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Background The aim of this experimental study was to assess the feasibility of complete endovascular arch reconstruction by in situ retrograde fenestration and to investigate the impact of stent-graft material on stent-graft fenestrations. Methods The experiments were performed using 8 cadaveric human thoracic aortas (aortic arch) using 2 different stent-graft types: woven polyester (Valiant Captivia; Medtronic Vascular, Santa Rosa, CA) and expanded polytetrafluoroethylene (conformable [C]-TAG; W.L. Gore & Associates, Flagstaff, AZ). A benchtop aortic pulsatile flow model was used. Stent-grafts were deployed into the aortic arch, covering the ostia of the supraaortic trunks. A 5-mm 30-degree angioscope was introduced into the ascending aorta to monitor the procedure. Retrograde fenestration and deployment of the balloon expandable stent-graft was performed sequentially for each supraaortic trunk. Subsequent to stent-graft explantation, macroscopic evaluation of each fenestration was performed. Results All attempts to fenestrate the C-TAG and Valiant stent-grafts and implant the covered stent through the supraaortic trunks were successful. In all cases, branch stents were patent and no endoleak was evident. The Valiant stent-graft was easier to puncture because of the higher radial force of the stent-graft providing better counterpressure; however, stent-graft material had no impact on the quality of fenestrations. Conclusions Total endovascular repair of the aortic arch through in situ retrograde fenestration of stent-grafts is feasible. The behavior of the 2 types of stent-graft was significantly different while the fenestrations were fashioned, but stent-graft material had no impact on the quality of fenestrations.

The Sapien 3 (S3) balloon expandable aortic valve equipped with an outer skirt to minimize paravalvular leakage (PVL) was built upon the predecessor Sapien XT (SXT) valve. There is scant comparative data of transcatheter aortic valve replacement using S3 versus SXT valve. The study shows that S3 valve is associated with reduced PVL rate compared with SXT, which is an important clinical advantage.

The expandable sheath was designed with a lower profile in order to reduce the incidence of vascular complications of transcatheter aortic valve implantation using transfemoral approach. However, once the prosthesis has crossed the sheath, it could be difficult to retrieve it from the body. This is the first case of successful bail-out in an instance of delivery balloon shaft malfunction subsequent to the crossing of an expandable sheath during implantation of an Edwards SAPIEN 3 prosthesis. © 2016 Wiley Periodicals, Inc.

Ricardo Allende, Rishi Puri, Eric Dumont, Maria del Trigo, Omar Abdul-Jawad Altisent, Josep Rodes-Cabau

The occurrence of conduction disturbances and the need for permanent pacemaker implantation remain a significant issue associated with transcatheter aortic valve replacement (TAVR) [(1)][1]. Indeed, the contiguity of the conduction system to the aortic annulus (landing zone of transcatheter valve

An 84-year-old woman was diagnosed with symptomatic severe aortic stenosis. She had previously undergone aortobifemoral bypass grafting (Y graft) for bilateral iliac stenosis. In view of a high surgical risk, a decision for transcatheter aortic valve implantation (TAVI) was made. An incision was made on the right limb of the Y graft and subsequently a 16 Fr e-sheath was smoothly advanced through the graft. A 23 mm balloon expandable valve was then advanced with no resistance and successfully deployed. This case highlights the feasibility of TAVI through the graft, but requires a thorough preprocedural assessment of the access route using multiple imaging modalities.

Despite the promising outcomes of transcatheter aortic valve replacement (TAVR), adverse events may occur as a result of suboptimal placement. The aim of this study is to evaluate the effect of various TAVR deployment positions on the risk for intra-procedural migration and of post-procedural paravalvular regurgitation. Finite Element (FE) and Computational Fluid Dynamics (CFD) models are presented for several procedural scenarios for a patient-specific morphology. Crimping and deployment of balloon-expandable Edwards SAPIEN were modeled in three locations. The proximal deployment resulted in higher risk for migration, while the distal and midway positioning resulted in comparable outcomes. These resulting configurations were used to assess diastolic hemodynamics. The distal case had preferred hemodynamics compared to the midway with more limited leakage. The proposed approach has the potential to be used in procedural planning to ultimately achieve better clinical outcomes.

Objectives The main goal of this study was to compare the occurrence of post-deployment leaflet injury between prostheses made of porcine and bovine pericardium. Methods Two types of prostheses, self-expandable prostheses with porcine pericardial leaflet on one side and balloon-expandable prostheses with bovine pericardial leaflet on the other side, were used. In each group, crimped prostheses were compared with control non-crimped prostheses. Following a 15-min period of crimping, prostheses were deployed, and their leaflets were removed and subjected to analyses. The analyses included determination of global and local hydraulic conductance of the leaflets, leaflet plasma insudation and microscopic analysis. The results were expressed as percentage (standard error of the mean) or median (interquartile range). Results A significant increase in the global hydraulic conductance was only observed in the crimped balloon-expandable prostheses: 20.1 (15.5-41.2) ml/h/m2/mmHg vs 12.3 (9.0-15.6) ml/h/m2/mmHg (P = 0.021). Similarly, areas of marked staining (a marker of local hydraulic conductance) were only seen in the bovine pericardium balloon-expandable prostheses. The incidence of leaflet plasmatic insudation was increased in the crimped prostheses compared with the control prostheses. The microscopic study revealed a higher occurrence of traumatic lesions in the crimped prostheses in comparison with the control prostheses: 33.3 ± 21.1% vs 5.5 ± 5.5% (P = 0.039) and 44.4 ± 20.5% vs 5.5 ± 5.5% (P = 0.017) in the bovine and the porcine leaflets, respectively. Conclusions Post-deployment leaflet injury occurred in both types of prostheses. However, alteration of the global and local hydraulic conductance was important in the bovine pericardium balloon-expandable prostheses.

A 59-year-old man with critical claudication underwent left femoro-anterior bypass grafting, which was uneventful. The graft was tunneled medially across the knee, then anterior to the tibia. His symptoms recurred 1 year later and he was found to have critical stenosis of the vein graft just proximal to the anterior tibial arterial anastomosis. This was treated with scaffolded balloon angioplasty and implantation of a coronary, zotarolimus-eluting balloon-expandable stent, which was also uneventful. However, his claudication again recurred 1 year later. Diagnostic angiography revealed crush, deformation and restenosis of the balloon-expandable stent requiring surgical revision of the bypass graft.

Transcatheter mitral valve-in-ring (VIR) implantation is known to be a feasible treatment for recurrent mitral regurgitation (MR) after failing surgical annuloplasty in inoperable patients. The difficulties of this procedure are related to different shapes and material characteristics of the

Transcatheter aortic-valve implantation (TAVI) is an accepted treatment for patients with severe aortic stenosis and high surgical risk. However, there is lack in data about TAVI in low-risk patients that are already being treated with this therapy in some clinical contexts.A retrospective analysis of patients treated with transfemoral TAVI using Edwards Sapien prosthesis in one center was performed, classifying the patients into three groups according to the surgical risk (high/intermediate/low risk for STS score8/4-8/4). Clinical characteristics, procedure and follow-up outcomes were collected, comparing the results between low and high surgical risk groups.89 TAVIs using Edwards balloon expandable prosthesis were performed (9 Sapien XT and 80 Sapien 3 valves were implanted). 40 patients (45%) presented a STS score4, while 33 (37%) had a STS8. Low-risk patients were significantly younger and had lower rates of coronary artery disease, peripheral vascular disease, pulmonary lung disease and atrial fibrillation. There were no significant differences in most of the technical variables of the procedure, apart from vascular complications and complete left bundle branch block after valve implant, which were higher in the group with STS8. Patients of low risk presented shorter hospital stay (2,91±1,6, vs 4,8±3,9 days), with lower rates of mortality at mid- and long follow-up (death from any cause 15,2% vs 0%, p 0,04).TAVI in low-risk patients is safe and associated with better outcome at mid and long-term follow-up compared to high-risk patients.

INTRODUCTION Three-dimensional (3D) prototyping is a novel technology which can be used to plan and guide complex procedures such as transcatheter mitral valve replacement (TMVR). METHODS Eight patients with severe mitral annular calcification (MAC) underwent TMVR. 3D digital models with digital balloon expandable valves were created from pre-procedure CT scans using dedicated software. Five models were printed. These models were used to assess prosthesis sizing, anchoring, expansion, paravalvular gaps, left ventricular outflow tract (LVOT) obstruction, and other potential procedure pitfalls. Results of 3D prototyping were then compared to post procedural imaging to determine how closely the achieved procedural result mirrored the 3D modeled result. RESULTS 3D prototyping simulated LVOT obstruction in one patient who developed it and in another patient who underwent alcohol septal ablation prior to TMVR. Valve sizing correlated with actual placed valve size in six out of the eight patients and more than mild paravalvular leak (PVL) was simulated in two of the three patients who had it. Patients who had mismatch between their modeled valve size and post-procedural imaging were the ones that had anterior leaflet resection which could have altered valve sizing and PVL simulation. 3D printed model of one of the latter patients allowed modification of anterior leaflet to simulate surgical resection and was able to estimate the size and location of the PVL after inserting a valve stent into the physical model. CONCLUSION 3D prototyping in TMVR for severe MAC is feasible for simulating valve sizing, apposition, expansion, PVL, and LVOT obstruction.

BackgroundEquipoise of transcatheter aortic valve replacement with surgical aortic valve replacement in intermediate-risk patients has been demonstrated. As transcatheter aortic valve replacement usage expands, questions regarding long-term durability become paramount. Valve design impacts durability with regions of increased leaflet stress being vulnerable to early failure. However, transcatheter aortic valve (TAV) leaflet stresses are unknown. The objective of this study was to determine stent and leaflet stresses of second-generation balloon-expandable TAV.MethodsCommercial 29-mm Edwards Sapien XT (Edwards Lifesciences, Irvine, CA) valves underwent high-resolution microcomputed tomography scanning to develop precise three-dimensional geometric mesh. Compressed and uncompressed TAVs were modeled under systemic pressure using finite element software. Material properties of stent were based on cobalt-chromium, whereas those for leaflets were obtained from surgical bioprostheses.ResultsMaximum and minimum principal stresses on uncompressed Sapien XT TAV were 1.63 MPa and-0.36 MPa on leaflets and 93.3 MPa and-105.6 MPa on stent at diastolic pressure. Peak leaflet stress was observed at commissural tips where leaflets connected to the stent. For compressed TAV to 26 mm, maximum and minimum principal stresses were 1.55 MPa and-0.63 MPa on leaflets and 526.1 MPa and-902.2 MPa on stent at diastolic pressure. Peak leaflet stress was located at similar position and also along the suture line with the Dacron (C. R. Bard, Haverhill, PA).ConclusionsStress analysis of two extreme deployed geometries of 29-mm Edwards Sapien XT using exact geometry from high-resolution scans demonstrated that peak stresses for TAV leaflets were present at commissural tips where leaflets were attached. These regions would be mostly likely to initiate degeneration.

AIMS We aimed to evaluate the effect of omitting predilation on feasibility, procedural results and safety in balloon-expandable TAVI. METHODS AND RESULTS We performed an analysis of all 680 patients scheduled for a balloon-expandable TAVI prosthesis between January 2011 and August 2016. Patients treated with or without predilation were compared. Procedure times decreased from 85.6±42.9 to 56.7±26.1 minutes (p

We report a case of successful, life-saving implantation of a covered Cheatham Platinum stent, an all-in-one NuDEL catheter system, in an adult with aortic rupture after bare-metal stenting for re-coarctation of the aorta.

Objective: It has been reported that balloon aortic valvuloplasty immediately before transfemoral or transapical transcatheter aortic valve implantation has mostly little to no clinical value. We aimed to provide data on the need for balloon aortic valvuloplasty in patients undergoing transaortic transcatheter aortic valve implantation. Methods: Patients undergoing transaortic transcatheter aortic valve implantation with the Edwards SAPIEN XT (Nyon, Switzerland) or 3 transcatheter heart valve were prospectively included at 18 sites across Europe. In the present analysis, we compare the periprocedural and 30-day outcomes of patients undergoing conventional (thorn balloon aortic valvuloplasty) versus direct (-balloon aortic valvuloplasty) transaortic transcatheter aortic valve implantation. Results: Of the 300 patients enrolled, 222 underwent conventional and 78 underwent direct transaortic transcatheter aortic valve implantation. Peak and mean transvalvular gradients were improved in both groups with no significant difference between groups. Procedural duration, contrast agent volume, and requirement for postdilation were also comparable. A trend toward fewer periprocedural complications was evident in the direct group (3.9% vs 11.3%; P = .053), with significantly lower rates of permanent pacemaker implantation (0% vs 5.0%; P = .034). Balloon aortic valvuloplasty omission had no significant effect on any of the 30-day safety and efficacy outcomes, including Valve Academic Research Consortium-2 composite end points (early safety events: 22.7% vs 17.4%, odds ratio, 1.17, 95% confidence interval, 0.53-2.62; clinical efficacy events: 20.5% vs 18.7%, odds ratio, 1.14, 95% confidence interval, 0.51-2.55). Conclusions: For many patients, balloon aortic valvuloplasty predilation seems to have little clinical value in transaortic transcatheter aortic valve implantation using a balloon expandable transcatheter valve and may result in a higher rate of periprocedural complications, particularly in terms of permanent pacemaker implantation.

Purpose: To show the feasibility of the Nellix device in conjunction with a chimney technique for treating juxtarenal aneurysms in two patients who were deemed unsuitable for fenestrated endovascular aneurysm repair or open surgery.Case Reports: Two men aged 83 and 81 years were referred with a juxtarenal abdominal aortic aneurysm (66 and 69 mm, respectively). Both were considered for open surgery as well as custom-made fenestrated stent-graft but deemed unsuitable for both options. They were both treated using the Nellix endoprosthesis in combination with chimney grafts to preserve the renal arteries. Technical success was achieved in both cases, with successful aneurysm exclusion and target vessel preservation (the right renal artery in the first case and both renal arteries in the second). At 6 months, duplex ultrasound and computed tomographic angiography of the first patient showed no signs of endoleak and patent renal arteries. The second patient developed a right retroperitoneal hematoma with minor extravasation near the lower pole of the right kidney for which coil embolization was necessary. The subsequent clinical sequelae led to respiratory insufficiency and ultimately death.Conclusion: The use of the Nellix endoprosthesis combined with chimney grafts is technically feasible. The addition of chimney grafts can increase the applicability of endovascular aneurysm sealing to treat short-neck and juxtarenal aneurysms. Further studies are needed to confirm these findings and establish longer term outcome.

Objective Intravascular stent placement in patients with congenital heart disease has replaced several surgical procedures because the desired outcome is achieved with a lower risk of complications. However, the blood vessels of children undergo a two- to threefold diameter increase due to somatic growth creating a dilemma: Can stents implanted in infants and children be serially dilated to significantly larger diameters without losing integrity and important mechanical characteristics? Our aim was to assess the expansion potential and to characterize mechanical parameters of balloon expandable stents at the maximum expansion diameter. Design Sixteen commonly used stent designs were evaluated. Physical attributes (sheath size and guide wire size) and the following mechanical parameters were determined, compared, and contrasted: fracture diameter, maximum expansion diameter, stent integrity, outer diameter, diameter uniformity, diameter recoil, length change, radial stiffness, and radial strength. Results Stents were dilated to an average of 1.7 times (range from 1.3 to 2.4 times) the nominal expansion diameter without losing mechanical integrity. Stents at the maximum expansion diameter maintained diameter uniformity (with less than 3.2% difference) and demonstrated minimal diameter recoil once the balloon catheter was deflated (less than 3.6% recoil). At the maximum expansion diameter, stent length varied depending on stent type. When dilated to the maximum expansion diameter, radial stiffness and radial strength of all stents increased compared with the stents’ nominal expansion diameter. Conclusions Balloon expandable stents maintain excellent mechanical characteristics when dilated beyond their manufacturers’ recommended nominal expansion diameter. These results support the use of balloon expandable stents in smaller vessels that require future serial redilation.

Stents are medical devices used in cardiovascular intervention for unblocking the diseased arteries and restoring blood flow. A setup for the measurement of the longitudinal flexibility of a coronary stent was developed based on machine vision technology. A crimped stent made by medical stainless steel thin-walled tube was tested with the setup. The results show that the bending deformation of stent includes two phases: the elastic deformation phase and the plastic deformation phase. The bending angle changed very little with the increase of bending moment during the elastic deformation. However, the bending angle changed significantly when a small moment was applied during the plastic deformation. In conclusion, the experimental setup can be used to study and compare flexibility of different design kinds of coronary stents and provides a convenient tool for designers to improve bending characteristics of new stents.

Transcatheter implantation of a balloon expandable valve in calcified severely stenosed native mitral valves has recently been described. The two cases reported so far utilized the surgical transapical approach generally used for transapical transcatheter aortic valve replacement. A percutaneous approach has not been published. We report the first successful percutaneous implantation of a balloon expandable transcatheter valve in the native mitral valve without a surgical incision.

We report a case of valve-in-valve (ViV) implantation by transfemoral approach with a 23-mm balloon-expandable prosthesis inside a stentless 19-mm acutely degenerated bioprosthesis, using a strategy of “extreme” underfilling. A 74-year-old patient presented to our institution in cardiogenic shock. An initial transesophageal echocardiography (TEE) showed severe central aortic regurgitation (AR) due to a torn leaflet. She was deemed inoperable and considered for urgent transcatheter aortic valve replacement. Given the fairly small true internal diameter, a strategy of 3-cc underfilling of a 23-mm transcatheter heart valve (THV) was planned. However, the final implantation was performed with 5-cc underfilling due to the incapacity to deliver the entire amount of fluid contained in the inflation syringe. TEE guidance confirmed the successful positioning and deployment of the prosthesis, with no AR and a mean gradient of 25 mm Hg. While implantation of a smaller prosthesis (20 mm) was debated during the Heart Team discussion, the risk of valve embolization due to inadequate anchoring inside the stentless prosthesis led to the selection of a 23-mm THV. At 6-month follow-up, the patient was in NYHA class I, with no AR and a mean gradient of 28 mm Hg. We report for the first time the use of in vivo THV with 5-cc underfilling with no acute or shortterm structural failure, and the first ViV implantation by transfemoral approach with a 23-mm balloon-expandable prosthesis inside a stentless 19-mm bioprosthesis. The current report presents the challenges related to ViV implantation inside a small stentless bioprosthesis and offers practical ways to overcome them. V C 2014 Wiley

Background We report the findings of the SOURCE-ANZ registry of the clinical outcomes of the Edwards SAPIEN™ Transcatheter Heart Valve (THV) in the Australian and New Zealand (ANZ) clinical environment. Methods This single arm registry of select patients treated in eight centres, represent the initial experience within ANZ with the balloon expandable Edwards SAPIEN THV delivered by transfemoral (TF) and transapical (TA) access. Results The total enrolment for the study was 132 patients, 63 patients treated by TF, 56 by TA, and 2 patients were withdrawn from the study. The mean ages: 83.7 (TF) and 81.7 (TA), female: 34.3% (TF) and 61.3% (TA), logistic EuroSCORE: 26.8% (TF) and 28.8% (TA), and with procedural success (successful implant without conversion to surgery or death): 92.4% (TF) and 87.1% (TA) (p=0.32). Outcomes were not significantly different between TF and TA implants. These included one year mortality of 13.6% (TF) and 21.7% (TA) (p=0.24), MACCE: 16.7% (TF) and 28.3% (TA) (p=0.12), pacemaker: 4.6% (TF) and 8.3% (TA) (p=0.39), and VARC major vascular complication of 4.6% (TF) and 5.0% (TA) (p=0.91). Conclusion TAVI in the ANZ clinical environment has demonstrated excellent outcomes for both the TA and TF approaches in highly selected patients. These results are consistent with those demonstrated in European, Canadian registries and the pivotal US clinical trials. ACTRN12611001026910.

Stent-grafts are widely used for the treatment of various conditions such as aortic lesions, aneurysms, emboli due to coronary intervention procedures and perforations in vasculature. Such stent-grafts are manufactured by covering a stent with a polymer membrane. An ideal stent-graft should have a biocompatible stent covered by a porous, thromboresistant, and biocompatible polymer membrane which mimics the extracellular matrix thereby promoting injury site healing. The goal of this protocol is to manufacture a small caliber stent-graft by encapsulating a balloon expandable stent within two layers of electrospun polyurethane nanofibers. Electrospinning of polyurethane has been shown to assist in healing by mimicking native extracellular matrix, thereby promoting endothelialization. Electrospinning polyurethane nanofibers on a slowly rotating mandrel enabled us to precisely control the thickness of the nanofibrous membrane, which is essential to achieve a small caliber balloon expandable stent-graft. Mechanical validation by crimping and expansion of the stent-graft has shown that the nanofibrous polyurethane membrane is sufficiently flexible to crimp and expand while staying patent without showing any signs of tearing or delamination. Furthermore, stent-grafts fabricated using the methods described here are capable of being implanted using a coronary intervention procedure using standard size guide catheters.

Percutaneous intervention with stents has emerged as a valid alternative to surgical revascularization to treat unprotected left main (LM) stem disease. Conventional, tubular, balloon expandable stents face technical challenges, particularly in large LM diameter, tapered anatomy requiring extensive

Isolated iliac aneurysms or combined with aortic aneurysms can be treated through implantation of three balloon expandable polytetrafluoroethylene-covered stents in order to create a new iliac bifurcation. We present nine patients, unfit for open surgery and anatomically non suitable for

The present paper shows an effective methodology which is based on Finite Element Analysis (FEA) for the fatigue life prediction (FLP) of a Balloon-Expandable (BE) stent made of stainless steel material (AISI316L). BE stent is a tubular, often mesh-like, structure which is expanded inside a diseased (stenosed) artery segment to restore blood flow and keep the vessel open following angioplasty. With design lives of 10–15 years, fatigue life prediction of these devices is critical for the designer, as fatigue failure may occur after deployment inside the blood vessel due to the heart beating (typically 4 × 10 7 cycles/year). Therefore, it is crucial to study the effect of stenting conditions and stent design on the fatigue life of BE stents. The objective of this paper is to provide quantitative measures of the stent’s stress amplitude and mean stress which are generated by the cardiac pulse pressure. This allows prediction of the device’s life and optimization of stent designs. In this paper, numerical investigations were conducted using an effective approach based on the well-known stress-based Goodman Diagram (GD) for the FLP of a given stent design. It has been demonstrated that the percentage of artery’s expansion as well as the dimensions of the struts (the fundamental structural unit that forms the stent), have both an impact on the fatigue behavior after stent deployment.

Background Self-expanding stents (SES) are reemerging as therapeutic alternatives to treat coronary artery disease. It has been proposed that SES can improve clinical outcomes by inducing less injury at implantation and achieving better vessel wall apposition. To date, little data exists comparing the vascular response to both methods of deployment in a controlled experimental setting. Objective To quantify differences in vascular injury and healing between second-generation SES and balloon-expandable stents (BES) and the effects of balloon postdilatation in a porcine coronary model. Methods Seventy-five bare SES (AXXESS or vProtect) and 42 BES (Vision) were implanted in porcine coronaries. A subset of these received balloon postdilatation (SES + D = 22, BES + D = 20). Follow-up was scheduled at 30 (BES = 10, BES + D = 6, SES = 19, SES + D = 8), 90 (BES = 6, BES + D = 8, SES = 19, SES + D = 8), and 180 days (BES = 6, BES + D = 6, SES = 15, SES + D = 6). Results In vivo imaging and histological analysis showed that neointimal formation peaks early (30 days) in BES. Conversely, for SES, the peak occurred later (90 days). However, the neointimal formation achieved in either group equalized at 180 days. For SES, postdilatation shortened the peak of neointimal formation to 30 days. Conversely, for BES, postdilatation delayed the peak of neointimal formation to 90 days. At 30 days, histology showed that SES had significantly less injury. However, at 90 days, injury scores tended to be higher for SES. By 180 days, injury scores were comparable between both groups. Conclusions The mechanism of stent expansion influences the degree of vascular injury and healing. The synergistic use of balloon postdilatation changes the dynamics of healing and may impact the potential beneficial effects inherent to SES technologies. © 2012 Wiley Periodicals, Inc.

TAVR specific risk assessment tools for one year mortality and morbidity are lacking. We evaluated 459 consecutive patients undergoing TAVR at our institution with balloon expandable valve. Data was collected using electronic medical record and imaging databases. Primary endpoint a composite of 12

Transcatheter aortic valve replacement (TAVR) maybe complicated by paravalvular leak (PVL). There are two TAVR valves used the most in the United States and Europe: self-expandable (SE) and balloon expandable (BE). We sought to demonstrate PVL progression based on valve type. Patients were from 3

We present a technique for endovascular management of unplanned coverage of the left common carotid artery during endovascular repair of a distal aortic arch aneurysm. A balloon expandable covered stent was placed into the proximal left common carotid artery by neck incision.

55-year-old woman, with a previous trans-catheter aortic valve replacement (TAVR)performed 5 years earlier by the transapicalapproach because of porcelain aorta (radiotherapyfor a Hodgkin lymphoma), developed progressiveheart failure (New York Heart Association func-tional class III). Echocardiography revealed a normo-functioning aortic bioprosthesis (mean gradient15 mm Hg; valve area 1.1 cm

Objectives We compared the mechanisms of lumen gain after Cappella Sideguard (CS) side branch (SB) bifurcation stent deployment versus a balloon-expandable stent in the corresponding main vessel (MV). Background The novel CS SB bifurcation stent is a self-expanding, thin-strut, nitinol device with anatomic flaring at the SB ostium. Methods In 28 bifurcation lesions, intravascular ultrasound imaging of both the SB and the MV was performed both pre- and postintervention; vessel and lumen areas were measured every 1 mm over a 5 mm segment beginning at the carina. Results Although minimum lumen area (MLA) within the distal 5 mm segment beginning at the carina increased from 2.8 ± 1.3 mm2 to 3.8 ± 1.1 mm2, P