Clinical predictors of improved long-term blood pressure control after successful stenting of hypertensive patients with obstructive renal artery atherosclerosis

Despite a high procedural success rate, long-term blood pressure control after successful renal artery stenting of hypertensive patients has been inconsistent. This most likely reflects the absence of clinical guidelines for the selection of patients likely to benefit from renal revascularization. A cohort of 150 consecutive hypertensive patients (mean age, 66.7 years; 86 women) with 180 renal artery lesions (≥75%) underwent primary Palmaz stent deployment. Mean arterial blood pressure (MAP), serum creatinine, and antihypertensive medication requirements were monitored prospectively. Specific definitions of blood pressure cure, improvement, or treatment failure were followed. Renal artery duplex Doppler or angiography was performed to assess stent patency at a mean 13 months (range, 7–15 months). Multivariate logistic regression analysis was used to select clinical variables that best related to a beneficial blood pressure control at follow-up. The procedural success rate was 97.3% (146 patients) and major in-laboratory complications were infrequent (1.3%). Late MAP values in 127 patients (91%) fell from 110 ± 13.7 to 97.6 ± 10.6 mm Hg (P < 0.001); antihypertensive medication requirements decreased from 2.9 ± 1.2 to 1.9 ± 1.1 (P < 0.01). The 13-month stent restenosis rate defined by duplex Doppler or angiography was 12%. Multivariate logistic regression analysis identified a preprocedure MAP of >110 mm Hg (odds ratio, 2.9; P = 0.003) and bilateral renal stenoses (odds ratio, 4.6; P = 0.009) as predictors of a beneficial blood pressure response at follow-up. This study provides general preprocedure guidelines for the selection of hypertensive patients with atherosclerotic renal lesions likely to benefit from primary Palmaz stenting and confirms a high procedural success and low stent restenosis rate. Cathet. Cardiovasc. Intervent. 47:167–172, 1999. © 1999 Wiley-Liss, Inc.     

Long stenting in native coronary arteries: Relation between vessel size and outcome

Procedural and 6-mo clinical outcomes were evaluated in 34 consecutive patients who had stenting (<40 mm) of a long segment of coronary artery. Procedural success was achieved in 32 (96%) patients. Before stenting, 32 (96%) patients had Canadian Cardiovascular Society Class 3 or 4 angina compared to 7 (21%) at 6-mo follow-up (^P<0.001). Eleven patients (32%) suffered either acute/subacute stent thrombosis (n=4) or restenosis (n=7). On logistic regression distal reference diameter <2.5 mm (odds ratio 26, ^P<0.01) and previous cardiac intervention (odds ratio 9.0, ^P<0.01) were independent predictors of a major adverse event during follow-up. There was no significant association between outcome and indication for stenting, type of stent, or use of ticlopidine and aspirin. These results indicate that distal vessel diameter <2.5 mm is a powerful predictor of subacute thrombosis or restenosis after long coronary artery stenting. Cathet. Cardiovasc. Diagn. 44:170-174, 1998. © 1998 Wiley-Liss, Inc.     

Reduced incidence of clinical restenosis with newer generation stents, stent oversizing, and high-pressure deployment: single-operator experience

BACKGROUND: Over the last 4 years, several newer generation stents have become available, promising to change the scenery of coronary angioplasty (PTCA) with its attendant restenosis rate. HYPOTHESIS: The aim of this study was to review prospectively the results of a single operator adopting a uniform approach with approximately 0.5 mm stent oversizing and high-pressure (> or = 12-16 bar) deployment and compare them with conventional PTCA in a series of 244 consecutive patients. METHODS: The study included 203 men and 41 women, aged 59 +/- 11 years, who presented with stable angina and/or positive exercise testing (n = 75), unstable angina (n = 161), or acute myocardial infarction (n = 8). Dilated vessels included the left anterior descending artery (n = 139), the right coronary artery (n = 86), the left circumflex artery (n = 47), the ramus branch (n = 4), or venous grafts (n = 2). Stents were implanted for dissection, suboptimal PTCA result, and electively. Two groups were compared: 83 patients who underwent balloon PTCA alone and 161 patients who also received stent(s). RESULTS: The two groups had similar demographics, age (58 +/- 10 vs. 59 +/- 11 years), initial vessel stenosis (92 +/- 7 vs. 93 +/- 6%), and left ventricular ejection fraction (51 +/- 9 vs. 51 +/- 8%). Procedural success was also similar (97.6 vs. 99.4%), but as expected the residual stenosis was much lower in the stent group (< or = 0 vs. 17%). The following stents were employed: J & J (n = 1), NIR (n = 117), ACS (n = 59), AVE (n = 9), Inflow GoldFlex (n = 9), Crossflex (n = 5), Wictor (n = 1), Jostent (n = 16), R stent (n = 9), Seaquence (n = 2) and Wallstent (n = 1). Single stents were used in 118 patients, two stents in 31 patients, three in 6 patients, and four in 6 patients. There was one in-hospital death at 3 days unrelated to the procedure. There were no events of subacute stent thrombosis; all patients in the stent group received combined therapy with aspirin and ticlopidine, the latter for 1 month. During 18 +/- 14 months, the clinical restenosis rate was significantly lower in the stent group (6.9%) than in the PTCA group (28.4%) (p = 0.001). CONCLUSION: In a series of 244 consecutive patients, newer generation stents and a consistent approach of stent oversizing and high-pressure stent deployment by a single operator resulted in high procedural success (99%), lack of stent thrombosis (0%), and a very low clinical restenosis rate (7%).     

Stent redilation in canine models of congenital heart disease: Pulmonary artery stenosis and coarctation of the aorta

In a canine puppy model, pulmonary artery stenosis was created by banding the left pulmonary artery to 30–40% of its original diameter. Animals underwent right heart catheterization and angiography 1–2 mo later, and Palmaz P308 stents were implanted. Stent redilation was performed 3–5 mo later. One mo postredilation, the animals were restudied and sacrificed. Coarctations of the aorta were created by transverse aortic incision and longitudinal repair. P308 stent implantation was performed 2–3 mo later. Stent redilation was performed after 6–10 mo, and the animals were restudied and sacrificed 1–2 mo later. Stent implantation was performed in 6 puppies with pulmonary artery stenosis, as 2 animals developed postoperative pulmonary arterial hypoplasia, precluding stenting. The stenosis diameter increased from 4.8 ± 0.5 mm to 7.4 ± 0.6 mm (mean ± SE) following stenting (P = 0.005), and increased further to 9.2 ± 0.7 mm following redilation (P < 0.001). There were no significant vessel tears or ruptures. Coarctation stenting was performed in 8 animals. The coarctation was dilated from 5.8 ± 0.9 mm to 9.8 ± 0.6 mm (P < 0.001), and to 13.5 ± 0.5 mm at redilation (P = 0.002). Redilation could not be performed in 1 animal. Aortic rupture and death occurred in 2 of 7 animals at redilation. Stent implantation and redilation in experimental pulmonary artery stenosis appears safe and effective. Though stent implantation for coarctation of the aorta appears safe, there was a 28% aortic rupture rate at stent redilation in this model. © 1996 Wiley-Liss, Inc.     

Peripheral vascular complications after intracoronary stent placement: Prevention by use of a pneumatic vascular compression device

Peripheral vascular complications are a significant source of morbidity after coronary artery stent implantation. The goal of this study was to assess the incidence, risk factors, and management of vascular complications after stent placement. The study population consisted of 101 consecutive patients who underwent stent placement for either elective or bailout indications. All patients received a standardized anticoagulation regimen of aspirin, dipyridamole, low molecular weight dextran, heparin, and warfarin. Peripheral vascular access sites were examined daily until hospital discharge. Vascular complications occurred in 16 of 101 (16%) patients, including femoral artery pseudoaneurysm (n = 11), hematoma requiring transfusion or surgery (n = 4), and arterlovenous fistula (n = 1). Intervention was required in 14 of 16 (88%) patients with complications. These included transfusion (n = 7), ultrasound-guided compression (n = 8), and/or vascular surgery (n = 7). Length of hospital stay was prolonged in patients with complications (14 ± 9 vs. 8 ± 5 d, P < 0.001). The development of peripheral vascular complications did not correlate with clinical or procedural variables such as age, cardiovascular risk factors, arterial sheath size, or elective vs. bailout indication. After the introduction of a pneumatic vascular compression device (FemoStop, C.A. Bard, Billerica, MA), a significant reduction In vascular complications was observed. Complications occurred in only 1 of 41 (2.4%) patients in whom the compression device was used in contrast to 13 of 58 (22.4%) patients compressed manually (P < 0.01). Thus peripheral vascular complications are frequent after coronary artery stent placement and are associated with serious morbidity and prolongation of hospital stay. These complications are significantly reduced by the use of a pneumatic vascular compression device despite intensive systemic anticoagulation. © 1996 Wiley-Liss, Inc.     

Sizing the gianturco-roubin coronary flexible coil stent

The balloon expandable, stainless steel, flexible coil stent is a useful device for the management of acute or threatened closure after percutaneous transluminal coronary angioplasty. Appropriate sizing is important to optimize immediate results and reduce the risk of acute thrombosis and restenosis. The in vivo size at deployment of this stent at nominal inflation pressures has not been evaluated. Forty patients who received a single flexible coil stent (10 patients each for stent sizes 4.0, 3.5, 3.0, and 2.5 mm) were studied. The stents were deployed at 3–5 atmospheres. The actual stent size achieved by the stent during deployment was found to be significantly less than the nominal size, being 3.7 ± 0.3, 3.2 ± 0.2, and 2.8 ± 0.2 mm for nominal stent sizes of 4.0, 3.5, and 3.0 mm, respectively (P < 0.005, P < 0.001, and P < 0.01). For a 2.5 mm stent, it was 2.4 ± 0.2 mm (P = ns). Thus, for optimal results with this device, we recommend that vessels 2.0–2.4 mm in diameter be supported by a 2.5 mm stent, vessels 2.5–2.9 mm in diameter by a 3.0 mm stent, vessels 3.0–3.4 mm in diameter by a 3.5 mm stent, and vessels 3.5–4.0 mm in diameter by a 4.0 mm stent. © 1994 Wiley-Liss,Inc..     

Endovascular stent placement is an acceptable alternative to reoperation in selected infants with residual or recurrent aortic arch obstruction

Objective : To describe endovascular stent placement in infants as a technically feasible option in circumstances where surgery is considered less favorable. Background : Endovascular stent placement has become established as a first line therapy for native coarctation of the aorta or recoarctation in older children where stents capable of expansion to adult size can be placed safely. Surgery remains the therapy of choice in infants and young children. The management of aortic arch obstruction in infants is, however, frequently complicated by complex anatomy or clinical condition that may make surgery or further surgery an unattractive option. There is little reported data and the implications thereof of transcatheter stent placement in aortic arch obstruction in infants. Methods : Between August 2004 and November 2009, 11 patients had aortic arch obstruction treated with endovascular stent placement. The median age and weight at first stent placement was 46 days (range 3–399 days) and 4 kg (range 1.4–8 kg), respectively. In 10 patients, surgical intervention preceded transcatheter stent placement. Four had complex aortic arch obstruction and seven had recoarctation. Results : Reduction in peak systolic gradient to <10 mm Hg was achieved in seven of 10 patients with an improvement in aortic artery diameter to >90% of adjacent aorta in all. The diameter of the arch obstruction increased from a median of 1.60 to 4.90 mm (P = 0.001) and the peak systolic gradient from 45 mm Hg to 8 mm Hg (P < 0.0001). Adverse events occurred in two patients one who required further surgical revision and a second who required placement of a second stent. The median follow up was 3.60 years (range 0.4–5.5 years) with two patients having died at 1.34 and 1.42 years poststent placement. Of the nine patients alive, six have since undergone further angioplasty at a median time interval of 0.77 years (range 0.17–2.76 years). Long‐term complications occurred in none. Conclusions : Endovascular stent placement in infants is technically feasible with good results achievable even in small babies. It should be considered as a therapeutic option in complex cases when surgical alternatives are less favorable. © 2010 Wiley‐Liss, Inc.     

Inter-Series differences in the restenosis rate of palmaz-schatz coronary stent placement: Differences in demographics and post-procedure lumen diameter

Restenosis rates following Palmaz-Schatz stenting vary between 13 and 36%. To determine whether the nearly three-fold interseries difference in restenosis rates reflects systematic factors (demographic and procedural variables such as post-treatment lumen diameter) rather than random variation, we pooled 486 lesions treated with the Palmaz-Schatz coronary stent in the U.S. Multicenter Registry (n = 259) with the single-center Beth Israel Hospital experience (n = 227) and analyzed the combined series using a continuous geometric model of restenosis. A greater proportion of lesions (66 vs. 50%; P < 0.001) in the Multicenter cohort represented restenosis after a prior intervention. The Multicenter experience also showed a smaller minimum lumen diameter following stent placement (2.61 vs. 3.43 mm; P < 0.001), higher post-stent percent stenosis (16 vs. –2%; P < 0.001), and less acute gain (1.79 vs. 2.67 mm; P < 0.001) than lesions treated in the Beth Israel cohort. At 6-month follow-up, the angiographic restenosis rate (≥ 50% diameter stenosis) was significantly higher in the Multicenter group (35 vs. 27%; P = 0.05), despite the development of less absolute late loss (0.96 vs. 1.32 mm; P < 0.001). Multivariable modeling, however, showed that the only independent predictors of restenosis were a post-procedure lumen diameter < 2.80 mm (odds ratio = 1.57; P = 0.04), diabetes mellitus (odds ratio = 3.55; P < 0.001), and prior restenosis (odds ratio = 1.84; P = 0.008). Since center (Beth Israel vs. Multicenter) was eliminated from the multivariable model after inclusion of these variables, the observed higher restenosis rate in the Multicenter series of Palmaz-Schatz coronary stents can thus be explained in part by differences in demographics (more previously treated lesions) and procedural details (a smaller posttreatment lumen diameter). Since post-procedure lumen diameter is a strong predictor of freedom from restenosis in the pooled experience, the probability of restenosis within a Palmaz-Schatz stent can be decreased by obtaining a large post-procedure lumen diameter.     

Iatrogenic subclavian steal syndrome

New complications are resulting from percutaneous transluminal angioplasty (PTA) and stent deployment. A 43-year-old female, admitted with weakness in the right arm, was diagnosed with right subclavian stenosis. Following PTA and a Palmaz stent deployment, her condition worsened, and symptoms spread. A corrective surgical procedure found the Palmaz stent to be almost completely compressed. The stent and plaques were carefully extracted. The etiology of compressed stent was probably due to an insufficient radial force or Hoop strength of stent. If an occlusion of the subclavian artery occurs at the segment proximal to the orifices of vertebral artery and internal mammary artery, a vertebral-subclavian steal syndrome may occur. This can be diagnosed in patients manifesting symptoms that include vertebral-basilar arterial insufficiency and a difference in brachial systolic blood pressure of at least 30 mm Hg between the two arms, with a bruit at the base of the neck or in the supraclavicular area.     

The paclitaxel-eluting Coroflex Please stent pilot study (PECOPS I): acute and 6-month clinical and angiographic follow-up.

BACKGROUND AND OBJECTIVES: Various active stent coatings significantly reduce restenosis rates and target lesion revascularization compared to bare metal stents. Therefore, the procedural and 6-month performance of the new paclitaxel-eluting Coroflex. Please stent was investigated. METHODS: Ninety-seven patients (66 +/- 7.6 years, 34/97(35.1%) diabetics, 11/97(11.3%) unstable angina) were enrolled per protocol for elective single stent deployment into native coronary de-novo or post-PTCA restenotic lesions (stenosis: >or= 70%, < 100%; reference diameter >or= 2.25 mm and <3.3 mm; lesion length 相似文献   

Predictors and outcomes of stent thrombosis: an intravascular ultrasound registry.

AIMS: To investigate whether intravascular ultrasound provides additional information regarding the prediction of stent thrombosis, a retrospective multicentre registry was designed to enrol patients with stent thrombosis following stent deployment under ultrasound guidance. METHODS AND RESULTS: A total of 53 patients were enrolled (mean age 61+/-9 years) with stable angina (43%), unstable angina (36%), and post-infarct angina (21%) who underwent intracoronary stenting. The majority had balloon angioplasty alone prior to stenting (94%) with 6% also undergoing rotational atherectomy. The indication for stenting was elective (53%), suboptimal result (32%) and bailout (15%). There were 1.6+/-0.8 stents/artery with 87% undergoing high-pressure dilatation (> or =14 atmospheres). The minimum stent area was 7.7+/-2.8 mm(2)with a mean stent expansion of 81.5+/-21.9%. Overall, 94% of cases demonstrated one abnormal ultrasound finding (stent under-expansion, malapposition, inflow/outflow disease, dissection, or thrombus). Angiography demonstrated an abnormality in only 32% of cases (chi-square=30.0, P<0.001). Stent thrombosis occurred at 132+/-125 h after deployment. Myocardial infarction occurred in 67% and there was an overall mortality of 15%. CONCLUSION: On comparison with angiography, the vast majority of stents associated with subsequent thrombosis have at least one abnormal feature by intravascular ultrasound at the time of stent deployment.     

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.     

Percutaneous transradial coronary palmaz-schatz stent implantation,guided by intravascular ultrasound

Intravascular ultrasound (IVUS) allows accurate assessment of stent deployment, its use being confined to the use of 8 French (F) guiding catheters. We evaluated the feasibility of combining transradial artery Palmaz-Schatz stent implantation through 6F guiding catheters with IVUS for assessment of stent diameter after delivery at moderate inflation pressures (10-12 atmospheres [atm]) with compliant balloons and after high pressure dilatations with balloons of intermediate compliance. In 8 consecutive patients, 12 stents were delivered with Scimed® Express^TM balloon catheters at 10-12 atm followed by IVUS (EndoSonics® CathScanner; Visions® FX 3.5F 20 MHz transducer). An ultrasound study was repeated after high pressure dilatations (16-20 atm) with Schneider® Magical Speedy^TM balloon catheters. The balloon diameters were derived from manufacturer provided specifications. In all patients the transducer could easily be advanced through the guiding catheters. Reference diameter of the stented segment was 3.7 ± 0.5 mm (2.7-4.5) and the diameter of Scimed® Express^TM balloons during inflation was 4.0 ± 0.3 mm (3.6-4.7). Stent diameter was 3.0 ± 0.1 mm (2.8-3.2) (P < 0.001 compared to the reference and the balloon diameter). The diameter of the Schneide® Magical Speedy^TM balloons at secondary dilatations with 16 ± 3 atm (14-20) was 4.1 ± 0.4 mm (3.3-4.5) (P = 0.50 compared to the initial balloon diameter). Final stent diameter was 3.3 ± 0.4 mm (2.9-4.1) (P = 0.02 compared to the initial stent diameter). All stents were symmetrically deployed and well apposed. No damage to vessel or stents was detected after passage of the transducer. Thus ultrasound guided stenting via 6F guiding catheters is feasible, and high pressure dilatations with balloons of intermediate compliance results in better stent expansion than after 10-12 atm inflations with compliant balloon catheters.     

Effect of gender on outcomes following renal artery stent placement for renovascular hypertension

To study the effect of gender on outcome following renal artery stent placement for renovascular hypertension, we prospectively followed 66 patients (30 males, 36 females) who underwent Palmaz stent placement in 88 renal arteries. There was no difference in the incidence of procedure-related complications between males and females. At 6-mo follow-up, the decrease in systolic (35 ± 30 mm Hg and 27 ± 25 mm Hg) and diastolic (15 ± 23 mm Hg and 14 ± 14 mm Hg) blood pressures was similar in female and male patients, respectively. Late follow-up at 19 ± 11 mo also showed no difference in blood pressure response. In 44 patients who underwent repeat angiography at a mean duration of 9.1 ± 5.6 mo after stent deployment, the incidence of restenosis was 26% in females and 24% in males (P = 0.85). We conclude that gender has no effect on the incidence of complications, blood pressure response, or angiographic restenosis in patients undergoing renal artery stent placement. Cathet. Cardiovasc. Diagn. 42:381–386, 1997. © 1997 Wiley-Liss, Inc.     

Clinical and angiographic outcomes with an everolimus‐eluting stent in large coronary arteries: The SPIRIT III 4.0 mm registry

Objective : This study evaluates the safety and efficacy of the XIENCE V® 4.0 mm stent for the treatment of de novo native coronary artery lesions. Background : In the SPIRIT III trial, the XIENCE V® everolimus‐eluting stent (EES), compared with the TAXUS EXPRESS² paclitaxel‐eluting stent (PES) in 2.5–3.75 mm diameter coronary arteries, resulted in reduced angiographic late loss (LL), noninferior rates of target vessel failure (TVF), and fewer major adverse cardiac events (MACE). Methods : The SPIRIT III 4.0 mm registry was a concurrent arm of the SPIRIT III trial consisting of 69 nonrandomized patients with lesions ≤28 mm in length and reference vessel diameter 3.75–4.25 mm treated with a 4.0 mm EES. The primary endpoint was 8‐month in‐segment LL compared with the randomized PES arm. Results : In‐segment LL was 0.17 ± 0.38 mm in the 4.0 mm EES registry compared with 0.28 ± 0.48 mm in the PES arm (P < 0.0001 for noninferiority). The 1‐year rates of ischemia‐driven TVF (cardiac death, myocardial infarction [MI], or target vessel revascularization) and MACE (cardiac death, MI, or target lesion revascularization [TLR]) were numerically, but not statistically, lower in the 4.0 mm EES patients compared with the randomized PES patients (5.9 vs. 11.3%, P = 0.27 and 5.9 vs. 10.3%, P = 0.36, respectively). There was no difference in 8‐month LL or 1‐year TVF or MACE between the 4.0 mm EES and randomized EES patients. Conclusions : In large coronary arteries, the 4.0 mm EES results in low rates of LL at 8 months and adverse clinical events at 1 year. © 2009 Wiley‐Liss, Inc.     

锁骨下动脉狭窄经皮介入治疗152例分析

目的评估经皮血管成形术治疗锁骨下动脉狭窄的安全性及近-中期疗效。方法连续152例住院患者,男88例,女64例,年龄17～82（58±16）岁,共179条（单侧125例,双侧27例）锁骨下动脉严重狭窄（直径狭窄70％～100％）,病因分别为动脉粥样硬化114例（75％）和大动脉炎38例（25％）,因患侧上肢间歇性运动无力130例（85．5％）,锁骨下动脉窃血138例（90．8％）,冠状动脉窃血综合征2例（1．8％）,蓝指综合征2例（1．8％）,或准备用患侧乳内动脉旁路移植的无症状患者10例（6．6％）,经股动脉（n=96）、肱动脉（n=25）或桡动脉（n=3）和联合（n=28）路径行经皮血管成形术,并随诊9个月观察手术的疗效。结果133处狭窄性病变（直径狭窄70％～99％）经皮血管成形术均获成功（100％）,46处完全闭塞性病变中36处经皮血管成形术成功（78．2％）。其中145处病变因单纯球囊成形结果不够满意而置入支架。经皮血管成形术成功后病变狭窄程度从术前的（90±8）％降至（5±8）％,病变动脉直径从术前的（1．0±0．9）mm升至（7．0±0．5）mm（P值均〈0．0001）。未发生严重的并发症。经皮血管成形术成功的142例患者术后随访9个月,其中135例患者血管通畅,疗效稳定,另有7例发生再狭窄,其中4例为大动脉炎患者,3例为动脉粥样硬化患者。结论经皮血管成形术治疗锁骨下动脉狭窄安全,近一中期疗效好,远期疗效有待进一步调查。     

Subclavian artery angioplasty in elderly patients with coronary-subclavian steal syndrome: preliminary comparison between a modified brachial technique and the standard femoral approach

Background and Objective Elderly patients who have been submitted to coronary bypass grafting with the left internal mammary artery (LIMA) may develop a coronary-subclavian steal syndrome because of a left subclavian artery (LSA) stenosis. Usually stenting of LSA is performed by the standard femoral route with guiding catheter technique, but this technique can be particularly difficult in elderly patients who often have iliac-femoral kinking and aortic tortuosity. We compared a new “ad hoc” brachial artery approach technique with the standard guiding catheter technique through the femoral access. Methods Between January 2005 and September 2006, four patients underwent LSA stenting using the left brachial artery access obtained with a 6F or 7F 45-cm-long valved anti-kinking sheath as the Super Arrow Flex sheath (Arrow International, PA, USA). The sheath was positioned just before the LIMA graft ostium and a 0.035 inch 260-cm-long Storq guidewire (Cordis Inc., Johnson & Johnson, Warren, NJ) was advanced across the lesion to the descending aorta. A balloon-expandable Genesis (Cordis Inc., Johnson & Johnson, Warren, NJ) endovascular stent was easily deployed, and the correct position was checked by direct contrast injection through the long sheath. This small group of patients has been compared to a group of 5 age-matched patients with coronary steal syndrome in whom the procedure has been performed with standard technique including femoral approach and guide catheter. Results The procedure was successful in all patients; vertebral and LIMA ostia remained patent in all cases. In the control group, cannulation of the subclavian artery was difficult in two cases, while one patient developed a groin hematoma. Mean pretreatment gradient was 32 mm Hg with a range of 25 to 40 mm Hg (34 mmHg, range 26- 43, in the control group, P=0.87) and fell to 2 mm Hg with a range of 0 to 4 mm Hg (3.1 mmHg, range 0 to 5, P=0.89) posttreatment. Mean contrast dose was 60±16 ml (138±26 ml in the control group, P>0.01), whereas mean fluoroscopy and procedural time were 5.7±1.6 minutes (10.8±1.0 minutes in the control group, P>0.01) and 15.7±6.3 minutes (28±7.1 minutes in the control group, P>0.01). At a mean follow-up of 10±3.2 months all patients are alive and free from angina and residual induced ischemia. Conclusions Our brief study suggested that brachial artery access be considered the optimal route to treat coronary-subclavian steal syndrome in elderly patients because of clear advantages; these included no manipulation of catheter to cannulate the artery, perfect coaxial position of the catheter at the site of LSA stenosis, clear visualization of the LIMA and vertebral ostia, and easy access to these vessels in case of plaque shifting or embolic protection device deployment.     

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.     

Coronary artery stenting in unstable angina pectoris: a comparison with stable angina pectoris

OBJECTIVE: To compare early complication rates in unselected cases of coronary artery stenting in patients with stable v unstable angina. SETTING: Tertiary referral centre. PATIENTS: 390 patients with stable angina pectoris (SAP) and 306 with unstable angina (UAP). Patients treated for acute myocardial infarction (primary angioplasty) or cardiogenic shock were excluded. INTERVENTIONS: 268 coronary stents were attempted in 211 patients (30.3%). Stents used included AVE (63%), Freedom (14%), NIR (7%), Palmaz-Schatz (5%), JO (5%), and Multilink (4%). Intravascular ultrasound was not used in any of the cases. All stented patients were treated with ticlopidine and aspirin together with periprocedural unfractionated heparin. RESULTS: 123 stents were successfully deployed in 99 SAP patients v 132 stents in 103 UAP patients. Failed deployment occurred with nine stents in SAP patients, v four in UAP patients (NS). Stent thrombosis occurred in four SAP patients and 11 UAP patients. Multivariate analysis showed no relation between stent thrombosis and clinical presentation (SAP v UAP), age, sex, target vessel, stent length, or make of stent. Stent thrombosis was associated with small vessel size (p < 0.001) and bailout stenting (p = 0.01) compared with elective stenting and stenting for suboptimal PTCA, with strong trends toward smaller stent diameter (p = 0.052) and number of stents deployed (p = 0.06). Most stent thromboses occurred in vessels < 3 mm diameter. CONCLUSIONS: Coronary artery stenting in unstable angina is safe in vessels >/= 3 mm diameter, with comparable initial success and stent thrombosis rates to stenting in stable angina.     

Implantation of balloon-expandable stents for coarctation of the aorta: Implantation data and short-term results

We report the immediate results and the short-term follow-up in a group of selected patients with coarctation of the aorta who underwent endovascular stent implantation. Balloon-expandable stents were implanted in 6 patients (mean age 19.8 ± 5.1 years) with coarctation of the aorta (4 recurrent and 2 native) who underwent a total of 7 procedures (6 implantation and 1 further expansion). The systolic peak pressure gradient was decreased from 36.7 ± 16.9 to 13.3 ± 23.2 mm Hg (P < 0.005). There was a 66% increase in the mean coarctation diameter from 9.3 ± 1.7 to 15.6 ± 3.1 mm (P = 0.001) with the ratio of the coarctation to descending aorta diameter, measured at the level of the diaphragm, increasing from 0.49 ± 0.1 to 0.81 ± 0.2 (P < 0.005). The dilatation was successful in expanding the stent to an acceptable diameter in 5 of 6 patients. One patient underwent successful further expansion of a stent implanted 22 months previously. There were no immediate complications during balloon expansion and stent implantation. One patient suffered a femoral arterial bleed requiring surgical repair. There was one unrelated death. All patients were hypertensive (systolic blood pressure >140 mm Hg) prior to stent implantation. At mean follow-up of 8 months, 3 patients are normotensive. There was no recurrence of coarctation, aortic dissection, or aneurysm formation in the patients in whom stent implantation was successful. These findings indicate that balloon-expandable stent implantation for coarctation of the aorta in selected patients is a safe and effective alternative approach for relieving the obstruction with a low complication rate and no recoarctation at short-term follow-up. © 1996 Wiley-Liss, Inc.