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Endovascular treatment in acute ischemic stroke is usually performed via a transfemoral approach. Catheterization can be problematic in cases with difficult anatomy: unfavorable arch type, vessel tortuosity and ostial stenosis, aorta coarc‑ tation, iliac artery occlusion. The aim of this review is to describe the place of another arterial approach in the manage‑ ment in acute ischemic stroke: direct common carotid

Background: This study was designed to evaluate the patterns of coronary artery disease in patients with chronic obstructive pulmonary disease (COPD) presenting with the acute coronary syndrome (ACS). Methods: This was a prospective, observational study, conducted on 69 patients with chronic obstructive pulmonary disease, presenting with acute coronary syndrome undergoing coronary angiogram from September 2017 to March 2021. All patients had undergone coronary angiogram; severity and morphology of lesion as well as the severity of calcium were analyzed. Results: The study showed that 69 patients with COPD who presented with ACS, 58.8% of patients were presented with NSTEMI, 30.2% STEMI and Unstable angina 11%. The average time of presentation after the onset of the symptom was 17.6 hours. 64% of patients were a smoker. Coronary involvement 10% of patients had LM, 50% TVD, 30% DVD, and 10% had SVD. Type a coronary lesion was seen in 5%, Type B in 20%, and Type C in 75% of patients. Mild Coronary calcium was seen in 25%. Moderate calcium was in 40% and severe calcium in 35%. Conclusions: COPD patients presenting with ACS, associated with increased severity of coronary calcium and coronary lesions.

This study aimed to investigate the association between red blood cell distribution width (RDW) and the risk of coronary artery lesions (CALs) in patients with Kawasaki disease (KD). A total of 1355 patients who met the diagnostic criteria for KD were reviewed between January 2018 and December 2019, including 636 patients with CALs and 719 patients without CALs. Blood samples for RDW were obtained at admission (before intravenous immunoglobulin treatment). A logistic regression analysis was performed, and a receiver operating characteristic curve was constructed to determine the prognostic value of RDW standard deviation (RDW-SD) and RDW coefficient of variation (RDW-CV). The study was registered at www.chictr.org.cn, No.: ChiCTR 2000040980. The results showed that RDW-SD increased in patients with complete KD and CALs compared with patients with complete KD without CALs (39 fL vs. 38 fL, respectively; p = 0.000). RDW-CV in patients with complete KD and CALs was significantly higher compared with patients with completed KD without CALs (p = 0.000). Further multivariate logistic regression analysis revealed that RDW-SD was an independent marker of CALs in patients with complete KD (p = 0.001), but no association was found between RDW-CV and CALs. The area under the curve of RDW-SD for predicting CALs in patients with complete KD was 0.606 (95% confidence interval 0.572–0.640; p = 0.000) with a sensitivity and specificity of 61% and 55%, respectively, when the optimal cut-off value of RDW-SD was 38.5 fL. RDW-CV increased in patients with incomplete KD and CALs compared with patients without CALs (13.55% vs 13.3%, respectively; p = 0.004), and multivariate logistic regression analysis revealed that RDW-CV was an independent marker of CALs in patients with incomplete KD (p = 0.021). The area under the curve of RDW-CV for predicting CALs in patients with incomplete KD was 0.597 (95% confidence interval 0.532–0.661; p = 0.004) with a sensitivity and specificity of 40% and 77%, respectively, when the optimal cut-off value of RDW-SD was 13.85%. Conclusion: RDW can be used as an independent predictive marker of CALs in patients with KD, but the type of KD should be considered. RDW-SD was an independent marker of CALs in patients with complete KD, while RDW-CV was a predictor of incomplete KD.

Background Myocardial perfusion imaging (MPI) is noninvasive test used for evaluation of functional significance of borderline coronary artery lesions. Moreover, instantaneous wave-free ratio (IFR) is a well-validated invasive method used for the same purpose. Objectives To compare the results of MPI and IFR in detection of ischemia in patients with single intermediate coronary artery lesion. Patients and methods A total of 60 patients with single intermediate coronary artery stenosis, visually judged as angiographic stenosis more than or equal to 50% and less than 70% during coronary angiography, were included. After coronary angiography, all patients were subjected to MPI and IFR at National Heart Institute between February 2018 and February 2020. IFR value less than or equal to 0.89 was considered significant, indicating functionally significant lesion, and IFR value more than or equal to 0.89 was considered insignificant, indicating functionally insignificant lesion. MPI results were considered positive when the defect size more than or equal to 10% in the territory of the affected vessel. Results Among 60 patients, 37 (61.7%) patients showed significant IFR value and 23 (38.3%) patients showed insignificant IFR value. Of 37 patients with significant IFR value, 30 (81.1%) patients showed positive MPI results and seven (18.9%) patients showed negative MPI results. Of 23 patients with insignificant IFR value, 19 (82.6%) patients showed negative MPI results, and four (17.4%) patients showed positive MPI results. So, there was good (kappa = 0.62), significant (P = 0.001) agreement between the MPI and IFR results. The sensitivity was 81.1%, the specificity was 82.6%, positive predictive value was 88.2%, the negative predictive value was 73.1%, and the accuracy was 81.7%. Conclusions MPI may be a valid alternative, noninvasive, less-expensive test than IFR for evaluation of functional significance of intermediate coronary artery lesions.

Graphical abstract, Highlights • TA is a progressive, relapsing large-vessel vasculitis. • TA usually affects the aorta and its major branches. • TA can cause LMCA or ostial lesions in young adults. • Involvement of the aorta in TA can cause AR of varying degrees. • Surgical rather than percutaneous revascularization produces better results in TA.

Background: We sought to investigate epidemiologic features of Kawasaki disease (KD) in Shanghai from 2013 through 2017 and identify risk factors for coronary artery lesions (CAL). Methods: As in our previous three surveys, a set of questionnaires and diagnostic guidelines for KD were sent to 50 hospitals providing pediatric medical care in Shanghai. Medical records of KD patients diagnosed from January 2013 through December 2017 were retrospectively analyzed. Multivariate logistic regression analysis was performed to identify risk factors for CAL. Results: A total of 4,452 cases were enrolled. Male-to-female ratio was 1.7:1. The incidence of KD was 68.8 to 107.3 per 100,000 children aged 10 days, were independently associated with CAL. Conclusions: The incidence of KD in Shanghai had substantially increased while the proportion of CAL had substantially decreased as compared with our previous surveys. Higher platelet levels, lower albumin levels, male sex, incomplete KD, IVIG resistance, and receiving initial IVIG ≤4 days or >10 days, were risk factors for CAL.

Because left main (LM) coronary artery stenosis is known to have higher mortality and morbidity compared to lesions in other territories, an early diagnosis and management are crucial to prevent worse outcomes. Due to limitations of coronary angiography (CA), the diagnosis of ostial LM stenosis solely based on CA may result in underdiagnosis of such lesions. Therefore, additional testing is often needed either by pressure wire or intravascular ultrasound (IVUS) to make appropriate diagnosis. We, hereby, present a case of left main ostial stenosis in a 56-year-old male that was missed on multiple coronary angiograms, and highlights many of the considerations in the diagnosis of LM disease.

A 60-year-old man with history of exertional angina pectoris was referred for treatment of an ostial left circumflex (LCX) coronary artery stenosis. The branch angle between left anterior descending artery (LAD) and LCX was shallow, therefore stent implantation seemed at risk of “carina shift” of plaque to the LAD ostium as well as higher in-stent restenosis. Therefore, directional coronary atherectomy (DCA, Atherocut™, L-size, NIPRO, Osaka, Japan) was performed at the ostium of the LCX lesion. After evaluating plaque accumulation using intravascular ultrasound (IVUS), DCA was circumferentially performed 16 times, from 2 atm to 3 atm, using an 8 fr guide system. Although angiogram and IVUS showed excellent results, adjunctive balloon dilatation with 3.5 mm paclitaxel-coated balloon was performed to prevent restenosis. At 8 months, the patient reported being angina-free, and subsequent follow-up angiogram showed no restenosis of LCX. Paclitaxel-coated balloon following DCA for LCX ostial stenosis seems to be safe and effective for both acute and chronic results, suggesting a potential stentless therapeutic option.

Thirty percent of angiographically significant coronary lesions may be functionally significant. Physiological assessment is essential to treat intermediate coronary lesions before taking the decision for percutaneous intervention. Even when coronary artery bypass is planned as treatment modality in triple-vessel coronary artery disease, the SYNTEX II trial has shown that functionally significant lesion treatment by bypass grafts improves the outcome of these patients. In this article, possible ways of estimating the physiologic assessment of coronary lesion, and the advantages and disadvantages of methods of estimating the physiologic assessment of coronary lesions is discussed.

Objective Drug-coated balloon (DCB) angioplasty has emerged as an effective management strategy worldwide. In June 2016, DCB became available for the treatment of de novo small coronary lesions in Japan; however, there has been no multicenter analysis in a post-approval real-world clinical setting to date. The aim of this study was to evaluate the efficacy of DCB for de novo small coronary lesions based on a Japanese multicenter registry. Methods and results From June 2016 to July 2017, a total of 111 lesions (102 patients) treated with DCB for de novo small coronary lesions were enrolled at six Japanese institutions. The primary endpoint was the rate of target lesion revascularization (TLR) at 12 months. Angiographic follow-up endpoints were binary restenosis and late lumen loss (LLL). Clinical follow-up data at 12 months were available for 106 lesions, excluding five lesions that required bailout stenting. The TLR rate was 5.7% (6/106 lesions). No cardiac death or target lesion thrombosis was observed. The binary restenosis rate was 14.4% and LLL was 0.0017 ± 0.37 mm. Conclusions DCB angioplasty for de novo small coronary lesions in the real-world environment in Japan is effective with acceptable 12-month outcomes.

Percutaneous coronary intervention (PCI) of left main coronary artery has become a strong alternative to coronary artery bypass surgery in selected patients. The treatment decision must be validated by the Heart Team. Several PCI techniques of distal left main PCI have been described but the KISSS (Keep it simple, swift and safe) principle recommended by the European Bifurcation Club must be kept in mind. Provisional stenting is the first-line technique. A two-stent strategy may be needed in the presence of≥2.5mm side branch diameter and significant ostial stenosis as well as in presumably difficult rewiring. In all cases, POT (Proximal Optimisation Technique) is mandatory. Intracoronary imaging can be of great help in perfecting the result or even to improve outcomes.

We report the case of a 70-year-old patient with history of chronic heart disease who underwent bypass surgery twice beforehand and was admitted due to non-ST segment elevation myocardial infarction. Angiography showed degeneration of all bypass grafts except the LIMA bypass, which showed significant ostial stenosis with severe calcification. Peri-operative risk was computed to be as high as 12.3% (STS Score). An interventional strategy was chosen: the very high-risk procedure was performed safely under the protection afforded by venoarterial ECMO and cardiac surgeons on standby using a coronary intravascular lithoplasty (IVL) balloon. After implantation of a drug eluting stent, the primary angiogram showed a satisfactory result. The patient was discharged without further complications short after the procedure and is closely followed-up.

Aim:To compare the diagnostic values by using transthoracic echocardiography (ECHO) and multi-slice spiral CT coronary angiography (CTCA) for identifying coronary artery thrombosis in children with Kawasaki disease (KD).Methods:Total 97 KD children with coronary artery dilation complications in our hospital from June 2012 to December 2020 were included in the study. CTCA and ECHO were performed after over 1 month of illness.Results:Coronary artery thrombosis was found in 14 out of 97 patients. Among them, 10 were identified as positive by CTCA, 9 were identified as positive by ECHO, and 5 were identified as positive by both CTCA and ECHO.Conclusion:Both CTCA and ECHO can be used to diagnose coronary artery thrombosis. ECHO has advantage in identifying low-density thrombus, and CTCA is better for the clot in distal coronary artery. They can complement each other.

Purpose: To assess the role of mitomycin-c (MMC) in preventing synechia formation and ostial stenosis following endoscopic nasal surgery.Patients and methods: This is a prospective comparative study on a total of thirty patients of different ages including both sexes. Patients were divided in two groups (A and B, 15 each). Group (A) had FESS operation and group (B) had partial inferior turbinectomy. In Group (A) 15 primary FESS procedures were performed in 15 patients: nine patients had bilateral pansinusitis, and six cases had bilateral nasal polyposis. MMC was applied at the site of middle meatal antrostomy on one side and the contra-lateral side served as the control. In Group (B), 15 endoscopic bilateral partial inferior turbinectomy was performed in 15 patients. MMC was applied between residual of right inferior turbinate and the septum, while the contra-lateral side served as a control. The data were analyzed after two months of follow up.Results: One patient (6.7%) had adhesion at Rt. Side and seven patients (46.7%) had adhesions at Lt. Side, while 14 patients (93.3%) had no adhesion at Rt. Side and eight patients (53.3%) had no adhesion on Lt. Side (P=0.013). In Group (B), three patients (20%) had adhesion at Rt. Side and nine patients (60%) had adhesions at Lt. Side, while 12 patients (80%) had no adhesion at Rt. Side and 6 patients (40%) had no adhesion on Lt. Side (P=0.025).Conclusion: Topical use of MMC is safe and beneficial in decreasing adhesion formation after endoscopic nasal surgery.

Rotational atherectomy (RA) is considered to be the last resort for a severely calcified coronary artery lesion. Severe complications such as vessel perforation or burr entrapment is closely associated with forceful burr manipulation during RA. The instructions for use of Rotablator (Boston Scientific, Marlborough, MA, USA) prohibit forceful burr manipulation when rotational resistance occurs. Nevertheless, RA operators tend to forcefully manipulate the burr if it cannot cross the lesion, because there has been no established strategy for an uncrossable lesion. We present a case with a severely calcified coronary lesion, which was uncrossable by a burr 1.5 mm with RotaWire Floppy (Boston Scientific). We intentionally switched 2 burrs (1.5-mm and 1.25-mm) and 2 RotaWires (Floppy and Extra-support) to cross the lesion. Uniquely, we downsized the burr (from 1.5-mm to 1.25-mm) initially for better penetration force, and upsized the burr (from 1.25-mm to 1.5-mm) finally for better contact to the calcification within the lesion. Our case suggests that 4 different types of combinations might work in a mutually complementary manner for an uncrossable calcified lesion.

We present the case of a 44-year-old gentleman, hospitalized in Interventional cardiology department with retrosternal pain. Percutaneous coronary investigation(PCI) was performed demonstrating bilateral ostial coronary artery stenosis with moderate aortic regurgitation. The patient was transferred in our department for urgent surgery. Cardiac surgery procedure was performed including: double coronary artery bypass grafting (CABG) combined with aortic valve replacement(AVR) with mechanical valve. The Venereal Disease Research Laboratory test (VDRL) and Treponema pallidum Haemagglutination(TPHA) test were done on admission – both of them being positive. Those results confirmed tertiary cardiovascular syphilis. The patient was discharged on POD 12, and was transferred to Dermatology and sexually transmitted diseases(STD) department for further antibiotic therapy concerning the syphilis infection.

We aimed to identify novel risk factors for the early prediction of coronary artery lesion (CAL) in children with Kawasaki disease (KD). We retrospectively analyzed data from hospitalized children newly diagnosed with KD between January 1, 2018, and December 31, 2020, with the following inclusion criteria: (1) diagnosis of KD, (2) first onset of CAL after admission, (3) with complete clinical records. Demographic and laboratory data were collected and analyzed. The independent risk factors of KD combined with CAL were identified by multivariate logistic regression analysis, followed by receiver operating characteristic (ROC) curve analysis to calculate the efficacy of identified risk factors in predicting KD combined with CAL. Among 241 initially recruited patients, 226 were eligible to be included in the study. Based on echocardiographic indications of CAL, 104 patients (46%) were assigned to the CAL (KD-CAL) group and 122 (54%) patients were assigned to the non-CAL (KD-nCAL) group. The levels of red blood cell count, red blood cell distribution width (RDW), C-reactive protein, tumor necrosis factor-α (TNF-α), and interleukin-6 were significantly higher in the KD-CAL group than those in the KD-nCAL group (all p 0.05). RDW and TNF-α were found as independent risk factors of CAL occurrence. The sensitivity and specificity of RDW, TNF-α, and RDW + TNF-α in predicting KD with CAL were 67.31% and 79.51%, 74.04% and 73.77%, and 79.81% and 80.33%, respectively.Conclusion: In conclusion, alterations in RDW and TNF-α levels can be used as novel biomarkers for early prediction of CAL in KD patients, although the differences in their absolute values were small and might not give any added value to echocardiography. What is Known: •Known risk factors of CAL in children with KD include male gender and delayed use of intravenous immune globulin. What is New: •Our current study identified that red blood cell distribution width (RDW) and tumor necrosis factor-α (TNF-α) are novel independent risk factors for predicting CAL combined with KD among patients. •The combination of these RDW and TNF-α together shows higher sensitivity and specificity than either one used alone.

(1) Background: Desquamation is a common characteristic of Kawasaki disease (KD). In this study, we analyzed patients’ varying desquamation levels in their hands or feet, in correlation with clinical presentation, to assess the relationship. (2) Methods: We retrospectively reviewed children with KD. We analyzed their age, laboratory data before intravenous immunoglobulin (IVIG) treatment and coronary artery abnormalities (CAA) based on the desquamation level of their hands and feet. We classified the desquamation level from 0 to 3 and defined high-grade desquamation as grade 2 and 3. (3) Results: We enrolled a total 112 patients in the study. We found the hands’ high-grade desquamation was positively associated with age and segmented neutrophil percentage (p = 0.047 and 0.029, respectively) but negatively associated with lymphocyte and monocyte percentage (p = 0.03 and 0.006, respectively). Meanwhile, the feet’s high-grade desquamation was positively associated with total white blood cell counts (p = 0.033). Furthermore, we found that high-grade hand desquamation had less probability of CAA formation compared with that of a low grade (7.1% vs. 40.8%, p = 0.016). (4) Conclusions: This report is the first to demonstrate that the desquamation level of hands or feet in KD is associated with different coronary artery abnormalities and laboratory findings.

Background: Kawasaki disease (KD) is a systemic vasculitis in childhood, which mainly causes damage to coronary arteries, and intravenous immunoglobulin (IVIG) is the initial therapy. IVIG resistance increased risk of coronary complication in KD. And genetic background is involved in the occurrence of IVIG resistance. Our previous study indicated the susceptibility of Multi-drug resistance protein 4 (MRP4) SNPs to KD. This study was to clarify the relationship between MRP4 polymorphisms and IVIG resistance.Methods: We genotyped the six polymorphisms of MRP4 gene in 760 cases of KD using Taqman methods.Results: Among the six polymorphisms, only the rs1751034 polymorphism was significantly associated with IVIG resistance in KD [CC vs. TT: adjusted odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.21–5.34; CC vs. TT/TC: adjusted OR = 2.33, 95% CI = 1.12–4.83, p = 0.023]. Combined analysis of three polymorphisms indicated that patients with 3–6 risk genotypes exhibited significantly elevated risk of IVIG resistance, when compared with those with 0–2 risk genotypes (adjusted OR = 1.52, 95% CI = 1.04–2.22, p = 0.0295). Stratified analysis revealed that in term of age and gender, rs1751034 CC carriers were associated with increased risk of IVIG resistance in those aged ≤ 60 months (adjusted OR = 2.65, 95% CI = 1.23–5.71, p = 0.0133). The presence of three or more risk genotypes was significantly associated with risk of IVIG resistance in children younger than 5 years of age and males.Conclusion: Our results suggest that MRP4 rs1751034 CC is associated with increased risk of IVIG resistance in KD.

Patient: Female, 34-year-old Final Diagnosis: Left atrial appendage ostial stenosis Symptoms: No symptoms Medication:— Clinical Procedure: — Specialty: Cardiology Objective: Rare disease Background: Left atrial appendage (LAA) ostial stenosis is a rare cardiac condition usually identified by transesophageal echocardiography (TEE). LAA ostial stenosis can be classified into 2 types: one is idiopathic and the other is a complication after incomplete surgical LAA ligation. The former one is even rarer and only 12 cases have previously been reported. Case Report: An asymptomatic young woman was found at a medical checkup to have an abnormal jet signal in the left atrium on transthoracic echocardiography. TEE revealed that the abnormal signal originated from a narrowed orifice of the LAA. There were no other cardiac abnormalities in this woman. Unlike the previously reported cases, our case had LAA ostial stenosis detected by transthoracic echocardiography but not by TEE. Conclusions: We describe a case of anatomic narrowing of the LAA orifice in a young woman. This was a first-ever case of idiopathic LAA ostial stenosis that was detected by transthoracic echocardiography. Because of the very small number of such cases reported, it remains unknown whether anticoagulation is required to prevent intra-atrial thrombus formation.

Background and aims: E-selectin is a cell adhesion molecule of the vascular endothelium that mediates leukocyte rolling in the early inflammatory responses in many diseases including Kawasaki disease (KD). Previous studies have demonstrated that the expression levels of E-selectin was significantly increased in the sera of KD patients and in endothelial cells of KD patient's autopsy. In this study, we aimed to examine E-selectin levels in endothelial cells treated with sera from KD patients and explore the underlying mechanisms.Methods: Human coronary artery endothelial cells (HCAECs) were randomly incubated with sera from either healthy children [healthy control (HC group)] or pediatric KD patients [assigned as KD with coronary artery lesion (KD-CAL+ group) and KD without coronary artery lesion (KD-CAL– group)]. E-selectin levels were determined by RT-qPCR, Western blotting, and immunofluorescence. Cell adhesion assay was performed to quantify the role of E-selectin in intercellular adhesion. High-throughput cell RNA sequencing followed by functional validation was performed to explore the underlying mechanism.Results: E-selectin levels were significantly increased in KD-CAL+ group vs. HC group and KD-CAL– group. Compared with the KD-CAL– group, endothelia–monocyte adhesion was increased in the KD-CAL+ group, while E-selectin-specific siRNA could significantly rescue it. High-throughput cell RNA sequencing analysis also found a significant difference in oxidative phosphorylation (OXPHOS) levels between KD-CAL+ group and KD-CAL– group. Functional validation results further confirmed that the OXPHOS was upregulated in the KD-CAL+ group and KD-CAL– group compared to that in the HC group, while the KD-CAL+ group exhibited a higher OXPHOS than the KD-CAL– group. We also found that the E-selectin levels and endothelia–monocyte adhesion were significantly decreased by OXPHOS inhibitor oligomycin in the KD-CAL+ group and KD-CAL– group, respectively.Conclusion: Sera from KD patients stimulate OXPHOS levels and enhance E-selectin expression in HCAECs, which may contribute to the development of CAL in KD patients.

Uncrossable lesions are lesions that cannot be crossed with a balloon or microcatheter after guide wire crossing. They constitute a considerable challenge in coronary interventions and are associated with poor outcome in patients undergoing rotational atherectomy (RA) [1]. Most of the documented methods cannot be applied in true aorto-ostial lesions with severe stenosis. Such lesions require a nonstandard approach that has not been precisely described in any expert documents so far [2–4].

Aim: To compare the perioperative outcome of patients treated with elective or urgent fenestrated and branched stent grafting (fbEVAR) for pararenal (pAAA) and thoraco-abdominal aortic aneurysm (TAAA) after previous open with previous endovascular abdominal aortic repair. Methods: Single center retrospective analysis of all patients undergoing fbEVAR after previous open (post-open fbEVAR group) or endovascular abdominal aortic repair (post-endo fbEVAR group) between January 2015 and December 2017. Primary outcomes were technical success and in-hospital all-cause mortality. Results: We identified 42 patients undergoing fbEVAR after previous open or endovascular abdominal aortic repair during this period. Twenty-one patients (post-open fbEVAR group) had previous open abdominal aortic repair, 13 with a bifurcated and eight with a tube graft. Of these, two patients presented with pAAA and 19 with TAAA. Twenty-one patients (post-endo fbEVAR group) had previous EVAR. Thirteen patients presented with pAAA, three of them with additional type Ia endoleak, two with stent-graft migration and two with previously failed fEVAR. Eight presented with TAAA. Median interval between previous repair and fbEVAR was 84 months (IQR 60-156) for the post-open fbEVAR group and 72 months (IQR 36-96) for the post-endo fbEVAR group (P=0.746). Eighteen patients (86%) had branched stent grafting in the post-open vs. eleven (52%) in the post-endo group (P

There is still no consensus on the optimal technique for performing percutaneous coronary intervention (PCI) in ostial coronary lesions, due to potential complications. The modified flower petal technique is one of the techniques to management of ostial lesions. It seems suitable technique in terms of covering the coronary ostium well. In this report, we discuss a patient who underwent PCI with sequential modified flower petal technique, first to the left anterior descending artery ostial lesion, and then to the circumflex artery (CXA) upon the ostium of CXA was affected after the procedure following coronary angiography.

Background: Kawasaki Disease is a systemic vasculitis, particularly involving coronary arteries. Rare involvement of other vascular districts is described, as central nervous system arteries, leading to a vasculitic neuropathy. Sensorineural hearing loss and alterations of evoked potentials are uncommonly reported complications.Methods: In an observational monocentric study, 59 children (37 males; 22 females; mean age: 2.7 ± 2.2 years) with documented Kawasaki Disease were enrolled. No risk factors for hearing loss and/or neurological impairment were identified in the cohort. Brainstem auditory evoked potentials and visual evoked potentials were correlated with clinical, hamatological and radiological data, evaluated in the acute phase of the Kawasaki Disease, and during the follow-up.Results: Evoked potentials were altered in 39/59 patients (66%): of these, 27/39 (69%) showed altered IV and V waves and/or III-V interwave latencies of brainstem auditory evoked potentials; 4/39 (10%) showed pathological visual evoked potentials; 8/39 (21%) had abnormalities of both brainstem auditory evoked potentials and visual evoked potentials. No permanent deafness was reported.Conclusion: Abnormalities in visual evoked potentials were not significantly correlated with coronary artery lesions; however, the presence of abnormalities of brainstem auditory evoked potentials were associated with the risk of coronary artery lesions.

Background:In the latest 2017 American Heart Association guidelines for Kawasaki disease (KD), there are no recommendations regarding the early administration of intravenous immunoglobulin (IVIG). Therefore, the purpose of this systematic review and meta-analysis was to investigate the effects of early IVIG therapy on KD.Methods:We searched databases including the PubMed, Medline, the Cochrane Library, and the Clinicaltrials.gov website until July 2019.Results:Fourteen studies involving a total of 70,396 patients were included. Early treatment with IVIG can lead to an increased risk of IVIG unresponsiveness [OR 2.24; 95% CI (1.76, 2.84);P= 0.000]. In contrast to the studies performed in Japan [OR 1.27; 95% CI (0.98, 1.64);P= 0.074] that found no significant difference in coronary artery lesions (CAL) development, studies conducted in China [OR 0.73; 95% CI (0.66, 0.80);P= 0.000] and the United States [OR 0.50; 95% CI (0.38, 0.66);P= 0.000] showed a reduced risk in the occurrence of CAL with early IVIG treatment.Conclusions:At present, the evidence does not support the treatment with IVIG in the early stage of the onset of KD. But, early IVIG treatment could be a protective factor against the development of CAL, which needs to be further clarified.

Objective: The current study was to evaluate the association of Lipoprotein (a) [Lp(a)] and in-hospital outcomes in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary inte...

Kawasaki disease (KD) is the most common cause of heart disease acquired in childhood. Even if treated with high-dose intravenous immunoglobulin G (IVIG) at the early stage, children are still at risk of developing coronary artery lesions. Accumulating evidence suggests that autophagy is enhanced in various heart diseases. Evaluating the pathogenic role of autophagy in KD and coronary artery lesions (CAL) may aid in identifying a potential therapeutic target for the treatment or prevention of the disease. Blood samples were obtained from 20 children with KD at the onset of disease and 21 days after IVIG therapy. Twenty children with other causes of febrile disease and 20 healthy children were included as controls. Total RNA was extracted from white blood cells, and autophagy-related gene mRNA expression levels were measured using real-time polymerase chain reaction. The patients with KD had downregulated levels of LC3B mRNA (0.50 &plusmn, 0.06 vs. 1.67 &plusmn, 0.15, p &lt, 0.001), BECN1 mRNA (0.70 &plusmn, 0.08 vs. 1.43 &plusmn, 0.23, 0.05), and ATG16L1 mRNA (0.28 &plusmn, 0.04 vs. 0.96 &plusmn, 0.16, 0.01) compared to the febrile control group. The values of these parameters all increased significantly 21 days after the IVIG therapy as follows: LC3B mRNA (1.77 &plusmn, 0.29 vs. 0.50 &plusmn, 0.06, 0.001), BECN1 mRNA (1.67 &plusmn, 0.36 vs. 0.70 &plusmn, 0.08, 0.05), and ATG16L1 mRNA (2.96 &plusmn, 0.43 vs. 0.28 &plusmn, 0.04, 0.001), while the level of ATG16L1 mRNA persists low in KD patients with CAL. Our results showed the autophagy-related genes expressions in KD and their change after IVIG administration. This suggests that autophagy may have a protective effect on KD.

Objectives: The direct correlation between Echocardiographic non-coronary calcium score (ECS) and lesion severity on invasive coronary angiography (ICA) is not reported. The aim of the present study was to find the correlation between ECS and Gensini score. Methods: One hundred seventy patients aged ≥18 years posted for clinically indicated ICA were included. All the patients underwent standard transthoracic echocardiography. ECS and Gensisni scores were calculated. The primary outcome measure was to find a correlation of ECS with Gensini score, whereas the secondary outcome measure was to correlate ECS with traditional risk factors for coronary artery disease. The Chi-square/Fisher exact test was used to compare qualitative variables. Spearman’s correlation analysis was used for assessing the correlation between ECS score and the Gensini score. Receiver-operating characteristic curve analysis was performed to detect the cut-off value of the ECS score. Results: The correlation of total ECS with Gensini score was positive and statistically significant (r = 0.550, p-value 1 detected CAD with 56.5% sensitivity, 79.5% specificity. Eight-nine percent of patients who had ECS >1, had Gensini score ≥18, whereas 44.3% of patients who had ECS ≤1, had Gensini score ≥18. The patients with ECS >1 had significantly higher Gensini scores than the patients with ECS ≤1. Conclusions: The correlation of total ECS with Gensini score was positive and statistically significant.

Background: Kawasaki diseases (KD) is a febrile systemic vasculitis in infants associated with coronary aneurysm. The etiology of KD remains unclear. Human neutrophils have great capacity to cause tissue damage in inflammatory diseases via their inappropriate activation to release reactive oxygen species (ROS). Brain natriuretic peptide (BNP) is a substantial modulator of neutrophil activation to regulate ROS production. It is increasingly released from the myocardium in heart failure and myocardial inflammatory states. Objective: The purpose of this study was to explore the potential role of neutrophil respiratory burst in the pathogenesis of coronary artery lesions (CAL) in KD. Materials and Methods: A total of 78 children were enrolled. Of all the cases, 20 cases are healthy control (HC), 20 are with coronary artery lesion (CAL), and 38 are with non-coronary artery lesion (NCAL). The activation ratio of neutrophils was evaluated by flow cytometry. In addition, plasma levels of BNP were detected. Results: Our results showed that the activation ratio of neutrophils in KD with CAL is significantly higher than the other two groups (HC and NCAL). Besides, the plasma levels of BNP in KD (with or without CAL) were higher than that in HC. Conclusions: These findings suggested that neutrophil respiratory burst may play a significant role in the pathogenesis of CAL, and predicts the risk of CAL in Kawasaki disease.

This study was to investigate the correlation of vagal activity with coronary artery lesion (CAL) in Kawasaki disease (KD) children, and assess the predictive value of heart rate deceleration capacity (DC) for CAL in acute phase of KD.50 KD children with CAL, 130 KD children without CAL, 30 children with acute upper respiratory infection and 100 healthy children were recruited and indicators reflecting vagal activity including DC were measstuogram. KD children with CAL showed decreased vagal activity with significantly lower values of DC. DC was negatively correlated with levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) in KD children. DC was a usable cardiac electrophysiological index to predict CAL in children with KD, with an area under the receiver operating characteristic curve (AUC) of 0.741. The cut-off value of DC for predicting CAL in KD children was 4.37 ms. DC was an independent predictor of CAL in children with KD, evaluated by multiple logistic regression analysis, KD children with DC ≤ 4.37 ms had an increased risk of CAL, with odds ratios (OR) of 5.94. Our study illustrates DC could be used to predict CAL in acute phase of KD.

This study aimed to examine and summarize clinical characteristics of Kawasaki disease (KD) at different ages to further strengthen clinicians understanding of children with KD, improving the level of diagnosis, and reducing coronary artery complications of KD. A total of 398 patients with KD who were diagnosed between January 2016 and December 2017 were reviewed retrospectively. These participants were allocated into three groups according to age: group A (

BackgroundKawasaki disease (KD) is a common, yet unknown etiology disease in Asian countries, which causes acquired heart disease in childhood. It is characterized by an inflammatory acute febrile vasculitis of medium-sized arteries, particularly the coronary arteries. High-mobility group box-1 protein (HMGB1) is a non-histone chromosomal-binding protein present in the nucleus of eukaryotic cells, which contains 215 amino acid residues. Although the cellular signal transduction mechanisms of HMGB1 are currently unclear, the important role of the receptor for advanced glycation end-products (RAGE), the main receptor for HMGB1 has been reported in detail. The purpose of our study was to verify the mechanism and clinical significance of HMGB1-RAGE in coronary artery injury of Kawasaki disease.Methods52 blood samples of patients in KD were collected, and the coronary arteryZscore was calculated according to the echocardiographic results. TheZscore ≥ 2.0 was classified as coronary artery lesions (CAL); otherwise, it was no-coronary artery lesions (NCAL). In addition, the fever group and control group were set. Among them, the fever group were children with fever due to respiratory tract infection at the same time period as KD (heat peak ≥ 38.5 ℃). The normal group were children at a routine physical examination in the outpatient clinic of Nantong University and the physical examination center of the child care insurance, and there were no infectious diseases and heart diseases. The serum levels of HMGB1, RAGE, and NF-κB in each group were detected by ELISA. The animal model of KD was established using the New Zealand young rabbits. We used RT-qPCR/H&E staining/immunohistochemistry/ELISA and western blot to detect the level of HMGB1/RAGE and NF-κB.ResultsIn this study, we found that the HMGB1/RAGE/NF-κB axis was elevated in the serum of children with KD. In addition, an animal model of KD was subsequently prepared to examine the pathological changes of the coronary arteries. We found that the serum levels of HMGB1/RAGE/NF-κB in rabbits with KD were significantly higher than those of the control group. Moreover, the lumen diameter of the coronary artery was slightly enlarged, and the wall of the tube became thinner and deformed. In addition, the HMGB1/RAGE/NF-κB levels in the coronary artery were higher in the rabbits with KD in the acute phase.ConclusionsOn the whole, the findings of this study demonstrate that the expression of HMGB1/RAGE/NF-κB is altered at different stages of KD, suggesting that the HMGB1/RAGE/NF-κB signaling pathway plays an important role in vascular injury in KD. The results of this study may have important implications for the early warning of coronary artery lesions in KD.

Non-alcoholic fatty liver disease (NAFLD) is associated with a higher risk of atherosclerotic disease. However, the relationships between the severity of coronary atherosclerosis and pathologic findings in patients with NAFLD remain unknown. We aimed to characterize the coronary artery lesions in patients with NAFLD using coronary computed tomography angiography (CCTA). Overall, 101 patients with liver biopsy-proven NAFLD who had chest pain or electrocardiographic abnormalities underwent CCTA. Coronary artery lesions, including coronary artery stenosis (CAS), calcium score (CACS, Agatston score), and coronary artery non-calcified plaque were assessed using multi-slice CT. Multivariate analysis showed that age, smoking status, prevalence of dyslipidemia (DLP) and non-alcoholic steatohepatitis (NASH), and stage of fibrosis were independent risk factors for CAS. Age, and the prevalence of DM and DLP, were independent risk factors for CACS, and the prevalence of NASH tended to be an independent risk factor. In addition, the prevalence of DLP and NASH were independent risk factors for non-calcified plaques. Coronary artery lesions are more common in patients with NASH than in those with non-alcoholic fatty liver, suggesting a higher risk in patients with NASH. Therefore, patients with NASH should be closely followed, with particular vigilance for coronary artery diseases.

Background Truncus arteriosus is associated with coronary anomalies. We identified coronary artery lesions in patients undergoing repair of truncus arteriosus, defined the impact of lesions on mortality, and studied the effect of surgical intervention of coronary lesions. Methods A retrospective review identified 107 patients with truncus repair (1995-2019). Coronary lesions were categorized as ostial stenosis, intramural, juxtacommissural origin, and single coronary. Survival analysis characterized survival after truncus repair and studied the association of coronary lesions and mortality. Results Among 107 patients with truncus repair 34 patients had at least 1 coronary lesion. Median follow-up time was 7 years, with 85% 5-year survival. Coronary lesions including ostial stenosis, intramurality, and juxtacommissural origin were associated with increased mortality, whereas single coronaries did not impact survival. Eleven patients had 1 coronary lesion and 6 patients with 2 coronary lesions had similar (80% and 83%, respectively) 5-year survival. Eight patients with 3 coronary lesions had 24% 5-year survival (P = .0003). Among patients with 1 or 2 lesions, surgical intervention on the coronary lesions tended to be associated with longer 5-year survival (100% vs 62%, respectively; P = .06). All patients with 3 lesions underwent coronary artery intervention, with 24% 5-year survival. Conclusions Impact of coronary lesions on mortality after truncus repair increases with the number of lesions. Coronary artery intervention may be associated with improved time-related survival among patients with 1 or 2 lesions. Patients with the most complex anomalies (3 lesions) have poor survival and warrant ongoing study of repair techniques.

Purpose of Review It is the aim of this review to demonstrate the relevance of stress echocardiography in the era of fractional flow reserve by establishing the current use of stress echocardiography and fractional flow reserve, underlining their physiological basis and through this demonstrating the clear differences in their application. Recent Findings The importance of the microcirculation is only now being understood, no more so than in the fact that abnormalities in the microcirculation, determined by abnormal coronary flow reserve, predict adverse mortality regardless of the normality of the epicardial coronary lesions. Stress echocardiography therefore gives a fuller picture of the overall cardiovascular risk to our patients in its ability to interrogate the epicardial vessels down to the microcirculation, with a number of techniques available to measure coronary flow reserve such as myocardial perfusion stress echocardiography and transthoracic Doppler stress echocardiography of epicardial coronary vessels. Fractional flow reserve can then add further information by determining whether a coronary artery lesion is responsible for myocardial ischaemia. Summary In an era of fractional flow reserve affording the resolution of myocardial ischaemia down to the specific lesion, it can be tempting to think that other generally non-invasive techniques no longer have a role in the investigation and management of coronary artery disease. This, however, betrays a lack of understanding of the scope and complexity of coronary artery disease from epicardial vessels down to the microvasculature, the physiological basis of the tests available and therefore what, in fact, is actually being measured. For some, fractional flow reserve is held as a gold standard by which to compare other techniques such as stress echocardiography as correct or incorrect. However, these tests do not measure the same thing, and therefore, they cannot be directly compared. Stress echocardiography gives a fuller picture through its ability to account for the coronary flow reserve, considering the epicardial vessels down to the microvasculature. Fractional flow reserve is far more specific, looking at the effect of the lesion being interrogated. Furthermore, where fractional flow reserve is normal, we now know that knowledge of the coronary flow reserve is critical as it is this that allows us to predict the overall mortality risk of our patient. We therefore require a combination of the two techniques.

Background Aortic stiffness (AS) and distensibility (AD) have been shown as predictors for cardiovascular morbidity and mortality. Aim: To assess the relation of aortic stiffness and distensibility using simple two-dimensional (2D) and tissue Doppler imaging (TDI) derived measures with the severity of coronary artery disease (CAD) assessed using the syntax score (SS), evaluating which of these measures has better predictivity for CAD severity. Methods We prospectively enrolled 150 individuals who underwent elective coronary angiography for suspected CAD, out of them 29 subjects (19.3%) had normal angiographic findings, while 121 (80.7%) subjects had CAD for whom the SS was calculated. All patients underwent simple 2D and TDI echocardiographic assessment of AS and AD. Results Patients with CAD had significantly higher aortic stiffness and elastic modulus and significantly lower aortic distensibility, aortic strain, aortic peak systolic and peak early diastolic velocities compared to those without CAD. Univariate and multivariate logistic regression analysis showed that decreased aortic distensibility, aortic strain, aortic peak early diastolic velocity and increased elastic modulus were predictors for the severity and complexity of CAD. However, along with diabetes, increased aortic stiffness index (> 17.7) was the only independent predictor of CAD severity, carrying twice the odds of having moderate-high syntax score (OR= 2.19, 95% CI= 0.97 – 4.95, p< 0.05). Conclusion Aortic stiffness index can be a screening tool for detecting patients with more severe CAD. Univariate analysis Multivariate analysis Variables Odd’s ratio 95% confidence interval P value Odd’s ratio 95% confidence interval P value Age (years) 0.98 0.94-1.01 0.3 – –- – Sex (male) 1.52 0.58- 3.94 0.3 – –- – Smoking 1.21 0.59- 2.50 0.5 – –- – Diabetes mellitus 5.00 2.29-10.90 0.000 4.99 2.21- 11.31 0.000 Body mass index 0.93 0.83- 1.04 0.2 – –- – ↓↓ Distensibility (≤3.8)* 2.62 1.08- 4.70 0.02 2.01 0.91- 4.46 0.08 ↑↑ Stiffness index (>17.7)* 2.06 0.99- 4.27 0.05 2.19 0.97- 4.95 68.7)* 2.22 1.06- 4.64 0.03 2.01 0.91- 4.45 0.08 ↓↓ Aortic strain (≤9.3%)* 2.04 0.97- 4.27 0.05 1.64 0.73- 3.67 0.2 ↓↓ SAo (≤7cm/sec) 1.49 0.71- 3.12 0.2 – –- – ↓↓ EAo (≤9cm/sec) 2.30 1.08- 4.90 0.03 1.80 0.79- 4.10 0.1 Predictors of severity and complexity of CAD

Many post‐vulvectomy vulvar reconstruction solutions, using local fasciocutaneous flaps where possible, have been proposed. We report the use of V‐Y advancement flaps from the gluteal fold in medium to large vulvar reconstructions and a simple modification we made to the technique in order to minimise wound‐related complications. Between 2006 and 2016, 30 vulvar reconstructions were performed via a total of 59 flaps, 24 of which were raised using the proposed modification to the plasty design. Short‐ and long‐term (24 months) follow‐up data were analysed, postoperative flap sensitivity was tested, and any arising complications were recorded. The mean age of patients treated was 75.3 years (51‐92 years). The mean monolateral defect dimensions were 7.5 × 4.7 × 2.8 cm. Minor complications were recorded in 23% of patients (14% of flaps). One case of ostial stenosis occurred. Micturition and ambulation recovery was rapid, and flap sensitivity was fully restored 24 months after reconstruction. Scars were well hidden by natural soft tissue folds. The outcomes in this case series confirm that the gluteal V‐Y advancement fasciocutaneous flap is a useful and simple technique for reconstructing even large vulvar defects. It has a low functional and aesthetic impact and enables rapid return to autonomy. Moreover, the simple modification to the V‐Y flap proposed, designed to reduce tension at the apical part of the wound, appears to reduce the complication rate.

Kawasaki disease (KD) is a systemic vasculitis in children, which is related to inflammation and abnormal activation of immune system. Platelet activating factor (PAF) and its acetylhydrolase (PAF-AH) may play an important role in the pathogenesis of KD. This study aimed to investigate diagnosis and prognostic value of serum PAF and PAF-AH in KD. One hundred thirteen KD children were divided into coronary artery lesion (CAL) KD, noncoronary artery lesion (NCAL) KD, intravenous immunoglobulin (IVIG)-responsive KD, and IVIG-nonresponsive KD group. Seventy cases of fever control (F) group and 71 cases of normal control (N) group were set up. Peripheral venous blood was collected to detect serum PAF and PAF-AH levels, combined with other inflammatory mediators. Results showed that the serum levels of PAF and PAF-AH were significantly elevated in the KD group compared with F group and N group (

Objective:Stenting of ostial pulmonary artery stenosis presents several unique challenges. These include difficulty in defining anatomy and need for precise stent placement in order to avoid missing the ostial stenosis or jailing either the contralateral branch pulmonary artery or the ipsilateral upper lobe branch.Design:A retrospective review of outcomes was conducted in 1.5 or 2-ventricle patients who underwent stent placement for ostial branch pulmonary artery stenosis. Specific catheterisation lab techniques were reviewed.Results:Forty-seven branch pulmonary arteries underwent stent placement for ostial stenosis in 43 patients. The median age and weight were 3.7 (0.3–18.1) years and 14.2 (5.6–70.0) kg, respectively. Three (2–8) angiographic projections were needed to profile the ostial stenosis. Open-cell stents were used in 23 and stents were modified in 5 cases. Following stent implantation, the minimum diameter improved from 3.6 (0.8–10.5) to 8.1 (4.2–16.5) mm (p < 0.001). The gradient improved from 21 (0–66) to 4 (0–27) mmHg (p < 0.001). Stent malposition occurred in eight (17%) of the stents placed. Five migrated distally causing suboptimal ostial coverage necessitating placement of a second stent in four. Three migrated proximally and partially jailed the contralateral pulmonary artery. Intentional jailing of the upper lobe branch occurred in four additional cases. At a follow-up of 2.4 (0.3–4.9) years, 15 stents underwent further dilation and 1 had a second stent placed within the exiting stent.Conclusion:Ostial branch pulmonary artery stenosis may require additional angiography to accurately define the ostial stenosis. Treatment with stents is effective but carries high rates of stent malposition.

To investigate the clinical significance of serum soluble tumor necrosis factor receptor (sTNFR) II level and sTNFR II/I ratio as indicators of the development of coronary artery lesions (CALs) in Kawasaki disease (KD), we measured levels of serum sTNFR I and II, interleukin (IL)-6, IL-18, and neopterin in 63 patients with KD, including nine patients with CALs and 20 healthy controls. At the time of diagnosis of KD before intravenous immunoglobulin (IVIG) treatment, serum sTNFR I and II levels were found to be significantly higher in non-responders to IVIG treatment than in responders. On the contrary, serum sTNFR II levels and sTNFR II/I ratio were significantly higher in patients with KD having CALs than in those without CALs. Longitudinal observation in a patient with KD who is unresponsive to IVIG revealed sustained elevation of serum sTNFR II level, and elevated sTNFR II/I ratio was linked to the CALs development. Increase in serum sTNFR II level and elevated sTNFR II/I ratio may be promising indicators of the development of CALs in KD.

Purpose This study aimed to analyse laboratory values according to fever duration, and evaluate the relationship across these values during the acute phase of Kawasaki disease (KD) to aid in the early diagnosis for early-presenting KD and incomplete KD patients. Methods Clinical and laboratory data of patients with KD (n=615) were evaluated according to duration of fever at presentation, and were compared between patients with and without coronary artery lesions (CALs). For evaluation of the relationships across laboratory indices, patients with a fever duration of 5 days or 6 days were used (n=204). Results The mean fever duration was 6.6±2.3 days, and the proportions of patients with CALs was 19.3% (n=114). C-reactive proteins (CRPs) and neutrophil differential values were highest and hemoglobin, albumin, and lymphocyte differential values were lowest in the 6-day group. Patients with CALs had longer total fever duration, higher CRP and neutrophil differential values and lower hemoglobin and albumin values compared to patients without CALs. CRP, albumin, neutrophil differential, and hemoglobin values at the peak inflammation stage of KD showed positive or negative correlations each other. Conclusion The severity of systemic inflammation in KD was reflected in the laboratory values including CRP, neutrophil differential, albumin, and hemoglobin. Observing changes in these laboratory parameters by repeated examinations prior to the peak of inflammation in acute KD may aid in diagnosis of early-presenting KD patients.

Background Discussion of health-care transition (HCT) for adults with a childhood history of coronary artery lesions (CAL) after Kawasaki disease (KD) is important. A nationwide questionnaire survey was performed with support by the Japanese Society of Kawasaki Disease. The purpose of this study was to clarify the reality of HCT and loss to follow-up in patients with CAL after KD. Methods The survey was emailed to 48 members of the Japanese Society of Kawasaki Disease from May to July 2014. Results Forty surveys were collected, giving a response rate of 83.3%. Sixty-five percent of the respondents belonged to a university hospital. Approximately 90% of the respondents dealt with patients who needed HCT, and 55% had patients who completed HCT. Approximately 70% of the respondents considered that pediatricians should continue sharing HCT information with cardiologists. More than 95% of the respondents had a favorable or average impression of HCT care provided by cardiologists. The percentage of respondents who had loss to follow up for HCT was >40%. Conclusion Adult cardiologists began managing patients with CAL after KD in more than half of the institutes in this study. Pediatricians should construct a support program for better management of these patients and for cooperation with cardiologists to prevent loss to follow up.

Purpose: To describe a novel technique designed to safely and precisely deploy the Supera stent accurately at the ostium of the proximal superficial femoral artery (SFA) without compromising the profunda and common femoral arteries. Technique: After antegrade crossing of the chronic total occlusion (CTO) at the SFA ostium and accurate predilation of the entire SFA lesion, a retrograde arterial access is obtained. The Supera stent is navigated in retrograde fashion to position the first crown to be released just at the SFA ostium. Antegrade dilation is performed across the retrograde access site to obtain adequate hemostasis. The technique has been applied successfully in 21 patients (mean age 78.1±8.2 years; 13 men) with critical limb ischemia using retrograde Supera stenting from the proximal anterior tibial artery (n=6), the posterior tibial artery (n=2), retrograde stent puncture in the mid to distal SFA (n=2), the native distal SFA/proximal popliteal segment (n=6), and the distal anterior tibial artery (n=5). No complications were observed. Conclusion: Distal retrograde Supera stent passage and reverse deployment allow precise and safe Supera stenting at the SFA ostium.