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Background: Transcatheter aortic valve replacement (TAVR) is typically performed under general anesthesia (GA). However, there is increasing data supporting the safety of performing TAVR under local anesthesia/conscious sedation (LA). We performed a meta-analysis to gain better understanding of the safety and efficacy of LA versus GA in patients with severe aortic stenosis undergoing TAVR., Methods and Results: We comprehensively searched EMBASE, PubMed, and Web of Science. Effect sizes were summarized using risk ratios (RRs) difference of the mean (DM), and 95% CIs (confidence intervals) for dichotomous and continuous variables respectively. Twenty-six studies and 10,572 patients were included in the meta-analysis. The use of LA for TAVR was associated with lower overall 30-day mortality (RR, 0.73; 95% CI, 0.57-0.93; P = 0.01), use of inotropic/vasopressor drugs (RR, 0.45; 95% CI, 0.28-0.72; P < 0.001), hospital length of stay (LOS) (DM, -2.09; 95% CI, -3.02 to -1.16; P < 0.001), intensive care unit LOS (DM, -0.18; 95% CI, -0.31 to -0.04; P = 0.01), procedure time (DM, -25.02; 95% CI, -32.70 to -17.35; P < 0.001); and fluoroscopy time (DM, -1.63; 95% CI, -3.02 to -0.24; P = 0.02). No differences were observed between LA and GA for stroke, cardiovascular mortality, myocardial infarction, permanent pacemaker implantation, acute kidney injury, paravalvular leak, vascular complications, major bleeding, procedural success, conduction abnormalities, and annular rupture., Conclusion: Our meta-analysis suggests that use of LA for TAVR is associated with a lower 30-day mortality, shorter procedure time, fluoroscopy time, ICU LOS, hospital length of stay, and reduced need for inotropic support., (© 2017 Wiley Periodicals, Inc.)

Objectives: To summarize the published data of combined transcatheter aortic and mitral valve intervention (CTAMVI)., Background: CTAMVI, a combination of either transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve-in-valve (TAViV) and transcatheter mitral valve replacement (TMVR), transcatheter mitral valve-in-valve/valve-in-ring (TMViV/ViR), or percutaneous mitral valve repair (PMVR) is an attractive alternative in high-surgical risk patients with combined aortic and mitral valve disease. However, its procedural details and clinical outcomes have not been well described., Methods: We performed a systematic review of all the published articles from PUBMED and EMBASE., Results: A total of 37 studies with 60 patients were included. The indication for CTAMVI was high or inoperable surgical risk and symptomatic severe aortic stenosis (92%) or severe aortic regurgitation (8%) combined with moderate to severe/severe mitral stenosis (30%) or moderate/severe mitral regurgitation (65%) or both (5%). In majority of the cases, aortic valve intervention was performed prior to the mitral valve. Mortality rate were 25% for TAVR + TMVR (range 42 days to 10 months), 17% for TAVR + TMViV/ViR (range 13 days to 6 months), 0% for TAViV + TMViV/ViR (range 6-365 days), and 15% for TAVR/ViV + PMVR (range 17 days to 419 days). Significant (more than moderate) paravalvular regurgitation post-procedure was rare., Conclusions: CTAMVI appears to confer reasonable clinical outcome. Further large study is warranted to clarify the optimal strategy, procedural details and clinical outcomes in the future., (© 2017 Wiley Periodicals, Inc.)

Objective: The aim of this study was to assess the effectiveness of a quality improvement (QI) program in reducing vascular complications during cardiac catheterization., Background: Vascular access complications during cardiac catheterization are associated with higher morbidity and mortality. We implemented a QI program focused on using micropuncture techniques and targeting the "safe zone," an area below the inferior border of the inferior epigastric artery and above the inferior border of the femoral head, for femoral artery puncture., Methods: Our catheterization laboratory implemented a protocol that required all operators to use micro puncture technique during diagnostic and/or percutaneous coronary interventions and to document arteriotomy in the "safe zone." We also encouraged use of vascular ultrasound, radial artery approach, and increased use of vascular closure devices (VCDS). We analyzed data on 3120 patients (2013, pre-QI cohort) and 3222 patients (2014, QI cohort). Data on vascular complications were prospectively collected and compared with the rate of complications that occurred during the same time one year prior when the QI project was not in effect., Results: Baseline characteristics of two cohorts of patients were similar. Compliance with the protocol was excellent. Appropriate documentation of the wire exiting the needle was observed in 95% of cases. VCD use increased from 35% in 2013 to 60% in 2014 (P < 0.001) There were no significant differences in the overall number of complications after implementation of the QI project (1.03% complications before QI implementation and 0.96% after QI implementation. P = 0.79) but there was an absolute reduction in the number of hematomas (0.77 vs. 0.40% in 2013 vs. 2014, respectively, P = 0.06) and of pseudoaneurysms (0.35 vs. 0.19% P = 0.20). Correlates of major vascular complications included), age > 75 years (HR 3.1, P < 0.0001), and PCI (vs. diagnostic cath)., Conclusions: Micropuncture technique in association with "safe zone targeting "did not significantly reduce vascular complications in patients undergoing cardiac catheterization, but a trend toward decrease of hematomas and pseudoaneurysms was noted. Factors such as age and type of procedure (PCI vs. diagnostic) play a significant role in the occurrence of vascular complications. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

We queried the National Inpatient Sample database from 2012 to 2014 to identify all patients aged ≥18 years undergoing transcatheter aortic valve implantation (TAVI) in the United States. Regional differences in TAVI utilization, in-hospital mortality, and health-care resource use were analyzed. Of 41,025 TAVI procedures in the United States between 2012 and 2014, 10,390 were performed in the Northeast, 9,090 in the Midwest, 14,095 in the South, and 7,450 in the West. Overall, the number of TAVI implants per million adults increased from 24.8 in 2012 to 63.2 in 2014. The utilization of TAVI increased during the study period in all 4 geographic regions, with the number of implants per million adults being highest in the Northeast, followed by the Midwest, South, and West, respectively. Overall in-hospital mortality was 4.2%. Compared with the Northeast, risk-adjusted in-hospital mortality was higher in the Midwest (adjusted odds ratio [aOR] 1.26 [1.07 to 1.48]) and the South (aOR 1.61 [1.40 to 1.85]) and similar in the West (aOR 1.00 [0.84 to 1.18]). Average length of stay was shorter in all other regions compared with the Northeast. Among patients surviving to discharge, disposition to a skilled nursing facility or home health care was most common in the Northeast, whereas home discharge was most common in the West. Average hospital costs were highest in the West. In conclusion, we observed significant regional differences in TAVI utilization, in-hospital mortality, and health-care resource use in the United States. The findings of our study may have important policy implications and should provide an impetus to understand the source of this regional variation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: This study sought to determine the association of chronic kidney disease (CKD) with in-hospital outcomes of transcatheter aortic valve replacement (TAVR)., Background: CKD is a known independent risk factor for worse outcomes after surgical aortic valve replacement (SAVR). However, data on outcomes of patients with CKD undergoing TAVR are limited, especially in those on chronic dialysis., Methods: The authors used data from the 2012 to 2014 National Inpatient Sample database to identify all patients ≥18 years of age who underwent TAVR. International Classification of Diseases-Ninth Revision-Clinical Modification codes were used to identify patients with no CKD, CKD (without chronic dialysis), or end-stage renal disease (ESRD) on long-term dialysis. Multivariable logistic regression models were constructed using generalized estimating equations to examine in-hospital outcomes., Results: Of 41,025 patients undergoing TAVR from 2012 to 2014, 25,585 (62.4%) had no CKD, 13,750 (33.5%) had CKD, and 1,690 (4.1%) had ESRD. Compared with patients with no CKD, in-hospital mortality was significantly higher in patients with CKD or ESRD (3.8% vs. 4.5% vs. 8.3%; adjusted odds ratio [no CKD as reference]: 1.39 [95% confidence interval: 1.24 to 1.55] for CKD and 2.58 [95% confidence interval: 2.09 to 3.13] for ESRD). Patients with CKD or ESRD had a higher incidence of major adverse cardiovascular events (composite of death, myocardial infarction, or stroke), net adverse cardiovascular events (composite of major adverse cardiovascular events, major bleeding, or vascular complications), and pacemaker implantation compared with patients without CKD. Acute kidney injury (AKI) and AKI requiring dialysis were associated with several-fold higher risk-adjusted in-hospital mortality in patients in the no CKD and CKD groups. Moreover, the incidence of AKI and AKI requiring dialysis did not decline during the study period., Conclusions: Patients with CKD or ESRD have worse in-hospital outcomes after TAVR. AKI is associated with higher in-hospital mortality in patients undergoing TAVR and the incidence of AKI has not declined over the years., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Since 2005, the American Board of Vascular Medicine (ABVM) endovascular examination has been used to certify vascular practitioners. Annual rigorous review has confirmed it is psychometrically valid and reliable. However, the evidence basis underlying the examination items has not been studied systematically. The aim of this study was to adjudicate class of recommendation (COR) and level of evidence (LOE) for the 2015 ABVM endovascular examination and establish an additional feedback mechanism for examination improvement based on contemporary evidence-based guidelines. We performed a pooled consensus process to classify each of the 110 items in the 2015 ABVM endovascular examination by COR and LOE as detailed in the current guideline statements. We added additional categories for items that were not eligible for assignment using traditional current evidence-based metrics: 'COR X', cannot be determined, not applicable, or simple recognition; and 'LOE X', cannot be determined or not applicable. COR classifications were assigned in the following proportion: Class I=15%, Class II=40%, Class III=3%, COR X=42%. LOE classifications were assigned in the following proportion: Level A=12%, Level B=34%, Level C=32%, LOE X=22%. Our analysis showed that nearly half of the 2015 ABVM endovascular examination items were supported by strong scientific evidence or fact-based knowledge. COR and LOE analysis yielded notably different results. Use of alternate classification schema may be powerful tools for improving certification exams in healthcare.

We sought to determine the association of Life's Simple Seven (LSS) with peripheral artery disease (PAD) in African Americans. We performed a cross-sectional analysis of baseline data (2000-2004) from subjects participating in the Jackson Heart Study. African American men and women (N = 4403) age 35-84 years participated in the study. PAD was defined by an ankle-brachial index (ABI) of < 0.9. We assessed frequency of LSS (body mass index [BMI], blood pressure, total cholesterol, glucose, dietary habits, physical activity, and smoking) among participants with and without PAD. LSS variables were categorized as ideal, intermediate, or poor to indicate a participant's health status. Data were analyzed using logistic regression to assess the association of PAD with LSS. PAD was diagnosed in 113 participants (2.6%). The percentage of the cohort meeting criteria for ideal health for each of the seven LSS factors was: 14.2% for BMI, 17.1% for blood pressure, 38.0% for total cholesterol, 72.9% for glucose, 1.0% for dietary habits, 19.2% for physical activity, and 84.6% for smoking. Having ≥ 3 LSS variables within the category of poor health was associated with elevated odds for PAD (odds ratio (OR) 1.34, 95% CI 1.11-1.63) after adjusting for age. Among African American adults, LSS variables are associated with PAD. Further studies are needed to determine the association of LSS with PAD among other racial/ethnic groups.

Aims: In an effort to minimize periprocedural stroke risk, increasingly, electrophysiological (EP) procedures are being performed on anticoagulation. The decrease in stroke has been accompanied by an increase in potentially devastating vascular access complications. Ultrasound guidance for femoral vein cannulation reduces complications in other applications. The aim of this study is to determine the utility of real-time two-dimensional (2D) ultrasound guidance for femoral vein cannulation in EP., Methods and Results: A comprehensive literature search of Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials was performed. Five years of conference abstracts from the Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society were reviewed. Two independent reviewers identified trials comparing ultrasound-guided with standard cannulation in EP procedures. Data were extracted on study design, study size, operator and patient characteristics, use of anticoagulation, vascular complication rates, first-pass success rate, and inadvertent arterial puncture. Four trials, with a total of 4065 subjects, were included in the review, with 1848 subjects in the ultrasound group and 2217 subjects in the palpation group. Ultrasound guidance for femoral vein cannulation was associated with a 60% reduction of major vascular bleeding (relative risk, 0.40; 95% confidence interval, 0.28-0.91). Additionally, there was a 66% reduction in minor vascular complications (relative risk, 0.34; 95% confidence interval, 0.15-0.78)., Conclusion: The use of real-time 2D ultrasound guidance for femoral vein cannulation decreases access-related bleeding rates and life-threatening vascular complications., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.)

The comparative outcomes of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in diabetes mellitus (DM) patients are scarce. We aimed to assess and compare the outcomes of TAVR versus SAVR in DM patients using the Nationwide Inpatient Sample database from 2011 to 2013. A complete case analysis was performed for the multivariate analysis and cases with missing data were excluded. The primary end point was in-patient all-cause mortality and secondary outcomes were perioperative complications. An estimated 5,719 TAVR procedures and 65,096 SAVR procedures were performed among DM patients in the United States between 2011 and 2013. TAVR patients were older (80 ± 8.1 vs 70 ± 10, p <0.001), majority of them were women (45% vs 38%, p <0.001), and predominantly white race (total of 80%). The adjusted odds ratio (OR) for the primary outcome was significantly lower in TAVR patients (2.8% vs 3.6%, OR 0.63, p = 0.02). TAVR patients were also at lower risk for bleeding requiring transfusions (13% vs 20%, OR 0.43, p <0.01), cardiac complications (6.1% vs 14%, OR 0.34, p <0.01), respiratory complications (1.2% vs 3.7%, OR 0.26, p <0.01), postoperative sepsis (1.7% vs 3.6%, OR 0.45, p = 0.03), and acute myocardial infarction (2.5% vs 2.9%, OR 0.62, p <0.01), compared with SAVR patients. Conversely, TAVR patients were at increased risk for vascular complications (5.7% vs 3.9%, OR 1.5, p <0.01) and new pacemaker implantation (10% vs 5.7%, OR 1.5, p <0.01). The mean hospitalization cost was lower for TAVR than SAVR ($58,878 vs $63,869, p = 0.003). Length of stay (median 6 vs 8 days, p <0.001) was shorter in TAVR patients. In conclusion, TAVR may result in better in-hospital outcome than SAVR in DM patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aims: Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. This study investigates the relationship of systolic loading and strain to PLF-AS to further define its pathophysiology., Methods: One hundred and twenty patients (age 79 ± 12 years, 37% men) with an indexed aortic valve area (AVAi) of 0.6 cm/m or less and an ejection fraction of 50% or higher were divided into two groups based on indexed stroke volume (SVi): PLF-AS, SVi ≤ 35 ml/m, N = 46; normal-flow aortic stenosis, SVi > 35 ml/m, N = 74). Valvular and arterial load were assessed using multiple measurements, and strain was assessed using speckle-tracking echocardiography., Results: Patients with PLF-AS were found to have more valvular load (lower AVAi, P = 0.028; lower energy loss coefficient, P = 0.001), more arterial load [decreased arterial compliance and increased systemic vascular resistance (SVR), both P < 0.001] and more total hydraulic load [increased valvuloarterial impedance (Zva), P < 0.001]. Transvalvular gradients and arterial pressures were similar. Longitudinal strain was lower in PLF-AS (P < 0.001), but circumferential and rotation strains were similar. On adjusted regression, AVAi, SVR and longitudinal strain were associated with PLF-AS [odds ratio (OR) = 1.34, P = 0.043; OR = 1.31, P = 0.004; OR = 1.34, P = 0.011, respectively]. When SVR and AVAi were replaced with Zva, longitudinal strain and Zva (OR = 1.38, P = 0.015; OR = 1.33, P < 0.001 for both, respectively) were associated with PLF-AS., Conclusion: Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.

Background: Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic-valve replacement (SAVR) for patients with severe symptomatic aortic stenosis (AS) who are at high operative risk. We sought to determine the long-term (≥1year follow-up) safety and efficacy TAVR compared with SAVR in patients with severe AS., Methods: A comprehensive search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, conference proceedings, and relevant Web sites from inception through 10 April 2016., Results: Fifty studies enrolling 44,247 patients met the inclusion criteria. The mean duration follow-up was 21.4months. No difference was found in long-term all-cause mortality (risk ratios (RR), 1.06; 95% confidence interval (CI) 0.91-1.22). There was a significant difference favoring TAVR in the incidence of stroke (RR, 0.82; 95% CI 0.71-0.94), atrial fibrillation (RR, 0.43; 95% CI 0.33-0.54), acute kidney injury (RR, 0.70; 95% CI 0.53-0.92), and major bleeding (RR, 0.57; 95% CI 0.40-0.81). TAVR had significant higher incidence of vascular complications (RR, 2.90; 95% CI 1.87-4.49), aortic regurgitation (RR, 7.00; 95% CI 5.27-9.30), and pacemaker implantation (PPM) (RR, 2.02; 95% CI 1.51-2.68). TAVR demonstrated significantly lower stroke risk compared to SAVR in high-risk patients (RR, 1.49; 95% CI 1.06-2.10); no differences in PPM implantation were observed in intermediate-risk patients (RR, 1.68; 95% CI 0.94-3.00). In a meta-regression analysis, the effect of TAVR baseline clinical features did not affect the long-term all-cause mortality outcome., Conclusion: TAVR and SAVR showed similar long-term survival in patients with severe AS; with important differences in treatment-associated morbidity., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: The transfemoral (TF) approach has become the preferred approach for transcatheter aortic valve replacement (TAVR) because of its low risk profile. However, the relative safety of the percutaneous approach (PC) compared to surgical cut-down (SC) remains unclear. Our aim was to compare the outcomes between PC versus SC access in patients undergoing TF-TAVR using a meta-analysis., Methods: We conducted a systematic electronic database search for studies reporting major and minor vascular complications (VC), major and minor bleeding, and perioperative all-cause mortality, in PC versus SC TF-TAVR cases. Complications were reported based on the Valve Academic Research Consortium criteria. A random-effects model was used to calculate odds ratios and 95% confidence intervals., Results: Eight observational cohort studies and one randomized control trial (2513 patients in PC and 1767 patients in SC) were included in the analysis. Major and minor VC, as well as bleeding complications, were comparable between the two approaches. The need for surgical intervention for VC was comparable between PC and SC. There was no difference in perioperative all-cause mortality., Conclusions: PC and SC have similar safety profiles and outcomes when used appropriately in selected patients., (© 2016 Wiley Periodicals, Inc.)

Background: Ventricular septal defects (VSD) are rarely reported as a complication following transcatheter aortic valve replacement (TAVR). We sought to characterise the patients, clinical management, and outcomes regarding this rare phenomenon., Methods: Relevant articles were identified by a systematic search of MEDLINE and EMBASE databases from January, 2002 to September, 2015., Results: A total of 18 case reports, including 20 patients, were identified. The median age was 83 years and six were male. Twelve were performed by trans-femoral approach. Pre-dilation was performed in 12 patients and post-dilation in four. Balloon expandable valves were used in the majority (85%) of cases. The clinical presentation varied from asymptomatic to progressive heart failure. The timing of the diagnosis also varied significantly from immediately post valve implantation to one year afterwards. There were two cases of Gerbode-type defect while the rest were inter-ventricular defects. The location was mostly membranous or perimembranous (79%) and adjacent to the valve landing zone. A total of seven interventions (one open surgery and six percutaneous closure) were performed. Four patients died during the same hospital admission. Sixteen survived past discharge (range 12 days to two years)., Conclusions: Ventricular septal defects post-TAVR were seen more with balloon expandable valves and with pre-dilation or post-dilation. Percutaneous treatment of the VSD was preferred over open cardiac surgery given the high surgical risk in this patient population. Some, but not all, patients survived TAVR and VSD and had a good prognosis for both patient groups with or without VSD closure., (Copyright © 2016 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Purpose: Left atrial appendage (LAA) flow velocity has not been extensively studied in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to assess the impact of TAVI on LAA flow velocity., Methods: Medical records of consecutive TAVI recipients were reviewed retrospectively. Patients with persistent atrial fibrillation were excluded. LAA velocities were measured before and after TAVI by transesophageal echocardiography., Results: Sixty-one patients were included. Mean LAA emptying (EV) and filling (FV) flow velocity before TAVI were 33 ± 16 cm/s and 31 ± 14 cm/s, respectively. They increased to 37 ± 20 (p = 0.0036) and 33 ± 13 cm/s (p = 0.047) after TAVI in the whole population sample, but not in patients with normal flow AS. In low-flow, low-gradient (LFLG) AS patients, EV and FV increased from 36 ± 22 to 47 ± 30 cm/s (p < 0.01), and from 29 ± 12 to 40 ± 15 cm/s (p < 0.01), respectively, after TAVI. There was no difference between normal flow and LFLG AS patients in the number of patients who achieved EV ≥ 40 cm/s post-TAVI (35% versus 47%, p = 0.54, respectively)., Conclusions: LAA EV and FV were low prior to TAVI and increased significantly after TAVI only in patients with LFLG AS. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:375-382, 2016., (© 2016 Wiley Periodicals, Inc.)

Objectives: Patients undergoing transcatheter aortic valve replacement (TAVR) often have spontaneous echocardiographic contrast (SEC) observed in the left atrium (LA). Mid-term prognosis of patients with SEC following TAVR is not well studied. We assessed the impact of SEC on outcomes after TAVR., Methods: Medical records of 93 consecutive patients who underwent TAVR at a single center were reviewed retrospectively. The primary endpoint was defined as the composite of a cardioembolic event, death from any cause, and admission for decompensated heart failure within 3 months of TAVR., Results: After excluding 3 patients who had procedural complications, 90 patients were included in the study. The mean age was 81 ± 8 years old and 50% were male. There were 12 patients with SEC in the LA (group 1) and 78 patients without SEC in the LA (group 2) during the TAVR procedure. Atrial fibrillation was more common in group 1 (50% vs 13%, respectively; P=.01) and diabetes was more common in group 2 (17% vs 53%, respectively; P=.03). The primary endpoint occurred in 22 patients (24%) and occurred more in group 1 (58% vs 19%, respectively; P<.01). On regression analysis, after adjusting for sex and STS score, SEC had a hazard ratio (HR) of 5.02 (95% confidence interval [CI], 1.96-12.9; P<.001) and STS ≥15 had an HR of 6.37 (95% CI, 2.02-20.1; P=.01). On survival analysis, group 1 had lower event-free survival compared with group 2 (log-rank P=.01)., Conclusion: SEC during TAVR procedure is a negative prognostic marker for death, cardioembolic events, or admission for decompensated heart failure in the first 3 months post procedure.

Since its advent in 1991, endovascular aortic aneurysm repair (EVAR) has become a mainstay of treatment for abdominal aortic aneurysms (AAA). Studies such as the comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR 1) trial, have demonstrated the effectiveness of EVAR in reducing perioperative mortality. Technological improvements in graft design and delivery account for an increasing utilization of endovascular repair. Newer branch and fenestrated graft designs have allowed for treatment of patients with complex aortic anatomy that previously could not be treated with EVAR. Endovascular repair, while dominant, is unlikely to eliminate the need for open repair or to relegate open surgery for AAA to historical interest only. The unprecedented adoption of EVAR has led to complications and modes of failure that were not seen with open repair. The rate of failure is markedly increased when endografts are used outside of the instructions for use (IFU). The long-term durability of fenestrated and investigational branch devices remains to be established. The demand for an endovascular approach by patients and the willingness of physicians to place endografts outside the anatomic IFU criteria may have resulted in the pendulum swinging too far away from open surgical management. The consequence of reduced open aortic surgeries is a concern for both patient care as well as training for vascular surgery fellows. Vascular surgery training programs will require innovative changes in training to assure that vascular surgery trainees will have the requisite skill and experience required to competently perform open surgical repair on what will undoubtedly be some of the most complex aortic pathology.

Background: Patients with severe aortic stenosis (AS) are known to have increased left ventricular apical rotation (ApRot) during systole, but its clinical relevance is unknown. The aim of this study was to assess the association of ApRot with patient symptoms and total mortality., Methods: A retrospective analysis was performed on 82 patients (mean age, 77 ± 14 years; 40% men) with newly diagnosed severe AS with indexed aortic valve areas ≤ 0.6 cm(2)/m(2) and left ventricular ejection fractions ≥ 50%. Sixty-three percent of patients were symptomatic. ApRot was calculated using speckle-tracking echocardiography. Patients were divided into two groups on the basis of ApRot: high ApRot (>4.0°, n = 41) and low ApRot (≤4.0°, n = 41)., Results: There were 33 deaths and 30 aortic valve replacement procedures after 33 ± 17 months of follow-up. Patients in the high-ApRot group had smaller indexed aortic valve areas (P = .021) and increased valvuloarterial impedance (P = .014). There was no difference in overall symptoms, but the low-ApRot group experienced more syncope (P = .020). Patients in the high-ApRot group had reduced survival with medical therapy (log-rank P = .018) after aortic valve replacement (log-rank P = .039) and overall (log-rank P = .009). Asymptomatic patients with low ApRot had the best survival, while asymptomatic patients with high ApRot had similar survival to that of symptomatic patients (log-rank P = .008). On adjusted Cox regression, ApRot ≥ 6.0° was independently associated with death (hazard ratio, 3.06; P = .003). On receiver operating characteristic curve analysis, ApRot added incremental prognostic value to indexed aortic valve area, symptom status, and aortic valve replacement status., Conclusion: Increased ApRot is independently associated with poor survival and may represent a compensatory mechanism to preserve cardiac output against severe obstruction to flow and high systolic load., (Copyright © 2015 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: In transcatheter aortic valve replacement (TAVR) the trans-apical approach (TA) is associated with apical myocardial injury but it is unknown if this injury impacts myocardial function. This study was performed to assess the impact of TA on apical longitudinal strain (ALS) and global longitudinal strain (GLS) after TAVR., Methods: 44 consecutive patients (age 81 ± 7 years, 48% male) underwent TAVR via trans-femoral (TF) (n=27) or TA (n=17) approach. Speckle-tracking analysis of left ventricular longitudinal strain was performed on images from peri-procedure transesophageal echocardiograms immediately before and after valve implantation. The primary endpoint was a GLS improvement of at least 25% post-TAVR., Results: GLS improved significantly above baseline after valve implantation in both TF (p<0.001) and TA (p=0.027) groups. The absolute magnitudes of ALS and GLS improvement were similar between TF and TA patients (ALS: p=0.282; GLS: p=0.248). Peak ALS and GLS achieved post-TAVR were similar between TF and TA patients (ALS: p=0.933; GLS: p=0.365). 47% of patients achieved a GLS improvement of >25%; 16 of which improved their GLS to <-15%. The severity of pre-TAVR GLS impairment was a strong independent predictor of GLS improvement (OR=1.61, p=0.003). A pre-TAVR GLS ≥-13.7% was 82% sensitive and 82% specific for TAVR to confer a GLS improvement >25%., Conclusion: Equal improvement in myocardial strain was observed in the TF and TA patients. Pre-TAVR GLS impairment was an independent predictor of post-TAVR GLS recovery, highlighting how it is the patient's baseline GLS dysfunction, not the method of approach, that dictates post-TAVR functional recovery.

Objectives: The goal of this meta-analysis was to determine the utility of real-time two-dimensional (2D) ultrasound guidance for femoral artery catheterization., Background: Despite the shift toward establishing vascular access via the radial artery rather than the femoral artery, femoral artery cannulation is still frequent in cardiac catheterization. Since vascular complications related to femoral artery cannulation can be quite devastating, preventing these complications is vital., Methods: A comprehensive literature search of Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials was performed. Additionally, five years of conference abstracts from critical care, interventional radiology, vascular surgery, and cardiology were reviewed. Two independent reviewers identified prospective, randomized controlled trials comparing ultrasound guidance with traditional palpation techniques of femoral artery catheterization (with or without fluoroscopy). Data were extracted on study design, study size, operator and patient characteristics, complication rates, first-pass success, procedure time, and number of attempts., Results: Four trials with a total of 1422 subjects were included in the review, with 703 subjects in the palpation group and 719 subjects in the ultrasound-guided group. Compared with traditional methods, ultrasound guidance for femoral artery catheterization was associated with 49% reduction in overall complications, including hematoma and accidental venipuncture (relative risk, 0.51; 95% confidence interval, 0.28-0.91). It was also associated with 42% improvement in the likelihood of first-attempt success (relative risk, 1.42; 95% confidence interval, 1.01-2.00)., Conclusions: The use of real-time 2D ultrasound guidance for femoral artery catheterization decreases life-threatening vascular complications and improves first-pass success rate.

This report describes the methods used to develop and maintain the endovascular medicine certification examination, which has been offered by the American Board of Vascular Medicine (ABVM) to practicing physicians since 2005. The report covers the methods and findings used to develop examination specifications which ensure the content and construct validity of the examination assessment such that the examination is reflective of the job tasks associated with the endovascular medicine specialty, as well as being a meaningful indicator of whether a candidate possesses the knowledge and skills necessary for competent practice. Further, this report covers the procedures used to develop, maintain, and administer the examination, including a summary of the content review process and the use of statistical information. Based on psychometric evaluation of the examination's performance, the ABVM's endovascular medicine examination appears to be a valid assessment of professional competency in the specialty area; a finding that supports the inference that candidates who pass the examination are qualified to practice in a manner that protects patients., (© The Author(s) 2015.)

The American Board of Vascular Medicine (ABVM) was conceived through the Society for Vascular Medicine and this year will complete 10 years of certifying physicians who practice vascular medicine and endovascular medicine. The value of certification to our physicians, patients, and field cannot be understated. This paper reviews the highlights of the test development process, quality assurance measures, and management of these high stakes examinations., (© The Author(s) 2014.)

Background: Compliance with guidelines for treating patients with peripheral artery disease (PAD) lags compliance for treating patients with coronary artery disease. We assessed the gap between guidelines and practice for patients with PAD who underwent lower extremity revascularization (LER) at our institution from 2007 to 2010., Methods: Quality of care (QoC) was calculated by measuring provider performance on four indicators (antiplatelet therapy, dyslipidemia management, control of hypertension, and diabetes) derived from the ACCF/AHA PAD guidelines. The QoC score was calculated at the time of admission and at time of discharge for each patient, and reflects the proportion of indicated treatments received., Results: Patients (n = 734, mean age 70±11, female 51%) were followed for a mean of 2.0±1.4 years (range 0-5.7) following LER. The indication for LER was claudication (24.8%), rest pain (16.7%), and tissue loss (58.4%). The percentage of patients with a perfect QoC score increased significantly during hospital admission (11% to 21%, p < 0.001). Significant multivariate predictors of perfect QoC score included race/ethnicity, Charlson score, severity of LE ischemia, and observation period (admission, discharge). Multivariate analysis demonstrated that age>75 years, heart failure, chronic kidney disease, rest pain, and tissue loss-but not compliance with four guideline-based therapies-were associated with decreased freedom from the composite endpoint of major amputation, repeat revascularization, and death., Conclusions: Although adherence to guidelines improved over time, we found a significant gap between guidelines and practice for this cohort of patients at increased risk for adverse cardiovascular events., (© The Author(s) 2014.)

Atherosclerotic carotid artery disease remains an important cause of cerebrovascular ischemic disease. We present a patient with residual stenosis of the distal internal carotid artery following carotid endarterectomy that was treated with stenting. The case highlights the potential complimentary benefits of carotid endarterectomy and carotid stenting., (Copyright © 2011. Published by Elsevier Inc.)

Tremendous advances have been made in the endovascular treatment of lower-extremity arterial occlusive disease. New technology has enabled operators to successfully revascularize patients with complex arterial occlusive disease. This article summarizes the latest advances in endovascular therapy of aortoiliac and femoral arteries and reviews the clinical outcomes and costs associated with the use of these treatments., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: We analyzed the risk of adverse events following carotid angioplasty and stenting (CAS) in patients <80 years (group I) compared with those > or = 80 years of age (group II)., Methods: Prospective data from 224 patients who underwent 235 consecutive CAS procedures at three participating institutions were reviewed retrospectively. All subjects were enrolled in Food and Drug Administration-approved clinical trials of CAS in high-risk patients or in institutional protocols. Procedural details and angiographic morphology were reviewed in all cases. All patients underwent independent neurological evaluation at 24hr and 30 days following CAS., Results: Mean age was 69.9 years in the younger cohort and 83.5 years in the older group. Embolic protection devices were successfully deployed in 97.5% of cases in group I compared with 98.7% in group II (p=nonsignificant [NS]). Procedural success, defined as <30% residual stenosis after CAS, was achieved in all cases. Mean hospital stay was similar in the two groups. Transient ischemia attacks occurred in 1.9% in group I and 1.3% in group II (p=NS). Within 30 days of CAS, the risk of minor or major stroke (p=NS) as well as the composite risk of stroke (minor or major) and death was 2.5% in group I and 3.8% in group II (p=NS). Multivariate logistic regression analysis showed that absence of hypertension (odds ratioi [OR]=0.38, p=0.0352) and chronic renal insufficiency (OR=2.62, p=0.0238) were significant predictors of the composite end point of stroke and all-cause mortality. Kaplan-Meier analysis revealed that survival and freedom from the combined end point of stroke and all-cause mortality were similar for patients in groups I and II., Conclusion: Octogenarians are not at increased risk of periprocedural adverse events following CAS compared to younger patients. Exclusion of high-risk patients from CAS based on age alone is unjustified., (Copyright 2009 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Background: Severe stenosis of the common carotid artery (CCA), while uncommon, is associated with increased risk of transient ischemic attack and stroke. To date, no validated duplex ultrasound criteria have been established for grading the severity of CCA stenosis. The goal of this study was to use receiver-operating curve (ROC) analysis with computed tomographic angiography as the reference standard to establish duplex ultrasound criteria for diagnosing >or=50% CCA stenosis., Methods: The study cohort included 64 patients (42 men, 22 women) with a mean age of 65 +/- 12 years (range, 16-89 years) who had CCA peak systolic velocity (PSV) >or=150 cm/sec and underwent computed tomographic angiography (CTA) of the cervical and intracerebral vessels within 1 month of the duplex examination. One study was excluded because the CTA was technically inadequate, whereas another was excluded because the patient underwent bilateral CCA stenting. The CCA ipsilateral to any of the following was excluded from the analysis: innominate artery occlusion (n = 1), previous stenting of the ICA or CCA (n = 7), carotid endarterectomy (n = 1), or carotid-to-carotid bypass (n = 1). Thus, the data set included 62 patients and 115 vessels. Bland-Altman analysis was used to examine the agreement between two measures of luminal reduction measured by CTA: percent diameter stenosis and percent area stenosis. Receiver operating characteristic (ROC) analysis was used to determine optimal PSV and EDV thresholds for diagnosing >or=50% CCA stenosis., Results: Severity of CCA stenosis was <50% in 76 vessels, 50%-59% in eight, 60%-69% in eight, 70%-79% in nine, 80%-89% in three, 90%-99% in five, and occluded in six. Duplex ultrasonography identified six of six (100%) patients with 100% CCA occlusion by CTA. Bland-Altman analysis showed poor agreement between percent stenosis determined by vessel diameter compared with percent stenosis determined by reduction in lumen area. Therefore, subsequent analysis was performed using percent stenosis by area. ROC analysis of different PSV thresholds for detecting stenosis >or=50% showed that >182 cm/sec was the most accurate with a sensitivity of 64% and specificity of 88% (P < .0001). Sensitivity, specificity, and accuracy of carotid duplex were higher when the stenosis was located in the mid or distal aspects of the CCA (sensitivity 76%, specificity 89%, area under curve 0.84, P < .001) than in the intrathoracic and proximal segment of the artery (P = NS). ROC analysis of different EDV thresholds for detecting CCA stenosis >or=50% showed that >30 cm/sec was the most accurate with a sensitivity of 54% and a specificity of 74% (P < .0239)., Conclusions: Duplex ultrasonography is highly sensitive, specific, and accurate for detecting CCA lesions in the mid and distal CCA. Use of peak systolic velocity may lead to improved detection of CCA disease and initiation of appropriate therapy to reduce the risk of stroke., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy., (Copyright © 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)

Carotid duplex ultrasonography (DUS) is routinely performed prior to coronary artery bypass graft surgery (CABG) on all patients > 65 years old because of the reported associated risk of finding concomitant carotid artery stenosis. Identifying risk factors that correlate with severe carotid stenosis may result in more cost-effective screening for patients with asymptomatic carotid artery disease prior to CABG. We performed a retrospective study to identify risk factors for significant carotid artery disease in patients scheduled to undergo CABG between March 2005 and March 2008 at the Massachusetts General Hospital. Patients with carotid stenosis >or= 70% identified by DUS (n = 50) were matched by age and sex to control patients who had < 50% stenosis (n = 50). Data were analyzed using the chi-squared test or analysis of variance as appropriate. Logistic regression was used to examine multivariate correlates of carotid stenosis. A total of 643 patients were screened to arrive at the patient cohorts described below. This produced a prevalence of 7.7% for significant (> 70%) carotid disease. The patient cohorts were predominantly male with no significant difference in the incidence of diabetes, hypertension, extent of coronary artery disease (CAD) (i.e. left main coronary artery disease (LMCA) and one, two-, or three-vessel CAD) or lipid abnormalities in the two groups. Univariate analysis identified the presence of peripheral arterial disease (PAD, p = 0.001), a cervical bruit (p < 0.0001), a prior neurological event (p = 0.020), and the presence of an abdominal aortic aneurysm (AAA; p = 0.046) as significant predictors of >or= 70% internal carotid artery stenosis. Logistic regression analysis revealed that the presence of a carotid bruit (p = 0.0068) and PAD (p = 0.0194) were associated with an increased risk of significant carotid artery disease. In conclusion, the presence of a carotid bruit or PAD predicts an increased likelihood of significant carotid artery disease in patients undergoing CABG. Unlike previous studies, LMCA or extent of CAD did not correlate with significant carotid artery disease. Using these predictive models, a prospective outcomes trial is required to validate these criteria.

The last decade has borne witness to a transformation in the care of patients with vascular disease. There has been a rapid transition towards minimally invasive techniques as interventionalists obtain increasingly advanced catheter-based skills and access to newer and more sophisticated devices. Patients who are not candidates for completely percutaneous revascularization, or those felt to be at prohibitive risk for traditional surgical reconstruction, may benefit from hybrid therapy, a combination of open surgery and endovascular repair that offers patients the opportunity for complete revascularization with decreased morbidity and mortality. This review examines applications of hybrid procedures for treating patients with disabling claudication and limb-threatening ischemia, aortic arch disease, thoracoabdominal aneurysms, extra-cranial carotid disease, and coronary artery disease.

Chronic critical limb ischemia (CLI), defined as > 2 weeks of rest pain, ulcers, or tissue loss attributed to arterial occlusive disease, is associated with great loss of both limb and life. Therapeutic goals in treating patients with CLI include reducing cardiovascular risk factors, relieving ischemic pain, healing ulcers, preventing major amputation, improving quality of life and increasing survival. These aims may be achieved through medical therapy, revascularization, or amputation. Medical therapy includes administration of analgesics, local wound care and pressure relief, treatment of infection, and aggressive therapy to modify atherosclerotic risk factors. For patients who are not candidates for revascularization, and who are unwilling or unable to undergo amputation, treatments such as intermittent pneumatic compression or spinal cord stimulation may offer symptom relief and promote wound healing. Revascularization offers the best option for limb salvage. The decision to perform surgery, endovascular therapy, or a combination of the two modalities ('hybrid' therapy) must be individualized. Patients who are relatively fit and able to withstand the rigors of an open procedure may benefit from the long-term durability of surgical repair. In contrast, frail patients with a limited life expectancy may experience better outcomes with endovascular reconstruction. Hybrid therapy is an attractive option for patients with limited autologous conduit, as it permits complete revascularization with a less extensive procedure, shorter duration of operation, and decreased risk of peri-operative complications. Amputation should be considered for patients who are non-ambulatory, demented, or unfit to undergo revascularization.

Although relatively uncommon, isolated iliac artery aneurysms are associated with significant risk of rupture and death. Clinical presentation can be confusing and ultrasound or CT imaging is paramount in establishing the diagnosis and anatomical extent of disease. Important considerations prior to intervention include determination of proximal neck, involvement of the internal iliac artery, and status of the contralateral internal iliac artery. Endovascular repair has evolved as the first choice treatment option for patients with anatomically suitable iliac artery aneurysms. In uncommon circumstances when endovascular treatment may result in significant pelvic ischemia or the primary symptoms are related to extrinsic compression of adjacent structures, surgical repair may be the preferred option., (Copyright 2008 Wiley-Liss, Inc.)

Patients with limb-threatening ischemia and a paucity of ipsilateral greater saphenous vein for conduit represent a challenge for lower extremity revascularization. We present four patients with limited autogenous conduit who underwent hybrid revascularization using the Silverhawk atherectomy device and infrapopliteal artery bypass for limb-threatening ischemia. All patients experienced complete wound healing in early follow-up. Hybrid revascularization appears safe, produces excellent short-term outcomes, and may be appropriate for patients with limited autogenous vein who require lower extremity revascularization.

Considerable interest exists in using endovascular techniques for assessing the renal circulation. The vasomotor response of the renal circulation in patients with hypertension and severe atherosclerotic renal artery stenosis was evaluated. Sixteen patients (5 men and 11 women) with a mean age of 73.2+/-7.1 years (range, 59-82 years) underwent noninvasive renal duplex ultrasonography and endovascular flow wire evaluation. The flow wire was positioned in the main renal artery distal to the stenosis and used to examine the reactivity of the renal circulation in response to intra-arterial papaverine before and after percutaneous revascularization. Resistive index was computed as (MPV - EDV)/MPV, where MPV is the maximum peak velocity and EDV is the end-diastolic velocity. Renal flow reserve was defined as the ratio of peak hyperemic response to baseline flow. Intervention was technically successful in 18/18 arteries. Heart rate (69+/-11 vs. 65+/-10 beats/min; P=NS) and systolic blood pressure (168+/-19 vs. 163+/-24 mm Hg; P=NS) remained constant following injection of intrarenal papaverine, while diastolic blood pressure decreased (77+/-13 vs. 65+/-11 mm Hg; P<0.006). Papaverine injection resulted in significant increases in average peak velocity (APV; 148% of baseline; P=0.0003), MPV (146% of baseline; P=0.001), and EDV (161% of baseline; P=0.0026), but had no effect on the endovascular resistive index (0.81+/-0.12 vs. 0.84+/-0.08; P=NS). Renal artery stenting produced no effect on APV or EDV, but a small increase in MPV (123% of baseline; P<0.05). In contrast, renal stenting resulted in a significant increase in the endovascular resistive index (0.77+/-012 vs. 0.84+/-0.08; P=0.003), pulsatility index (1.84+/-0.61 vs. 2.23+/-0.70; P<0.014), and renal flow reserve (1.49+/-0.44 vs. 1.86+/-0.73; P<0.0071). A correlation was found between the noninvasive and endovascular measures diastolic/systolic ratio (r=0.73; P<0.0009) and resistive index (r=0.63; P<0.0053). Patients with atherosclerotic renal artery stenosis have preserved vasomotor response to papaverine, as well as marked increases in renal flow and resistive index following successful renal artery stenting. Endovascular flow wire measurements are safe, easy to perform, and correlate well with noninvasive Doppler measurements., (Copyright (c) 2006 Wiley-Liss, Inc.)

The most common clinical manifestations of fibromuscular dysplasia (FMD) are hypertension due to renal artery involvement and transient ischemic attack or stroke due to carotid or vertebral artery involvement. Patients with renal artery FMD and hypertension should undergo primary angioplasty with the goal of curing the hypertension. If the blood pressure fails to normalize following angioplasty, the physician should institute antihypertensive medications according to the recommendations of the Joint National Committee on the Prevention, Detection, and Treatment of High Blood Pressure VII. In patients with cerebrovascular FMD, antiplatelet agents represent the cornerstone of therapy. Percutaneous angioplasty has emerged as the preferred treatment for symptomatic cerebrovascular FMD.

Unsuspected subclavian or axillary disease may cause failure of axillofemoral bypass grafts. A 52-year-old woman who underwent left axillofemoral bypass grafting 5 years ago presented with 24 h of left foot pain. Routine duplex ultrasonography 2 months previously demonstrated velocities throughout the graft > 80 cm/s. Emergent angiography revealed thrombotic occlusion of the axillofemoral bypass graft. Both rheolytic thrombectomy and pulse spray thrombolysis using tissue plasminogen activator were used to restore graft patency. Arterial pressure waveform and pressure remained damped throughout the graft; a 50 mmHg gradient was found from the descending thoracic aorta to the mid-left subclavian artery. Angiography revealed a 70% diameter stenosis at the origin of the left subclavian artery. Following balloon angioplasty and stent placement, the pressure gradient was eliminated. In conclusion, careful evaluation of arterial inflow to bypass grafts is critical for ensuring long-term graft patency.

The objective of this study was to describe the development of a comprehensive surveillance program for monitoring the long-term follow-up of endoluminal stent graft (ELG) patients. Despite high procedural success rates, ELG patients remain at ongoing risk for aneurysm sac expansion, rupture, and other adverse events that make long-term surveillance imperative. As they perform more ELG, practitioners face increased logistical difficulty performing appropriate patient follow-up. A computer-based data ELG registry was created using Epi Info, a program developed by the Centers for Disease Control and Prevention that enables users to design a data entry form, enter data, and perform statistical analyses. The database has been used to track 259 patients (214 men and 45 women) who underwent ELG between November 1999 and October 2003. One-year follow-up was available for 182 patients, 2-year follow-up for 104 patients, and 3-year surveillance data for 40 patients, which represent follow-up rates of 89.6%, 78.8%, and 61.5%, respectively. There were 25 late deaths. The Kaplan-Meier estimate for 1-year survival was 92.5%. Twenty-one patients underwent 24 secondary angiographic procedures at a mean 8.6 +/- 10.3 months (range, 1-37.6) after stent-graft repair. No mortality was observed in association with a secondary intervention. There were no late conversions to open aneurysm repair. The Kaplan-Meier estimate for freedom from secondary intervention for all patients at 1 year was 91.0%. A computer-based registry facilitates appropriate and timely patient follow-up and may improve the long-term outcome from ELG., (Copyright 2004 Wiley-Liss, Inc.)

Objective: Following denervation, arteries demonstrate a heightened sensitivity to alpha-adrenergic agonists and increased oscillatory contractions that may partly result from increased gap junction expression. Hence, we wanted to study the effect of sympathetic denervation on connexin43 (Cx43) expression and agonist-induced contractility in the vascular smooth muscle (VSM)., Methods: Effects of denervation with reserpine (3 mg/kg/day, i.p.) or topical 5% phenol-glycerol on VSM contractions and expression of the gap junction Cx43 mRNA by reverse transcriptase polymerase chain reaction (RT-PCR) and Western blotting for Cx43 protein were examined. Wistar-Kyoto (WKY) rat tail arteries were exposed to norepinephrine (NE) (10(-9)-10(-5) M). Reactivity was also examined in the carotid arteries and thoracic aortas from Cx43 heterozygote deficient (KO) mice., Results: The concentration for NE-induced contraction was lower in reserpine- and phenol-treated vessels than controls (p<0.05). NE-induced oscillatory activity (OA) was seen in 5/5 reserpine- and 5/8 phenol-treated vessels vs. 0/12 controls (p<0.05). Spontaneous OA was observed more frequently in carotid and aortic rings from WT than Cx43 KO rings. Cumulative OA in response to alpha-adrenergic stimulation was significantly greater in WT carotid (429+/-101 vs. 128+/-7 mN s, p<0.05) and aortic rings (337+/-85 vs. 134+/-11 mN s, p<0.05) than in Cx43 KO rings. Following denervation, RT-PCR showed significantly increased levels of Cx43 mRNA (p<0.05). Western blot analysis revealed near doubling of Cx43 protein (p<0.05)., Conclusion: We conclude that sympathetic denervation results in increased expression of Cx43, which in turn, contributes to increased spontaneous and agonist-induced OA in VSM.

Endovascular techniques including angioplasty, stenting, and endoluminal stent grafts represent important therapeutic options for the treatment of vascular disease. Technologic advances have allowed for the treatment of aneurysmal disease as well as extra-cranial carotid disease that previously required surgical methods. The success of various endovascular therapies varies based on anatomic location and extent of disease. The clinical results in different arterial segments are increasingly recognized in the published literature. The aortoiliac arterial bed appears to respond most favorably, with less favorable results observed in the infra-inguinal and infrapopliteal locations. There is increasing evidence that stent-supported carotid angioplasty using cerebral protection will play an important future role in the treatment of carotid artery stenosis. Less invasive techniques to treat abdominal aortic aneurysms with endoluminal stent grafts have dramatically changed the available therapeutic options. Improved devices and delivery systems will likely increase the number of patients who can be successfully treated in this manner. The evolution of endovascular therapies will continue to change the way we treat vascular disease.