Management of coronary artery rupture: Covered stent or microcoil embolization

The management of three cases of coronary artery rupture is described: (1) after high-pressure balloon angioplasty following uneventful placement of three Gianturco-Roubin stents, (2) following balloon angioplasty of an occluded diagonal branch, and (3) subsequent to rotational ablation of a left main and proximal circumflex arteries. Placement of an autologous veincovered Palmaz stent or microcoil embolic vessel occlusion solved each problem. In each case, emergency surgery was avoided; subsequent management, including anticoagulation (when indicated), was performed without incident. This is the first communication detailing correction of a coronary vessel rupture with an autologous vein-covered stent or by microcoil embolic vessel occlusion.     

Impact of coronary calcium on outcome following sirolimus-eluting stent implantation

There remain a small but sizable number of patients who develop restenosis after sirolimus-eluting stent (SES) implantation. However, the cause of SES restenosis has not been fully elucidated. The study population consisted of 52 patients with 69 lesions who underwent noninvasive coronary imaging by 64-slice multidetector computed tomography before SES deployment. Agatston calcium scores in target lesions were measured. All patients underwent follow-up coronary angiography at 8 months. Three coronary segments (in stent, proximal edge, and distal edge) were analyzed by quantitative coronary angiography. Agatston calcium score in target lesions averaged 214.7. Late lumen losses in the proximal edge, stent, and distal edge were 0.16 ± 0.45, 0.47 ± 0.58, and 0.07 ± 0.29 mm, respectively. Lesions with restenosis at follow-up showed a trend to produce higher preprocedural calcium scores (629) compared to those without restenosis (153, p = 0.08). There was a significant positive correlation between lesion calcium score and in-stent late lumen loss (r = 0.47, p <0.01). In conclusion, assessment of coronary calcium by multidetector computed tomography might be useful to predict outcomes after SES implantation.     

Long-term outcome of percutaneous coronary interventions following failed beta-brachytherapy

BACKGROUND: Recurrent restenosis following vascular brachytherapy (VBT) has been reported in up to one-third of the patients enrolled in clinical trials. The long-term outcome of repeat percutaneous intervention (PCI) after failed beta-brachytherapy is currently unknown. METHODS: We retrospectively analyzed 97 consecutive patients undergoing percutaneous coronary reintervention after failed beta-brachytherapy at our institution (80.8% of all brachytherapy failures). Long-term incidence of major adverse cardiac events (MACE, death, myocardial infarction, target lesion revascularization) was assessed. RESULTS: The procedure was successful in 90 patients (92.8%). A new stent was implanted in 72% of the procedures (sirolimus-eluting stent in 16.5%). After 3 years, survival was 94.3%, survival-free from myocardial infarction was 86.7% and MACE-free survival was 66.1%. No difference was observed in MACE-free survival between patients originally treated with brachytherapy for recurrent in-stent restenosis and patients receiving irradiation for de novo lesions (68.2% de novo group versus 61.2% ISR group; p=0.6 by log rank test). Overall, a second target lesion revascularization was performed in 27 patients (27.8%) after an average of 11.2 11.2 months; 21 patients (21.6%) had restenosis, and 6 (6.2%) developed late total vessel occlusion (related to acute myocardial infarction in 2 cases). CONCLUSION: Repeat PCI is the most common choice after failed brachytherapy. This strategy appears to be a reasonable therapeutic option for this complex iterative pathology.     

Contained rupture following percutaneous transluminal coronary angioplasty: Long-term outcome

Coronary artery aneurysm formation can occur as a complication of balloon angioplasty. We present a case of a contained rupture of the left circumflex artery following angioplasty which resulted in an unusual pseudoaneurysm on angiography at 3-year follow-up. © 1993 Wiley-Liss, Inc.     

Long-term (> or =8 years) outcome after Palmaz-Schatz stent implantation.

The purpose of this single-center study was to evaluate the long-term (> or =8 years) outcome of Palmaz-Schatz intracoronary stenting and to identify independent predictors of outcome. Although short-term results of Palmaz-Schatz intracoronary stenting have been promising, with a reduction in both angiographic restenosis and clinical cardiac events up to 3 years, longer-term follow-up has not been established. We analyzed clinical outcome in 426 consecutive patients at least 8 years after coronary stenting. Demographic, clinical, and procedural predictors of restenosis, survival, and event-free survival, defined as freedom from death, myocardial infarction (MI), and coronary revascularization (target stented site, target vessel, and any revascularization) were analyzed. Before discharge, 28 patients (6.6%) sustained at least 1 major cardiovascular event: 3 deaths (0.7%), 18 MIs (4.2%), and 17 repeat revascularizations. Surviving patients were followed for 8.9 years (interquartile range 8.4 to 9.4). After discharge, 59 patients (13.9%) died, 47 (11.1%) sustained an MI, and 188 (44.4%) underwent coronary revascularization. The 8-year event-free survival (freedom from death, freedom from death/MI/target-stented site revascularization, and freedom from death/MI/any coronary revascularization) was (mean +/- SE) 0.86 +/- 0.01, 0.62 +/- 0.03, and 0.47 +/- 0.02, respectively. Unstable angina, lower left ventricular ejection fraction, and saphenous vein graft stenting were found to be independent predictors of death during follow-up. Hypertension, unstable angina, multivessel disease, and multiple stent implantation were found to be independent predictors of the composite of death/MI/any coronary revascularization during follow-up. This study provided a useful assessment of very long-term outcome in survival, event-free survival, and predictors of major cardiac events 8 to 10 years after Palmaz-Schatz stent implantation.     

Cholesterol embolization following coronary angioplasty.

Cholesterol emboli syndrome is an uncommon complication seen after an invasive vascular procedure or surgery in a patient with atherosclerotic disease. The obstruction of small arteries by cholesterol crystals may be responsible for its clinical features, such as livedo reticularis, "purple toe" syndrome, renal failure, involvement of the gastrointestinal tract, coronary arteries, central nervous system or the multiple cholesterol emboli syndrome. Certain laboratory abnormalities are frequently associated: an elevated erythrocyte sedimentation rate and eosinophilia, BUN and creatinine increase in the cases with renal failure and creatine phosphokines augmentation suggesting muscle involvement. Disseminated microemboli composed mainly of cholesterol crystals are the usual pathological findings. A case of cholesterol embolism occurring after left heart catheterization and percutaneous transluminal coronary angioplasty is reported. Twenty-four hours after the procedure, the patient developed purplish discoloration of toes and soles, livedo reticularis on lumbar region, buttocks and limbs, and renal failure. Patient did well two months after anticoagulant therapy. Prognosis of these cases is related to the extent of systemic involvement and the most significant impact on this syndrome can be made by its prevention.     

Short-term clinical outcome of drug-eluting coronary stent

Objective To evaluate short-term outcome of coronary drug-eluting stent (DES) in patients with coronary artery disease (CAD) by comparing with standard bare stents.     

Impact of final coronary flow velocity reserve on late outcome following stent implantation.

Aims To assess whether coronary flow velocity reserve following stent implantation is predictive of the subsequent need of target lesion revascularization.Methods and Results The outcome was examined of 417 patients enrolled in a multicentre prospective randomized study (DESTINI), who received a successful single vessel stent implantation in native coronary arteries and in whom coronary flow velocity reserve was measured. Logistic regression analysis and the receiver operator characteristic curve were used. When compared with 358 patients not requiring target lesion revascularization, 59 patients (14%) who underwent target lesion revascularization had a lower final coronary flow velocity reserve (2.33 +/- 0.87 vs 2.48+/- 0.80, P= 0.20) and smaller final minimal lumen diameter (2.62 +/- 0.66 mm vs 2.73+/- 0.60, P= 0.19); however, those differences were not statistically significant. Patients with a coronary flow velocity reserve of < 2.0 (n=109, 26%) exhibited a significantly higher target lesion revascularization rate than patients with a coronary flow velocity reserve of > or = 2.0 (22% vs 11%, P= 0.010). This difference remained significant (odds ratio=2.01, 95% CI=1.11 to 3.66) after adjustment for other variables that were also correlated with the incidence of target lesion revascularization.Conclusion The presence of a final coronary flow velocity reserve of < 2.0 is an independent predictor of the need for target lesion revascularization after stent implantation in native coronary artery lesions.     

Long-term angiographic and clinical outcome after implantation of a ballon-expandable stent in the native coronary circulation

Objectives. The purpose of this study was to examine the long-term clinical and angiographic outcome after coronary implantation.Background. Previous reports haw shown a discordance between the excellent initial angiographic results and subsequent adverse clinical events after coronary artery stenting.Methods. Single Palmaz-Schatz stents were electively implanted in the native coronary arteries of 300 consecutive patients. Angiograms were obtained at baseline, after balloon angioplasty, after stent implantation and at 6 months after implantation. Films were analyzed by a panel of engiographers utilizing en automated edge detection program, Clinical events, including death, myocardial infarction, coronary bypass surgery and repeat angioplasty, were recorded for 1 year.Results. Although there were no acute in-laboratory vessel closures, stent thrombosis occurred in 14 patients (4.7%) at a mean ±SD of 5 ± 3 days after implantation. Two hundred fifty-eight (90%) of 286 eligible patients had follow-up angiography at 6.1 ± 2.2 months after stent implantation. Minimal lumen diameter increased from 0.80 ± 039 mm at baseline to 1.65 +- 0.51 mm after angioplasty and further increased to 2.55 ± 0.49 mm after stent placement (p = 0.0001). At follow-up there was a 0.85-mm late loss in lumen diameter, with a final minimal lumen diameter at 6 months of 1.70 ± 0.71 mm. Restenosis, defined as ≥ 50% diameter stenosis at follow-up, occurred in 14% of patients with previously untreated lesions and in 39% of patients with previous angioplasty (p < 0.001). Clinical events after 1 year for the entire group of 300 patients included death in 0.7%, myocardial infarction in 3.7%, bypass grafting in 8% and repeat angioplasty in 13%. Freedom from any adverse clinical event was 80% for all treated patients and 87% for those with previously untreated lesions.Conclusions. Elective use of this balloon-expandable stent in the native coronary circulation is associated with a low restenosis rate by quantitative angiography in previously untreated lesions and a favorable clinical outcome with an excellent event-free survival rate at 1 year.     

Long-term outcome of simultaneous kissing stenting technique with sirolimus-eluting stent for large bifurcation coronary lesions.

OBJECTIVES: This study was conducted to evaluate the outcomes of simultaneous kissing stenting with sirolimus-eluting stent (SES). BACKGROUND: Percutaneous intervention for bifurcation coronary lesions is still challenging. METHODS: This study was designed to evaluate the long-term outcomes of 36 consecutive patients with large bifurcation coronary lesions who underwent simultaneous kissing stenting with SES. RESULTS: Lesion location was unprotected left main in 29 patients (81%) and anterior descending artery in 7 (19%). The patients received a combination of aspirin and clopidogrel for 6 months and cilostazol for 1 month. Mean proximal reference diameter was 4.05 +/- 0.68 mm. Compared with the side branch (SB), the main vessel (MV) involved longer lesions (25.8 +/- 17.0 mm vs. 10.2 +/- 10.8 mm, P < 0.001) and smaller preprocedural minimal lumen diameters (1.02 +/- 0.53 mm vs. 1.46 +/- 0.78 mm, P = 0.006) and was treated with larger stents (3.1 +/- 0.3 mm vs. 3.0 +/- 0.3 mm, P = 0.006). Angiographic success rate was 100%. Over the follow-up of 26.7 +/- 8.6 months, no deaths, myocardial infarctions or stent thromboses occurred. Target lesion revascularization was performed in five patients (14%). Overall angiographic restenosis occurred in 5/30 patients (17%), consisting of 4 (13%) at MV and 3 (10%) at SB. At follow-up angiography, a membranous diaphragm at the carina was identified in 14 patients (47%), but only one of whom was associated with angiographic restenosis. CONCLUSION: Simultaneous kissing stenting with SES appears a feasible stenting technique in large bifurcation coronary lesions. However, a new angiographic structure of carinal membrane developed in a half of patients at follow-up and its influence needs to be further investigated.     

冠心病患者介入治疗失败后行急诊冠状动脉旁路移植术的预后

目的 探讨冠心病患者经皮冠状动脉介入治疗失败后行急诊冠状动脉旁路移植术(CABG)的预后.方法回顾性分析2002年1月至2010年12月阜外心血管病医院11例经皮冠状动脉介入治疗失败后行急诊CABG患者的临床资料,并进行随访.院内随访内容包括心脏性死亡、Q波心肌梗死、肾功能不全、神经系统事件;院外随访的研究终点为主要心血管不良事件,包括死亡、心肌梗死和靶病变血管重建.结果 患者年龄(61±5)岁.冠状动脉造影显示三支病变患者5例(45.5％).在介入治疗的靶血管病变中,9例(81.8％)位于左前降支,中、重度钙化、慢性完全闭塞及弥漫性长病变分别为3例(27.3％)、4例(36.4％)和4例(36.4％).11例患者均有行急诊CABG的指征,其中冠状动脉夹层5例(45.5％)、冠状动脉穿孔 3例(27.3％)、病变无法充分扩张1例(9.1％)、血管急性闭塞1例(9.1％)和支架脱载1例(9.1％).CABG术后随访(47±33)个月.院内随访期间,发生心脏性死亡1例(9.1％),Q波心肌梗死2例(18.2％).院外随访期间,1例(9.1％)患者死于肾功能衰竭,无因心原性事件再次住院的患者.结论经皮冠状动脉介入治疗失败后行急诊CABG多见于复杂冠状动脉病变,术后患者的长期预后良好.     

经冠状动脉造影证实的初次冠状动脉支架内血栓形成长期临床预后:431例临床分析

<正>本研究(Dutch Stent Thrombosis Registry)为一项多中心研究,纳入了2004年1月至2007年2月期间经造影确认的ST病例。本研究ST的定义根据ARC分类为明确的血栓形成。根据事件发生的时间分为急性(24 h之内)、亚急性(24h～30 d)、晚期(30 d～1年)和极晚期(1年以后)血栓形成。临床随访采用电话方式询问患者、亲属及家庭医生,或从药房、医院记录获得患者情况。随访内容为主要不良心血管事件(MACE)的发生率(包括死亡、再发ST、心肌梗死和冠状动脉重建术)。研究的一级终点为心源性死亡和明确的再发ST(ARC分类);二级终点为全因死亡、心源性死亡、再发明确的ST、再发明确的或可能的ST、靶血管或非靶血管相关的心肌梗死和任何缺血驱使的靶血管血运重建。共437例患者有明确ST纳入本研究。其中6例因既往曾有ST而被剔除。第1次发生明确ST的431例患者中,140例为急性ST[占总数的32.5%,占金属裸支架(BMS)的33%,占药物洗脱支架(DES)的30%],177例为亚急性ST(占总数     

Periprocedural plasma fibrinogen levels and coronary stent outcome

Aim

Percutaneous intervention is one of the treatment option for coronary artery disease. Reinfarction and restenosis is one of the complication of the procedure. So this study was conducted to assess plasma fibrinogen levels pre- and post coronary stenting and its relation with outcome.

Methods

After obtaining informed consent, venous blood samples were collected at three timed points in relation to stenting – 24 h before, 24 h after and 72 h after stenting to assess fibrinogen levels. Patients were followed up for six months. Repeat revascularization, myocardial infarction and symptomatic angina were considered as major adverse clinical events.

Results

57 patients who underwent successful stenting and followed up for six months up were included in the study. Mean age was 53 years and 87.7% were males and 29.8% were diabetics. Baseline plasma fibrinogen level was significantly high in patients who developed repeat angina and myocardial infarction after the stenting [288.64 ± 59.43 vs 393.75 ± 32.97 mg/dL, p = 0.003] and it remained high during serial assessment [322.74 ± 63.92 vs 422.00 ± 55.28 mg/dL, 326.23 ± 65.81 vs 419.50 ± 45.82 mg/dL, 0.008, 0.012 respectively]. Patients who developed adverse events denied any drug default.

Conclusion

We conclude that plasma fibrinogen plays a significant role in the development of adverse events following stenting shown by high level of plasma fibrinogen in patients who developed adverse events.     

Incidence of thrombocytopenia following coronary stent placement using abciximab plus clopidogrel or ticlopidine.

The incidence of thrombocytopenia with ticlopidine and clopidogrel when used in conjunction with abciximab has not been systematically addressed. We evaluated the rate of thrombocytopenia in patients undergoing intracoronary stent implantation receiving bolus plus infusion of abciximab and either ticlopidine or clopidogrel. We noted an incidence of 24% with the combination of 300-mg clopidogrel and abciximab. Other doses of ticlopidine (250 and 500 mg) and clopidogrel (75 mg) did not result in a statistically significant increase in thrombocytopenia over that of the 2.5%-5.2% reported incidence with abciximab alone. Length of hospital stay was 2.3 vs. 6.4 days in those developing thrombocytopenia (P = 0.06). Four (25%) developed thrombocytopenia requiring blood transfusion. Eight (50%) had no sequelae. The combination of 300-mg clopidogrel and abciximab results in a significant increase in the incidence of thrombocytopenia. This is an important clinical observation that merits further study.     

Long-term outcome of first-generation metallic coronary stent implantation in patients with coronary artery disease: observational study over a decade.

BACKGROUND: In the era of drug-eluting stents, percutaneous coronary intervention (PCI) has been considered an established therapeutic modality for patients with coronary artery disease (CAD). However, little is known about the long-term prognosis. METHODS AND RESULTS: Using data obtained from a single-center registry for cases of first-generation bare metallic stent (BMS) implantation, a 10-year follow-up study in patients with CAD was performed. Data for 125 serial patients (aged 62+/-9 years, 104 males) in whom a BMS was successfully implanted was analyzed. Cardiac death (n=16 [12.8%]), including sudden cardiac death (n=9 [7.2%]), non-cardiac death (n=17 [13.6%]) and non-fatal acute myocardial infarction (n=16 [12.8%]) were documented. At 10 years, cumulative probabilities of target and non-target lesion revascularization were 20.5% and 41.5%, respectively, and only 39.2% of the patients were free from cardiac events (cardiac death/myocardial infarction/unplanned revascularization). Age and left ventricular ejection fraction (LVEF) were significant predictors of total death, and LVEF and the use of diuretics were predictors of cardiac events. CONCLUSIONS: Stabilization of the initial stented site was relatively good and the majority of cardiac events might have originated in non-target lesions. Prevention of systemic arteriosclerosis progression is important for patients with CAD, even after successful PCI.