冠状动脉介入治疗后造影复查支架再狭窄结果分析

目的:分析不同类型支架置入术后冠状动脉(冠脉)造影复查的影像学特点.方法:入选行冠脉介入治疗后进行造影复查的577例患者的846处病变,根据置入支架类型及方式不同分别分析其临床资料及冠脉造影资料.结果:冠脉造影随访率为22.62%;药物支架虽然病变更复杂,但其冠脉造影复查再狭窄率明显低于裸支架(20.29%VS 42.56%,P=0.000);裸支架重叠、药物支架重叠、裸支架与药物支架重叠时再狭窄率分别为53.49%,25.55%,35.29%.药物支架在支架内弥漫性、支架内弥漫性累及两端及支架内局限性再狭窄率明显低于裸支架,差异均有统计学意义(P=0.001,P=0.013,P=0.031),药物支架支架近端局限性再狭窄率高于裸支架,差异有统计学意义(P=0.000);不同药物支架冠脉造影复查再狭窄率没有统计学差异(P=0.193);药物支架和裸支架在糖尿病患者中冠脉造影复查再狭窄率为23.85%和42.65%(P=0.012).结论:①长病变需要重叠支架时尽量使用药物支架重叠;②药物支架改变了支架再狭窄类型,由弥漫型再狭窄转为局限型;③不同种类药物支架效果良好;④药物支架对糖尿病患者同样有效.     

直接冠状动脉内支架术的初步临床应用

目的探讨直接冠脉内支架术的可行性及安全性.方法回顾性分析139例直接冠脉内支架置入术病人的临床资料及影像学资料,并对其中95例病人进行临床随访.结果139例病人中直接冠脉内支架置入术成功率95.7%.在失败的6例病人(4.3%)中,2例为支架不能顺利到达目标病变,回收支架后经用球囊预扩张后顺利置入支架;4例为支架置入后不能完全覆盖病变或支架边缘部位出现夹层,需置入第2个支架.最后所有病变均取得残余狭窄率<20%,TIMI3级血流,且无重大心脏事件.对其中95例(68%)进行为期1～23个月,平均4.7个月的临床随访,其中7例(7.4%)病人因目标病变再狭窄,再次行PTCA术.结论直接支架术在选择性病人中应用具有满意的可行性及安全性.     

冠状动脉腔内成形术加支架置入术预防冠状动脉再狭窄的临床研究

目的 探讨冠状动脉支架预防经皮冠状动脉(下简称冠脉)腔内成形术(PTCA)后冠脉再狭窄的效果及活动平板试验诊断冠脉再狭窄的价值。方法 将60例PTCA成功者随机分为联合组和PTCA组,联合组在PTCA基础上置入支架,PTCA组单纯行PTCA。两组均于术后1周及6个月分别行次极量活动平板试验;术后6个月重复冠脉造影,观察两组冠脉再狭窄率。结果 联合组术后即刻狭窄率低于PTCA组(P<0.01),术后6个月仍有明显差异(P<0.001),术后6个月两组13例冠脉再狭窄者活动平板试验阳性11例,占84.62％。结论冠脉支架置人具有预防PTCA术后冠脉再狭窄的作用,活动平板试验结合心绞痛复发症状可检出冠脉再狭窄的高危患者。     

冠状动脉内支架置入术后再狭窄与尿酸的关系

目的 :探讨冠状动脉 (冠脉 )内支架置入术后再狭窄与血清尿酸的关系。方法 :2 13例冠脉内支架术后患者因胸痛复发或医生动员行冠脉造影随访 ,以支架置入段内径狭窄≥ 5 0 %为再狭窄。记录这些患者的冠心病易患因素 ,并测定血清尿酸浓度。结果 :2 13例患者共 2 5 7处病变所置入的支架中 ,支架内再狭窄 87例 (138处病变 ) ,其血清尿酸浓度明显高于无再狭窄患者 (P <0 .0 5 )。多因素Logistic逐步回归分析显示 :高尿酸血症是支架内再狭窄的独立危险因素 (OR =1.15 )。结论 :高尿酸血症与冠脉内支架再狭窄明显相关 ,降低血尿酸浓度可能减少再狭窄的发生     

小血管支架术290例临床疗效观察

目的　观察小血管支架术手术成功率、术后即刻效果、术后主要临床不良事件发生情况及远期再狭窄率。方法　观察我院 1997年 4月至 2 0 0 2年 3月所纳入的 2 90例小血管支架患者的 2 99支血管 30 4处病变共 316个小血管支架 (支架直径 <3 0mm)术后的手术成功率 ,术后即刻效果 ,主要临床不良事件发生情况及远期再狭窄率。随访 1个月至 4年 ,其中 12 2例行冠状动脉造影术复查。结果　手术成功率 10 0 % ,支架全部顺利置入。血管狭窄率由 89%± 12 %改善至术后的 5 %± 5 % (直径法 ) ,术后 1个月随访 2 0 2例( 6 9 7% ) ,存活 197例 ,5例于术后 3h～ 7d死亡。 2例死于术后持续低血压 ,1例死于急性左心衰 ,2例猝死。 180例随访 5个月至 4年 ,无事件存活率 (NES) 73 3% ( 132 / 180 )。其中 12 2例行冠状动脉造影复查 ,39例发生支架内再狭窄( 30 3% ) ,37例二次行PCI,2例行CABG ,再狭窄患者中 2例二次PCI后再次发作心绞痛 ,经冠脉造影证实再次再狭窄1例行第 3次PTCA ,1例行CABG。 1例患者术后 2年死于心衰 ,1例术后 3年再发急性心肌梗死 (为支架术相关动脉 )。结论　小血管支架术手术成功率高 ,术后即刻效果好 ,术后主要不良事件率 (死亡、AMI及TLR)未增高 ,术后远期无事件存活率较高 ,再狭窄率较大血管支架     

选择性左冠状动脉主干病变的介入治疗

目的冠状动脉旁路移植术(CABG)是多支血管病变血运重建的最佳方法,是无保护性左冠状动脉主干(LMCA)病变的标准治疗.本研究探讨无保护性LMCA病变介入治疗的疗效和可行性.方法总结分析1996年10月～2000年8月间20例住院的冠心病左主干病变患者接受直接支架术治疗.入选患者例行左室造影(LVEF>45%),冠状动脉血管成形术及其疗效评判采用常规标准,合并右冠脉严重弥漫狭窄病变或前降支(LAD)与回旋支(LCX)同时严重狭窄者不行该术.结果 20例中男17例、女3例,年龄42～71(平均64±12)岁,临床呈心绞痛Ⅱ-Ⅲ级,其中合并高血压9例、糖尿病(2型)1例.冠脉造影显示,左冠脉主干病变呈单纯狭窄者8例,其中近中段狭窄(50%～80%)者6例、开口狭窄(50%～60%)者2例,左主干夹层分离者2例,动脉瘤者1例,合并LAD或LCX病变(狭均>70%)者9例(狭窄50%～70%).全部患者左主干病变均进行直接支架术,其中6例伴LAD或LCX病变者先行PTCA或支架术后再进行左主干病变的支架置入术.置入左主干内的支架均为管状宽径短支架,16例为4.0 mm×9 mm(直径×长度)支架,3例为3.5 mm×9 mm支架,1例冠状动脉瘤者应用4.5 mm×9mm支架.左主干支架术成功率为100%,无残余狭窄或残余狭窄<10%,无任何并发症如支架血栓形成、急性心肌梗死、紧急CABG及死亡等.9例合并LAD(6例)或LCX(3例)狭窄者,先行LAD或LCX的PTCA术,其中3例PTCA术后残余狭窄<20%,5例残余狭窄30%～40%者中2例置入3.0×16mm支架、1例3.5×20mm支架、1例3.0×14 mm支架,1例LCX开口后狭窄(75%)者因PTCA后发生夹层放置3.5×12 mm支架,造影示夹层消失,无残余狭窄.冠状动脉瘤行带膜支架术者造影示瘤体消失,左主干管壁平整.随访1～4年,14例心绞痛发作消失、6例心绞痛复发但显著减轻(心绞痛Ⅰ级),后者有4例于术后半年～1年内复查冠脉造影提示早期再狭窄,其中2例单纯LMCA再狭窄者再次行冠脉血管成形术、2例LMCA合并LAD再狭窄者行CABG手术,无急性心肌梗塞或死亡等严重心脏事件发生,患者均能维持正常生活.结论本研究结果表明,选择性无保护性左冠状动脉主干病变支架术在临床上切实可行、疗效显著,可以是继CABG的另一治疗选择.     

雷帕霉素涂层支架预防支架内再狭窄的研究进展

单纯球囊经皮腔内冠状动脉 (冠脉 )成形术 (PTCA)后有30 %～ 5 0 %的患者发生再狭窄 ,冠脉内支架置入术不仅可以避免球囊扩张后因血管急性弹性回缩造成的急性闭塞 (发生率 4 %～ 8% ) ,防治内膜撕裂 ,减少再次介入治疗和急诊旁路术 ,而且可以抑制PTCA后的血管重构 ,降低远期再狭窄率。但支架本身造成的血管损伤和炎症反应却促进了血管新生内膜增生 ,致使 2 0 %～ 30 %的患者发生支架内再狭窄。支架内再狭窄是当代冠心病介入治疗学的焦点问题 ,近距离放射疗法 (brachytherapy)对其治疗效果肯定 ,但难于预防其发生 ,且有后期血栓形成、“…     

冠状动脉内球囊扩张成形术治疗Gianturco-RoubinⅡ型支架内再狭窄

目的 观察经文冠状动脉腔内成形术(PTCA)治疗Gianturco-RoubinⅡ(GRⅡ)型支架内再狭窄的疗效并探讨其机理.方法和结果 在成功植入GRⅡ型支架后6个月行血管造影,对20例患者的22条支架内再狭窄血管再次行PTCA术.手术成功率为96%(21/22),4例完全闭塞病变中有1例失败是因导丝不能通过闭塞处.无死亡,无急性或亚急性闭塞并发症.定量血管造影显示:平均最狭窄处血管直径从(0.85±0.34)mm增加到(2.32±0.41)mm,平均狭窄程度由(71±16)%下降至(18±12)%,而手术前后支架本身变化不明显.结论 重复PTCA术治疗GRⅡ型支架内再狭窄,安全有效,成功率高,并发症少.管腔扩大的原理主要为动脉样硬化班块组织被挤出支架.     

急诊冠状动脉内支架置入治疗不稳定性心绞痛

目的　探讨在不稳定性心绞痛病人症状未缓解状态下行急诊冠状动脉内支架置入的疗效及安全性。方法　对53例不稳定性心绞痛病人在心绞痛反复发作时即行冠状动脉造影，明确病变后行冠状动脉支架置入术。结果　53处病变置入56个支架，术中无严重并发症，34例心绞痛消失；9例有不典型胸痛，症状在1～2天内消失，无急诊冠状动脉搭桥及死亡。随访3个月～3年,6例冠脉造影证实再狭窄，5例行再次PTCA术后症状消失，1例行PTCA后仍有症状行冠状动脉旁路移植术(CABG)，无死亡病例。结论　冠状动脉内支架置入治疗急性冠状动脉综合征近期及远期效果较好，治疗成功率及安全性较高。     

直接冠状动脉内支架术治疗急性心肌梗塞

目的　评价冠状动脉内支架术治疗急性心肌梗塞的安全性和有效性。方法　 2 8例发病在1 5～ 6 5小时的AMI患者行直接PTCA术 ,其中 2 2例置入冠状动脉内支架 ,成功率 1 0 0 %。梗塞相关血管 (IRA)的TIMI 3级血流恢复率 96 4 % ,无住院死亡。 2例合并出血 ,2例术后急性左心衰。 1 8例术后出院前重复冠脉造影示IRA无血栓形成。术后随访 1 0 1 6个月 ,3例因多支病变再次行PTCA术 ,5例 ( 1 7 8% )复发心绞痛 ,无死亡病例。结论　AMI的直接冠脉内支架术是安全有效的 ,可以改善病人的近期和远期预后。     

A Clinical Trial Comparing Primary Stenting of the Infarct-Related Artery With Optimal Primary Angioplasty for Acute Myocardial Infarction: Results From the Florence Randomized Elective Stenting in Acute Coronary Occlusions (FRESCO) Trial

Objectives. This study sought to compare stenting of the primary infarct-related artery (IRA) with optimal primary percutaneous transluminal coronary angioplasty (PTCA) with respect to clinical and angiographic outcomes of patients with an acute myocardial infarction.Background. Early and late restenosis or reocclusion of the IRA after successful primary PTCA significantly contributes to increased patient morbidity and mortality. Coronary stenting results in a lower rate of angiographic and clinical restenosis than standard PTCA in patients with angina and with previously untreated, noncomplex lesions.Methods. After successful primary PTCA, 150 patients were randomly assigned to elective stenting or no further intervention. The primary end point of the trial was a composite end point, defined as death, reinfarction or repeat target vessel revascularization as a consequence of recurrent ischemia within 6 months of randomization. The secondary end point was angiographic evidence of restenosis or reocclusion at 6 months after randomization.Results. Stenting of the IRA was successful in all patients randomized to stent treatment. At 6 months, the incidence of the primary end point was 9% in the stent group and 28% in the PTCA group (p = 0.003); the incidence of restenosis or reocclusion was 17% in the stent group and 43% in the PTCA group (p = 0.001).Conclusions. Primary stenting of the IRA, compared with optimal primary angioplasty, results in a lower rate of major adverse events related to recurrent ischemia and a lower rate of angiographically detected restenosis or reocclusion of the IRA.     

Late target lesion revascularization after implantation of sirolimus‐eluting stent

Objectives : We evaluated the incidence, clinical presentation, and angiographic in‐stent restenosis (ISR) pattern of late target lesion revascularization (TLR) after sirolimus‐eluting stent (SES) implantation. Background : Late TLR is an unusual finding beyond 6–9 months after bare‐metal stent implantation. However, late TLR after SES implantation has not been sufficiently evaluated. Methods : The study population consisted of 804 patients with 1,020 native lesions that were patent at 6‐month follow‐up angiogram after SES implantation. Results : Late TLR was performed in 18 patients with 18 lesions (1.8%) at 24.1 ± 2.6 months (range; 18–30 months) after SES implantation. Clinical presentation of late TLR patients was silent ischemia in eight patients and recurrent angina in 10 patients, but none had an acute coronary syndrome. Angiographic ISR pattern of late TLR lesions were focal ISR in 12 lesions (67%) and diffuse ISR in six lesions (33%). Serial quantitative coronary angiographic analysis of these lesions showed a minimal lumen diameter of 2.6 ± 0.5 mm immediately after SES implantation, 2.4 ± 0.4 mm at 6‐month follow‐up and 0.7 ± 0.6 mm at 24‐month follow‐up (ANOVA P < 0.001). By stepwise multiple logistic regression analysis, the only independent predictor of late TLR was stent length (P < 0.001, OR = 1.040, 95% CI = 1.019–1.061). Conclusions : Late TLR was performed in 1.8% of 1,020 native lesions that were patent at 6‐month follow‐up angiogram. Clinical presentations of late TLR was either silent ischemia or recurrent angina, but not acute coronary syndrome. Two‐thirds of late TLR lesions had a focal angiographic ISR pattern. © 2007 Wiley‐Liss, Inc.     

Angiographic patterns of in-stent restenosis and implications on subsequent revascularization.

Stent implantation has become the mainstay of percutaneous revascularization for most coronary lesions; in-stent restenosis (ISR) can occur in 6%-40% of stent procedures and the subsequent response to repeat intervention can possibly be predicted by the angiographic patterns of ISR. This study evaluated the incidence and predictors of angiographic patterns of ISR and its impact on subsequent target lesion revascularization (TLR) in 100 consecutive patients having Palmaz-Schatz ISR undergoing intervention. Diffuse ISR (>/=10 mm) was observed in 78% and focal ISR (>10 mm) in 22%. Diffuse vs. focal ISR occurred earlier after stent implantation and was more common in diabetics. Angiographic predictors of diffuse ISR were stent implantation for a restenotic lesion, long lesions, smaller vessel, stenting without debulking, and high-pressure balloon inflation (>16 atm). TLR after repeat intervention was 46% for diffuse and 14% for focal ISR (P < 0.02). Rotational atherectomy resulted in lower TLR (31%) vs. PTCA or restent (64%) in diffuse ISR (P < 0.004). Therefore, diffuse ISR is more common than focal ISR, usually occurs in the setting of aggressive intimal hyperplasia, and can be predicted by clinical and angiographic variables. Also, diffuse intimal hyperplasia within a stent responds poorly to PTCA and may benefit from a more aggressive debulking strategy such as rotational atherectomy. Cathet. Cardiovasc. Intervent. 49:23-29, 2000.     

Long-term angiographic follow-up after successful repeat balloon angioplasty for in-stent restenosis

BACKGROUND: Coronary stent implantation is associated with improved angiographic short-term and mid-term clinical outcome. However, restenosis rate still remains between 20 and 30%. HYPOTHESIS: The purpose of the study, performed as a prospective angiographic follow-up to detect restenosis, was to evaluate the immediate and the 6-month angiographic results of repeat balloon angioplasty for in-stent restenosis. METHODS: From April 1996 to September 1997, 335 stenting procedures performed in 327 patients underwent prospectively 6-month control angiography. Of the 96 lesions that showed in-stent restenosis (> 50% diameter stenosis) (29%), 72 underwent balloon angioplasty. RESULTS: The primary success rate was 100%. Follow-up angiogram at a mean of 6.9 +/- 2.4 months was obtained in 54 patients. Recurrent restenosis was observed in 24 of the 55 stents (44%). Repeat intervention for diffuse and body location in-stent restenosis before repeat intervention was associated with significantly higher rates of recurrent restenosis (p < 0.001 and p < 0.05, respectively). Of the 19 patients who underwent further balloon angioplasty (100% success rate), coronary angiography was performed in 18 (95%) at a mean of 8.2 +/- 2.0 months and showed recurrent restenosis in 12 patients (67%). Further repeat intervention for diffuse and severe in-stent restenosis before the second repeat intervention was associated with significantly higher rates of further recurrent restenosis (p < 0.05 and p < 0.005, respectively). CONCLUSIONS: Although balloon angioplasty can be safely, successfully, and repeatedly performed after stent restenosis, it carries a progressively high recurrence of angiographic restenosis rate during repeat 6-month follow-ups. The subgroup of patients with diffuse, severe, and/or body location in-stent restenosis proved to be at higher risk of recurrent restenosis.     

Is Palmaz-Schatz stenting effective for second restenosis?

The long-term outcome after coronary stent placement in restenotic lesions after balloon angioplasty (percutaneous transluminal coronary angioplasty: PTCA)may be less favorable compared to stent treatment of de novo lesions, but the role of stents in restenotic lesions after 2 prior PTCA procedures is unknown. Elective Palmaz-Schatz stent placement was performed in 124 consecutive patients. Stents were placed in 70 patients(56%) in the native coronary arteries for de novo lesions(de novo group), in 33 patients (27%)for restenotic lesions after one prior PTCA(restenosis group), and 21 patients(17%)for restenotic lesions after 2 prior PTCA(second restenosis group). The 3 groups were well matched with respect to lesion type, lesion length, and reference diameter. Stent size was similar in the 3 groups. Follow-up angiograms taken about 6 months after stenting were available for all patients. The restenosis rate after stenting was similar for the de novo group and restenosis group(19% vs 27%, NS). The second restenosis group tended to have a higher restenosis rate after stenting than the de novo group(38% vs 19%, p = 0.06). The frequency of diffuse type in-stent restenosis of the second restenosis group tended to be higher than that of the de novo group(63% vs 13%, p = 0.08). Our results suggest that the restenosis rate after stenting was higher in patients with repeated restenosis. Therefore, other therapeutic methods should be considered.     

Multiple stent implantation in single coronary arteries: Acute results and six-month angiographic follow-up

A total of 147 stents were implanted (in overlapping manner in 76% of vessels) in a single coronary artery in 59 patients (60 vessels, 97 lesions, 2.45 stents/vessel) over a period of 18 mo using high pressure stent deployment without ultrasound guidance. The indications for stenting were suboptimal percutaneous transluminal coronary angioplasty (PTCA) result (45%), primary prevention of restenosis (44%), acute closure (10%), and restenosis after plain balloon angioplasty (1%). One patient required emergency coronary artery bypass grafting (CABG) (extensive dissection), and one required early intervention with plain balloon angioplasty and intracoronary urokinase for stent thrombosis. There were no deaths. Thirteen patients had recurrence of angina within 6 mo and angiograms were performed in all. These showed intrastent restenosis in nine (all had successful repeat plain balloon angioplasty), development of new disease in other vessels along with restenosis close to the stent in the target vessel in one (underwent elective CABG) and normal angiograms with widely patent stents in three. Forty-five patients (77%) remained free of recurrent angina and 25 of these had follow-up angiograms (56%) at a mean of 172 days, two showing restenosis. Thus, the restenosis rate per patient in the symptomatic group (angiographic follow-up in 100%) was 77% and in the asymptomatic group (angiographic follow-up in 56%) was 8%. The restenosis rate in the subgroup with bailout stenting (n = 6) was 20% (angiographic follow-up in 83%). The overall restenosis rate per patient was 32% (overall angiographic follow-up in 66%). During the 6-mo follow-up period, one patient underwent elective CABG (1.7%), one sustained a non-Q myocardial infarction (1.7%), nine had repeat PTCA to the target vessel (15.5%), and there were no deaths. The event-free survival rate was 77%. Multiple stent implantation aided by high pressure stent deployment without ultrasound guidance and with adjunctive optimal antiplatelet therapy without oral anticoagulation seems to be a useful and effective revascularisation strategy to deal with long lesions and acute dissections with a high procedural success rate. The restenosis rate is acceptable and is not appreciably high as reported in previous studies from the “warfarin era.” Cathet. Cardiovasc. Diagn. 42:158–165, 1997. © 1997 Wiley-Liss, Inc.     

A randomized comparison of repeat stenting with balloon angioplasty in patients with in-stent restenosis

OBJECTIVES: This randomized trial compared repeat stenting with balloon angioplasty (BA) in patients with in-stent restenosis (ISR). BACKGROUND: Stent restenosis constitutes a therapeutic challenge. Repeat coronary interventions are currently used in this setting, but the recurrence risk remains high. METHODS: We randomly assigned 450 patients with ISR to elective stent implantation (224 patients) or conventional BA (226 patients). Primary end point was recurrent restenosis rate at six months. Secondary end points included minimal lumen diameter (MLD), prespecified subgroup analyses, and a composite of major adverse events. RESULTS: Procedural success was similar in both groups, but in-hospital complications were more frequent in the balloon group. After the procedure MLD was larger in the stent group (2.77 +/- 0.4 vs. 2.25 +/- 0.5 mm, p < 0.001). At follow-up, MLD was larger after stenting when the in-lesion site was considered (1.69 +/- 0.8 vs. 1.54 +/- 0.7 mm, p = 0.046). However, the binary restenosis rate (38% stent group, 39% balloon group) was similar with the two strategies. One-year event-free survival (follow-up 100%) was also similar in both groups (77% stent vs. 71% balloon, p = 0.19). Nevertheless, in the prespecified subgroup of patients with large vessels (> or =3 mm) the restenosis rate (27% vs. 49%, p = 0.007) and the event-free survival (84% vs. 62%, p = 0.002) were better after repeat stenting. CONCLUSIONS: In patients with ISR, repeat coronary stenting provided better initial angiographic results but failed to improve restenosis rate and clinical outcome when compared with BA. However, in patients with large vessels coronary stenting improved the long-term clinical and angiographic outcome.     

Rotational atherectomy for in-stent restenosis: acute and long-term results of the first 100 cases

Objectives. This study evaluated the clinical safety and long-term results of rotational atherectomy (RA) followed by low-pressure balloon dilatation (percutaneous transluminal coronary angioplasty [PTCA]) for the treatment of in-stent restenosis (ISR).Background. In-stent restenosis is associated with a high incidence of recurrence after interventional treatment. Because ISR is due to neointimal hyperplasia, rotational ablation may be a more effective treatment than PTCA.Methods. Between November 1995 and November 1996, 100 consecutive patients with first-time ISR were treated by RA. Quantitative coronary angiography and intravascular ultrasound (IVUS) were used to analyze the acute procedural results. The incidence of repeat in-stent restenosis and target vessel revascularization (TVR) at follow-up was determined.Results. Procedural success without any major in-hospital complications was achieved in 100% of cases. Slow flow was observed in 3% and creatine kinase-MB enzyme elevation >3× normal occurred in 2%. The mean burr-to-artery ratio was 0.68 ± 0.18 and adjuvant balloon dilatation was performed at 4.2 ± 2.1 atm. Minimum luminal diameter increased from 0.86 ± 0.28 mm to 1.89 ± 0.21 mm after RA and to 2.56 ± 0.29 mm after adjunct PTCA. Quantitative IVUS analysis showed that 77% of the luminal gain occurred due to rotational ablation of the restenotic tissue and only 23% occurred after adjunct balloon dilation, and further stent expansion did not contribute to the luminal enlargement. At a mean follow-up of 13 ± 5 months, repeat in-stent restenosis occurred in 28% of patients with TVR of 26%. Univariate predictors of repeat restenosis were burr-to-artery ratio <0.6, ISR in <90 days of stenting, ostial lesion, stent for a restenotic lesion and diffuse type ISR.Conclusions. Rotational atherectomy is a safe and feasible technique for treatment of ISR and is associated with a relatively low recurrent restenosis in comparison to historical controls of balloon angioplasty.     

Incidence and predictors of late total occlusion following coronary stenting

To determine the incidence and predictors of total occlusion in‐stent restenosis, we reviewed three randomized stent vs. stent trials and one stent registry, which provided 955 coronary artery lesions with 6‐month angiographic follow‐up. Fifteen (1.6%) of the 955 stented lesions were totally occluded at 6‐month follow‐up. Most patients with total occlusion presented with recurrent angina at the time of repeat angiography (60.0%) while no patient presented with an acute ST segment elevation myocardial infarction. The univariate predictors of total occlusion following elective coronary stenting included stenting for restenosis after a previous percutaneous intervention (P = 0.001), longer stent length (P < 0.001), longer lesion length (P < 0.001), smaller reference vessel diameter (P = 0.022), smaller preprocedure minimum lumen diameter (MLD; P = 0.004), and smaller postprocedure MLD (P = 0.036). Stepwise multiple logistic regression analysis demonstrated that stenting for restenotic lesions (P = 0.004), longer stent length (P < 0.001), and smaller preprocedure MLD (P = 0.012) were independent predictors of total occlusion following coronary stenting. Catheter Cardiovasc Interv 2003;60:344‐351. © 2003 Wiley‐Liss, Inc.     

Optimal coronary balloon angioplasty with provisional stenting versus primary stent (OCBAS): Immediate and long-term follow-up results

Objective. This study sought to compare two strategies of revascularization in patients obtaining a good immediate angiographic result after percutaneous transluminal coronary angioplasty (PTCA): elective stenting versus optimal PTCA. A good immediate angiographic result with provisional stenting was considered to occur only if early loss in minimal luminal diameter (MLD) was documented at 30 min post-PTCA angiography.Background. Coronary stenting reduces restenosis in lesions exhibiting early deterioration (>0.3 mm) in MLD within the first 24 hours (early loss) after successful PTCA. Lesions with no early loss after PTCA have a low restenosis rate.Methods. To compare angiographic restenosis and target vessel revascularization (TVR) of lesions treated with coronary stenting versus those treated with optimal PTCA, 116 patients were randomized to stent (n = 57) or to optimal PTCA (n = 59). After randomization in the PTCA group, 13.5% of the patients crossed over to stent due to early loss (provisional stenting).Results. Baseline demographic and angiographic characteristics were similar in both groups of patients. At 7.6 months, 96.6% of the entire population had a follow-up angiographic study: 98.2% in the stent and 94.9% in the PTCA group. Immediate and follow-up angiographic data showed that acute gain was significantly higher in the stent than in the PTCA group (1.95 vs. 1.5 mm; p < 0.03). However, late loss was significantly higher in the stent than the PTCA group (0.63 ± 0.59 vs. 0.26 ± 0.44, respectively; p = 0.01). Hence, net gain with both techniques was similar (1.32 ± 0.3 vs. 1.24 ± 0.29 mm for the stent and the PTCA groups, respectively; p = NS). Angiographic restenosis rate at follow-up (19.2% in stent vs. 16.4% in PTCA; p = NS) and TVR (17.5% in stent vs. 13.5% in PTCA; p = NS) were similar. Furthermore, event-free survival was 80.8% in the stent versus 83.1% in the PTCA group (p = NS). Overall costs (hospital and follow-up) were US $591,740 in the stent versus US $398,480 in the PTCA group (p < 0.02).Conclusions. The strategy of PTCA with delay angiogram and provisional stent if early loss occurs had similar restenosis rate and TVR, but lower cost than primary stenting after PTCA.