Recanalization of peripheral arteries by interventional cardiologists: rationale and results

The coexistence of peripheral artery disease (PAD) and multilevel atherosclerosis increases death and stroke rates in patients with coronary artery disease (CAD). These patients are often treated conservatively without revascularisation of inferior limbs. We included 66 consecutive patients with complex CAD diagnosed by coronary angiography. All patients underwent percutaneous coronary intervention (PCI) for non-ST elevation acute coronary syndrome (NSTEACS) before or simultaneously with peripheral angioplasty (PTA). Major adverse cardiac and cerebrovascular events (MACCE) during long-term follow-up were assessed. There were 3 deaths, one myocardial infarction, two urgent PCIs, two ischaemic strokes and two TIAs, 8 repeated PTAs in previously treated peripheral lesions, 7 elective PTAs of other vessels after the index procedure in different hospitalisations and no amputation. Patients with concomitant CAD and PAD could safely undergo percutaneous cardiovascular interventions with promising long-term follow-up.     

Increased urinary albumin excretion rates can be a marker of coexisting coronary artery disease in patients with peripheral arterial disease

Coexisting coronary artery disease (CAD) is an important cause of morbidity and mortality in patients with peripheral arterial disease (PAD). Clinical evaluation and noninvasive tests have some important limitations for the detection of CAD in patients with PAD. The purpose of this study was to investigate whether urinary albumin excretion (UAE) was a sign of atherosclerotic involvement of coronary arteries in patients with PAD. Our study consisted of 65 consecutive patients (56 men, 9 women, mean age; 59.7+/-7.9 years) with PAD who underwent coronary angiography. Urinary albumin excretion was measured in 24-hour urine samples by immunoprecipitation technique. PAD was defined as the presence of > or =50% stenotic lesions in at least 1 of the iliac, femoral, popliteal, tibialis anterior, tibialis posterior, or peroneal arteries. CAD was defined as > or =25% diameter stenosis in at least 1 coronary artery. Patients without any coronary lesions were accepted as having normal coronaries. Age, sex, distributions of coronary risk factors, and UAE rates were compared between patients with and without CAD. Mean UAE was 17.9+/-15.6 mg/day in the total population. Thirty-seven percent of patients had CAD, and 63% had no coronary lesion. UAE rates were 22.33+/-18.74 and 15.32+/-13.01 mg/day in patients with CAD and those with normal coronary arteries, respectively (p = 0.021). Microalbuminuria was detected in 25% in patients with CAD and 12% in those without coronary artery lesions (p = 0.184). The difference was not statistically significant. The distributions of other risk factors and sex were not different between the 2 groups. These data suggest that in patients with PAD, urinary albumin excretion rates may be used to determine those with a high probability of CAD. Further studies are required to decide whether this noninvasive testing is appropriate in detecting high-risk patients.     

Measurement of fractional flow reserve in patients with multi-vessel coronary artery disease and borderline lesions prevents unnecessary revascularisation procedures

BACKGROUND: Patients with multi-vessel coronary artery disease (CAD) are selected for percutaneous coronary interventions (PCI) or surgical revascularisation. The appropriateness of "ad hoc" PCI of borderline lesions (<70% of lumen diameter) in patients with a multi-vessel CAD has not been proven. However, delayed PCI of another lesion and gaining additional information from non-invasive tests is not a widely accepted strategy. When left anterior descending (LAD) coronary artery is one of the affected vessels, selection for surgical revascularisation is most likely. AIM: To assess long-term outcome in patients with multi-vessel CAD and borderline lesions, including LAD, in whom fractional flow reserve (FFR) in all affected vessels was measured and used for selection for PCI or conservative treatment. METHODS: The study group consisted of 16 patients with stable angina (11 males, mean age 60+/-9 years) with 34 lesions localised in the main epicardial coronary arteries [LAD / left main (LM) / right coronary artery (RCA) / intermediate branch (IB) / circumflex artery (Cx) - 15/1/5/5/8] of which at least two were borderline stenoses. Each lesion underwent FFR measurement. "Ad hoc" PCI was performed when FFR was <0.75, and conservative therapy was instituted when FFR was >0.75. RESULTS: Of 34 lesions, in 8 (23%) the FFR value was <0.75 and these lesions were treated with PCI (LAD/IB/Cx - 3/2/3). In the remaining 26 (77%) lesions, FFR was >0.75 and conservative therapy was instituted. During the mean follow-up of 15+/-6 months (range 6-28 months, median 15 months) in 8 of 9 conservatively treated patients no aggravation of anginal symptoms nor other coronary events were observed. One patient developed acute myocardial infarction due to thrombus occluding a borderline LAD lesion. Of 8 lesions treated with PCI (baseline FFR = 0.63+/-0.10 vs post-PCI FFR = 0.92+/-0.08, p=0.0002), in one case an in-stent restenosis in LAD occurred 9 months after PCI. Of a total of 26 lesions which were conservatively treated (mean FFR 0.91+/-0.05), in 2 (7.7%) the progression of CAD was noted. CONCLUSIONS: In patients with multi-vessel CAD and borderline lesions, FFR measurement identifies those, who can be treated conservatively with a good long-term outcome, and prevents unnecessary PCI.     

Efficacy and safety of argatroban in patients with heparin induced thrombocytopenia undergoing endovascular intervention for peripheral arterial disease

Objectives: This study aimed to evaluate the efficacy and safety of argatroban during percutaneous interventions for peripheral arterial disease (PAD). Background: Endovascular interventions are commonly used in patients with peripheral arterial disease. Heparin is routinely administered during these procedures, but cannot be used in patients with a history of heparin‐induced thrombocytopenia (HIT). Argatroban is an approved direct thrombin inhibitor for treatment of patients with HIT. There are currently few data on the efficacy and safety of argatroban during endovascular interventions for PAD. Methods: Patients who underwent endovascular interventions for PAD on argatroban between 2002 and 2005 were identified from out database. Efficacy was evaluated using a composite of death, urgent revascularization, and amputation, while safety was assessed by TIMI major bleeding during the index hospitalization. Results: A total of 48 patients undergoing lower extremity revascularization on argatroban were identified. Thirty two of these patients (67%) had antibody‐confirmed HIT and the other 16 (33%) had suspected HIT. A mean dose of argatroban was 173.5 ± 143 μg/kg bolus, followed by a 10.7 ± 9.64 μg/kg/min infusion during the procedure. Twelve patients (25%) met the composite end point (two deaths, one urgent revascularization, nine amputations because of progressive peripheral arterial disease). TIMI major bleeding occurred in three (6%) patients. Conclusion: In patients with confirmed or suspected HIT undergoing endovascular intervention for PAD, argatroban appears to be effective and safe. A larger study is warranted to confirm these findings from a single center. © 2008 Wiley‐Liss, Inc.     

Outcomes and risk prediction model for peripheral arterial disease in patients with stable coronary artery disease

We used the National Heart, Lung, and Blood Institute Limited Access Dataset of Prevention of Events with Angiotensin-Converting Enzyme Inhibition (PEACE) Trial (n = 8290) which included patients with stable coronary artery disease (CAD) and preserved ejection fraction (>40%). We identified risk factors for the development of critical peripheral arterial disease (PAD; those needing angioplasty, bypass grafting, or aneurysm repair) and formulated a risk score by multivariate analyses. A total of 220 patients (2.8%) developed critical PAD over a mean follow-up of 4.7 years. Significant predictors of critical PAD were history of intermittent claudication, smoking, hypertension (HTN), coronary-artery bypass grafting (CABG), diabetes, age, serum cholesterol, and body mass index (BMI). Incident critical PAD was associated with increased composite outcome of cardiovascular death, myocardial infarction, percutaneous transluminal coronary angioplasty, or CABG (hazard ratio 1.82, 95% CI 1.50-2.22, P < .001). Risk assessment using our score may identify CAD patients at risk for critical PAD events.     

Single center experience with provisional abciximab therapy in complex lower limb interventions

Background: Abciximab, a glycoprotein IIb/IIIa antagonist has been shown to improve patency and clinical outcome in patients undergoing endovascular recanalization of femoro-popliteal occlusions. However, data on abciximab therapy in complex peripheral catheter interventions of lower limbs are quite limited. The objective of this retrospective study was to evaluate the clinical and hemodynamic outcomes of patients treated with provisional abciximab during complex peripheral catheter interventions. Patients and methods: Analysis of a consecutive series of 44 patients with provisional abciximab therapy in complex peripheral catheter interventions with imminent risk of early rethrombosis defined as revascularization of arterial occlusions associated with one or more of the following additional circumstances named as time-consuming intervention > 3 hours, compromised contrast flow not solved by stenting, distal embolization not solved by mechanical thromboembolectomy, and peri-interventional notice of thrombus evolution despite adequate heparin adjustment of lower limbs. Adjunctive abciximab therapy was started in accordance to percutaneous coronary bailout situations. The decision to add abciximab was based on the decision of the operator and went along with the judgement that there is a rising risk of reocclusion due to the progressive complexity of an individual intervention. A bolus of 0.25 mg per kilogram of body weight, followed by a maintenance infusion of 0.125 mug/kg/min (up to a maximum dosage of 10 mug/min) for 12 hours was administered. Clinical and hemodynamic outcome was prospectively assessed at discharge, three and six months after the index procedure. Results: The occluded artery of 44 limbs was in the iliac (2%), in the femoro-popliteal (73%) or below the knee segment (25%). Overall, occlusion length was 11.5 +/- 6.5 cm. Technical success rate was 95%. Mean ABI increased from 0.5 +/- 0.16 to 0.88 +/- 0.19 (p < 0.001) with immediate hemodynamic improvement of 91%. Overall, sustained clinical improvement was 84% and 66% at three and six months follow-up, with best results in iliac (100%), followed by below the knee (73%) and by femoro-popliteal segment (63%) at six months, respectively. Overall, secondary clinical improvement was 86% at six months. Minor and major bleeding complications were 16% and 9%, respectively. Conclusion: Abciximab should be noticed as medical adjunct in the interventional armamentarium to prevent imminent rethrombosis in complex peripheral catheter interventions.     

The prevalence of peripheral arterial disease in high risk subjects and coronary or cerebrovascular patients

Atherosclerosis is a generalized disease with considerable overlap of its coronary, carotid, and peripheral manifestations. As an indicator of multifocal atherosclerosis, peripheral arterial disease (PAD) is emerging as an important aid in risk stratification of patients with coronary artery (CAD) or cerebrovascular disease (CVD). Therefore, the aim of the study was to assess the prevalence of PAD in high risk subjects and its ability to identify coronary or cerebrovascular patients. A total of 952 (63.3% male; age 63.7 +/-10.7 years) patients at high cardiovascular risk (>or=2 risk factors), or with evidence of CAD or CVD were screened for PAD by means of ankle-brachial index (ABI) assessment; 226 patients were at high risk (>or=2 risk factors), 575 had CAD, and 151 had CVD. A total of 42% of patients with CAD and 36% of patients with CVD had PAD. In patients with CAD one half of cases of PAD were asymptomatic. Asymptomatic PAD (pathological ABI) was strongly associated with CAD and CVD, even after adjustment for age, gender, and other risk factors. No significant differences between CAD, PAD, and CVD patients were observed in terms of risk profiles. In conclusion, our findings confirm a high prevalence of both symptomatic and asymptomatic PAD in patients at high cardiovascular risk and its association with both CAD and CVD.     

Frequency of coronary artery disease in patients undergoing peripheral artery disease surgery

The prevalence of coronary artery disease (CAD) in patients with peripheral arterial disease (PAD) varies widely in published reports. This is likely due at least in part to significant differences in how PAD and CAD were both defined and diagnosed. In this report, the investigators describe 78 patients with PAD who underwent preoperative coronary angiography before elective peripheral revascularization and provide a review of published case series. Among the patients included, the number with concomitant CAD varied from 55% in those with lower-extremity stenoses to as high as 80% in those with carotid artery disease. The number of coronary arteries narrowed by ≥50% was 1 in 28%, 2 in 24%, and 3 in 19%; 28% did not have any angiographic evidence of CAD. The review of published research resulted in the identification of 19 case series in which a total of 3,969 patients underwent preoperative coronary angiography before elective PAD surgery; in the 2,687 who were described according to the location of the PAD, 55% had ≥1 epicardial coronary artery with ≥70% diameter narrowing. The highest prevalence of concomitant CAD was in patients with severe carotid artery disease (64%). In conclusion, despite sharing similar risk factors, the prevalence of obstructive CAD in patients with PAD ranges widely and appears to differ across PAD locations. Thus, the decision to perform coronary angiography should be based on indications independent of the planned PAD surgery.     

Prognostic factors in patients with advanced multi-vessel coronary artery disease

BACKGROUND: Multivessel coronary artery disease (CAD) not suitable for revascularisation remains a challenge for present cardiology. Due to high mortality and difficulties in pharmacological therapy patients with this particular disease constitute a group of great interest. AIM: To define the main unfavourable prognostic factors in patients with clinically stable multivessel CAD who do not qualify for percutaneous or surgical revascularisation. METHODS: The analysed group consisted of 106 patients (79 men, 66+/-8 years) with multi-vessel CAD, confirmed in coronary angiography, who were primarily disqualified from interventional treatment. Thirty-eight (36%) of them had diabetes and 5 (5%) had a previous stroke. The left ventricular ejection fraction was 37+/-15%, and mean Gensini score - 72+/-34. RESULTS: During 7.4+/-4 years of follow-up, 19 (18%) patients died. Predicting factors of mortality included older age (p=0.014), higher heart rate (p=0.02), diabetes (0.003), renal failure (p=0.0003), heart failure (p=0.013), past stroke (p=0.006) and lower left ventricular ejection fraction (p=0.0012). In multivariate logistic analysis the only significant parameter related to prognosis was decreased level of haemoglobin (p=0.007) and elevated leucocytosis (p=0.002). The ROC curves analysis showed that decreased Hgb (<12.3 g/dl) and increased leucocytosis (>11.3 t/mm3) were significantly associated with higher mortality (HR 6.3). CONCLUSIONS: In patients with multi-vessel CAD not amendable revascularization the haemoglobin level and leucocytosis seem to be at least as important as well known risk factors. More intensive complex pharmacotherapy and innovative cell and gene therapeutic methods may improve the prognosis in this group of patients.     

Erythrocyte mean corpuscular volume associated with the anatomical distribution in peripheral arterial disease

BACKGROUND: Elevated erythrocyte mean corpuscular volume (MCV) has been suggested to be a risk factor for peripheral arterial disease (PAD). The aim of the present study was to evaluate whether MCV was associated with a distinct pattern of severe atherosclerosis (lumen reductions > or = 75%) in patients with symptomatic PAD, as measured by angiography. PATIENTS AND METHODS: 100 consecutively admitted male PAD patients with iliac, femoral-popliteal and crural disease manifestation were compared with 100 male age-matched control subjects without PAD on the basis of angiographically determined lumen reductions > or = 75%. RESULTS: The pattern of severe atherosclerosis was as follows: 41 PAD patients displayed stenoses/occlusions in the iliac segment, 68 in the femoral-popliteal and 15 in the crural segment. When comparing the PAD patients with the controls by multivariate conditional logistic regression analysis, MCV was an independent predictor of severe atherosclerosis in the iliac (OR = 2.72 for an increment of 5 fl, 95% CI = 1.15-6.40) and the femoral-popliteal segment (OR = 3.13 for an increment of 5 fl, 95% CI = 1.51-6.49) but not in the crural site. This pattern was similar to the impact of smoking. CONCLUSION: Higher MCV values contributed to lumen reductions > or = 75% of the proximal segments in patients with symptomatic PAD. This observation could be clinically important since revascularisation procedures are done predominantly in these segments. As a consequence, observance of elevated MCV values should be considered in PAD patients.     

Immediate results of endovascular treatment of coronary arteries in patients with ischemic heart disease

AIM: To assess immediate results of percutaneous coronary interventions (PCI) and finding the predictors of the successful outcomes in various subgroups of patients with coronary artery disease (CAD). MATERIAL: Patients (n=1066, (average age 55.7+/-9.2 years, women 12%) treated with coronary artery stenting between 1999 and 2004. According to coronary angiography, 383 (36%) patients had 1-vessel, 502 (47%) - 2-vessel, and 181 (17%) - 3-vessel CAD. The endovascular treatment was made on 1694 coronary stenoses (in average 1.6 stenosis/patient), 356 stenoses (21%) was defined as type A, 745 (44%) - type capital B, and 593 (35%) - type C. PCI was performed with use of inhibitors of glycoprotein receptors IIb/IIIa in 107 (18%) patients. RESULTS: The complete or partial immediate procedural success of PCI (elimination of at least one coronary stenosis) was achieved in 1002 (94%) patients. The immediate success was achieved in 1575 stenoses (93%). Total rate of major adverse cardiac events (MACE) was 1.3%. There were no deaths, 11 patients (1%) had acute myocardial infarctions, 3 (0.28%) patients had an emergent coronary artery bypass grafting. The immediate procedural success was significantly lower in patients with chronic coronary occlusions (76%) than in patients without coronary occlusions (97%, p<0.0001), as well in patients with stenoses type C as compared with stenoses type A, and B (success rate 77%, 98% and 100%, accordingly, p<0.0001). CONCLUSION: By multifactorial analysis, independent predictors of procedural failure were stenosis type C (small p<0.0001) and chronic occlusion of coronary artery (p=0,03).     

Causes and outcomes of coronary arteries perforations

Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions. Aim of this study--to assess inhospital and long term outcomes in patients in whom perforation occurred during coronary intervention and elucidation of predictors of coronary artery perforation. Between May 1997 and October 2002 perforations were formed in the course of percutaneous interventions in 127 patients what amounted 1.08% of 11,793 patients, subjected to coronary interventions, and 0.77% of 16,494 treated coronary segments. Causes of perforations were complex stenoses, chronic occlusions, calcified lesions, small predicted and minimal vessel lumen, high percent stenosis, use of excimer laser or thromboextrator. Rates of arterial perforations and subsequent adverse events including cardiac tamponade and urgent coronary artery bypass surgery as well as mortality had been declining throughout observation period.     

Atherosclerotic risk factor reduction in peripheral arterial diseasea: results of a national physician survey

OBJECTIVE: Individuals with peripheral arterial disease (PAD) have a 3- to 6-fold increased risk of coronary heart disease and stroke compared to those without PAD. We documented physician-reported practice behavior, knowledge, and attitudes regarding atherosclerotic risk factor reduction in patients with PAD. DESIGN: National physician survey. PATIENTS/PARTICIPANTS: General internists (N = 406), family practitioners (N = 435), cardiologists (N = 473), and vascular surgeons (N = 264) randomly identified using the American Medical Association's physician database. MEASUREMENTS AND MAIN RESULTS: Physicians were randomized to 1 of 3 questionnaires describing a) a 55- to 65-year-old patient with PAD; b) a 55- to 65-year-old patient with coronary artery disease (CAD), or c) a 55- to 65-year-old patient without clinically evident atherosclerosis (no disease). A mailed questionnaire was used to compare physician behavior, knowledge, and attitude regarding risk factor reduction for each patient. Rates of prescribed antiplatelet therapy were significantly lower for the patient with PAD than for the patient with CAD. Average low-density lipoprotein levels at which physicians "almost always" initiated lipid-lowering drugs were 121.6 +/- 23.5 mg/dL, 136.3 +/- 28.9 mg/dL, and 149.7 +/- 24.4 mg/dL for the CAD, PAD, and no-disease patients, respectively (P <.001). Physicians stated that antiplatelet therapy (P <.001) and cholesterol-lowering therapy (P <.001) were extremely important significantly more often for the CAD than for the PAD patient. Perceived importance of risk factor interventions was highly correlated with practice behavior. Compared to other specialties, cardiologists had lowest thresholds, whereas vascular surgeons had the highest thresholds for initiating cholesterol-lowering interventions for the patient with PAD. Cardiologists were significantly more likely to report "almost always" prescribing antiplatelet therapy for the patient with PAD than were all other physicians. CONCLUSIONS: Deficiencies in physician knowledge and attitudes contribute to lower rates of atherosclerotic risk factor reduction for patients with PAD. Reversing these deficiencies may reduce the high rates of cardiovascular morbidity and mortality associated with PAD.     

Prevalence and incidence of cardiovascular disease in 1160 older men and 2464 older women in a long-term health care facility.

BACKGROUND: We report the prevalence and incidence of cardiovascular disease in older men and women in a long-term health care facility. METHODS: The prevalence of hypertension, chronic atrial fibrillation, pacemaker rhythm, coronary artery disease (CAD), thromboembolic stroke, and symptomatic peripheral arterial disease (PAD) and the incidence of new coronary events, thromboembolic stroke, and congestive heart failure (CHF) were investigated in 1160 men, mean age 80 +/- 8 years, and in 2464 women, mean age 81 +/- 8 years, in a long-term health care facility. Mean follow-up was 46 +/- 30 months. RESULTS: The prevalences of hypertension, pacemaker rhythm, CAD, and thromboembolic stroke were similar in men and women. The prevalence of atrial fibrillation was higher in men (16%) than in women (13%; p =.019). The prevalence of PAD was higher in men (32%) than in women (26%; p =.0001). At the 46-month follow-up, the incidences of new coronary events, thromboembolic stroke, and CHF were similar in men and women. CONCLUSIONS: Older men and women in a long-term health care facility have a high prevalence and incidence of cardiovascular disease. The prevalences of hypertension, pacemaker rhythm, CAD, and thromboembolic stroke and the incidences of new coronary events, thromboembolic stroke, and CHF were similar in men and women. However, the prevalences of atrial fibrillation and of PAD were higher in men than in women.     

High prevalence of peripheral arterial disease and low treatment rates in elderly primary care patients with diabetes.

Representative data on peripheral arterial disease (PAD) in community-based office practice are scarce while at the same time of high interest. Thus, we aimed to determine the prevalence of peripheral arterial disease (PAD), comorbidity of atherothrombotic manifestations, and treatment intensity among elderly diabetic patients in primary care. In this monitored cross-sectional study, 344 general practitioners throughout Germany determined the ankle-brachial index (ABI) of 6880 consecutive, unselected patients aged 65 years or older with bilateral Doppler ultrasound measurements. PAD was defined according to the recent American Heart Association guidelines (using the higher of the 2 systolic ankle pressures: ABI < 0.9) or peripheral revascularisation, or amputation because of PAD. Coronary events (CAD) and cerebrovascular events (CVD) were taken from the patient's history without additional diagnostic measures. Diabetes was defined according to the clinical diagnosis of the physician and/or HbA1c > or = 6.5 % and/or intake of oral antidiabetic medication and/or application of insulin. 1.743 patients were classified as diabetics: the median disease duration was 6 years (1st; 3rd quartile: 2; 11), median HbA1c 6.6 % (5.9; 7.3), mean age 72.5 +/- 5.4 years, and 51.4 % were females. Diabetics had in comparison with non-diabetics a higher prevalence of PAD defined as ABI < 0.9 (26.3 % vs. 15.3 %, univariate odds ratio 2.0 [95 % confidence interval: 1.7; 2.3]), intermittent claudication (5.1 % vs. 2.1 %, OR: 2.5 [1.9; 3.4]), known CAD (16.1 % vs. 10.6 %, OR: 1.6 [1.4; 1.9]), and known CVD (6.8 % vs. 4.8 %; OR: 1.4 [1.2; 1.8]). 57.4 % of the diabetics with previously known PAD (as only atherothrombotic manifestation) received antiplatelet therapy (vs. 75.1 % with CAD and/or CVD only). The ABI was suitable as screening measure in the primary care setting. In elderly diabetics in comparison to non-diabetics, the prevalence of PAD was very high. Despite the known benefits of antiplatelet therapy, PAD patients were less intensively treated than patients with CAD or CVD.     

Prevalence of left main coronary artery disease,of three- or four-vessel coronary artery disease,and of obstructive coronary artery disease in patients with and without peripheral arterial disease undergoing coronary angiography for suspected coronary artery disease

Data from the present investigation showed that the prevalence of current cigarette smoking, current or ex-cigarette smoking, systemic hypertension, diabetes mellitus, and dyslipidemia was significantly higher in patients with peripheral arterial disease (PAD) than in patients without PAD. The present report also showed that compared with patients without PAD undergoing coronary angiography for suspected coronary artery disease (CAD), patients with PAD undergoing coronary angiography for suspected CAD had a higher prevalence of left main CAD (18% vs <1%), a higher prevalence of 3- or 4-vessel CAD (63% vs 11%), and a higher prevalence of obstructive CAD (98% vs 81%).     

Determinants of amount of contrast utilized in patients undergoing percutaneous coronary procedures

OBJECTIVE: To determine predictors of contrast amount during coronary angiography and percutaneous coronary intervention. BACKGROUND: Contrast-induced nephropathy is a leading cause of hospital-acquired acute renal insufficiency. During percutaneous coronary procedures, contrast amount is a major risk factor incriminated in development of contrast-induced nephropathy. METHODS: Demographic and procedural details were obtained for consecutive patients undergoing percutaneous coronary procedures between January 2002 and October 2005 (N=962, mean+/-standard error of contrast amount: 216.6+/-3.0 ml) at a tertiary care hospital. RESULTS: A significant difference (P value <0.05) in unadjusted mean contrast volume was observed between subgroups of percutaneous coronary intervention vs. coronary angiography, patients with a history of coronary artery bypass grafting, patients undergoing additional procedures and multivessel and multisite percutaneous coronary interventions. On General Linear Model analysis, independent predictors (beta coefficient, 95% confidence interval, P value) of increased contrast amount during percutaneous coronary procedures were history of coronary artery bypass grafting (44.4, 30.6-58.2, <0.001), type of coronary procedure (85.2, 73.4-97.0, <0.001 for percutaneous coronary intervention vs. coronary angiography), number of interventions and number of additional procedures performed. Among additional procedures, rotablation, intravascular ultrasound and Angiojet were associated with increased contrast use. No significant independent effect on the contrast amount was observed with percutaneous coronary intervention location (right coronary artery vs. left anterior descending artery vs. circumflex artery) site (ostial vs. proximal vs. mid vs. distal) of percutaneous coronary intervention or with interventions on chronic total occlusions on the contrast amount. CONCLUSION: Data from our study could guide the coronary angiographer in moderating the volume of contrast utilized as well as assist with the elective planning of complex therapeutic procedures.     

The new Polish stent Chopin. Assessment of safety and efficacy in the treatment of de-novo coronary lesions using percutaneous angioplasty

AIM: The aim of the present study was to assess the safety and efficacy of percutaneous coronary interventions (PCI) using the new Polish stent "Chopin" (Balton, Poland). METHODS: The study consisted of experimental and clinical parts. In the experimental phase, the new stent was implanted into 5 pigs and control coronary angiography as well as intracoronary ultrasonography (ICUS) were performed 30 days later. In the clinical phase, 101 patients (57% of males, mean age 55.6+/-10 years) with symptomatic coronary artery disease (CAD) with "de novo" coronary lesions (including 12% of patients with unstable angina and 19% with acute myocardial infarction [MI]) underwent stent implantation. The patients were followed for 6 months for the occurrence of cardiac events. Quantitative coronary angiography was performed at baseline and after 6 months. RESULTS: In total, we attempted to implant 107 stents, which resulted in the successful deployment of 106 stents to 105 coronary arteries. The mean diameter of the stents was 3.2+/-0.3 mm, and length - 15.4+/-2 mm. During a one month follow-up period no cardiac events were noted. During a 6-month follow-up no death or new MI were recorded. Repeated target vessel revascularisation due to recurrent angina and in-stent restenosis was required in 15 (15.5%) patients. Control coronary angiography was performed in 97 (96%) patients. Of 101 stents, angiographic restenosis (narrowing of dilated lesion by >50% of vessel lumen) was documented in 18.8% of cases. The mean late vessel lumen loss was 0.77+/-0.6 mm, and stenosis - 29.1+/-20%. The restenosis rate was significantly higher in patients with unstable angina rather than in those with stable angina or acute MI. CONCLUSIONS: Implantation of the new Polish stent "Chopin" during PCI is safe and effective.     

无保护左主干病变冠状动脉搭桥术与雷帕霉素洗脱支架治疗的对比研究

目的:回顾性分析无保护左主干病变患者使用雷帕霉素洗脱支架(DES)的经皮冠状动脉介入治疗(PCI)与冠状动脉旁路移植手术(CABG)治疗的中、远期疗效,并探讨应用SYNTAX SCORE来评估病变风险与临床事件的相关性。方法:本研究回顾性收集了176例无保护左主干病变患者,其中CABG组80例,PCI-DES组96例。收集患者的基本情况、左主干病变特点及SYNTAX评分、CABG和PCI手术情况,随访患者术后3年的主要不良心脑血管事件(MACCE)的发生率。结果:术后3年随访,PCI-DES组与CABG组的MACCE发生率及无MACCE生存率比较差异无统计学意义,但PCI组靶血管再次血运重建率(TVR)明显高于CABG组(P<0.05)。用SYNTAX SCORE把PCI-DES和CABG两组患者分为高积分组(≥30.0)和低积分组(<30.0):高积分组,术后3年PCI-DES亚组MACCE事件发生率高于CABG亚组(23.53%∶18.05%,P<0.05),无MACCE事件生存率低于CABG亚组(51.47%∶70.83%,P<0.05)。低积分组,术后3年MACCE事件发生率CABG亚组高于PCI-DES亚组(12.50%∶7.14%,P>0.05),而无MACCE事件生存率低于PCI-DES亚组(75.00%∶82.14%,P<0.05)。结论:PCI-DES与CABG治疗无保护左主干病变患者总体疗效相似。用SYNTAX SCORE指导无保护左主干病变血管重建方式的选择有重要价值,但在不同的患者人群中,仍应结合临床特征和冠状动脉病变特点选择恰当的血运重建术。     

Stenting of unprotected left main coronary artery in patients with low preoperative risk of coronary artery bypass grafting

INTRODUCTION: Available data indicate that stenting of the left main coronary artery (LMN) is safe and effective. Restenosis remains the main factor limiting the effectiveness of percutaneous coronary intervention (PCI). AIM: To evaluate immediate and long-term results of treatment of patients with LMN disease and low preoperative risk of coronary artery bypass grafting. METHODS: Coronary stents were implanted into LMN in 64 patients. The following strategy was applied: drug eluting stent (DES) for LMN diameter < or =3.5 mm (28 subjects) and bare metal stent (BMS) for LMN diameter >3.5 mm (36 subjects). Patients enrolled in the study underwent clinical evaluation and coronary angiography. Immediate effect of the procedure and main adverse cardiac events were assessed: death, myocardial infarction and additional target lesion or non-target lesion revascularization. RESULTS: Angiographic and clinical effectiveness of the interventions was 100%. Full revascularisation of ischaemic regions of the myocardium was performed. Mean clinical follow-up period was 9.4+/-4.0 months. Neither death nor myocardial infarction occurred. Additional PCIs were performed in 11 (17.2%) patients; however, target vessel revascularisation (TVR) rate within LMN was 9.4% (i.e. 6 subjects with BMS), and non-TVR rate was 7.8% (5 subjects). CONCLUSIONS: LMN stenting is associated with high effectiveness of PCI in patients with low operative risk. Long-term follow-up revealed low incidence of major adverse cardiac events. Strategy of selective use of DESs in the study group produced good clinical outcome. Multivessel disease with LMN stenosis was associated with high rate of additional revascularisation of other vessels. Further improvement of treatment results may be obtained by more common use of DES for multivessel disease and LMN diameters larger than 4.0 mm.