Impact of shaggy aorta on intraoperative cerebral embolism during carotid artery stenting.

BACKGROUND: Careful selection of patients for carotid stenting is necessary. We suggest that patients with a shaggy aorta syndrome may be at higher risk for perioperative embolic complications. METHODS: The study is a retrospective subanalysis of the SIBERIA Trial. We included 72 patients undergoing transfemoral carotid artery stenting. Patients were monitored during the procedures using multifrequency transcranial Doppler with embolus detection and differentiation. Pre- and postprocedural (2 and 30 days) cerebral diffusion-weighted cerebral MRIs were performed. RESULTS: Forty-six patients had shaggy aorta syndrome. Intraoperative embolisms were recorded in 82.6% and 46.1% of patients with and without shaggy aorta syndrome, respectively (P=0.001). New asymptomatic ischemic brain lesions in the postoperative period occurred in 78.3% and in 26.9% of patients with and without shaggy aorta syndrome, respectively (P<0.001). There were no cases of stroke within 2 days in both groups. 3 (6.5%) cases of stroke within 30 days after the procedure were observed only in patients with shaggy aorta syndrome. There were no cases of contralateral stroke. Shaggy aorta syndrome (OR 5.54 [1.83:16.7], P=0.001) and aortic arch ulceration (OR 6.67 [1.19: 37.3], P=0.02) were independently associated with cerebral embolism. Shaggy aorta syndrome (OR 9.77 [3.14-30.37], P<0.001) and aortic arch ulceration (OR 12.9 [2.3: 72.8], P=0.003) were independently associated with ipsilateral new asymptomatic ischemic brain lesions. CONCLUSIONS: Shaggy aorta syndrome and aortic arch ulceration significantly increase the odds of intraoperative embolism and new asymptomatic ischemic brain lesions. Carotid endarterectomy or transcervical carotid stent should be selected in patients with shaggy aorta syndrome.

The phenomenon of drug-coating embolism during lower extremity endovascular interventions with paclitaxel-coated balloon.

INTRODUCTION: There is a risk of distal embolization lower extremity endovascular interventions. Possibly a drug-coating embolism caused by coating detachment from intravascular devices. METHODS: This review focuses on providing updated information on distal embolism in endovascular revascularization of lower extremity arteries, including the use of drug-coated balloons. RESULTS: Drug-coating embolism is a special case of distal embolization during recanalization of the arteries of the lower extremities. Preclinical studies have demonstrated embolization of drug-coated balloons during angioplasty of lower extremity arteries. However, the clinical role of drug-coating embolism is not completely clear. A 2020 meta-analysis found an increased risk of major lower extremity amputation after drug-coated balloon angioplasty in patients with critical limb ischemia. But long-term research is emerging to support the safety of using these devices. Perhaps a more thorough assessment of the quality of life and the degree of compensation of lower limb ischemia with an intraoperative assessment of the frequency of peripheral embolizations using ultrasound emboli detection, as well as microcirculation with transcutaneous oximetry and laser Doppler flowmetry of the operated lower limb will allow a more detailed study of the phenomenon of drug-coating embolism and its impact on long-term clinical outcomes. CONCLUSION: According to the results of preclinical studies, the use of paclitaxel-coated balloons leads to an increase in the concentration of paclitaxel in distal skeletal muscles. However, paclitaxel concentration in skeletal muscle was significantly higher in first-generation DCBs. The non-target effects of drug-coating balloon are not fully understood and require further study. Understanding the phenomenon of drug-coating embolism can help physicians to better assess the patient risk and to minimize complications.

Treatment of Long Femoropopliteal Occlusive Lesions With Self-expanding Interwoven Nitinol Stent: 24 Month Outcomes of the STELLA-SUPERA-SIBERIA Register Trial.

PURPOSE: The efficacy and safety of the Supera stent in superficial femoral artery (SFA) have been reported mostly in shorter lesions with relatively low proportion of occlusions. There are little data on the effectiveness of the Supera stent in long lesions. The aim of this study was to assess the clinical safety and efficiency of the Supera stent in the treatment of long femoropopliteal occlusive lesions (Trans-Atlantic Inter-Society Consensus [TASC] C/D) in patients with symptomatic peripheral artery disease. MATERIALS AND METHODS: The STELLA-SUPERA-SIBERIA is a prospective, single-center, single-arm study. Patients with symptomatic (Rutherford stages 3-6) de novo and TASC C/D occlusive lesions of the femoropopliteal segment were treated with Supera stent. The primary endpoint was the 12 month rate of primary sustained clinical improvement (upward shift on the Rutherford classification to a one level without the need for repeated target lesion revascularization (TLR) in surviving patients without the need for unplanned amputation). Secondary endpoints were the 24 month of primary sustained clinical improvement, MALE, limb salvage, the primary patency, the secondary patency, 24 month MACE. Follow-up included clinical examination, duplex scan, and biplane x-ray up to 24 months. RESULTS: Between April 2019 and January 2020, 52 symptomatic patients with 55 long femoropopliteal occlusive lesions (52.7% TASC D lesions and 47.3% TASC C lesions) were treated. The mean target lesion length was 205±72 mm. All patients had total occlusions. The mean lesion length of the implanted Supera stents was 198±82 mm. At 12 and 24 months, the primary sustained clinical improvement rate was 80.2% and 63.6%, respectively. The Rutherford category assessment was significantly improved at 24 months compared with baseline (p=0.02). The primary patency rate at 12 and 24 months was 78.1% and 60.0%, respectively. At 12 and 24 months, freedom from TLR was 83.5% and 81.8%, respectively. There were no stent fractures at 24 months. CONCLUSION: Supera Stent implantation for TASC C/D femoropopliteal lesions revascularization appears to be a safe and efficient implant given the complexity of the treated lesions. Head-to-head studies are mandatory to establish Supera Stent as an alternative tool to open surgery for long femoropopliteal lesions. CLINICAL IMPACT: Our study indicated, that using self-expanding interwoven nitinol stent for TASC C/D femoropopliteal lesions revascularization appears to be a safe and efficient implant given the complexity of the treated lesions. Although bypass grafting is recommended for prolonged femoropopliteal lesions, open surgery is more traumatic and is associated with greater risks than endovascular procedures. Our findings suggest that the use of interwoven nitinol stents can overcome the disadvantages of traditional stents in such cases, which may help to improve patients' outcomes and reduce the risk of adverse events.

A prospective randomized trial on endovascular recanalization with stenting versus remote endarterectomy for the superficial femoral artery total occlusive lesions.

OBJECTIVE: The objective of this randomized study was to compare the short- and long-term safety and efficacy of endovascular recanalization with stenting (EI) and remote endarterectomy (RE) for patients with superficial femoral artery (SFA) total occlusive lesions (≥250 mm). METHODS: Between July 2013 and July 2017, eligible patients with SFA total occlusive lesions were randomized to EI or RE. The EI group underwent recanalization and stenting of long SFA atherosclerotic occlusive lesions. The RE group underwent semiclosed endarterectomy. Short- (30-day) and long-term (48-month) morbidity, mortality, and patency rates were compared between both groups. RESULTS: Of 400 patients assessed, 238 were ultimately randomized (119 EI and 119 RE). The cumulative primary patencies were 83% (EI) vs 82% (RE) at 12 months and 28% (EI) vs 46% (RE) at 48 months (P = .04). The limb salvage was 98% (EI) vs 95% (RE) at 12 months and 87% (EI) vs 92% (RE) at 48 months (P = .26). One-year and 4-year secondary patencies were 98% and 87% in the EI group and 100% and 90% in the RE group, respectively (P = .4). A total of 65 patients in the stenting group and 32 patients in the endarterectomy group underwent endovascular reintervention. Four-year patencies of endovascular reintervention subgroups were 37% and 60% (P = .04), respectively. CONCLUSIONS: RE shows significantly better results in the long term than primary stenting of SFA long lesions (TASC-II D lesions). In case of loss patency, a desobliterated artery can be successfully subjected to endovascular revascularization and stenting with good short- and long-term results.

The effect of the stented iliac lesions TASC-II C, D on the femoropopliteal bypass patency: Propensity score-matched observational study.

INTRODUCTION: Concurrent stenting of complex iliac lesions during infrainguinal bypasses can increase the complexity of a case and impact outcomes. OBJECTIVE: Our aim was to evaluate the effect of inflow stenting of TASC-II C, D iliac lesions on femoropopliteal bypass patency. METHODS: A retrospective observational cohort study of patients who underwent femoropopliteal bypass with TASC-II C, D iliac artery stenting (hybrid group) or without inflow lesions (non-hybrid group) was conducted. After propensity score matching, 120 patients were included in the non-hybrid group and 60 patients in the hybrid one. The median follow-up was 432 (193; 1313) days in the hybrid group and 472 (196; 1376) days in the non-hybrid group (p = 0.94). RESULTS: No significant differences were found between the groups in 30-day morbidity and serious adverse events. At 3 years, primary and secondary bypass patency for the hybrid group and non-hybrid group were 62.2% versus 59.9% (p = 0.36) and 63.7% versus 64.3% (p = 0.077), respectively. The primary patency of the iliac stents in patients of the hybrid group was 95% at 3 years. The estimated hazard ratio for primary patency for hybrid versus non-hybrid was 0.77, with 90% CI: 0.50-1.21; the noninferiority upper bound being 1.31, which corresponds to a 10% additive noninferiority margin for probabilities. The 3 years of freedom from amputation in patients with chronic limb-threatening ischemia was 94.1% and 75.0% in the hybrid and non-hybrid groups, respectively (p = 0.09). CONCLUSION: The outcomes of the femoropopliteal bypass in hybrid surgery supplemented with stenting of TASC-II C, D iliac lesions was similar to femoropopliteal bypass with intact inflow arteries.

Is it possible to prevent cerebral embolization by improving the design and technology of carotid stent implantation?

INTRODUCTION: The prevention of atherosclerotic plaque fragmentation during carotid artery stenting is a fundamental problem in decreasing the risk of disability of patients. The goal of this review is to clarify whether the stent design can have a decisive impact on the rate of intraoperative and postoperative complications. AREAS COVERED: Different designs of the carotid stents are briefed and the advantages and disadvantages of different stent designs are discussed as well as the results of their clinical use. Various solutions are presented to reduce cerebral embolism during carotid artery stenting. EXPERT OPINION: There is no conclusive evidence for the benefits of closed cell and hybrid stents. The stent design cannot completely resolve the problem of cerebral embolism. Most of the events of cerebral microembolism occur at the stages of stent delivery rather than protrusion of an atherosclerotic plaque in the long-term follow-up. Most likely, minimization of the risks for periprocedural and postprocedural strokes requires not only the new solutions in stent design as well as the corresponding delivery systems and brain embolic protection systems, but also the new strategies of preprocedural drug stabilization of the atherosclerotic plaque in the carotid artery. Abbreviations: CAS, carotid artery stenting; CE, carotid endarterectomy; DW-MRI, diffusion-weighted magnetic resonance imaging; ECA, external carotid artery; ICA, internal carotid artery; IVUS, intravascular ultrasound examination; OCT, optical coherence tomography.

Cell therapy of critical limb ischemia-problems and prospects.

Cell therapy is proposed for indirect revascularization for the patient's incurable by endovascular or surgical revascularization. The therapy with stem cells (SCs) or progenitor cells is assumed to be more efficient as compared with protein or gene therapy not only because of their direct vasculogenic properties, but also thanks to their paracrine effect via secretion of manifold biologically active substances. This review gives an overview of the potential of SC-based therapy for critical limb ischemia (CLI), putative mechanism underlying cell therapy, and comparison of cell therapy to angiogenesis gene therapy in CLI treatment. Human trial data and meta-analysis, as well as some problems of clinical trials and considerations for future SC-based therapy in CLI are also discussed.