cardiovascular-agents and Embolism

Successful revascularization of the epicardial coronary artery can be achieved in over 90% of percutaneous coronary intervention (PCI) procedures. However, postprocedural microvascular obstruction, despite the presence of normal epicardial flow, remains an important limitation which substantially reduces the beneficial effects of PCI. In this review article, a number of different methods available to diagnose microvascular obstruction after PCI are outlined. We also discussed the various pharmacological and mechanical strategies to reduce the occurrence of microvascular obstruction. In this regard, pretreatment with antiplatelet therapy remains crucial. In urgent PCI for acute myocardial infarction, available data suggest that manual thrombus aspiration device is beneficial in reducing the occurrence of procedure-related microvascular obstruction and possibly improve long-term clinical outcomes.

Topics: Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Artery Disease; Coronary Circulation; Coronary Occlusion; Embolism; Humans; Microcirculation; Myocardial Infarction; Prostheses and Implants; Thrombectomy

Microvascular obstruction (MVO) commonly occurs following percutaneous coronary interventions (PCI), may lead to myocardial injury, and is an independent predictor of adverse outcome. Severe MVO may manifest angiographically as reduced flow in the patent upstream epicardial arteries, a situation that is termed "no-reflow." Microvascular obstruction can be broadly categorized according to the duration of myocardial ischemia preceding PCI. In "interventional MVO" (e.g., elective PCI), obstruction typically involves myocardium that was not exposed to acute ischemia before PCI. Conversely "reperfusion MVO" (e.g., primary PCI for acute myocardial infarction) occurs within a myocardial territory that was ischemic before the coronary intervention. Interventional and reperfusion MVO have distinct pathophysiological mechanisms and may require individualized therapeutic approaches. Interventional MVO is triggered predominantly by downstream embolization of atherosclerotic material from the epicardial vessel wall into the distal microvasculature. Reperfusion MVO results from both distal embolization and ischemia-reperfusion injury within the subtended ischemic tissue. Management of MVO and no-reflow may be targeted at different levels: the epicardial artery, microvasculature, and tissue. The aim of the present report is to advocate a systematic approach to prevention and treatment of MVO in different clinical settings. Randomized clinical trials have studied strategies for prevention of MVO and no-reflow; however, the efficacy of measures for reversing MVO once no-reflow has been demonstrated angiographically is unclear. New approaches for prevention and treatment of MVO will require a better understanding of intracellular cardioprotective pathways such as the blockade of the mitochondrial permeability transition pore.

Topics: Angioplasty, Balloon, Coronary; Animals; Cardiovascular Agents; Coronary Circulation; Embolism; Evidence-Based Medicine; Filtration; Humans; Ischemic Preconditioning, Myocardial; Microcirculation; Myocardial Ischemia; Myocardial Reperfusion Injury; Myocardium; No-Reflow Phenomenon; Treatment Outcome

Cardioembolic stroke accounts for one third of all ischemic strokes, and atrial fibrillation (AF) is the cardiac source of emboli in 50% of them. However, the absolute risk of stroke associated with AF has enormous variability, and several clinical risk stratification schemes have been proposed. One of the most validated and used in clinical practice is the CHADS2 index, characterized by its simplicity and rapid application. Current recommendations about antithrombotic therapy in AF patients are based on assessment of annual risk of stroke; thus, antiaggregation is indicated in patients with a low risk, and anticoagulation is prescribed when annual risk is greater than 2.5%. Relevant studies comparing rate and rhythm control do not defend achievement and maintenance of sinus rhythm as a routine management of AF patients and demonstrate that rate control is comparable or even better than rhythm control in terms of survival and quality of life. Optimal control of blood pressure is a relevant factor in preventing cardioembolic stroke in AF patients, because hypertension multiplies the risk of stroke by 12. Antihypertensive drugs such as angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers proved to reduce AF recurrences, especially in the context of left ventricular dysfunction and ventricular hypertrophy.

Topics: Anti-Arrhythmia Agents; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Cardiovascular Agents; Embolism; Fibrinolytic Agents; Heart Diseases; Humans; Hypertension; Patient Care Team; Patient Selection; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Risk Assessment; Risk Factors; Secondary Prevention; Stroke; Treatment Outcome

Coronary microembolization from the erosion or rupture of a vulnerable atherosclerotic plaque occurs spontaneously in acute coronary syndromes and iatrogenically during percutaneous coronary interventions. Typical consequences of coronary microembolization are microinfarcts with an inflammatory response, contractile dysfunction, and reduced coronary reserve. Apart from transient elevations of creatine kinase and troponin, microemboli can be visualized by intracoronary Doppler and the resulting microinfarcts by late-enhancement nuclear magnetic resonance. Statins, antiplatelet agents, and coronary vasodilators protect against microembolization and microinfarction when started before percutaneous coronary interventions. Distal protection devices can retrieve atherothrombotic debris and prevent its embolization into the microcirculation, but their effect on clinical outcome has been disappointing so far, except for saphenous vein bypass grafts. Devices for aspiration of thrombi and thrombus-derived vasoconstrictor, thrombogenic, and inflammatory substances, however, reduce thrombus burden, improve perfusion, and provide protection in patients with acute myocardial infarction.

Topics: Animals; Biomarkers; Cardiovascular Agents; Coronary Circulation; Diagnostic Imaging; Embolism; Equipment and Supplies; Hematologic Agents; Humans; Microcirculation; Myocardial Contraction

Endovascular interventions focused on the treatment of superficial femoral artery occlusive disease have increased exponentially as technologic advances have provided the practitioner with a wide array of treatment options. Unfortunately, there is a lack of comparative trials available to guide the practitioner in determining when these devices are best utilized. In the current report, the available comparative data, single-arm trials, and registry data are reviewed and device recommendations are proposed based on TASC II classification, lesion morphology, and indication.

Topics: Angioplasty, Balloon; Arterial Occlusive Diseases; Atherectomy; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Cardiovascular Agents; Embolism; Femoral Artery; Humans; Laser Therapy; Patient Selection; Practice Guidelines as Topic; Prosthesis Design; Radiography; Stents; Treatment Outcome; Vascular Surgical Procedures

Topics: Arteriosclerosis; Cardiovascular Agents; Cardiovascular Diseases; Embolism; Endocarditis, Bacterial; Eye Diseases; Giant Cell Arteritis; Humans; Medical History Taking; Ocular Hypertension; Retinal Vein Occlusion; Syndrome

Slow flow, no reflow and distal embolization often occur during primary angioplasty in ST segment elevation myocardial infarction (STEMI), compromising optimal myocardial reperfusion.. This study aimed at assessing the impact of deferred stenting (DS) on periprocedural events as compared to immediate stenting (IS). The second objective was to gather the reasons advocated by the physicians for deferring stenting.. All consecutive patients referred for primary angioplasty were included between September 2010 and November 2011. Physicians were free to choose the strategy between DS and IS but had to justify their choice. DS patients underwent a coronary angiogram control in a delay > 24h.. Ninety-eight patients were included. Forty patients underwent DS and 58 IS. DS strategy involved thrombus management by thromboaspiration (33 patients 82.5%) and by the use of AntiGpIIbIIIa (23 patients 62.2%). This strategy could be achieved with a low complication rate. In particular, one patient had a reocclusion leading to a rapid reintervention and one had a distal embolization. In comparison, 11 periprocedural events occurred in the IS subgroup. In addition, among DS patients, 7 were treated medically because of a non-significant stenosis. The major criteria considered by the operator to prefer DS in the presence of a TIMI 3 flow concerned thrombotic load.. This mono-centric experience confirmed the feasibility and the safety of DS. On top of reducing periprocedural events, it may allow for other treatment options in selected STEMI patients, e.g. surgery or medical treatment. The reasons leading physicians to choose DS were large thrombus burden on top of resolution of chest pain and normalization of the ECG. These criteria could help selecting situations in which DS may be of particular value as compared to IS.

Topics: Adult; Aged; Aged, 80 and over; Cardiac Catheterization; Cardiovascular Agents; Chest Pain; Comorbidity; Coronary Angiography; Coronary Thrombosis; Electrocardiography; Embolism; Feasibility Studies; Female; Heart Arrest; Hemorrhage; Hospital Mortality; Humans; Male; Middle Aged; Motivation; Myocardial Infarction; No-Reflow Phenomenon; Percutaneous Coronary Intervention; Physicians; Risk Factors; Shock, Cardiogenic; Stents; Thrombectomy; Time Factors

Several trials have shown that paclitaxel drug-coated balloons (DCBs) significantly reduce restenosis rates. However, some reports have shown distal embolisms occurring after DCBs. No study has analyzed the clinical outcomes of patients with DCB-induced distal embolism. This study aimed to investigate the clinical outcomes of DCB-induced distal embolism in patients with femoropopliteal artery disease. Between February 2018 and April 2019, consecutive patients (n = 32) who presented with de novo femoropopliteal artery disease and underwent endovascular therapy using DCB were retrospectively reviewed in a single-center study. Patients were divided into two groups based on whether distal embolism was detected using laser doppler flowmetry (DEL group) or not (non-DEL group). Baseline characteristics and 1-year clinical outcomes were compared between the groups. DEL was found in 44% of limbs (DEL group: n = 15, non-DEL group: n = 19). Below-the-knee arterial runoff ≤ 1 (p = 0.033), popliteal lesion (p = 0.044), ambulation difficulty (p = 0.021), and previous history of coronary artery disease (p = 0.013) were identified as predictive factors of DEL. Procedural factors, reference vessel diameter, lesion length, and total drug amount were not predictive of DEL. The overall target lesion restenosis (TLR) rate was 17.4% (n = 5). The TLR rate was not significantly different between the DEL and non-DEL groups (13.3% vs. 15.8%, p = 0.55). Severe calcification was the only significant factor for TLR (4.2% vs. 40.0%, p = 0.02). Among patients with femoropopliteal disease, there was no difference in 1-year clinical outcome between patients who underwent DEL and those who did not.

Topics: Angioplasty, Balloon; Cardiovascular Agents; Coated Materials, Biocompatible; Constriction, Pathologic; Embolism; Femoral Artery; Humans; Laser-Doppler Flowmetry; Peripheral Arterial Disease; Popliteal Artery; Retrospective Studies; Time Factors; Treatment Outcome; Vascular Patency

We present here a case of an uncommon cutaneous manifestation after paclitaxel-coated balloon angioplasty. In this case, the patient underwent drug-coated balloon angioplasty for stenosis of a prior vein bypass graft. The patient subsequently developed extensive cutaneous lesions not confined to a single arterial distribution. This case represents a rare complication related to paclitaxel-eluting balloons and provides a cautionary tale as well as clinical acumen for providers in using such devices in their practice.

Topics: Analgesics; Angioplasty, Balloon; Cardiovascular Agents; Embolism; Graft Occlusion, Vascular; Humans; Lower Extremity; Male; Middle Aged; Paclitaxel; Treatment Outcome; Vascular Access Devices

Different carrier excipients unique to individual drug-coated balloons (DCBs) may influence embolic safety characteristics in peripheral vascular territories through embolization of released particulates. A comparator study of IN.PACT Admiral vs Lutonix 035 balloons in healthy swine was therefore performed to assess which balloon produces more downstream emboli.. Single or overlapping 80-mm IN.PACT and Lutonix 035 DCBs were assessed in the femoral arteries of 21 swine with 28- and 90-day follow-up, with standard balloon angioplasty as a control. Histologic analysis of arterial wall and downstream skeletal muscle and coronary band was performed. This analysis was supported by an analytic measurement of paclitaxel levels.. IN.PACT DCBs demonstrated a more pronounced change in medial wall composition, characterized by a paclitaxel-induced loss of medial smooth muscle cells accompanied by increased proteoglycans. The percentage of sections with arterioles exhibiting paclitaxel-associated fibrinoid necrosis in downstream tissues was higher at 90 days with overlapping IN.PACT DBCs compared with Lutonix 035 DCBs (46.2% [interquartile range, 19.2-57.7] vs 0.0% [0.0-11.5]; P = .01), with similar trends noted for 28-day single and overlapping DCBs. Drug analysis in parallel tissues further confirmed higher paclitaxel concentrations in nontarget tissues for IN.PACT than Lutonix 035 balloons for single and overlapping configurations at both time points. Rare embolic crystalline material was observed in downstream tissues, but only for IN.PACT balloons.. There was more fibrinoid necrosis in tissues treated with IN.PACT DCBs compared with Lutonix DCBs, suggesting increased emboli debris with higher paclitaxel levels.

Topics: Angioplasty, Balloon; Animals; Arterioles; Cardiovascular Agents; Coated Materials, Biocompatible; Coronary Vessels; Embolism; Equipment Design; Femoral Artery; Fibrosis; Models, Animal; Muscle, Skeletal; Necrosis; Neointima; Paclitaxel; Sus scrofa; Time Factors; Vascular Access Devices

Topics: Cardiovascular Agents; Coronary Angiography; Coronary Artery Disease; Coronary Stenosis; Drug-Eluting Stents; Embolic Protection Devices; Embolism; Humans; Male; Middle Aged; Paclitaxel; Patient Selection; Percutaneous Coronary Intervention; Predictive Value of Tests; Prosthesis Design; Risk Assessment; Risk Factors; Severity of Illness Index; Spectroscopy, Near-Infrared; Tomography, Optical Coherence; Treatment Outcome; Ultrasonography, Interventional

Topics: Acute Coronary Syndrome; Anti-Bacterial Agents; Cardiobacterium; Cardiovascular Agents; Coronary Angiography; Dental Caries; Echocardiography, Transesophageal; Embolism; Endocarditis, Bacterial; Gram-Negative Bacterial Infections; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Mitral Valve Insufficiency; Treatment Outcome

Topics: Anticoagulants; Antidiuretic Hormone Receptor Antagonists; Aspirin; Benzazepines; Cardiovascular Agents; Drug Combinations; Embolism; Gastrointestinal Hemorrhage; Hemorrhage; Humans; Hypernatremia; Japan; Platelet Aggregation Inhibitors; Substance Withdrawal Syndrome; Tolvaptan

Percutaneous intervention carries a higher risk of distal embolization and poorer outcome in saphenous vein grafts (SVG) than in native coronary vessels. Embolic protection devices (EPD) have demonstrated value in decreasing the risk of embolization and post-procedural enzymes elevation after SVG intervention. Although there is ample evidence to support the routine use of EPD for SVG interventions, frequently those devices are not utilized or cannot be used because of technical reasons. As we previously reported, the "undersized stenting" approach seems to be an attractive strategy when EPD cannot be used. We present a case with severe SVG degeneration that illustrates the feasibility of this strategy.

Topics: Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Drug-Eluting Stents; Embolism; Everolimus; Graft Occlusion, Vascular; Humans; Male; Prosthesis Design; Saphenous Vein; Sirolimus; Thrombosis; Tomography, Optical Coherence; Treatment Outcome; Ultrasonography, Interventional

We report the case of a patient with a huge nonocclusive left main thrombus without underlying angiographic coronary lesion associated with bilateral coronary embolization, which was successfully and exclusively medically treated.

Topics: Cardiovascular Agents; Coronary Angiography; Coronary Thrombosis; Electrocardiography; Embolism; Humans; Male; Middle Aged; Treatment Outcome

Percutaneous treatment of old, degenerated saphenous vein grafts (SVG) is associated with a high likelihood of major adverse cardiac events. When an acute coronary syndrome (ACS) develops in a patient with old SVG, fresh thrombus may superimpose on an old, degenerative atheroma: a sudden increase in the athero-thrombotic burden ensues with consequent, frequent total occlusion of the lumen. In this scenario, transluminal recanalization of the graft is usually associated with the highest chance of distal embolization and no-reflow and positioning of an embolic protection device (EPD) is almost mandatory. However, distal EPD are difficult to place when the vessel is totally occluded and do not completely avoid distal embolization. We report two cases of totally occluded SVG in patients admitted for ACS that were recanalized with the aid of a proximal EPD system with angiographic and clinical success.

Topics: Acute Coronary Syndrome; Aged; Angioplasty, Balloon, Coronary; Cardiovascular Agents; Coronary Angiography; Coronary Artery Bypass; Drug-Eluting Stents; Embolism; Equipment Design; Everolimus; Female; Filtration; Graft Occlusion, Vascular; Humans; Male; Metals; Middle Aged; Prosthesis Design; Saphenous Vein; Sirolimus; Stents; Thrombectomy; Thrombosis; Treatment Outcome; Vascular Patency

Much effort has been made to study first-ever stroke patients. However, recurrent stroke has not been investigated as extensively. It is unclear which risk factors dominate, and whether adequate secondary prevention has been provided to patients who suffer from recurrent stroke. Also, the different types of recurrent stroke need further evaluation.. The study included patients with recurrent stroke admitted to twenty-three Swedish stroke centers. The type of previous and recurrent stroke was determined, as well as evaluation (when applicable) of recurrent ischemic stroke according to the TOAST classification. Presence of vascular risk factors was registered and compared to the type of stroke. Also assessed was ongoing secondary prevention treatment at recurrent stroke onset.. A total of 889 patients with recurrent stroke (mean age 77) were included in the study. Of these, 805 (91%) had ischemic stroke, 78 (9%) had intracerebral hemorrhage and 6 (<1%) stroke of unknown origin. The most frequent vascular risk factors were hypertension (75%) and hyperlipidemia (56%). Among the 889 patients, 29% had atrial fibrillation. Of the patients in the ischemic group with cardiac embolism, only 21% were on anticoagulation treatment. The majority of the patients (75%) had their most recent previous stroke >12 months before admission.. Few patients had a recurrent stroke shortly after the previous stroke in this study. This indicates that it is meaningful to prevent a second event with an adequate long-term treatment strategy for secondary prevention after first-ever stroke. There also seems to be a clear potential for improving secondary prevention after stroke.

Topics: Adult; Aged; Aged, 80 and over; Anticoagulants; Antihypertensive Agents; Atrial Fibrillation; Brain Ischemia; Cardiovascular Agents; Cerebral Hemorrhage; Diabetes Complications; Embolism; Female; Humans; Hyperlipidemias; Hypertension; Male; Middle Aged; Odds Ratio; Platelet Aggregation Inhibitors; Registries; Risk Assessment; Risk Factors; Secondary Prevention; Smoking; Stroke; Sweden; Time Factors; Treatment Outcome

We have characterized the coronary vascular reserve, left ventricular function and inotropic response in dogs with chronic heart failure consequent to intracoronary embolization (EMB) with 50 microns spheres. We conducted studies 12-39 months after embolization and contrasted the findings with normal (CON) dogs. Acute embolization produced sustained LV volume enlargement and increased wall thickness, reduction of LV ejection fraction and elevated end-diastolic pressures; resting catecholamine levels were also increased. Responses to phenylephrine, nitroprusside, and dobutamine were identical in CON and EMB and coronary vasodilator reserve was reduced despite larger coronary vascular volume. Analysis by light microscopy showed a diffuse focal and interstitial fibrosis distributed uniformly from endocardium to epicardium associated with 14% loss of myocytes. This created a functional separation of myocardial muscle bundles and a disruption of the syncytial nature of the heart. Electron microscopy of the areas of fibrosis revealed myocytes in states ranging from normal appearing, to ghosts with evidence of cytolysis and loss of the sarcolemma. This model of chronic congestive heart failure with LV systolic dysfunction and elevated LV diastolic pressures shares a number of features with the syndrome in humans.

Topics: Animals; Blood Flow Velocity; Cardiovascular Agents; Chronic Disease; Coronary Circulation; Coronary Vessels; Disease Models, Animal; Dogs; Echocardiography; Embolism; Heart Failure; Hemodynamics; Hyperemia; Microscopy, Electron; Myocardial Ischemia; Myocardium; Ventricular Dysfunction, Left

Topics: Anti-Allergic Agents; Cardiovascular Agents; Embolism; Ergot Alkaloids; Histamine H1 Antagonists; Humans