SummaryBackgroundStents are an alternative treatment to carotid endarterectomy for symptomatic carotid stenosis, but previous trials have not established equivalent safety and efficacy. We compared the safety of carotid artery stenting with that of carotid endarterectomy.MethodsThe International Carotid Stenting Study (ICSS) is a multicentre, international, randomised controlled trial with blinded adjudication of outcomes. Patients with recently symptomatic carotid artery stenosis were randomly assigned in a 1:1 ratio to receive carotid artery stenting or carotid endarterectomy. Randomisation was by telephone call or fax to a central computerised service and was stratified by centre with minimisation for sex, age, contralateral occlusion, and side of the randomised artery. Patients and investigators were not masked to treatment assignment. Patients were followed up by independent clinicians not directly involved in delivering the randomised treatment. The primary outcome measure of the trial is the 3-year rate of fatal or disabling stroke in any territory, which has not been analysed yet. The main outcome measure for the interim safety analysis was the 120-day rate of stroke, death, or procedural myocardial infarction. Analysis was by intention to treat (ITT). This study is registered, number ISRCTN25337470.FindingsThe trial enrolled 1713 patients (stenting group, n=855; endarterectomy group, n=858). Two patients in the stenting group and one in the endarterectomy group withdrew immediately after randomisation, and were not included in the ITT analysis. Between randomisation and 120 days, there were 34 (Kaplan-Meier estimate 4·0%) events of disabling stroke or death in the stenting group compared with 27 (3·2%) events in the endarterectomy group (hazard ratio [HR] 1·28, 95% CI 0·77–2·11). The incidence of stroke, death, or procedural myocardial infarction was 8·5% in the stenting group compared with 5·2% in the endarterectomy group (72 vs 44 events; HR 1·69, 1·16–2·45, p=0·006). Risks of any stroke (65 vs 35 events; HR 1·92, 1·27–2·89) and all-cause death (19 vs seven events; HR 2·76, 1·16–6·56) were higher in the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group. There was one event of cranial nerve palsy in the stenting group compared with 45 in the endarterectomy group. There were also fewer haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0·0197).InterpretationCompletion of long-term follow-up is needed to establish the efficacy of carotid artery stenting compared with endarterectomy. In the meantime, carotid endarterectomy should remain the treatment of choice for patients suitable for surgery.FundingMedical Research Council, the Stroke Association, Sanofi-Synthélabo, European Union.

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The most frequently encountered AOCCA is LCx branching-off from RCA. AOCCA may either be difficult to cannulate and PCI aborted even in STEMI, or missed, especially when the intermediate branch from LCA is mimicking proper LCx.

IntroductionEchocardiographic evaluation of regional myocardial function helps to assess the efficacy of therapeutic interventions and to predict the prognosis and clinical outcomes.AimTo assess whether myocardial strain can be useful in estimation of left ventricle (LV) function in patients who have undergone transcatheter aortic valve implantation (TAVI).Material and methodsTwenty-six patients with severe aortic stenosis, who successfully underwent TAVI, were enrolled in the study. Left ventricular peak systolic longitudinal strain (LV PSLS) was obtained before and 1 year after the procedure. Analysis included the potent influence of factors such as sex, LV ejection fraction (LVEF), type of prosthesis implanted or the type of the approach on LV PSLS values.ResultsWe observed a significant improvement in LV PSLS values after TAVI (–10.9 ±5.7 vs. –13.4 ±4.7, p < 0.05). Men had better improvement in LV PSLS after TAVI, but their starting values were considerably lower (M: –10.7 ±4.5 before vs. –13.3 ±4.9 after, p < 0.05; W: –11.8 ±6.8 before vs. –11.9 ±5.6 after, p = NS). Patients with starting LVEF ≤ 40% benefited from the procedure (LV PSLS: –10.3 ±6.4 before vs. –13.7 ±2.9 after, p < 0.05), but in the group of patients with the higher starting LVEF no significant changes in LV PSLS were observed. We also did not note any differences in LV PSLS depending on type of the prosthesis implemented (Edwards Sapiens/CoreValve). Patients in whom the prostheses were implemented via the femoral approach only presented significant increase in LV PSLS values (before: –10.4 ±6.7 vs. after: –13.6 ±3.7, p < 0.05).ConclusionsThe TAVI results in improvement of LV systolic function according to LV PSLS values. Some factors, especially lower baseline LVEF, are related to increased benefit in LV PSLS after TAVI.

The best predictors of remodeling in 6 months' observation have appeared to be lower left ventricular ejection fraction at discharge, poorer perfusion assessed angiographically (MBG scale), and the rate of signal intensity increase reflecting the mean bubble velocity of the myocardium by contrast as assessed by contrast echocardiography. Quantitative perfusion angiography independently has high predictive value for the development of remodeling in long-term follow-up.

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Ischemic MR in STEMI is frequent, even despite effective primary PCI. The regurgitation grade and lower LVEF assessed at hospital discharge and lack of abciximab administration could predict development of LVR at 6 months.

A 75-year-old man was transferred to our department from the local hospital because of recurrent episodes of dyspnea and angina at rest, with significant 3.0-mV STsegment depressions in ECG leads V 3 through V 6 . His medical history was significant for coronary artery disease, 2-vessel coronary artery bypass grafts (1999), nondisabling stroke (2004), type 2 diabetes mellitus, hypertension, and peripheral vascular disease. The patient also complained of dizziness and weakness of the left hand. Clinical examination was characterized by lack of radial pulse, and blood pressure could not be measured on the left arm. The echocardiogram showed apex and inferior wall hypokinesis with slightly diminished ejection fraction (50%).Ultrasound examination revealed occlusion of the left internal carotid artery and reversed flow through the left vertebral artery, confirmed by angiography (Figure 1). Symptomatic vertebral-subclavian steal syndrome was diagnosed.Angiography of the left coronary artery showed the entire left internal mammary artery (LIMA) graft (Figure 2) with reversed flow of contrast into the subclavian artery. The right and circumflex coronary arteries were occluded, as well as the venous graft to the right coronary artery. Contrast injection into the subclavian artery demonstrated critical 90% stenosis in the proximal part of the subclavian artery, with a translesion pressure gradient of 80 mmHg (Figure 3). Contrast selectively injected beyond the lesion merely showed the proximal parts of the left vertebral artery and LIMA, indicating the presence of reversed flow. Direct stenting of the subclavian artery was performed (Figure 4), and anterograde flow through the left vertebral artery and LIMA was reestablished. Control coronary angiography revealed only minor retrograde filling of the distal part of the LIMA, indicating that the subclavian angioplasty had produced favorable results ( Figure 5). At discharge from the hospital, the patient was asymptomatic and the left radial pulse was palpable. Although subclavian steal syndrome is rather rare, it can be manifested as acute coronary syndrome among patients with LIMA grafts or vertebrobasilar insufficiency, especially in the presence of concomitant internal carotid artery occlusion. Percutaneous angioplasty is the preferred treatment option for those patients. DisclosuresNone.