Revascularization by percutaneous coronary intervention (PCI) has become the predominant mode of symptom relief in patients with ischemic heart disease. However, certain lesion subsets still require surgical revascularization, including those that cannot be successfully crossed or dilated because of a heavy calcium burden. Percutaneous transluminal rotational atherectomy (PTRA) is a technique which can be used to 'de-bulk' lesions to assist both balloon dilatation and stent expansion. We retrospectively studied our outcomes when using adjunctive PTRA prior to stent insertion. Using institutional and provincial databases, 145 consecutive Nova Scotia patients were identified to have undergone 146 attempted PTRA procedures with stent insertion at our centre between November 2003 and January 2009. Major adverse cardiac events (MACE), comprising death, myocardial infarction (MI) and target vessel revascularization (TVR) were determined at 12 month follow-up. Indications for PTRA included heavily calcified lesions, ostial lesions or prior failure of balloon dilatation. Femoral arterial access predominated (77%). Most cases used 7Fr guides (37%) and combination heparin/glycoprotein IIb/IIIa inhibitor therapy (83%). An average of 2 stents per vessel were deployed, with 57% of cases receiving at least one DES. Average stented length was 39 mm (range 8-137 mm), with a mean stent diameter of 3.0 mm and a final angiographic success rate of 98%. Average procedure time was 114 min (range 37-244 min). There were 4 procedural failures. Three patients died in hospital (2.0%), two of whom required emergency CABG and one who developed refractory CHF. The overall one year MACE rate was 20% (death 6.9%, acute myocardial infarction 4.1% and TVR 7.5%). In our experience, PTRA combined with intracoronary stenting in a complex patient cohort, is associated with a high frequency of procedural success and good long-term clinical outcomes.

data are available with regard to the pharmacodynamics and safety of combining enoxaparin with glycoprotein IIb/IIIa inhibition during elective percutaneous coronary interventions (PCIs). We randomized 200 patients to receive open-label enoxaparin (0.75 mg/kg intravenous bolus) or unfractionated heparin (60 U/kg intravenous bolus) and eptifibatide or tirofiban during PCI. This yielded 4 groups of combination therapy (50 patients/group). The first 10 patients per group had anti-Xa activity and inhibition of platelet aggregation measured at baseline, and at 5 minutes, 10 minutes, 4 hours, and 24 hours. All patients received aspirin and clopidogrel therapy before PCI. Patients who received enoxaparin and heparin achieved therapeutic peak anti-Xa activity observed shortly after drug administration. At 4 hours, a differential anticoagulant effect was observed, with patients who received enoxaparin having a more gradual decrease in anti-Xa activity. Patients who received eptifibatide achieved > 80% inhibition of platelet aggregation soon after initiation of therapy more often than did those who received tirofiban. Type of heparin did not affect inhibition of platelet aggregation. Compared with patients who received heparin, periprocedural myocardial infarction and bleeding events occurred less frequently among those who re-ceived enoxaparin (14% vs 8% and 10% vs 5%); however, these differences were not statistically significant. Three cases of intraprocedural thrombus occurred among patients who received enoxaparin. Two patients received concomitant tirofiban therapy. Compared with unfractionated heparin, similar levels of anticoagulation and platelet inhibition are achieved with enoxaparin when concomitant therapy with eptifibatide or tirofiban is used during elective PCI, without an observed increase in early bleeding events or periprocedural ischemic complications. (c) 2005 by Excerpta Medica Inc.

The use of intravenous glycoprotein (GP) IIb/IIIa platelet receptor antagonists in the management of patients with acute coronary syndrome or those undergoing percutaneous coronary intervention (PCI) has become increasingly common in recent years. There are three GP IIb/IIIa receptor antagonists currently available for clinical use. Patients on GP IIb/IIIa receptor antagonists who require emergency surgical revascularization may be at increased risk for excessive peri- and postoperative bleeding. The duration of action of eptifibatide and tirofiban are short because they bind reversibly to the GP IIb/IIIa receptor and have a short half-life. Therefore, within a relatively short time after discontinuation of these agents, surgery can be performed with little or no increased risk of bleeding and without the need for additional hemostatic measures. Abciximab has a short plasma half-life but a long duration of action due to its high-affinity binding of GP IIb/IIIa receptors. Early retrospective studies demonstrated a higher incidence of major bleeding and requirement for blood transfusion, especially in those undergoing surgery within 12 hours of the discontinuation of abciximab. However, platelet transfusion has been shown to successfully reduce the incidence of these complications. The current evidence therefore indicates that, with appropriate measures, urgent surgical revascularization can be safely performed in patients who have received a GP IIb/IIIa receptor antagonist with little added risk. The benefits of these agents in the treatment of patients with an acute coronary syndrome or undergoing PCI are not obviated by the need for emergency bypass surgery.

Intravascular ultrasound (IVUS) is an invasive imaging modality, which provides detailed two‐dimensional images of blood vessels. There are currently two different types of IVUS catheters available, namely, the phased‐array and the mechanical designs. The operating ultrasound frequency of these catheters ranges from 20 to 40 MHz. This study sought to evaluate the image quality, accuracy of diameter and pullback length measurements, and catheter handling characteristics of three different IVUS catheters currently available for clinical use using both in vitro phantom models and in patients undergoing percutaneous coronary intervention (PCI). In gelatin phantom models, image quality assessed on a semiquantitative scale was significantly different between the three IVUS catheters ( P = 0.01) with the 40‐MHz catheter providing the best images. Accuracy of lumen diameter measurements, when compared to optical microscopy, were similar between the three IVUS catheter designs (all R 2 = 0.99). There were no significant differences in accuracy of pullback length measurements in vitro between the three designs. However, there were differences in the performance of the three IVUS catheters when used for preinterventional imaging in patients undergoing PCI. Both mechanical IVUS catheters were associated with lower procedural, fluoroscopy, and lesion crossing times compared to the phased‐array catheter (all P < 0.05). There were no significant differences between the catheters during postinterventional IVUS imaging. There were also small but potentially important differences with regards to clinical events and complications associated with the use of the different IVUS catheters during the PCI procedures, reflecting differences in catheter design. Cathet Cardiovasc Intervent 2001;52:382–392. © 2001 Wiley‐Liss, Inc.

A case of Y stenting using radiopaque stents for a bifurcation stenosis is described. Angiography and intravascular ultrasound demonstrate that in spite of optimal stent placement there is an area of the lesion that is not fully covered by the stents. This may predispose to subacute thrombosis and restenosis. This case illustrates a potential deficiency of this type of bifurcation stenting.

BACKGROUND: The technique of coronary stenting has evolved over recent years, with improved stent technology and effective antiplatelet therapies to prevent stent thrombosis. In Europe, reductions in stent and equipment costs have resulted from increased market competition. The impact changes on the in-hospital procedural cost of percutaneous coronary intervention (PCI) in the current clinical setting is not known. METHODS: We compared the initial equipment and pharmaceutical costs of one hundred consecutive, unselected patients undergoing PCI in 1998 to a similar population who underwent PCI in 1994. RESULTS: Similar patient characteristics were noted, yet more complex disease (multivessel, AHA type B2/C lesions) was treated in the 1998 population. The stent utilization rate (83% vs 15%, p < 0.0001) and use of intravenous and/or oral antiplatelet therapy (abciximab, ticlopidine) (64% vs 4%, p < 0.0001) was higher in 1998. Similar angiographic success was achieved in each group with low complication rates. Mean hospital stay was reduced in the 1998 group of these (2.6 - 2.8 vs 4.3 - 3.8 days, p < 0.001). Repeat PCI was required more frequently in the 1994 population (26% vs 9%, p < 0.001). Overall there was no significant difference in the mean equipment cost between the two groups ( 1551 vs 1422, p =ns). CONCLUSION: Despite the widespread use of coronary stenting and antiplatelet therapies there appears to be no difference in current in-hospital equipment costs for PCI compared to 1994. Improved clinical outcomes in the 1998 population imply that stenting is a cost-effective therapy. (Int J Cardiovasc Intervent 2000; 3: 161-165)

OBJECTIVE To review the diagnosis and management of noncritical left main stem disease. DATA SOURCES MEDLINE was searched using the key phrases 'intravascular ultrasound' and 'left main coronary artery'. DATA EXTRACTION Articles addressing the angiographic or ultrasound assessment of left main stem disease were systematically reviewed. Reference is also made to articles dealing with outcomes for patients with left main stem disease. DATA SYNTHESIS The assessment of left main stem disease by coronary angiography is often suboptimal. Intravascular ultrasound has demonstrated significant left main stem disease in angiographically normal arteries. It has also demonstrated that mild to moderate left main stem disease frequently accompanies disease in the other coronary arteries. The natural history of mild to moderate left main stem disease has not been well characterized; thus, the optimum management of this condition is not known. CONCLUSIONS To establish the natural history of noncritical left main stem stenosis, it is proposed that centres performing frequent intravascular ultrasound examinations systematically and quantitatively interrogate the left main stem during all left coronary examinations. Angiographic and ultrasonic measures of left main stem disease can then be correlated with clinical outcome during long term follow-up. This will clearly require the collaboration of several centres to generate a sufficiently large database to address these clinical questions.

Basic fibroblast growth factor (bFGF) has been shown to induce angiogenesis in various animal models, but the methods of administration used experimentally are not clinically feasible. The objective of this study was to determine whether a single intracoronary bolus injection of bFGF would improve coronary perfusion in a porcine ischemic model that mimics clinical chronic ischemia. A copper coil studded with gold was delivered into the proximal right coronary artery of juvenile Yorkshire pigs and deployed by interventional techniques. After a four-week interval for stenosis maturation, bFGF (100 micrograms) was administered by bolus injection into the left coronary artery in five animals, and vehicle alone was administered in four animals. Angiogenesis and change in right coronary perfusion area were assessed two weeks later by angiography, myocardial contrast echocardiography and immunohistochemistry. The right coronary perfusion area increased significantly after treatment in all but one of the animals that received bFGF but not in any of the controls. Intimal hyperplasia was not induced by bFGF. Capillary density determined histochemically was not different in the two groups. In conclusion, in a porcine ischemic model, bFGF administered by a single bolus intracoronary injection into the contralateral artery improved antegrade perfusion into the ischemic territory although without histological evidence of angiogenesis. This preliminary work merits further investigation.

Over the past few years, rates of intracoronary stenting during percutaneous revascularisation procedures have increased substantially. This increase has been due largely to the demonstration of reduced restenosis rates compared with conventional balloon angioplasty (PTCA) in large randomised trials. 1 Serruys PW de Jaegere P Kiemeneij F et al. A comparison of balloon-expandable stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med. 1994; 331: 489-495 Crossref PubMed Scopus (4370) Google Scholar , 2 Fishman DL Leon MB Baim DS et al. for the Stent Restenosis Study InvestigatorsA randomised comparison of coronary stent placement and balloon angioplasty in the treatment of coronary artery disease. N Engl J Med. 1994; 331: 496-501 Crossref PubMed Scopus (4138) Google Scholar However, economic analyses of intracoronary-stent placement based on these trial results have shown poor cost-effectiveness, largely as a result of increased in-hospital expenditure due to the complex anticoagulation regimens used and the direct stent costs. 3 Cohen DJ Krumholz HM Sukin CA et al. In-hospital and one year economic outcomes after coronary stenting or balloon angioplasty: results from a randomised clinical trial. Stent Restenosis Study Investigators. Circulation. 1995; 92: 2480-2487 Crossref PubMed Scopus (168) Google Scholar , 4 Goods CM Liu MW Iyer SS et al. A cost analysis of coronary stenting without anticoagulation versus stenting with anticoagulation using warfarin. Am J Cardiol. 1996; 78: 334-336 Summary Full Text Full Text PDF PubMed Scopus (12) Google Scholar A recent study of optimum elective Palmaz-Schatz stent placement reported a $2200 increase in in-hospital laboratory costs compared with PTCA alone. 5 Sukin CA Baim DS Caputo BP et al. The impact of optimal stenting techniques on cardiac catheterisation laboratory resource utilisation and costs. Am J Cardiol. 1997; 79: 275-280 Summary Full Text Full Text PDF PubMed Scopus (21) Google Scholar These analyses may be less relevant to current practice since improved deployment techniques have reduced anticoagulation requirements and shortened hospital stay. Additionally, increased competition in the interventional product market has led to reduced stent and angioplasty equipment costs.

This report describes a case of successful percutaneous coronary transluminal angioplasty (PTCA) of a coronary artery bifurcating lesion using multiple intracoronary stents in an inverted 'Y' configuration. Balloon angioplasty of bifurcation coronary stenoses has a lower procedural success rate, higher restenosis rate and potential for side branch occlusion compared with nonbifurcation lesions. Numerous techniques, including two ('kissing') angioplasty balloons, have been used to overcome these problems. The authors believe that the technique described in this report, inserting stents into both branches simultaneously followed by a third proximal stent in a 'Y' configuration, allows successful dilatation of the bifurcation lesion while preserving flow into both branches and should be considered for similar complex anatomical subsets.