Search

Kidney failure is particularly common in the United States, where it affects over 700,000 individuals. It is typically treated through repeated sessions of hemodialysis to filter and clean the blood. Hemodialysis requires vascular access, in about 70% of cases through an arteriovenous fistula (AVF) surgically created by connecting an artery and vein. AVF take 6 weeks or more to mature. Mature fistulae often require intervention, most often percutaneous transluminal angioplasty (PTA), also known as fistulaplasty, to maintain the patency of the fistula. PTA is also the first-line intervention to restore blood flow and prolong the use of an AVF, and many patients undergo the procedure multiple times. Although PTA is important for AVF maturation and maintenance, research into predictive models of AVF function following PTA has been limited. Therefore, in this paper we hypothesize that based on patient-specific information collected during PTA, a predictive model can be created to help improve treatment planning. We test a set of rich, multimodal data from 28 patients that includes medical history, AVF blood flow, and interventional angiographic imaging (specifically excluding any post-PTA measurements) and build deep hybrid neural networks. A hybrid model combining a 3D convolutional neural network with a multi-layer perceptron to classify AVF was established. We found using this model that we were able to identify the association between different factors and evaluate whether the PTA procedure can maintain primary patency for more than 3 months. The testing accuracy achieved was 0.75 with a weighted F1-score of 0.75, and AUROC of 0.75. These results indicate that evaluating multimodal clinical data using artificial neural networks can predict the outcome of PTA. These initial findings suggest that the hybrid model combining clinical data, imaging and hemodynamic analysis can be useful to treatment planning for hemodialysis. Further study based on a large cohort is need

Acute vascular injury provokes an inflammatory response, resulting in neointimal hyperplasia (NIH) and downstream pathologies. The resolution of inflammation is an active process in which specialized proresolving lipid mediators (SPM) and their receptors play a central role. We sought to examine the acute phase response of SPM and their receptors in both circulating blood and the arterial wall in a rat angioplasty model. We found that the ratio of proresolving to pro-inflammatory lipid mediators (LM) in plasma decreased sharply 1 day after vascular injury, then increased slightly by day 7, while that in arteries remained depressed. Granulocyte expression of SPM receptors ALX/FPR2 and DRV2/GPR18, and a leukotriene B4 receptor BLT1 increased postinjury, while ERV1/ChemR23 expression was reduced early and then recovered by day 7. Importantly, we show unique arterial expression patterns of SPM receptors in the acute setting, with generally low levels through day 7 that contrasted sharply with that of the pro-inflammatory CCR2 receptor. Overall, these data document acute, time-dependent changes of LM biosynthesis and SPM receptor expression in plasma, leukocytes, and artery walls following acute vascular injury. A biochemical imbalance between inflammation and resolution LM pathways appears persistent 7 days after angioplasty in this model. These findings may help guide therapeutic approaches to accelerate vascular healing and improve the outcomes of vascular interventions for patients with advanced atherosclerosis.

Introducción: La angioplastia primaria (ATCp) es el tratamiento de elección para el infarto agudo de miocardio con elevación del segmento ST (IAMCEST). En nuestro país, de tanta extensión territorial y con tiempos a la reperfusión subóptimos, la estrategia farmacoinvasiva (Finv) podría considerarse. Material y métodos: El ARGEN-IAM-ST es un registro prospectivo, multicéntrico, nacional y observacional. Se incluyen pacientes con IAMCEST dentro de las 36 horas de evolución. Se definió en el mismo la utilización de Finv y las variables asociadas. Resultados: Se analizaron 4788 pacientes de los cuales en el 88,56 % se realizó ATCp, en el 8,46 % trombolíticos con reperfusión positiva (TL+), y solo en un 2,98% Finv. La mediana y rango intercuartílico (RIC) del tiempo total de isquemia fueron menores en aquellos que recibieron TL+ (165 min, RIC 100-269) y los que fueron a Finv (191 min, RIC 100-330) que en aquellos que fueron a ATCp (280 min, RIC 179- 520), p <0,001. No existieron diferencias en mortalidad intrahospitalaria, en el grupo Finv 4,9%, 5,2% en el grupo TL + y en el grupo ATCp 7,8% (p = 0,081). No hubo diferencias en término de sangrados mayores. Se observó que un 57% de los pacientes con TL+ reunían características de alto riesgo, y no recibieron Finv acorde a lo recomendado Conclusiones: Solo 3 de cada 100 pacientes con IAMCEST que se reperfunden reciben Finv. Su implementación no está ligada en forma sistemática al alto riesgo de eventos. Pese a esta subutilización, por presentar un menor tiempo total de isquemia que la ATCp, sin aumento en los sangrados clínicamente relevantes persiste como una opción a considerar en nuestra realidad., Background: Primary percutaneous coronary intervention (PPCI) is the treatment of choice for acute ST-elevation myocardial infarction (STEMI). In Argentina, a country with a large area and suboptimal reperfusion times, the pharmacoinvasive (PI) strategy might be considered. Methods: ARGEN-IAM-ST is a national prospective, multicenter, and observational registry that includes STEMI patients with less than 36 hours of progression. The PI strategy usage and its associated variables were defined. Results: In this registry, 4788 patients were analyzed, of which 88.56% underwent PPCI, 8.46% received thrombolytics with positive reperfusion (TL+), and only 2.98% received PI strategy. Median and interquartile range (IQR) of total ischemia time were lower in patients receiving TL+ (165 min, IQR 100-269) and PI (191 min, IQR 100-330) than in patients undergoing PPCI (280 min, IQR 179-520), p <0.001. No differences in intra-hospital mortality were observed: 4.9% in the PI strategy group, 5.2% in the TL+ group and 7.8% in the PPCI group (p = 0.081). No differences in major bleeding events were observed. It was observed that 57% of the TL+ patients met the criteria for high cardiovascular risk, but they did not receive PI strategy, as recommended. Conclusions: Only 3 out of 100 reperfused STEMI patients received PI strategy. Its administration is not systematically associated to high cardiovascular risk. Despite the under-usage, it remains an option to be considered due to its total ischemia time lower than in the PPCI, with no increase in clinically significant bleedings.

A pesar de los avances en el diseño de stent para el tratamiento percutáneo de la enfermedad coronarias severa, aún no se ha logrado la combinación de fármacos, plataformas y recubrimientos que permitan eliminar por completo la reestenosis del stent a largo plazo, precisando un tratamiento de doble antiagregante plaquetario como medida preventiva en la aparición de un nuevo evento coronario, que no es tan infrecuente, ni tan benigno. Junto con el desarrollo de medidas como elección del stent, emplear técnicas minuciosas adaptadas al tipo de lesión y tratamiento antitrombótico ajustado a las circunstancias de cada paciente para evitar situaciones indeseables, es necesario identificar a los pacientes coronarios más vulnerables y realizar acciones dirigidas a un cambio de estilo de vida y una buena adherencia terapéutica, con el fin de reducir factores de riesgos cardiovasculares y promover bienestar. Para ello, la intervención de enfermería desde la atención secundaria es fundamental., Despite the progress in drug stent design for the percutaneous treatment of severe coronary disease, a suitable combination of medication, platforms, and coatings that allow complete elimination of in-stent restenosis in the long term has not yet been achieved, thus requiring dual anti-aggregation therapy as a preventative measure against another coronary event, which is not too inf requent, nor benign. Together with the development of measures such as the choice of stent, the use of detailed techniques adapted to the type of lesion, and antithrombotic therapy adjusted to each patient‘s condition to avoid any adverse situations, it is also necessary to identify the most vulnerable coronary patients and act toward changing the patient‘s lifestyle and achieving good therapeutic adherence, to reduce the cardiovascular risk factors and promote wellness. To this end, nursing interventions as of secondary care are fundamental.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a treatable form of pulmonary hypertension and right heart failure. CTEPH (group 4 pulmonary hypertension) is caused by persistent organized thromboembolic obstruction of the pulmonary arteries from incompletely resolved acute pulmonary embolism. CTEPH also may present without prior VTE history, which can contribute to its underrecognition. The true incidence of CTEPH is unclear, but is estimated to be approximately 3% after acute pulmonary embolism. V˙/Q˙ scintigraphy is the best screening test for CTEPH, with CT scan imaging and other advanced imaging methods now playing a larger role in disease detection and confirmation. Perfusion defects on V˙/Q˙ scintigraphy in the setting of pulmonary hypertension are suggestive of CTEPH, but pulmonary angiography and right heart catheterization are required for confirmation and treatment planning. CTEPH potentially is curative with pulmonary thromboendarterectomy surgery, with mortality rates of approximately 2% at expert centers. Advances in operative techniques are allowing more distal endarterectomies to be performed successfully with favorable outcomes. However, more than one-third of patients may be considered inoperable. Although these patients previously had minimal therapeutic options, effective treatments now are available with pharmacotherapy and balloon pulmonary angioplasty. Diagnosis of CTEPH should be considered in all patients with suspicion of pulmonary hypertension. Treatments for CTEPH have advanced with improvements in outcomes for both operable and inoperable patients. Therapy should be tailored based on multidisciplinary team evaluation to ensure optimal treatment response.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. It is caused by persistent obstruction of pulmonary arteries by chronic organised fibrotic clots, despite adequate anticoagulation. The pulmonary hypertension is also caused by concomitant microvasculopathy which may progress without timely treatment. Timely and accurate diagnosis requires the combination of imaging and haemodynamic assessment. Optimal therapy should be individualised to each case and determined by an experienced multidisciplinary CTEPH team with the ability to offer all current treatment modalities. This report summarises current knowledge and presents key messages from the International CTEPH Conference, Bad Nauheim, Germany, 2021. Sessions were dedicated to 1) disease definition; 2) pathophysiology, including the impact of the hypertrophied bronchial circulation, right ventricle (dys)function, genetics and inflammation; 3) diagnosis, early after acute pulmonary embolism, using computed tomography and perfusion techniques, and supporting the selection of appropriate therapies; 4) surgical treatment, pulmonary endarterectomy for proximal and distal disease, and peri-operative management; 5) percutaneous approach or balloon pulmonary angioplasty, techniques and complications; and 6) medical treatment, including anticoagulation and pulmonary hypertension drugs, and in combination with interventional treatments. Chronic thromboembolic pulmonary disease without pulmonary hypertension is also discussed in terms of its diagnostic and therapeutic aspects.

Introduction and objectives: Geographical and organizational differences between different autonomous communities (AC) can generate differences in care for ST-segment elevation myocardial infarction (STEMI). A total of 17 heart attack code programs have been compared in terms of incidence rate, clinical characteristics, reperfusion therapy, delay to reperfusion, and 30-day mortality. Methods: National prospective observational study (83 centers included in 17 infarction networks). The recruitment period was 3 months (April 1 to June 30, 2019) with clinical follow-up at 30 days. Results: 4366 patients with STEMI were included. The incidence rate was variable between different AC (P < .0001), as was gender (P = .003) and the prevalence of cardiovascular risk factors (P < .0001). Reperfusion treatment was primary angioplasty (range 77.5%-97.8%), fibrinolysis (range 0%-12.9%) or no treatment (range 2.2%- 13.5%). The analysis of the delay to reperfusion showed significant differences (P < .001) for all the intervals analyzed. There were significant differences in 30-days mortality that disappeared after adjusting for clinical and healthcare network characteristics. Conclusions: Large differences in STEMI care have been detected between the different AC, in terms of incidence rate, clinical characteristics, reperfusion treatment, delay until reperfusion, and 30-day mortality. The differences in mortality disappeared after adjusting for the characteristics of the patient and the care network., Introducción y objetivos: Las diferencias geográficas y organizativas entre distintas comunidades autónomas (CCAA) pueden generar diferencias en la atención al infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Se han comparado 17 programas de Código Infarto en términos de incidencia, características clínicas, tratamiento de reperfusión, retraso hasta la reperfusión y mortalidad a 30 días. Métodos: Estudio observacional prospectivo nacional (83 centros en 17 redes de infarto). El periodo de selección fue de 3 meses (1 de abril a 30 de junio de 2019), con seguimiento clínico a 30 días. Resultados: Se incluyeron 4.366 pacientes con IAMCEST. La tasa de incidencia fue variable entre las CCAA (p < 0,0001), igual que el sexo (p = 0,003) y la prevalencia de factores de riesgo cardiovascular (p < 0,0001). El tratamiento de reperfusión fue angioplastia primaria (rango 77,5-97,8%), fibrinolisis (rango 0- 12,9%) o ninguno (rango 2,2-13,5%). El análisis del retraso hasta la reperfusión mostró diferencias significativas (p < 0,001) para todos los intervalos analizados. Hubo diferencias significativas en la mortalidad cruda a 30 días que desaparecieron tras ajustar por las características clínicas y dependientes de la red asistencial (primer contacto, tiempo hasta la reperfusión y abordaje de críticos). Conclusiones: Se han detectado diferencias en la atención al IAMCEST entre las distintas CCAA, en términos de incidencia, características clínicas, tratamiento de reperfusión, retraso hasta la reperfusión y mortalidad a 30 días. Las diferencias en mortalidad desaparecen tras ajustar por las características del paciente y de la red asistencial.

Background: Previous large multi-centre randomised controlled trials have not provided clear benefit with routine intracoronary thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI). Aim: To determine whether there is a difference in outcomes with the use of manual TA prior to PCI, compared with PCI alone in a cohort of patients with STEMI. Methods: We analysed data from 6270 consecutive patients undergoing primary PCI for STEMI prospectively enrolled in the Melbourne Interventional Group registry between 2007 and 2018. Multivariable analysis was performed to determine predictors of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and long-term mortality. Results: We compared 1621 (26%) patients undergoing primary PCI with TA to 4649 (74%) patients undergoing PCI alone. Male gender (81% vs 78%; P < 0.01), younger age (61 vs 63 years; P = 0.03), GP-IIb/IIIa use (76% vs 58%, P < 0.01), and current smoking (40% vs 36%; P < 0.01) were more common in the TA group. TA was more likely to be used in patients with complex lesions (83% vs 66%; P < 0.01) with TIMI 0 flow (77% vs 56%; P < 0.01). No significant difference in post-procedural TIMI flow, stroke, 30-day mortality, or long-term mortality were identified. Multivariable analysis demonstrated a reduction in 30-day MACCE (hazard ratio (HR) 0.75; confidence interval (CI) 0.63–0.89; P < 0.01) in the TA group, but was not associated with long-term mortality (HR 0.98; CI 0.85–1.1; P = 0.73). Conclusion: The use of TA in patients undergoing primary PCI for STEMI was not associated with improved short or long-term mortality when compared with PCI alone.

[Resumen] Introducción: La enfermedad arterial periférica de miembros inferiores es una patología caracterizada por la disminución del diámetro interno de la arteria, limitando su riego sanguíneo. Sus síntomas son claudicación intermitente de predominio en los músculos gastrocnemios, presencia de úlceras y dolor en reposo. El tratamiento endovascular sobre todo debajo de la rodilla, en la región sural, aún no tiene consenso debido a su baja permeabilidad y dificultad anatómica. Mientras que las técnicas endovasculares son preferibles en pacientes mayores y con alta morbilidad, las técnicas de cirugía abierta se ofertan al resto de pacientes. No obstante, la progresión de la enfermedad y las comorbilidades asociadas incrementan el riesgo de amputación mayor del miembro pese a una revascularización endovascular. Objetivo: Determinar el riesgo de amputación mayor del miembro inferior, posterior a una revascularización endovascular de troncos infrapoplíteos con permeabilidad de al menos un vaso. Material y método: Estudio unicéntrico de cohorte retrospectiva de pacientes diagnosticados de EAP (enfermedad arterial periférica) grado IIb invalidantes, III o IV que fueron intervenidos de RETI (Revascularización endovascular de troncos infrapoplíteos), estableciendo un grupo de RETI con un vaso infrapoplíteo y otro sin vaso infrapoplíteo permeable. Se analizará el riesgo de amputación mayor, tipo de angioplastia y factores de riesgo asociados. Se incluirán 230 pacientes de forma consecutiva. Los datos serán cargados en la plataforma R para su cálculo, se contrastarán hipótesis mediante el test de chi cuadrado y una regresión lineal para valorar su relación. El estudio se realizará con la autorización del Comité de Ética de la Investigación biomédica de Andalucía, así como con el consentimiento informado de los pacientes., [Resumo] Introdución: A enfermidade arterial periférica dos membros inferiores é unha diminución do diámetro interno da arteria que limita a súa irrigación sanguínea. Os seus síntomas son claudicación intermitente de predominio nos músculos gastrocnemios, presenza de úlceras e dor en repouso. O tratamento endovascular da patoloxía, especialmente por debaixo do xeonllo, na rexión sural, aínda non ten consenso debido a súa baixa permeabilidade e dificultade anatómica. Mentres que as técnicas endovasculares son preferibles en pacientes maiores e con alta morbilidade, as técnicas de cirurxía aberta ofértanse ao resto dos pacientes. Non obstante, a progresión da enfermidade e as comorbilidades asociadas incrementan o risco de amputación maior do membro a pesar da revascularización endovascular. Obxectivo: Determinar o risco de amputación maior do membro inferior, despois da revascularización endovascular de troncos infrapoplíteos con permeabilidade de polo menos un vaso. Material e métodos: Estudo de cohorte retrospectivo monocéntrico de pacientes diagnosticados de EAP invalidante grao IIb, III ou IV que se someteron a RETI, establecendo un grupo RETI con vaso infrapoplíteo e outro sen vaso infrapoplíteo patente. Posteriormente, analizarase o risco de amputación maior, tipo de anxioplastia e factores de risco asociados. Incluiranse 230 pacientes consecutivos. Os datos cargaranse na plataforma R para o seu cálculo, contrastaranse hipóteses mediante a proba de chi cadrado e unha regresión lineal para avaliar a súa relación. O estudo realizarase coa autorización do Comité Ético da Investigación correspondente, así como co consentimento informado dos pacientes., [Abstract] Background: Peripheral arterial disease of the lower limbs is a decrease in the internal diameter of the artery that limits its blood supply. Its symptoms are calf claudication at walking, the presence of ulcers and rest pain. The endovascular treatment of the pathology, especially below the knee, due to its low permeability and anatomical difficulty, still has no consensus. Endovascular techniques are preferable in older patients with high morbidity, open surgery techniques are offered to other patients. However, disease progression and associated comorbidities increase the risk of major limb amputation despite endovascular revascularization. Objective: To determine the risk of major amputation of the lower limb, after endovascular revascularization of below the knee trunks with permeability of at least one vessel. Methods: Single-center retrospective cohort study of patients diagnosed with disabling PAD (peripheral artery disease) grade IIb, III or IV who underwent RETI, establishing a RETI group with a below the knee vessel and another without a patent below the knee vessel. Later, the risk of major amputation, type of angioplasty and associated risks factors will be analized. 230 patients will be included consecutively. The data will be loaded into the R platform for its analysis, hypotheses will be contrasted using the chi-square test and a linear regression to assess their relationship. The study will be carried out with the authorization of the corresponding Research Ethics Committee, as well as with the informed consent of the patients.

Purpose: Pediatric liver transplant surgery is burdened by arterial complications whose endovascular treatment is not standardized. We report the outcomes of a cohort of pediatric recipients with hepatic artery complications treated by endoluminal procedures. Materials and Methods: From December 2019 to December 2022, consecutive transplanted pediatric patients who underwent endovascular treatment of hepatic artery complications were reviewed. The analysis included: type of complication (occlusion, stenosis, pseudoaneurysm); onset (acute = < 15 days, subacute = 15–90 days, late = > 90 days); endovascular technique (angioplasty, stenting); complications and outcomes. Technical success was defined as the opacification of the hepatic artery at the final angiogram with < 50% residual stenosis and no pseudoaneurysms. Clinical success was defined by graft’s and patient’s survival. Results: Seventeen patients (8 males; median age 33 months, IQR 9–103) underwent 21 hepatic arteriography procedures for predominantly acute or subacute occlusions (n = 7) or stenosis (n = 11) with concurrent pseudoaneurysms (n = 4). Primary and secondary technical success was achieved in 13/18 and 3/3 procedures, respectively, with overall technical success of 76%. Angioplasty alone was successful in 5/21 procedures; stent-retriever thrombectomy was performed in one occlusion with thrombosis; stenting was required in 9/17 (53%) patients. Clinical success was obtained in 14/17 (82%) patients with hepatic artery patency after a median of 367 days (IQR 114.5–500). Clinical failure occurred in 3 permanent occlusions, with 2 deaths and 1 re-transplantation. Procedure-related complications included minor events in 3/17 (18%) patients and 1/17 (6%) death. Conclusion: In liver transplanted children with hepatic artery complications, endovascular treatment may provide clinical success, with stenting often required in acute and subacute conditions. Level of Evidence: Level 4. Graphical Abstract

Introduction and objectives: Coronary artery aneurysms are a complex situation. Our main objective is to describe the frequency of use of covered stents (grafts) for their management, as well as to characterize their long-term results compared to drug-eluting stents. Methods: Ambispective observational study with data from the International Coronary Artery Aneurysm Registry (CAAR) (NCT-02563626). Only patients who received a stent-graft or a drug-eluting stent where the aneurysm occurred were selected. Results: A total of 17 patients received, at least, 1 stent-graft while 196 received 1 drug-eluting in the aneurysmal vessel. Male predominance, a higher rate of dyslipidemia, a past medical history of coronary artery disease, previously revascularized coronary artery disease, and giant aneurysms were reported in the stent-graft cohort. The independent predictive variables of the composite endpoint of all-cause mortality, heart failure, unstable angina, reinfarction, stroke, systemic embolism, bleeding or any aneurysmal complications at the median follow-up of 38 months were suggestive of the existence of connective tissue diseases (HR, 5.94; 95%CI, 1.82-19.37), left ventricular dysfunction ≤ 55% (HR, 1.84; 95%CI, 1.09-3.1), and an acute indication for heart catheterization (HR, 2.98; 95%CI, 1.39-6.3). The use of stent-grafts was not associated with the occurrence of more composite endpoints (23.5% vs 29.6%; P = .598). Conclusions: The use of stent-grafts to treat coronary aneurysms is feasible and safe in the long-term. Randomized clinical trials are needed to decide what the best treatment is for these complex lesions., Introducción y objetivos: Los aneurismas coronarios son una situación compleja. Planteamos como objetivo principal describir la frecuencia de utilización de stents recubiertos (grafts) para su tratamiento y caracterizar sus resultados a largo plazo en comparación con stents farmacoactivos. Métodos: Estudio observacional ambispectivo, con información procedente del Registro Internacional de Aneurismas Coronarios (CAAR) (NCT-02563626). Se seleccionaron los pacientes que recibieron un stent-graft o un stent farmacoactivo en la zona del aneurisma. Resultados: Un total de 17 pacientes recibieron al menos un stent-graft y 196 un stent farmacoactivo en la zona aneurismática. Se observa un predominio del sexo masculino y una mayor frecuencia de dislipemia, antecedentes de coronariopatía, enfermedad coronaria revascularizada previamente y aneurismas gigantes en la cohorte de stent-graft. Como variables independientes predictoras del desarrollo del evento combinado (muerte por cualquier causa, insuficiencia cardiaca, angina inestable, reinfarto, ictus, embolia sistémica, sangrado o cualquier complicación en el aneurisma), tras una mediana de seguimiento de 38 meses, destacaron la existencia de conectivopatías (hazard ratio [HR] = 5,94; intervalo de confianza del 95% [IC95%], 1,82-19,37), la disfunción del ventrículo izquierdo ≤ 55% (HR = 1,84; IC95%, 1,09-3,1) y la indicación aguda del cateterismo índice (HR = 2,98; IC95%, 1,39-6,3). El uso de stent-grafts comparado con el de stents farmacoactivos no se asoció al desarrollo de más eventos combinados (23,5 frente a 29,6%; p = 0,598). Conclusiones: El uso de stents recubiertos en aneurismas coronarios es factible y seguro a largo plazo. Se necesitan estudios clínicos aleatorizados para decidir el mejor tratamiento de este tipo de lesiones complejas.

A lotus root-like appearance of the coronary artery diagnosed by optical coherence tomography (OCT) is characterized by old coronary thrombi that form small lumen channels. Herein, serial OCT images of a left anterior descending artery with a lotus root-like appearance, treated with drug-coated balloon angioplasty are described.

BackgroundGiant cell arteritis (GCA) is a systemic vasculitis that may cause ischemic stroke. Rarely, GCA can present with aggressive intracranial stenoses, which are refractory to medical therapy. Endovascular treatment (EVT) is a possible rescue strategy to prevent ischemic complications in intracranial GCA but the safety and efficacy of EVT in this setting are not well-described.MethodsA systematic literature review was performed to identify case reports and series with individual patient-level data describing EVT for intracranial GCA. The clinical course, therapeutic considerations, and technique of seven endovascular treatments in a single patient from the authors' experience are presented.ResultsThe literature review identified 9 reports of 19 treatments, including percutaneous transluminal angioplasty (PTA) with or without stenting, in 14 patients (mean age 69.6 ± 6.3 years). Out of 12 patients 8 (66.7%) with sufficient data had > 1 pre-existing cardiovascular risk factor. All patients had infarction on MRI while on glucocorticoids and 7/14 (50%) progressed despite adjuvant immunosuppressive agents. Treatment was PTA alone in 15/19 (78.9%) cases and PTA + stent in 4/19 (21.1%). Repeat treatments were performed in 4/14 (28.6%) of patients (PTA-only). Non-flow limiting dissection was reported in 2/19 (10.5%) of treatments. The indications, technical details, and results of PTA are discussed in a single illustrative case. We report the novel use of intra-arterial calcium channel blocker infusion (verapamil) as adjuvant to PTA and as monotherapy, resulting in immediate improvement in cerebral blood flow.ConclusionEndovascular treatment, including PTA with or without stenting or calcium channel blocker infusion, may be effective therapies in medically refractory GCA with intracranial stenosis.

BackgroundThere is limited "real-world" evidence examining treatment modalities and outcomes in patients with symptomatic peripheral arterial disease undergoing endovascular treatment of femoropopliteal (FP) in-stent restenosis (ISR).Materials and methodsWe compared outcomes in 2,895 patients from the XLPAD registry (NCT01904851) between 2006 and 2019 treated for FP ISR (n = 347) and non-ISR (n = 2,548) lesions. Primary endpoint included major adverse limb events (MALE) at 1 year, a composite of all-cause death, target limb repeat revascularization, or major amputation.ResultsISR patients were more frequently on antiplatelet (94.5% vs 89.4%, p=0.007) and statin (68.9% vs 60.3%, p=0.003) therapies. Lesion length was similar (ISR: 145 ± 99 mm vs. non-ISR: 142 ± 99 mm, p=0.55). Fewer treated ISR lesions were chronic total occlusions (47.3% vs. 53.7%, p=0.02) and severely calcified (22.4% vs. 44.7%, p < 0.001). Atherectomy (63.5% vs. 45.0%, p < 0.001) and drug-coated balloons (DCB; 4.7% vs. 1.7%, p < 0.001) were more frequently used in ISR lesions. The distal embolization rate was higher in ISR lesions (2.4% vs. 0.9%, p=0.02). Repeat revascularization (21.5% vs. 16.7%, p=0.04; Figure) was higher and freedom from MALE at 1 year was significantly lower (87% vs. 92.5%, p < 0.001) in the ISR group.ConclusionAtherectomy and DCB are more frequently used to treat FP ISR lesions. Patients with FP ISR have more intraprocedural distal embolization, higher repeat revascularization procedures, and lower freedom from MALE at 1 year.

Objective. To determine the effect of interdisciplinary discharge planning on treatment adherence and readmission in the patients undergoing coronary artery angioplasty in the south of Iran in 2020. Methods. This experimental study had an intervention group and a control group with pre-test and post-test. 70 patients participated in the study who were randomly divided into the groups (intervention group (n=35) and control group (n=35)). In the intervention group, discharge planning was performed based on an interdisciplinary approach. Treatment adherence before, immediately, and one month after the intervention was evaluated with a 10-question survey scored from 1 to 5 (maximum score = 50), as well as readmission three months after the discharge was examined in both groups. Results. Before the intervention, there was no statistically significant difference between the intervention and the control groups in the treatment adherence score (18.22 versus 17.37; p=0.84) but immediately and one month after the intervention statistically significant differences between the groups were showed (21.51 versus 46.14 and 23.28 versus 43.12, respectively; p<0.001). Within three months after discharge, the readmission rate was 11.4% in the control group, while no readmission was reported in the intervention group. Within three months after discharge, the readmission rate was 11.4% in the control group, while no readmission was reported in the intervention group. Conclusion. The implementation of interdisciplinary discharge planning had positive effects on treatment adherence and readmission rate in patients undergoing coronary artery angioplasty; therefore, it is suggested that health care system managers make the necessary plans to institutionalize this new educational approach for other patients discharge planning., Objetivo. Determinar o efeito do planejamento de alta interdisciplinar na adesão ao tratamento e readmissão em pacientes submetidos à angioplastia de artéria coronária no sul do Irã em 2020. Métodos. Este estudo experimental contou com um grupo intervenção e um grupo controle com avaliação pré-teste e pós-teste. Participaram do estudo 70 pacientes que foram divididos aleatoriamente em grupos. No grupo intervenção, o planejamento da alta foi realizado com base na abordagem interdisciplinar. Em ambos os grupos, a adesão ao tratamento foi examinada antes, imediatamente e um mês após a intervenção com um questionário de 10 questões pontuadas de 1 a 5 (pontuação máxima = 50), bem como a readmissão até três meses após a alta. Resultados. Antes da intervenção, não houve diferenças estatisticamente significativas entre os grupos intervenção e controle na pontuação de adesão ao tratamento (18.22 vr. 17.37; p = 0.84), mas imediatamente e um mês após a intervenção os grupos apresentaram diferença estatisticamente significativa (21.51 vr. 46.14 e 23.28 vr. 43.12, respectivamente; p <0.001). Aos três meses após a alta, a taxa de readmissão foi de 11.4% no grupo de controle, enquanto nenhuma readmissão foi registrada no grupo de intervenção. Conclusão. A aplicação do planejamento de alta interdisciplinar teve efeitos positivos na adesão ao tratamento e na taxa de readmissão em pacientes submetidos à angioplastia de artéria coronária; portanto, sugere-se que os gestores do sistema de saúde façam os planos necessários para institucionalizar essa nova abordagem educativa para o planejamento da alta de outros pacientes., Objetivo. Determinar el efecto de la planificación interdisciplinaria del alta en la adherencia al tratamiento y el reingreso en los pacientes sometidos a angioplastia de la arteria coronaria en el sur de Irán en 2020. Métodos. Este estudio experimental contó con un grupo de intervención y un grupo de control con evaluación pre-test y post-test. Participaron en el estudio 70 pacientes que se dividieron aleatoriamente en los grupos. En el grupo de intervención, la planificación del alta se realizó sobre la base de un enfoque interdisciplinario. En ambos grupos se examinó la adherencia al tratamiento antes, inmediatamente y un mes después de la intervención con una encuesta de 10 preguntas puntuadas de 1 a 5 (máximo puntaje = 50), así como el reingreso hasta tres meses después del alta. Resultados. Antes de la intervención, no hubo diferencias estadísticamente significativas entre el grupo de intervención y el de control en la puntuación de la adherencia al tratamiento (18.22 versus 17.37; p=0.84), pero inmediatamente y un mes después de la intervención los grupos mostraron una diferencia estadísticamente significativa (21.51 versus 46.14 y 23.28 versus. 43.12, respectivamente; p<0.001). A los tres meses del alta, la tasa de reingreso fue del 11.4% en el grupo de control, mientras que no se registró ningún reingreso en el grupo de intervención. Conclusión. La aplicación de la planificación interdisciplinaria del alta tuvo efectos positivos la adherencia del tratamiento y la tasa de reingreso en los pacientes sometidos a angioplastia de las arterias coronarias; por lo tanto, se sugiere que los gestores del sistema sanitario hagan los planes necesarios para institucionalizar este nuevo enfoque educativo para la planificación del alta de otros pacientes.

In this paper we present the case of an 89-year-old patient undergoing cardiac catheterization, in which an important severe coronary calcification was observed throughout the area of the anterior descending artery. Assessing the patient‘s clinical situation and, after discussion by the multidisciplinary team, percutaneous intervention was decided to treat this injury, during the course of which an unusual complication occurred, that is, rupture of the balloon tube, becoming trapped inside said artery. This unexpected event made it necessary to proceed with the extraction of said «foreign body» via different techniques, finally using the double-guidewire technique plus trapping, with which the complication could be resolved and the foreign body extracted, with no angiographic data of dissection, perforation, or thrombosis, with an open artery and reasonable distal flow, although severe stenosis of the vessel persisted Marjory Gordon‘s functional health patterns were used to carry out the assessment and resolution of the patient‘s health problems by applying the NANDA, NOC, and NIC taxonomies, formulating the diagnoses of risk of deterioration of skin integrity, risk of peripheral tissue dysfunction, risk of infection, risk of bleeding and anxiety. In addition, results were proposed along with their evaluable indicators and some nursing activities to resolve these problems. This clinical case presents a rare complication that can arise during an angioplasty procedure and serves to highlight the importance of good care planning., En el presente trabajo presentamos el caso de un paciente de 89 años, sometido a un cateterismo cardiaco en el que se observa una importante calcificación coronaria severa en todo el territorio de la descendente anterior. Valorando la situación clínica del paciente, y tras la discusión en equipo multidisciplinar, se decide intervencionismo percutáneo para tratar dicha lesión en el trascurso del cual ocurre una complicación poco habitual como es la rotura del tubo del balón, quedando atrapado en el interior de dicha arteria. Este evento inesperado obliga a proceder a la extracción de dicho «cuerpo extraño», utilizando diferentes técnicas, empleando finalmente la técnica de doble guía más trapping, con la que se pudo resolver la complicación y extraer el cuerpo extraño, sin datos angiográficos de disección, perforación o trombosis, con arteria abierta y razonable flujo distal, persistiendo, eso sí, una estenosis severa del vaso. Se utilizaron los patrones funcionales de Marjory Gordon para llevar a cabo la valoración y resolución de los problemas de salud del paciente aplicando la taxonomía NANDA, NOC, NIC, formulándose, para ello, los diagnósticos de Riesgo de deterioro de la integridad cutánea, Riesgo de disfunción tisular periférica, Riesgo de infección, Riesgo de sangrado y ansiedad. Además, se propusieron unos resultados con sus indicadores evaluables, y unas actividades de enfermería para conseguir solventar dichos problemas. Este caso clínico presenta una complicación poco frecuente, que puede surgir durante un procedimiento de angioplastia, y sirve para resaltar la importancia de una buena planificación de los cuidados.

ntroduction: Coronary stents were developed to prevent arterial retraction and restenosis after balloon dilation. Sirolimus was one of the antiproliferative drugs used initially in first-generation drug-eluting stents. Sirolimus-eluting stents have progressed over time with improvements in their structure, bringing with them a significant reduction in restenosis, late lumen loss, and the rate of revascularization of the lesion / target vessel compared to other stents. Objective: To describe the recent scientific evolution of studies on the efficacy of sirolimus-releasing stents and their application in Cuba. Method: An extensive search was carried out in databases such as Pubmed, Dialnet, Scielo, Scopus, national and international journals of high scientific impact, with the use of 36 bibliographic references. Results: Of the research found, the studies ̈ RESET, ̈ BIOSCIENCIE, the BIOFLOW series, and the NANO registry stand out, where excellent results are exposed after each generation of sirolimus-releasing stents that has been created. Conclusions: Sirolimus-eluting stents have had a constant scientific evolution, from their first appearance as part of the first generation of drug-eluting stents to the fourth generation. Numerous published studies demonstrate, with their results, the efficacy and safety of these devices. In Cuba its application began more than a decade ago and has been constantly perfected., ntroducción: Los stents coronarios se desarrollaron para evitar la retracción arterial y la reestenosis después de una dilatación con balón. El sirolimus fue uno de los fármacos antiproliferativos utilizados inicialmente en los stents farmacoactivos de primera generación. Los stents liberadores de sirolimus han progresado en el tiempo con mejoras en su estructura, trayendo consigo una reducción significativa de la reestenosis, la pérdida de luz tardía y la tasa de revascularización de la lesión/vaso diana en comparación con otro stents. Objetivo: Describir la reciente evolución científica de estudios sobre eficacia de los stents liberadores de sirolimus y su aplicación en Cuba. Método: Se realizó una extensa búsqueda en base de datos como Pubmed, Dialnet, Scielo, Scopus, revistas nacionales e internacionales de alto impacto científico, con la utilización 36 referencias bibliográficas. Resultados: De las investigaciones encontradas se destacan los estudios ̈RESET, ̈BIOSCIENCIE, la serie de los BIOFLOW, y el registro NANO, donde se exponen excelentes resultados tras cada generación de stent liberadores de sirolimus que ha sido creada. Conclusiones: Los stents liberadores de sirolimus han tenido una evolución científica constante, desde su primera aparición formando parte de la primera generación de stents farmacoactivos hasta la cuarta generación. Numerosos estudios publicados demuestran, con sus resultados, la eficacia y seguridad de estos dispositivos. En Cuba su aplicación inició hace más de una década y se ha perfeccionado constantemente.

Subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome or venous thoracic outlet syndrome, is an uncommon condition that affects individuals with an irregularly narrow thoracic outlet who engage in repetitive overhead motions of the affected arm. Venous injury arises from microtraumas that occur from the repetitive compression of the SCV between the first rib and the overlying clavicle. Additional sources of extrinsic compression can be due to the anterior scalene muscle, subclavius muscle, and costoclavicular ligament. SCV effort thrombosis is a distinct entity from other forms of deep venous thrombosis and requires unique diagnostic and treatment considerations. Early catheter-directed therapy in the form of pharmacomechanical or catheter-directed thrombolysis combined with prompt surgical thoracic outlet decompression offers patients the best chances for early and durable symptom relief.

A lotus root-like appearance of the coronary artery diagnosed by optical coherence tomography (OCT) is characterized by old coronary thrombi that form small lumen channels. Herein, serial OCT images of a left anterior descending artery with a lotus root-like appearance, treated with drug-coated balloon angioplasty are described.

Unprotected left main (LM) percutaneous coronary intervention (PCI) at centers without onsite cardiac surgery remains controversial. We aimed to evaluate the effect of onsite cardiac surgery on short-term and long-term outcomes in patients who had unprotected LM PCI. We analyzed Victorian Cardiac Outcomes Registry data on consecutive patients who had unprotected LM PCI at cardiac surgical centers (SCs) and non-SCs (NSCs) between January 2014 to December 2018. Compared with the SC group (n = 594, 81%), the NSC group (n = 136) were younger (69 vs 72 years) and presented with more ST-elevation myocardial infarction (35% vs 16%) and cardiogenic shock (25% vs 15%), with higher rates of preprocedural intubation (17% vs 11%) and mechanical circulatory support (20% vs 9.3%), all p <0.01. Unadjusted in-hospital mortality (23% vs 11.4%), and 30-day major adverse cardiac events (composite of mortality, myocardial infarction, stent thrombosis, or unplanned revascularization) (26% vs 16%) were higher in NSC patients, all p <0.01. However, following multivariable adjustment, SC was neither a predictor of in-hospital mortality (odds ratio 0.68, 95% confidence interval [CI] 0.32 to 1.43, p = 0.31), 30-day mortality (odds ratio 0.70, 95% CI 0.33 to 1.48, p = 0.35) nor long-term survival at 60 months (hazard ratio 0.88, 95% CI 0.62 to 1.27, p = 0.51). Propensity score analysis confirmed the neutral effect of onsite cardiac surgery on long-term survival (hazard ratio 0.99, 95% CI 0.66 to 1.50, p = 0.97). In conclusion, patients who underwent unprotected LM PCI at NSCs presented with greater acuity of illness. Despite this, the availability of onsite cardiac surgical support was not associated with in-hospital, 30-day, or long-term outcomes underscoring the safety of LM PCI in NSCs.

Aims Stent implantation during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) occasionally results in flow disturbances and distal embolization, which may cause adverse clinical outcomes. Deferred stent implantation seems to reduce the impairment on myocardial function, although the mechanisms have not been clarified. We sought to evaluate whether deferred stenting could reduce flow disturbance in patients treated with primary PCI. Methods and results Patients with STEMI included in the DANAMI-3-DEFER trial were randomized to deferred versus immediate stent implantation. The primary and secondary outcomes of this substudy were the incidences of slow/no reflow and distal embolization. A total of 1205 patients were included. Deferred stenting (n = 594) resulted in lower incidences of distal embolization [odds ratio (OR) 0.67, 95% confidence interval (CI) 0.46-0.98, P = 0.040] and slow/no reflow (OR 0.60, 95%CI 0.37-0.97, P = 0.039). In high-risk subgroups, the protective effect was greatest in patients >65 years of age (slow/no reflow: OR 0.36, 95% CI 0.17-0.72, P = 0.004 and distal embolization: OR 0.34, 95% CI 0.18-0.63, P = 0.001), in patients presenting with occluded culprit artery at admission (slow/no reflow: OR 0.33, 95% CI 0.16-0.65, P = 0.001 and distal embolization: OR 0.54, 95% CI 0.31-0.96, P = 0.036) and in patients with thrombus grade >3 (slow/no reflow: OR 0.37, 95% CI 0.20-0.67, P = 0.001 and distal embolization: OR 0.39, 95% CI 0.24-0.64, P < 0.001) with a significant P for interaction for all. Conclusion Deferred stent implantation reduces the incidences of slow/no reflow and distal embolization, especially in older patients and in those with total coronary occlusion or high level of thrombus burden.

Background Coronary angiography (CAG) and percutaneous coronary intervention (PCI) are performed via the femoral or radial arteries. In patients examined via transfemoral access, closure devices facilitate hemostasis, but it is unknown whether it is safe to mobilize these patients immediately and how acceptable this may be in terms of patient comfort. Objective The aims of this study were to investigate bleeding complications in patients mobilized immediately after transfemoral CAG or PCI compared with patients on bed rest (BR) for 2 hours after the procedure and, furthermore, to investigate patient comfort in relation to mobilization and BR. Methods SAMOVAR was a noninferiority trial with patients randomized to immediate mobilization (IM) or 2 hours of BR after transfemoral CAG or PCI and use of the AngioSeal as a closure device and reversal of heparin effect. The primary end point was development of hematoma greater than 5 cm, pseudoaneurysm, or bleeding requiring blood transfusion. Secondary end points were oozing from the puncture site, small hematoma, and patient comfort. Results Of 2027 patients (IM, 1010; BR, 1017), 40% underwent PCI. The primary outcome was recorded in 0.7% patients randomized to IM versus 0.5% in BR (P =.58). There was no difference in the incidence of small hematoma, whereas persistent oozing was seen slightly more often after IM compared with BR (12% vs 9%, P =.04). Patients mobilized immediately reported less back pain and micturition problems (P <.001). Conclusions In patients who had CAG and PCI performed through transfemoral access, reversal of anticoagulation and use of closure devices allowed IM with low rates of complications and improved patient comfort.

Objective: To compare the efficacy of angioplasty using drug-eluting balloons (DEB) compared with plain old balloon angioplasty (POBA) to reduce the rate of restenosis. Methods: This prospective, single-centre, single-blinded, 1:1 randomized, clinical trial enrolled patients that had primary or restenotic lesions in native upper extremity arteriovenous (AV) fistulas or at the graft-venous anastomosis. Patients were randomized to angioplasty with a POBA or a DEB. The primary effectiveness endpoints were freedom from target lesion revascularization (TLR) and functional status of access circuit at 12 months. Results: A total of 42 (28 male, 14 female; age range, 42–83 years) patients were enrolled. Patients were followed for 12 months. No significant differences were detected between the POBA and DEB groups regarding total number of TLR procedures (31 versus 36, respectively), freedom from TLR (3 versus 4, respectively) and functional status of the access circuit at 12 months (14 of 20 patients [70%] versus 17 of 22 patients [77%], respectively). Conclusion: This clinical trial did not demonstrate any significant differences between DEB angioplasty and standard balloon angioplasty when treating dysfunctional haemodialysis access.

Objective: To compare the efficacy of angioplasty using drug-eluting balloons (DEB) compared with plain old balloon angioplasty (POBA) to reduce the rate of restenosis. Methods: This prospective, single-centre, single-blinded, 1:1 randomized, clinical trial enrolled patients that had primary or restenotic lesions in native upper extremity arteriovenous (AV) fistulas or at the graft-venous anastomosis. Patients were randomized to angioplasty with a POBA or a DEB. The primary effectiveness endpoints were freedom from target lesion revascularization (TLR) and functional status of access circuit at 12 months. Results: A total of 42 (28 male, 14 female; age range, 42–83 years) patients were enrolled. Patients were followed for 12 months. No significant differences were detected between the POBA and DEB groups regarding total number of TLR procedures (31 versus 36, respectively), freedom from TLR (3 versus 4, respectively) and functional status of the access circuit at 12 months (14 of 20 patients [70%] versus 17 of 22 patients [77%], respectively). Conclusion: This clinical trial did not demonstrate any significant differences between DEB angioplasty and standard balloon angioplasty when treating dysfunctional haemodialysis access.

Background: In health economic evaluation, utility associated with a health state is outcome-oriented and usually measured using the QALY methodology. Even though there is consistent evidence of utility not only being derived from outcomes but also from procedures, process utility has not been fully integrated in QALY calculations. The aim of this paper is twofold: first, to provide evidence of process utility associated with an alternative treatment to angioplasty, and second, to estimate a monetary value of such process utility using the willingness to pay (WTP) approach. Methods: A total of 1514 people were polled on their WTP to avoid angioplasty to have a drug-eluting stent (DES) implanted. WTP is estimated with a contingent valuation (CV) survey. Individuals are also asked if they would be WTP for a non-invasive procedure with similar results being achieved. WTP responses were analyzed using a double bounded (DB) logit model. Results: Most of the participants showed positive preferences for avoiding angioplasty, with an estimated mean WTP of €5692.87. Using QALY gains for avoiding angioplasty, varying from 0.0035 to 0.08 QALYs, our WTP estimate imply monetary values per QALY that range from €71,160.87 to €1,626,534.28. Discussion: A WTP of €5692.87 to avoid angioplasty imply a monetary value per QALY that greatly exceed the cost per QALY thresholds established in different countries to consider health programs as beneficial to society. Our results reflect how different methodologies for HTA may lead to different conclusions. From the ICER perspective, the cost that would make the treatment with pills option cost-effective, using a threshold of €40,000/QALY, would be €224. However, a cost-benefit approach could support health programs even with a higher cost. Conclusion: WTP methodology captures outcome and process factors related to angioplasty as our WTP estimations are non-significantly different for the costs of angioplasty. WTP approach must be considered

Objetivos: O objetivo primário do estudo será avaliar a segurança e descrever a experiência inicial da implementação da alta precoce (no mesmo dia) dos pacientes coronarianos provenientes do Sistema Único de Saúde submetidos à intervenção coronariana percutânea eletiva, não complicada, por via transradial. O objetivo secundário será avaliar o impacto no custo direito por paciente em comparação aos dados previamente conhecidos da internação clássica utilizada (pernoite no hospital). Métodos: Estudo observacional e prospectivo de pacientes submetidos a intervenção coronariana percutânea eletiva não complicada por via transradial com alta precoce, respeitando os critérios de inclusão e exclusão. Será realizado seguimento dos pacientes para comprovar a segurança da nova estratégia na população do Sistema Único de Saúde e comparar os custos diretos entre o pernoite hospitalar e a de alta no mesmo dia. Este será o primeiro estudo dedicado em avaliar primariamente a segurança da alta precoce após angioplastia coronariana eletiva não complicada por via transradial validando este protocolo na população do sistema público de saúde brasileiro., Objectives: The study's primary objective will be to evaluate the safety and describe the initial experience of implementing early discharge (on the same day) of coronary patients from the Unified Health System undergoing elective, uncomplicated, transradial percutaneous coronary intervention. The secondary objective will be to assess the impact on the direct cost per patient compared to previously known data from the classic hospital stay used (hospital overnight). Methods: Observational and prospective study of patients undergoing elective uncomplicated transradial percutaneous coronary intervention with early discharge, respecting the inclusion and exclusion criteria. Follow-up of patients will be carried out to prove the safety of the new strategy in the population of the Unified Health System and to compare the direct costs between overnight stays and discharge on the same day. This will be the first study dedicated to primarily evaluating the safety of early discharge after elective uncomplicated transradial coronary angioplasty, validating this protocol in the population of the Brazilian public health system.

Objetivos: O objetivo primário do estudo será avaliar a segurança e descrever a experiência inicial da implementação da alta precoce (no mesmo dia) dos pacientes coronarianos provenientes do Sistema Único de Saúde submetidos à intervenção coronariana percutânea eletiva, não complicada, por via transradial. O objetivo secundário será avaliar o impacto no custo direito por paciente em comparação aos dados previamente conhecidos da internação clássica utilizada (pernoite no hospital). Métodos: Estudo observacional e prospectivo de pacientes submetidos a intervenção coronariana percutânea eletiva não complicada por via transradial com alta precoce, respeitando os critérios de inclusão e exclusão. Será realizado seguimento dos pacientes para comprovar a segurança da nova estratégia na população do Sistema Único de Saúde e comparar os custos diretos entre o pernoite hospitalar e a de alta no mesmo dia. Este será o primeiro estudo dedicado em avaliar primariamente a segurança da alta precoce após angioplastia coronariana eletiva não complicada por via transradial validando este protocolo na população do sistema público de saúde brasileiro., Objectives: The study's primary objective will be to evaluate the safety and describe the initial experience of implementing early discharge (on the same day) of coronary patients from the Unified Health System undergoing elective, uncomplicated, transradial percutaneous coronary intervention. The secondary objective will be to assess the impact on the direct cost per patient compared to previously known data from the classic hospital stay used (hospital overnight). Methods: Observational and prospective study of patients undergoing elective uncomplicated transradial percutaneous coronary intervention with early discharge, respecting the inclusion and exclusion criteria. Follow-up of patients will be carried out to prove the safety of the new strategy in the population of the Unified Health System and to compare the direct costs between overnight stays and discharge on the same day. This will be the first study dedicated to primarily evaluating the safety of early discharge after elective uncomplicated transradial coronary angioplasty, validating this protocol in the population of the Brazilian public health system.

Objetivos: O objetivo primário do estudo será avaliar a segurança e descrever a experiência inicial da implementação da alta precoce (no mesmo dia) dos pacientes coronarianos provenientes do Sistema Único de Saúde submetidos à intervenção coronariana percutânea eletiva, não complicada, por via transradial. O objetivo secundário será avaliar o impacto no custo direito por paciente em comparação aos dados previamente conhecidos da internação clássica utilizada (pernoite no hospital). Métodos: Estudo observacional e prospectivo de pacientes submetidos a intervenção coronariana percutânea eletiva não complicada por via transradial com alta precoce, respeitando os critérios de inclusão e exclusão. Será realizado seguimento dos pacientes para comprovar a segurança da nova estratégia na população do Sistema Único de Saúde e comparar os custos diretos entre o pernoite hospitalar e a de alta no mesmo dia. Este será o primeiro estudo dedicado em avaliar primariamente a segurança da alta precoce após angioplastia coronariana eletiva não complicada por via transradial validando este protocolo na população do sistema público de saúde brasileiro., Objectives: The study's primary objective will be to evaluate the safety and describe the initial experience of implementing early discharge (on the same day) of coronary patients from the Unified Health System undergoing elective, uncomplicated, transradial percutaneous coronary intervention. The secondary objective will be to assess the impact on the direct cost per patient compared to previously known data from the classic hospital stay used (hospital overnight). Methods: Observational and prospective study of patients undergoing elective uncomplicated transradial percutaneous coronary intervention with early discharge, respecting the inclusion and exclusion criteria. Follow-up of patients will be carried out to prove the safety of the new strategy in the population of the Unified Health System and to compare the direct costs between overnight stays and discharge on the same day. This will be the first study dedicated to primarily evaluating the safety of early discharge after elective uncomplicated transradial coronary angioplasty, validating this protocol in the population of the Brazilian public health system.

Background: In health economic evaluation, utility associated with a health state is outcome-oriented and usually measured using the QALY methodology. Even though there is consistent evidence of utility not only being derived from outcomes but also from procedures, process utility has not been fully integrated in QALY calculations. The aim of this paper is twofold: first, to provide evidence of process utility associated with an alternative treatment to angioplasty, and second, to estimate a monetary value of such process utility using the willingness to pay (WTP) approach. Methods: A total of 1514 people were polled on their WTP to avoid angioplasty to have a drug-eluting stent (DES) implanted. WTP is estimated with a contingent valuation (CV) survey. Individuals are also asked if they would be WTP for a non-invasive procedure with similar results being achieved. WTP responses were analyzed using a double bounded (DB) logit model. Results: Most of the participants showed positive preferences for avoiding angioplasty, with an estimated mean WTP of €5692.87. Using QALY gains for avoiding angioplasty, varying from 0.0035 to 0.08 QALYs, our WTP estimate imply monetary values per QALY that range from €71,160.87 to €1,626,534.28. Discussion: A WTP of €5692.87 to avoid angioplasty imply a monetary value per QALY that greatly exceed the cost per QALY thresholds established in different countries to consider health programs as beneficial to society. Our results reflect how different methodologies for HTA may lead to different conclusions. From the ICER perspective, the cost that would make the treatment with pills option cost-effective, using a threshold of €40,000/QALY, would be €224. However, a cost-benefit approach could support health programs even with a higher cost. Conclusion: WTP methodology captures outcome and process factors related to angioplasty as our WTP estimations are non-significantly different for the costs of angioplasty. WTP approach must be considered

BACKGROUND: In patients with chronic coronary syndrome undergoing percutaneous coronary intervention, the optimal timing of P2Y12 inhibitors' administration is uncertain. We compared pretreatment versus treatment in the catheterization laboratory (In-Cathlab) in a real-world population. METHODS: In Swedish Coronary Angiography and Angioplasty Registry, all patients with chronic coronary syndrome undergoing coronary angiography and ad hoc percutaneous coronary intervention, between 2006 and 2017 were identified. Pretreatment was defined as P2Y12 inhibitor administration before coronary angiography, outside the catheterization laboratory. Outcomes were net adverse clinical events including death, myocardial infarction, stroke, or bleeding within 30 days of the index procedure and in-hospital bleeding. RESULTS: We included 26 814 patients, 8237 in the In-Cathlab, and 18 577 in the pretreatment group. In-Cathlab treatment compared with pretreatment was associated with lower risk for net adverse clinical event (4.2 versus 5.1%, adjusted hazard ratio 0.79 [0.63-0.99]), bleeding (2.3 versus 2.6%, adjusted hazard ratio, 0.76 [0.57-1.01]). and in-hospital bleeding (1.9 versus 2.1%, adjusted odds ratio, 0.70 [0.51-0.96]). The risk for death, myocardial infarction, or stroke did not significantly differ between the groups. Among the In-Cathlab treated patients, 41% received ticagrelor or prasugrel and 59% clopidogrel. Treatment with ticagrelor or prasugrel was associated with higher risk for net adverse clinical events (5.4% versus 3.4%, adjusted hazard ratio, 1.66 [1.12-2.48]), bleeding (3.4 versus 1.6%, adjusted hazard ratio, 2.14 [1.34-3.42]), and in-hospital bleeding (2.9 versus 1.2%, adjusted odds ratio, 2.24 [1.29-3.90]) but similar risk for death, myocardial infarction, or stroke, compared with clopidogrel. CONCLUSIONS: In patients with chronic coronary syndrome undergoing coronary angiography and ad hoc percutaneous coronary intervention, pretreatment with P2Y12 inhibi

Background: In health economic evaluation, utility associated with a health state is outcome-oriented and usually measured using the QALY methodology. Even though there is consistent evidence of utility not only being derived from outcomes but also from procedures, process utility has not been fully integrated in QALY calculations. The aim of this paper is twofold: first, to provide evidence of process utility associated with an alternative treatment to angioplasty, and second, to estimate a monetary value of such process utility using the willingness to pay (WTP) approach. Methods: A total of 1514 people were polled on their WTP to avoid angioplasty to have a drug-eluting stent (DES) implanted. WTP is estimated with a contingent valuation (CV) survey. Individuals are also asked if they would be WTP for a non-invasive procedure with similar results being achieved. WTP responses were analyzed using a double bounded (DB) logit model. Results: Most of the participants showed positive preferences for avoiding angioplasty, with an estimated mean WTP of €5692.87. Using QALY gains for avoiding angioplasty, varying from 0.0035 to 0.08 QALYs, our WTP estimate imply monetary values per QALY that range from €71,160.87 to €1,626,534.28. Discussion: A WTP of €5692.87 to avoid angioplasty imply a monetary value per QALY that greatly exceed the cost per QALY thresholds established in different countries to consider health programs as beneficial to society. Our results reflect how different methodologies for HTA may lead to different conclusions. From the ICER perspective, the cost that would make the treatment with pills option cost-effective, using a threshold of €40,000/QALY, would be €224. However, a cost-benefit approach could support health programs even with a higher cost. Conclusion: WTP methodology captures outcome and process factors related to angioplasty as our WTP estimations are non-significantly different for the costs of angioplasty. WTP approach must be considered

Background: In health economic evaluation, utility associated with a health state is outcome-oriented and usually measured using the QALY methodology. Even though there is consistent evidence of utility not only being derived from outcomes but also from procedures, process utility has not been fully integrated in QALY calculations. The aim of this paper is twofold: first, to provide evidence of process utility associated with an alternative treatment to angioplasty, and second, to estimate a monetary value of such process utility using the willingness to pay (WTP) approach. Methods: A total of 1514 people were polled on their WTP to avoid angioplasty to have a drug-eluting stent (DES) implanted. WTP is estimated with a contingent valuation (CV) survey. Individuals are also asked if they would be WTP for a non-invasive procedure with similar results being achieved. WTP responses were analyzed using a double bounded (DB) logit model. Results: Most of the participants showed positive preferences for avoiding angioplasty, with an estimated mean WTP of €5692.87. Using QALY gains for avoiding angioplasty, varying from 0.0035 to 0.08 QALYs, our WTP estimate imply monetary values per QALY that range from €71,160.87 to €1,626,534.28. Discussion: A WTP of €5692.87 to avoid angioplasty imply a monetary value per QALY that greatly exceed the cost per QALY thresholds established in different countries to consider health programs as beneficial to society. Our results reflect how different methodologies for HTA may lead to different conclusions. From the ICER perspective, the cost that would make the treatment with pills option cost-effective, using a threshold of €40,000/QALY, would be €224. However, a cost-benefit approach could support health programs even with a higher cost. Conclusion: WTP methodology captures outcome and process factors related to angioplasty as our WTP estimations are non-significantly different for the costs of angioplasty. WTP approach must be considered

BackgroundPoststent ballooning/angioplasty (post-SB) have been shown to increase the risk of stroke risk after transfemoral carotid artery stenting. With the advancement of transcarotid artery revascularization (TCAR) with dynamic cerebral blood flow reversal, we aimed to study the impact of post-SB during TCAR.MethodsPatients undergoing TCAR in the Vascular Quality Initiative between September 2016 and May 2019 were included and were divided into three groups: those who received prestent deployment angioplasty only (pre-SB, reference group), those who received poststent deployment ballooning only (post-SB), and those who received both prestent and poststent deployment ballooning (prepost-SB). Patients who did not receive any angioplasty during their procedure (n = 367 [6.7%]) were excluded because these represent a different group of patients with less complex lesions than those requiring angioplasty. Primary outcome was in-hospital stroke or death. Analysis was performed using univariable and multivariable logistic regression models.ResultsOf 5161 patients undergoing TCAR, 34.7% had pre-SB only, 25% had post-SB only, and 40.3% had both (prepost-SB). No differences in the rates of in-hospital and 30-day stroke, death, and stroke/death were observed among the three groups; in-hospital stroke/death in the pre-SB group was 1.4% (n = 25), post-SB 1.2% (n = 16), and prepost-SB 1.4% (n = 29; P = .92). However, patients undergoing post-SB and prepost-SB had higher rates of in-hospital transient ischemic attacks (TIA) (post-SB, 0.9%; prepost-SB, 1% vs pre-SB, 0.2%, P < .01) and postprocedural hypotension (16.6% and 16.8% vs 13.1%, respectively; P < .001). Post-SB also had longer operative times, as well as flow reversal and fluoroscopy times. On multivariable analysis, no association was seen between post-SB and the primary outcome of in-hospital stroke/death (post-SB odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44-1.73; pr

BackgroundPeripheral vascular devices (stents and balloons) coated with paclitaxel were developed to address suboptimal outcomes associated with percutaneous revascularization procedures of the femoral-popliteal arteries. In randomized controlled trials (RCT), paclitaxel-coated devices (PCD) provided increased long-term patency and a decreased need for repeat revascularization procedures compared with uncoated devices. This finding resulted in the adoption of their use for endovascular lower extremity revascularization procedures. However, in late 2018 a study-level meta-analysis showed increased all-cause mortality at 2 years or more after the procedure in patients treated with PCDs. This review examines the subsequent data evaluation following the publication of the meta-analysis.MethodsWe review the published responses of physicians, regulatory agencies, and patient advocates during 15-month period after the meta-analysis. We present the additional data gathered from RCTs that comprised the meta-analysis and safety outcomes from large insurance databases in both the United States and Europe.ResultsImmediately after the publication of the meta-analysis, concern for patient safety resulted in less PCD use, the suspension of large RCTs evaluating their use, and the publication of a letter from the U.S. Food and Drug Administration informing physicians that there was uncertainty in the benefit-risk profile of these devices for indicated patients and that the potential risk should be assessed before the use of PCDs. Review of the meta-analysis found that a mortality signal was present, but criticisms included that the evaluation was performed on study-level, not patient-level data, and the studies in the analysis were heterogenous in device type, paclitaxel doses, and patient characteristics. Further, the studies were not designed to be pooled nor were they powered for evaluating long-term safety. Clinical characteristics associated with a drug effect or causal r

Objectives: The study's primary objective will be to evaluate the safety and describe the initial experience of implementing early discharge (on the same day) of coronary patients from the Unified Health System undergoing elective, uncomplicated, transradial percutaneous coronary intervention. The secondary objective will be to assess the impact on the direct cost per patient compared to previously known data from the classic hospital stay used (hospital overnight). Methods: Observational and prospective study of patients undergoing elective uncomplicated transradial percutaneous coronary intervention with early discharge, respecting the inclusion and exclusion criteria. Follow-up of patients will be carried out to prove the safety of the new strategy in the population of the Unified Health System and to compare the direct costs between overnight stays and discharge on the same day. This will be the first study dedicated to primarily evaluating the safety of early discharge after elective uncomplicated transradial coronary angioplasty, validating this protocol in the population of the Brazilian public health system., Objetivos: O objetivo primário do estudo será avaliar a segurança e descrever a experiência inicial da implementação da alta precoce (no mesmo dia) dos pacientes coronarianos provenientes do Sistema Único de Saúde submetidos à intervenção coronariana percutânea eletiva, não complicada, por via transradial. O objetivo secundário será avaliar o impacto no custo direito por paciente em comparação aos dados previamente conhecidos da internação clássica utilizada (pernoite no hospital). Métodos: Estudo observacional e prospectivo de pacientes submetidos a intervenção coronariana percutânea eletiva não complicada por via transradial com alta precoce, respeitando os critérios de inclusão e exclusão. Será realizado seguimento dos pacientes para comprovar a segurança da nova estratégia na população do Sistema Único de Saúde e comparar os custos diretos entre o pernoite hospitalar e a de alta no mesmo dia. Este será o primeiro estudo dedicado em avaliar primariamente a segurança da alta precoce após angioplastia coronariana eletiva não complicada por via transradial validando este protocolo na população do sistema público de saúde brasileiro.

Chronic thromboembolic pulmonary hypertension is a pulmonary circulation disorder resulting from the persistent obstruction of the pulmonary vascular bed due to organized thrombotic material. Thrombotic pulmonary hypertension represents the only potentially curable pulmonary hypertension subtype. The treatment of choice is a surgical intervention (pulmonary thromboendarterectomy) although it is not a viable option for a third of patients due to various reasons. As an alternative or additive therapy for inoperable patients, balloon pulmonary angioplasty has achieved excellent results regarding haemodynamic and clinical improvements in published studies, yet the procedure is not without its complications. A nursing care program was described for a patient with inoperable chronic thromboembolic pulmonary hypertension who underwent balloon pulmonary angioplasty. Nursing assessment was performed using Marjory Gordon‘s functional patterns of health and NANDA, NOC, NIC taxonomies were applied to detected problems, thereby identifying the bleeding risk, anxiety, acute pain and infection risk. Goals of interventions and activities aiming to solve problems were set up and the assessment of their compliance was performed using evaluable indicators. Implementation of the nursing care program enabled problem solving during the angioplasty procedure and the nursing team worked in a systematic way., La hipertensión pulmonar tromboembólica crónica es un trastorno de la circulación pulmonar debido a la obstrucción persistente del lecho vascular pulmonar por material trombótico organizado. El interés de esta patología radica en que es la única variante de hipertensión pulmonar potencialmente curable. El tratamiento de elección es quirúrgico (tromboendarterectomía) no siendo factible para un tercio de los pacientes por diversas causas. Como terapia alternativa o coadyuvante para los pacientes inoperables, se presenta la angioplastia con balón de arterias pulmonares, con excelentes resultados hemodinámicos y clínicos en estudios publicados, aunque no está exenta de complicaciones. Se describe el plan de cuidados en un paciente con hipertensión pulmonar tromboembólica crónica inoperable que se sometió a tratamiento de angioplastia con balón de arterias pulmonares. Se utilizaron los patrones funcionales de salud de Marjory Gordon para la valoración de enfermería, observándose alteraciones y detectando problemas para los cuales se aplicó la taxonomía NANDA, NOC, NIC, formulándose los diagnósticos de riesgo de sangrado, ansiedad, dolor agudo y riesgo de infección. Se plantearon unos resultados y unas intervenciones con actividades destinadas a resolver los problemas detectados, y se valoró el cumplimiento de los resultados propuestos a través de indicadores evaluables. La implementación del plan de cuidados permitió solucionar los problemas surgidos durante el procedimiento de angioplastia y además se consiguió trabajar de forma sistematizada.

The objective of this study is to evaluate the safety of transradial catheterization without prior withdrawal of anticoagulant treatment in patients undergoing coronary angiography and/or PTCA. A total of 150 patients who underwent transradial catheterization were included in a retrospective registry from January 2018 to December 2019. Patients were divided into 3 groups: those taking anticoagulant treatment with Sintrom®, those with direct-acting anticoagulant treatment and patients who are not on anticoagulant treatment. Each group of patients was evaluated according to sex, age, INR at the time of catheterization, type of procedure, dose of heparin administered during the procedure and complications after removal of the compression bandage. No significant differences were found between groups and, with regard to complications, the results were similar in anticoagulated versus non-anticoagulated patients. In conclusion, transradial access in patients receiving chronic anticoagulation is a safe alternative and may represent the technique of choice avoiding the inconveniences and complications related to the suspension of anticoagulation therapy., El objetivo de este estudio es evaluar la seguridad de realizar un cateterismo transradial sin la retirada previa del tratamiento anticoagulante, en pacientes sometidos a angiografía coronaria +/- angioplastia. Se han incluido un total de 150 pacientes a los que se les realizó un cateterismo transradial en un registro retrospectivo desde enero del 2018 a diciembre 2019, divididos en 3 grupos: pacientes con tratamiento anticoagulante con Sintrom®, pacientes con tratamiento anticoagulante de acción directa y pacientes que no están con tratamiento anticoagulante. Se han evaluado según sexo, edad, tiempo de protombina (INR) en el momento del cateterismo, tipo de procedimiento, dosis de heparina administrada durante el procedimiento y complicaciones tras la retirada del vendaje; en cada uno de los grupos estudiados. No se han encontrado diferencias significativas y los resultados de las complicaciones son similares en pacientes anticoagulados o no. La vía transradial puede ser una alternativa segura en pacientes tratados con anticoagulantes de forma continua y puede representar la técnica de elección porque evita los inconvenientes y las complicaciones relacionadas con la suspensión de los anticoagulantes.

Brief review of current indications, materials, techniques, complications, results, and controversies around percutaneous procedures for the management of pulmonary valve and arterial branches disease. This article gives the interventional cardiologist a perspective on the material currently available., Se presentan las indicaciones actuales, el material, las técnicas, las complicaciones, los resultados y las controversias de los procedimientos percutáneos que permiten abordar la patología valvular y de las ramas pulmonares. El presente artículo ofrece una perspectiva del material actualmente disponible de forma clara para el cardiólogo intervencionista.

Background: In health economic evaluation, utility associated with a health state is outcome-oriented and usually measured using the QALY methodology. Even though there is consistent evidence of utility not only being derived from outcomes but also from procedures, process utility has not been fully integrated in QALY calculations. The aim of this paper is twofold: first, to provide evidence of process utility associated with an alternative treatment to angioplasty, and second, to estimate a monetary value of such process utility using the willingness to pay (WTP) approach. Methods: A total of 1514 people were polled on their WTP to avoid angioplasty to have a drug-eluting stent (DES) implanted. WTP is estimated with a contingent valuation (CV) survey. Individuals are also asked if they would be WTP for a non-invasive procedure with similar results being achieved. WTP responses were analyzed using a double bounded (DB) logit model. Results: Most of the participants showed positive preferences for avoiding angioplasty, with an estimated mean WTP of €5692.87. Using QALY gains for avoiding angioplasty, varying from 0.0035 to 0.08 QALYs, our WTP estimate imply monetary values per QALY that range from €71,160.87 to €1,626,534.28. Discussion: A WTP of €5692.87 to avoid angioplasty imply a monetary value per QALY that greatly exceed the cost per QALY thresholds established in different countries to consider health programs as beneficial to society. Our results reflect how different methodologies for HTA may lead to different conclusions. From the ICER perspective, the cost that would make the treatment with pills option cost-effective, using a threshold of €40,000/QALY, would be €224. However, a cost-benefit approach could support health programs even with a higher cost. Conclusion: WTP methodology captures outcome and process factors related to angioplasty as our WTP estimations are non-significantly different for the costs of angioplasty. WTP approach must be considered

Objectives: The study's primary objective will be to evaluate the safety and describe the initial experience of implementing early discharge (on the same day) of coronary patients from the Unified Health System undergoing elective, uncomplicated, transradial percutaneous coronary intervention. The secondary objective will be to assess the impact on the direct cost per patient compared to previously known data from the classic hospital stay used (hospital overnight). Methods: Observational and prospective study of patients undergoing elective uncomplicated transradial percutaneous coronary intervention with early discharge, respecting the inclusion and exclusion criteria. Follow-up of patients will be carried out to prove the safety of the new strategy in the population of the Unified Health System and to compare the direct costs between overnight stays and discharge on the same day. This will be the first study dedicated to primarily evaluating the safety of early discharge after elective uncomplicated transradial coronary angioplasty, validating this protocol in the population of the Brazilian public health system., Objetivos: O objetivo primário do estudo será avaliar a segurança e descrever a experiência inicial da implementação da alta precoce (no mesmo dia) dos pacientes coronarianos provenientes do Sistema Único de Saúde submetidos à intervenção coronariana percutânea eletiva, não complicada, por via transradial. O objetivo secundário será avaliar o impacto no custo direito por paciente em comparação aos dados previamente conhecidos da internação clássica utilizada (pernoite no hospital). Métodos: Estudo observacional e prospectivo de pacientes submetidos a intervenção coronariana percutânea eletiva não complicada por via transradial com alta precoce, respeitando os critérios de inclusão e exclusão. Será realizado seguimento dos pacientes para comprovar a segurança da nova estratégia na população do Sistema Único de Saúde e comparar os custos diretos entre o pernoite hospitalar e a de alta no mesmo dia. Este será o primeiro estudo dedicado em avaliar primariamente a segurança da alta precoce após angioplastia coronariana eletiva não complicada por via transradial validando este protocolo na população do sistema público de saúde brasileiro.

Objectives: The study's primary objective will be to evaluate the safety and describe the initial experience of implementing early discharge (on the same day) of coronary patients from the Unified Health System undergoing elective, uncomplicated, transradial percutaneous coronary intervention. The secondary objective will be to assess the impact on the direct cost per patient compared to previously known data from the classic hospital stay used (hospital overnight). Methods: Observational and prospective study of patients undergoing elective uncomplicated transradial percutaneous coronary intervention with early discharge, respecting the inclusion and exclusion criteria. Follow-up of patients will be carried out to prove the safety of the new strategy in the population of the Unified Health System and to compare the direct costs between overnight stays and discharge on the same day. This will be the first study dedicated to primarily evaluating the safety of early discharge after elective uncomplicated transradial coronary angioplasty, validating this protocol in the population of the Brazilian public health system., Objetivos: O objetivo primário do estudo será avaliar a segurança e descrever a experiência inicial da implementação da alta precoce (no mesmo dia) dos pacientes coronarianos provenientes do Sistema Único de Saúde submetidos à intervenção coronariana percutânea eletiva, não complicada, por via transradial. O objetivo secundário será avaliar o impacto no custo direito por paciente em comparação aos dados previamente conhecidos da internação clássica utilizada (pernoite no hospital). Métodos: Estudo observacional e prospectivo de pacientes submetidos a intervenção coronariana percutânea eletiva não complicada por via transradial com alta precoce, respeitando os critérios de inclusão e exclusão. Será realizado seguimento dos pacientes para comprovar a segurança da nova estratégia na população do Sistema Único de Saúde e comparar os custos diretos entre o pernoite hospitalar e a de alta no mesmo dia. Este será o primeiro estudo dedicado em avaliar primariamente a segurança da alta precoce após angioplastia coronariana eletiva não complicada por via transradial validando este protocolo na população do sistema público de saúde brasileiro.

N/A

Background: In health economic evaluation, utility associated with a health state is outcome-oriented and usually measured using the QALY methodology. Even though there is consistent evidence of utility not only being derived from outcomes but also from procedures, process utility has not been fully integrated in QALY calculations. The aim of this paper is twofold: first, to provide evidence of process utility associated with an alternative treatment to angioplasty, and second, to estimate a monetary value of such process utility using the willingness to pay (WTP) approach. Methods: A total of 1514 people were polled on their WTP to avoid angioplasty to have a drug-eluting stent (DES) implanted. WTP is estimated with a contingent valuation (CV) survey. Individuals are also asked if they would be WTP for a non-invasive procedure with similar results being achieved. WTP responses were analyzed using a double bounded (DB) logit model. Results: Most of the participants showed positive preferences for avoiding angioplasty, with an estimated mean WTP of €5692.87. Using QALY gains for avoiding angioplasty, varying from 0.0035 to 0.08 QALYs, our WTP estimate imply monetary values per QALY that range from €71,160.87 to €1,626,534.28. Discussion: A WTP of €5692.87 to avoid angioplasty imply a monetary value per QALY that greatly exceed the cost per QALY thresholds established in different countries to consider health programs as beneficial to society. Our results reflect how different methodologies for HTA may lead to different conclusions. From the ICER perspective, the cost that would make the treatment with pills option cost-effective, using a threshold of €40,000/QALY, would be €224. However, a cost-benefit approach could support health programs even with a higher cost. Conclusion: WTP methodology captures outcome and process factors related to angioplasty as our WTP estimations are non-significantly different for the costs of angioplasty. WTP approach must be considered

Background: Anomalies of the portal venous system can be congenital or acquired, the latter being related to spontaneous thrombosis or iatrogenic alterations such as complications of perinatal catheterization of the umbilical vein. These conditions can be clinically silent for years and then manifest abruptly causing severe clinical emergencies. Case presentation: This case report describes the diagnosis and interventional management of a singular abnormality in the portal venous system of an 8-year-old female that led to severe portal hypertension and acute variceal bleeding. Peculiar imaging findings were not pathognomonic for any of the known congenital and acquired portal vein anomalies: absence of a normal extrahepatic portal vein; splenic and mesenteric veins merging into a dilated left gastric vein; presence of an aberrant mesenteric venous collateral with a stenotic connection with the intrahepatic right portal branch; and absence of porto-systemic shunt. The case was successfully managed with percutaneous transhepatic portography and angioplasty. Conclusions: Prompt non-invasive imaging characterization allowed to understand the singular vascular abnormality and mini-invasive interventional radiology management resolved portal hypertension and variceal bleeding.

Clinical management of renal artery stenosis has seen a major shift, after randomised clinical trials have shown no group benefit of endovascular intervention relative to optimal medical control. However, the inclusion criteria of these trials have been criticised for focusing on a subset of patients with atherosclerotic renal artery stenosis where intervention was unlikely to be beneficial. Moreover, new imaging and computational techniques have become available, which have the potential to improve identification of patients that will respond to interventional treatment. This review addresses the challenges associated with clinical decision making in patients with renal artery stenosis. Opportunities for novel diagnostic techniques to improve patient selection are discussed, along with ongoing Dutch studies and network initiatives that investigate these strategies.

BACKGROUND:Hepatic artery stenosis is a complication of orthotopic liver transplant occurring in 3.1%-7.4% of patients that can result in graft failure and need for re-transplantation. Endovascular therapy with angioplasty and stenting has been used with a high degree of technical success and good clinical outcomes, but tortuous hepatic arteries present a unique challenge for intervention. Suitable stents for this application should be maneuverable and conformable while also exerting adequate radial force to maintain a patent lumen. CASE SUMMARY:Herein we report our experience with a neurovascular Wingspan stent system in a challenging case of recurrent hepatic artery stenosis and discuss the literature of stenting in tortuous transplant hepatic arteries. CONCLUSION:Wingspan neurovascular stent is self-expanding, has good conformability, and adequate radial resistance and as such it could be added to the armamentarium of interventionalists in the setting of a tortuous and stenotic transplant hepatic artery.

Percutaneous transluminal angioplasty (PTA) is an effective treatment strategy for peripheral artery disease (PAD). Data are limiting regarding sex differences in patients with PAD who underwent PTA. We assessed the sex-related differences on 5-year clinical outcomes in patients with PAD who underwent PTA. We prospectively evaluated 765 patients with PAD (596 males and 169 females) who underwent PTA. We performed propensity score matching (PSM) analysis to adjust for any potential confounders. The primary endpoints were 5-year major adverse cardiac and cerebrovascular events (MACE) and major adverse lower-limb events (MALE) assessed by Kaplan-Meier curved analysis and log rank test. After PSM analysis, baseline clinical characteristics were similar in male and female patients. There was a trend toward a higher rate of major hematoma in female patients (6.1% vs. 0.9%, p = 0.066) and a lower rate of below the ankle amputation (24.7% vs. 16.5%, p = 0.097). During the 5-year clinical follow-up, male and female patients had similar rates of MACE (14.9% vs. 15.8%, log rank p = 0.838) and MALE (34.8% vs. 28.2%, log rank p = 0.264) as well as the individual endpoints. In subgroup analysis adjusted by PSM, female patients had a higher risk of bleeding complications in age ≥ 65 years, hypertension, diabetes mellitus, chronic kidney disease, and in the non-critical limb ischemia patients. Of patients with preserved renal function, female patients had a higher risk of MALE as compared to males. In conclusion, female patients with PAD who underwent PTA showed similar 5-year MACE and MALE compared with male patients.

Inflammation ensuing from vascular injury promotes intimal hyperplasia (IH) and restenosis. Resolvin D1 (RvD1) is a lipid mediator that attenuates IH in vivo when delivered locally to the vessel wall in animal models. We tested the hypothesis that peri-procedural oral administration of RvD1 could blunt the local inflammatory response to angioplasty, and attenuate downstream IH. Carotid angioplasty was performed on rats fed with either RvD1 or vehicle through oral gavage, starting one day prior to injury until post-operative day (POD) 3 or 14 when arteries were harvested. To study pharmacokinetics and bioactivity of oral RvD1, we measured plasma RvD1 by ELISA, whole blood phagocytosis activity using flow cytometry, and cAMP levels in the thoracic aorta by ELISA. Carotid arteries were harvested on POD3 for staining (anti-CD45, anti-Myeloperoxidase (MPO), anti-Ki67 or dihydroethidium (DHE) for reactive oxygen species), mRNA expression of target genes (quantitative RT-PCR), or on POD14 for morphometry (elastin stain). RvD1 plasma concentration peaked 3 h after gavage in rats, at which point we concurrently observed an increase in circulating monocyte phagocytosis activity and aortic cAMP levels in RvD1-treated rats vs. vehicle. Oral RvD1 attenuated local arterial inflammation after angioplasty by reducing CD45+, MPO+, Ki67+ cells, and DHE staining intensity. Oral RvD1 also reduced the expression of several pro-inflammatory genes within the injured vessels. However, oral RvD1 did not significantly reduce IH. Oral RvD1 attenuated acute inflammation within the arterial wall after angioplasty in rats, but did not significantly affect IH.