Percutaneous transluminal angioplasty of radial artery grafts

The radial artery is being used with increasing frequency to replace the saphenous vein as a coronary artery bypass graft, in the belief that it will provide improved long-term patency. Several centers have confirmed that the early results of surgery using the radial artery seem to be better than those obtained with saphenous grafts. Despite these apparent gains, early failure of the radial artery graft can occur and is frequently associated with symptomatic myocardial ischemia. Percutaneous angioplasty is an alternative to reoperation to treat lesions occurring on radial artery grafts. We report on 4 patients who underwent angioplasty of radial artery grafts. Cathet. Cardiovasc. Diagn. 45:400–404, 1998. © 1998 Wiley-Liss, Inc.     

Endoluminal stenting of narrowed saphenous vein grafts: long-term clinical and angiographic follow-up

From April 1986 through April 1993, 58 intracoronary stents (41 Wall and 17 Wiktor stents) were implanted for the treatment of saphenous vein graft stenosis in 40 symptomatic patients. The indication was a primary stenosis in 44 and restenosis in 14 procedures. In-hospital complications were subacute stent thrombosis (2%), myocardial infarction (2%), and emergency coronary artery bypass grafting (CABG) (2%). Complications during a mean follow-up period of 42±27 months were restenosis (35% by patient, 33% by lesion), myocardial infarction (12%), late bypass grafting (12%), and death (7%). On quantitative coronary angiographic analysis, the mean minimal luminal diameter (and its confidence interval) increased from 1.3 mm (1.1–1.5 mm, preprocedure) to 2.9 mm (2.7–3.1 mm, postprocedure) and 2.2 mm (2.0–2.5 mm, 6 months follow-up, 95% angiographic follow-up). Progression of the underlying coronary artery disease and restenosis were the main reasons for a continual decline of the proportion without cardiac event on a Kaplan-Meier estimate. Restenosis occurred in one-third of cases beyond the first 6 months of follow-up. A relative risk ratio analysis for restenosis, performed on 14 variables, disclosed an increased risk for the following variables: (1) stenting of the proximal, distal or anastomosis part of the vein graft (relative risk 2.41, confidence interval: 1.28–3.59), (2) the implantation of stents <4.5 mm (2.59, 1.18–4.00), and (3) stenting of a redo–CABG vein graft (2.37, 1.17–3.58). Saphenous vein graft stenting seems to be characterized by excellent immediate clinical and angiographic results; in particular, stent thrombosis is rare. In this study, it appears that restenosis rates are lower than after conventional balloon angioplasty, but several procedural factors are related to an increased restenosis risk. Despite a lasting success in the majority of stented lesions, the estimated proportion without cardiac event is low at 5 years follow-up. Progression of the underlying coronary artery disease, a non-procedure-related event, constitutes the major limitation of saphenous vein graft stenting. © 1994 Wiley-Liss,Inc..     

Clinical outcomes following stent implantation in internal mammary artery grafts.

We evaluated our experience with percutaneous coronary intervention (PCI) of internal mammary artery (IMA) grafts. From the institution's database we identified 288 patients with 311 IMA lesions. Of these, 82 (26.4%) had stents placed during PCI. Angiographic success was 92%. Mortality at 1 month was 1.7%, myocardial infarction (MI) 15.7%, and target lesion revascularization (TLR) 0.4%. Cumulative 1-year event rates were mortality 6.4%, MI 20.4%, and TLR 8.0%. TLR rates were significantly higher in the stented lesions than lesions treated with angioplasty alone (19.2% vs. 4.9%; P = 0.004). The higher TLR rate in stented lesions was most apparent at the anastomotic site (25.0% vs. 4.2%; P = 0.006). Percutaneous revascularization of IMA grafts can be performed safely with high procedural success and excellent short- and long-term results. Stenting, particularly at the anastomotic site, was associated with significantly greater rates of TLR than angioplasty alone.     

Percutaneous treatment of symptomatic vertebral artery stenosis with coronary stents.

Atherosclerotic disease of the vertebral artery can pose a significant clinical problem. The treatment of that disease is not uniformly accepted. We report two cases of patients with vertebral basilar insufficiency due to stenosis of the vertebral artery origins and contralateral occlusions that were treated percutaneously with coronary stent placement.     

LPYP20压迫止血器和Medplus桡动脉止血带在经皮冠状动脉介入治疗后的止血效果对比

目的比较LPYP20压迫止血器和Medplus桡动脉止血带在经皮冠状动脉介入治疗后桡动脉止血中的安全性、有效性及优缺点。方法经桡动脉行经皮冠状动脉介入治疗的患者116例,电脑数字随机法分成两组,其中64例采用LPYP20压迫止血器,52例采用Medplus桡动脉止血带。观察两组术后止血情况、桡动脉闭塞及局部并发症情况并进行对比。结果两组术后均能成功止血。两组在出血及桡动脉闭塞方面比较,差异无统计学意义(P0.05);在包扎远端肿胀、麻木、皮肤破损方面,Medplus桡动脉止血带优于LPYP20压迫止血器[17.3%(9/52)vs.35.9%(23/64),P0.05;13.5%(7/52)vs.32.8%(21/64),P0.05;1.9%(1/52)vs.12.5%(8/64),P0.05]。结论两种压迫器均能成功达到止血目的 ,但Medplus桡动脉止血带对周围组织压迫更少,对皮肤损伤更小。     

Percutaneous revascularization of the common femoral artery for limb ischemia.

We performed percutaneous transluminal intervention in 20 consecutive patients (21 limbs) with common femoral artery (CFA) lesions causing symptomatic limb ischemia. In 12 limbs, concurrent additional percutaneous intervention proximal or distal to the target CFA lesion was performed. Angiographic success was obtained in 100%, with procedural success (angiographic success without a major in-hospital complications) in 90% and clinical success (procedural success and in-hospital improvement by at least one Fontaine functional class) in 81% of the limbs. The in-hospital Fontaine class improved by at least one functional class in 17 of 19 patients (89%), and the overall in-hospital event-free survival was 90% (18 of 20 patients). At follow-up (11.4 +/- 6 months), the overall event-free survival was 90% (18 of 20 patients) and 17 of 19 patients (89%) continue to show improvement by at least one functional (Fontaine) class. Percutaneous intervention of the CFA can be performed with a rate of high technical success and a low complication rate. It provides excellent clinical results at mid-term follow-up and appears to be a reasonable alternative to surgical therapy in patients at high risk for surgery.     

Percutaneous transluminal angioplasty of ostial lesions of internal mammary artery grafts.

The internal mammary artery (IMA) is currently the best graft for coronary bypass surgery and is therefore preferentially anastomosed to major arteries, usually the left anterior descending (LAD) artery. This graft may develop a stenosis, most often at the distal anastomosis. Ostial stenoses are rare and their pathophysiology uncertain. While angioplasty of distal anastomotic lesions provides adequate results, the very small number of published cases of angioplasty of ostial lesions explains the lack of knowledge on results of this type of procedure. The authors report six procedures of this type on five patients, including two with stenting. The primary success rate was 100%, with only one hospital complication in the form of pulmonary edema. Mean follow-up for 35 months revealed one sudden death due to probable restenosis, another death 3 years after angioplasty from rapid fatal shock without complementary investigation, and one case of unstable angina secondary to intrastent restenosis. These results suggest that this type of angioplasty is technically feasible with low risk, and that the restenosis rate seems relatively high, potentially presenting as sudden death, in the same way as unprotected dilatation of the native left main artery. A very close clinical follow-up of these patients is therefore necessary, with angiographic control in case of suspected ischemia.     

Arterial autologous graft-stent for treatment of coronary artery disease: A new technique

The radial artery has been used as a free bypass graft with excellent results. An autologous vein graft-coated stent, a novel type of stent developed at our institution, has been applied successfully under both experimental and clinical conditions. To extend the spectrum of biological linings for coated stents, we used an arterial graft. We describe the first application of the radial artery as an autologous coating for a conventional stent to be used in treatment of coronary artery disease. Cathet. Cardiovasc. Diagn. 40:302–307, 1997. © 1997 Wiley-Liss, Inc.     

经桡动脉植入Firebird药物支架86例临床观察

目的 观察经桡动脉途径植入Firebird药物支架在冠状动脉性心脏病(冠心病)介入治疗中的安全性和有效性.方法 回顾性分析86例经桡动脉途径植入国产药物洗脱支架冠心病患者的临床资料,观察术中并发症发生率、术后随访主要心血管不良事件发生率和血管再狭窄率.结果 共植入国产药物洗脱支架113枚.86例患者住院期间无血栓形成和临床随访无主要心血管事件发生,术后6个月冠状动脉造影复查无支架内再狭窄.结论 经桡动脉途径在冠心病介入治疗中安全有效,国产药物支架近期能够有效预防冠状动脉介入治疗后血管再狭窄.     

Incidence and outcome of radial artery occlusion following transradial artery coronary angioplasty

Coronary angioplasty with 6F guiding catheters via the radial artery is associated with a minimal risk for major entry site-related complications. Although the incidence of radial artery occlusion (RAO) in the literature is approximately 30% after prolonged cannulations, little is known about the incidence and its clinical consequences of RAO following transradial percutaneous coronary angioplasty. In a prospective study, 563 patients with a normal Allen test were evaluated on patency and function of the radial artery after transradial angioplasty, by physical and ultrasound examination at discharge, and at 1 month follow-up. At discharge, 30 patients (5.3%) had clinical evidence of RAO. At follow-up, persistent RAO was found in 16 patients (2.8%). In this study we found a low incidence of RAO after transradial percutaneous coronary angioplasty. None of the patients with temporary or persistent RAO had any major clinical symptoms. Therefore, the occurrence of RAO can be considered a minor complication in patients with a previously good double blood supply to the hand. Cathet. Cardiovasc. Diagn. 40:156–158, 1997. © 1997 Wiley-Liss, Inc.     

冠状动脉旁路移植术和药物支架植入术远期疗效的比较

目的比较冠心病患者非药物治疗手段冠状动脉旁路移植术（CABG）和经皮冠状动脉介入治疗（PCI）术后的桥血管和支架的再通率。方法CABG术后和药物支架植入术后再次出现心绞痛症状的冠心病患者各40例,其年龄、性别、心肌梗死、高血压、高脂血症、心功能不全、脑卒中、药物治疗病史具有可比性。通过冠状动脉造影术比较两组患者的桥血管和药物支架的效率和寿命的远期效果。结果与行CABG患者的桥血管比较,行PCI患者的药物支架远期狭窄或者闭塞率降低34．3％。与行CABG患者的左乳内动脉（LIMA）桥血管比较,行PCI患者的左前降支的药物支架远期狭窄或者闭塞率降低14．8％。与行CABG患者的左回旋支和右冠状动脉静脉桥血管比较,行PCI患者的左回旋支以及右冠状动脉的药物支架远期狭窄或者闭塞率降低49．8％。结论冠状动脉药物支架植入术的远期通畅率较CABG明显增高,冠状动脉药物支架植入术的药物支架的效率和寿命要优于CABG的桥血管。     

Clinical and angiographic outcomes after overdilatation of undersized sirolimus-eluting stents with largely oversized balloons: an observational study.

The purpose of this study was to assess the safety and effectiveness of sirolimus-eluting stent (SES) postdilatation with largely oversized balloons. We evaluated the clinical outcome of 68 consecutive patients enrolled in the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) registry who underwent percutaneous coronary intervention with SES implantation and further postdilatation with balloons > 1 mm larger than the stent nominal size. Angiographic follow-up was either scheduled for selected subgroups or clinically driven. Overall, 75 lesions were treated. The procedure was successful in 98.5% of the cases. One patient (1.5%) underwent emergency coronary bypass surgery for acute vessel occlusion. During 10.1 +/- 1.7 months of follow-up, three patients (4.5%) died, one (1.5%) had acute myocardial infarction, and four (6%) had target vessel revascularization. At angiographic follow-up, loss index was 0.13 +/- 0.34 and restenosis rate was 7.7%. Although not routinely recommended in every patient, SES postdilatation with largely oversized balloons appears a safe and effective strategy for selected patients.     

Renal frame count: a quantitative angiographic assessment of renal perfusion.

Renal perfusion may be measured by a variety of noninvasive methods; however, there is no objective angiographic method to assess renal perfusion. We measured the renal frame count (RFC) in 26 patients (50 kidneys) with normal renal function and normal renal angiograms and 9 patients (15 kidneys) with renal artery fibromuscular dysplasia (FMD) and normal renal function. The mean age of the patients with normal renal arteries was 61.5 +/- 9.5 (range, 47-82 years) and the mean age of patients with FMD was 72.5 +/- 9.2 (range, 54-86 years; P = 0.005). There was no correlation between the age and RFC in both the normal renal artery group and the FMD group. The mean RFC for the normal renal arteries was 20.4 +/- 3 (95% CI = 19.5-21.2), which was significantly lower than the FMD group's mean RFC of 26.9 +/- 9.9 (95% CI = 21.4-32.4; P = 0.0001). RFC is an objective angiographic measure to quantify renal perfusion. Compared to normal renal arteries, those with FMD had significantly increased RFC consistent with decreased perfusion.     

老年女性患者经桡动脉和股动脉途径行冠状动脉介入治疗的对比分析

目的评价老年女性患者经桡动脉和股动脉途径行PCI的安全性和临床效果。方法选择行PCI、年龄≥75岁的老年女性患者332例,按手术入径方式分为桡动脉组184例和股动脉组148例,回顾性分析患者的临床资料。冠状动脉造影检查显示,冠状动脉狭窄≥75%者行冠状动脉支架置入术。比较桡动脉和股动脉途径介入治疗临床疗效。结果 332例患者中有96例接受PCI,桡动脉组和股动脉组患者3支病变比率分别为39.7%和47.4%,分叉病变比率分别为60.3%和52.6%。与桡动脉组比较,股动脉组患者手术时间长,外周血管损伤明显增多(P0.05),术后观察时间及卧床时间明显延长,假性动脉瘤、下肢静脉血栓例数明显增多,穿刺动脉闭塞明显减少(P0.05)。结论老年女性患者自身病情复杂,选择桡动脉途径行PCI可以减少局部血管并发症,近期治疗风险小,病死率低,可取得较理想疗效。     

经桡动脉行无保护左主干病变介入治疗

目的:回顾性总结29例冠状动脉造影发现为无保护左主干开口及体部狭窄病例的冠脉介入治疗(PCI)资料,以探讨手术的安全性和可行性。方法:术前给予常规药物治疗,经桡动脉途径行PCI,观察桡动脉穿刺成功率、PCI即刻成功率、手术时间、支架扩张时间和扩张压力、住院期间严重并发症发生率、出院前心绞痛发作情况评估及术前心电图(ECG)特点分析。结果:29例患者桡动脉穿刺成功率和PCI即刻成功率均为100%,手术时间25～50(38±8)min,支架扩张时间3～7(5±1.3)s,支架扩张压力14～20(16.0±1.9)atm(1atm=101.325kPa),住院期间无严重并发症发生,前臂肿胀3例,术后心绞痛显著缓解。术前胸痛发作时ECG特点:典型"左主干"心电图17例,胸前导联ST-T改变者10例,间歇性左束支阻滞2例。结论:经桡动脉途径对无保护左主干开口和体部病变行PCI治疗,成功率高,安全有效。     

In-hospital outcomes of contemporary percutaneous coronary interventions in the very elderly.

Coronary heart disease is the leading cause of death among the elderly (> 65 years) and the very elderly (> 85 years). Little information is available regarding the outcome of very elderly patients referred for PCI in the current era of improved techniques, devices, and pharmacotherapy. The objective of the current study was to evaluate the clinical characteristics and outcomes of very elderly patients > or = 85 years of age in a large, contemporary, multi-institutional PCI database. Five hospitals in the New York City metropolitan area contributed these prospectively defined data elements on consecutive patients undergoing PCI from 1 January 1998 to 1 October 1999. Of 10,847 patients, 5,341 (49%) were younger than 65 years, 3,342 (31%) were 65-74 years, 1,885 (17%) were 75-84 years, and 279 (2.6%) were at least 85 years of age. Following PCI, the very elderly developed stroke (P < 0.001) and renal failure requiring dialysis (P = 0.002) more commonly than younger patients following PCI. The very elderly had a significantly increased in-hospital mortality rate at 2.5% (P < 0.001). However, on multivariate analysis, age > or = 85 years was not an independent predictor of in-hospital mortality (OR = 1.22; 95% CI = 0.37-4.07). The very elderly should not be refused PCI on the basis of advanced age alone.     

Calculated mean arterial pressure in the posterior tibial and radial artery pressure wave in newbown infants

Mean arterial pressure (MAP) is the area under the pressure wave averaged over the cardiac cycle, and therefore depends on pressure wave contour. A generally used rule of thumb to estimate MAP of peripheral arteries in adults is adding one-third of the arterial pulse pressure (PP) to diastolic arterial pressure (DAP). As peripheral pressure wave forms in neonates do not resemble adult peripheral wave forms, it may be expected that this rule of thumb does not hold for neonates. Previously, we found that MAP can be calculated by adding 50% PP to DAP in radial artery waves in neonates. In the present study, we investigated in neonates how MAP in the posterior tibial artery depends on systolic and diastolic pressure and we compared these findings to those found in the radial artery. Forty infants admitted for intensive care were studied. We analyzed 5000 invasively and accurately obtained blood pressure waves in the posterior tibial artery of 20 neonates and another 5000 waves similarly obtained from the radial artery in another group of 20 neonates. We found that MAP in posterior tibial artery waves is well approximated by adding 41.5±2.0% of PP to DAP, whereas MAP in radial artery waves can be calculated by adding 46.7±1.7% of PP to DAP. These values are significantly different (p<0.0001). In conclusion, the rule of thumb as used in the adult to find MAP, where 33% PP is added to DAP, does not hold for the newborn. We recommend to calculate MAP in the tibial artery by adding 40% of PP to DAP and in the radial artery by adding 50% of PP to DAP.Abbreviations ABP Arterial Blood Pressure - SAP Systolic Arterial Pressure - DAP Diastolic Arterial Pressure - MAP Mean Arterial Pressure - PP Pulse Pressure - MAP% (MAP-DAP)/(SAP-DAP)x100% i.e. the level of the MAP in the wave, expressed in % PP - IRDS Idiopathic Respiratory Distress Syndrome - PDA Patent Ductus Arteriosus     

Elective sirolimus-eluting stent implantation for left main coronary artery disease: six-month angiographic follow-up and 1-year clinical outcome.

The effectiveness of sirolimus-eluting stent (SES) implantation in patients treated electively for left main (LM) stenoses has not been yet ascertained. The present study reports on the clinical and angiographic outcome of 16 consecutive patients treated electively for de novo stenoses in the LM. The impact of SES implantation on major adverse cardiac events was evaluated. Mean age was 65 +/- 11 years. Unprotected LM was present in nine (56%), and eight patients (50%) received stents extending into both the left anterior descending and circumflex arteries for stenoses of the distal left main bifurcation. In-house mortality and reintervention rate was zero. One patient developed a non-Q-wave myocardial infarction related to the index procedure. At 1-year clinical follow-up, there were no deaths or further myocardial infarctions; one (6%) patient required target lesion revascularization. A total of 12 patients (75%) underwent 6-month angiographic follow-up with a late lumen loss of 0.04 +/- 0.65 mm and one focal restenosis (8% of patients). Elective SES implantation for LM disease was associated with zero mortality and a very low incidence of additional major adverse events at 1 year.     

Percutaneous coronary intervention with drug-eluting stents in octogenarians: characteristics, clinical presentation, and outcomes.

OBJECTIVES: We aimed to compare clinical outcomes of octogenarians > or =80 years of age after coronary drug-eluting stent (DES) implantation. BACKGROUND: Although octogenarians constitute a fast-growing portion of cardiovascular patients, they are not adequately represented in current clinical revascularization trials. METHODS: We analyzed the data of 3,166 consecutive patients who underwent percutaneous coronary intervention (PCI) and DES implantation since March 2003. Periprocedural events, 1- and 6-month clinical outcomes were compared between octogenarians (n = 339) and patients <80 years of age (n = 2,827). RESULTS: Baseline characteristics revealed a higher prevalence of females (P < 0.001), Caucasians (P = 0.004), chronic renal failure (P < 0.001), heart failure (P < 0.001), number of diseased vessels (P = 0.009), and lower ejection fraction (P = 0.03) in octogenarians. Patients <80 years showed more positive family history (P < 0.001), hyperlipidemia (P = 0.006), smoking (P < 0.001), and obesity (P < 0.001). Clinical presentation and procedural success were similar in both groups as were death, myocardial infarction (MI), and repeat revascularization in-hospital. At 6 months, restenosis rates were low and comparable. In the subgroup of octogenarians who presented with acute coronary syndrome, mortality (15% vs. 3%, P < 0.001) and Q-wave MI occurred more often. Multivariate analysis revealed age >80 (P = 0.008), cardiogenic shock (P < 0.001), Q-wave MI at presentation (P = 0.003), and length of hospital stay (P = 0.003) to be independent predictors of mortality. CONCLUSIONS: PCI with DES in octogenarians results in a similar reduction of restenosis rates when compared to patients <80 years. Yet in octogenarians who presented with acute coronary syndrome, incidence of mortality and Q-wave MI at 6 months was higher as compared to younger patients.     

New device for compression of the radial artery after diagnostic and interventional cardiac procedures

Recently the transradial route has emerged as a valuable alternative to the femoral approach for coronary angiography and angioplasty. However, sheath and catheter size and their immediate removal after the procedure, combined with aggressive antiplatelet and anticoagulant therapies, have favored mechanical compression of the radial artery to achieve satisfactory hemostasis. We report on our initial clinical experience with a new device specially designed for prolonged controlled mechanical compression of the radial artery (the RadiStop™ radial compression system, RADI Medical Systems AB, Uppsala, Sweden). A total of 159 consecutive patients (mean age 60 ± 11 yr, 130 males) who required either coronary angiography (group 1, 103 patients) or ad hoc or elective coronary angioplasty (group 2, 56 patients) via the right radial route had local hemostasis with the RadiStop™ system. In group 1, 4F and 5F sheaths and catheters were used, whereas in group 2, 6F systems were inserted in the radial artery. Hemostasis was achieved with the device in all patients but was considered difficult to obtain in 4 patients (2.5%). Twenty-eight patients (18%) considered the device uncomfortable or painful, but no release of pressure was necessary. The mean compression time was 151 ± 82 min (114 ± 64 min in group 1, and 223 ± 64 min in group 2; P = 0.0001). There were 23 local complications (15%). In 7 patients (4.4%), the radial pulse was absent after compression and at discharge, without major clinical consequences. In one patient, recurrent bleeding occurred 2 hr after compression, requiring a new compression session. In 15 patients, a small local hematoma was observed. Neither heparin dosage nor the use of a 6F sheath affected the rate of radial artery patency in this survey. We conclude that the use of this device for mechanical compression of the radial artery after coronary angiography and angioplasty is efficient, and that its use is related to an acceptable rate of local complications. Cathet. Cardiovasc. Diagn. 40:297–300, 1997. © 1997 Wiley-Liss. Inc.