Percutaneous coronary intervention of left main pseudoaneurysm with customized covered stents

Left main pseuodaneurysm is a rare entity and is one of the potentially lethal consequences of coronary artery dissection. We describe a case of a young woman who almost a week after her delivery developed spontaneous left main dissection, manifested as acute anterior myocardial infarction. Left on medical treatment alone over a month, spontaneous dissection progressed to symptomatic large left main pseuodaneurysm, which was treated percutaneously with covered stents. © 2011 Wiley‐Liss, Inc.     

Revascularization of unprotected left main coronary artery disease with percutaneous coronary intervention: the role of drug-eluting stents

The percutaneous revascularization of left main coronary artery stenosis has until recently been reserved for patients at prohibitive surgical risk or for selected emergent cases. This adopted practice of coronary artery bypass grafting, as the standard of care for left main coronary artery stenosis, has largely occurred secondary to disappointing results with bare metal stents implanted in the left main coronary artery. However, in the current era of drug-eluting stents (DES) which significantly reduce restenosis compared to bare metal stents, there has been a renewed interest in examining the role of percutaneous coronary intervention as a means of revascularization of left main disease. This article discusses recent and ongoing studies investigating the role of percutaneous intervention of left main disease, with an emphasis on the use of DES for this purpose.     

Safety of drug-eluting stents in patients with left ventricular dysfunction undergoing percutaneous coronary intervention

Recent studies have reported a higher incidence of late stent thrombosis in patients undergoing drug-eluting stent (DES). Reduced left ventricular (LV) ejection fraction (EF) is considered a risk factor for this complication after both bare-metal stent (BMS) and DES implantation. Therefore, the aim of this study was to evaluate the safety of DES on long-term follow-up in patients with LV dysfunction undergoing percutaneous coronary intervention. We retrospectively selected all patients with an EF <45% undergoing percutaneous coronary intervention with implantation of >/=1 sirolimus- or paclitaxel-eluting stent at our institution. The primary endpoint of the study was all-cause mortality, retrieved using both Social Security Database and hospital records. We also compared the results of this group with a historical cohort of patients with LV dysfunction undergoing BMS implantation; 121 patients who received >/=1 DES were enrolled. The mean LVEF was 36 +/- 8%, with 20 patients (16%) with a LVEF 相似文献   

Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.

OBJECTIVES: This study evaluated the clinical outcomes of consecutive, selected patients treated with coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main coronary artery (ULMCA) disease. BACKGROUND: Although recent data suggest that PCI with DES provides better clinical outcomes compared to bare-metal stenting for ULMCA disease, there is a paucity of data comparing PCI with DES to CABG. METHODS: Since April 2003, when DES first became available at our institution, 123 patients underwent CABG, and 50 patients underwent PCI with DES for ULMCA disease. RESULTS: High-risk patients (Parsonnet score >15) comprised 46% of the CABG group and 64% of the PCI group (p = 0.04). The 30-day major adverse cardiac and cerebrovascular event (MACCE) rate for CABG and PCI was 17% and 2% (p < 0.01), respectively. The mean follow-up was 6.7 +/- 6.2 months in the CABG group and 5.6 +/- 3.9 months in the PCI group (p = 0.26). The estimated MACCE-free survival at six months and one year was 83% and 75% in the CABG group versus 89% and 83% in the PCI group (p = 0.20). By multivariable Cox regression, Parsonnet score, diabetes, and CABG were independent predictors of MACCE. CONCLUSIONS: Despite a higher percentage of high-risk patients, PCI with DES for ULMCA disease was not associated with an increase in immediate or medium-term complications compared with CABG. Our data suggest that a randomized comparison between the two revascularization strategies for ULMCA may be warranted.     

Outcome of percutaneous coronary intervention utilizing drug-eluting stents in patients with reduced left ventricular ejection fraction

Ischemic cardiomyopathy with depressed left ventricular ejection fraction (LVEF) is predictive of death after percutaneous coronary intervention (PCI), but its association with stent thrombosis (ST) and the need for repeat revascularization is less clearly defined. In total 5,377 patients undergoing PCI were retrospectively evaluated. Multivariable Cox proportional hazards regression and competitive outcome analysis were employed. The primary end point was 1-year major adverse cardiac events (all-cause death, Q-wave myocardial infarction, ST, and target lesion revascularization [TLR]). Individual end points of ST and of TLR were also evaluated. Patients with normal LVEF (>50%) were compared to those with mild (41% to 50%), moderate (25% to 40%), and severe (<25%) decreases in LVEF. Patients with abnormal LVEF were older and more commonly diabetic and had renal insufficiency and heart failure syndrome (p <0.001 for all variables). These patients demonstrated more angiographically complex lesions and less frequently received a drug-eluting stent. The primary end point was significantly increased in patients with lower LVEF (9.7% for normal LVEF vs 20.6% for severely decreased LVEF, p <0.001). ST occurred more frequently in these patients (1.4% for normal LVEF vs 6% for severely decreased LVEF, p <0.001), but clinically driven TLR did not significantly change across LVEF categories. After adjustment, only moderate and severe LVEF decreases (i.e., LVEF ≤40%) demonstrated an association with major adverse cardiac events and with the individual outcome of ST. Subgroup analysis of patients receiving only a drug-eluting stent or a bare-metal stent demonstrated no statistically significant differences for the probability of ST. In conclusion, decreased LVEF is not associated with clinically driven TLR but does increase the risk of ST. Patients with LVEF ≤40% appear to be at significantly higher risk for ST and therefore might benefit from interventional and pharmacologic strategies aimed at minimizing this risk.     

无保护左主干病变支架介入治疗后冠状动脉造影随访结果分析

目的观察无保护左主干病变,应用药物洗脱支架介入治疗后冠状动脉造影随访结果,并分析其影响因素。方法选择无保护左主干病变患者150例,其中48例在平均(10.0±7.5)个月进行了冠状动脉造影复查,根据冠状动脉造影显示有无狭窄分为:再狭窄组12例和无再狭窄组36例。结果与无再狭窄组比较,再狭窄组患者随访时最小管腔直径明显减小[(2.7±1.0)mm vs (3.5±0.4)mm,P=0.0001]、直径狭窄率明显升高[(31.4±26.4)% vs (8.3±5.3)%,P=0.0000]、晚期管腔丢失明显升高[(0.8±0.7)mm vs (0.2±0.3)mm,P=0.0000];双支架置入术的再狭窄率明显高于单支架置入术[(75.0% vs 13.9%),P=0.0011]。结论左主干远端分叉病变双支架置入术的疗效较差,冠状动脉旁路移植术应作为首选。     

Early and long-term outcomes after percutaneous coronary intervention of unprotected left main coronary disease with drug-eluting stents in patients with non-ST-elevation acute coronary syndrome

Background

Patients presenting with non-ST-elevation acute coronary syndrome (NSTE-ACS) and unprotected left main coronary disease (ULMCD) are among the highest risk patients but current consensus guidelines do not address the optimal timing and mode of revascularization for these individuals.

Methods

In this single-centre registry, we evaluated the clinical outcomes of 151 consecutive patients with NSTE-ACS and ULMCD who underwent percutaneous coronary intervention with drug-eluting stents from 2005 to 2009.

Results

Overall in-hospital major adverse cardiac event (MACE) rate was 5.3%, mortality rate was 0.7%. At 30 months ± 15 months, 30 patients (19.9%) experienced MACE. The 4-year cumulative survival rate of no MACE was 73.2% and cumulative survival rate was 90.6%. Left ventricular ejection fraction (hazard ratio [HR] 0.947; 95% confidence interval [CI], 0.898-0.998; P = 0.043) and SYNTAX [SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery] score ≥ 33 (HR 1.28; 95% CI, 1.025-1.433; P = 0.029) were associated with MACE, while only left ventricular ejection fraction (HR 0.82; 95% CI, 0.69-0.973; P = 0.023) was associated with mortality.

Conclusions

Our study demonstrates the feasibility of percutaneous coronary intervention with drug-eluting stents in patients with NSTE-ACS and ULMCD. The early and long-term outcomes were acceptable. Left ventricular ejection fraction and SYNTAX score ≥ 33 predict MACE and only left ventricular ejection fraction predicts mortality.     

第二代药物洗脱支架治疗无保护左主干病变的疗效及安全性分析

目的探讨第二代药物洗脱支架（DES）置入治疗无保护左主干（ULM）病变患者的疗效及安全性。方法回顾性研究南京医科大学附属南京医院诊断为ULM病变并接受DES治疗的患者216例。接受第一代DES的患者121例为F组,接受第二代DES的患者95例为S组。患者术后常规服用阿司匹林100 mg,每日一次;氯吡格雷150 mg,每日一次（维持至少1年）。主要研究终点为主要不良心血管事件（MACE）,包括心源性死亡、非致死性心肌梗死和再次靶血管血运重建（TVR）;次要终点为12个月时定量冠状动脉造影（CAG）参数。结果在（342±23）d随访期内,总体复合MACE 22例（10.2%）,主要构成为TVR 16例（7.4%）。S组复合MACE为5.3%显著低于F组14.0%（χ2=4.491,P=0.034,RR 2.669,95%CI 1.022~6.975）。S组复合MACE的减少主要表现为TVR减少（χ2=4.465,P=0.035,RR 3.402,95%CI 0.998~11.60）。随访血管造影再狭窄F组与S组分别为17例（14.5%）和8例（8.4%）,差异无统计学意义（χ2=1.647,P=0.199）。血管内超声提示的晚期获得性支架贴壁不良于F组和S组分别为7例（5.8%）和1例（1.1%）,F组有增加趋势,但差异无统计学意义（χ2=3.342,P=0.068）。结论与第一代DES相比较,使用第二代DES治疗ULM病变MACE发生率低,主要表现为TVR减少;第二代DES治疗ULM病变具有更好的疗效和安全性。     

Percutaneous coronary intervention for unprotected left main disease in very high risk patients: safety of drug-eluting stents

Percutaneous treatment of unprotected left main coronary artery (ULMCA) stenosis using drug-eluting stents (DES) has been suggested as the best approach for patients who are poor surgical candidates. Some concerns have recently been raised regarding the risk of stent thrombosis following DES implantation. This study was performed in order to evaluate the safety of DES, as compared to bare metal stents (BMS), for ULMCA stenosis treatment in very high risk patients with a high likelihood of stent thrombosis. Forty-two consecutive patients were treated with either BMS (20) or DES (22) for ULMCA critical stenosis. Inclusion criteria were: ST elevation myocardial infarction, non-ST elevation myocardial infarction, cardiogenic shock, or logistic European System for Cardiac Operative Risk Evaluation ≥ 13%. At 1 year, one case of late thrombosis and three cases of restenosis were reported in the BMS group and none in the DES group, leading to a significantly inferior rate of target lesion revascularization (20.0 vs. 0%, p = 0.048) and major adverse cardiac events (65.0 vs. 19%, p = 0.004). DES placement for ULMCA stenosis also appears to be a safe therapeutic choice in very high-risk patients, as it provides the benefit of a reduction in restenosis without increasing the risk of early or late stent thrombosis.     

Impact of overlapping drug-eluting stents in patients undergoing percutaneous coronary intervention.

BACKGROUND: Sirolimus-eluting stent (SES) implantation for the treatment of single coronary lesions is proven to be effective and durable. However, the safety and efficacy of overlapping SES for the treatment of long lesions have not been well established. Objectives: We conducted a retrospective analysis to compare the clinical outcomes of overlapping versus nonoverlapping SES. METHODS: Fifty-five patients who received overlapping SES were compared with 39 patients who received nonoverlapping SES. RESULTS: The baseline clinical and angiographic characteristics were balanced between the two study groups. The in-hospital complications were similar between groups, except that non-Q-wave myocardial infarction was significantly higher in the Overlapping SES group when compared with the Nonoverlapping SES group (23.6% vs. 7.7%, P = 0.04). This higher rate of myonecrosis is due to periprocedural side branch compromises, including side branch narrowing, occlusion, and flow reduction. At 30 days and 6 months follow-up, all clinical outcomes were similar between the study groups. In addition, the event-free survival rate was similar between groups (P = 0.87). CONCLUSIONS: The implantation of overlapping SES for the treatment of long, native coronary lesions is feasible and effective but is associated with an increased rate of periprocedural myonecrosis. This phenomenon is caused primarily by side branch compromises, but does not have any adverse impact on late clinical events.     

High-risk diabetic patients with unprotected left main coronary artery disease: characteristics and medium-term outcomes of percutaneous revascularization with drug-eluting stents

Percutaneous coronary intervention with drug-eluting stents is an alternative for patients with high-risk unprotected left main coronary artery disease; those with diabetes mellitus are at even higher risk. Recent advances in percutaneous coronary intervention could lead to better results. The aim of this study was to evaluate medium-term results in a real-world sample of high-risk diabetic patients undergoing percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease.From 3 tertiary hospitals, we retrospectively identified 334 high-risk patients, of whom 141 (42%) were diabetic and 193 (58%) were nondiabetic. The diabetes mellitus group showed a higher prevalence of peripheral vascular disease and left ventricular dysfunction. Angiographic and procedural characteristics did not differ significantly, with the exception of poor distal vessels in the diabetes mellitus group (44.5% vs 28.5%, P = 0.006). The use of intra-aortic balloon pumping and intravascular ultrasonography was low in both diabetic and nondiabetic patients. After a median follow-up of 22.4 months, cardiac death was higher in the diabetes mellitus group (16.2% vs 7.5%, P = 0.015), especially in insulin-dependent diabetic patients (25.8%). The incidence of major adverse cardiac events, including cardiac death, target-lesion revascularization, and myocardial infarction was similar in both groups (23.8% vs 18.3%, P = NS).High-risk diabetic patients who undergo percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease present with a worse clinical profile that carries a higher cardiac mortality rate in the medium term, especially in insulin-dependent diabetic patients.     

Safety and efficacy of everolimus-eluting stents compared with first-generation drug-eluting stents in patients undergoing primary percutaneous coronary intervention

ObjectiveTo assess the safety and efficacy everolimus-eluting stents (EES) compared with first-generation drug-eluting stents (DES) in patients with acute myocardial infarction (MI) undergoing primary percutaneous coronary intervention (PCI).BackgroundEES have been associated with improved clinical outcomes compared to paclitaxel-eluting stents (PES) and with similar outcomes compared to sirolimus-eluting stents (SES).MethodsA total of 520 patients who presented with ST-elevation myocardial infarction (STEMI) from 2003 to 2013, who underwent primary PCI with DES, were retrospectively analyzed. Of these, 247 received SES, 136 PES, and 137 EES. Patients were followed up to 2 years for major adverse cardiac events (MACE). Univariate and multivariate models detected correlates to outcome.ResultsEES implantation, compared with PES and SES, resulted in comparable rates of MACE (8.8% vs. 16.2%, p = 0.06 and 8.8% vs. 12.6%, respectively, p = 0.26), stent thrombosis, MI, and target lesion revascularization. Patients who received EES had lower rates of all-cause mortality (3.7% vs. 12.6% vs. 9.4%, p = 0.03) at 1-year follow up. However, in the univariate and multivariate analyses, stent type was not independently associated with the primary outcome or with all-cause mortality. Diabetes mellitus and number of stents implanted were independently associated with the primary outcome.ConclusionWhile EES seem to be associated with better outcome when compared to PES, the main correlates of STEMI patients are the presence of diabetes and number of stents implanted, and not the type of stent used for intervention.     

Balancing efficacy and safety of drug-eluting stents in patients undergoing percutaneous coronary intervention

Drug-eluting stents reduce the occurrence of in-stent restenosis and the need for subsequent target vessel revascularization compared with bare-metal stents. However, the safety of drug-eluting stents has been called into question because of an apparent increase in late stent thrombosis, a frequently fatal event. A substantial body of research has focused on determining the magnitude of these competing events, often reaching contradictory results even with analyses of the same data. Although larger, adequately powered, randomized trials are needed to fully assess the net clinical effects of drug-eluting stents compared with bare-metal stents, the evidence seems to suggest that the net clinical benefit of drug-eluting stents may outweigh their risks. The evidence is clearer that premature discontinuation of antiplatelet therapy is an important trigger for stent thrombosis; therefore, patients who are candidates for implantation of drug-eluting stents should be screened for their ability to receive and tolerate uninterrupted antiplatelet therapy longer than is necessary with bare-metal stents. The evidence suggests that drug-eluting stents relieve obstructive coronary artery disease, provide durable mechanical results, and do more good than harm, but all patients also should be given antiplatelet and other optimal medical therapies to achieve the best outcomes.