70岁以上冠心病患者经皮冠状动脉介入治疗

目的 评价70岁以上冠心病患者经皮冠状动脉介入治疗的安全性和疗效。方法 70岁以上冠心病患者37例,应用常规方法行经皮冠状动脉腔内成形术和(或)支架术。结果 病例成功率为94.6％,病变成功率为87.7％,32例患者接受支架术,共置入支架47枚。住院期间,介入治疗成功的患者都无心绞痛发作或症状减轻,死亡2例。33例患者接受6～42月随访,平均(24±9)月,15例无心绞痛发作,9例心绞痛明显减轻,2例非致命性心肌梗死,1例因支架内再狭窄行冠脉搭桥术,3例死亡。结论 高龄冠心病患者进行介入治疗成功率高并且安全,近期和远期疗效良好。     

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.     

Expansion of the Multilink-Tristar stent after direct implantation and predilatation: comparison of clinical,angiography and intravascular ultrasound parameters

Coronary stenting has become the primary therapeutic option for many coronary lesions. As opposed to conventional stenting the advantages of direct stenting are a reduction of procedural time, radiation exposure and costs. However, data about the incidence of in-stent restenosis are so far not available. It was the aim of this prospective study to compare the expansion of the Multilink stent after direct stenting and predilatation by quantitative coronary angiography (QCA) and intravascular ultrasound (IVUS). Between January 2000 and June 2001, 82 patients were assigned to direct stenting (46 lesions) or predilatation (40 lesions) in lesions of coronary arteries > 3 mm. The procedural success rate was 92% in patients undergoing direct stenting. The baseline clinical characteristics were similar in both groups. The comparison of the angiographic data shows that direct stenting was performed in lesions with a lower degree of stenosis (71 +/- 12% vs 79 +/- 11%, p = 0.01) and that significantly shorter stents were used (14.4 +/- 3.0 vs 17.8 +/- 4.1 mm, p = 0.0007). The mean stenosis length was not significantly different in either group (10.5 +/- 3.4 vs 11.7 +/- 4.3 mm, n.s.). The QCA data after stent implantation show no differences of either implantation technique. Stent expansion was assessed by IVUS estimation of the proximal, distal and minimal in stent area. The minimal in-stent area (9.53 +/- 3.23, mm2 vs 8.65 +/- 1.96 mm2, n.s.) and the stent symmetry index (0.88 vs 0.88 n.s.) were not different in either patient group. These results indicate that in this subset of selected coronary lesions > 3 mm, elective stent implantation with and without predilatation effectively can achieve comparable stent expansion as assessed by QCA and IVUS. In comparison to conventional stent implantation stents, which were implanted without predilatation, were significantly shorter to cover the same lesion length.     

Angiographic restenosis after successful Wallstent stent implantation: an analysis of risk predictors.

Follow-up angiographic study was performed in 86 patients after initially successful Wallstent stent (Medinvent, Lausanne, Switzerland) implantation between April 1986 and October 1990. The stent angiographic restenosis rate was 16% at a mean of 8 months after stenting despite the inclusion of a substantial number of patients at high risk of restenosis after percutaneous transluminal coronary angioplasty (PTCA). Of a total 15 variables analyzed, only suboptimal stent placement was found to be a significant predictor of stent restenosis. Age; gender; baseline New York Heart Association functional class; previous PTCA; indication for stenting; left ventricular ejection fraction; preangioplasty and immediate postangioplasty diameter stenosis severity; stented vessel site, lesional morphology; number, diameter, and length of stents implanted; and the interval between stenting and follow-up angiographic restudy were not significant risk factors of stent restenosis. Our study suggests that intracoronary stent implantation with the Wallstent may be a useful and promising adjunctive option after PTCA, particularly in patients at high risk of restenosis after PTCA. However, because of the significantly enhanced risk of restenosis after suboptimal stent implantation, we strongly recommend the selection and placement of Wallstent stents that adequately cover the entire length of the dilated coronary segment.     

Latin American randomized trial of balloon angioplasty versus coronary stenting in diabetic patients with small vessel reference size (Latin American Small Vessel [LASMAL II] Trial): immediate and long-term results

Percutaneous coronary interventions (PCIs) in diabetic patients with small reference diameter vessels remain an important challenge in interventional cardiology because it is associated with increased complications and restenosis rates. Plain old balloon angioplasty (POBA) has limited efficacy in patients with lesions in small vessels. Although coronary stenting (stent) has been demonstrated to improve both immediate and long-term results after coronary intervention, small reference diameter is a strong predictor of restenosis after stent implantation. Thus, the question of how to best treat diabetic patients with lesions in small reference diameter remains unanswered. The purpose of this international and multicenter study was to compare the incidence of angiographic restenosis between percutaneous transluminal coronary angioplasty (PTCA) and stent in diabetic patients undergoing PCI of small reference diameter vessels using a specially designed phosphoryl choline (PC)-coated stent for small vessels. The patient population comprised of 220 diabetic patients with lesions in small reference diameter (< 2.9 mm but > 2.0 mm) that were randomized into two different PCI strategies: PTCA with provisional stenting (n = 109) versus stent (n = 111). In the PTCA arm, 26 patients (24%) crossed over to stent during the initial procedure; glycoproteins IIb to IIIa was used in 40.5% of patients in both groups. During initial procedure and at 30 days, both strategies of revascularitation had similar clinical success and acute complications. During long-term follow-up, even though requirements of target vessel revascularization and incidence of major adverse cardiovascular event were similar with both techniques, angiographic binary restenosis (45% with PTCA and 28% with stents, P = .047), net gain (0.74 mm with POBA and 0.94 mm with stents, P = .008), and freedom from target vessel failure (66% with POBA and 81.2% with stents, P = .013) were significantly improved when diabetic patients were initially treated with stent therapy. In summary, in diabetic patients with small coronary arteries, the use of a coronary PC coated stent as a primary device during percutaneous interventions was associated with better angiographic and long-term outcome.     

Comparison of PRE-dilatation vs direct stenting in coronary treatment using the Medtronic AVE S670 Coronary Stent System (the PREDICT trial).

Current stent delivery systems make primary stenting (stent placement without predilatation) possible, but few controlled trials have been performed to evaluate the success, safety, cost saving, and potential benefit of this approach in reducing late restenosis. The Comparison of PRE-Dilatation Versus Direct Stenting In Coronary Treatment using the Medtronic AVE S670 Coronary Stent System trial was a 399-patient study comparing results with the Medtronic-AVE S670 stent to objective performance criteria based on prior approved stents, with subrandomization to direct stenting versus stenting after balloon predilatation. Overall, results with the S670 stent showed excellent success and safety, with delivery success of 99%, a 14-day adverse event rate of 6.8% (including 6.5% non–Q-wave myocardial infarction), and favorable angiographic (20%) and clinical (12%) restenosis rates. Direct stenting was successful in 92% of cases, with a 99.5% secondary success rate including additional pretreatment of initially unsuccessful direct-stenting attempts, and no increase in complications. There were modest (10%) savings in fluoroscopy time, contrast use, and a decrease in angioplasty balloon use (0.6 vs 1.3 balloons/case), but no reduction in clinical or angiographic restenosis. Patients treated later in the study, with a device that had less balloon extension beyond the edges of the stent, had slightly lower angiographic restenosis rates (19% vs 23%). In conclusion, the S670 stent showed excellent overall performance. Although direct stenting was safe and highly successful, it offered only modest cost savings, and no reduction in late restenosis compared with stenting after predilatation.     

Angiographic outcome in multivessel disease (GABI II study) using new coronary device interventions and comparison with GABI I trial results

Percutaneous coronary interventions using stents were investigated in patients with multivessel disease. Acute and long-term results were compared with those of the German Angioplasty Bypass Surgery Investigation trial in a prospective multicenter study. The study included 134 patients in whom 277 lesions were treated. Angiographic success and procedural success were achieved in 268 of 277 lesions (97%) and 118 of 134 patients (88%), respectively. Control angiography performed in 90 of 118 eligible patients (76%) exhibited restenosis in 43 of 182 lesions (24%). Multivariate regression analysis found that a diffuse lesion, the lesion and stent length, and the final luminal diameter were predictive for restenosis. Thus, immediate and long-term results of multivessel coronary intervention utilizing stents were improved compared to percutaneous transluminal coronary angioplasty of multivessel lesions. However, there is still need for improvement of long-term results, especially in particular lesion subgroups.     

Provisional stenting for multivessel PCI

Background: Bare stents reduce acute complications and repeat revascularization following percutaneous coronary intervention (PCI), but are costly and may lead to in‐stent restenosis. It remains unclear whether stents should be universally implanted or whether provisional stenting mainly to suboptimal balloon dilatation results is an acceptable approach for multivessel PCI. Objective: To compare the long‐term clinical restenosis and target lesion revascularization (TLR) of stented and non‐stented coronary artery lesions in patients who had multivessel PCI. Methods: We performed retrospective analysis of matched data from 129 consecutive patients who underwent multivessel PCI (at least optimal balloon angioplasty to one coronary artery segment and balloon angioplasty plus stenting to another coronary artery in the same patient, all lesions are de novo native coronary artery lesions with vessel diameter ?2.5?mm). The study endpoint was restenosis and repeat revascularization at one‐year follow‐up. Results: Baseline characteristics were similar in both groups. Low in‐hospital MACE (3.1%). Acute myocardial infarction, emergency revascularization via either PCI or CABG was detected and angiographic success was achieved in 99.3% of lesions in both groups. The rate of clinically driven angiographic restenosis and TLR at one‐year (follow‐up?100%) was similar (17.1% versus 18.6%, P?=?0.871, and 13.9% versus 16.3%, P?=?0.728, for optimal balloon angioplasty versus provisional stenting. Conclusions: The main findings from this study are that long‐term angiographic restenosis and TLR was comparable for optimal balloon angioplasty and provisional stenting, suggesting that provisional stenting is an acceptable approach for multivessel PCI.     

Direct coronary stent implantation does not reduce the incidence of in-stent restenosis or major adverse cardiac events: six month results of a randomized trial.

STUDY OBJECTIVE: To compare the long-term angiographic, clinical and economic outcome of direct stenting vs stenting after balloon predilatation. PATIENT POPULATION AND METHODS: Four hundred patients with coronary stenoses in a single native vessel were randomized to direct stenting vs stenting after predilatation. A major adverse cardiac and cerebral event (MACCE) was defined as death, myocardial infarction, stent thrombosis, target restenosis, repeat target- and non-target vessel-related percutaneous coronary intervention, target lesion revascularization, coronary artery bypass surgery and stroke. RESULTS: Stents were successfully implanted in 98.3% of patients randomized to direct stenting vs 97.8% randomized to stenting preceded by predilatation. The primary success rate of direct stenting was 88.3%, vs 97.8% for stenting preceded by balloon dilatation (P=0.01). The angiographic follow-up at 6 months included 333 of the 400 patients (83%). The binary in-stent restenosis rate was 23.1% of 163 patients randomized to direct stenting vs 18.8% of 166 patients randomized to balloon predilatation (P=0.32). By 185+/-25 days, MACCE had occurred in 31 of 200 (15.5%) patients randomized to direct stenting, vs 33 of 200 (16.5%) randomized to predilatation (P=0.89). At 6 months, costs associated with the direct stenting strategy (Euros 3222/patient) were similar to those associated with predilatation (Euros 3428/patient, P=0.43). However, procedural costs were significantly lower. It is noteworthy that, on multivariate analysis, a baseline C-reactive protein level >10 mg l(-1)was a predictor of restenosis (odds ratio: 2.10, P=0.025) as well as of MACCE (odds ratio: 1.94, P=0.045). CONCLUSIONS: Compared to stenting preceded by balloon predilatation, direct stenting was associated with similar 6-month restenosis and MACCE rates. Procedural, but not overall 6-month costs, were reduced by direct stenting. An increased baseline CRP level was an independent predictor of adverse long-term outcome after coronary stent implantation.     

Short and long term results after intracoronary stenting in human coronary arteries: monocentre experience with the balloon-expandable Palmaz-Schatz stent.

OBJECTIVE--Intracoronary stenting was designed to overcome acute complications after percutaneous transluminal coronary angioplasty and to achieve a reduced rate of restenosis, both of which are major limitations of this well accepted method for treating coronary heart disease. This report describes the experience at one centre with the implantation of balloon-expandable Palmaz-Schatz stents and focuses on device related complications and the short and long term angiographic outcome. DESIGN--A retrospective data analysis. PATIENTS--Stenting was attempted in 50 patients. Restenosis after an initially successful angioplasty procedure, inadequate postangioplasty results, saphenous coronary bypass stenoses, and bail-out situations were regarded as indications. MAIN OUTCOME MEASURES AND RESULTS--In 49 of 50 attempted patients 61 stents (1-4 per patient) were implanted. Delivery problems occurred in three patients and were successfully overcome in two patients. Bail-out situations were successfully managed in 16 patients. Complications included acute thrombus formation within the stent immediately after implantation in one patient, which was successfully treated by thrombolysis. One patient was sent for bypass surgery the day after implantation; another died 10 days after implantation for unknown reasons. Subacute stent thrombosis occurred in seven patients 5-9 days after implantation and was successfully treated by thrombolysis or balloon angioplasty in five patients. Bleeding complications occurred in nine patients, five of whom required blood transfusions. Angiography showed long term vessel patency after 4-6 months in 31 (76%) of the 41 patients who were followed up, restenosis in six (14%), and reocclusion in four (10%). Late restenosis or reocclusion was found in five (15%) of 33 patients with a single stent in contrast to five (63%) of eight patients with multiple stents. CONCLUSIONS--Balloon-expandable intracoronary stenting is a feasible method for treating the acute complications of balloon angioplasty. It reduced the rate of restenosis for single stent implantation. Subacute thrombotic events must be regarded as previously unknown and serious complications.     

Short and long term results after intracoronary stenting in human coronary arteries: monocentre experience with the balloon-expandable Palmaz-Schatz stent.

OBJECTIVE--Intracoronary stenting was designed to overcome acute complications after percutaneous transluminal coronary angioplasty and to achieve a reduced rate of restenosis, both of which are major limitations of this well accepted method for treating coronary heart disease. This report describes the experience at one centre with the implantation of balloon-expandable Palmaz-Schatz stents and focuses on device related complications and the short and long term angiographic outcome. DESIGN--A retrospective data analysis. PATIENTS--Stenting was attempted in 50 patients. Restenosis after an initially successful angioplasty procedure, inadequate postangioplasty results, saphenous coronary bypass stenoses, and bail-out situations were regarded as indications. MAIN OUTCOME MEASURES AND RESULTS--In 49 of 50 attempted patients 61 stents (1-4 per patient) were implanted. Delivery problems occurred in three patients and were successfully overcome in two patients. Bail-out situations were successfully managed in 16 patients. Complications included acute thrombus formation within the stent immediately after implantation in one patient, which was successfully treated by thrombolysis. One patient was sent for bypass surgery the day after implantation; another died 10 days after implantation for unknown reasons. Subacute stent thrombosis occurred in seven patients 5-9 days after implantation and was successfully treated by thrombolysis or balloon angioplasty in five patients. Bleeding complications occurred in nine patients, five of whom required blood transfusions. Angiography showed long term vessel patency after 4-6 months in 31 (76%) of the 41 patients who were followed up, restenosis in six (14%), and reocclusion in four (10%). Late restenosis or reocclusion was found in five (15%) of 33 patients with a single stent in contrast to five (63%) of eight patients with multiple stents. CONCLUSIONS--Balloon-expandable intracoronary stenting is a feasible method for treating the acute complications of balloon angioplasty. It reduced the rate of restenosis for single stent implantation. Subacute thrombotic events must be regarded as previously unknown and serious complications.     

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.     

Coronary intervention in the diabetic patient: improved outcome following stent implantation compared with balloon angioplasty

BACKGROUND: Diabetic patients undergoing coronary interventional procedures are at increased risk of restenosis and adverse clinical events. The relative impact of stents compared with balloon angioplasty on the outcome of percutaneous intervention in diabetics remains controversial. HYPOTHESIS: The goal of this study was to determine whether stent placement was superior to balloon angioplasty in reducing restenosis of diabetic patients undergoing coronary intervention. METHODS: The STRESS Trial was a prospective randomized comparison of stent placement and balloon angioplasty in the treatment of new native coronary lesions. Of 594 randomized patients. 92 (16%) were diabetic. In this substudy analysis of the STRESS Trial, the outcomes after stenting and balloon angioplasty in diabetic patients were compared. The primary endpoint was restenosis as determined by angiography at 6 months. Clinical outcomes at 1 year were assessed. RESULTS: Procedural success was achieved in 82% of diabetic patients assigned to angioplasty and in 100% assigned to stenting (p < 0.01). Compared with angioplasty, stenting resulted in a larger postprocedural lumen diameter (2.34 +/- 0.44 vs. 1.87 +/- 0.52 mm, p < 0.001) and greater acute luminal gain (1.61 +/- 0.47 vs. 1.06 +/- 0.46 mm, p < 0.001). At 6 months, stenting conferred a larger lumen (1.69 +/- 0.57 vs. 1.38 +/- 0.60 mm, p = 0.03) and greater net luminal gain (0.97 +/- 0.55 vs. 0.52 +/- 0.52 mm, p < 0.001). Restenosis occurred in 60% of the angioplasty group and in 24% of the stent group (p < 0.01). This was accompanied by a lower need for repeat target vessel revascularization after stenting (31 vs. 13%, p < 0.03). CONCLUSIONS: Compared with balloon angioplasty, stent placement in diabetic patients with focal de novo lesions resulted in superior procedural results, reduced restenosis, and improved clinical outcome with fewer repeat revascularization procedures.     

冠状动脉内支架置入术治疗老年患者复杂冠状动脉病变

目的　探讨经皮冠状动脉腔内支架置入术治疗老年患者复杂性冠状动脉病变的疗效及安全性。方法对 4 5例冠心病患者施行冠状动脉内支架置入术 ,病变血管共 5 8支 ,B型病变 4 9处 ,C型病变 1 3处 ,慢性完全闭塞病变 4处 ,共置入支架 64只。置入左前降支 2 7只 ,左回旋支 1 3只 ,右冠状动脉 2 4只。De Novo支架置入 4 4只 ,Suboptimal支架置入 1 5只 ,Bail-out支架置入 3只 ,再狭窄病变支架置入 2只。结果　术后经冠状动脉造影证实疗效满意 ,支架置入成功率为 98.4 %。术前病变平均直径狭窄 (86.5± 7.8) % ,术后残余直径狭窄 (5 .1± 1 0 .3 ) %。住院期间无亚急性支架血栓形成。 1例出现假性动脉瘤 ,1例在术中及术后出现三次心室颤动 ,4例患者术后心绞痛复发 ,复查冠状动脉造影发现了 3个支架节段血管有再狭窄。结论　对于老年冠心病患者复杂冠状动脉病变 ,经皮冠状动脉内支架置入术是一种安全有效的介入性治疗技术 ,其成功率高 ,并发症发生率低     

A randomized comparison of balloon angioplasty versus rotational atherectomy in complex coronary lesions (COBRA study).

AIMS: Rotablation is a widely used technique for the treatment of complex coronary artery lesions but is so far only poorly supported by controlled studies. The Comparison of Balloon-Angioplasty versus Rotational Atherectomy study (COBRA) is a multicentre, prospective, randomized trial to compare short- and long-term effects of percutaneous transluminal coronary angioplasty (PTCA) and rotablation in patients with angiographically pre-defined complex coronary artery lesions. METHODS AND RESULTS: At seven clinical sites 502 patients with pre-defined complex coronary artery lesions were assigned to either PTCA (n=250) or rotablation (n=252). Primary end-points were procedural success, 6-month restenosis rates in the treated segments, and major cardiac events during follow-up. Procedural success was achieved in 78% (PTCA), and 85% (rotablation) (P=0.038) of cases. Crossover from PTCA to rotablation was 4% and 10% vice versa (P=0.019). There was no difference between PTCA and rotablation with respect to procedure-related complications such as Q wave infarctions (2.4% each), emergency bypass surgery (1.2% versus 2.4%), and death (1.6% versus 0.4%). However, more stents were required after PTCA (14.9% versus 6.4%, P<0.002), predominantly for bailout or unsatisfactory results. Including bail-out stents as an end-point, the procedural success rates were 73% for angioplasty and 84% for rotablation (P=0.006). At 6 months, symptomatic outcome, target vessel reinterventions and restenosis rates (PTCA 51% versus rotablation 49%, P=0.33) were not different. CONCLUSION: Complex coronary artery lesions can be treated with a high level of success and low complication rates either by PTCA with adjunctive stenting or rotablation. The long-term clinical and angiographic outcome is comparable.     

Comparison of PRE-dilatation vs Direct stenting In Coronary Treatment using the Medtronic AVE S670 Coronary Stent System (the PREDICT trial)

Current stent delivery systems make primary stenting (stent placement without predilatation) possible, but few controlled trials have been performed to evaluate the success, safety, cost saving, and potential benefit of this approach in reducing late restenosis. The Comparison of PRE-Dilatation Versus Direct Stenting In Coronary Treatment using the Medtronic AVE S670 Coronary Stent System trial was a 399-patient study comparing results with the Medtronic-AVE S670 stent to objective performance criteria based on prior approved stents, with subrandomization to direct stenting versus stenting after balloon predilatation. Overall, results with the S670 stent showed excellent success and safety, with delivery success of 99%, a 14-day adverse event rate of 6.8% (including 6.5% non–Q-wave myocardial infarction), and favorable angiographic (20%) and clinical (12%) restenosis rates. Direct stenting was successful in 92% of cases, with a 99.5% secondary success rate including additional pretreatment of initially unsuccessful direct-stenting attempts, and no increase in complications. There were modest (10%) savings in fluoroscopy time, contrast use, and a decrease in angioplasty balloon use (0.6 vs 1.3 balloons/case), but no reduction in clinical or angiographic restenosis. Patients treated later in the study, with a device that had less balloon extension beyond the edges of the stent, had slightly lower angiographic restenosis rates (19% vs 23%). In conclusion, the S670 stent showed excellent overall performance. Although direct stenting was safe and highly successful, it offered only modest cost savings, and no reduction in late restenosis compared with stenting after predilatation.     

Clinical and angiographic predictors of recurrent restenosis after percutaneous transluminal rotational atherectomy for treatment of diffuse in-stent restenosis

Due to the widespread use of stents in complex coronary lesions, stent restenosis represents an increasing problem, for which optimal treatment is under debate. "Debulking" of in-stent neointimal tissue using percutaneous transluminal rotational atherectomy (PTRA) offers an alternative approach to tissue compression and extrusion achieved by balloon angioplasty. One hundred patients (70 men, aged 58 +/- 11 years) with a first in-stent restenosis underwent PTRA using an incremental burr size approach followed by adjunctive angioplasty. The average lesion length by quantitative angiography was 21 +/- 8 mm (range 5 to 68) including 22 patients with a length > or = 40 mm. Twenty-nine patients had complete stent occlusions with a lesion length of 44 +/- 23 mm. Baseline diameter stenosis measured 78 +/- 17%, was reduced to 32 +/- 9% after PTRA, and further reduced to 21 +/- 10% after adjunctive angioplasty. Primary PTRA was successful in 97 of 100 patients. Clinical success was 97%, whereas 2 patients developed non-Q-wave infarctions without clinical sequelae. Clinical follow-up was available for all patients at 5 +/- 4 months without any cardiac event. Angiography in 72 patients revealed restenosis in 49%, with necessary target lesion reintervention in 35%. The incidence of rerestenosis correlated with the length of the primarily stented segment and the length of a first in-stent restenosis. Thus, PTRA offers an alternative approach to treat diffuse in-stent restenosis. Neointimal debulking of stenosed stents can be achieved effectively and safely. PTRA resulted in an acceptable recurrent restenosis rate in short and modestly diffuse lesion, whereas the restenosis rate in very long lesions remains high despite debulking.     

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.     

Direct coronary stenting without predilatation: A new therapeutic approach with a special balloon catheter design

Coronary stenting is the primary therapeutic option for many coronary lesions, after the risk of subacute stent thrombosis and bleeding complications has been reduced by antithrombotic regimens and improved stent expansion. It would be desirable to shorten the procedure and the duration of ischemia, and to reduce the risk of ischemic complications during balloon inflation by implanting the stent without previous dilatation of the lesion. This is not possible with the presently available stent delivery systems. This new therapeutic concept was tested with a specially designed balloon catheter, on which slotted-tube stents can be fixed between two conical radiopaque markers. Sixty-one patients elegible for angioplasty underwent direct stent implantation without predilatation. Four procedures were performed for acute myocardial infarction, and two as high-risk PTCA. Single slotted-tube stents (Palmaz-Schatz, NIR, or JOStent) of 14–16-mm length were mounted between the conical radiopaque markers of a special balloon which provided a fixation for the crimped stent. The direct implantation was successful in 80% of all patients, while in 10% the stent could be deployed after predilatation of the lesion. In 10% of lesions a stent could not be implanted with this and any other delivery system. When patients with successful direct stenting were compared with those with indirect (after predilatation) or unsuccessful stent deployment, the presence of angiographically visible calcification was higher in the unsuccessful cases (75% vs. 19%; P < 0.01), and the patients were older (72 ± 8 vs. 61 ± 12 years; P < 0.01). Radiation exposure time was only 8.7 ± 5.1 min as compared with 12.6 ± 7.6 min in conventional stent procedures with predilatation (P < 0.05). The number of balloons used per lesion was also lower than with conventional stenting. Stent dislocation was observed in 5%, and no embolization occurred. The new therapeutic approach of direct stenting without predilatation proved to be a safe and successful procedure in this initial series of coronary angioplasties. When calcified coronary lesions are avoided, it provides a way to rationalize stent implantation with shorter radiation exposure times, fewer balloons, and the potential advantage of fewer ischemic complications as no balloon predilatation is required. Cathet. Cardiovasc. Diagn. 43:245–252, 1998. © 1998 Wiley-Liss, Inc.     

Long-term clinical outcome after implantation of medium Palmaz (biliary) stents in very large native coronary arteries.

Intracoronary stenting has been shown to improve acute and long-term clinical results compared with coronary angioplasty. However, clinical outcome after medium Palmaz biliary (PB) stent implantation in very large native coronary arteries (> 4 mm in diameter) is unknown. This study evaluated restenosis and long-term clinical outcome after PB stenting in large native coronary arteries. Between June 1993 and December 1998, 55 patients with 56 lesions were treated with PB stents. Intracoronary stent deployment was successful in all 56 vessels attempted (100%). The mean stenosis was reduced from 65% +/- 10% to 4% +/- 14%. In 48 of the 56 vessels (86%), vessel size was greater than 4.0 mm in diameter and the mean reference vessel diameter was 4.73 +/- 0.7 mm after stenting. Angiographic success was achieved in 100%. Five patients had postprocedural cardiac enzyme elevation. There was no periprocedural death, emergency coronary artery bypass surgery, repeat target lesion revascularization, or acute stent thrombosis. Long-term clinical follow-up at mean of 28 +/- 15 months was obtained in 96% of the patients. Clinical restenosis rate occurred in 18% of ostial (6/34) and 0% of nonostial (0/22) lesions (P < 0.0001) with an overall clinical restenosis rate of 11%. Repeat angioplasty were performed in these six patients. There were three cardiac and three noncardiac deaths. The overall event-free survival at 1 and 3 years was 92% +/- 4% and 80% +/- 6%, respectively. PB stent implantation in very large native coronary arteries can be performed with a high degree of procedural success and low in-hospital complications. The long-term clinical outcome of patients undergoing PB stenting is associated with excellent event-free survival. However, stenting of ostial lesions remains as an important factor for restenosis even in very large coronary artery stenting.