Management of Coronary Artery Perforation

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), however if recognized and managed promptly, its adverse consequences can be minimized. Risk factors for CAP include the use of advanced PCI technique (such as atherectomy and chronic total occlusion interventions) and treatment of severely calcified lesions. There are 3 major types of CAP depending on location: (a) large vessel perforation, (b) distal vessel perforation, and (c) collateral perforation.Large vessel perforation is usually treated with implantation of a covered stent, whereas distal and collateral vessel perforations are usually treated with coil or fat embolization. In this article we provide a state-of-the-art overview of the contemporary management of CAP.     

冠心病合并糖尿病患者置入药物洗脱支架和裸金属支架2年临床观察

目的:评价冠心病合并糖尿病患者成功置入药物洗脱支架(DES)和裸金属支架(BMS)2年后的有效性和安全性。方法:本研究入选了2004-04至2006-10在我院行择期支架置入术的冠心病合并糖尿病患者1565例。入选患者分为DES组(n=1317)和BMS组(n=248例)。随访资料包括术后30天、1年和2年的死亡、心肌梗死、血栓、靶病变血运重建和靶血管血运重建。本研究比较了DES和BMS两组间各种临床事件累积发生率的差异,同时通过倾向性评分调整后的Cox比例风险模型比较两组术后2年的临床随访结果。结果:DES和BMS两组患者术后2年出现学术研究联合会(ARC)定义的支架内血栓形成率差异无统计学意义,但DES组术后30天明确血栓形成率显著低于BMS组(0.08%比0.81%,P=0.016)。术后2年与BMS相比,DES组靶病变血运重建率[3.88%比10.89%;风险比0.159(95%可信区间:0.151～0.444),P0.0001]和靶血管血运重建率[5.48%比11.69%;风险比0.383(95%可信区间:0.232～0.633),P0.0001]的风险均显著降低,差异均有统计学意义。两组间全因死亡率、心肌梗死发生率及全因死亡/心肌梗死发生率差异均无统计学意义。结论:对于冠心病合并糖尿病患者而言,与置入BMS相比,使用DES可以显著降低靶病变血运重建率和靶血管血运重建率,但是全因死亡率、心肌梗死发生率和血栓形成率的差异均无统计学意义。     

冠状动脉支架术后再狭窄的危险因子

冠心病危险因素、血管造影下冠状动脉病变特征、支架术操作技术参数是影响冠脉病变支架术后再狭窄的主要危险因子。这些危险因子主要有糖尿病、冠脉病变长度、病变狭窄程度、病变类型,以及支架长度、支架类型等,这些危险因子在不同基础疾病和冠脉病变条件下对支架术后再狭窄的影响作用不同。     

Coronary Artery Spasm Induced by Stent Implantation: Studies in a Swine Model

Mechanical stimulation is a known cause of arterial spasm. Since stent implantation in the coronary arteries imparts mechanical trauma, we investigated, in an animal model that simulates human coronary anatomy and physiology, the frequency of occurrence and factors that influence the development of spasm. In 28 Hanford miniature swine, 9 of which were atherosclerotic and 19 of which were nonatherosclerotic, spasm occurred in 15 (54%). Stent-induced spasm directly caused the death of one animal and was implicated in the death of two others. Factors that significantly contributed to coronary spasm were the stent: artery ratio (more spasm with oversized stents) and the size of the artery (more spasm with smaller arteries). There was a trend toward more spasm in atherosclerotic arteries. Spasm occurred despite the use of antispasmodic agents before, during, and after the scenting procedure. Our data suggest that coronary artery spasm may be an important clinical accompaniment to stent implantation in man and may be minimized by the judicious selection of stent size to avoid overdistention of the artery and the avoidance of stent placement in smaller arteries . (J Interven Cardiol 1993; 6:149–155)     

年轻冠心病患者冠状动脉裸支架术即刻及长期疗效随访

目的评估年轻冠心病患者(<45岁)冠状动脉(冠脉)内支架术的长期疗效。方法选65例年龄<45岁的患者接受冠脉内支架术治疗(年轻组),随机同期选取65例年龄>45岁行冠脉内支架术患者作为对照组。比较两组一般情况、冠脉病变、介入治疗及3年临床随访情况。结果年轻组患者心梗68%比对照组35%多见,P<0.05;单支冠脉病变患者明显增多(83%比57%,P=0.001);介入治疗后达到完全血运重建者增多(95%比78%,P=0.004)。平均随访87±13月,年轻组患者再发胸痛及再次住院发生率明显高于对照组(分别为35%和17%,P=0.02,28%和14%,P=0.05),新生病变发生率明显高于对照组(分别为23%和9%,P=0.03;35%和17%,P=0.02)。结论年轻患者冠脉裸支架术完全血运重建率高,术后心脏事件的发生主要由新生冠脉病变引起。冠脉支架植入术可作为年轻冠心病患者的可选治疗方式之一。     

Successful Coronary Stent Implantation Using Local Nitric Oxide Donor Delivery

With the introduction of high pressure balloon inflations and antiplatelet therapy, the incidence of stent thrombosis has been markedly reduced, but the incidence of late stent restenosis has not. A new strategy may be local drug delivery, which maintains sustained local concentration and limits systemic complications. To evaluate the efficacy of local nitric oxide (NO) donor delivery on stent thrombosis and complications, local NO donor delivery was performed in stented patients. NO donor (2.0-mg molsidomine) was delivered (1.0 mL/min > 10 min) using the Dispatch Catheter after predilation of target lesions in 13 patients (6 angina, 7 myocardial infarction, age 53.1 ± 11.4 years). After local NO donor delivery, Palmaz-Schutz stents were placed using standard methods. Follow-up coronary angiograms were performed 48 hours and 6 months after stenting. None of the patients had hypotensive effects, ischemic symptoms, or ECG changes during and after local NO donor delivery. APTT and CK values were unchanged at 3 and 24 hours after local NO donor delivery and stenting. Follow-up coronary angiograms at 48 hours and 6 months showed all stents patent with TIMI III flow and without intrastent thrombus. No target lesion revascularization and 100% event-free survival were observed during the 6-month clinical follow-up period. Intracoronary stenting may be performed safely and effectively by local NO donor delivery prior to stent implantation.     

肾动脉狭窄支架置入术后冠状动脉旁路移植术的安全性及疗效

目的:探讨冠心病患者肾动脉狭窄支架置入术后行冠状动脉(冠脉)旁路移植术的安全性及疗效.方法:22例行肾动脉狭窄支架置入术后接受冠脉旁路移植术冠心病患者,记录各例临床、冠脉、肾动脉造影情况,随访分析各例肾动脉狭窄支架置入术前后肾功能及冠脉旁路移植术情况,并测定手术前、后及随访期间血清肌酐水平.结果:22例患者均成功置入肾动脉支架(25枚),旁路移植术后72小时血清肌酐较基础测值明显下降[(153±22)μmol/L比(163±31)μmol/L,P<0.05].各例平均移植旁路血管(3.12±0.77)支,术后1例发生脑梗塞.平均随访(15±8)个月,各例血清肌酐水平进一步下降,2例复发胸痛,其中1例接受冠脉支架术,无严重心脏事件生存率95.5%.结论:肾动脉狭窄支架置入术有助于改善患者肾功能,增加冠脉旁路移植术的安全性及改善预后.     

药物洗脱支架与金属裸支架对冠状动脉临界病变的远期疗效

目的:评估药物洗脱支架与金属裸支架对于治疗冠状动脉临界病变的远期疗效。方法:自身冠状动脉首次介入治疗病变(在线定量冠状动脉造影分析50%≤管腔狭窄直径≤70%)的患者入选本研究,共计151例患者分为药物洗脱支架组(n=102)和金属裸支架组(n=49),两组的基本临床特征和冠状动脉造影结果差异无统计学意义。术前、术后和随访6～12个月时进行定量冠状动脉造影分析,并在住院期间、30天和6～12个月时观察严重不良心脏事件的发生。结果:151例患者支架置入成功率均为100%。住院期间严重不良心脏事件发生率,在药物洗脱支架组和金属裸支架组差异无统计学意义(0%和2.0%,P=0.15)。在随访30天时,两组均无死亡和支架内血栓形成。6～12个月随访期间,药物洗脱支架组和金属裸支架组比较①严重不良心脏事件发生率(3.9%vs8.1%,P=0.97),②靶病变重复血管重建率(2.9%vs6.1%,P=0.39),③急性心肌梗死发生率(1.96%vs2.04%,P=0.95),差异均无统计学意义。12个月时药物洗脱支架组和金属裸支架组比较,支架内血栓发生率和病死率差异也无统计学意义(1.96%vs0%,P=0.34;0%vs4.08%,P0.05)。定量冠状动脉造影分析显示:远期管腔丢失药物洗脱支架组明显低于金属裸支架组[(0.23±0.73)mmvs(0.95±0.94)mm,P=0.01],两组比较差异有统计学意义;而支架内再狭窄率两组比较差异无统计学意义(12.9%vs25.0%,P=0.34)。结论:药物洗脱支架和金属裸支架对于治疗自身冠状动脉临界病变安全有效,两组远期严重不良心脏事件发生率差异无统计学意义。     

Long-Term Clinical Follow-up after Sirolimus-Eluting Stent versus Bare Metal Stent Implantation in Patients with Acute Coronary Syndrome

Background and Objective: Drug-eluting stents have been shown to reduce the incidence of restenosis and target vessel revascularization (TVR) compared with bare metal stents (BMSs); however, the long-term efficacy of sirolimus-eluting stent (SES) implantation in patients with acute coronary syndrome (ACS) has not been well established. We have investigated the long-term clinical outcome of SES in patients with ACS.
Methods: Consecutive 245 patients with ACS treated by primary stenting within 24 hours after onset were enrolled. There were 128 patients treated with SES and 117 patients were treated with BMS. We evaluated the incidence of major cardiac events (MACE; total death, nonfatal myocardial infarction, TVR) at 3 years, comparing with 8-month clinical outcome.
Results: Eight-month clinical follow-up shows a significantly lower incidence of TVR in the SES group, 3.1% in the SES group versus 9.4% in the BMS group (P = 0.04). At 3-year clinical follow-up, there was no significant difference in the rate of TVR between the two groups, 8.4% versus 12.4% (P = 0.37). Cumulative incidence of total MACE was 9.2% in the SES group compared with 15.9% in the BMS group (P = 0.18). Only one case of stent thrombosis was observed in the SES (late thrombosis), while two cases of stent thrombosis occurred in the BMS group (late and very late thrombosis; P = 0.55).
Conclusion: SES implantation in patients with ACS is associated with favorable long-term clinical outcome with no excess of late stent thrombosis. Further long-term clinical follow-up will be warranted to confirm the safety and efficacy of SES.     

Bare Stent Implantation Through a Side Slot of Another Stent in a Bifurcation Lesion

A case of a patient with significant (≈ 90%) stenosis of the circumflex at its origin from the left main artery and of the first marginal branch, 20 mm after its origin from the circumflex, is described. The case was treated with implantation of two stents, one at the marginal and another at the circumflex through a side slot of the first stent.     

血管内超声引导冠脉支架植入的应用进展

血管内超声 (IVUS)是近十年来发展起来的一项介入影像学新技术 ,在冠心病的诊断和治疗方面有很重要的应用价值 ,其引导冠脉支架植入 ,可获得尽可能大的管腔直径 ,降低支架术后再狭窄率的发生。本文综述IVUS在引导冠脉支架植入的作用及进展     

Clinical Outcomes Following Covered Stent for the Treatment of Coronary Artery Perforation

Background

This study aimed to evaluate short‐ and long‐term outcomes of polytetrafluoroethylene covered stent for patients with coronary artery perforation.

Methods

During April 2004 and February 2016, a total 48 patients underwent implantation using polytetrafluoroethylene‐covered JOSTENT GraftMaster stents (Abbott Vascular, Santa Clara, CA) in the native coronary arteries implantation for coronary artery perforation. Clinical outcomes such as target lesion revascularization (TLR), myocardial infarction (MI), definite or possible stent thrombosis, cardiovascular mortality, and all‐cause mortality were analyzed.

Results

The average age of study patients was 68.02 ± 13.49 years, and the majorities were men (76.6%). The most frequent devices cause of perforation were stents (37.5%). Eighteen patients (37.5%) experienced cardiac tamponade and 20 patients (41.7%) underwent emergent pericardiocentesis. Only 1 patient (2.1%) experienced emergent surgical repair after covered stent. At the 30‐day follow‐up, the rate of all‐cause mortality was 16.7% and cardiovascular mortality was 13.0%. At the 1‐year follow‐up, the rate of MI was 6.1%, the rate of TLR was 21.9%, the rate of definite or possible stent thrombosis was 15.6%, the rate of cardiovascular mortality was 22.0%, and the rate of all‐cause mortality was 26.2%. Between the patients with and without cardiac tamponade, patients with cardiac tamponade had higher cardiovascular mortality in 30‐day and also higher all‐cause mortality in 30‐day and 1‐year follow‐up.

Conclusion

The covered stent could solve emergent condition for patients with coronary artery perforation with high TLR and stent thrombosis rate at long‐term follow‐up. The patients with cardiac tamponade had worse clinical outcomes in 30‐day and 1‐year follow‐up.

     

Outpatient Coronary Stent Implantation

Objectives. This study was performed to explore the feasibility of coronary Palmaz-Schatz stent implantation on an outpatient basis.Background. To optimize the applicability of coronary stenting by limiting bleeding complications and length of hospital stay, the transradial approach has been demonstrated to be an effective technique. Immediate ambulation opens the way to outpatient treatment.Methods. Patients selected for Palmaz-Schatz stent implantation received anticoagulation with Coumadin. At an international normalized ratio >2.5, stenting was performed through the radial approach. Starting in December 1994, patients were treated with Ticlopidin. Heparin was administered during the procedure. Suitability for same-day discharge was assessed on the basis of preprocedural, postprocedural and periprocedural criteria. Patients were mobilized after immediate sheath removal, followed by same-day discharge. Follow-up examinations were performed the next day, at 2 weeks and at 1 month after stenting.Results. Of 188 patients who underwent Palmaz-Schatz coronary stent implantation through the radial artery between May 1994 and July 1995, 88 remained in the hospital for various reasons. In the 100 outpatients (Canadian Cardiovascular Society classes III and IV, n = 90 [90%]), 125 stents had been implanted to cover 110 lesions. No cardiac or bleeding events were encountered within 24 h (95% confidence interval 0 to 3.6) of stenting. At 2-week follow-up, one patient was readmitted (day 4) because of a bleeding abdominal aortic aneurysm requiring operation. Two patients were readmitted 2 weeks after discharge, one with subacute thrombosis and one with angina and anemia that was treated with blood transfusions. At 1-month follow-up, no complications were observed.Conclusions. After an optimal transradial Palmaz-Schatz coronary stent result, patients can safely be discharged on the day of treatment.(J Am Coll Cardiol 1997;29:323–7)