Surgical and endovascular treatment of popliteal artery aneurysms

Abstracts / Cardiovascular Revascularization Medicine 12 (2011) e1–e46 Results: Mean age was 63±7.3 years, 95% were men and 100% were diabetic. Mean lesion length was 156.9±94.7 mm; 43.5% were total occlusions. Mean presenting Rutherford category was 3.0±0.3. A total of 20 limbs (43.5%) were debulked using laser atherectomy, rotational atherectomy, directional atherectomy and/or cutting balloons. Immediate postprocedural mean PVR was significantly lower in the debulking group compared to the conventional balloon predilation group (0.96 vs. 1.07, P=.01). Furthermore, mean ABI was significantly lower in patients who had PVR ≥2 compared with patients who PVR ≤2 at 6 months and 1 year postprocedure (0.64 vs. 0.89, P=.005; 0.42 vs. 0.70, P=.01, respectively). Mean NDEMD was lower in the debulking group; however, the difference was not statistically significant. Conclusion: Our results suggest the potential utility of debulking prior to the deployment of n-SES in complex SFA lesions in diabetics.

e3

chronic (between 1 and 6 months). There were no statistical difference in plaque/thrombus volume between baseline (pretreatment) and control ClearWay treatment (saline infusion) (P=.911, n=4). Also, there was no statistical difference in plaque/thrombus volume between pretreatment baseline and ClearWay tpA treatment (P=.628). Following Angiojet rheolytic thrombectomy (n=8 patients) post-ClearWay lytic treatment, there was a statistical reduction of plaque/thrombus volume vs. ClearWay lytic treatment alone (P=.03) or pretreatment baseline (P=.029). There were no deaths or amputations. Macrodebris N2 mm were present in 50% of patients captured by embolic filter protection. In-hospital reocclusion of the treated vessel occurred in one patient (5%), and 30-day reocclusion occurred in two patients (10%) on follow-up. Conclusion: Using the ClearWay to deliver lytic therapy appears safe in this small feasibility study. Although lytic treatment with the ClearWay balloon alone did not demonstrate reduction in plaque/thrombus volume in this small population, the use of Angiojet rheolytic thrombectomy following ClearWay did reduce plaque volume. Further data are needed to address definitive effects of ClearWay balloon alone and utility to facilitate Angiojet thromboreduction. doi:10.1016/j.carrev.2011.04.252

Complications of aortic stenting in patients below 20 years old: immediate and intermediate follow-up Akbar Molaei, Mahmood Meraji Rajaee Heart Center, Tehran, Islamic Republic of Iran

Fig. 1. Peak Systolic Velocity Ratios in stented SFA segments b24 hours post-procedure in patients whose lesions were either debulked or dilated with conventional balloons prior to stent implantation. Systolic Velocities were obtained by duplex ultrasound. doi:10.1016/j.carrev.2011.04.251

Dethrombosis of lower extremity arteries by local delivery of thrombolysis using the ClearWay transcatheter balloon irrigation system: a feasibility study Nicolas W. Shammas, Neil J. Weissman, Denise Coiner, Gail A. Shammas, Michael Jerin, Lori Christensen Midwest Cardiovascular Research Foundation, Davenport, IA, USA Background: Thrombus is highly prevalent in patients with recent symptoms (b6 months) of claudication or limb ischemia and occluded culprit lower extremity vessels. Treatment of these thrombotic occlusions is challenging. In this feasibility study, the Vascular ClearWayTM Irrigating PTFE Balloon Catheter (Atrium) has been tested for its safety and ability to dissolve thrombus in patients with recent arterial occlusions. Methods: Volumetric core lab assessment of the thrombus was performed at baseline and after ClearWay thrombolysis but prior to definitive treatment of the vessel to evaluate thrombus resolution. Twenty consecutive patients were prospectively enrolled. Four controls and 10 study subjects treated with tPA (doses from 0.25 mg/cm to 0.6 mg/cm of treated occlusion; eight patients treated with Angiojet following ClearWay treatment) had interpretable intravascular ultrasound images by the core lab blind to sequence and free of calcium, allowing volumetric analysis. Results: Twenty consecutive patients were enrolled in this study (11 males, mean age 68.54±8.15 years). Based on patients' symptom onset, 1 patient was acute (b24 h), 4 subacute (N24 h, b30 days) and 15

Background: Optimal timing and mode of treatment for patients with coarctation of the aorta (COA) remain controversial, particularly in children. Surgery, balloon dilatation and stent implantation have all proven effective in the treatment of moderate or severe obstruction. In this report, we describe the use of stents to treat coarctation in pediatric population. Aim: The aim of this study is the assessment of complications of COA stenting angioplasty in pediatric patients. Case study: This retrospective, descriptive study has performed on less than 20-year-old patients that have undergone aortic stenting angioplasty because of congenital COA in the pediatric catheterization laboratory of Rajaee Cardiovascular Medical & Research Center between 2005 and 2010. Results: The present study enrolled 26 patients of congenital COA that have undergone aortic stenting angioplasty, 18 of whom (65.4%) were male and 9 of whom (34.6%) were female. Nineteen of these patients had native COA (73.1%), and seven had re-COA (26.9%). Most of the early complications were minor and temporary; early major complication occurred in just one of the patients. In follow-up duration, none of the native group showed late complications, while in the re-COA group, 28.57% of patients had restenosis and 14.28% had chronic systemic hypertension which needed drug therapy. Conclusion: Based on our findings regarding complications of native and reCOA groups, COA treatment by stent implantation can be an effective and safe method even in young patients with native COA if selected appropriately. doi:10.1016/j.carrev.2011.04.253

Surgical and endovascular treatment of popliteal artery aneurysms Francesco Pollice Sr. a, Paolo Pollice a, Bernard Lachat b a Private Clinic, Andria, Italy b University of Lausanne, Lausanne, Switzerland Background: Popliteal aneurysms (PAs) are the most frequent peripheral artery aneurysms, and those of more than 2 cm in diameter are considered candidates for elective surgery. Although the standard treatment of popliteal artery aneurysms has been open repair, there are increasing reports in the literature of endovascular management, which allows a quicker recovery and

e4

Abstracts / Cardiovascular Revascularization Medicine 12 (2011) e1–e46

a shorter hospital stay. In this study, results after either open or endovascular treatments are assessed. Methods: Between January 2004 and January 2009, 21 PAs were treated in 21 patients: short- and midterm outcomes have been retrospectively evaluated. Results: Six patients (28.6%) presented bilateral PAs. Mean age was 73 years (range 46–95 years). One patient was female. Mean diameter of PAs was 3.7 cm (range 1.6–9.5 cm). Two (9.1%) aneurysms were asymptomatic. Seven (33.3%) patients presented claudicatio intermittens, and 13 (61.9%) patients had acute ischemia of lower limbs (ALI). Fifteen (68.2%) patients, 13 with ALI and 2 with severe claudicatio intermittens, underwent intraarterial thrombolytic therapy. Eleven (50%) patients were operated on, six (54.5%) through medial approach. In one patient, an ePTFE graft was implanted for an unsuitable saphenous vein. Nine (40.9%) patients underwent endovascular aneurysmal exclusion. Five patients presented an asymptomatic PA, contralateral to the treated one, with mean diameter of 1.32 cm (range 1.2–1.5 cm, S.D. 0.13). All these small and asymptomatic PAs were not treated. A 57-year-old patient presented ALI due to complete thrombosis of a PA with diameter of 1.6 cm, and he successfully underwent intraarterial thrombolytic therapy followed by oral anticoagulants, without any further treatment. The mean follow-up of endovascularly approached patients was 15 months. Three surgically treated patients, suffering ALI and an extremely poor distal runoff, underwent early amputation (30 days). In surgically treated patients, primary and secondary patency rates were, respectively, 62.5% (5/8 patients) and 87.5% (7/8 patients). After endovascular exclusion, primary and secondary patency rates were 60% (6/9+1, hybrid, patients) and 100%. Conclusion: Endovascular exclusion of PAs appears to allow short- and midterm results associated with endovascular treatment options that come at a cost of diminished durability and potentially increased need for reintervention, further forcing tighter postprocedural follow-up. doi:10.1016/j.carrev.2011.04.254

Single-center 1-year outcomes of carotid artery stenting Jamil Y. Abuzetun, Ratna Gangi, Madhu Y. Reddy, Islam Al-howadi, Thomas Lanspa Creighton University Medical Center, Omaha, NE Background: Endovascular treatment has been used increasingly for the treatment of carotid artery stenosis. Studies of carotid artery stenting have shown conflicting results. Methods: To address this disparity, we reviewed 100 patients with carotid artery stenosis who underwent carotid artery stenting at Creighton University medical Center between January 2005 and December 2008. The mean age of patients was 73.8 years; 69% were males. Forty-three percent had symptomatic carotid stenosis, 26% were smokers, 89% have hypertension, 33% have diabetes mellitus, 83% have dyslipidemia, 11% have previous cerebrovascular accident, 92% were taking aspirin, 65% were on Plavix, 87% were on statins and 58% were receiving angiotensinconverting enzyme (ACE) inhibitors. Results: Immediate complications were transient ischemic attack (TIA) in 11%, bleeding in 4% and hypotension requiring the use of pressors in 23%. The 30-day major adverse cardiac events (MACEs), which include TIAs, stroke, MI or death, were seen in 12%. One-year MACE was 16%, with TIA being the most common at 13%. Incidence of myocardial infarction was 3%; death, 3%; and stroke, 1%. Patients who were on ACE inhibitors and statins have less incidence of MACE with statistically significant P value of .02 and .04, respectively. Conclusion: Carotid artery stenting is a viable alternative to carotid endarterectomy in patients with carotid artery disease if performed by an expert operator. Angiotensin-converting enzyme inhibitors and statins decrease the incidence of MACE in patients undergoing carotid artery stenting. doi:10.1016/j.carrev.2011.04.255

Drug-eluting stents Vascular function of bioabsorbable stented site after complete absorption of the stent Jinsheng Li, Jianing Yue, Dongming Hou, Daisuke Musimuto, Takamitsu Nakamura, Refat Jabara, Spencer B. King III, Jaipal Singh, Nicolas Chronos Saint Joseph's Translational Research Institute, Atlanta, GA Background: Drug-eluting bioabsorbable stents (DEBSs) represent a new device-based therapy for coronary artery disease. It has been reported that the stented segment becomes reendothelialized after 1 month and the segments proximal and distal to the stented site are functional at 2 years. In order to examine whether, after complete degradation, the DEBS site function was similar to the unstented segments, we performed ex vivo vasomotor function studies using pig coronary arteries. Methods: Eighteen months after implantation in the pig coronary arteries, 10 DEBS sites (4 LAD, 4 RCA and 2 LCX) were assessed for vasomotor function using an organ chamber apparatus. They were stimulated with potassium chloride (KCl), prostaglandin2α (PGF) and three concentrations of endothelin-1 (ET). Endothelium-dependant relaxation (EDR) to substance P (SbP; 0.01–100 pM) and endothelium-independent relaxation (EIDR) to sodium nitroprusside (SNP; 0.001–10 μM) were assessed following constriction with PGF. Remaining stent segments were fixed for histologic examination. Results: The DEBS sites showed rapid response to low and high concentrations of KCl, PGF and ET. The EIDR showed concentrationdependent relaxation to SNP (13.3%±4.3%, 21.3%±5.6%, 52.7%±7.1%, 85.5%±5.4% and 100%±0%). However, there was no EDR to SbP concentration-dependent stimulation. HE and VM staining showed evidence of SMCs migration across polymer struts, and formation of a new abluminal layer was observed. There was complete polymer strut degradation, infiltration of inflammatory cells and minor fibrosis around some DEBS sites. Myocardial degeneration (∼1×1.5 cm) was found in the septum adjacent to the stented LAD sites (n=4). Vessel wall within the stented segment was thicker and the lumen was narrower than in the proximal and distal segments. Conclusion: During DEBS degradation period, medial SMCs migrate to NI, developing new layers. We have demonstrated for the first time the ex vivo contraction and relaxation responses at DEBS sites to vasoactive agents after complete degradation of the stent. SMCs recovered contractile and relaxing capabilities in this segment, but endothelial function was still impaired. doi:10.1016/j.carrev.2011.04.256

Impact of diabetes mellitus on clinical outcomes of patients with end-stage renal disease undergoing percutaneous coronary intervention Gabriel L. Sardi, Gabriel Maluenda, Rafael Romaguera, Michael A. Gaglia Jr., Kohei Wakabayashi, Michael Mahmoudi, Itsik Ben-Dor, Ana Laynez-Carnicero, Rebecca Torguson, William O. Suddath, Augusto D. Pichard, Lowell F. Satler, Ron Waksman Washington Hospital Center, Washington, DC Background: The presence of end-stage renal disease (ESRD) after percutaneous coronary interventions (PCIs) is associated with poor outcomes, but the specific contribution of diabetes mellitus (DM) is not established. Methods: A cohort of 198 patients with ESRD on hemodialysis, who underwent PCI with stents, was followed clinically for 1 year, and the clinical events rates were recorded. We retrospectively compared patients with DM to those without DM. Results: From all patients with ESRD on hemodialysis, 48.5% had DM. Nondiabetic patients were more commonly male and had older grafts. Both groups had a similar incidence of acute coronary syndromes, and both received a similar proportion of bare metal and drug-eluting stents. Ostial