[Revascularization of renal artery stenosis--state of the art]. / Revaskularisation der Nierenarterienstenose: State of the Art.

Atherosclerotic renal artery stenoses (aRAS) are often associated with an aorto-iliac type of peripheral occlusive artery disease and may result in deterioration of blood pressure control, chronic kidney disease and myocardial dysfunction. Stenting of aRAS has almost replaced surgical revascularisation. However, the benefit of endovascular treatment of aRAS was challenged by the results of the STAR and ASTRAL trials demonstrating similar outcomes for revascularisation and conservative treatment. Due to severe limitations in trial design, the study results can only be applied to a small proportion of the affected patient population. A clinical benefit of renal stenting can only be expected if the indication for endovascular procedure was correct, in particular if the hemodynamic relevance of the lesion was verified by non-invasive (duplex) or invasive (pressure gradient) methods. The known predictors (pulse pressure > 50 ± 10 mmHg, high diastolic blood pressure, elevated BNP levels, renal insufficiency) for clinical success are often not sufficiently implemented in the decision-making process. Unquestioned by international guidelines is the indication for revascularisation of aRAS of a single functioning kidneys, severe bilateral lesions, resistant hypertension, worsening of renal function, and in each kind of severe RAS of non-atherosclerotic nature.

Acute and long-term outcome of Silverhawk assisted atherectomy for femoro-popliteal lesions according the TASC II classification: a single-center experience.

BACKGROUND: Directional atherectomy (DA) has become popular in some centers to remove atherosclerotic plaques in femoro-popliteal lesions. Although immediate and also short - term outcome data are promising, solid long-term data are warranted to justify the widespread use in daily practice. PATIENTS AND METHODS: In this prospective study de novo and restenotic lesions of the femoro-popliteal segments were treated with the Silverhawk device. 161 consecutive patients (164 lesions) with peripheral artery disease (PAD) Rutherford classes 2 to 5 were included from June 2002 to October 2004 and October 2006 to June 2007 (59 % male, mean age 67 +/- 11 years, range 40 to 88) and the outcome analyzed according to the TASC II classification. RESULTS: DA alone was performed successfully in 28 % (n = 46), adjunctive balloon angioplasty in 65 % (n = 107) and stenting in 7 % (n = 11). The overall technical success rate was 76 % (124 / 164) and the procedural success rate 95 % (154 / 164). At 12 months primary patency rate was 61 % (85 / 140) and the secondary patency rate was 75 % (105 / 140) in the entire cohort, being less favourable in TASC D compared to TASC A to C lesions (p = 0.034 and p < 0.001, respectively). Furthermore the restenosis rate differed trendwise (p = 0.06) between de novo and restenotic lesions. Changes in the ABI and the Rutherford classes were significantly in favour of TASC A to C lesions compared to TASC D after 12 months (p = 0.004). The event free survival (MI, TIA, or restenosis) was 48 % at 12 months and 38.5 % at 24 months. Predictor for restenosis in the multivariable analysis was only male gender (p=0.04). CONCLUSIONS: The results in TASC D lesions are inferior to those in the lesser stages. DA of femoro-popliteal arteries leads shows a trend to better long-term technical and clinical outcome in de novo lesions compared to restenotic lesions.

Percutaneous iliac vein recanalization 17 years after thrombotic occlusion.

Persistent venous outflow obstruction of the iliac veins is one of the mechanisms that seem to portend the greatest risk for late development of severe complications. We report the case of a 42-year-old male with postthrombotic occlusion of the left external iliac artery since the age of 25. We managed to recanalize the obstructed vessel and establish a good flow into the inferior vena cava by venous stenting. After successful intervention the patient reported instant symptom relief and was free from venous claudication and leg heaviness at the 6 month follow-up examination. Even after long history of postthrombotic syndrome, venous stenting can be an option for patients with chronic outflow obstructions of the iliac veins.

Coil embolisation of an internal iliac artery aneurysm after surgical repair of an infrarenal aortic aneurysm.

We report a case of an 86-year-old asymptomatic patient, who underwent a repair of the infrarenal abdominal aortic aneurysm 13 years ago. He presented with a left internal iliac artery (IIA) aneurysm with a short neck of 3 mm, and a partially thrombosed lumen with a cross sectional diameter of 5.6 cm and a length of 8.9 cm. With respect to the high morbidity and mortality and awareness of the recommendation to treat aneurysms larger than 3 cm in diameter, we discussed the optimal treatment options. As endoprosthesis implantation was not feasible we performed a selective coil embolisation of the distal branches of the left internal artery, which successively lead to a complete thrombosis of the aneurysm. Although coiling additive to other procedures is applied frequently, only few cases of internal iliac aneurysm were treated with coil embolisation alone. During a first outpatient visit 2 months following the procedure the aneurysm was still completely thrombosed.

Enhancement of platelet inhibition of ticlopidine plus aspirin vs aspirin alone given prior to elective PTCA.

BACKGROUND: In many patients today, elective percutaneous transluminal coronary angioplasty is followed by implantation of coronary stents to achieve optimal results. The current medical strategy to prevent early reocclusion is the inhibition of platelet aggregation by administration of ticlopidine, in addition to aspirin, immediately after the procedure. In order to inhibit platelet aggregation as early as possible, many centres begin to treat patients with additional ticlopidine the day before elective coronary intervention. The aim of this study was to determine the effect of this strategy on platelet aggregation before angioplasty. METHOD: Fifty-two consecutive patients admitted to hospital for elective balloon angioplasty were prospectively randomized to receive either standard oral aspirin 100 mg per day or standard therapy plus 250 mg ticlopidine at the time of admission and the morning before angioplasty. Adenosine diphosphate-, collagen- and epinephrine-induced platelet aggregation was measured immediately before the procedure by an investigator who was blinded concerning the arm of therapy. RESULTS: The two groups of patients were comparable in terms of age, sex, body mass index, anginal state, time interval between application of study drug and coronary intervention. Patients on aspirin and ticlopidine had a mean maximal platelet aggregation of 36 +/- 12% with adenosine diphosphate as agonist. For the control group, 54 +/- 12% was measured (P < 0.001). Myocardial infarction or emergency coronary bypass grafting did not occur in either group. Local haemorrhagic complications at the arterial access site occurred in five (aspirin) and six (aspirin and ticlopidine) patients (P = ns) none of them requiring blood transfusion. CONCLUSION: The additional application of ticlopidine to chronic aspirin therapy the day before elective coronary balloon angioplasty leads to a significantly higher inhibition of platelet aggregation at the time of the intervention. It seems to be safe compared to the standard procedure.