A hub-and-spoke model in South India improved STEMI care through greater use of PCI and may improve 1-year mortality. This model may serve as an example for developing STEMI systems of care in other low- to middle-income countries.

No abstract

Purpose: To describe a precannulated fenestrated endograft system utilizing externalized guidewires to facilitate aortic arch endovascular repair and to report its use in 2 patients with challenging anatomy. Technique: For distal arch repair, a fenestration for the left subclavian artery (LSA) is made onsite in a standard thoracic endograft tailored to the patient anatomy; it is precannulated with a nitinol guidewire (NGw), which is passed from the femoral artery and externalized from the left brachial artery prior to endograft delivery system introduction over a parallel stiff guidewire. Steps are then taken to remove guidewire intertwining, prevent NGw wrapping around the delivery system, and orient the LSA fenestration superiorly when the delivery system moves into the arch. Gentle traction on the ends of the NGw during endograft deployment facilitates proper fenestration alignment. A covered stent is deployed in the LSA fenestration. The technique is illustrated in a patient with congenital coarctation of the aorta and descending aortic aneurysm. For total arch repair, endograft fenestrations are made for all 3 arch branches; the left common carotid artery (LCCA) and LSA fenestrations are each cannulated with NGws, which travel together from the femoral artery, pass through a LSA snare loop, and are exteriorized from the LCCA. After endograft deployment, the innominate artery fenestration is separately cannulated using right brachial access. Placement of a parallel externalized hydrophilic guidewire passing through the LCCA fenestration (but not the LSA snare loop) and removal of the LCCA fenestration NGw allows exteriorization of the LSA fenestration NGw from the left brachial artery by pulling the LSA snare. Covered stents are deployed in all 3 fenestrations. The technique is presented in a patient with type B aortic dissection. Conclusion: Use of the precannulated fenestrated endograft system described is feasible and has the potential to make aortic arch endovascular repair simpler, more reliable, and safer.

Accurate assessment of aortic annular dimensions is essential for successful transcatheter aortic valve implantation (TAVI). Annular dimensions are conventionally measured in mid-systole by multidetector computed tomography (MDCT), echocardiography and angiography. Significant differences in systolic and diastolic aortic annular dimensions have been demonstrated in cohorts without aortic stenosis (AS), but it is unknown whether similar dynamic variation in annular dimensions exists in patients with severe calcific AS in whom aortic compliance is likely to be substantially reduced. We investigated the variation in aortic annular dimensions between systole and diastole in patients with severe calcific AS. Patients with severe calcific AS referred for TAVI were evaluated by 128-slice MDCT. Aortic annular diameter was measured during diastole and systole in the modified coronal, modified sagittal, and basal ring planes (maximal, minimal and mean diameters). Differences between systole and diastole were analysed by paired t test. Fifty-nine patients were included in the analysis. Three of the five aortic dimensions measured increased significantly during systole. The largest change was a 0.75 mm (3.4%) mean increase in the minimal diameter of the basal ring during systole (p = 0.004). This corresponds closely to the modified sagittal view, which also increased by mean 0.42 mm (1.9%) during systole (p = 0.008). There was no significant change in the maximal diameter of the basal ring or the modified coronal view during systole (p > 0.05). There is a small magnitude but statistically significant difference in aortic annulus dimensions of patients with severe AS referred for TAVI when measured in diastole and systole. This small difference is unlikely to alter clinical decisions regarding prosthesis size or suitability for TAVI.

No abstract

No abstract

BackgroundUse of iodinated contrast agents for angiography in patients with renal insufficiency risks further deterioration of renal function and its adverse sequelae.ObjectiveTo study the effectiveness and safety of carbon dioxide (CO2) angiography in guiding percutaneous renal-related interventions in patients with Takayasu arteritis and renal insufficiency.MethodsData on CO2 angiography-guided interventions were obtained from a 23-year database of 692 Takayasu arteritis patients who underwent percutaneous interventions and were analyzed retrospectively. Follow-up data were also obtained. The CO2 angiography system used was developed in-house and was pressure-driven.ResultsSeven patients (6 female, age 16–59 years, baseline serum creatinine 1.62–4.55 mg/dl, estimated glomerular filtration rate 12.2–36.9 ml/min/1.73 m2) underwent CO2 angiography-guided interventions: five underwent angioplasty or stenting to treat six stenotic/occluded renal arteries, one underwent extensive endovascular repair for spontaneous focal abdominal aortic dissection with false lumen aneurysm and aorto-iliac true lumen narrowing, and one underwent balloon dilatation of previously deployed aortic stents used to treat aortic occlusion at two levels. Follow-up (median 5 years, range 2 months–16 years) was obtained in all patients. All the procedures were successful and resulted in relief of symptoms, better blood pressure control, improvement in left ventricular systolic function and recovery or stabilization of renal function. There were no early or late complications related to CO2 angiography. Three renal lesions that had restenosis at follow-up were managed successfully by repeat intervention.ConclusionCO2 angiography-guided renal-related interventions are effective and safe in patients with Takayasu arteritis and renal insufficiency; they significantly improve the care of such patients.

No abstract