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Purpose: To report the 3-year safety and effectiveness outcomes from the prospective all-comers DEBATE-ISR study (ClinicalTrials.gov identifier NCT01558531) of symptomatic diabetic patients with femoropopliteal in-stent restenosis (ISR) undergoing treatment with paclitaxel-eluting balloons compared with historical diabetic controls.Methods: From January 2010 to December 2011, 44 consecutive diabetic patients (mean age 74±11 years; 32 men) were treated with drug-eluting balloons (DEBs) and enrolled in the study. The control group comprised 42 consecutive diabetic patients (age 76±7 years; 23 men) treated with conventional balloon angioplasty (BA) from 2008 to 2009.Results: No significant differences in terms of clinical, angiographic, or procedural characteristics were observed between the study groups. Critical limb ischemia was present in the majority of patients. Tosaka class III ISR was observed in more than half of the patients. Mean lesion length was 132±86 and 137±82 mm in the DEB and BA groups, respectively (p=0.7). At 3-year follow-up, the rate of target lesion revascularization (TLR) was 40% in the DEB group vs 43% in the BA group (p=0.8); Kaplan-Meier analysis showed no significant differences in terms of freedom from TLR. The presence of a Tosaka class III occlusion was associated with a worse outcome in both study groups (odds ratio 3.96, 95% confidence interval 1.55 to 10.1, p=0.004).Conclusion: Using DEBs for femoropopliteal ISR yielded similar results to BA in terms of TLR at 3-year follow-up. The treatment of more complex ISR lesions was associated with an increased rate of TLR, irrespective of the technology used. [ABSTRACT FROM AUTHOR]

Drug‐eluting stents (DES) have significantly reduced the incidence of in‐stent restenosis (ISR) compared to bare metal stents (BMS). However, recent randomized trials comparing DES with BMS reported few cases of late DES thrombosis. We report the case of late sirolimus‐eluting stent thrombosis occurring 22 months after its elective implantation in a restenotic BMS and soon after the interruption of combined anti‐platelet therapy with aspirin and Clopidogrel. [ABSTRACT FROM AUTHOR]

Similarly to what happened for myocardial infarction treatment during the two previous decades, ischemic stroke therapy has radically changed in recent years after the encouraging clinical results on the use of mechanical revascularization systems. The ever-increasing use of thrombectomy, which is now the first-choice approach for achieving rapid reperfusion of the ischemic brain, inaugurates a new era in the treatment of ischemic stroke, with important social and healthcare implications and the need for effective integrated stroke networks on a regional basis.Given the high annual rates of stroke and that approximately 35% of strokes are caused by the thrombotic occlusion of a large cerebral vessel, with a treatment window reaching up to 24 h after onset in selected cases, the resources of interventional neuroradiology are not enough to meet treatment needs in terms of performing centers and number of operators. The possibility of using centers already active for the treatment of acute myocardial infarction has therefore been taken into consideration. This article presents objective data to support the validity of this strategy and discusses how to create treatment networks using the interventional skills of cardiologists with the implementation of multidisciplinary functional structures.

Background: Delirium is a frequent in-hospital complication in elderly patients, and is associated with poor clinical outcome. Its clinical impact, however, has not yet been fully addressed in the setting of the cardiac intensive care unit (CICU). The present study is a prospective, two-centre registry aimed at assessing the incidence, prevalence and significance of delirium in elderly patients with acute cardiac diseases., Methods: Between January 2014 and March 2015, all consecutive patients aged 65 years or older admitted to the CICU of our institutions were enrolled and followed for 6 months. Delirium was defined according to the confusion assessment method., Results: During the study period, 726 patients were screened for delirium. The mean age was 79.1±7.8 years. A total of 111 individuals (15.3%) were diagnosed with delirium; of them, 46 (41.4%) showed prevalent delirium (PD), while 65 (58.6%) developed incident delirium (ID). Patients 85 years or older showed a delirium rate of 52.3%. Hospital stay was longer in delirious versus non-delirious patients. Patients with delirium showed higher in-hospital, 30-day and 6-month mortality compared to non-delirious patients, irrespective of the onset time (overall, ID or PD). Six-month re-hospitalisation was significantly higher in overall delirium and the PD group, as compared to non-delirious patients. Kaplan-Meier analysis showed a significant reduction of 6-month survival in patients with delirium compared to those without, irrespective of delirium onset time (i.e. ID or PD). A positive confusion assessment method was an independent predictor of short and long-term mortality., Conclusions: Delirium is a common complication in elderly CICU patients, and is associated with a longer and more complicated hospital stay and increased short and long-term mortality. Our findings suggest the usefulness of a protocol for the early identification of delirium in the CICU. Clinicaltrials.gov: NCT02004665.

Background: The aim of this study was to assess the long-term clinical outcome of percutaneous peripheral interventions in diabetic patients with critical limb ischemia (CLI) in terms of occurrence of major amputation and mortality., Methods: From January 2004 to December 2007, all diabetic patients undergoing peripheral angiography and percutaneous revascularization for the presence of CLI were enrolled in this registry and followed prospectively. Limb salvage, mortality, and repeat revascularization were reported at long term., Results: 267 diabetic patients (mean age 72.2 +/- 9.6 years) with 290 ischemic limbs represent the study population. Hypertension was present in 227 patients (85%), hypercholesterolemia in 85 (32%), chronic renal failure in 61 (23%). Ischemic heart disease was present in 80 patients (30%), carotid disease in 75 (28%). According to the Texas Diabetic Ulcers Classification, 203 patients (70%) had type CIII lesion, 29 (10%) CII, 9 (3%) CI, 20 (7%) DIII, 23 (8%) DII, and 6 (2%) DI; 440 lesions (169 tibial arteries, 261 femoro-popliteal arteries, and 10 iliac arteries) were dilated with stent implantation in 290 of them (66%). The procedure was successful in 415 (94%) with restoration of direct flow in at least one tibial artery. The ankle-brachial index was 0.32 +/- 0.11 before procedure and increased to 0.77 +/- 0.23 (p<0.001). One patient died suddenly during hospital stay. Mean follow-up length was 17 +/- 11 months. Of the 290 limbs, major amputation was necessary in 17 (6%) of which 10 had an unsuccessful procedure. Amputation was fatal in 7 cases (41%). Complete foot lesion healing was obtained in 238 (82%) and partial healing in 35 (12%). Death occurred in 42 patients (16%) and it was related to cardiac events in 16 (6%), cerebrovascular events in 8 (3%), acute renal failure in 8 (3%), and cancer in 10 (4%). Repeat revascularization occurred in 67 patients (23%) in the target limb and in 29 (11%) in the contralateral limb., Conclusions: Peripheral angioplasty with stent implantation is an effective procedure for limb salvage in diabetic patients with CLI. The high mortality is probably related to the systemic atherosclerosis process with involvement of coronary and cerebral circulation that leads to heart and cerebral fatal ischemic events.

Restoration of normal flow and tissue-level perfusion are key factors in the reduction of mortality in acute myocardial infarction. The goal of reperfusion during primary percutaneous coronary intervention (PCI) should be to restore not only epicardial patency and flow, but also downstream myocardial tissue perfusion. This review will focus on the techniques able to evaluate and quantify epicardial and microvascular perfusion and on the available therapeutic tools that may be useful in primary PCI. After primary PCI, rates of TIMI flow grade 3 of 80 to 100% have been reported. Furthermore, after stenting during primary PCI more than one third of patients have persistently abnormal corrected TIMI frame counts related to increased downstream resistance. Achievement of TIMI flow grade 3 is no longer sufficient to define an optimal result of primary PCI and restoration of normal tissue-level perfusion is also required. Coronary no/slow reflow and myocardial hypoperfusion after otherwise successful recanalization of infarct-related arteries may involve more than just classical non-reperfusion of the myocardium that is already dead: distal embolization of debris or microparticulate atheromatous material, capillary edema, inflammation, and neurohormonal reflexes and vasoconstriction may play a crucial role. Evolving treatments of the no-reflow phenomenon are directed toward the restoration of microvascular flow abnormalities because these either directly or indirectly contribute to cell death. Promising adjunctive therapies that may reduce microemboli include intensive antiplatelet therapy with aspirin and ticlopidine, platelet glycoprotein IIb/IIIa inhibitors, coronary vasodilators, and embolization protection devices. Therapy targeting microvascular vasospasm also appears promising. Finally a variety of interventional new approaches have been focused on the setting of primary PCI, like atherectomy and thrombectomy devices, distal protection devices, hypothermia and hyperoxemic therapy, that are under investigation in numerous trials before they can be used routinarily.