Endovascular management of patients with coronary artery disease and diabetic foot syndrome： A long-term follow-up

Background To investigate the long-term results of global coronary and peripheral interventional treatment of diabetic foot patients. Methods We retrospectively included 220 diabetic patients （78.5 ±15.8 years, 107 females, all with Fontaine Ⅲor Ⅳclass） who were referred to our centre for diabetic foot syndrome and severe limb ischemia from January 2006 to December 2010. Patients were evaluated by a team of interventional cardiologists and diabetologists in order to assess presence of concomitant coronary artery disease （CAD） and eventual need for coronary revascularization. Stress-echo was performed in all patients before diagnostic peripheral angiography. Patients with indications for coronary angiography were submitted to combined diagnostic angiography and then to eventual staged peripheral and coronary interventions. Doppler ultrasonography and foot transcutaneous oximetry of transcutaneous oxygen pressure （TcPO2） before and after the procedure were performed as well as stress-echocardiography and combined cardiologic and diabetic examination at 1 and 6 month and yearly. Results Stress-echocardiography was performed in 94/220 patients and resulted positive in 56 patients who underwent combined coronary and peripheral angiography. In the rest of 126 patients, combined coronary and peripheral angiography was performed directly for concomitant signs and symptoms of coronary heart disease in 35 patients. Coronary revascularization was judged necessary in 85/129 patients and was performed percutaneously after peripheral interventions in 72 patients and surgically in 13 patients. For Diabetic foot interventions the preferred approach was ipsilateral femoral antegrade in 170/220 patients （77.7%） and contralateral cross-over in 40/220 patients （18.8%） and popliteal retrograde ＋ femoral antegrade in 10/220 patients （4.5%）. Balloon angioplasty was performed in 252 legs （32 patients had bilateral disease）： the procedure was successful in 239/252 legs with an immediate success rate of 94.8% and a significant improvement in TcPO2 and ABI with ulcer healing in 233/252 legs （92.4%）. Freedom from major amputation was 82.8% at a mean follow-up of 3.1 ±1.8 years （range 1 to 5 years） whereas survival was 88%. Conclusions Global coronary and peripheral endovascular management of diabetic foot syndrome patients seems to lead to an high immediate success and limb salvage rates and increasing survival compared to historical series.

Congenital coronary artery-left ventricle direct micro-fistulas may cause effort angina and positive stress tests in Western adults

Coronary artery anomalies （CAAs） occur in 0.64 % to 5.6% of patients undergoing coronary angiography, Most pathophysiology and clinical histories involving CCAs have been fully clarified in the past 30 years. Isolated congenital coronary artery-left ventricle direct microfismlas （CVmF） have been recently described, but the clinical significance and anatomical characteristics associated with this rare type of CAA in a western population are still unclear.

Endovascular interventions of the femoro-popliteal disease in the elderly

In the last few years the treatment of superficial femoral artery (SFA) occlusive disease has undergone greater changes in management including more aggressive endoluminal therapy, especially in the elderly patients who are at high risk for extra-vascular comorbidities from the surgical approach. While acute and chronic arterial limb ischemia is the conditions which the interventional cardiologists frequently encounter, the elderly population represents special problematic clinical and anatomical setting due to heavy calcification and poor distal run-off. Arterial thrombolysis, rheolytic thrombectomy, mechanical thrombectomy, laser angioplasty, cryoplasty, and new flexible long stents are some of the promising techniques to improve the technical and clinical outcomes in these elderly patients.

Local drug-delivery balloon for proliferative occlusive in-stent restenosis after drug-eluting stent

Drug-coated balloon has been developed as an alternative to drug-eluting stents for in-stent restenosis but the performance of drug infusion balloon in such setting has not been previously described. We present a case of particularly aggressive in-stent restenosis after drug eluting stent implantation treated with a new kind of drug infusion balloon developed in order to overcome the impossibility to inflate regular drug-coated balloon for several dilatation.

Left main bifurcation stenting:the impact of strut thickness on long-term outcomes

Over the latest years,both randomized controlled trials(RCTs)and observational studies have provided solid basis for percutaneous coronary intervention as a treatment option for unprotected left main(LM)bifurcation coronary artery disease.A recent meta-analysis comparing the long-term outcome between LM bifurcation disease one-stent technique versus twostent technique,the study has demonstrated that one-stent strategy resulted associated with both major adverse cardiac events and target lesion revascularizations(TLRs)lower rates but resulted equivalent to two-stent strategy in terms of cardiovascular mortality,target lesion failure and stent thrombosis(ST)even at one-year and three-year follow-up.[1]

Diagnostic chest X-ray in atrial septal defects

A 66-year-old woman with lower limb edema and exertional dyspnea presented to the emergency department.Posteroanterior chest X-ray revealed a Fleischner’s sign in both lungs(Figure 1A)suggesting a pulmonary hypertension.A subsequent transthoracic echocardiogram revealed a 24 mm diameter secundum atrial septal defect(ASD)(Figure 1B)with a dilated right heart and a mean pulmonary pressure of 68 mmHg.Fleischner’s sign refers to a prominent central pulmonary artery that can be commonly caused either by pulmonary hypertension or acute pulmonary embolism.This radiological finding is very rare in patients with secundum ASD unless the defect remains undiagnosed till the elderly.Chest X-ray remains fundamental in making diagnosis of cardiovascular disease.

Peripheral vascular bifurcation： features and techniques

The systemic nature of vascular atherosclerosis involves all vascular territories.. As interventional cardiologists, we are familiar with coronary artery bifurcation treatment. In other parts of the human body, the vascular tree develops similar bifurcation in the carotid, renal, aortoiliac and tibio-peroneal segments. Even with some differences depending on specific vascular wall composition, the atherosclerotic process affects all such bifurcations in a similar way.