Probe, a balloon wire: initial experience

Coronary angioplasty is unsuccessful in less than 3-5% of cases because the balloon catheter fails to follow a guidewire that has traversed a lesion. Between June 1986 and August 1987, 31 lesions were unable to be crossed with at least two standard angioplasty catheters. Finally, a 2.0-mm-diameter Hartzler LPS (ACS) was utilized and successfully crossed and dilated 16 out of 31 lesions (52%). In the remaining 15 lesions, the Probe (USCI) 2.0 mm diameter x 1.5 cm long balloon wire was able to cross the lesions in 13 (82%) and successfully dilated 12. In one case, lesion rigidity prevented the balloon from expanding at 14 atm. A right coronary artery lesion was attempted in 11 cases, and a left anterior descending and circumflex artery lesion in two patients each. No complications were encountered. In seven out of 12 successful Probe cases, a larger balloon catheter was used to further dilate the artery. This new balloon wire has increased our success rate in severe stenoses and in tortuous vessels with severe distal lesions, in which presently available angioplasty equipment has failed.     

Probe™, a balloon wire: Initial experience

Coronary angioplasty is unsuccessful in <3–5% of cases because the balloon catheter fails to follow a guidewire that has traversed a lesion. Between June 1986 and August 1987, 31 lesions were unable to be crossed with at least two standard angioplasty catheters. Finally, a 2.0-mm-diameter Hartzler LPS (ACS) was utilized and successfully crossed and dilated 16 out of 31 lesions (52%). In the remaining 15 lesions, the Probe^TM (USCI) 2.0 mm diameter × 1.5 cm long balloon wire was able to cross the lesions in 13 (82%) and successfully dilated 12. In one case, lesion rigidity prevented the balloon from expanding at 14 atm. A right coronary artery lesion was attempted in 11 cases, and a left anterior descending and circumflex artery lesion in two patients each. No complications were encountered. In seven out of 12 successful Probe^TM cases, a larger balloon catheter was used to further dilate the artery. This new balloon wire has increased our success rate in severe stenoses and in tortuous vessels with severe distal lesions, in which presently available angioplasty equipment has failed.     

High speed rotational coronary atherectomy for patients with diffuse coronary artery disease

High speed rotational coronary atherectomy was undertaken using the Rotablator in 42 patients who were suboptimal candidates for balloon angioplasty. Most patients (71%) had diffuse coronary artery disease, defined as a stenosis greater than 1 cm in length. Previous restenosis after balloon angioplasty was present in 21% and 10% had an ostial lesion. Adjunctive balloon angioplasty was not used to reduce residual stenosis after atherectomy. The procedure was successful in 76% of patients. Procedural success was achieved in 92% of patients with a lesion less than or equal to 1 cm in length, but in only 70% of patients with a lesion greater than 1 cm in length (p less than 0.01). One patient sustained abrupt closure of the target vessel, resulting in emergency bypass surgery and death. Small non-Q wave myocardial infarction occurred in eight patients (19%) and was associated with a longer lesion. The mean peak creatine kinase value in patients with non-Q wave myocardial infarction was 683 U/liter. Transient regional wall motion abnormalities were noted on the postatherectomy left ventricular angiogram in four of the eight patients with non-Q wave myocardial infarction. Follow-up angiography (at a mean interval of 6.2 +/- 2.6 months) was performed in 91% of patients and revealed restenosis (greater than 50% narrowing) in 59% The resistance rate was 22% for short lesions (less than or equal to 1 cm) and 75% for long lesions (greater than 1 cm) (p less than 0.05). In this study, the results of high speed rotational coronary atherectomy were strongly influenced by lesion length.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long balloon angioplasty with focal stenting for the treatment of diffuse coronary artery disease.

The objective of this study was to evaluate the efficacy of treating long coronary lesions (> 30 mm) with either a 40 or a 60 mm long Scimed Cobra balloon followed by focal (contingency) stenting of areas with suboptimal results. Diffuse lesion length is a morphological characteristic associated with a poorer clinical outcome after balloon angioplasty with or without stenting. Patients were enrolled in a prospective randomized fashion to have initial PTCA with either a 40 or a 60 mm long balloon followed by focal stenting in areas with suboptimal results. The MACE rate at 6-month follow-up was collected from all patients and was the primary endpoint of the study. A total of 41 patients were enrolled into the study. The acute procedural success rate was 97.5% with a 6-month MACE rate of 9.8%. The use of long balloons with contingency stenting is a highly effective strategy for the treatment of diffuse coronary lesions.     

Update on Cutting Balloon Angioplasty

Cutting balloon (CB) is a unique balloon catheter with 3 or 4 metal blades on its surface making controlled endovascular surgical incisions that show promise of causing less vessel wall injury and less intimai proliferation. Multicenter randomized trials have revealed that CB angioplasty with multiple inflations achieved better lumen enlargement than single inflation and reduced coronary dissection more than plain old balloon angioplasty (POBA). Follow-up results showed CB angioplasty had a smaller late loss and loss index, resulting in lessened restenosis and target lesion revascularization rates. The main indication of CB angioplasty is basically a noncalcified lesion with concentric plaque; however, it could be applied effectively to some lesions unsuitable for POBA including in-stent restenosis, small vessel, long diffuse lesion, or ostial lesion. Additional evaluation would be necessary to determine the role of CB angioplasty in the stent era.     

Cutting balloon angioplasty for children with small-vessel pulmonary artery stenoses.

Patients with complex congenital heart disease may have pulmonary artery stenoses that are either congenital or associated with scarring following surgical procedures. This study evaluates cutting balloon angioplasty for small-vessel pulmonary artery stenoses resistant to standard balloon angioplasty. Between October 1998 and December 1999, patients were enrolled in an FDA-approved compassionate-use protocol. During four catheterizations, there were seven lesions found resistant to standard balloon angioplasty (mean lesion diameter was unchanged: 1.8 mm +/- 0.8 mm to 1.9 +/- 0.8 mm). A cutting balloon was inflated twice in each of these lesions. Standard balloon angioplasty was then repeated. Final mean lesion diameter was increased significantly (1.9 mm +/- 0.8 mm to 3.8 +/- 1.3 mm; P 相似文献   

A Systematic Review of Jailed Balloon Technique for Coronary Bifurcation Lesion: Conventional-Jailed Balloon Technique vs Modified-Jailed Balloon Technique

BackgroundIn this systematic review, we aim to evaluate the latest evidence on the efficacy and safety of conventional jailed balloon technique and modified jailed balloon technique for bifurcation lesion, and also whether the former or latter is more effective for preventing side branch occlusion during main branch stenting in bifurcation lesions.MethodsWe performed comprehensive search on studies assessing the efficacy and safety of conventional jailed balloon and modified jailed balloon technique for bifurcation lesion from several electronic databases.ResultsThere were 908 patients from six studies comprising of 615 in conventional jailed balloon technique group and 293 in modified jailed balloon technique group. Side branch loss was lower in modified jailed balloon technique group, however, the proportion of lesions with TIMI flow <3 in the final percutaneous coronary intervention result was somewhat higher in the modified jailed balloon technique group. The efficacy issue regarding side branch dissection was reported as high as 3.4%, especially at proximal stent edge in conventional jailed balloon technique group, but not quantitatively described in the modified jailed balloon technique group. Zero percent major adverse cardiovascular events at 9–12 months follow up was demonstrated in modified jailed balloon technique group, and 1–5% in the conventional jailed balloon group at a longer observation period up to 2.7 years.ConclusionOur study showed that modified jailed balloon technique is potentially better compared to conventional jailed balloon in terms of side branch loss, dissection, and major adverse cardiovascular events. Further controlled studies are warranted for definite conclusion.     

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.     

Successful excimer laser angioplasty following unsuccessful primary balloon angioplasty

We report five patients where excimer laser coronary angioplasty facilitated successful balloon dilatation of heavily calcified lesions that could not be dilated by conventional angioplasty techniques alone. In each case, the lesion was crossed successfully with a guide wire. Conventional angioplasty failed because of inability to cross the lesion with a balloon (four lesions) or inability to dilate the lesion with balloon inflation (two lesions). These cases illustrate an indication for excimer laser coronary angioplasty as an adjunctive procedure in heavily calcified coronary stenoses. © 1993 Wiley-Liss, Inc.     

An algorithmic approach to balloon undilatable coronary lesions

Balloon undilatable lesions are lesions that have been successfully crossed by both a guidewire and a balloon but cannot be expanded despite multiple high-pressure balloon inflations. Balloon undilatable lesions can be de novo or in-stent. We describe a systematic, algorithmic approach to treat both de novo and in-stent balloon undilatable lesions using various techniques, such as high-pressure balloon inflation, plaque modification balloons, intravascular lithotripsy, very high-pressure balloon inflation, coronary atherectomy, laser coronary angioplasty, and extraplaque lesion crossing. Knowledge of the various techniques can increase the efficiency, success and safety of the procedure.     

Influence of lesion length on restenosis after coronary stent placement

The length of a coronary lesion is a significant predictor of restenosis after balloon angioplasty. The influence of lesion length has not comprehensively been assessed after coronary stent placement. This study includes 2,736 consecutive patients with coronary stent placement. Only patients with recent or chronic occlusions before the intervention were excluded. Patients were divided in 2 groups: 573 patients with long lesions (≥15 mm) and 2,163 patients with short lesions (<15 mm). There were no significant differences between the groups with respect to the procedural success rate and incidence of subacute thrombosis. One-year event-free survival was lower in patients with long lesions (73.3% vs 80.0%, p = 0.001). Six-month angiography was performed in 82.5% of the eligible patients. The incidence of binary restenosis (≥50% diameter stenosis) was higher in patients with long lesions (36.9% vs 27.9%, p <0.001). Similarly, patients with long lesions presented more late lumen loss than those with short lesions (1.29 ± 0.89 vs 1.07 ± 0.77 mm, p <0.001). Multivariate models for both binary restenosis and late lumen loss demonstrated that lesion length was an independent risk factor for restenosis. The risk was further increased by multiple stent placement and overlapping stents that were also independent risk factors of restenosis. Stented segment length did not show any independent effect. Therefore, long lesions represent an independent risk factor for restenosis after coronary stent placement. The results of this study suggest that a possible way to reduce the risk is to cover the lesion with a minimal number of nonoverlapping stents.     

Effect of balloon inflation time on expansion of sirolimus-eluting stent

There is little information about the relationship between balloon inflation time and sirolimus-eluting stent (SES) expansion. In this randomized intravascular ultrasound (IVUS) study, 92 de novo lesions in native coronary arteries that underwent SES implantation were enrolled. Sirolimus-eluting stent was implanted using an inflation pressure of 14 atm. Stent balloon was gradually inflated until 14 atm in 10 s. In the short inflation group, it was deflated immediately after an image of the balloon inflated at 14 atm was taken. Stent balloon inflation lasted 60 s in the long inflation group. Intravascular ultrasound was then performed. The long balloon inflation resulted in a larger stent cross-sectional area (4.9 ± 1.6 mm² vs 4.3 ± 1.4 mm², P < 0.05) and expansion (71% ± 13% vs 60% ± 13%, P < 0.001) compared to the short balloon inflation, although stent expansion was relatively low in both groups. The relatively longer balloon inflation time using an inflation pressure of 14 atm results in better SES expansion. However, in the majority of lesions, adequate stent expansion is not achieved even using long balloon inflation, if it is inflated at 14 atm.     

Probe angioplasty through an intracoronary probing catheter in lesions which are difficult to cross

The clinical records of the first 17 consecutive patients (20 lesions) in whom percutaneous transluminal coronary angioplasty was done using the ultra-low profile "balloon-on-wire probe" passed through an intracoronary probing catheter were reviewed. All patients had high-grade "difficult" lesions. In 15 lesions (12 patients) other balloon systems (over-the-wire low profile balloons (n = 9), and balloon-on-wire used alone, (n = 6)) had failed to cross the lesion. Acute ischemia due to complete occlusion at the site of the lesion during attempts to cross was seen in 3 of these patients. The intracoronary probing catheter was used to deliver the probe across the lesion in all these cases. Successful dilatation was achieved in 14 lesions (93%). In 5 lesions (5 patients) this combination was used as the initial strategy. Three of these had chronic total occlusions. Successful dilatation was achieved in 3 lesions (60%) using this combination and in 1 lesion over-the-wire balloon finally succeeded. There was 1 failure. The intracoronary probing catheter in combination with probe balloon wire offers a promising method to increase the success rate in patients with high grade "difficult" lesions. This combination is especially useful in situations where other balloon systems fail to cross the lesion.     

Antegrade ballooning with retrograde approach for the treatment of long restenotic total occlusion

A retrograde approach through collateral channels is thought to improve the success rate of percutaneous coronary intervention for chronic total coronary occlusion (CTO). Among CTO lesions, the in-stent chronic total reocclusion (ISR-CTO) is a subset with an unsatisfactory outcome despite repeated procedures. Various strategies and techniques are required to improve the success rate of this novel approach. We describe a case in which a long ISR-CTO was successfully recanalized by a drug-eluting balloon after antegrade ballooning of the proximal part of the lesion with retrograde wire crossing, and discuss the availability of this approach for the treatment of long ISR-CTO.     

Usefulness of morphologic parameters in predicting the outcome of coronary excimer laser angioplasty

The treatment of complex coronary lesions with conventional balloon angioplasty is associated with a reduced success rate and an increased incidence of complications. To evaluate the influence of lesion morphology on the outcome of coronary excimer laser angioplasty, morphologic parameters of 148 target lesions in 147 consecutive patients were determined. Morphologic analysis included target vessel, involved vessel segment, vessel diameter, minimal lumen diameter, length of the lesion, single discrete (concentric/eccentric) or complex lesions (occlusions, bifurcational, tandem or long segmental lesions), American College of Cardiology/American Heart Association Task Force classification, lesion location in curved or straight vessel segments, prestenotic vessel tortuosity and the direction of the laser approach in curved vessels with eccentric lesions. Failure of laser angioplasty occurred in 17 patients because of failed guidewire placement (n = 8), catheter placement (n = 6), or inability to pass the lesion with the laser catheter (n = 3). Successful stand-alone laser angioplasty was achieved in 68 procedures. In 63 interventions additional balloon angioplasty was necessary (n = 60) or stand-alone laser angioplasty was not successful (n = 3). The frequency of complex lesions, particularly total occlusions (p less than 0.001) and prestenotic vessel tortuosity (p = 0.002) was significantly increased in the group with failed laser attempts. Statistical analysis of the morphologic parameters in successful stand-alone laser interventions compared with combined or unsuccessful interventions revealed no significant difference. These data suggest that failure of laser angioplasty occurs because of low catheter flexibility and the need for guidewire support in treating totally occluded vessels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Treatment Strategies for Long and Calcified Lesions

This study discusses the treatment strategies used to approach long lesions, lesions in small vessels, and calcified lesions. Traditional treatment strategies for these lesion subtypes have yielded high acute complication rates and poor long-term outcome. A prospective analysis of 160 lesions was performed using intravascular ultrasound (IVUS) guided PTCA for the treatment of long lesions and lesions in small vessels, while a retrospective analysis of 106 calcified lesions was performed that were treated with the combination of rotablation and stenting. Acute and short-term results of TVUS guided PTCA with spot stenting show a 30-day major adverse cardiac event rate (MACE) of 5% with a high procedural success rate (96%), while the long-term outcome resulted in an agiographic restenosis rate of 17.4% and a target lesion revascularization rate of 13%. The combination of rotablation and stenting also rendered results in calcified lesions of a 93% angiographic success rate and a long-term outcome of restenosis of 22.5%. Optimal coronary stenting after rotational atherectomy in calcified lesions can be performed with a high success rate, an acceptable rate of procedural complications, and a low rate of stent thrombosis. This approach was associated with a low incidence of angiographic restenosis compared with results obtained with other interventional approaches. IVUS guided PTCA with spot stenting allows safe treatment of long lesions and lesions in small vessels. Short-term and long-term outcomes including 6-month MACE and angiographic restenosis appear to be better than results achieved in historical controls that utilize balloon angioplasty alone or stents in a manner where the lesion is covered from the proximal normal segment to the distal normal segment.     

经桡动脉行复杂冠状动脉病变的介入治疗

目的探讨经桡动脉行复杂冠状动脉病变介入治疗的可行性。方法将178例左主干开口病变、分叉病变、慢性闭塞病变、长度≥30mm的长病变、纡曲成角病变及严重钙化病变等复杂冠状动脉病变患者经桡动脉途径进行PCI。结果经桡动脉PCI完成率97.2%。因导引导管支撑力不够,采用双导丝技术18例,采用子母导管技术5例,微导管技术6例,锚技术3例。左主干开口病变8处即刻全部成功。左主干分叉病变双支架置入17例,单支架置入9例。其他分叉病变67处,单支架置入47处,双支架置入20处。双支架置入后对吻球囊扩张成功率100%。34处慢性闭塞病变PCI成功27处。长度≥30mm的长病变91处、纡曲成角病变23处、严重钙化病变27处全部PCI成功。术中支架内血栓2例,住院期间亚急性血栓形成2例。死亡1例。穿刺处并发症:桡动脉闭塞8例,前臂肿胀4例,无血肿及神经损伤。结论经桡动脉途径进行冠状动脉复杂病变的PCI有较高的成功率。     

Immediate stent recoil in an anastomotic vein graft lesion treated by cutting balloon angioplasty

Saphenous vein graft (SVG) anastomotic lesions can have significant fibromuscular hyperplasia and may be resistant to balloon angioplasty alone. Stents have been used successfully to treat these lesions. There are no reports of immediate stent recoil following such treatment in the literature. We describe immediate and persistent stent recoil in an anastomotic SVG lesion even after initial and post-deployment complete balloon dilatation of the stent and its successful treatment by cutting balloon angioplasty.     

USEFULNESS OF ENDOSCOPIC TREATMENT FOR DUODENAL ADENOMA

In recent years, due to the increasing prevalence of upper gastrointestinal endoscopy, there have been an increasing number of reports on duodenal adenoma and early stage cancer. However, endoscopic techniques for the resection of duodenal adenomas are difficult, due to the anatomical features of the duodenum, and the long distance to the lesion. There have only been a few reports on the use of endoscopic techniques for duodenal adenomas compared to those focused on the stomach and large intestine. For duodenal adenomas, we used a conventional endoscope for lesions proximal to the major duodenal papilla, and a short‐type double balloon endoscope for lesions distal to the papilla. The en‐bloc resection rate was 93.8%. There was only one case of microperforation. Endoscopic manipulation is considered difficult in the deep areas of the duodenum, but double balloon endoscopy enabled stable manipulation and successful resection of the tumor in the majority of cases.     

Early and late clinical outcomes after rotational atherectomy with stenting versus rotational atherectomy with balloon angioplasty for complex coronary lesions

Limited data are available on the effect of rotational atherectomy plus stenting versus rotational atherectomy plus balloon angioplasty for complex coronary lesions. We compared the early and late clinical outcomes between rotational atherectomy plus stenting (158 patients, 171 lesions) and rotational atherectomy plus balloon angioplasty (165 patients, 186 lesions) for complex lesions. Baseline characteristics were similar between the two groups. The procedural success rate was similar between the 2 groups (94% in rotational atherectomy plus stenting versus 96% in rotational atherectomy plus balloon angioplasty; p = 0.54). There were no significant differences in the in-hospital complications between the 2 groups. During mean follow-up of 40.4 +/- 20.2 months, fourteen patients died: 6 in rotational atherectomy plus stenting and 8 in rotational atherectomy plus balloon angioplasty. Target lesion revascularization was similar between the 2 groups (20% in rotational atherectomy plus stenting versus 24% in rotational atherectomy plus balloon angioplasty; p = 0.46). Three-year event (death, nonfatal myocardial infarction and target lesion revascularization)-free survival rate was 79 +/- 4% in the rotational atherectomy plus stenting group and 75 +/- 3% in the rotational atherectomy plus balloon angioplasty group (p = 0.44). In conclusion, rotational atherectomy followed by stenting or balloon angioplasty is associated with favorable long-term outcomes. Compared with rotational atherectomy plus balloon angioplasty, routine stenting after rotational atherectomy does not provide additional benefits in the clinical outcomes in complex coronary lesions.