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Treatment of spontaneous coronary artery dissection by bio-resorbable vascular scaffolds
Full text linkBACKGROUND
SUMMARY
Spontaneous coronary artery dissection (SCAD) is a rare, but perhaps underestimate cause of acute coronary syndrome, and recent studies reported a surge in the recognition of this condition, particularly in young women presenting with acute coronary syndrome. However, despite the latest insights in epidemiological knowledge and advance in diagnostic capability using intracoronary tomographic imaging, the management of SCAD remains unsettled. Bioresorbable vascular scaffold (BRS) might represent an attractive therapeutic tool in SCAD, allowing for transient sealing of intimal flap and scaffolding of intramural hematoma, overcoming late pathology related to metallic stent. At the same time, BRS implantation could reduce the risk of late malapposition due to intramural hematoma reabsorption. The aim of this study was to investigate feasibility and safety of BRS in SCAD.
METHODS
In a multicenter prospective registry, 27 patients affected by SCAD presenting with ACS and treated by BRS between 2013 and 2015 were included. Diagnosis of SCAD was based on angiography when pathognomonic angiographic appearance with contrast dye staining of the arterial wall with multiple radiolucent lumens was appreciated (type I of Saw Classification); smooth and diffuse narrowing with abrupt change in arterial caliber, with demarcation from normal diameter to diffuse narrowing, or long and linear stenosis, or hazy long lesions (type II and III of Saw classification) were considered as SCAD, especially in absence of atherosclerotic changes in the other vessels and high clinical suspicion of SCAD; when angiography was considered inconclusive diagnosis was definitely accomplished by IVUS Inclusion criteria were: SCAD with ongoing ischemia, or flow-limiting, or severe lumen narrowing and proximal location, visual estimated RVD > 2.5 mm < 4.0 mm. Exclusion criteria were: pregnancy, contraindication to DAPT, hyper-reactivity to poly-lactate. In SCAD type II and III, IVUS/OCT was strongly suggested to confirm diagnosis. Angiographic success was defined as successful delivery of BRS at intended target lesion with TIMI-3 flow and stenosis <30%; clinical procedural success (patient level) as angiographic success without the occurrence of cardiac death, myocardial infarction/re-infarction or target vessel revascularization (TVR) during the hospital stay. Clinical plus CT-scan or angiography was planned at 12-months follow-up.
RESULTS
All but 2 patients were female, mean age 48±9 years; risk factors for SCAD were identified in 14 patients. Presentation was STEMI (48%), NSTE-ACS (37%), or life-threatening arrhythmias (15%). LAD was the most common culprit vessel (69%); 2 patients underwent BRS on 2 vessels: thus, 29 coronary arteries were treated. Revascularization was accomplished with 1 to 5 BRS per patient (mean total scaffold length 57±28 mm). IVUS guidance was used in 45%, post-dilatation in 72%. Device success was obtained in 100% of cases. Angiographic success was achieved in 28 of 29 (97%) lesions. Procedural success was achieved in 25 of 27 (93%) patients. No in-hospital deaths or non-fatal myocardial re-infarction were observed; 1 patient underwent TVR due to symptomatic SCAD progression at scaffolds’ edge. At 1-year follow-up, 1 TVR due to asymptomatic BRS recoil was observed. Coronary imaging (either invasive or not invasive) follow- up was performed in 15 patients with 1 year follow up showing BVS patency in 14 of 15 cases; one case of recurrent SCAD and one case of SCAD persistence were registered.
CONCLUSIONS
Our study, on the largest cohort of patients to date, suggests the feasibility and safety of bio- resorbable coronary scaffolds in Spontaneous Coronary Artery Dissection, with high rates of
angiographic and procedural success, and favorable 1-year results. Nevertheless, longer evaluation in larger studies is needed
Newer generation self-expandable coronary stent bail-out re-sheathing
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Conduction disorders in the setting of transcatheter aortic valve implantation: a clinical perspective
No full textThe presence of periprocedural conduction disorders (CDs) and the need for permanent pacemaker (PPM) after transcatheter aortic valve implantation (TAVI) are frequent findings in clinical practice. Notwithstanding, robust information on the prognostic and therapeutic implications of these complications are lacking. The newly occurrence of CD after TAVI seems related to the trauma of the conduction system during procedure. On the contrary, major predictors for PPM implantation after TAVI seem to be the use of CoreValve prosthesis (Medtronic, Minneapolis, MN) and the presence of CD before TAVI. An accurate pre-TAVI screening, careful valve implantation, as well as post-TAVI monitoring must be pursued to prevent avoidable PPM implantation. The aim of this report is to analyze the available data on this field and to propose some practical clinical tips to prevent or to manage these complications
Mitral paravalvular leak closure by antegrade percutaneous approach: Three-dimensional transesophageal echocardiographic guided multiple Amplatzer implantation by a modified sequential anchoring based technique
No full textWe describe the technical aspects and the possible advantages of a modified anchoring-based technique for the implantation of multiple Amplatzer devices, in a case of large anteroseptal mitral paravalvular leak causing massive regurgitation, that was managed by antegrade trans-septal, single stage, percutaneous approach. Real-time three-dimensional transesofageal echocardiographic guidance was crucial to ensure successful re-crossings of the target defect and the optimal anatomical closure
A case of combined percutaneous transfemoral mitral valvuloplasty and aortic valve implantation.
No full textWe present the case of an 83-year-old man who was admitted with New York Heart Association class III dyspnea and paroxysmal nocturnal dyspnea. Because of high surgical risk, a percutaneous treatment of both mitral and aortic valvulopathies was planned. This case reports the feasibility of a totally percutaneous approach in combined rheumatic mitral and aortic valve disease for patients with prohibitive surgical risk
[The worst complication during percutaneous coronary intervention: left main coronary artery dissection]
No full textAlthough rare, left main coronary artery dissection is a cause of periprocedural mortality during percutaneous coronary interventions. We report a case of iatrogenic dissection of the left main coronary artery causing cardiogenic shock, treated by extracorporeal membrane oxygenation (ECMO) support and later on by multiple balloon angioplasty and drug-eluting stent deployment, due to clinical worsening despite patent left coronary arteries with preserved good TIMI flow grade. We also reviewed the management strategies of this complication reported in the literature
[High-risk ST-elevation acute coronary syndrome in a patient with multivessel coronary artery disease complicated by refractory cardiogenic shock undergoing complex percutaneous coronary revascularization: role and timing of mechanical circulatory support devices]
No full textCardiogenic shock (CS) following acute myocardial infarction complicated by severe ventricular dysfunction remains the leading cause of death despite customized pharmacological therapy and optimal revascularization. The use of temporary mechanical circulatory support (MCS) devices during refractory CS might represent the only chance of survival to address the underlying systemic inflammatory response preventing the development of multiorgan failure. We report the case of a patient with a very-high-risk non-ST-elevation acute coronary syndrome and multivessel calcific coronary artery disease complicated by refractory CS undergoing complex percutaneous coronary revascularization. We show a gradual and complementary use of MCS devices tailored on hemodynamic monitoring, clinical and laboratory variables and multidisciplinary collaboration to early recognize the downward spiral that may ensue with multiorgan dysfunction or potential complications leading to death
The "plastic healing concept": Implantation of bioabsorbable scaffolds in spontaneous coronary artery dissection
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