TOPIC2015開催に合わせて、第2回EVT Case Competitionを開催致しました。
Special Gest Commentatorsとして、昨年に引き続き韓国のEVT界ビッグネームであるTae-Hoon Ahn先生（Gil Medical Center）、Seung-Woon Rha先生（Korea University Guro Hospital）をお招きし、本会中は参加者全員がすべて英語のみの3時間を過ごしました。5名のdoctorsによるプレゼンテーションおよびディスカッションとなった今回は、EVTのyoung expertとしてすでに世界でご活躍中の猛者たちにご参加もいただいたこともあり、予定時間を大幅にオーバーして大盛り上がりの会となりました。
上記2名のGuest CommentatorとSUNRISE世話人による採点のもと、『Best Presentation Award』と『Dr. Ahn Special Award』の2名を選出させていただきました。Winnerにはそれぞれ今年のGuro live、ENCORE liveのinvited facultyとなっていただき、lectureと2nd operatorを務めていただくことになります。
1. 相原 英明 先生 (筑波メディカルセンター病院)
2. 山口 徹雄 先生 (武蔵野赤十字病院)
3. 寺村 真範 先生 (一宮西病院)
4. 仲間 達也 先生 (宮崎市郡医師会病院)
5. 鈴木 頼快 先生 (名古屋ハートセンター)
A 19-year-old female was referred to our outpatient clinic for hypertension. Her blood pressure was 196/120 mmHg. Laboratory data showed elevation of both plasma renin activity (PRA: 23.7 ng/ml/hour) and plasma aldosterone concentration (PAC: 371 pg/ml). Computed tomography with contrast showed bilateral renal artery (RA) stenosis with negative remodeling. Renogram showed left renal excretory dysfunction. We examined whole body arteries, but no other stenosis was found. Because her blood pressure was still high after medical therapy, we performed PTRA to bilateral RA. To prevent dissection, the balloon size was determined as B/A ratio₌0.9. We finished procedure from the findings of FFR >0.9 after balloon angioplasty (left: 0.59→0.93, right: 0.64→0.94). Soon after PTRA, her blood pressure, PRA, and PAC were normalized.
Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic disorder that leads to arterial stenosis, and is common among young females. Recurrent rate after PTRA for FMD is reported only 10%, so stenting should be avoided. We need to achieve Pd/Pa >0.9 to normalize PRA, so using pressure wire is useful to determine endpoint.
A 76 years old male suffered from ulcer in his right toe (1th, 5th). And he had chronic kidney disease with hemodialysis due to diabetes mellitus. Since MRA showed rt.CIA, rt.SFA and multiple BTK disease, he was then referred to us. Although 1st EVT was performed immediately for rt.CIA and rt.SFA, his ulcer did not improve. So we planned 2nd EVT for rt.BTK lesions. According to angiosome, 2nd EVT was planned EVT for rt. ATA with ipsi-lateral antegrade approach.
Although stiff 0.014 guidewire could reach at the distal ATA, any devices could not pass the calcified lesion even with improvement of back-up force by bidirectional approach and externalization. Because Rotablator could not reach either, 5Fr. guiding catheter was inserted into half of the ATA. Finally, we completely perform ablation with Rotablator and ballooning through the ATA. In summary, it was difficult to treat highly calcified CTO-lesion. Stiff guidewire passed relatively easily CTO part, but any device was impossible to pass the lesion. Although tugging delivery is very effective as a strengthening of the backup, it was not enough in the current case. Using guiding catheter and guiding sheath (5 in 4.5 Fr.), Rotablator was effective.
In case of severe calcified artery disease below the knee, even Tornus PV or Rotablator is often difficult to pass the lesion in conventional fashion. Enhanced back-up by tagging delivery or child and mother catheter technique could facilitate passage through the severe calcified lesion.