We report a modified technique to perform iliac artery stenting through the brachial artery access. A 6F Brite tip sheath (Cordis, Jonhson & Jonhson Medical, Miami Lakes, FL, USA) is inserted into either brachial artery and a standard 4F Judkins Right diagnostic catheter was inserted over a 260 cm 0.038 Terumo Stiff wire (Terumo Corp, Tokyo, Japan) through the sheath. The catheter is navigated down to the aortic bifurcation, and after selecting the common iliac artery ostium, the wire is navigated through the lesion and advanced to the ipsilateral superficial femoral arteries. The catheter should be then moved forward over the wires beyond the lesion and the Terumo guidewire is replaced by two 0.038 260 cm Supracor wires (Boston Scientific Corporation, San Jose, CA, USA). In order to facilitate advancement of the stent without risk of dislodgement as well as to check the position with low contrast dose injection, a 6 F (or 7F if large stent is selected) 90cm Shuttle Flexor introducer long sheath (Cook Group, Bloomington, IN, USA) should be advanced over the Supracor wire until it reaches the common iliac artery ostium. A road-map technique can be used to check the ostium position in order to properly deploy the selected stent. This technique promises to be safe and effective offering more support than guiding catheter technique; moreover it reduces the stress on the arterial vessel at the subclavian site and enables a stiff balloon or stent catheter to be advanced even through a very elongated and calcified aorta without the risk of stent dislodgement.

In the last few years the treatment of superficial femoral artery (SFA) occlusive disease has undergone greater changes in management including more aggressive endoluminal therapy, especially in the elderly patients who are at high risk for extra-vascular comorbidities from the surgical approach. While acute and chronic arterial limb ischemia is the conditions which the interventional cardiologists frequently encounter, the elderly population represents special problematic clinical and anatomical setting due to heavy calcification and poor distal run-off. Arterial thrombolysis, rheolytic thrombectomy, mechanical thrombectomy, laser angioplasty, cryoplasty, and new flexible long stents are some of the promising techniques to improve the technical and clinical outcomes in these elderly patients.

Drug-coated balloon has been developed as an alternative to drug-eluting stents for in-stent restenosis but the performance of drug infusion balloon in such setting has not been previously described. We present a case of particularly aggressive in-stem restenosis after drug eluting stent implantation treated with a new kind of drug infusion balloon developed in order to overcome the impossibility to inflate regular drug-coated balloon for several dilatation.

Objective Recently it has been suggested that,in patients with large patent foramen ovale (PFO) and atrial septal aneurysms (ASA),a certain amount of left atrial (LA) dysfunction may be active as an alternate mechanism promoting arterial embolism-Following this hypothesis,elderly patients,being more susceptible to atrial chambers stiffness,should present a more severe LA dysfunction profile.We sought to evaluate the grade of LA dysfunction in elderly patients submitted to transcatheter PFO closure.Methods We retrospectively enrolled 28 consecutive patients with previous stroke (mean age 67±12.5 years,18 females) referred to our centre for catheter-based PFO closure after recurrent stroke.Baseline values of LA passive and active emptying,LA conduit function,LA ejection fraction,and spontaneous echocontrast (SEC) in the LA and LA appendage were compared with those of 50 atrial fibrillation patients,as well as a sex/age/cardiac risk matched population of 70 healthy controls.Results Pre-closure elderly subjects demonstrated significantly greater reservoir function as well as passive and active emptying,with reduced conduit function and LA ejection fraction,when compared to healthy and younger patients.After closure in elderly patients,LA parameters did not return completely to the levels of healthy patients,whereas LA dysfunction in younger subjects returned normal.Conclusions This study suggests that elderly patients have more severe LA dysfunction than younger patients,which affects the LA remodelling after closure.

Background and objectives Peripheral vascular disease (PVD) is a major risk factor in candidates for cardiac surgery and can impact morbidity and mortality in the perioperative and follow-up period. Elderly patients with PVD may benefit from endovascular treatment prior to cardiac surgery. We sought to assess the common clinical settings requiring prophylactic endovascular treatment before coronary surgery in elderly patients, the results, and the mid-term impact on subsequent revascularization. Methods Between November 2002 and June 2006, 37 patients (25 males, mean age 79.9±8.3 years, mean serum creatinine 1.9±0.6 mg/dl) underwent endovascular repair of PVD before cardiac surgery. For each patient, diagnostic methods, indications for intervention, types of interventions, procedural success, and complications were recorded. Results Four clinical settings were identified: renal artery stenting prior to coronary surgery (7 patients), iliac artery angioplasty and stenting (10 patients) in order to facilitate aortic balloon pump insertion after surgery, subclavian artery angioplasty and stenting prior to utilization of ipsilateral arterial conduits bypass surgery (5patients), and carotid artery stenting before coronary surgery (15 patients). Technical success was achieved in all patients (100%);complications included brachial artery occlusion (1 patient), minor stroke (2 patients), contrast nephropathy (1 patient), and minor bleeding at the puncture site (3 patients). All patients underwent successful coronary or valvular surgery; no patients died in the perioperative period. After a mean follow-up of 26.6±3.1 months, all patients are alive and free from anginal symptoms or valvular dysfunction without clinical or Doppler ultrasonography evidence of restenosis of the implanted peripheral vascular stents. Conclusions It is not unusual for elderly patients who are candidates for cardiac surgery to require endovascular intervention for significant PVD prior to coronary bypass or valvular surgery. The results showed a low complication rate. The cardiologists have a fundamental role,not only in the diagnosis of peripheral vascular stenosis, which was seen frequently in patients with significant CAD, but also in the appropriate endovascular management of these high-risk patients.

Background and Objective Elderly patients who have been submitted to coronary bypass grafting with the left internal mammary artery (LIMA) may develop a coronary-subclavian steal syndrome because of a left subclavian artery (LSA) stenosis. Usually stenting of LSA is performed by the standard femoral route with guiding catheter technique, but this technique can be particularly difficult in elderly patients who often have iliac-femoral kinking and aortic tortuosity. We compared a new ad hoc brachial artery approach technique with the standard guiding catheter technique through the femoral access. Methods Between January 2005 and September 2006, four patients underwent LSA stenting using the left brachial artery access obtained with a 6F or 7F 45-cm-long valved anti-kinking sheath as the Super Arrow Flex sheath (Arrow International, PA, USA). The sheath was positioned just before the LIMA graft ostium and a 0.035 inch 260-cm-long Storq guidewire (Cordis Inc., Johnson & Johnson, Warren, NJ) was advanced across the lesion to the descending aorta. A balloon-expandable Genesis (Cordis Inc., Johnson & Johnson, Warren, NJ) endovascular stent was easily deployed, and the correct position was checked by direct contrast injection through the long sheath. This small group of patients has been compared to a group of 5 age-matched patients with coronary steal syndrome in whom the procedure has been performed with standard technique including femoral approach and guide catheter. Results The procedure was successful in all patients; vertebral and LIMA ostia remained patent in all cases. In the control group, cannulation of the subclavian artery was difficult in two cases, while one patient developed a groin hematoma. Mean pretreatment gradient was 32 mm Hg with a range of 25 to 40 mm Hg (34 mmHg, range 26-43, in the control group, P=0.87) and fell to 2 mm Hg with a range of 0 to 4 mm Hg (3.1 mmHg, range 0 to 5, P=0.89) posttreatment. Mean contrast dose was 60±16 ml (138±26 ml in the control group, P＞0.01), whereas mean fluoroscopy and procedural time were 5.7±1.6 minutes (10.8±1.0 minutes in the control group, P＞0.01) and 15.7±6.3 minutes (28±7.1 minutes in the control group, P＞0.01). At a mean follow-up of 10±3.2 months all patients are alive and free from angina and residual induced ischemia. Conclusions Our brief study suggested that brachial artery access be considered the optimal route to treat coronary-subclavian steal syndrome in elderly patients because of clear advantages; these included no manipulation of catheter to cannulate the artery, perfect coaxial position of the catheter at the site of LSA stenosis, clear visualization of the LIMA and vertebral ostia, and easy access to these vessels in case of plaque shifting or embolic protection device deployment.

Objective Accelerated left main coronary stenosis (LMCS) is a known potential late complication of coronary artery catheter procedures. The aim of this study was to assess the current occurrence of LMCS as a delayed complication of percutaneous angioplasty (PTCA) of the left coronary branches in our institution. Methods The medical records of patients referred for coronary artery by-pass surgery from the same Cardiology Unit in the January 2003 to December 2006 period and presenting a significant (> 50%) LMCS as a new finding following a PTCA of the left coronary artery branches, were reviewed. Patients with retrospective evidence of any LMCS at previous coronary angiographies preceding the percutaneous procedure were excluded. Results Thirty-seven patients (5 females, mean age 71.1±8.6 years) out of 944 (4%) having undergone a PTCA, fulfilled the inclusion criteria, 19 (51%) after a procedure also involving the LAD coronary artery. Extraback-up guiding catheters were used in most cases. Use of multiple wires or balloons was observed in 3 cases (8%). Rotablator and proximal occlusion device were used in one case respectively (3%). Twenty patients (54%) have had more than one percutaneous coronary intervention on the left coronary branches. The mean time elapsed from the first angioplasty and surgical intervention was 18.1±7.8 months. Conclusions The potential occurrence of LMCS following a percutaneous intervention procedure, especially when complicated and repeated, should not be underestimated in the current era. This evidence may offer the rationale to schedule non-invasive imaging tests to monitor left main coronary patency after the procedure as well as to fuel further research to develop less traumatic materials.

Objectives To assess the impact on stent implantation rate and mid-term outcomes of prolonged high pressure angioplasty of femoropopliteal lesions. Methods We retrospectively enrolled 620 consecutive patients from January 2011 to December 2011 (75.6 ±12.3 years, 355 males, 76.5%in Rutherford class 5-6), referred for critical limb ischemia and submitted to prolonged high-pressure angioplasty of femoropopliteal lesions. The definition of prolonged high-pressure angioplasty includes dilation to at least 18 atm for at least 120 s. Proce-dural data, and clinical and instrumental follow-up were analyzed to assess stent implantation rate and mid-term outcomes. Results The preferred approach was ipsilateral femoral antegrade in 433/620 patients (69.7%) and contralateral cross-over in 164/620 (26.4%) and pop-liteal retrograde+femoral antegrade in 23/620 (3.7%). Techniques included subintimal angioplasty in 427/620 patients (68.8%) and endolu-minal angioplasty in 193/620 patients (31.2%). The prolonged high pressure balloon angioplasty procedure was successful in 86.2%(minor intra-procedural complications rate 15.7%), stent implantation was performed in 74 patients (11.9%), with a significant improvement of ankle-brachial index (0.29 ±0.6 vs. 0.88 ±0.3, P<00.1) and Rutherford class (5.3 ±0.8 vs. 0.7 ±1.9, P<0.01), a primary patency rate of 86.7%, restenosis of 18.6%on Doppler ultrasound and a target lesion revascularization of 14.8%at a mean follow-up of 18.1 ±6.4 months (range 1-24 months). Secondary patency rate was 87.7%. Conclusions Prolonged high pressure angioplasty of femoropopliteal lesions appears to be safe and effective allowing for an acceptable patency and restenosis rates on mid-term.

Background To investigate the long-term results of global coronary and peripheral interventional treatment of diabetic foot patients.Methods We retrospectively included 220 diabetic patients (78.5±15.8 years,107 females,all with Fontaine III or IV class) who were referred to our centre for diabetic foot syndrome and severe limb ischemia from January 2006 to December 2010.Patients were evaluated by a team of interventional cardiologists and diabetologists in order to assess presence of concomitant coronary artery disease (CAD) and eventual need for coronary revascularization. Stress-echo was performed in all patients before diagnostic peripheral angiography. Patients with indications for coronary angiography were submitted to combined diagnostic angiography and then to eventual staged peripheral and coronary interventions.Doppler ultrasonography and foot transcutaneous oximetry of transcutaneous oxygen pressure (TcPO2) before and after the procedure were performed as well as stressechocardiography and combined cardiologic and diabetic examination at 1 and 6 month and yearly.Results Stress-echocardiography was performed in 94/220 patients and resulted positive in 56 patients who underwent combined coronary and peripheral angiography.In the rest of 126 patients,combined coronary and peripheral angiography was performed directly for concomitant signs and symptoms of coronary heart disease in 35 patients.Coronary revascularization was judged necessary in 85/129 patients and was performed percutaneously after peripheral interventions in 72 patients and surgically in 13 patients.For Diabetic foot interventions the preferred approach was ipsilateral femoral antegrade in 170/220 patients (77.7%) and contralateral cross-over in 40/220 patients (18.8%) and popliteal retrograde+femoral antegrade in 10/220 patients (4.5%).Balloon angioplasty was performed in 252 legs (32 patients had bilateral disease):the procedure was successful in 239/252 legs with an immediate success rate of 94.8% and a significant improvement in TcP02 and ABI with ulcer healing in 233/252 legs (92.4%).Freedom from major amputation was 82.8% at a mean follow-up of 3.1±1.8 years (range 1 to 5 years) whereas survival was 88%.Conclusions Global coronary and peripheral endovascular management of diabetic foot syndrome patients seems to lead to an high immediate success and limb salvage rates and increasing survival compared to historical series.

Arteries ; physiopathology ; surgery ; Atherosclerosis ; diagnostic imaging ; physiopathology ; surgery ; Hemodynamics ; Humans ; Radiography