: Between July 2004 and September 2009, 140 consecutive patients underwent percutaneous stent implantation to treat aortic coarctation. Eleven (7.9%) patients had coarctation associated with aortic wall aneurysm: three with native coarctation with wall aneurysm, three with previous surgical coarctation repair, three with previous balloon angioplasty, and two with previous bare stent implantation. The e-PTFE-covered 8Zig Cheatham-Platinum stents were used to treat all 11 patients. RESULTS: Median age at procedure was 13 years (range, 6-66 years). Successful device deployment was achieved in all patients. Systolic pressure gradient reduced significantly from a median baseline of 30 mm Hg (range, 25-50 mm Hg) to a postprocedural median of 5 mm Hg (range, 0-20 mm Hg) (P < 0.01). Aortic diameter increased from a median value of 6 mm (range, 0.5-11 mm) to a median value of 12 mm (range, 10-22 mm) (P < 0.001). No early complications occurred, with successful relief of stenoses and complete sealing of all aneurysms. Median follow-up was 50 months (range, 16-61 months). Redilatation was required in four patients (one patient with intrastent restenosis secondary to significant endothelial growth, whereas the other three patients showed restenosis secondary to somatic growth). Redilatation with a larger balloon was performed without complication in all cases. CONCLUSIONS: Our data show that covered stents are a safe and effective treatment with low risk of complications for the treatment of coarctation associated with aortic wall aneurysm.