BACKGROUND: PCI for long coronary lesions remains a challenge because of high incidence of early complications and late restenosis. Cutting balloon angioplasty may result in reduced procedural complications and late restenosis than angioplasty with conventional long balloons (LBA) due to minimized injury to the culprit arteries. OBJECTIVE: To compare the immediate and one‐year outcomes of CBA and LBA for long coronary lesions. METHODS: 169 consecutive patients were retrospectively identified who underwent CBA or LBA for de novo lesions⩾20 mm in length and⩾2.5 mm in diameter. The primary endpoint was immediate procedural outcomes and angiographic restenosis at one year. RESULTS: CBA was performed in 54 patients (56 lesions) and LBA in 115 patients (151 lesions). Baseline characteristics were similar in both groups with a mean lesion length of 34.89±11.19 mm, and vessel diameter of 3.03±0.54 mm. CBA resulted in reduced incidence of side branch loss (23.2% versus 41.7%, P = 0.022) which was associated with less peri‐procedural infarction (OR: 11.39 (95% CI: 1.34–96.53), P = 0.026). It also caused less dissection (23.2% versus 38.4%, P = 0.048) leading to a trend of less provisional focal stenting (32.1% versus 41.1%, P = 0.264). The rate of angiographic restenosis and clinically driven target lesion revascularization at one year (follow‐up 91.1%) was similar (25% versus 21.2%, and 20.4% versus 20%, for CBA versus LBA, both P = NS). The mean event‐free survival was also similar (10.15±0.45 months for CBA versus 9.50±0.39 months for LBA, P = NS). CONCLUSION: CBA demonstrated better immediate results and equivalent late results than LBA, and therefore, it may be considered a reasonable firstline approach for PCI of long coronary lesions.
Ancient Greek physicians named the principal arteries of the neck as the carotid arteries as they believed that pressing hard on these arteries made mammals and humans become sleepy or lose consciousness (Karotides Greek, the arteries of the neck vkaros heavy sleep vkaroun to choke, to stupefy). The carotid artery bifurcation is the most common location of craniocervical atheromatous disease, which may induce brain ischaemia or be a source of thromboembolic material, accounting for 20–30% of strokes. The current indication for revascularization of carotid stenosis is prevention of stroke, and therefore, it is clear that the risk of the procedure has to be smaller than the clinical benefit rendered. Thus, individualized assessment of the risk–benefit ratio is heavily affected by both the initial risk (i.e. death or stroke rate) associated with the procedure and the natural history of the atherosclerotic carotid disease treated conservatively. Several prospective, randomized trials (1–6) have supported the benefit of carotid endarterectomy (CEA) over medical therapy for the treatment of significant obstructive carotid lesions. Since its introduction half a century ago, CEA has become one of the most commonly performed peripheral vascular procedures. Importantly, the benefit of CEA has been directly related to the severity of stenosis (3,7) and the projected benefit is clinically justified only if CEA can be performed with a risk of post-procedural death or disabling stroke of less than 6% for symptomatic patients and 3% for asymptomatic patients. When an inappropriately high complication rate occurs the clinical benefit is markedly impeded, thereby questioning the performance of CEA under those circumstances (7,8). Therefore, there is a rationale for exploring alternative revascularization techniques in patients considered at high surgical risk for periprocedural events. Accordingly, the 30-day rate of death or disabling stroke rate has been proposed to be a unifying standard for the evaluation of the postprocedural risk (9), that can be used to compare horizontally different revascularization methods. The 30-day rate of death or disabling stroke was 5.8% in the North American Symptomatic Carotid Endarterectomy Trial (NASCET) (2) and 7.1% rate in the European Carotid Surgery Trial (ECST) trial (6). In this context, carotid artery stenting (CAS) as a new method that achieves percutaneous carotid artery revascularization should first be evaluated with respect to its 30-day safety results. Elective CAS was initiated in the mid 1990s, using an endovascular approach avoiding all surgical wound-related complications of CEA, and the need for general anaesthesia. Therefore, CAS has the potential for becoming the preferred revascularization method, especially in patients who would be considered at significantly high risk for CEA. However, while the prospective, multicentre Carotid and Vertebral Transluminal Angioplasty Study (CAVATAS) conducted between the years 1992 and 1997 reported a similar major risk and effectiveness for CAS and CEA for symptomatic patients with carotid artery disease (13), other registries failed to show a substantial benefit in patients who underwent CAS (14). In those trials, stents were used in only one-third of the patients, and obviously, the stents as well as the techniques of the procedure have since then been refined. Despite
OBJECTIVE:We examined our experience using the sirolimus eluting stents (Cypher) as an alternative to surgical revascularization in carefully selected cohort of patients undergoing multi-vessel percutaneous coronary intervention. METHODS:Fifty consecutive patients with multi-vessel disease who were good candidates for both surgical and percutaneous revascularization were included in the current analysis. All patients underwent a careful clinical evaluation prior to the intervention, and they were followed for procedural and clinical outcomes for nine months. RESULTS:Mean age was 64+/-11 years (40 males, 30% diabetics) and 10 patients (20%) had three-vessel disease. Angina class was 2.7+/-0.6 at baseline. Overall, 116 lesions were treated using 122 stents (mean 2.4 stents per patient). Total mean stent length was 43+/-12 mm (range: 21-90 mm). Overall, one patient died during follow-up (2%), no patient had stroke or Q wave MI and one patient experienced non-Q myocardial infarction. There was no documented stent thrombosis and two patients (4%) underwent target-vessel revascularization. The hierarchical cumulative major adverse cardiac event rate was 8% and the cardiac event-free survival rate was thus 92%. CONCLUSION:Multi-vessel stenting using Cypher stents is a viable treatment strategy in selected group of patients with multi-vessel coronary artery disease. It is associated with excellent intermediate-term clinical outcomes and thus it could serve as the primary revascularization strategy of choice in appropriate candidates.
A 52‐year‐old asymptomatic man, with cardiac risk factors of hypertension, Type II diabetes, hypertriglyceridemia, low HDL, obesity, and positive family history for early coronary artery disease (CAD), was referred to nuclear stress test. He exercised for 14 minutes, achieved his target heart rate, without any symptoms or ECG changes. Nuclear images were entirely normal. However, the patient was still concerned and anxious so he underwent CT angiography that revealed coronary narrowings. Next, he underwent coronary angiography with similar findings. The lesions were treated with stents. We present a case report to illustrate how newer technology such as CT angiography alters the way in which we diagnose CAD and decide on whether to pursue further invasive therapy.
Background: Current X‐ray technology displays the complex 3‐dimensional (3‐D) geometry of the coronary arterial tree as 2‐dimensional (2‐D) images. To overcome this limitation, an algorithm was developed for the reconstruction of the 3‐D pathway of the coronary arterial tree using routine single‐plane 2‐D angiographic imaging. This method provides information in real‐time and is suitable for routine use in the cardiovascular catheterization laboratory. Objectives: The purpose of this study was to evaluate the precision of this algorithm and to compare it with 2‐D quantitative coronary angiography (QCA) system. Methods: Thirty‐eight angiographic images were acquired from 11 randomly selected patients with coronary artery disease undergoing diagnostic cardiac catheterization. The 2‐D images were analyzed using QCA software. For the 3‐D reconstruction, an algorithm integrating information from at least two single‐plane angiographic images taken from different angles was formulated. Results: 3‐D acquisition was feasible in all patients and in all selected angiographic frames. Comparison between pairs of values yielded greater precision of the 3‐D than the 2‐D measurements of the minimal lesion diameter (P<0.005), minimal lesion area (P<0.05) and lesion length (P<0.01). Conclusions: The study validates the 3‐D reconstruction algorithm, which may provide new insights into vessel morphology in 3‐D space. This method is a promising clinical tool, making it possible for cardiologists to appreciate the complex curvilinear structure of the coronary arterial tree and to quantify atherosclerotic lesions more precisely.
The ubiquitin-proteasome system is the two sequential labeling and degradation system that accounts for the degradation of 80-90% of all intracellular proteins. Based on the diversity of its substrates, it is integrated in many different biological processes, especially inflammation and cell proliferation. Given the significance of these two processes for primary atherosclerosis and restenosis, the ubiquitin-proteasome system may be an amendable target in cardiovascular therapy. This review provides background information on the ubiquitin-proteasome system, currently available data on its involvement in cardiovascular diseases, and a future perspective on the targeted use proteasome inhibitors, including drug-eluting stents.
Perforation of the left main stem is a rare complication associated with combined aortic valve replacement and by‐pass surgery. One‐year following aortic valve replacement a 70‐year‐old male presented with chest pain. This was related to a slowly expanding haematoma caused by a low profile chronic perforation of the left main. Subsequently, a tailored percutaneous modification of the main stem was performed. At three months follow‐up, he had no complaints and selective coronary angiography confirmed the successful sealing of the perforation with a concomitant regression of the prior haematoma.
Exercise tolerance testing (ETT) is the commonest non-invasive method for investigating stable patients presenting with cardiac-sounding chest pain. The sensitivity and specificity of the ETT for the detection of myocardial ischaemia are approximately 70% in men (1). However, this test is less sensitive for large patient sub-groups including women and patients with abnormal resting ECG’s (2,3). Myocardial Perfusion Scintigraphy has a higher sensitivity and specificity than ETT (4) and its use is less dependent on the functional capacity of the patient. Nevertheless, it remains a relatively expensive test with limited availability. PRIME ECG (manufactured by Meridian Medical Technologies, Belfast, Northern Ireland) is a Body Surface Mapping (BSM) system that utilizes an 80electrode ECG ‘vest’ to detect electro cardiac activity over a much wider distribution of the thorax than the conventional 12-lead ECG electrodes. Electrocardiac data is recorded for all 80 electrodes. A beat marker is manually positioned at the end of the QRS complex. Isopotential map recordings are then taken at 60 ms after the beat marker (ST60) for all leads. The ST 60 data acquired at baseline can be subtracted, for each electrode, from the data derived from subsequent acquisitions taken during exercise or pharmacological stress. The PRIME software allocates a colour scale proportional to the degree of ST segment shift and displays this on a diagramatic torso corresponding to the position of the leads detecting the ST shift (ST elevation—red scale, ST depression—blue scale). Only the ST60 change from baseline for a given electrode is therefore displayed as a colour. This is the visually intuitive ‘Delta Map’. This novel technique has been used to demonstrate transient regional myocardial ischaemia following balloon inflation during percutaneous coronary angioplasty in patients with single vessel coronary artery disease (5). We report, for the first time, a case in which transient regional ischaemia induced during stress nuclear perfusion imaging is also accurately displayed using the PRIME Delta Map, and correlates with a significant stenosis in the epicardial coronary artery perfusing this territory.
INTRODUCTION:The most effective strategy for bifurcation stenting is currently undefined. The Culotte technique was developed as a method that ensures complete bifurcation lesion coverage. However, it went out of favour due to a high rate of restenosis when utilizing bare metal stents. Drug-eluting stents reduce the rate of restenosis and need for repeat lesion revascularization compared with bare metal stents; we re-evaluated this technique with drug-eluting stent implantation.METHODS:Between April 2002 and October 2003, 207 patients were treated for at least one bifurcation lesion with drug-eluting stent implantation to both the main vessel and side branch. Of these, 23 were treated with the Culotte technique (11.1%) for 24 lesions. Sirolimus-eluting stents were used in 8.3%, and paclitaxel-eluting stents in the remaining 92.7%.RESULTS:Clinical follow-up was obtained in 100%. One patient had a myocardial infarction at 14 days (maximum rise in creatine kinase 872 IU/L) related to thrombosis occurring in another lesion, and underwent repeat revascularization. There were no episodes of stent thrombosis in the Culotte lesions. At eight months follow-up, there were no deaths and no further myocardial infarction. One patient required target lesion revascularization (TLR), and a second underwent target vessel revascularization. The cumulative rates of survival-free of TLR and major adverse cardiac events were 94.7% and 84.6% respectively. Angiographic follow-up was obtained in 16 patients (69.6%) at a mean period of 8.3+/-4.3 months. The late lumen loss for the main vessel and side branch were 0.48+/-0.56 mm and 0.53+/-0.33 mm respectively, with binary restenosis rates of 18.8% and 12.5%.CONCLUSIONS:In this small study of bifurcation stenting utilizing the Culotte technique with drug-eluting stent implantation, there was a low rate of major adverse events and need for target lesion revascularization at eight months, when compared with historical data of bifurcation stenting with bare metal stents. Further re-evaluation of this technique utilizing drug-eluting stents, is warranted in the setting of larger randomized studies.
Grey scale intravascular ultrasound (IVUS) is a valuable clinical tool to assess the extent and severity of coronary atheroma. However, it cannot reliably identify plaques with a high-risk of future clinical events. Serial IVUS studies to assess the progression and/or regression of atherosclerotic plaques demonstrated only modest effects, of pharmacological intervention on plaque burden, even when clinical efficacy is documented. Spectral analysis of radiofrequency ultrasound data (IVUS-virtual histology (IVUS-VH), Volcano Therapeutics, Rancho Cordova, CA) has the potential to characterize accurately plaque composition. The Integrated Biomarker and Imaging Study (IBIS) evaluated both invasive and non-invasive imaging techniques along with the assessment of novel biomarkers to characterize sub-clinical atherosclerosis. IVUS-VH was not included at the start of the IBIS protocol. The purpose of this paper is to describe the methodology we used to obtain and analyse IVUS-VH images and the approach to cross-correlations with the other techniques.
OBJECTIVES. Herein, we investigated the percentage of T‐helper (Th1) and Th2 cells among the general T‐cell population in the peripheral blood of patients with stable angina (SA) and unstable angina (UA). BACKGROUND. Recent evidence suggests that Th1 cells and the cytokines that they secrete (especially IFN‐γ) have a role in the activation of macrophages, promotion of clot formation and destabilization of atherosclerotic plaques. Thus, Th1 cytokines may contribute to the initiation and progression of UA. In contrast, cytokines secreted by Th2 cells (e.g. IL‐10) are known to inhibit activation and proliferation of Th1 cells and the secretion of IFN‐γ, lysosomal enzymes and metalloproteinases. Therefore, we sought to examine whether the ratio of IFN‐γ to IL‐10 secreting cells is altered in patients with UA. METHODS. The percentage of Th1 and Th2 cells among the general T‐cell population was determined by fluorescent intracellular cytokine staining (IFN‐γ and IL‐10, out of the total CD3 positive cells). RESULTS. The percentage of T‐cells positive for intracellular IFN‐γ was significantly higher in patients with UA (n = 22) in comparison with SA (n = 20) patients (39.0±2.8% and 29.6±2.7%, respectively. P = 0.02). There was no significant difference in intracellular IL‐10 positive cells between the two groups. In addition, there was no significant difference in the ratio between the intracellular IFN‐γ positive cells and the intracellular IL‐10 positive cells. CONCLUSIONS. There is an increased activity of Th1 cells in patients with UA in comparison with patients with SA. There is no evidence of heightened activity of Th2 cells in either group. Thus, IFN‐γ secreted by peripheral blood T‐lymphocytes,may be an important immunomodulator contributing to destabilization of the atheromatous plaque lying at the base of the etiopathogenesis of unstable angina.
Dextrocardia is rare and percutaneous intervention in such patients presents additional challenges to the operator. This report describes successful two-vessel angioplasty and stenting, including a chronic, sub-totally occluded proximal left anterior descending artery.
In this case report, we present the use of intracardiac echocardiography (ICE) for guiding the cardiac catheterization and subsequent hemodynamic investigation in an unusual patient case with multiple congenital abnormalities (bicuspid aortic valve, left cervical aortic arch, two aortic coarctations) and two aortic valve replacement operations in the past. The ICE catheter (AcuNav) permitted us to accurately and safely puncture the interatrial septum and place the Swan-Ganz catheter in the left ventricle; additionally, visualization of the aortic coarctation in the ascending aorta was also achieved.
BACKGROUND:Pressure derived myocardial FFR, a functional index of epicardial stenosis has been proposed for the assessment of optimal stent deployment. The following study evaluated the potential of serial fractional flow reserve (FFR) measurements in comparison to the 'gold standard' intravascular ultrasound (IVUS) for optimal stent deployment and its long-term outcome.METHODS:35 patients with a single de novo lesion underwent PTCA followed by stent implantation with an initial inflation pressure of 12 atm. If optimal stent expansion using IVUS-criteria were not fulfilled, re-dilatation at 16 atm as well as additional inflations with larger balloon sizes were performed to reach the procedural end-point. IVUS and FFR were performed after each dilatation (n = 136). Angiography was repeated after 6 months.RESULTS:In 30 pts who fulfilled IVUS criteria, mean lumen area (2.9+/-1.3 mm2) increased after PTCA and stent implantation to 10.0+/-3.0 mm2. In six pts, optimum stent deployment according to a value of FFR0.94 was not reached. Four of six pts reached the IVUS criteria at 12 atm and two pts at 16 atm, respectively. Positive and negative predictive values of FFR were 26 and 64%. Three of the 30 pts (10%) revealed a restenosis at three months follow-up. One of these restenosis was seen in a patient with a post-procedural FFR<0.94.CONCLUSIONS:FFR was not valid to predict optimal stent expansion according to IVUS criteria but could delineate under-expanded stents despite a reasonable angiographic appearance. Morphologic (IVUS) and functional criteria (FFR) for optimal stent deployment revealed a comparably low restenosis rate.
BACKGROUND:Bare stents reduce acute complications and repeat revascularization following percutaneous coronary intervention (PCI), but are costly and may lead to in-stent restenosis. It remains unclear whether stents should be universally implanted or whether provisional stenting mainly to suboptimal balloon dilatation results is an acceptable approach for multivessel PCI.OBJECTIVE:To compare the long-term clinical restenosis and target lesion revascularization (TLR) of stented and non-stented coronary artery lesions in patients who had multivessel PCI.METHODS:We performed retrospective analysis of matched data from 129 consecutive patients who underwent multivessel PCI (at least optimal balloon angioplasty to one coronary artery segment and balloon angioplasty plus stenting to another coronary artery in the same patient, all lesions are de novo native coronary artery lesions with vessel diameter >/=2.5 mm). The study endpoint was restenosis and repeat revascularization at one-year follow-up.RESULTS:Baseline characteristics were similar in both groups. Low in-hospital MACE (3.1%). Acute myocardial infarction, emergency revascularization via either PCI or CABG was detected and angiographic success was achieved in 99.3% of lesions in both groups. The rate of clinically driven angiographic restenosis and TLR at one-year (follow-up 100%) was similar (17.1% versus 18.6%, P=0.871, and 13.9% versus 16.3%, P=0.728, for optimal balloon angioplasty versus provisional stenting.CONCLUSIONS:The main findings from this study are that long-term angiographic restenosis and TLR was comparable for optimal balloon angioplasty and provisional stenting, suggesting that provisional stenting is an acceptable approach for multivessel PCI.
Percutaneous mitral commissurotomy and aortic valvuloplasty have been being performed since the mid‐1980s. Balloon commissurotomy has been used in thousands of cases worldwide and it provides good short‐ and long‐term results in a wide range of patients. It has virtually replaced surgical commissurotomy in the treatment of mitral stenosis. In contrast, percutaneous aortic valvuloplasty is almost abandoned worldwide due to its lack of efficacy and the risks involved. The new techniques of percutaneous valve intervention: aortic valve replacement and mitral valve repair are at an early stage: the first in‐man applications of these fledgling techniques started in 2002. Preliminary series show that they are feasible; however, they need to be further evaluated in comparison with contemporary treatment to assess accurately how efficient they are and the risks involved. Currently potential applications concern high‐risk patients, however, in the future, after thorough evaluation, this may be extended to others. Thus, percutaneous interventions already play an important role in treatment of valvular heart disease, a role that seems set for future expansion.
BACKGROUND:Multi-detector row spiral CT (MDCT) can be applied as a noninvasive tool for the assessment of coronary artery stenoses. Few, confounding reports have been published using 16 detector rows. The aim of the present study was to determine the accuracy of 16-detector row MDCT for the detection of significant stenoses in the coronary arteries, in comparison to conventional invasive coronary angiography.METHODS:Twenty-two patients with suspected coronary artery disease, were prospectively evaluated by 16-slice retrospectively ECG-gated CT coronary angiography and quantitative invasive coronary angiography. The findings were compared for the detection of significant coronary artery stenoses (>50%) in all segments with diameter >1.5 mm.RESULTS:MDCT correctly classified all 14 patients (100%) that were found to have significant coronary artery disease on conventional angiography. Overall, 288 segments were included in the analysis, regardless of their image quality. Significant stenoses were detected in 24 segments by CT and in 28 segments by conventional angiography. Out of 260 segments that were negative for significant stenoses on conventional angiography, 255 were correctly identified on CT. The sensitivity, specificity, positive and negative predictive values were 86, 98, 83 and 98%, respectively. MDCT also revealed supplementary findings that invasive angiography was unable to visualize, including anomalous vessel course, the course of vessels filling via collaterals, intramyocardial course of vessels and non-stenotic plaques.CONCLUSIONS:MDCT coronary angiography utilizing 16-detector rows shows promising results for reliable detection of coronary artery stenoses and particularly for ruling out significant disease.
BACKGROUND:Percutaneous transluminal septal myocardial ablation (PTSMA) recently emerged as an alternative to myectomy for hypertrophic obstructive cardiomyopathy (HOCM) patients with drug-refractory symptoms. The target septal branch selection is a main point to achieve the therapeutic result.METHODS AND RESULTS:We report about PTSMA performed using intracardiac echocardiography (ICE) to guide the procedure in 9 symptomatic HOCM patients. The target septal branch was chosen on the basis of the risk-area visualized using ICE after injection of a contrast agent. During alcohol administration a backscattered signal enhancement of the infarcted area was detected. The procedures were uncomplicated and effective to reduce the gradient from 78.9+/-20.4 mmHg to 7.8+/-7.9 mmHg (p<0.0001).CONCLUSIONS:In this initial experience ICE monitoring during PTSMA was safe and provided high quality and continuous imaging of the treated segment of the septum during the whole procedure.
OBJECTIVES. We evaluated clinical outcome of consecutive patients with in stent restenosis (ISR) treated with drug‐eluting stents (DES) at two intervention centres from April 2002 to April 2004, reflecting ‘real world’ practice. BACKGROUND. ISR is the major limitation to successful long‐term outcome after implantation of bare metal stents during percutaneous coronary intervention (PCI). The optimal strategy for the treatment of ISR has yet to be determined. METHODS. 121 consecutive patients with significant ISR were treated with DES. Sirolimus DES were used in 60 patients and paclitaxel DES in the remainder. All patients were followed up to evaluate the incidence of major adverse cardiac events (MACE), angina class and clinically driven angiography. Data were collected between 7 and 27 months after the procedure (mean follow up of 16.5 months). RESULTS. Overall MACE rate at 16.5 months was 13.2% (16 patients) including 4 deaths (3%). Fifteen (12.3%) patients underwent clinically driven angiography. Eight patients (6.6%) developed ISR within the treated segment, of whom, four underwent further PCI and 4 CABG. Mean Canadian angina class decreased from 2.46±0.7 pre‐procedure to 0.69±0.6 at follow up. All patients achieved an improvement in angina, with 59% being rendered angina free and 87% free of MACE. There were no differences in clinical outcome in those who received a paclitaxel and sirolimus DES. CONCLUSIONS. The use of DES implantation for the treatment of ISR is safe, effective and associated with low recurrence rates in a ‘real world’ large cohort of patients with a complex mix of anatomical and clinical factors.
Calcified lesions are encountered with increasing frequency in the catheterization laboratory. Percutaneous coronary interventions of calcified lesions are associated with a higher complication rate than percutaneous intervention on non‐calcified lesions. The review focuses on current management strategies in the drug eluting stent era of this complex lesion subset.Evidence based approaches to treat calcified coronary lesions with balloon based and atherectomy devices as adjunctive modalities in the drug eluting stent era are discussed in this article.
