Incidence of extracerebral paradoxical embolisms in patients with intracardiac shunts.

BACKGROUND: Although extracerebral embolism accounts for 5-10% of all paradoxical embolisms, it still remains a ghostlike entity in cardiovascular pathophysiology. The aim of this brief report was to analyze the profile of patients with paradoxical extracerebral embolism and intracardiac shunts, and the role of shunt closure on the recurrence of extracerebral paradoxical embolism (EPE) in a population of patients evaluated for patent foramen ovale (PFO)/atrial septal defect (ASD) transcatheter closure. METHODS: From July 2003 to December 2006, 150 patients (mean age 51.4+/-15.1 years, range13-78 years, M/F=49/101) were planned for transcatheter closure of PFO/ASD at our institutional program of Adult Congenital Heart Disease Management. Clinical history and medical records of all patients were reviewed searching for association of PFO/ASD, stroke, and presumptive EPE. RESULTS: Association of PFO with presumptive EPE was found in nine patients (6%, mean age 40.1+/-14 years, M/F=3/6). Five patients had ST-elevation myocardial infarction (mean value of troponin was 15.3+/-2.1 ng/ml), while four patients had inferior limb acute ischemia. In patients with coronary embolism, coronary angiography was performed immediately after chest pain onset revealing normal coronary artery and only a mild hypokinesia. In patients with peripheral acute ischemia, early (>4 h from symptoms onset) angiography demonstrated normal main peripheral vessel and an embolic closure of popliteal artery (one patient), distal tibial artery (two patients), or peroneal artery (one patient) that normalized with heparin therapy in a few hours except in one patient. Migraine with aura was present in seven of nine patients. Cerebral MRI revealed previous ischemic areas in four of nine patients. Coagulation disorders were detected in six of nine patients. Echocardiography demonstrated a large to medium PFO in seven patients and a cribrosus ASD in two patients. CONCLUSION: Although a large study is required to assess optimal diagnosis and clinical implications of EPE, the clinical profile emerging from our study may help to identify some easy criteria of diagnosis in order to improve diagnosis and decrease the recurrence of such probably underestimated manifestations of PFO/ASD.

Subclavian artery angioplasty in elderly patients with coronary-subclavian steal syndrome: preliminary comparison between a modified brachial technique and the standard femoral approach / 老年心脏病学杂志（英文版）

Background and Objective Elderly patients who have been submitted to coronary bypass grafting with the left internal mammary artery (LIMA) may develop a coronary-subclavian steal syndrome because of a left subclavian artery (LSA) stenosis. Usually stenting of LSA is performed by the standard femoral route with guiding catheter technique, but this technique can be particularly difficult in elderly patients who often have iliac-femoral kinking and aortic tortuosity. We compared a new ad hoc brachial artery approach technique with the standard guiding catheter technique through the femoral access. Methods Between January 2005 and September 2006, four patients underwent LSA stenting using the left brachial artery access obtained with a 6F or 7F 45-cm-long valved anti-kinking sheath as the Super Arrow Flex sheath (Arrow International, PA, USA). The sheath was positioned just before the LIMA graft ostium and a 0.035 inch 260-cm-long Storq guidewire (Cordis Inc., Johnson & Johnson, Warren, NJ) was advanced across the lesion to the descending aorta. A balloon-expandable Genesis (Cordis Inc., Johnson & Johnson, Warren, NJ) endovascular stent was easily deployed, and the correct position was checked by direct contrast injection through the long sheath. This small group of patients has been compared to a group of 5 age-matched patients with coronary steal syndrome in whom the procedure has been performed with standard technique including femoral approach and guide catheter. Results The procedure was successful in all patients; vertebral and LIMA ostia remained patent in all cases. In the control group, cannulation of the subclavian artery was difficult in two cases, while one patient developed a groin hematoma. Mean pretreatment gradient was 32 mm Hg with a range of 25 to 40 mm Hg (34 mmHg, range 26-43, in the control group, P=0.87) and fell to 2 mm Hg with a range of 0 to 4 mm Hg (3.1 mmHg, range 0 to 5, P=0.89) posttreatment. Mean contrast dose was 60±16 ml (138±26 ml in the control group, P＞0.01), whereas mean fluoroscopy and procedural time were 5.7±1.6 minutes (10.8±1.0 minutes in the control group, P＞0.01) and 15.7±6.3 minutes (28±7.1 minutes in the control group, P＞0.01). At a mean follow-up of 10±3.2 months all patients are alive and free from angina and residual induced ischemia. Conclusions Our brief study suggested that brachial artery access be considered the optimal route to treat coronary-subclavian steal syndrome in elderly patients because of clear advantages; these included no manipulation of catheter to cannulate the artery, perfect coaxial position of the catheter at the site of LSA stenosis, clear visualization of the LIMA and vertebral ostia, and easy access to these vessels in case of plaque shifting or embolic protection device deployment.

Combined percutaneous aspiration thrombectomy and rheolytic thrombectomy in massive subacute vena cava thrombosis with IVC filter occlusion.

PURPOSE: To report the combined use of percutaneous aspiration thrombectomy and rheolytic thrombectomy in the setting of extensive inferior vena cava (IVC) thrombosis and filter occlusion. CASE REPORT: A 28-year-old paraplegic man with a vena cava filter in situ for previous deep vein thrombosis (DVT) was referred to our center for evaluation of dyspnea and right leg edema and swelling. Computed tomography excluded a pulmonary embolism and revealed severe, massive DVT of both iliac veins and the IVC, including the vena cava filter. Percutaneous aspiration thrombectomy was attempted because intravenous heparin therapy was ineffective, and moderate anemia contraindicated regional thrombolysis. Several passes of a guiding catheter proximally and distally to the filter, with suction provided by a 50-mL syringe, achieved minimal IVC recanalization. Subsequently, a 6-F AngioJet catheter was passed via the guiding catheter through the filter, the IVC, and both iliac veins, obtaining a satisfactory result. The patient was discharged after 7 days and did very well at 6-month follow-up, with no recurrent DVT. CONCLUSION: This case demonstrates the usefulness of combined percutaneous aspiration and rheolytic thrombectomy in treating extensive IVC thrombosis and occluded IVC filters, especially when thrombolytic therapy cannot be used.