Treatment of acute limb ischemia with a percutaneous mechanical thrombectomy‐based endovascular approach: 5‐year limb salvage and survival results from a single center series

Objectives: The study evaluated long‐term limb salvage and survival of an endovascular approach that incorporates mechanical thrombectomy (PMT) in the management of arterial thrombosis. Background: Acute limb ischemia is associated with a high risk of amputation and death. Previous reports from the United States (U.S.) of surgical and nonsurgical treatments are limited to primarily 30 days to 1 year. Methods: Single‐center, retrospective review of 57 consecutive patients (30 male, 27 female; mean age 63.8 ± 13.8 years) treated for limb threatening ischemia due to thrombotic arterial occlusions. Data includes baseline assessments, procedural outcomes, in‐hospital complications, 30‐day, and long‐term follow‐up. Results: Ninety‐three percent of patients (n = 53) presented with onset of symptoms (<14 days). Angiography following PMT showed thrombus removal complete/substantial 36 (63.6%), partial 16 (28.0%), and minimal 5 (8.8%), respectively. Catheter‐directed thrombolysis was used after PMT in 18 patients (31.6%). In‐hospital success with limb salvage was attained in 96.5% (n = 55) with mortality of 3.5% (n = 2). Thirty‐day limb salvage and mortality were 94.7% (n = 54) and 5.3% (n = 3), respectively. At mean 5‐year follow‐up (mean = 62 months), three patients have been lost to follow‐up. The results of 54/57 (94.7%) are available. Amputation free survival was 94.7% (n = 36/38) with long‐term mortality rate of 29.6% (n = 16/54). Conclusions: Acute limb ischemia treated with PMT alone or in combination with thrombolysis, followed by definitive therapy, results in favorable long‐term limb salvage. Allowing for appreciable long‐term mortality in vascular patients, survivors demonstrate amputation‐free success from the initial endovascular procedure with low reintervention rate. © 2008 Wiley‐Liss, Inc.     

Effects of aspiration thrombectomy on necrosis size and ejection fraction after transradial percutaneous coronary intervention in acute ST‐elevation myocardial infarction

Background: The use of routine aspiration thrombectomy in primary percutaneous coronary intervention (PCI) remains controversial. Methods: Patients in the EArly Discharge after Transradial Stenting of CoronarY Arteries in Acute Myocardial Infarction (n = 105) study were treated with aspirin, clopidogrel, and abciximab within 6 hr of symptoms onset. Operators were allowed to use 6 Fr Export aspiration catheter at their discretion. In this observational analysis, we compared acute and late results in patients treated with and without thrombectomy using cardiac biomarkers, angiographic, cardiovascular magnetic resonance (CMR), and clinical parameters. Results. Patients in the thrombectomy group (n = 44) had longer symptoms to balloon time (196 ± 86 min vs. 164 ± 62, P = 0.039) and higher incidence of preprocedural TIMI flow grade 0 or 1 (84% vs. 64%, P = 0.028). Following PCI, both groups had similar incidence of TIMI flow grade 3 (93 vs. 92%, P = 0.73) and myocardial blush grade 2 or 3 (80 vs. 77%, P = 0.86), respectively. Patients in thrombectomy group had significantly higher post‐PCI maximum values of creatine kinase‐MB (P = 0.0007) and troponin T (P = 0.0010). Accordingly, post‐PCI myocardial necrosis by CMR was higher (P = 0.0030) in patients in the thrombectomy group. At 6‐month follow‐up, necrosis size remained higher (20.7% ± 13.3% vs. 13.5% ± 11.1%, P = 0.012) in the thrombectomy group. Ejection fraction at 6 months was 65% ± 9% in patients in thrombectomy group compared to 70% ± 11% in patients without (P = 0.070). Results were not affected by initial TIMI flow or symptoms to balloon time. Clinical events remained comparable in both groups at 12 months follow‐up. Conclusion: In patients with ST‐segment elevation myocardial infarction presenting within 6 hr of symptoms and undergoing primary angioplasty with maximal antiplatelet therapy, acute and late results did not suggest significant benefit for additional aspiration thrombectomy, irrespective of initial TIMI flow or total ischemic time. © 2010 Wiley‐Liss, Inc.     

Integrilin in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Background: The adjunctive use of eptifibatide in patients undergoing primary percutaneous coronary intervention (PCI) for ST‐elevation myocardial infarction (STEMI) remains controversial. We therefore set out to determine the safety and efficacy of eptifibatide in this population. Methods: The study comprised 857 consecutive patients who underwent primary PCI for STEMI at the Washington Hospital Center. Three hundred eighteen patients also received adjunctive therapy with eptifibatide. Patients who had received thrombolysis prior to undergoing cardiac catheterization were excluded. The primary end‐point was all‐cause mortality and the composite of all‐cause mortality or Q‐wave MI. The primary safety end‐point was the rate of thrombolysis in myocardial infarction (TIMI) major bleeding. Results: The eptifibatide group was younger, had a higher body mass index, and a lower proportion of patients with systemic hypertension, diabetes mellitus, previous history of ischemic heart disease, coronary revascularization, and congestive heart failure. This cohort also used bivalirudin less often (23.3% vs. 72%; P < 0.001). Following multivariable analysis, the eptifibatide group had a significantly lower rate of all‐cause mortality (hazard ratio 0.55; 95% confidence interval 0.34–0.89; P = 0.01) and the composite of all‐cause mortality or Q‐wave MI (hazard ratio 0.59; 95% confidence interval 0.37–0.95; P = 0.03) at 6 months. The rate of TIMI major bleeding was similar in both groups (hazard ratio 0.54; 95% confidence interval 0.25–1.17; P = 0.12). Conclusion: The adjunctive use of eptifibatide in patients presenting with STEMI may be associated with improved clinical outcomes. (J Interven Cardiol 2011;24:351–356)     

Long‐term outcomes with aspiration thrombectomy for patients undergoing primary percutaneous coronary intervention: A meta‐analysis of randomized trials

Randomized clinical trials that examined long‐term clinical outcomes of routine aspiration thrombectomy prior to primary percutaneous coronary intervention (PCI ) in patients with acute ST ‐segment elevation myocardial infarction have yielded different results. We hypothesized that the routine use of manual thrombus aspiration prior to primary PCI lacks long‐term clinical benefits. Electronic databases were searched for randomized trials comparing routine aspiration thrombectomy and conventional PCI . We included only trials that reported clinical outcomes beyond 6 months. The primary outcome was all‐cause mortality, and the secondary outcomes included major adverse cardiovascular events, re‐infarction, cardiovascular mortality, and stent thrombosis (ST) . A DerSimonian ‐Laird model was used to construct the summary estimates risk ratio (RR ). We retrieved 18 trials with 20 641 ST ‐segment elevation myocardial infarction patients, of whom 10 331 patients underwent routine aspiration thrombectomy prior to primary PCI . At a mean follow‐up of 12 months, there was no significant decrease in the risk of all‐cause mortality (RR : 0.93, 95% confidence interval [CI ]: 0.82‐1.05, P = 0.22), major adverse cardiac events (RR : 0.95, 95% CI : 0.87‐1.03, P = 0.18), re‐infarction (RR : 0.95, 95% CI : 0.80‐1.13, P = 0.59), cardiovascular mortality (RR : 0.80, 95% CI : 0.47‐1.36, P = 0.40), or ST (RR : 0.80, 95% CI : 0.63‐1.01, P = 0.06) with routine aspiration thrombectomy. Routine aspiration thrombectomy prior to primary PCI was not associated with a reduction in long‐term mortality or clinical outcomes. Future randomized trials are warranted to further evaluate the role of aspiration thrombectomy in select patients and coronary lesions.     

A Bayesian Meta‐Analysis Comparing AngioJet® Thrombectomy to Percutaneous Coronary Intervention Alone in Acute Myocardial Infarction

Objective: The purpose of this meta‐analysis was to compare outcomes for AngioJet thrombectomy versus percutaneous coronary intervention (PCI) without thrombectomy in acute myocardial infarction (AMI) patients. Background: PCI is the preferred treatment for revascularizing the infarct‐related artery in patients with AMI. There is controversy about the benefits of thrombectomy as an adjunct to PCI. Methods: AMI studies published between January 1, 1999, and March 1, 2007, were used to compare AngioJet thrombectomy plus PCI to PCI alone. Bayesian meta‐analytic estimates were used to estimate the odds ratios (95% CI) for short‐term mortality, major adverse cardiac events (MACE), and final TIMI 3 flow. Results: The AngioJet data included 11 studies and 1,018 patients. The PCI data included 81 studies and 24,076 patients. The AngioJet group included more patients with large thrombus burden, rescue PCI after failed thrombolytic therapy, and longer symptom duration compared to the PCI group. Despite the higher risk profile of AngioJet patients, the groups had similar odds of short‐term mortality, 0.98 (0.53, 1.50), MACE, 1.25 (0.54, 2.40), and final TIMI 3 flow, 1.12 (0.70, 2.27). Conclusion: AngioJet thrombectomy results in clinical and angiographic outcomes that are similar to PCI in lower risk AMI patients. These observations suggest that AngioJet thrombectomy may reduce the additional risk associated with visible thrombus in the infarct‐related lesion.     

Aspiration coronary thrombectomy for acute myocardial infarction increases myocardial salvage

Objectives : The aim of the study was to assess if aspiration thrombectomy in high risk patients with STEMI and angiographic evidence of thrombus may improve myocardial salvage. Background : It is unclear if thrombus aspiration before percutaneous intervention (PCI) improves myocardial salvage. Methods : The trial was a prospective randomized study. The inclusion criteria were: first STEMI within 12 hr from symptoms onset, culprit lesion in left anterior descending or right coronary artery, culprit artery TIMI flow ≤ 2 and angiographic evidence of thrombus. The primary endpoint was myocardial salvage index (MSI) as assessed by ^99mTc‐sestamibi SPECT imaging. Results : We randomized 137 patients (98 male, mean age 64.1 ± 12.5 years) either to aspiration thrombectomy followed by standard PCI with stent implantation (n = 67) or to standard primary PCI (n = 70). Index perfusion defect was similar in both study groups: 34.2% ± 13.1% in thrombectomy group versus 37.1% ± 12.0% in primary PCI group (P = 0.2). MSI was larger in aspiration thrombectomy group than in control patients [25.4% (IQR 13.5–44) vs. 18.5% (IQR 7.7–30.3) respectively, P = 0.02]. The final infarct size was smaller in patients treated with aspiration thrombectomy (23.1% ± 13.3% vs. 28.9% ± 10.2% in the control group, P = 0.002). Conclusions : Aspiration thrombectomy improves myocardial salvage in high risk STEMI patients with angiographic evidence of thrombus. © 2011 Wiley‐Liss, Inc.     

Poor long‐term patient and graft survival after primary percutaneous coronary intervention for acute myocardial infarction due to saphenous vein graft occlusion

Primary percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI) due to saphenous vein graft (SVG) occlusion has been associated with poor procedural results and poor short‐term outcomes, but long‐term graft patency and patient survival have not been evaluated. Consecutive patients (n = 2,240) with STEMI treated with primary PCI from 1984 to 2003 were followed for 6.6 years (median). Follow‐up angiography was obtained in 80% of hospital survivors following primary PCI for SVG occlusion at 2.3 years (median). Patients with primary PCI for SVG occlusion (n = 57) vs. native artery occlusion had more prior MI, advanced Killip class, and three‐vessel coronary disease and lower acute ejection fraction (EF). Patients with SVG occlusion had lower rates of TIMI 3 flow post‐PCI (80.7% vs. 93.6%; P = 0.0001), higher in‐hospital mortality (21.1% vs. 8.0%; P = 0.0004), and lower follow‐up EF (49.3% vs. 54.7%; P = 0.055). Culprit SVGs were patent in 64% of patients at 1 year and 56% at 5 years. Late survival was strikingly worse in patients with primary PCI for SVG occlusion vs. native vessel occlusion (49% vs. 76% at 10 years), and SVG occlusion was the second strongest predictor of late cardiac mortality by multivariate analysis (HR = 2.11; 95% CI = 1.38–3.23; P = 0.0006). Patients with STEMI due to SVG occlusion treated with primary PCI have poor acute procedural results, frequent late reocclusion, and very high late mortality. The introduction of new adjunctive therapies (distal protection, thrombectomy, and drug‐eluting stents) may improve short‐term outcomes, but improved long‐term outcomes may require new and more durable revascularization strategies. © 2005 Wiley‐Liss, Inc.     

Distal Radial Artery Pressures Predict Angiographic Result and Short‐Term Patency Outcome in Hemodialysis Patients With Juxta‐Anastomotic Inflow Stenosis of Radiocephalic Fistula Undergoing Transradial Angioplasty

Distal radial artery pressure (RAP) was observed to be reduced after transradial percutaneous transluminal angioplasty (PTA) on the juxta‐anastomotic venous stenosis of radiocephalic arteriovenous fistula (RCAVF). Distal RAPs are easily obtained from a pressure transducer connected with an introducer retrograde inserted into distal radial artery. The clinical role of distal RAP in the setting of transradial PTA remains unknown. This prospective and observational study aimed to explore the relationship between distal RAPs and clinical outcomes. This study recruited hemodialysis patients with RCAVF juxta‐anastomotic venous stenosis undergoing transradial PTA. RAP‐related variables and procedural data before PTA (pre‐PTA) and after PTA (post‐PTA) were analyzed. The study endpoint was dysfunction‐driven re‐PTA during the 1‐year follow‐up. Overall, 73 PTAs significantly reduced the mean of systolic RAPs from 159.6 ± 41.4 to 108.4 ± 41.5 mm Hg; P < 0.0001. Post‐PTA systolic RAP was associated with angiographic outcome (P = 0.004) and unassisted patency at 3 months (P = 0.036), but not at 6, 9, or 12 months (P > 0.05). The group with angiographically successful PTAs had a significantly lower mean of post‐PTA systolic RAPs compared with that with unsuccessful PTAs (98.4 ± 35.4 vs. 128.7 ± 46.1 mm Hg; P = 0.003). The post‐PTA systolic RAP may be seen as a predictor for 3‐month unassisted patency (AUC = 0.669; P = 0.048). In conclusion, this study provides the RAP profile to help guide transradial PTA on RCAVF juxta‐anastomotic venous stenosis and predict 3‐month unassisted patency in a hemodynamic manner.     

Long‐term results of cephalad arteries percutanoeus transluminal angioplasty with stent implantation (The CAPTAS registry)

Introduction : Carotid artery stenting (CAS) has become an alternative to carotid endarterectomy. Moreover, percutaneous transluminal angioplasty (PTA) allows other cephalad arteries revascularization. The aim of this study was to evaluate late outcomes of cephalad arteries PTA. Methods : This is an international multicenter registry of 434 consecutive patients in which 497 PTAs were performed. Patients with symptomatic >50% stenosis or asymptomatic >70% stenosis were enrolled. Stenting of 577 internal carotid arteries (ICA) and 13 common carotid arteries was performed, 20.7% procedures were complex in which bilateral carotid stenoses or carotid and vertebral arteries stenoses were revascularized at one stage. In 15.9% patients, one‐stage coronary intervention was carried out. Distal protection devices were used in 69.6% of cases. PTAs were divided into high (n = 330) and low (n = 167) risk of major adverse coronary and cerebral events (MACCE). Results : At 30 days, there were 15 (3.5%) cases of MACCE [0.9% deaths, 2.1% strokes, and 0.9% myocardial infarction (MI)]. TIAs were observed in 15 (3.9%) patients. There was no significant difference in stroke incidence between procedures with or without neuroprotection (1.8 vs. 3%; P = 0.66) as well as in MACCE occurrence between high and low‐risk groups (4.3 vs. 2%; P = 0.34). Bilateral stenoses increased while hypertension decreased the risk of MACCE. Left ICA lesions increased the risk of cerebrovascular accidents (CVA). At 4 years (1–11 years), the mortality rate was 11.5%, 6% of patients had stroke, and 3% MIs. Restenosis occurred in 3%. There was a trend toward higher mortality rate (13.3 vs. 6.9%; P = 0.07) and MACCE risk in high‐risk group (23.5 vs.14.7% P = 0.06). Age > 65 y.o. and stent length < 24 mm increased, while the statin therapy on admission decreased the risk of long‐term death. Structural valve disease and stent length <30 mm increased the risk of MACCE, while implantation of Acculink stent decreased the risk of CVA. Conclusions : CAS is safe and successful procedure with low early and long‐term adverse events. Special attention should be put on patients with bilateral and left ICA stenoses. If possible, longer stents should be applied. © 2011 Wiley Periodicals, Inc.     

Impact of abciximab on mortality and reinfarction in patients with acute ST‐segment elevation myocardial infarction treated with primary stenting

Objectives: To combine data from all randomized trials of abciximab versus placebo or open‐label control in patients with STEMI treated with primary stenting to assess the short‐term and long‐term mortality, reinfarction, and bleeding complications. Background: Clinical trials of adjunctive abciximab therapy in patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary stenting have produced conflicting results. Methods: Formal searches of electronic databases (Medline, Cochrane) from January 1990 to April 2009 were performed. Five trials randomizing 2,937 patients (1,475 in the abciximab group, 1,462 in the placebo group) were included in the analysis. Results: When compared with placebo, abciximab was not associated with a significant reduction in the odds of 30‐day (OR 0.71, 95% CI: 0.45–1.14, P = 0.16) or long‐term (OR 0.85, 95% CI: 0.48–1.50, P = 0.57) mortality. Similarly, the rate of reinfarction was not statistically different at 30 days (OR 0.59, 95% CI: 0.30–1.17, P = 0.13) or at long‐term follow‐up (OR 0.67; 95% CI: 0.39–1.16, P = 0.16). However, when trials with upstream use of thienopyridines were excluded, abciximab was associated with a significant reduction in the composite of death or reinfarction at 30 days (OR 0.45; 95% CI: 0.26–0.77, P = 0.004) but not at long‐term follow‐up (OR 0.59; 95% CI: 0.27–1.28, P = 0.18). Conclusion: Routine use of abciximab in patients with STEMI treated with primary stenting may reduce short‐term rates of death or reinfarction in patients not administered preprocedural thienopyridine therapy, but does not appear to be beneficial in those who receive preprocedural thienopyridines. © 2009 Wiley‐Liss, Inc.     

Percutaneous revascularization of long femoral artery lesions for claudication

Background : Angioplasty and stenting are preferred treatments for revascularizing femoral artery lesions up to 100 mm, but surgical bypass is recommended for longer lesions. We assessed long‐term patency after percutaneous revascularization of long femoral artery lesions for claudication with intensive out‐patient surveillance. Methods : We followed a cohort of 111 consecutive patients receiving angioplasty or stenting in 142 limbs in two institutions. Patients were followed for 2.5 years, and event curves and multivariable survival analysis used to compare outcomes in three groups according to lesion length (< 100 mm, 100–200 mm, and greater than 200 mm). Failed patency was defined as recurrence of symptoms with a decline in ankle brachial index, or stenosis identified by duplex ultrasound, or reintervention. Results : Compared to lesions less than 100 mm, longer lesions had higher failed primary patency (100–200 mm: HR = 2.0, P = 0.16, >200 mm: HR = 2.6, P = 0.03). Failed secondary patency was similar for short and intermediate lesions (< 5% incidence), but trended higher for lesions >200 mm (HR = 4.2, P = 0.06). An initial procedure residual stenosis greater than 20% was the only significant multivariable factor related to poorer long‐term patency (HR = 15.8, P = 0.003). Compared to short lesions, the gain in long‐term patency with out‐patient surveillance and reintervention was higher for longer lesions and significantly so for intermediate lesions (100–200 mm = 23% versus <100 mm = 8%, P = 0.041). Conclusion : Percutaneous treatment of long femoral artery lesions can provide acceptable long‐term patency for patients with claudication when out‐patient surveillance is used to identify patients who require repeat interventions. Future long‐term studies should consider overall patency encompassing more than one percutaneous reintervention. © 2011 Wiley‐Liss, Inc.     

Balloon angioplasty versus stenting with nitinol stents in intermediate length superficial femoral artery lesions

Background : Recent randomized trials investigating stent implantation compared with balloon angioplasty for treatment of superficial femoral artery (SFA) disease have given divergent results in short (mean 5 cm) and intermediate (mean 10 cm) lesions. We reinvestigated whether primary nitinol stenting is associated with a morphologic and clinical benefit when compared with percutaneous transluminal angioplasty with optional stenting (PTA) in intermediate‐length lesions. Methods : We randomly assigned 73 patients with severe claudication or chronic limb ischemia and average 8 cm long (range 3–20 cm) SFA stenosis or occlusion to primary stent implantation (n = 34) or PTA (n = 39). Restenosis >50% and clinical outcome were assessed at 3, 6, and 12 months postintervention. Results : Average length of the treated segments was 98 ± 54 mm and 71 ± 43 mm in the stent and PTA groups (P = 0.011), respectively. In the PTA group, secondary stenting was performed in 10 of 39 patients (26%) due to a suboptimal result after balloon dilation. Restenosis rates in the stent and PTA groups were 21.9% versus 55.6% (P = 0.005) at 6 months by CT‐angiography, and 2.9% versus 18.9% (P = 0.033), 18.2% versus 50.0% (P = 0.006), and 34.4% versus 61.1% (P = 0.028) at 3, 6, and 12 months by sonography, respectively. Clinically, patients in the stent group reported a significantly higher maximum walking capacity compared with the PTA group at 6 and 12 months. Conclusion : In this randomized multicenter trial, primary stenting with a self‐expanding nitinol stent for treatment of intermediate length SFA disease resulted morphologically and clinically superior midterm results compared with balloon angioplasty with optional secondary stenting. © 2009 Wiley‐Liss, Inc.     

Treatment Outcome of Overactive Bladder Patients Receiving Antimuscarinic Therapy for More than One Year

Objectives

Details on the therapeutic effects of long‐term antimuscarinic therapy have not been reported. Thus, the aim of this study is to evaluate the detailed long‐term therapeutic effect of antimuscarinic therapy.

Methods

All consecutive patients who visited the urologic outpatient clinics of a medical center for treatment of overactive bladder syndrome and received antimuscarinic therapy of 12 months or more were retrospectively reviewed. All medical records, including the Overactive Bladder Symptom score (OABSS), the modified Indevus Urgency Severity Scale and the International Prostate Symptoms score (IPSS) questionnaires, and uroflowmetry parameters were reviewed at each visit.

Results

A total of 140 patients had received 12 months or more of antimuscarinic therapy. Sustained therapeutic effects were observed by persistent decreases of IPSS‐storage score, IPSS‐total score and OABSS score. Moreover, the maximum flow rate did not change over time. A temporary increase in postvoid residual volume and decrease in voiding efficiency were found, but these parameters improved over long‐term visits. Side‐effects were observed in 81 patients (57.9%) and included dry mouth (n = 58, 41.4%), constipation (n = 48, 34.3%) and blurred vision (n = 4, 2.9%); all side‐effects were tolerable. Patients aged 75 years or more (n = 94) had a higher comorbidity rate (n = 46, 48.9%) before treatment but generally exhibited similar therapeutic effects as overall patients; elderly patients could also tolerate side‐effects.

Conclusion

Sustained therapeutic effects were observed in patients who received 12 months or more of antimuscarinic therapy, even in elderly patients. In addition, side‐effects in patients receiving long‐term therapy were also common but tolerable.     

Percutaneous mechanical thrombectomy for massive pulmonary embolism using a conservative treatment strategy

Introduction: Percutaneous mechanical thrombectomy (PMT) for treatment of massive pulmonary embolism (PE) has been shown to be technically feasible, although the complication rate of the procedure appears relatively high. Whether a conservative treatment approach defined by an early termination of the PMT procedure once hemodynamic and clinical parameters of the patient have improved is associated with lower complication rates is unknown. We report our experience of PMT in patients with massive PE using the Angiojet system following a conservative treatment strategy. Methods: From April 2003 until November 2007, 13 patients underwent PMT with the Angiojet system. Indications for PMT were massive PE and either failed thrombolysis or contraindications to thrombolytic therapy. All patients were deemed high risk for surgical thrombectomy. Results: Technical success was achieved in 12 patients (92%). Mean systemic arterial pressure increased from 87 to 106 mmHg following PMT (P = 0.011), while the heart rate decreased from 119 to 97 beats per minute (P = 0.041). In‐hospital mortality was 15% (2 of 13 patients). No complications occurred which were attributable to the PMT procedure. Right ventricular size and function improved in the majority of patients following the PMT procedure. Conclusion: Using a conservative treatment approach of PMT for the treatment of massive PE carries a low periprocedural complication rate. The low morbidity was achieved without compromising clinical outcome, documented by an in‐hospital mortality of 15%. PMT using a conservative treatment approach may result in comparable mortality, but lower morbidity than PMT using more aggressive, angiographically guided treatment strategies.     

The effect of thrombectomy on myocardial blush in primary angioplasty: The randomized evaluation of thrombus aspiration by two thrombectomy devices in acute myocardial infarction (RETAMI) trial

Background: In patients with ST‐segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) may cause thrombus dislodgment leading to microvascular function impairment, which is a negative independent predictor of myocardial function recovery. Compared with conventional stenting, pretreatment with aspiration thrombectomy during primary PCI significantly improves coronary epicardial flow and myocardial tissue perfusion parameters. We sought to evaluate the angiographic findings of two different manual aspiration thrombectomy devices (Diver‐Invatec® (DI) and Export‐Medtronic®® (EM)) in STEMI patients undergoing primary angioplasty. Methods: We randomized 103 STEMI patients referred to our hospital to undergo primary PCI (<12 hr from symptoms onset) to DI (n = 52) and EM (n = 51) devices. The primary angiographic composite end‐points were the rates of post‐thrombectomy thrombus score (TS) ≤≤2, TIMI flow grade ≥≥2, and post‐stenting myocardial blush grade (MBG) ≥≥2 in the two groups. Results: Baseline, clinical, and angiographic preprocedural findings did not differ between the two groups. After aspiration thrombectomy, a TS ≤≤ 2 was more frequently present in EM group (92.3 vs. 69.3%, P = 0.0052). Also the rate of post‐thrombectomy TIMI ≥≥ 2 (69.3 vs. 92.2%, P = 0.0052) and post‐stenting MBG ≥≥2 (88.2 vs. 69.3%, P = 0.029) were significantly higher in EM group. No significative differences were observed in terms of clinical events at 1 and 12 months. Conclusions: In this single‐center, prospective, randomized study, a EM use before stenting in STEMI patients seems to remove more thrombotic burden compared with DI, providing a greater post‐thrombectomy epicardial flow and a better post‐stenting microvascular perfusion. © 2008 Wiley‐Liss, Inc.     

Visible angiographic complications predict short and long‐term outcomes in patients with post‐procedural creatine‐phosphokinase elevation

Objectives : To assess whether visible angiographic complication is related to outcome in patients with elevated creatine phosphokinase (CK‐MB) following percutaneous coronary intervention (PCI). Background : Elevated biomarkers following PCI are associated with increased incidence of adverse events but the absolute risk of such events is low. A more specific marker of risk is needed. Methods : Consecutive patients with elevated post‐PCI CK‐MB were divided into two groups according to presence (n = 115, 43%) or absence (n = 150, 57%) of an angiographic complication. A control group (n = 250) was randomly chosen from 2,403 patients undergoing PCI during the same period without CK‐MB elevation. Major adverse cardiac events (MACE) were assessed at 30 days and 1 year. Results : Patients with an identifiable angiographic complication and elevated postprocedural CK‐MB had significantly worse outcomes at 30 days and 1 year compared with biomarker positive patients without an identifiable complication and control patients (30 day MACE rate: 8% vs 0% vs 0.4%, respectively, p < 0.001; 1 year MACE rate: 26% vs 11% vs 11%, respectively, p = 0.002, all p‐values for angiographic complication vs no angiographic complication and for angiographic complication vs control). Biomarker positive patients without identifiable angiographic complication had an excellent short and long term outcome, which was no different from biomarker negative patients (1 year MACE rate: 11% vs 11%, p = 0.53). Conclusion : Post‐PCI patients without visible angiographic complications have an excellent short and long term outcome. These findings call into question the need for routine CK‐MB monitoring after PCI in the absence of clinical symptoms or angiographic complication. © 2010 Wiley‐Liss, Inc.     

Prospective study of short-term peginterferon-alpha-2a monotherapy in patients who had a virological response at 2 weeks after initiation of interferon therapy

Background and Aims: Long‐term interferon (IFN) therapy is effective in eliminating hepatitis C virus (HCV). However, it carries the risk of adverse effects and reduced quality of life. To assess whether short‐term IFN therapy effectively eliminates HCV, we performed a prospective pilot study of pegylated (peg)IFN‐α‐2a therapy for 8 or 24 weeks. Methods: After excluding patients with high titers of genotype‐1, 55 HCV patients received pegIFN‐α‐2a. Patients who became negative for HCV‐RNA at week 2 were allocated to either an 8‐week (n = 19) or 24‐week (n = 15) course of IFN. We evaluated the efficacy of and tolerance to IFN therapy. Results: The sustained virological response rate was excellent in the two groups (8 weeks, 89.5% [17/19]; 24 weeks, 100% [15/15], respectively,). IFN dose reduction was required in one patient of the 8‐week group, but in six patients of the 24‐week group (P = 0.028). Treatment was completed by all patients of the 8‐week group, but discontinued in five patients of the 24‐week group (P = 0.011). Conclusions: The 8‐week IFN therapy is more tolerable than the 24‐week therapy and had similar outcomes. Excluding the patients with high titers of genotype‐1, we recommend switching to an 8‐week course of pegIFN‐α monotherapy once patients show an ultra rapid virological response at week 2 from the start of IFN therapy.     

Intragraft pressures predict outcomes in hemodialysis patients with graft outflow lesions undergoing percutaneous transluminal angioplasty

Objectives : This study is to introduce intragraft pressure (IGP) as intraprocedural parameter for outcome survey in hemodialysis patients with graft outflow lesions undergoing percutaneous transluminal angioplasty (PTA). Background : The role of IGP on procedural endpoint and patency is unknown. Methods : Seventy‐five participants with graft outflow lesions receiving PTA were enrolled. Procedural data regarding IGP and angiographic findings were collected and the 1‐year graft patency through collaboration with hemodialysis units. Analyses and comparisons among IGP, angiographic findings, and patency were conducted. Using the receiver operating characteristic (ROC) curve and Kaplan–Meier survival analysis, we intended to detect significance and the cut‐off points of IGP for patency prediction, and difference in patency between the two groups divided by using the cut‐off points. Results : Pre‐PTA and post‐PTA IGP were significantly associated with 1‐year patency (both significance <0.01) with 0.756 and 0.791 areas under the ROC curves, respectively. The cut‐off points of pre‐PTA and post‐PTA IGP were closer to 106 and 47 mm Hg for prediction of 1‐year patency (sensitivity = 0.76, specificity = 0.69; sensitivity = 0.79, specificity = 0.69, respectively; 95% CI). Significant reductions in 1‐year patency were shown in the subjects with greater than the cut‐off values, either pre‐PTA or post‐PTA IGP, compared with those with smaller than these values (both log rank test < 0.001). Conclusion : IGP might be useful to evaluate procedural endpoints and predict patency outcomes in hemodialysis patients with graft outflow lesions undergoing PTA. Patients with the greater pre‐PTA or post‐PTA IGP, to some level, seem to have the shorter patency. © 2010 Wiley‐Liss, Inc.     

Aspiration thrombectomy during primary percutaneous coronary intervention as adjunctive therapy to early (in-ambulance) abciximab administration in patients with acute ST elevation myocardial infarction: an analysis from Leiden MISSION! acute myocardial infarction treatment optimization program

Background: The benefits of early abciximab administration and thrombus aspiration in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI) have previously been elaborated. However, whether there is an adjunctive effect of thrombus aspiration among STEMI patients, with angiographic evidence of thrombus, receiving early prehospital abciximab remains unclear. Methods: In the context of a fixed protocol for PPCI, 158 consecutive patients with STEMI were enrolled, in whom abciximab was started early before hospital arrival (in‐ambulance); 79 patients who had PPCI with thrombus aspiration (thrombectomy‐facilitated PCI group), were compared to 79 who had PPCI without thrombus aspiration (conventional PCI group) in a prospective nonrandomized study. The primary end‐point was complete ST‐segment resolution within 90 minutes. Secondary end points included distal embolization, enzymatic infarct size as well as left ventricular ejection fraction (LVEF) assessed by gated single‐photon emission computed tomography. Major adverse cardiac events (MACEs) were evaluated up to 12 months. Results: Both groups were comparable for baseline characteristics. ST‐segment resolution was significantly higher in the thrombectomy‐facilitated group (P = 0.002), and multivariate analysis identified thrombectomy as an independent predictor of ST‐segment resolution (OR = 9.4, 95% CI = 2.6–33.5, P = 0.001). Distal embolization was higher in the conventional PCI group among patients with higher thrombus grades. No difference was observed between both groups in infarct size assessed by peak creatine kinase (p = 0.689) and peak Tn‐T levels (P = 0.435). Also, the LVEF at 3 months was similar (P = 0.957). At 12 month clinical follow‐up, thrombus aspiration was, however, associated with reduced all‐cause mortality (log‐rank p = 0.032). Conclusion: Among STEMI patients treated with PPCI and in‐ambulance abciximab, it appears that a selective strategy of thrombus aspiration still has additive benefit. (J Interven Cardiol 2012;25:1–9)     

Percutaneous rheolytic thrombectomy for large pulmonary embolism: a promising treatment option.

BACKGROUND: Pulmonary embolism (PE) is a common cardiovascular disease with significant mortality. Some patients with large PE are not eligible for current treatment options such as thrombolysis or surgical embolectomy. We report our experience of percutaneous rheolytic thrombectomy (PRT) using the AngioJet system combined with adjunctive local thrombolytic therapy and inferior vena cava (IVC) filter placement to treat massive or submassive PE in patients ineligible for current treatment options. METHODS AND RESULTS: Of the 14 consecutive patients ineligible for thrombolysis or embolectomy treated with PRT, 10 patients had massive PE (6 patients were hypotensive and 4 patients had intractable hypoxemia) and 4 patients had submassive PE. Adjunctive local thrombolysis was performed in 5 patients. An IVC filter was placed in 11 patients. Angiographic success based on Miller score was achieved in 13 patients (92.9%). Procedure success was obtained in 12 patients (85.7%). Procedural mortality occurred in one patient who presented in cardiogenic shock (7.1%) and non-fatal hemoptysis occurred in 1 patient (7.1%). Total in-hospital mortality occurred in 3 patients (21.4%). On a mean follow-up of 9 months, all 11 survivors had noted significant improvement in symptoms without recurrence. CONCLUSIONS: Percutaneous rheolytic thrombectomy using the AngioJet may be a treatment option for patients with massive or submassive PE who may not be eligible for thrombolytic therapy or surgical embolectomy.