Rescue Snorkel Technique in a Giant Ruptured Aortic Aneurysm With Thoracic Endovascular Aortic Repair Failure.

A 67-year-old man was sent to our center because of progressively worsening chest pain. A giant ruptured thoracic aortic aneurysm was documented. We performed a successfully rescue snorkel technique for thoracic endovascular aortic repair failure because of type IA endoleak after the first endoprosthesis implantation. The patient was discharged after 6 weeks. (Level of Difficulty: Advanced.).

Repeat stenting for the prevention of the early lumen loss phenomenon in patients with in-stent restenosis. Angiographic and intravascular ultrasound findings of a randomized study.

BACKGROUND: Early lumen loss (ELL) may be detected in patients undergoing coronary interventions for in-stent restenosis. This phenomenon may contribute to recurrences. This prospective, randomized study was designed to determine if repeat stent implantation may prevent ELL in patients with in-stent restenosis. METHODS: Forty patients were randomized: 20 were allocated to elective stent implantation and 20 to conventional balloon angioplasty. Quantitative coronary angiography and intravascular ultrasound (IVUS) volumetric studies were systematically performed (1) before the procedure, (2) immediately after intervention, and (3) 30 to 60 minutes later. RESULTS: Baseline characteristics were similar in both groups. After the delay time interval (46 +/- 8 minutes), quantitative coronary angiography revealed a significant reduction in minimal lumen diameter (2.2 +/- 0.5 mm vs 1.7 +/- 0.5 mm, P < .001) in the balloon angioplasty arm. Likewise, in this group, IVUS demonstrated a reduction in mean lumen area (7.1 +/- 2 mm2 vs 6.2 +/- 2 mm2 , P < .001) and lumen volume (144 +/- 59 mm3 vs 126 +/- 54 mm3 , P < .001). In 4 of these patients, ELL was severe enough to require further intervention. In the stent arm, however, angiographic data and IVUS mean lumen area (7.7 +/- 3 mm2 vs 7.7 +/- 3 mm2) and lumen volume (161 +/- 72 mm3 vs 160 +/- 69 mm3) remained unchanged after the delay time interval. On multivariate analysis, stent implantation was an independent predictor of the absence of ELL by quantitative coronary angiography and by IVUS. In addition, patients with a larger ELL on IVUS had a lower event-free survival at 1 year (40% vs 79%, log rank P = .003). CONCLUSIONS: This randomized study demonstrates that (1) ELL is frequently detected after treatment of in-stent restenosis with balloon angioplasty, that (2) ELL influences the long-term clinical outcome of these patients, and that (3) repeat stent implantation prevents ELL.

Intracoronary brachytherapy after stenting de novo lesions in diabetic patients: results of a randomized intravascular ultrasound study.

OBJECTIVES: We studied the efficacy of intracoronary brachytherapy (ICB) after successful coronary stenting in diabetic patients with de novo lesions. BACKGROUND: Intracoronary brachytherapy has proven effective in preventing recurrences in patients with in-stent restenosis. However, the role of ICB for the treatment of de novo coronary stenoses remains controversial. METHODS: Ninety-two patients were randomized to either ICB or no radiation after stenting. Primary end points were in-stent mean neointimal area (primary end point of efficacy) and minimal luminal area of the entire vessel segment (primary end point of effectiveness), as assessed by intravascular ultrasound at six-month follow-up. Quantitative coronary angiography analysis was performed at the target, injured, irradiated, and entire vessel segments. RESULTS: At follow-up, the in-stent mean neointimal area was 52% smaller in the ICB group (p < 0.0001). However, there was no difference in the minimal luminal area of the vessel segment (4.5 +/- 2.4 mm2 vs. 4.4 +/- 2.1 mm2). Restenosis rates increased progressively by the analyzed segment in the ICB group: target (7.1% vs. 20.9%, p = 0.07), injured (9.5% vs. 20.9%, p = NS), irradiated (14.3% vs. 20.9%, p = NS), and vessel segment (23.8% vs. 25.6%, p = NS). At one year, 1 cardiac death, 6 myocardial infarctions (MIs) (3 due to late stent thrombosis), and 10 target vessel revascularizations (TVRs) (6 due to the edge effect) occurred in the ICB group, whereas in the nonradiation group, there were 11 TVRs and no deaths or MIs. CONCLUSIONS: Intracoronary brachytherapy significantly inhibited in-stent neointimal hyperplasia after stenting in diabetic patients. However, clinically this was counteracted by the occurrence of the edge effect and late stent thrombosis.

Predictors and implications of residual plaque burden after coronary stenting: an intravascular ultrasound study.

BACKGROUND: Residual plaque burden after coronary stenting may be visualized by use of intravascular ultrasound. Determinants and implications of residual atherosclerotic plaque burden after coronary stenting are not well established. In particular, the implications of residual plaque burden, after adjusting for confounding factors, are still unknown. METHODS: Sixty-two consecutive patients (age 56 +/- 9 years) undergoing coronary stenting under intravascular ultrasound imaging guidance were prospectively studied. A total of 616 slices were analyzed (every 2 mm of stent length) from motorized pull-back recordings. Residual plaque burden was calculated as residual plaque/vessel area x 100. RESULTS: In 565 slices (89%), both residual plaque area and stent area could be measured. Mean residual plaque burden was 46.5% +/- 6%. By use of multiple regression analysis, lesion plaque area and reference segment plaque burden were identified as independent predictors of residual plaque burden after stenting. In addition, a significant correlation was found between residual plaque burden and most relevant angiographic parameters at follow-up (including minimal lumen diameter, percent diameter stenosis, and loss index), which persisted after adjustment. Furthermore, stents with a residual plaque burden >or=46% had higher a restenosis rate (relative risk [RR] 4.4, 95% CI 1.09-18.2, P =.03). On logistic regression analysis, residual plaque burden (RR 4.8, 95% CI 4.1-5.6, P =.01) and diabetes (RR 4.3, 95% CI 3.6-5.1, P =.03) emerged as the only independent predictors of restenosis. CONCLUSIONS: The amount of residual plaque burden after coronary stenting plays an independent role on the late angiographic outcome of these patients.

Utilidad y seguridad de la prueba de esfuerzo temprana después de angioplastía coronaria / Early stress test after coronary angioplasty

La prueba de esfuerzo (PE) antes del egreso en pacientes sometidos a angioplastía coronaria (ACTP) ha sido usada para conocer el resultado clínico inmediato, aun cuando no se tiene información clara de cuál es su importancia pronóstica y sus posibles complicaciones en este período. El objeto del estudio fue determinar la seguridad y el valor pronóstico de la prueba de esfuerzo temprana post-ACTP, en nuestro hospital. En forma retrospectiva, se revisaron los expedientes clínicos de enfermos consecutivos sometidos a ACTP. Se seleccionaron quienes tenían realizada una PE los primeros 10 días después de la intervención y se analizaron las variables del procedimiento, los datos clínicos y de seguimiento. Se incluyeron 224 pacientes sometidos a ACTP convencional. De ellos, 83(34 por ciento) tuvieron PE temprana (edad 52.8 ñ 9.7 años, 84 por ciento hombres). Todos ellos con ACTP exitosa (112 lesiones), 78 por ciento de un vaso, 19 por ciento y 2.5 por ciento de dos y tres vasos, respectivamente. Las PE se realizaron a los 5.1 días (margen 2 a 10) y en 27 (32.5 por ciento) fueron en los primeros tres días. No hubo ninguna complicación vascular en el sitio de punción, ni angor inestable o infarto relacionados con la prueba. Sólo hubo cuatro pruebas tempranas positivas (5 por ciento): en dos casos con revascularización incompleta (3 vasos) y dos completa sin complicaciones. En todos ellos se confirmó isquemia residual en el estudio de control. Tres de ellos tuvieron restenosis significante en el cateterismo a los tres o seis meses. El cuarto enfermo continúa asintomáticos, el talio documentó isquemia residual leve y el médico trata te no consideró necesario el estudo angiográfico. Ocho (9 por ciento) con prueba temprana post-ACTP es segura, y puede ser aplicada a todo enfermo antes de su egreso en ausencia de alto riesgo de oclusión aguda. Su positividad no deve indicar un estudio angiográfico inmediato, pero puede estar en relación con mayor frecuencia de isquemia residual y restenosis