Intravascular ultrasound-guided angioplasty and stenting in a case of transplant coronary artery disease

Allograft vasculopathy in cardiac transplant recipients occurs commonly at 5 years post transplantation. We report a case of post-transplant right coronary discrete stenosis which was treated with balloon angioplasty and stent implantation under intravascular ultrasound guidance.     

Improving results of bailout coronary stenting after failed balloon angioplasty

Stent implantation can be a valuable alternative to emergent bypass surgery to treat established or threatening abrupt closure following coronary balloon angioplasty. To evaluate several sequentially introduced changes in our practice of bail-out stenting, we compared the first (group I) and second half (group II) of our single center experience (n = 88). Use of bailout stenting increased over time (2% of all angioplasty procedures in group I vs. 6% in group II, P < 0.001), more often to prevent rather than to reverse abrupt closure. Technical success of stent implantation was unchanged (95% vs. 93%), and there was a decreasing trend for stent thrombosis (14% vs. 5%), in-hospital death (5% vs. 2%), Q-wave myocardial infarction (9% vs. 7%), and requirement for surgery (9% vs. 7%). The incidence of non-Q-wave myocardial infarction (29% vs. 7% P < 0.01), bleeding complications (27% vs. 7% P < 0.01), and hospital stay duration (11 ± 11 vs. 8 ± 5 days P < 0.05) decreased. Our data suggest that coronary stent implantation is currently an effective stand-alone bailout procedure for a large majority of failed angioplasty procedures. © 1994 Wiley-Liss,Inc..     

Intravascular ultrasound-guided percutaneous transluminal coronary angioplasty with provisional spot stenting for treatment of long coronary lesions.

OBJECTIVES: The purpose of this study was to evaluate the approach of intravascular ultrasound (IVUS)-guided percutaneous transluminal coronary angioplasty (PTCA) with spot stenting (SS) for the treatment of long coronary lesions. BACKGROUND: Treating long coronary lesions with balloon angioplasty results in suboptimal short- and long-term outcomes. Full lesion coverage with traditional stenting (TS) has been associated with a high restenosis rate. METHODS: We prospectively evaluated a consecutive series of 130 long lesions (>15 mm) in 101 patients treated with IVUS-guided PTCA and SS. The results were compared with those of TS in a matched group of patients. Coronary angioplasty was performed with a balloon to vessel ratio of 1:1, according to the IVUS media-to-media diameter of the vessel at the lesion site, to achieve prespecified IVUS criteria: lumen cross-sectional area (CSA) > or =5.5 mm(2) or > or =50% of the vessel CSA at the lesion site. The stents were implanted only in the vessel segment where the criteria were not met. RESULTS: In the SS group, stents were implanted in 67 of 130 lesions, and the mean stent length was shorter than that of lesions in the matched TS group (10.4 +/- 13 mm vs. 32.4 +/- 13 mm, p < 0.005). The 30-day major adverse cardiac event (MACE) rate was similar (5%) for both groups. Angiographic restenosis was 25% with IVUS-guided SS, as compared with 39% in the TS group (p < 0.05). Follow-up MACE and target lesion revascularization rates were lower in the SS group than in the TS group (22% vs. 38% [p < 0.05] and 19% vs. 34% [p < 0.05], respectively). CONCLUSIONS: Intravascular ultrasound-guided SS for the treatment of long coronary lesions is associated with good acute outcome. Angiographic restenosis and follow-up MACE rates were significantly lower than those with TS.     

Early and late results of intracoronary arterial stenting after coronary angioplasty in dogs

Intimal dissection with acute closure represents the major complication associated with percutaneous transluminal coronary angioplasty (PTCA). Intracoronary stent devices offer the possibility of treatment for this sequela. We developed a balloon catheter-mounted, flexible coil stent for use in such cases. To determine the utility of this device and its immediate and long-term influence on arterial patency, 39 mongrel dogs had the stent placed after PTCA of the left circumflex or left anterior descending coronary arteries. Thirteen animals were treated before and after the procedure with warfarin. In this group there were three early deaths associated with stent thrombosis. Twenty-six animals were subsequently treated before and after with aspirin and dipyridamole. There were no early thrombotic events associated with stent placement in these animals. Late arteriographic examination revealed patent vessels in all dogs. Diameter stenosis for warfarin-treated dogs was 8 +/- 5% (mean +/- SD) at 2 months (n = 9), 6 +/- 4% at 6 months (n = 5), and 11 +/- 7% at 12 months (n = 3). Diameter stenosis for aspirin/dipyridamole-treated dogs was 9 +/- 3% at 2 months (n = 8), 8 +/- 5% at 6 months (n = 12), and 5% at 12 months (n = 1). Light and scanning electron microscopic analyses of stented arteries demonstrated incorporation of the stent wires into the arterial wall. Early findings included mild thrombosis localized to areas of wire entrenchment followed by rapid regrowth of endothelial and/or pseudoendothelial cells over trenches, exposed wires, and elastica.(ABSTRACT TRUNCATED AT 250 WORDS)     

经皮冠状动脉腔内成形术及置入支架的长期预后分析

目的探讨经皮冠状动脉腔内成形术（PTCA）和PTCA＋支架治疗对我国冠心病患者的远期疗效。方法对1986年12月～1998年6月期间在我院接受PTCA和PTCA＋支架治疗的938例冠心病患者中的790例进行了随访,随访率84.2%。随访方式包括门诊随访和信访。随访时间为0.9－12.7(3.5±2.4)年。结果随访期中死亡4例(0.5%),非致命性急性心肌梗死22例(2.8%),重复PTCA98例(12.4%),行冠状动脉旁路移植术10例(1.3%)。以Kaplan-Meier法计算术后12年的生存率为99.5%,无心脏事件生存率1年为88.2%,12年为80.6%。Cox回归分析显示,陈旧性心肌梗死病史和是否放置支架与心脏事件呈负相关,而病变支数与心脏事件正相关。与单纯PTCA组比较,PTCA＋支架组急性心肌梗死发生率和再次PTCA率均显著降低。结论PTCA、特别是PTCA＋支架治疗对我国冠心病患者有良好的疗效,可作为血管重建治疗的首选方法。     

Efficacy and safety of direct stenting in coronary angioplasty

BACKGROUND: Direct stenting is the deployment of an intracoronary stent without lesion predilation. Potential advantages include shorter procedural time, lower contrast dose and reduced spiral dissections. There is also the potential financial benefit of less balloon and/or stent usage. Concern still exists among some operators, however, regarding failure of stent deployment and local complications. METHODS: Of 467 consecutive angioplasty cases at the Alfred Hospital between August 1, 1997 and May 22, 1998, direct stenting was attempted in 93 patients (20%). Interventionalist preference determined whether direct stenting was attempted. Vessels with excessive calcification, severe proximal tortuosity or small caliber were typically considered unsuitable for direct stenting. RESULTS: A total of 102 lesions (38 type A, 60 type B, and 4 type C) were treated with direct stenting. Initial deployment was successful in 98 of 102 lesions, with a further 3 lesions successfully stented following predilation. A stent was unable to be deployed in only 1 case; however, the lesion was treated with balloon angioplasty alone. The majority of lesions required only 1 stent (an average of 1.1 stents were used per lesion). Distal complications occurred in 5 patients. In 3 patients, a small distal dissection was successfully stented, and in 1 case embolization of debris occurred down the distal vessel, resulting in a small procedural myocardial infarction. Only 1 patient out of 93 (1%) developed a large distal dissection requiring the deployment of multiple stents, compared with 22 of the remaining 374 patients (5.9%) who underwent conventional angioplasty. This was a significant difference in favor of direct stenting (Chi-square, p < 0.05). When compared with a cohort of patients matched by lesion grade treated with conventional stenting, direct stenting used significantly less contrast per case (154 +/- 7.6 ml compared with 202 +/- 9.5 ml for conventional stenting; p = 0.0001). CONCLUSION: Direct stenting is a safe and effective method for treating coronary artery disease. In appropriately selected cases, it has a low rate of procedural failure and results in less contrast usage and fewer distal complications than conventional angioplasty and stenting.     

经桡动脉PTCA及支架植入术在冠心病中的应用

目的 :评价经桡动脉冠状动脉腔内成形术在冠心病应用的可行性。方法 :选自 1999- 0 3～ 2 0 0 2 - 0 4行经桡动脉冠状动脉腔内成形术 （PTCA） 70 （男 5 6,女 14）例 ,年龄 5 6.8± 8.2岁。结果 :共对 82处病变实施了 PTCA,其中 A型病变 18处 ,B型病变 3 1处 ,C型病变 2 1处 ;置入支架 86枚 ,其中 A型病变 2 2枚 ,B型病变 3 9枚 ,C型病变 2 5枚 ,最短支架为 9m m,最长为 3 5 m m;最小直径为 2 .0 mm,最大为 3 .5 m m。所有病例均为冠状动脉造影后即刻行PTCA,手术成功率 92 .9% （65 / 70 ） ,5例未成功。术后未见桡动脉闭塞及血管并发症。结论 :经桡动脉 PTCA,对患者创伤小 ,恢复快 ,是进行 PTCA的又一安全、可行的选择途径     

Provisional stenting in the real world: results in 1058 consecutive patients undergoing percutaneous coronary angioplasty

OBJECTIVE: To study a strategy of aggressive coronary balloon angioplasty with provisional stenting in allcomers. In randomized trials, stenting has improved the outcome of patients undergoing coronary intervention. However, whether these results hold up in clinical practice is largely unknown. Furthermore, the results of balloon angioplasty have also improved dramatically. It is therefore essential to evaluate the current results of balloon angioplasty and to assess whether stents are required in all patients. METHODS: The authors prospectively studied the occurrence of death, myocardial infarction (MI) and target lesion revascularization (TLR) of a large consecutive group of patients undergoing aggressive balloon angioplasty with provisional stenting. None of the patients received a platelet glycoprotein IIb/IIIa receptor blocker. The results were compared with the outcome of routine stenting in recent randomized trials. RESULTS: Angioplasty was performed in 1058 patients of whom 369 (34.9%) received a stent. The angiographic success rate was 98.9%. During hospital stay, 4.8% of the patients suffered any cardiac event. At one-year follow-up, death occurred in 1.1%, MI in 3.3%, TLR in 12.4% and any event in 16.7% of the patients. Event-free survival at one-year was 82.3%. These results compare favorably with routine stenting in recent trials. CONCLUSIONS: Aggressive balloon angioplasty with provisional stenting yields excellent results in a general patient population.     

Intravascular ultrasound findings after excimer laser coronary angioplasty

Intravascular ultrasound (IVUS) was used to study 104 lesions in 98 patients after excimer laser coronary angioplasty (ELCA). Lesion site external elastic membrane (EEM) and lumen cross-sectional areas (CSA) were measured; plaque + media (P + M = EEM − lumen) CSA and percentage of cross-sectional narrowing (CSN = P + M CSA/EEM CSA) were calculated; and the results were compared to a reference site. The lumen CSA (2.6 ± 1.0 mm²) averaged 24% larger than the cross-sectional area of the largest laser catheter used, and 64 lesions (62%) fit the definition of arterial expansion (lesion EEM CSA > reference site EEM CSA). The residual percentage of cross-sectional narrowing averaged 83.8 ± 8.8%. Dissections were present in 44% of lesions, and were more common in lesions with superficial calcium (59%) than in lesions with only deep calcium (31%) or no calcium (20%, P = 0.0102). Dissections of superficial calcified plaque had an unusual “shattered” or “fragmented” appearance. These findings suggest that excimer laser angioplasty causes forced vessel expansion with dissection, but limited atheroablation. © 1996 Wiley-Liss, Inc.     

Improving the results of coronary angioplasty

Coronary angioplasty has changed dramatically in the past three years with major reductions in suboptimal results and restenosis rates, and improvements in safety, efficacy and cost-effectiveness. Intracoronary stent implantation with optimisation of strut expansion and the abandonment of anticoagulants after deployment, have led to less entry-site complications, facilitated early hospital discharge, virtually abolished subacute stent thrombosis and resulted in a 50% reduction in target vessel revascularisation. Adjuvant medical treatment with anti-platelet agents, including glycoprotein IIb/IIIa receptor inhibitors, improves the safety of angioplasty and may further reduce the restenosis rate. Selective use ofdebulking devices has extended the indications for angioplasty. High resolution fluoroscopy, quantitative coronary angiography and intracoronary ultrasound leading to improved diagnosis, equipment selection and treatment have contributed to better outcomes. Further clinical trials will compare angioplasty and stent implantation with coronary bypass surgery in patients with multivessel coronary disease, and may extend the indications for percutaneous transluminal coronary angioplasty (PTCA) to selected patients with three vessel disease.     

经皮冠状动脉成形术和支架植入术后血小板活化状态变化

目的观察PTCA组和Stenting组的冠心病患者术前术后血小板活化状态变化，探讨其临床意义。方法分别采用酶免疫法测定和放免疫法测定两组各30例患者术前术后血浆11－DH－TXB2和血小板内cAMP浓度。结果术前两组病人血浆11－DH－TXB2水平无显著差别，术后均降低，尤以支架为明显。结论支架植入术后其急性或亚急性闭塞风险大于PTCA，故需要慎重的抗血小板治疗。     

Intravascular ultrasound catheter entrapment after coronary artery stenting.

Intracoronary ultrasound (IVUS) facilitates optimal stent deployment in the treatment of coronary artery disease, which may favorably improve long-term outcome after stenting. Complications associated with IVUS include coronary vasospasm and rarely more serious adverse events such as vessel perforation or stent deformation. We report an IVUS catheter tip entrapment within a self-deploying nitinol stent.     

Intravascular ultrasonic predictors of angiographic restenosis after long coronary stenting

The intravascular ultrasound (IVUS) criteria for stent optimization have not been determined in stenting long lesions. We evaluated the predictors of angiographic restenosis and compared it with stent lumen cross-sectional area (CSA) and stent length between short (stent length <20 mm) and long (> or =20 mm) coronary stenting. IVUS-guided coronary stenting was successfully performed in 285 consecutive patients with 304 native coronary lesions. Six-month follow-up angiogram was performed in 236 patients (82.8%) with 246 lesions (80.9%). Results were evaluated using conventional (clinical, angiographic, and IVUS) methods. The overall angiographic restenosis rate was 22.8% (56 of 246 lesions) (short stent 17.6% vs. long stent 32.2%, p = 0.009). Using multivariate logistic regression analysis, the independent predictors of angiographic restenosis were the IVUS stent lumen CSA (odds ratio 1.51, 95% confidence intervals 1.18 to 1.92, p = 0.001) and stent length (odds ratio 0.95, 95% confidence intervals 0.91 to 1.00, p = 0.039). The angiographic restenosis rate was 54.8% for stent lumen CSA of <5.0 mm2 (short stent 37.5% vs. long stent 73.3%, p = 0.049), 27.4% for CSA between 5.0 and 7.0 mm2 (short stent 24.1% vs. long stent 31.7%, p = 0.409), 10.5% for CSA between 7.0 and 9.0 mm2 (short stent 10.0% vs. long stent 12.5%, p = 0.772), and 11.4% for stent lumen CSA of > or =9.0 mm2 (short stent 10.4% vs. long stent 13.3%, p = 0.767) (p = 0.001). Compared with short coronary stenting, long coronary stenting is effective treatment modality to cover long lesions with comparable long-term clinical outcomes in cases of stent lumen CSA of > or =7.0 mm2. Regardless of the stent length, the most important factor determining angiographic restenosis was the IVUS stent lumen CSA in relatively large coronary artery lesions.     

老年冠心病患者经皮冠状动脉腔内成形术结果评价

目的评价一组老年冠心病患者行经皮冠状动脉腔内成形术（ＰＴＣＡ）的疗效。方法将６５例老年（８９支血管）和１１７例老年前期（１４９支血管）冠心病患者的ＰＴＣＡ结果作对比研究。结果老年组血管扩张成功率９４．４％，临床成功率９２．３％，主要并发症发生率为６．１％，再狭窄发生率为３２．５％。以上结果与老年前期组比较差异均无显著性。术后症状改善率两组相同，都在９０．０％以上。仅老年组再次ＰＴＣＡ频率明显高于老年前期组（ｘ２检验，Ｐ值＜０．０５）。结论对于老年冠心病患者，ＰＴＣＡ是一种有效及安全的冠脉血管重建措施。     

经皮冠状动脉内成形术与支架术的临床应用（附103例报告）

103例冠心病患者行经皮冠状动脉内成形术(PTCA),其中96例置入支架135枚,成功率100%,未出现明显并发症.PTCA所用的球囊直径平均为2.48±0.43mm,平均长度20.40±2.84mm,球囊所加压力平均为6.23±1.81atm.支架直径平均为3.96±0.38mm,平均长度为21.29±6.30mm,释放支架时球囊所加压力平均为9.65±3.08atm.所用支架主要是BX45枚(33.33%),NIR30枚(22.22%),AVE27枚(20.00%),MAC16枚(11.85%),Jomed和其他共17枚(12.59%).支架置入LAD内71枚(52.59%),RCA内48枚(35.55%),LCX和Diag16枚(11.85%).     

Limited role of coronary angioplasty and stenting in coronary spastic angina with organic stenosis

OBJECTIVES: We investigated the efficacy of percutaneous coronary intervention (PCI) in patients with coronary spastic angina (CSA) and severe organic stenosis. BACKGROUND: Coronary spasm occurs at the site of organic stenosis in most patients with CSA and severe stenosis, whereas multivessel spasm occurs frequently in those with normal coronary arteries. The incidence of multivessel spasm and the efficacy of PCI in patients with CSA and severe stenosis have not been fully elucidated. METHODS: Forty-five patients with CSA and severe stenosis underwent spasm provocative testing with intracoronary acetylcholine before and 7 +/- 3 months after PCI (20 patients had angioplasty and 25 patients had stenting), when all patients were free of restenosis. RESULTS: Spasm was induced at the site of severe stenosis in 30 patients (66.7%) with (n = 12) or without (n = 18) spasm induced in another vessel. In the remaining 15 patients, spasm was induced at a different site in the stenotic vessel and/or in another vessel. Repeat provocative tests were performed in 43 of 45 patients. Although spasm was never induced at exactly the same site of the initial stenosis that had been dilated, spasm was induced at a different site in the dilated vessel and/or in another vessel, in 33 (76.7%) of 43 patients. Multivessel spasm occurred in 28 (62.2%) of 45 patients on one or both provocations. CONCLUSIONS: Spasm was frequently induced at a site different from the initial stenosis, even in the absence of restenosis after PCI. Calcium antagonists should be continued in most patients with CSA who show no restenosis after PCI.