Purpose: To determine whether diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFR CT ) together with targeted coronary revascularization of ischemia-producing coronary lesions following lower-extremity revascularization can reduce adverse cardiac events and improve long-term survival of patients with chronic limb-threatening ischemia (CLTI). Materials and methods: Prospective cohort study of CLTI patients with no cardiac history or symptoms undergoing elective lower-extremity revascularization. Patients with pre-operative coronary computed tomography angiography (CTA) and FFR CT evaluation with selective post-operative coronary revascularization (FFR CT group) were compared with patients with standard pre-operative evaluation and no post-operative coronary revascularization (control group). Lesion-specific coronary ischemia was defined as FFR CT ≤0.80 distal to a coronary stenosis with FFR CT ≤0.75 indicating severe ischemia. Endpoints included all-cause death, cardiac death, myocardial infarction (MI) and major adverse cardiovascular (CV) events (MACE=CV death, MI, stroke, or unplanned coronary revascularization) during 5 year follow-up. Results: In the FFR CT group (n=111), FFR CT analysis revealed asymptomatic (silent) coronary ischemia (FFR CT ≤0.80) in 69% of patients, with severe ischemia (FFR CT ≤0.75) in 58%, left main ischemia in 8%, and multivessel ischemia in 40% of patients. The status of coronary ischemia in the control group (n=120) was unknown. Following lower-extremity revascularization, 42% of patients in FFR CT had elective coronary revascularization with no elective revascularization in controls. Both groups received guideline-directed medical therapy. During 5 year follow-up, compared with control, the FFR CT group had fewer all-cause deaths (24% vs 47%, hazard ratio [HR]=0.43 [95% confidence interval [CI]=0.27-0.69], p<0.001), fewer cardiac deaths (5% vs 26%, HR=0.18 [95% CI=0.07-0.45], p<0.001), fewer MIs (7% vs 28%, HR=0.21 [95% CI=0.10-0.47], p<0.001), and fewer MACE events (14% vs 39%, HR=0.28 [95% CI=0.15-0.51], p<0.001). Conclusions: Ischemia-guided coronary revascularization of CLTI patients with asymptomatic (silent) coronary ischemia following lower-extremity revascularization resulted in more than 2-fold reduction in all-cause death, cardiac death, MI, and MACE with improved 5 year survival compared with patients with standard cardiac evaluation and care (76% vs 53%, p<0.001). Clinical Impact Silent coronary ischemia in patients with chronic limb-threatening ischemia (CLTI) is common even in the absence of cardiac history or symptoms. FFRCT is a convenient tool to diagnose silent coronary ischemia perioperatively. Our data suggest that post-surgery elective FFRCT-guided coronary revascularization reduces adverse cardiac events and improves long-term survival in this very-high risk patient group. Randomized study is warranted to finally test this concept.
A 63-year-old man with a ruptured abdominal aortic aneurysm (AAA) into the inferior vena cava (IVC) underwent aortobifemoral bypass and closure of the aortocaval fistula (ACF). An additional bypass graft from the right iliac limb to the right internal iliac artery was placed to avoid colonic and pelvic ischemia. Preoperative computed tomography angiography (CTA) revealed an 8.6 cm AAA with rupture into the IVC through an 8.5 mm ACF (A). In addition, there was a 5.8 cm right common iliac and a 5.3 cm left common iliac artery aneurysm (B). The patient became hemodynamically unstable during CTA, and suffered a cardiac arrest with prompt cardiac resuscitation, intubation, and immediate transfer to the operating room. Ten hours after successful surgery the patient was awake and stable. He had no cardiac history, no symptoms suggestive of coronary artery disease (CAD) and had no electrocardiographic changes. However, the troponin level increased to 217,479.7 ng/L and the creatine kinase MB level increased to 504.6 ng/mL. Coronary angiography revealed left main coronary stenosis and subocclusion of the right coronary artery (C). Percutaneous coronary revascularization was performed with implantation of drug-eluting stents in the left main and right coronary artery. The patient recovered uneventfully. The 6-month follow-up CTA demonstrated patent aortobifemoral and right internal iliac bypass grafts and the IVC without signs of stenosis (D). Written informed consent was obtained from the patient for his anonymized information to be published in this article. AAA rupture into the IVC is rare and is associated with high mortality.1Davidovic L. Dragas M. Cvetkovic S. Kostic D. Cinara I. Banzic I. Twenty years of experience in the treatment of spontaneous aorto-venous fistulas in a developing country.World J Surg. 2011; 35: 1829-1834Crossref PubMed Scopus (19) Google Scholar, 2Simons J. Baril D. Goodney P. Bertges D. Robinson W. Cronewett J. et al.The effect of postoperative myocardial ischemia on long -term survival after vascular surgery.J Vasc Surg. 2013; 58: 1600-1608Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar, 3Krievins D. Zellans E. Erglis A. Zvaigzne L. Lacis A. Jegere S. et al.High prevalence of asymptomatic ischemia-producing coronary stenosis in patients with critical limb ischemia: anatomic and functional assessment with coronary CT-derived fractional flow reserve (FFRCT).Vasc Dis Manag. 2018; 15: E96-E101Google Scholar, 4Aboyans V. Ricco J.B. Bartelink M.E.L. Björck M. Brodmann M. Cohnert T. et al.2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS).Eur Heart J. 2018; 39: 763-816Crossref PubMed Scopus (1389) Google Scholar Preoperative diagnosis of ACF with CTA facilitated expeditious surgical treatment in this patient. Patients who survive surgery but have biomarker evidence of myocardial injury have reduced long-term survival.2Simons J. Baril D. Goodney P. Bertges D. Robinson W. Cronewett J. et al.The effect of postoperative myocardial ischemia on long -term survival after vascular surgery.J Vasc Surg. 2013; 58: 1600-1608Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Patients with AAA commonly have coexistent CAD. Pre-operative diagnosis of silent coronary ischemia with coronary CTA and fractional flow reserve derived from CT (FFRCT) can identify high risk patients who may benefit from coronary revascularisation.3Krievins D. Zellans E. Erglis A. Zvaigzne L. Lacis A. Jegere S. et al.High prevalence of asymptomatic ischemia-producing coronary stenosis in patients with critical limb ischemia: anatomic and functional assessment with coronary CT-derived fractional flow reserve (FFRCT).Vasc Dis Manag. 2018; 15: E96-E101Google Scholar Ruptured AAA into IVC with unsuspected CAD can be successfully treated with prompt image-based diagnosis and involvement of a multidisciplinary vascular team.4Aboyans V. Ricco J.B. Bartelink M.E.L. Björck M. Brodmann M. Cohnert T. et al.2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European Society for Vascular Surgery (ESVS).Eur Heart J. 2018; 39: 763-816Crossref PubMed Scopus (1389) Google Scholar
Up to 3% of all HCC present with a tumor thrombus (TT) in the inferior vena cava (IVC) and right atrium (RA). Extensive growth of HCC into the IVC and the RA is associated with a particularly poor prognosis. This clinical condition is related to a high risk of sudden death due to pulmonary embolism or acute heart failure. Therefore, a technically challenging treatment undergoing hepatectomy and cavo-atrial thrombectomy is necessary. We report a 61-year-old man presenting with right subcostal pain, progressive weakness and periodic shortness of breath for 3 months. He was diagnosed with advanced HCC with a tumor thrombus (TT) extending from the right hepatic vein into the inferior vena cava (IVC) and right atrium (RA). A multidisciplinary meeting with cardiovascular and hepatobiliary surgeons, oncologists, cardiologists, anesthesiologists and radiologists was held to determine the best treatment approach. Initially, the patient underwent right hemihepatectomy. As follows, the cardiovascular stage using cardiopulmonary bypass was successfully performed, removing the TT from the RA and ICV. In the early postoperative period the patient remained stable and was discharged on the 8th postoperative day. A morphological examination revealed Grade 2/3 HCC, a clear cell variant with the microvascular and macrovascular invasion. Immunohistochemical staining was positive for HEP-1, CD10, whereas negative for S100. The morphological and immunohistochemical results corresponded to HCC. The treatment of such patients requires the cooperation of various specialties. Although, the approach of the surgery is extremely complex including specific technical support, as well as high perioperative risks, the result offers favorable clinical outcomes.
Objectives: The aim of this study was to determine whether selective coronary revascularization of Peripheral Artery Disease (PAD) patients with silent coronary ischemia can improve survival following lower-extremity revascularization compared to patients with no cardiac symptoms receiving best medical therapy alone.
Methods: Matched cohort analysis of PAD patients with no cardiac history or symptoms with (a) pre-operative CT-derived fractional flow reserve (FFRCT) evaluation to detect silent coronary ischemia and selective post-operative coronary revascularization (FFRCT-Guided) or (b) standard pre-operative cardiac evaluation with monitored post-operative medical therapy in the VOYAGER PAD trial (Medical Therapy). The status of silent ischemia in Medical Therapy was unknown. Study endpoints included death, Myocardial Infarction (MI) and death or MI.
Results: Among 78 FFRCT-Guided patients, 53 (68%) had silent coronary ischemia (FFRCT ≤ 0.80) of which 29 (55%) had post-operative coronary revascularization. Among 79 Medical Therapy patients none had elective coronary revascularization. During a median follow-up of 30 months, compared to Medical Therapy, FFRCT-Guided patients had fewer deaths (5.1% vs. 22.8%; adjusted Hazard Ratio (HR): 0.292; 95% Confidence Interval (CI) 0.086-0.997; p=0.049), fewer MIs (3.8% vs. 15.2%; HR: 0.233; 95% CI 0.058-0.936; p=0.040) and fewer deaths or MI (7.7% vs. 26.6%, HR 0.323, 95% CI 0.115-0.909, p=0.032).
Conclusion: Coronary revascularization of PAD patients with silent ischemia in addition to medical therapy was associated with fewer deaths and MIs following lower-extremity revascularization compared to PAD patients with no coronary symptoms receiving best medical therapy alone.
Up to 3% of all hepatocellular carcinomas (HCCs) present with a tumor thrombus (TT) in the inferior vena cava (IVC) and right atrium (RA). Extensive growth of HCC into the IVC and the RA is associated with a particularly poor prognosis. This clinical condition is related to a high risk of sudden death due to pulmonary embolism or acute heart failure. Therefore, a technically challenging treatment undergoing hepatectomy and cavo-atrial thrombectomy is necessary. We report a 61-year-old man presenting with right subcostal pain, progressive weakness, and periodic shortness of breath for 3 months. He was diagnosed with advanced HCC with a TT extending from the right hepatic vein into the IVC and RA. A multidisciplinary meeting with cardiovascular and hepatobiliary surgeons, oncologists, cardiologists, anesthesiologists, and radiologists was held to determine the best treatment approach. Initially, the patient underwent right hemihepatectomy. As follows, the cardiovascular stage using cardiopulmonary bypass was successfully performed, removing the TT from the RA and ICV. In the early postoperative period, the patient remained stable and was discharged on the 8th postoperative day. A morphological examination revealed grade 2/3 HCC, a clear cell variant with microvascular and macrovascular invasion. Immunohistochemical staining was positive for HEP-1, CD10, whereas negative for S100. The morphological and immunohistochemical results corresponded to HCC. The treatment of such patients requires the cooperation of various specialties. Although the approach of the surgery is extremely complex including specific technical support, as well as high perioperative risks, the result offers favorable clinical outcomes.
We present a saccular asymptomatic juxtarenal abdominal aortic aneurysm in a 70-year-old male with a very short left renal artery supplying the only kidney. The case was successfully treated with the Nellix EndoVascular Aneurysm Sealing system combined with a chimney technique.
Patients undergoing peripheral vascular surgery have increased risk of death and myocardial infarction (MI), which may be due to unsuspected (silent) coronary ischaemia. The aim was to determine whether pre-operative diagnosis of silent ischaemia using coronary computed tomography (CT) derived fractional flow reserve (FFRCT) can facilitate multidisciplinary care to reduce post-operative death and MI, and improve survival.This was a single centre prospective study with historic controls. Patients with no cardiac symptoms undergoing lower extremity surgical revascularisation with pre-operative coronary CTA-FFRCT testing were compared with historic controls with standard pre-operative testing. Silent coronary ischaemia was defined as FFRCT ≤ 0.80 distal to coronary stenosis with FFRCT ≤ 0.75 indicating severe ischaemia. End points included cardiovascular (CV) death, MI, and all cause death through one year follow up.There were no statistically significant differences between CT angiography (CTA-FFRCT) (n = 135) and control (n = 135) patients with regard to age (66 ± 8 years), sex, comorbidities, or surgery performed. Coronary CTA showed ≥ 50% stenosis in 70% of patients with left main stenosis in 7%. FFRCT revealed silent coronary ischaemia in 68% of patients with severe ischaemia in 53%. The status of coronary ischaemia was unknown in the controls. At 30 days, CV death and MI in the CTA-FFRCT group were not statistically significantly different from controls (0% vs. 3.7% [p = .060] and 0.7% vs. 5.2% [p = .066], respectively). Post-operative coronary revascularisation was performed in 54 patients to relieve silent ischaemia (percutaneous coronary intervention in 47, coronary artery bypass graft in seven). At one year, CTA-FFRCT patients had fewer CV deaths (0.7% vs. 5.9%; p = .036) and MIs (2.2% vs. 8.1%; p = .028) and improved survival (p = .018) compared with controls.Pre-operative diagnosis of silent coronary ischaemia in patients undergoing lower extremity revascularisation surgery can facilitate multidisciplinary patient care with selective post-operative coronary revascularisation. This strategy reduced post-operative death and MI and improved one year survival compared with standard care.
Long segment occlusive disease in the superficial femoral artery remains a treatment challenge despite advances in open surgical and endovascular approaches. We report initial clinical results of an entirely new procedure to perform percutaneous femoro-popliteal bypass using the DETOUR System. First-in-human patients were performed in New Zealand from December 2013 to June 2014. After modifications to the technique and devices had significantly refined the procedure, the Detour I Trial commenced.Review of initial results in the first five patients treated at a single site enrolled in IRB-approved, prospective clinical study using the DETOUR System. All patients signed informed consent with planned 2-year follow-up. The DETOUR System was used to create a stent graft bypass which originates in the SFA, travels through the femoral vein, and ends in the popliteal artery, bypassing the diseased segment.A cohort of patients were treated in Latvia from January 2015 to October 2015. The initial five patients in this cohort (age 67.2±11.4 years) with long femoral artery occlusions (29.5±14.1 cm) were treated at a single clinical site. TORUS stent grafts were successfully implanted in all 5 patients (100%) using an 8F delivery system. There were no perioperative 30-day major adverse events (death, major bleeding, deep vein thrombosis, target vessel revascularization or major amputation) observed. At 24 months' follow-up, the primary patency rate was 80% (4/5) and primary assisted patency was 100% (5/5). Significant improvement in ankle-brachial index and Rutherford class were observed in all patients. There was a single secondary procedure performed in these patients (proximal stent edge stenosis at 24 months). The venous function has not been damaged or compromised in any patient.Early results suggest that properly-selected patients with long-segment occlusive disease above the knee can be safely treated using the DETOUR System for percutaneous bypass, with favorable clinical outcomes extending to 2 years. Further clinical investigation is warranted to evaluate the role of this approach in the treatment of long femoral lesions.
BackgroundPatients undergoing vascular surgery procedures have poor long-term survival due to coexisting coronary artery disease (CAD) which is often asymptomatic, undiagnosed and undertreated. We sought to determine whether pre-operative diagnosis of asymptomatic (silent) coronary ischemia using coronary CT -derived fractional flow reserve (FFRCT) together with post-operative ischemia-targeted coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery.MethodsIn this observational cohort study of 522 patients with no known CAD undergoing elective carotid, peripheral or aneurysm surgery we compared two groups of patients. Group I: 288 patients enrolled in a prospective IRB-approved study of pre-operative coronary CTA and FFRCT testing to detect silent coronary ischemia with selective post-operative coronary revascularization in addition to best medical therapy (BMT) (FFRCT guided) and Group II: 234 matched controls with standard pre-operative cardiac evaluation and post-operative BMT alone with no elective coronary revascularization (Usual Care). In the FFRCT group lesion-specific coronary ischemia was defined as FFRCT ≤0.80 distal to a coronary stenosis, with severe ischemia defined as FFRCT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular (CV) death, myocardial infarction (MI) and MACE (major adverse cardiovascular events = death, MI or stroke) during 5-year follow up.ResultsThe two groups were similar in age, gender, and comorbidities. In FFRCT, 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Usual Care. Vascular surgery was performed as planned in both cohorts with no difference in 30-day mortality. In FFRCT, elective ischemia-targeted coronary revascularization was performed in 103 patients 1-3 months following surgery. Usual Care had no elective post-operative coronary revascularizations. At five years, compared to Usual Care, FFRCT guided had fewer all-cause deaths (16% vs 36%, HR 0.37, 95% CI 0.22-0.60, P<.001), fewer cardiovascular deaths (4% vs 21%, HR 0.11, 95% CI 0.04-0.33, P<.001), fewer myocardial infarctions (4% vs 24%, HR 0.13, 95% CI 0.05-0.33, P<.001) and fewer MACE events (20% vs 47%, HR 0.36, 95% CI 0.23-0.56, P<.001). Five-year survival was 84% in FFRCT compared to 64% in Usual Care (p<.001).ConclusionsDiagnosis of silent coronary ischemia with ischemia-targeted coronary revascularization in addition to BMT following major vascular surgery was associated with fewer adverse cardiovascular events and improved 5-year survival compared patients treated with BMT alone as per current guidelines.
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