Abstract:

Introduction: in recanalization of chronic total occlusions (CTO), contralateral injection is the most important stage, significantly increasing chance of technical success and reducing the incidence of complications.

Materials and methods: 60-year old male patients, with angina pectoris, 3 functional class. After the examination, decision was made to conduct coronary angiography. According to coronarography, occlusion of proximal third of right coronary artery (RCA) was revealed, with collateral filling from the left coronary artery (LCA) R2 and the development of collaterals CC0. According to the scintigraphy data, a «viable myocardium» was detected behind the occlusion zone. Patient underwent mechanical recanalization of RCA with contralateral contrast-agent injection, balloon angioplasty, drug-eluting stents (DES) 3,5?38 mm and 3,5?24 mm were sequentially implanted with a good angiographic result.

Result: contralateral contrast-agent injection during this recanalization helped to avoid complications associated with perforation of lateral branches and greatly facilitated the positioning of guidewire into true lumen of artery. Patient continued military service under the contract.

Conclusion: in case of proper examination, management, and selection of patients, recanalization of chronic occlusion can significantly improve patient's quality of life. It is worth noting that for many patients, social indications are also important, such as the possibility to continue military service or work in a specialty. However, medical indications should be considered first, since unjustified recanalization of chronic occlusion will not improve patient's condition, and a number of serious complications may occur during the operation.

Abstract:

Introduction: about 200 million people in the world suffer from ischemia of lower limbs. This pathology occupies a large part in the structure of all lesions of the vascular bed. Most patients with lesions of lower limb arteries have critical lower limb ischemia (CLLI), which is characterized by pain at rest and/or trophic lesions of foot. CLLI is the final stage of lower limb vascular bed lesion and is always accompanied by a deterioration in the quality of life, high morbidity and mortality. The only effective way to treat this pathology is revascularization, however, the current lack of clinical data does not allow us to determine the optimal strategy in treatment of this pathology.

Aim: was to determine advantages and disadvantages of using various methods of lower limb revascularization.

Material and methods: literature data from information aggregators Cyberleninka, Pubmed and MEDLINE on this topic, published in Russian and English for the period from 2010 to 2021, were selected for analysis. Articles written in German and French were included in the study in case of available translation to English. Termins as an inclusion criteria: critical limb ischaemia, ischaemic pain, tissue loss, gangrene, hybrid intervention, open surgical recanalization, endovascular revascularization, claudication, stenosis.

Results: it is determined that revascularization by open surgery showed better long-term results, however, it cannot be recommended for patients with severe comorbid diseases and defeat of lower limb and foot arteries, while endovascular revascularization techniques allow the procedure to be performed in almost all patients, regardless of the severity of their somatic status, however, extended multilevel lesions are poorly amenable to this method of treatment, and also have a relatively lower patency in the long-term period. Hybrid interventions combine advantages of both methods, however, they have high requirements for the equipment of the medical institution and the qualifications of the staff. In addition, hybrid methods are also more dangerous for the patient in comparison with revascularization by endovascular methods.

Abstract:

Aim: was to estimate results of endovascular treatment of subclavian arteries lesions.

Materials and methods: study analyzes results of endovascular treatment of patients with occlusive-stenotic lesions of subclavian arteries. For the period 2014-2018, 87 endovascular interventions were performed on subclavian arteries. Indication for surgery was occlusion of subclavian artery or stenosis of more than 70% with the development of steal-syndrome. Before surgery, all patients underwent duplex scanning of brachiocephalic vessels and CT angiography of branches of the aortic arch with cerebral phase. There was no difference in severity of symptoms and comorbidity between patients with stenosis or occlusions (р>0,05). In case of stenosis, direct stenting of subclavian artery was performed. For occlusions, mechanical recanalization was performed using hydrophilic wires, balloon angioplasty followed by stenting. In all cases, we used a balloon-expandable stent.

Results: technical success was achieved in 98,8% of interventions. There were no lethal outcomes, myocardial infarction, or stroke. In one patient, brachial artery thrombosis occurred in early postoperative period; thrombectomy from the brachial artery was performed with restoration of blood flow. Patency of subclavian artery after 1 and 3 years was 100% and 94%, respectively.

Conclusions: endovascular interventions for occlusive-stenotic lesions of subclavian arteries is an effective and safe method of treatment of vertebrobasilar insufficiency.

References

1.     Piradov MA, Maksimova MYu, Tanashyan MM. Stroke: guidelines. M: GEOTAR-Media. 2019; 288 [In Russ].

2.     Woo EY, Fairman RM, Velazquez OC, et al. Endovascular therapy of symptomatic innominate-subclavian arterial occlusive lesions. Vasc. Endovasc.Surg. 2006; 40(1): 27-33.

3.     Tan TY, Schminke U, Lien LM, et al. Subclavian steal syndrome: can the blood pressure difference between arms predict the severity of steal?. J. Neuroimaging. 2002; 12: 131-35.

4.     Hennerici M, Klemm C, Rautenberg W. The subclavian steal phenomenon: a common vascular disorder with rare neurologic deficits. Neurology. 1988; 38: 669-73.

5.     Perren F. Vertebral artery hypoplasia: a predisposing factor for posterior circulation stroke. Neurology. 2007; 2: 6

6.     Sigala F, Galyfos G, Coutelle AG, et al. Open reconstructions for symptomatic atheroscherotic lesions of the supra-aortic vessels: thirty years results from two university hospitals. Ann Vasc Surg. 2015 (29): 404.

7.     Towne JB, Hollier LH. Complications in vascular surgery. New York, Marcel. Dekken. 2005; 457-466.

8.     Bachman DM, Kim RM, Bachman DM, et al. Transluminal dilatation for subclavian steal syndrome. Am J Roentgenol. 1980; 135: 995-996.

9.     Eisenhauer AC. Subclavian and innominate revascularization: surgical therapy versus catheter-based intervention. Curr. Interv. Cardiol. 2000; 2: 101-110.

10.   Mousa AY, Abu Rahma AF, Bozzay J, et al. Anatomic and clinical predictors of reintervention after subclavian artery stenting. J. Vasc. Surg. 2015; 15.

11.   Tomoi Y, Soga Y, Fujihara M, et al. Outcomes of endovascular therapy for upper extremity peripheral artery disease with critical hand ischemia. J Endovasc Ther. 2016; 23: 717-22

12.   Endovascular surgery. National guideline: In 4 books. Vol.3. (ed.by acad. BG Alekyan). М: Litterra, 2017 [In Russ].

13.   National guidelines by treatment of patients whith brachiocephalic arteries deseases. Angiology and vascular surgery (Suppl.). 2013; 19(2) [In Russ].

14.   Usai MV, Bosiers M, Bisdas T, et al. Surgical versus endovascular revascularization of subclavian artery arteriosclerotic disease. The Journal of Cardiovascular Surgery. 2018.

15.   Aboyans V, Ricco J-B, Bartelink M-L, et al. 2017 ESC Guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018; 55: 305-368.

16.   Benhammamia M, Mazzaccaro D, Ben Mrad M, et al. Endovascular And Surgical Management Of Subclavian Artery Occlusive Disease: Early And Long Term Outcomes. Annals of Vascular Surgery. 2020.

17.   Alekyan BG, Zakaryan NV, Shumilina MV, et al. Low term and long term outcomes of stenting by subclavian artery deseases. Thoracic and cardiovascular surgery. 2011; 1: 24-31 [In Russ].

18.   De Vries JP, Jager LC, van den Berg JC. Durability of Percutaneous trans- luminal angioplasty for obstructive lesions of proximal subclavian artery: long term results. J. Vasc. Surg. 2005; 41: 19-23.

19.   Linni K, Ugurluoglu A, Mader N, et al. Endovascular management versus surgery for proximal subclavian artery lesions. Ann. Vasc. Surg. 2008; 22(6): 769-67.

Abstract:

Background: study presents data of recanalization of occlusions of access vein in patients after pacemaker implantation.

Material and methods: for the period of 2010-2018 a total of 461 patients underwent repeated antiarrhythmic device implantation. In 82(17,8%) patients we found malfunctioning leads. Total venous occlusion was found in 8(10%) cases. Attempt of recanalization was performed in 4 patients, in rest 4 cases recanalization was not performed, because of different reasons, and in 1 case it was unsuccessful.

Results: In 3 cases successful recanalization of venous occlusion and leads reimplantation were performed. In 2 cases - recanalization was performed using a guidewire and in 1 case a dilator for leads extraction was used. 5 patients underwent the contralateral implantation of a completely new system were performed.

Conclusions: recanalization of venous occlusion using a guidewire or a dilator is an effective method of treatment. These techniques allow to save contralateral access for other lifesaving procedures. However, recanalization using a dilator sheath might be associated with greater risk of complications such as perforation of subclavian vein, innominate vein or superior vena cava.

Thus, the choice of one or another strategy of recanalization is associated with technical difficulties and requires specialized tools and special skills of operating surgeon.

References

1.      Stoney W.S., Addlestone R.B., Alford Jr. W.C., Burrus G.R., Frist R.A., Thomas Jr C.S. The incidence of venous thrombosis following long-term transvenous pacing. The Annals of Thoracic Surgery. 1976; 22 (2): 166170.

2.      Mitrovic V., Thormann J., Schlepper M., Neuss H. Thrombotic complications with pacemakers. International Journal of Cardiology. 1983; 2: 363-374.

3.      Basil Abu-El-Haija, MD; Prashant D. Bhave, MD, FHRS; Dwayne N. Campbell, MD, FHRS; Alexander Mazur, MD; Denice M. Hodgson-Zingman, MD, FHRS; Vlad Cotar- lan, MD; Michael C. Giudici, MD, FHRS. Venous Stenosis After Transvenous Lead Placement: A Study of Outcomes and Risk Factors in 212 Consecutive Patients. Journal of the American Heart Association. 2015; 1-6.

4.      Jose M. Marcial, MD, Seth J. Worley, MD, FHRS. Venous System Interventions for Device Implantation. Cardiac Electrophysiology Clinics. 2018; 10: 163-177

5.      Haran Burri. Overcoming the challenge of venous occlusion for lead implantation. Indian pacing and electrophysiology journal. 2015; 15: 110-112.

6.      Lars Lickfett, Alexander Bitzen, Aravind Arepally. Khurram Nasir. Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography on patients presenting for their first elective ICD generator replacement. EP Europace. 2004; 6: 25-31.

7.      Mehrdad Golian, Minh Vo, Amir Ravandi, Colette M. Seifer. Venoplasty of a chronic venous occlusion allowing for cardiac device lead placement: A team approach. Indian pacing and electrophysiology journal. 2016; 6: 197-200.

8.      Marcio GK, MD, MSc, PhD, Ricardo Luiz Lima Andrade, MD, Gustavo Ramalho da Silva, MD, Hanry Barros Souto, MD. ICD Leads Extraction and Clearing of Access Way in a Patient With Superior Vena Cava Syndrome. Medicine. 2015; 38: 1-4.

9.      Maytin M, Epstein LM, Henrikson CA. Lead extraction is preferred for lead revisions and system upgrades: when less is more. Circulation: Arrhythmia and Electrophysiology. 2010; 3(4): 413-424.

10.    Worley SJ, Gohn DC, Pulliam RW. Excimer laser to open refractory subclavian occlusion in 12 consecutive patients. Heart Rhythm. 2010; 7(5): 634-638.

11.    Mathur G, Stables RH, Heaven D, Ingram A., Sutton R. Permanent pacemaker implantation via the femoral vein: an alternative in cases with contraindications to the pectoral approach. EP Europace. 2001; 3: 56-59.

12.    Agosti S, Brunelli C, Bertero G. Biventricular pacemaker implantation via the femoral vein. Journal of Clinical Medicine Research. 2012; 4: 289-291.

13.    Elayi CS, Allen CL, Leung S, Lusher S, Morales GX, Wiisanen M, et al. Inside-out access: a new method of lead placement for patients with central venous occlusions. Heart Rhythm. 2011; 8: 851-857.

14.    Auricchio A, Delnoy PP, Butter C, Brachmann J, Van Erven L, Spitzer S, et al. Feasibility, safety, and short-term outcome of leadless ultrasound-based endocardial left ventricular resynchronization in heart failure patients: results of the wireless stimulation endocardially for CRT (WiSE-CRT) study. Europace. 2014; 16: 681-688.

15.    Reddy VY Exner DV, Cantillon DJ, et al. Percutaneous Implantation of an Entirely Intracardiac Leadless Pacemaker. The New England Journal of Medicine. 2015; 373: 1125—1135.

16.    Worley SJ, Gohn DC, Pulliam RW, et al. Subclavian venoplasty by the implanting physicians in 373 patients over 11 years. Heart Rhythm. 2011; 8(4): 526-533.

17.    Ozyer U, Harman A, Yildirim E, Aytekin C, Karakayali F, Boyvat F. Long-term results of angioplasty and stent placement for treatment of central venous obstruction in 126 hemodialysis patients: a 10-year single-center experience. American Jounnal of Rentgenology 2009; 193(6): 1672-1679. 

Abstract:

Purpose. To assess the effectiveness of palliative endovascular interventions in patients with CTO anatomy infavorable for recanalisation.

Material and methods. The authors analyzed the results of interventions in 60 patients (50 male (83,3%), 10 female (16,7%)) aged 38 – 75 years (mean age 53,9±3,2), with occlusive coronary disease. Palliative revascularizations were performed in 30 patients, and CTO recanalization was done in 30 cases. The LV function was assessed echocardiographically in both groups before and after the intervention.

Results. 12 month follow-up showed significant improvement or normalization of LV function in both groups. Results of palliative interventions were shown to be as effective as recanalization of CTO.

Conclusions. Endovascular palliation is effective in treatment of patients with coronary CTO. It results in myocardial function improvement comparable to that in patients with complete coronary revascularization.   

References

1.        Danchin N., Angioi M., Rodriguez R. Angioplasty in chronic coronary occlusion. Arch. Mal. Coeur Vaiss. 1999, 99 (11): 1657–1660.

2.        Meier B. Chronic total coronary acclusion angioplasty. Cathet Cardiovasc. Diagn, 2006; 25: 1–11.

3.        Ганюков В.И., Осиев А.Г. Частные вопросы коронарной ангиопластики. Новосибирск. 2002; 4–23.

4.        Лопотовский П.Ю., Яницкая М.В. Клинический эффект эндоваскулярной реперфузии миокарда в бассейне длительно окклюзированной коронарной артерии. Между народный журнал интервенционной кардиоангиологии. 2006; 10: 22–26.

5.        Султан М.В. Реваскуляризация миокарда при остром коронарном синдроме. Авто-реф. дис. канд. мед. наук. М. 2006: 15–20.  

6.        Иоселиани Д.Г., Громов Д.Г., Сухоруков О.Е., Хоткевич Е.Ю., Семитко С.П., Исаева И.В., Верне Ж.-Ш., Арабаджян И.С., Овесян З.Р., Алигишева З.А. Хирургическая и эндоваскулярная реваскуляризация миокарда у больных с многососудистым поражением венечного русла: сравнительный анализ ближайших и среднеотдаленных результатов. Международный журнал интервенционной кардиоангиологии. 2008; 15: 22–31.

7.        Араблинский А.В. Степень реваскуляризации миокарда с помощью транслюминальной баллонной ангиопластики у больных с многососудистым поражением коронарного русла. Международный медицинский журнал. 2000; 1: 2–6.

8.        Ott R.A., Tobis J.M., Mills T.C., Allen B.J., Dwyer M.L. ECMO assisted angioplasty for cardiomyopathy patients with unstable angina. Department of Cardiothoracic Surgery, University of California. Irvine Medical Center. 2006.  

9.        Gaudino M., Santarelli P., Bruno P., Piancone F.L., Possati G. Palliative coronary artery surgery in patients with severe noncardiac diseases. Department of Cardiac Surgery, Catholic University. Rome. Italy. 2006.  

10.      Гринхальх Т. Основы доказательной медицины. Учебное пособие. М. 2004; 58.  

11.      Петросян Ю.С., Иоселиани Д.Г. О суммарной оценке состояния коронарного русла у больных ишемической болезнью сердца. Кардиология. 1976; 12 (16): 41–46.

12.      Петросян Ю.С., Шахов Б.Е. Коронарное русло у больных с постинфарктной аневризмой левого желудочка сердца. Горький. 1983; 17–37.

13.      Rahimtoola S.H. The hibernating myocardium. Ibid. 1989; 117: 211–221.

Abstract:

Case report is devoted to atypical recanalization of chronic occlusions of the common iliac artery Today, there are several ways for recanalization of chronic occlusions of arteries of lower limbs. Recanalization is known to be the major point of endovascular procedures. The success of endovascular surgery at recanalization depends mainly on 2 factors. One of the most important factors is the choice of access. Another factor is the choise of recanalization method . In case of rare failures - performing open surgery.

Refrrences 

1.    Pokrovsky A.V. and other. Russian consensus. Recommended standards for the evaluation of patients with chronic lower limb ischemia. M. 2001; 16 [In Russ].

2.    Koshkin V.M. Outpatient treatment of atherosclerotic lesions of lower extremities. Angiology and Vascular Surgery. 1999; 1: 106-113 [In Russ].

3.    Saket R.R. et al. Novel intravaskular ultrasound-guided method to create transintimal arterial communications: initial experience in peripheral occlusive disease and aortic dissection. J.Endovasc. Ther. 2004; 11 (3): 274-280.

4.    Troickij A.V., Behtev A.G., Habazov R.I., Beljakov G.A., Lysenko E.R., Kolodiev G.P. Gibridnaja hirurgija pri mnogojetazhnyh ateroskleroticheskih porazhenijah arterij aorto-podvzdoshnogo i bedrenno-podkolennogo segmentov. Diagnosticheskaja i intervencionnaja radiologija. 2012; 6(4): 67-77 [In Russ].

5.    Zatevakhin 1.1., Shipovskiy V.N., Zolkin V.N. Balloon angioplasty for lower limb ischemia. M. 2004; 176-229 [In Russ].