TOPIC2014開催に合わせて、Special Gest Commentatorとして、韓国のEVT界ビッグネームであるTae-Hoon Ahn先生（Korea University Guro Hospital）、Seung-Woon Rha先生（Korea University Guro Hospital）をお招きして、EVT Case Competitionを開催致しました。
本会中は参加者全員がすべて英語のみ、6名の先生方によるプレゼンテーションおよびディスカッションは大いに盛り上がりました。3時間もの長丁場にも関わらず、全員参加の大変熱く楽しい時間となりました。『Best Presentation Award』は、上記2名のGest CommentatorとSUNRISE世話人による採点のもと、Gold、Silver、Bronzeを表彰させていただきました（皆さん甲乙つけ難く審査も難渋しました）。
以下は『Best Presentation Award』に輝いた3名の先生方のプレゼンテーションです。ご参考ください。
A 75-year-old female was referred to our clinic for her right leg intermittent claudication. Both ABI were decreased (right:0.57, left:0.63), and CT showed substantial calcification on both common femoral arteries (CFA). Angiogram showed eccentric stenosis on her right CFA, and we performed transluminal ballooning to the lesion, and the pressure gradient disappeared immediately after the angioplasty. However, ABI did not change, and the symptom relapsed in 2 months. Two months after the first PTA, angiography was performed and it revealed lesion recoil. Given the unsuccessful short-term result, we changed the strategy, penetrating the guide-wire into the center of the plaque, and inflated a balloon within the plaque. After the procedure, the ABI improved (right:0.76) and the symptom disappeared, and ABI was still maintained to the same level in 10 months after the procedure. PTA to CFA is challenging because stenting is not favorable. For lesions with eccentric plaque, transluminal ballooning is not effective since the lesion easily recoils. We used intra plaque ballooning technique for the eccentric plaque in the right CFA, which has been successful. These findings suggest that intra plaque ballooning might be more effective for lesions with eccentric plaque than transluminal ballooning.
A 65-years-old woman with hypertension, dyslipidemia, diabetes, and past smoking had planned to undergo total arch replacement for TAA. However, chest CT and carotid echo showed that occluded right internal carotid artery, and 70% stenosis in left internal carotid artery with increased peak systolic velocity (250cm/sec). Head MRI showed the old cerebral infarction in left side. We decided to treat her left carotid artery first, because neurologist alerted that the risk of stroke in perioperative period would be high. However, carotid artery stenting (CAS) to this patient was at a high risk for embolic stroke due to her diseased aortic arch. In addition, carotid endarterectomy was not feasible and safe because of contralateral carotid artery occlusion, and severe COPD. This is why we decided to perform “hybrid” procedure, transcervical CAS. Transcervical CAS was performed successfully and she discharged 3 days after the procedure. Transcervical CAS could be one of the choices for the carotid artery stenosis especially for the patients with aortic aneurysm.
Distal embolism inducing stroke is the one of the most terrible complication during CAS. When we could know which plaque is vulnerable before the procedure, we can choice the feasible protection method. So the aim of the present study is to elucidate whether BB-MRI of plaque could indicate the plaque stability.
Methods and results:
We evaluated the consecutive 25 patients (27 cases) who were undergone CAS from July 2010 to December 2013. In 23 patients (24 cases), BB-MRI with T1 weighted image (T1WI), T2 weighted image (T2WI) and time of flight (TOF) was taken prior to the CAS. Average age was 72 and 4 patients (14.8 %) were octogenarian. Twenty-two patients (81.5 %) were male gender. We perform CAS with distal protection using filter in 2 cases and with proximal protection in 22 cases. Precise stent was used in 4 cases, and Carotid wall stent in 20 cases. When debris was observed at the filter or stop/slow flow phenomenon occurred or plaque protrusion was seen by intravascular ultrasound after stenting in the course of CAS, the case was defined as unstable. Plaque protrusion was seen in 2 cases (18.5%) and additional stent was needed in 1 case. In 11 cases (40.7 %), debris was trapped at the filter. We calculated the ratio of the intensity of the plaque and sternocleidomastoid muscle (P/S) in the same slice. We evaluated the value of P/S in the unstable cases (group U, n = 15) and the stable cases (group S, n = 9). The value of P/S in T1WI was significantly higher in the group U than group S (1.43 ± 0.23 and 0.85 ± 0.41, p value = 0.0017).
The plaque with high P/S value in T1WI could be vulnerable and induce embolic complication. We should consider the proximal protection or consult a vascular surgeon for CEA.