Endovascular Treatment of Complicated Popliteal Aneurysms Using the Novel "Trap and Fix" Technique.

Herein, we present 2 patients with lower limb ischemia caused by complicated popliteal aneurysms with thrombosis and distal embolization, compromising blood flow to the foot. In both cases, covered stents were first implanted guided by intravascular ultrasound and computed tomography angiography, respectively. After "trapping" the thrombi, mechanical thrombectomy or further stent implantations were performed, "fixing" the remaining lesions and preventing embolization. (Level of Difficulty: Intermediate.).

The Implementation of Renal Denervation in the Management of Resistant Hypertension Despite Use of Multitherapy Antihypertensives at Maximally Tolerated Doses: A Contemporary Literature Review.

Refractory hypertension is highly prevalent among the hypertensive population, and current clinical management has failed to provide optimal control for these individuals. This subtype of arterial hypertension is defined as a persistently elevated systolic blood pressure reading of 140 mmHg, or higher, despite multiple antihypertensive use at maximally tolerated dosing. These patients have an elevated risk of cardiovascular and renal complications, urging for the need of more effective therapeutic management. Renal sympathetic efferent nerves have been noted to play an important role in volume and blood pressure homeostasis. Before the implementation of oral antihypertensives, the use of surgical lumbar sympathectomy for the reduction of persistent hypertension was considered a life-saving approach. However, individuals were left with debilitating side effects, such as postural hypotension, syncope, and impotence. A new and minimally invasive technique has been proposed, where the kidneys undergo selective denervation in hopes of providing decreased cardiovascular morbidity and mortality for patients with resistant hypertension. Some studies demonstrated promising outcomes with a reduction in blood pressure, a decrease in medication reliance, and a potential long-lasting effect of the procedure with an overall improvement in cardiovascular health. Unfortunately, most of the available data was obtained from observational, uncontrolled studies with short-term follow-up, small sample sizes, and high variability in blood pressure measurement. Therefore, further evidence is needed to determine whether renal denervation provides long-term benefits for blood pressure control and improves outcomes for mortality and cardiovascular events in this patient population.

Sudden Cardiac Arrest in Patient With Ventricular Septal Defect and Marijuana Consumption: A Case Report and Review of Literature.

This case report presents a detailed analysis of a 28-year-old woman who experienced sudden cardiac arrest (SCA). The patient had a history of marijuana consumption and was also diagnosed with a congenital ventricular septal defect (VSD) with no prior intervention or treatment. VSD is a common acyanotic congenital heart disease, which poses a constant risk of premature ventricular contractions (PVCs). During the evaluation, the patient's electrocardiogram PVCs and a prolonged QT interval were revealed. This study highlights the risk associated with the administration or consumption of drugs that can prolong the QT interval in patients with VSD. It also indicates that patients with VSD and who have a history of marijuana consumption should be cautioned about the risk of arrhythmias causing SCA due to prolonged QT interval caused by the cannabinoid. This case emphasizes the requirement of cardiac health monitoring in individuals with VSD and caution while prescribing medications that can affect the QT interval leading to life-threatening arrhythmias.

Successful Revascularization of Infrapopliteal Chronic Total Occlusions Using the Plantar Arch as a Conduit and Retrograde Pedal Access.

Background: With the rising prevalence of critical limb ischemia (CLI), the pedal-plantar loop technique and retrograde access may be needed to increase interventional success. Case Report: A 63-year-old female with severe peripheral artery disease presented with a 2-month nonhealing wound on the dorsum of her left foot despite wound care. We inserted a 65-cm Destination Guiding Sheath and crossed the right superficial femoral artery (SFA) chronic total occlusion (CTO) that we initially treated with a 4.0-mm Ultraverse balloon. We attempted unsuccessfully to cross the distal anterior tibial artery into the dorsalis pedis artery. We obtained antegrade access of the posterior tibial artery at the level of the ankle with a 2.9-French Cook pedal access kit. We inserted a 90-cm CXI catheter with a 0.014 Fielder XT wire and used the lateral plantar artery as a conduit to cross the dorsalis pedis artery and distal anterior tibial artery CTO with retrograde wire manipulation via lateral plantar artery. Finally, we performed distal anterior tibial and dorsalis pedis CTO balloon angioplasty with a 2.5 × 220-mm Ultraverse balloon and performed SFA percutaneous transluminal angioplasty and stenting with a 7.0 × 120-mm Zilver PTX stent, postdilated with a 6.0-mm Ultraverse balloon. We successfully established in-line flow to the foot with 3-vessel runoff. The patient's wound healed in a month. Conclusion: Retrograde pedal access can improve the success rate of recanalization of below-the-knee disease in patients with CLI.

Percutaneous deep vein arterialization: An emerging technique for no-option chronic limb-threatening ischemia patients.

Chronic limb-threatening ischemia (CLTI), with characteristic ischemic rest pain, non-healing ulcers, or gangrene attributable to arterial occlusive disease, requires successful revascularization to minimize tissue loss. End-stage CLTI in particular, with occlusion of the pedal arteries, results in a lack of suitable targets for bypass and can result in failure of endovascular revascularization procedures, leaving no option for treatment other than amputation. With limb salvage as the primary goal, nontraditional revascularization techniques such as percutaneous deep vein arterialization (pDVA) may help minimize incidence of amputation. We present a case of a patient with no-option CLTI, at high risk of amputation who failed conventional endovascular revascularization attempts facing imminent major amputation. The limb was salvaged with a successful pDVA procedure.

Optimal treatment of renal artery in-stent restenosis: repeat stent placement versus angioplasty alone.

OBJECTIVE: We investigated whether repeat renal artery stent placement compared with treatment with balloon angioplasty alone results in better patency in patients presenting with renal artery in-stent restenosis (ISR). BACKGROUND: Although stent placement for renal artery stenosis has been demonstrated to be superior to balloon angioplasty for "de novo" renal artery lesions, the optimal therapy for ISR remains unclear. METHODS: Between January 1997 and August 2006, 34 consecutive patients (41 renal arteries) with ISR were treated at the discretion of the operator with balloon angioplasty or repeat stent placement. Quantitative angiography was performed before and immediately after intervention and at follow-up. Angiographic follow-up was obtained for clinical indications in 75% of lesions and routine noninvasive follow-up imaging was obtained in 95% of lesions. RESULTS: Repeat renal artery stent placement demonstrated improved patency compared with balloon angioplasty alone with a 58% reduction in recurrent ISR (29.4% vs. 71.4%, P = 0.02) and a 30% reduction in follow-up diameter stenosis (41% vs. 58.2%, P = 0.03). The repeat stent group also had better secondary patency (P = 0.05) and a greater freedom from repeat ISR (P = 0.01) when compared with balloon angioplasty alone. There was a trend favoring repeat stent placement for cumulative freedom from target vessel revascularization (TVR) (P = 0.08). CONCLUSIONS: Repeat stent placement appears to result in superior patency compared with balloon angioplasty alone for the treatment of renal ISR.

Multiple retinal emboli following a new carotid stenting procedure.

This report discusses the observation of multiple retinal emboli following placement of a new carotid stenting device. Especially dense plaques in the carotid artery can shatter into dust-like particles that may be fine enough to penetrate the filter of the new device, thus posing the danger of retinal perfusion.