Safety Aspects in Carotid Artery Stenting - Is Flow Reversal the Solution? Johan Formgren Head of Peripheral Vascular Interventions, Department of Medical Imaging, Södersjukhuset AB, Stockholm
Since the publication of the Endarterectomy versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) and Stent-supported Percutaneous Angioplasty of the Carotid Artery versus Endarterectomy (SPACE) studies, doubts have been raised regarding the safety of CAS as an alternative carotid intervention to CEA.
Emergency coronary angiography showed angiographically normal coronary arteries in all with ventriculographic confirmation of apical ballooning observed by echocardiogram (Figure 2). Due to acute refractory heart failure, intraortic balloon pump was used in 2 patients. At ventriculography all of the patients showed apical akinesis and normokinesis of middle and basal segments. All patients were uneventfully discharged and remained asymptomatic at follow – up (median 44, range 12–68 months). At follow-up echocardiogram, normal regional and global left ventricular systolic and diastolic function were restored (Table 2).
Discussion We described 6 cases of tako-tsubo cardiomyopathy in a region of Southern Italy close to Naples. In the contemporary definition and classification of the Cardiomyopathies proposed in 2006 by the American Heart Association, stress ("Tako-Tsubo") cardiomyopathy is classified among acquired forms of cardiomyopathy [6]. A recent systematic review on apical ballooning syndrome identified 14 case series published on international peer-reviewed literature, totalling about 200 patients [7]. Our data are broadly consistent with these previous reports, regarding epidemiological profile, clinical presentation and long-term follow-up. ABS accounts 2% of acute coronary syndromes, with most cases occurring in post-menopausal women. Ischemic-like ST-T changes most frequently occur with mild elevation of cardiac biomarkers. The acute left ventricular dysfunction typically involves the apex, although recently some apex-sparing variants of the syndrome have been described [8]. The acute left ventricular dysfunction usually recovers in a few days or weeks, and long-term follow-up is usually uneventful. Of note, the geographic origin of published reports originates from Japan (9 studies), USA (3 studies), Belgium and Spain (1 study each) [9]. In the present case series, we describe 6 cases all originating from Irpinia, a region of Southern Italy, near Naples but with different ethnic origin and lifestyles (Figure 3). This report again emphasizes that ABS can be much more diffuse than previously thought, and it can be easily recognized, if one thinks of it and applies clearly pre-defined criteria.
Clinicians should consider this syndrome in the differential diagnosis of acute coronary syndromes, especially in post-menopausal women with a recent history of acute emotional or physical stress. The non-invasive suspicion rests on the typical echocardiographic appearance apical ballooning – usually reversible within a few days or weeks. The angiographic documentation of normal coronary arteries is necessary to substantiate the diagnosis.
