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Chronic total occlusions (CTOs) are seen in 30%-40% of symptomatic superficial femoral artery (SFA) disease. Despite advances in revascularization techniques, 10%-20% of these occlusions cannot be crossed. We report 1 case and review the literature on transcollateral retrograde crossing of the SFA from the profunda femoris. The procedural steps and devices (wires and crossing catheters) utilized by various operators are outlined. Based on an overview of current cases in the literature (19 cases, 21 CTOs), success rate was 95.2% with no complications reported. We conclude that transcollateral recanalization of chronically occluded SFA appears to be a viable technique when antegrade access is not feasible.

Purpose: To present a new approach route for recanalization of a chronically occluded superior mesenteric artery (SMA). Technique: Percutaneous treatment of an SMA occlusion can be accomplished in some cases via retrograde crossing through collaterals from the celiac artery. From a right common femoral artery (CFA) approach, an 8-F RDC guide catheter is advanced to the origin of the celiac artery via. Using a 5-F angled Glidecath, a long 0.035-inch stiff Glidewire, and a Choice PT wire, the glide catheter is advanced via the celiac artery into the superior pancreaticoduodenal artery. Using the angled Glidewire and the Choice PT wire, the occluded SMA is cannulated in a retrograde fashion. Through an 8-F sheath in the left CFA, an 8-F RDC guide catheter is advanced into the abdominal aorta. A goose neck snare is used to capture the Choice wire, which is withdrawn through the left catheter and sheath. The SMA occlusion is dilated, and the RDC guide is advanced into the SMA origin over the balloon. Another Choice PT wire and a 0.035-inch Wholey High Torque wire are placed in an antegrade fashion through the now open SMA. Angioplasty and stenting are then completed in the SMA over the Wholey wire. Conclusion: Retrograde recanalization of the SMA via celiac collaterals offers a new endovascular approach to treating patients with chronic mesenteric ischemia and a chronically occluded SMA.

Left main trifurcating coronary artery disease (LMTCAD) is a complex and challenging anatomy to treat percutaneously. We report on the immediate- and mid-term outcomes of 52 consecutive patients with LMTCAD treated with the Taxus(R) paclitaxel- eluting stent (PES) (Boston Scientific Corp., Natick, Mass.) in our center over a period of 2 years.All patients (n = 52) who underwent LMTCAD at our center in 2006-2007 and treated with the PES form the basis of this report. Demographic, clinical, procedural and in-hospital outcome variables were reviewed. Angiograms were analyzed by an operator blinded to the patients' history. Mid-term follow up was achieved from medical records and/or phone calls. The primary endpoint of the study was either cardiac death, nonfatal myocardial infarction or target lesion revascularization (TLR) on follow up. Follow up was achieved in 47/51 patients (92.2%) at a mean of 292.8 +/- 104.6 days. Patients were classified as Type A (30.8%) disease involving the LM and origin of branches, or Type B (69.2%) disease involving the origin of the trifurcation branches only, but not the LM artery. All patients were treated with kissing balloon after stenting. Descriptive analysis was performed on all variables with mean +/- standard deviation for continuous variables and percentages describing dichotomous variables. Univariate and logistic regression analyses were performed to determine the predictors of the primary endpoint.The mean patient age was 67.6 +/- 12.7 years. The LM artery was unprotected in 88.5% of cases. On follow up, the primary endpoint was met in 34% of patients. TLR occurred in 31.9% of patients, and target vessel revascularization (TVR) in 40.4%. One patient had cardiac death (2.1%) 5 months after the index procedure, possibly related to acute stent thrombosis. By univariate analysis, Type A lesions (vs. Type B; p = 0.02) and the placement of a greater number of stents (p = 0.044) correlated with a higher event rate. Logistic regression analysis showed that Type A lesions are the only predictors of the combined endpoint (p = 0.011).LM trifurcation stenting carries an overall high rate of adverse events, mostly driven by a high TLR rate. Type A lesions and the number of stents placed predicted a higher combined endpoint of death, nonfatal MI and TLR. By logistic regression analysis, Type A lesions are the only independent predictors of the primary outcome.

Left main trifurcation coronary artery disease stenting is a challenging and complex percutaneous procedure that has been infrequently reported. We present our own experience with left main trifurcation stenting using the Taxus paclitaxel-eluting stent (Boston Scientific).Twenty consecutive left main trifurcation stenting procedures were performed in 2005 at our institution. The primary endpoint of the study was the combined endpoints of death, acute stent thrombosis and target lesion revascularization (TLR). Conditional logistic regression analysis was performed to determine the predictors of the primary endpoint using a number of variable combinations.The mean patient age was 71.7 +/- 8.9 years. The procedure was urgent in 10%, and the left main artery was unprotected in 95% of cases. Follow up was achieved in 17/20 (85%) patients, either from medical records or by phone calls. The follow-up median duration was 272 days (range 30 to 534 days). The primary endpoint was met in 5/17 (29.4%) patients. One of 19 patients (5.3%) had a sudden cardiac death 1 month after the procedure, 2/20 patients (10%) experienced an acute in-hospital stent thrombosis, and 2/17 (11.8%) patients underwent TLR. Conditional logistic regression analysis could not identify a relationship between the stenting method and the primary endpoint. The 2 patients who experienced in-hospital thrombosis were the only patients who received a clopidogrel load (600 mg) post-procedure after arrival to the floor, and were not on a glycoprotein IIb/IIIa inhibitor. All others received their clopidogrel either during the procedure (n = 7) or were on it chronically (n = 11). One patient with acute stent thrombosis did not have a kissing balloon performed post-stent deployment.Left main trifurcation stenting carries an overall high rate of adverse events and may need to be reserved for patients who are at high risk or who refuse bypass surgery. Overall TLR is low, but stent thrombosis remains a concern. Although we suspect that thrombosis could be related to failure to perform kissing balloon post-stent deployment and/or not receiving a clopidogrel load until after the procedure, the small number of patients in this study prevents us from making definite statistical conclusions about this observation.

An acute inflammatory response occurs following percutaneous coronary and peripheral vascular interventions (PVI), partly mediated by platelet activation. Glycoprotein (GP) IIb-IIIa inhibitors might partially attenuate this inflammation rise in the coronary patient, but data in patients undergoing PVI are lacking. In the Integrilin Reduces Inflammation in Peripheral Vascular Interventions trial (INFLAME), we hypothesized that eptifibatide reduces the acute inflammatory responses following PVI. This is a single-center, randomized, open-label study of intravenous eptifibatide (180 micro/kg bolus x 2, 10 minutes apart, then 2 micro/kg/min infusion over 18 hours) and low-dose unfractionated heparin (60 Units per kg, target activated clotting time (ACT) 200-250 sec) [LDH+I group; n = 21] versus high-dose unfractionated heparin alone (100 Units per kg, target ACT 300-400 sec) [HDH group; n = 21] in patients undergoing iliac and infrainguinal interventions. The primary endpoints of the study were markers of inflammation (soluble CD-40L [sCD-40L], high-sensitivity C-reactive protein [hs-CRP] and interleukin-6 [IL-6]), thrombin generation (Fragment 1.2 [F1.2]), and fibrinogen measured at baseline and postrandomization. Markers were assayed at baseline, postdilatation at 30 minutes, 2 hours, 18 hours, 48 hours and 7 days. Mean platelet inhibition with eptifibatide was 98% (range 92-100%) using the Accumetrics Rapid Platelet Function Assay at 10 minutes after final bolus. After adjusting for baseline values, the mean +/- SE difference in sCD-40L (loge scale), hs-CRP and F1.2 between the LDH+I group and the HDH was not significant. Fibrinogen had significantly higher mean levels at 7 days for the LDH+I group (541.19 mg/dL versus 472.26 mg/dL; p-value = 0.024). IL-6 was more detectable in the LDH+I group compared to the HDH following intervention. We conclude that LDH+I combination did not reduce acute inflammatory responses as compared to HDH in patients undergoing peripheral vascular interventions.

AngioSeal (AS) and VasoSeal (VS) are collagen-based arterial closure devices utilized to achieve earlier hemostasis and ambulation in diagnostic and interventional percutaneous procedures. To our knowledge, there has been no randomized studies comparing these two devices as approved for use in the United States. One hundred fifty-seven patients were randomized to receive either the 8 Fr AS (n = 79) or VS (n = 78) closure device. Data on 95 patients who had coronary angiography (49 AS, 46 VS) and 55 patients who underwent angioplasty (28 AS, 27 VS) were completed. Heparin was not administered during the coronary angiogram procedure. The activated clotting time was kept at approximately 300 sec during angioplasty. Patients on coumadin or GP IIb/IIIa platelet inhibitors were not included in this study. The time unit interval to achieve hemostasis in this study was based on the time the AS tension spring was left over the common femoral artery following collagen deployment as per the manufacturer's instructions (20 min). Time to hemostasis, time to ambulation, and major and minor complications were prospectively recorded. Two-tailed t-test and chi-square analysis were performed on continuous and dichotomous variables, respectively. For the angiogram-only subgroup, time (min) to hemostasis (20.51 +/- 4.36 vs. 18.59 +/- 11.77; P = 0.30) and ambulation (145.71 +/- 124 vs. 109.89 +/- 60.37; P = 0.075) were not statistically different for the AS and VS, respectively. Similarly, for the angioplasty subgroup, time (min) to hemostasis (24.23 +/- 12.70 vs. 19.57 +/- 2.27; P = 0.077) and ambulation (607.32 +/- 344.22 vs. 486.48 +/- 200.37; P = 0.12) were not statistically different for both AS and VS, respectively. Furthermore, there were no statistical differences in deployment failure, major, minor, or total complication rates between the two devices. In the absence of GP IIb/IIIa inhibitors, VS and the 8 Fr AS devices have statistically similar time to hemostasis and ambulation as well as device failures and complication rates following coronary angiography and angioplasty.