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Vascular Disease Blogs
The unending saga of renal artery stenting: A “slam-dunk” intervention that turned out not to be
Consider the following:
– Renal artery stenosis (RAS) is a frequent finding on patients with severe atherosclerotic disease;
– RAS is well documented to be an important treatable cause of severe hypertension;
- It can also lead to significant or even critical renal dysfunction when the entire renal-parenchyma mass is affected, most typically in the setting of severe bilateral RAS;
- Other potential but less common complications of RAS are well known as well, particularly cardiac dysfunction leading to flash pulmonary edema and aggravated angina symptoms;
Bare-Metal or Covered SFA Stents: Still a struggle!
Smoking cessation and exercise regimens are the textbook answer to the treatment of patients with claudication symptoms. Surgical bypass can be complicated by wound-healing issues, graft thrombosis, etc. In light of this, the traditional approach to superficial femoral artery (SFA) disease is nonoperative, unless the patient has claudication that is debilitating and prevents the patient from performing their job appropriately.
Percutaneous therapy has changed our opinion of claudication. I (and many others) have become very aggressive about catheter-based approaches to SFA disease. My pref
Role of Vascular Specialists to Perform Intra-Arterial Delivery of Thrombolytics for Acute Thromboembolic Stroke
Acute management of thromboembolic stroke has undergone a paradigm shift in the last decade with the advent of intra-arterial delivery of thrombolytics. However, this area remains the domain of neuroradiologists. A handful of neurosurgeons and a very small number of cardiologists are performing such advanced neuro-rescue therapies. The window of time to treat patients with acute thromboembolic stroke can be extended if such therapies are more widely available. Vascular specialists in the next decade should focus on increasing training sites for neurovascular interventions. Such advances in neu
Can Real-World Data Be Obtained for Lower-Extremity Revascularization?
As we continue to dissect the data and science for lower-extremity revascularization, do you think it possible to obtain “real-world” data in a scientific way? This question is critical as we see many “registries” comparing to potentially FDA-mandated optimal performance criteria (OPC). The FDA has accepted as “de facto” the OPC (Rocha-Singh CCI 2007) as the metric for all things SFA. How do we obtain reasonable data for “real-world” patients? What is critical in my read of the OPC is that it is based on only 6 good trials both by industry and by single centers where randomizat
Successful Two-Vessel CTO Intervention: Importance of the Radial Approach
Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI and John E. Lassetter, MD, FACC, FSCAI
This 70-year-old gentleman was told his right coronary artery (RCA) had been 100% occluded for 6 years. He presented with continued angina and ischemia not only in the inferior territory but also the lateral territory. His risk factors for coronary disease include hypertension, hyperlipidemia and known chronic occlusion of his RCA for the last 5 to 6 years.
Angiography showed that a total occlusion of the obtuse marginal was present; multiple injections with several catheters were una
Where Will the SFA Data Ultimately Lead?
Continuing with the SFA for now, I wanted to ask the following: Where will the data ultimately lead? If someone has the proverbial “crystal ball” that allows one to see the future, where are we heading? This is important, since most every company’s device and device iteration suggests it is or should be considered the “workhorse” in the femoral artery. This is clearly not true.
How is this possible when many devices provide methods to change either arterial compliance or create a channel that needs further intervention either via angioplasty or stenting? Short of simple balloon an
Use of Approved Products in Vascular Intervention Labs
At our medical center the hospital is monitoring the use of FDA-approved versus unapproved stents and balloons in the peripheral vasculature. So far, the hospital has not said anything related to reimbursement. Is this a CMS survey to determine use of off-label products? If so, how will this impact the peripheral interventions? Only SFA stents, renal stents and few balloons are approved, so what will be the fate of the rest of the products? Can reimbursement by the CMS be tied with the use of on-label products only?
Aravinda Nanjundappa, MD, FACC, FSCAI, RVT
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New Options for High-Risk CTOs: The Provia Wires Used with the Impella Device
Richard Heuser, MD and Shishir Murarka, MD*
*Banner Estrella Medical Center, Phoenix, Arizona
CLINICAL HISTORY
Our patient is a 59-year-old male who has a history of a large anterior wall myocardial infarction in 1988. On September 30, 2009, he had a stent placed to the circumflex coronary artery. There was stenosis of the right coronary artery with patent previous stents. The left anterior descending artery (LAD) was chronically occluded in the distal segment. His left ventricular function was diminished with an ejection fraction of
Bio-mechanics have reached their limit: The days of “The Plumber” are coming to an end… or, are they?
The following statement might be descriptive of an emerging view on endovascular technologies: “Mechanical solutions – bio-mechanics – have propelled vascular surgery and endovascular interventions to new levels of achievement. And they have proved transformational in every way. The ‘aortic space’ is perhaps one of the best examples as endograft repair appears poised to replace standard open surgery. But the flame may be extinguishing itself as purely mechanical developments reach their limit… Many experts would predict that the dominant technologies of tomorrow and beyond will e
Successful Laser Recanalization of Totally Occluded Posterior Tibial Artery
Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI and Timothy Kieborz, DO
A 62 year-old white female has had chronic venous stasis ulcers for at least the last 12 to 15 years. For the past 2 years, she has had a non-healing ulcer. She was first seen at the end of January at the wound care center. At that time, she states that she had undergone a cardiovascular work-up, including an arterial work-up, and was told everything was normal. She even underwent a cardiac catheterization that was completely normal.
Her risk factors for coronary disease include a remote smoking
EVAR Surveillance in 2010
I am returning now from the Society for Vascular Surgery (SVS) Meeting in Boston. I was honored to be asked to co-moderate one of the post-graduate courses offered by the SVS the day before the meeting. Ten endovascular experts, with a special interest in EVAR, spoke about surveillance, endoleaks and late failure management.
One point is very clear to me: we have made a tremendous amount of progress since Dr. Parodi’s initial EVAR report in 1990, but on the other hand, we still have not even come close to reaching a consensus about EVAR follow-up. CTA? Ultrasound? Pressure sensors? Tre
Strategies to Reduce Embolization in Endovascular Revascularization
I just finished an intervention on a subtotally, heavily calcified superficial femoral artery (SFA), with the use of an embolic protection device. The SFA was had the appearance of “popcorn” calcifications — densely calcified, with an eccentric true lumen. I performed the intervention in a lab that has previously not done any significant amount of peripheral work and definitely not any complex SFA interventions. After the diagnostic angiogram, I thought that the embolic risk was high and such an event would not be well tolerated by the patient nor by this lab. Fortunately, an embolic p
The SFA Conundrum Continued
For this month’s discussion, I wanted to continue with the SFA revascularization conundrum. Where do we think the SFA interventional data are going? Do we still believe that the data will “prove” that a durable patency is possible in many if not all our “real-world” patients with claudication and present with SFA disease to include long total occlusions?
Currently, the data suggest that the answer is No. The “plumbers” of the group will disagree, but clearly, the benefit from endovascular therapies seems to be primarily clinical (“doctor, my leg feels better”)
Status of Carotid Artery Stenting in 2010
The recent clinical trial from the International Carotid Registry published in March 2010 in the Lancet raises interesting questions. The trial included centers that had performed only 10 carotid stent procedures as “experienced centers”, and the rest were “supervised centers”, with 0 to 9 carotid stenting procedures experience. Embolic protection device use was 70%+, and not 100%. Among 27 charts, they could not determine if a filter was used.
How could the investigators continue conducting clinical trials with operators who have marginal experience? It is very puz
Retrograde Recanalization of a Chronic Total Occlusion of the Posterior Tibial Artery
A 69-year-old male was evaluated for a non-healing ulcer of his right foot. His comorbidities included end-stage renal disease on dialysis, diabetes, coronary artery disease, permanent pacemaker implantation and known peripheral vascular disease with previous left above-the-knee amputation. On examination, he had only a faint distal pulse on the right lower extremity.
Peripheral angiography was performed via the left (contralateral) groin. The superficial femoral artery (SFA) showed no critical stenosis. The deep femoral artery was 100% occluded, the anterior tibial artery was 100% occluded
Endoleaks… and unintended consequences
The new age of aortic surgery is one of minimally-invasive endovascular procedures where endograft devices are the dominant technological force. It was relatively early during these developments that the term “endoleak” was coined by White et al (Ref. 1) to denote the presence of persistent blood flow inside the aneurysm sac — but outside of the implanted endoluminal endograft device (Figure 1). In other words, they felt this was not a true “leak”, as there was no extravasation of contrast outside the aorta (“rupture”), but the presence of circulating blood and perhaps pressure
CREST: MI or Stroke? (In other words, Has CREST changed your practice?)
The CREST results were eagerly anticipated for many years. We hoped that a prospective, randomized trial for carotid disease would clarify how people should be treated with high-grade carotid stenosis. I don’t think that the actual picture is as clear as we were hoping when the trial results were announced.
I think it is clear that there is a slightly higher risk of MI for surgical patients. But, there is a slightly lower risk of neurologic events in the surgical arm. It also seems that older patients (greater than 70 years old) do better with an operation.
So, have you changed you
More on the SFA Data Discussion
Continuing the discussion regarding superficial femoral artery (SFA) revascularization from last month, we had a couple of responses that centered on the fact that the “data” remain scant and the likelihood of long-term benefit would favor surgical revascularization. So to be controversial and challenging…
Given that, I believe, we cannot compare the surgical data to endovascular data currently because we do not have the apples-to-apples comparisons either from the endovascular group being less sick according to the surgical view, or because the surgical lesion types are ill-defined f
A Case of Renal Vascular Hypertension
by Richard Heuser, MD and Shishir Murarka, MD (Banner Estrella Medical Center)
A 59-year-old African-American female patient presented with malignant hypertension. She had nonischemic cardiomyopathy, an ejection fraction of 34%, and has been followed for her other medical problems including hypertension, sleep apnea, a previous stent in her left renal artery, hyperlipidemia and chronic renal insufficiency. The left renal stent was initially placed on January 18, 2008, with a 5 x 18 mm HercuLink stent (Abbott Vascular, Abbott Park, Illinois), and was dilated on Au
Vascular Disease in the West Indies — We’ve Got It Good in the U.S.
I made a recent medical assistance trip to St. Vincent, West Indies, a picture-perfect island with homes for the rich and famous. The local hospital tour revealed some astonishing numbers in terms of vascular disease. The number of amputations in a year was about 228 for a population of 100,000. Also, the mean age of the amputees — 39 years old — was disturbing. In the U.S., the rate of amputation is 24.95 per 100,000. This emphasizes the need to improve primary prevention of atherosclerosis and to control diabetes mellitus.
I would also like to mention a brief conversation I had with a
Vascular Disease Blogs
- Frank J. Criado, MD, FACS, FSVM
- Robert S. Dieter, MD, RVT and Aravinda Nanjundappa, MD, RVT
VDM Monthly Poll
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Terumo Clinical Case Update This clinical case update was supported through an unrestricted educational grant from Terumo Medical Corporation.
Vascular Disease News Wire
- Tuesday, August 31, 2010 - 13:44
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