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In the past decade, the Transradial Approach (TRA) has constantly gained ground among interventional cardiologists. TRA’s anatomical advantages, in addition to patients’ acceptance and financial benefits, due to rapid patient mobilization and shorter hospital stay, made it the default approach in most catheterization laboratories. Access-site complications of TRA are rare and usually of little clinical impact, thus, they are often overlooked and underdiagnosed. Radial Artery Occlusion (RAO) is the most common, followed by radial artery spasm, perforation, hemorrhagic complications, pseudoaneurysm, arterio-venous fistula, and even rarer complications, such as nerve injury, sterile granuloma, eversion endarterectomy or skin necrosis. Most of them are conservatively treated, but rarely, surgical treatment may be needed and late diagnosis may lead to life-threatening situations, such as hand ischemia or compartment syndrome and tissue loss. Additionally, some complications may eventually lead to TRA failure and switch to a different approach. On the other hand, it is the opinion of the authors that non-occlusive radial artery injury, commonly included in TRA’s complications in the literature, should be regarded more as an anticipated functional and anatomical cascade, following radial artery puncture and sheath insertion.

We describe a case report of a 30-year-old bodybuilder suffering acute myocardial infarction (AMI). He had been taking stanozolol and testosterone for two months. The coronary angiogram showed high thrombotic burden in the left anterior descending artery without underlying atherosclerosis. Few case reports of AMI in athletes taking anabolic androgenic steroids (AASs) have been reported so far. AAS-related AMI is possibly underreported in the medical literature due to the desire of the affected individuals to hide AAS use. Physicians should always consider the possibility of AAS abuse in the context of a young athlete suffering AMI. AASs can predispose to AMI through the acceleration of coronary atherosclerosis. Additionally, thrombosis without underlying atherosclerosis or vasospasm is highly possible to cause AMI in AAS users. Complications after AMI may be more frequent in AAS users.

AIMS: Conflicting data exist on the impact on outcome of the use of different stent types during carotid artery stenting (CAS). The aim of this study was to evaluate clinical outcomes according to different carotid stent design among the population of the European Registry of Carotid Artery Stenting (ERCAS). METHODS AND RESULTS: The present study was conducted in 1,604 patients who underwent neuroprotected CAS in ERCAS. All types of commercially available carotid stent were used. Open-cell design stents were classified according to free cell area into 7.5 mm2. A total of 713 closed-cell, 456 hybrid-cell, 238 7.5 mm2 open-cell stents were implanted. Overall, the 30-day stroke and death rate was 1.37%. At 30 days, 19 strokes occurred (1.18%): eight in the group of patients treated with a closed-cell (1.12%), two in those with a hybrid-cell (0.44%), three in those with a 7.5 mm2 open-cell stent (3.05%) (p=0.045). CONCLUSIONS: Data of the present study suggest that, in the setting of neuroprotected CAS performed in high-volume centres by properly trained operators, the use of an open-cell design stent with a free cell area >7.5 mm2 may be associated with an increased 30-day stroke risk.

Background De novo formation of arteriovenous malformations (AVMs) and arteriovenous fistulas (AVFs) is increasingly being reported in the neurosurgical literature, challenging the notion that AVMs are congenital in origin. Most of this literature centers around the pediatric population. After treatment of an AVM or AVF, recurrence, if any, appears to occur locally to the original insult. We present, to the best of our knowledge, the first case of a de novo direct AVF involving an anterior communicating artery aneurysm in a remote site from a prior ruptured AVM in a pediatric patient. Case Description We present a case of a 14-year-old female who presented 2 years prior with an intraparenchymal hemorrhage secondary to a left parietal arteriovenous malformation. That AVM was successfully microsurgically resected and revealed complete angiographic obliteration on postoperative and surveillance angiograms. This patient now presents with a spontaneous intraventricular hemorrhage secondary to a ruptured anterior communicating artery complex aneurysm with a fistulous connection from this aneurysm to the inferior petrosal sinus. The aneurysm and direct AVF were not identified on prior surveillance imaging, indicating de novo formation in a remote site from her prior AVM. Conclusions This case highlights the importance of long-term imaging surveillance in patients with AVMs. Further prospective studies are indicated to evaluate the long-term imaging surveillance necessary to detect early recurrence, thereby allowing doctors to institute earlier definitive treatment. The exact pathophysiology behind these lesions is not fully understood; however, this case lends support to an acquired etiology to vascular malformations.

Compared with conventional angiogram-guided procedure, intravascular imaging modalities give us a lot of useful information to make the procedure better. Intravascular imaging modalities give us the information about lesion characters, reference vessel diameter and the interaction between the stent strut and the plaque such as stent strut malapposition or plaque prolapse in real time during the procedure. We can change our strategy according to this information. Intravascular ultrasound (IVUS) is a most common intravascular imaging modality during carotid artery stenting (CAS) in these days. Its advantage is easy to use compared with optical coherence tomograpy (OCT) which has been reported recently in some case reports or case series. However, due to its high resolution, OCT provides more detailed information especially about plaque prolapse and strut malapposition. IVUS and OCT have a potential to improve acute result and reduce the procedural complication by providing the data of lesion character, reference vessel diameter and the interaction of stent strut and vessel wall. Interventionalists who perform CAS procedure should acquire proficiency in imaging modalities during CAS procedure.

Carotid artery stenting (CAS) is considered an alternative option to carotid endarterectomy (CEA) for significant carotid stenosis, in both symptomatic and asymptomatic patients. Comparing to CEA, CAS offers significant advantages. The most important arise from the minimally invasive nature of the procedure, which reduces the surgical complications and adds significant comfort to the patient, without compromising the efficacy. Nowadays, CAS can achieve acute and long-term outcome results comparable to CEA, maintaining low rates of periprocedural embolic events. Evolution of the stent design and routine application of protection devices, played an important role to CAS performance. In this review, we aim to present all available new data on stent design and protection devices while we pose a set of unanswered questions that need to be addressed in the future.

Objective We examined trans-radial approach (TRA) use in coronary angiographies (CAs) as well as in percutaneous coronary interventions (PCIs) in specific regions of Greece, its distribution in public and private catheterization laboratories (CLs) and its preference by operators. Reliable data regarding the use of TRA are not available in Greece. Methods The study was performed in northern and central Greece, which constitutes 35.32% of the national population. This study focused on the years 2004, 2009 and 2013. Results There are 12 CLs. CAs performed using TRA were 0.43% in 2004, 12.28% in 2009 and 39.81% in 2013, whereas PCIs performed using TRA were 0.38%, 9.20% and 39.48%, respectively. Operators familiar with TRA, but who performed TRA electively, were 13.33% in 2004, 60.38% in 2009 and 42.37% in 2013. However, operators performing TRA routinely were 2.2%, 5.66%, and 49.15%, respectively. In 2013, there was a 3.76% decrease in CAs and 4.51% decrease in PCIs compared to 2009; in private CLs, there was a 29.63% decrease in CAs and 34.72% decrease in PCIs performed, which was contradictory to the 27.27% increase observed in CAs and 29.83% increase in PCIs in public CLs. Conclusions This is the first study to reveal the volumes and trends in interventions performed via TRA across central and northern Greece. TRA has gained a reputation among operators in both public and private CLs. Due to the financial crisis in Greece, catheterizations have been diminished, whereas private CLs have lost a great amount of their turnover.

BACKGROUND: Plagiocephaly, involving positional deformity of the calvarium in infants, is one of the most common reasons for pediatric neurosurgical consultation. OBJECTIVE: To answer the question: “what is the evidence for the effectiveness of repositioning for positional plagiocephaly?” Treatment recommendations are provided based on the available evidence. METHODS: The National Library of Medicine MEDLINE database and the Cochrane Library were queried using MeSH headings and key words relevant to repositioning as a means to treat plagiocephaly and brachycephaly. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III). RESULTS: There were 3 randomized trials (Class I), 1 prospective cohort study (Class II), and 6 retrospective cohort studies (Class III). Repositioning education was found to be equal to a repositioning device and inferior to a physical therapy program. Five of the 7 cohort studies comparing repositioning with a helmet reported helmets to be better and take less time. CONCLUSION: Within the limits of this systematic review, repositioning education is effective in affording some degree of correction in virtually all infants with positional plagiocephaly or brachycephaly. Most studies suggest that a molding helmet corrects asymmetry more rapidly and to a greater degree than repositioning education. In a Class I study, repositioning education was as effective as repositioning education in conjunction with a repositioning wrap/device. Another Class I study demonstrated that a bedding pillow was superior to physical therapy for some infants. However, in keeping with the American Academy of Pediatrics' warning against the use of soft positioning pillows in the sleeping environment, the Task Force recommends physical therapy over any positioning device. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_3.

Percutaneous coronary intervention of chronic total occlusion carries the risk of severe complications that are responsible for a significant morbidity and mortality rate associated with these procedures. Complications may be cardiac, such as acute myocardial infarction and coronary perforation, or extracardiac, such as aortic dissection, contrast-induced nephropathy and radiation skin injuries. The mechanisms, prevention and treatment of complications associated with percutaneous coronary intervention of chronic total occlusion are reviewed in this article.

PURPOSE To determine the safety, feasibility, and efficacy of carotid artery stenting (CAS) in patients with acute stroke who underwent angioplasty of the extracranial internal carotid artery (ICA). METHODS Patients were eligible for CAS if they presented within 6 hours of symptom onset and had a National Institutes of Health Stroke Scale (NIHSS) score >4. The records of all 18 acute stroke patients (11 men; mean age 68.3+/-14.3 years) who underwent endovascular intervention in the stroke-related extracranial ICA between May 2003 and February 2006 were reviewed. Fourteen (77.8%) had atheromatous obstructions and 4 (22.2%) had dissection of the extracranial ICA. Major adverse cerebral and cardiac events (MACCEs) and neurological status, including NIHSS and the modified Rankin Scale (mRS) scores, were recorded for all patients. RESULTS Successful revascularization was achieved in 83.3% (15/18) of the patients. Cerebral protection devices were applied successfully in 13 (72.2%). At discharge, a neurological improvement (NIHSS reduction > or =4) was observed in 77.8% (14/18) of patients. The clinical success rate was 72.2% (13/18). The median NIHSS was 8.5 on admission versus 4.5 at discharge (p

Only limited data exist regarding the long-term efficacy of beta-brachytherapy (beta-VBT) in routine clinical practice and the impact of the prolonged (6 months) combined antiplatelet therapy after beta-VBT. Our aim is to examine the long-term clinical efficacy of routine beta brachytherapy (beta-VBT) followed by indefinite administration of combined antiplatelet therapy in patients at high restenotic risk.Sixty-one patients with 65 lesions [de novo: 41, in-stent restenotic (ISR): 24] underwent intracoronary beta-VBT and were followed prospectively. All patients received indefinite administration of aspirin and clopidogrel, underwent routine angiography 6 months later and were followed-up clinically for 43.7 months (range: 32 to 52 months).Acute success was achieved in 60/61 (98.4%) patients. Lesion length was 36.1 (+/-17.6) mm for the de novo and 22.0 (+/-9.8) mm for the ISR (p=0.001). Stents were implanted in 35/41 de novo and 7/24 ISR lesions (p0.01). Six-month binary restenosis after successful beta-VBT was 35.9% (23/64). During follow-up patients with de-novo lesions who received a new stent during index procedure had a higher incidence of major cardiac events than patients with ISR lesions without a new stent (log rank test, p=0.02). Acute and late thrombotic events were reported at 6 patients, all with de novo lesions and stent implantation.Beta-VBT plus stenting in de novo lesions is related to an unacceptable high rate of thrombotic complications and clinical restenosis despite prolonged administration of combined antiplatelet therapy. Brachytherapy remains a reasonable option for patients with ISR lesions until full data from large randomized trials comparing drug eluting stents with brachytherapy are available.

Intracranial infectious aneurysms in the pediatric population are rare. Although surgery has been the traditional treatment of ruptured pediatric infectious aneurysms, endovascular coil embolization has become an attractive alternative due to its low rate of morbidity and mortality. A 9-year-old boy with a significant medical history of aortic valve replacement, antibiotic-treated infective endocarditis, and multiple embolic cerebral infarcts presented with a high-grade intraventricular hemorrhage due to the rupture of a large infectious proximal posterior circulation aneurysm. Computed tomography and cerebral angiogram demonstrated a right crural/ambient cistern hematoma and an associated infectious aneurysm of the right proximal posterior cerebral artery. The ruptured infectious aneurysm was coil-embolized with hydrogel-coated platinum coils without sacrifice of the distal parent artery. The aneurysm was completely occluded, and the patient regained all neurological function. Ruptured infectious aneurysms in the pediatric population occur despite aggressive medical therapy. Patients with infective endocarditis and embolic infarcts should be followed closely due to the risk of major hemorrhagic events, including aneurysm rupture. Hybrid coil embolization of ruptured infectious aneurysms with preservation of the distal parent artery is exceedingly rare and effective in the management of ruptured infectious aneurysms in the pediatric population.

Coronary artery aneurysm is an uncommon disease, whose natural history and therapeutic approach are still controversial: medical therapy, surgical revascularization with or without aneurysm ligation or excision, and endovascular exclusion with membrane covered stents are all accepted and viable options, according to anatomic characteristics. Intracranial aneurysms are adequately treated by means of coil embolization, an option that, to our knowledge, has never been tested in coronary interventions. We report the first case of a coronary aneurysm involving the distal left main and the proximal left anterior descending artery treated with “stent-assisted” coil embolization. © 2011 Wiley-Liss, Inc.

Objectives The aim of this study was to assess the safety and effectiveness of carotid artery stenting (CAS) with proximal cerebral protection in patients showing string sign at carotid angiography. Background Presence of string sign is a well-known factor for adverse events in patients with severe carotid artery disease undergoing CAS. Methods We used retrospective analysis of a cohort of patients who underwent carotid angiography with the intention to undergo carotid stenting and had angiographically documented string sign in the target lesion. Results From October 2006 to August 2007, 25 patients (21 men and 4 women, mean age 70.9 ± 8.7 years) presented with string sign during carotid angiography. This was 6.0% of a total of 416 patients studied during the time of the study. Twenty patients (80.0%) were symptomatic, and 5 (20.0%) were asymptomatic. Carotid artery stenting was performed successively in all patients. Proximal cerebral protection was applied in all but 1 patient. The 30-day death/stroke rate was 0%. At 12-month follow-up neurological events did not occur; 1 patient developed a nonfatal myocardial infarction, and another patient died from noncardiac cause. The 12-month death/stroke rate was 4.0%. Conclusions Carotid stenting under proximal cerebral protection seems to be a feasible and safe procedure to manage patients with severe carotid stenosis in presence of angiographic string sign. Further prospective trials are required to prove efficacy of CAS in larger study populations.

Aortic coarctation is a congenital malformation of the aorta usually diagnosed and corrected early in life. Long-term survival is exceptional in patients with untreated aortic coarctation. In this case report, we present a late diagnosis of aortic coarctation in a 72-year-old female. Our patient was relatively asymptomatic until she presented with exertional dyspnea and fatigue in her seventh decade of life. The patient was managed conservatively with aggressive antihypertensive medication. After the 1-year follow-up visit, the patient was in good clinical condition, without, however, adequate control of blood pressure.