First nine‐month complete invasive assessment (angiography,IVUS, and OCT) of the novel NEVO™ sirolimus‐eluting stent with biodegradable polymer

At present, percutaneous coronary intervention with drug‐eluting stent (DES) implantation represents the default strategy to treat coronary artery disease in many institutions around the world. However, concerns regarding long‐term safety of first‐generation DES have prompted the development of novel DES systems such as the NEVO? (Cordis Corporation, Johnson & Johnson, Warren, NJ) sirolimus‐eluting stent with biodegradable polymer and reservoir technology. In the current report, we present, for the first time, a complete midterm invasive assessment of a patient treated with this novel device in the Res‐Elution I study. © 2010 Wiley‐Liss, Inc.     

Does IVUS guidance of coronary interventions affect outcome? a prime example of the failure of randomized clinical trials

There has been a decline in the role of intravascular ultrasound (IVUS) guiding stenting. IVUS has lost favor with interventional cardiologists largely due to the emergence of drug eluting stents (DES). The advent of DES has lowered the need to maximize the final result due to the known low late‐loss. This phenomenon has contributed to reduced interest in optimizing results with IVUS guidance. However, current concerns regarding stent thrombosis in relation to DES and its associated significant morbidity and mortality has once more focused attention on optimal stent deployment. Prior to DES, the evidence base was rather ambiguous, as some randomized and observational studies supported IVUS guided bare metal stent insertion in terms of reducing rates of restenosis and clinically driven target lesion revascularisation whereas others demonstrated no such benefit. As there is an additional cost and learning curve with IVUS, it has become difficult to justify its routine use. We present here a oontemporary argument for the resurgence of IVUS optimized stent insertion. We also highlight deficiencies in previously adopted IVUS optimization criteria, which were based on distal and proximal lumen sizes. The new criteria proposed are based on vessel size at different segments of the stented area and therefore take advantage of vessel remodeling. The availability of high pressure, non‐compliant balloons have made attainment of these new optimization targets possible without increasing the risk of complications. We hope to demonstrate this statement with the completion of the angiographically versus IVUS optimization (AVIO) study that soon will be initiated. © 2008 Wiley‐Liss, Inc.     

Coronary pressure never lies

Fractional Flow Reserve (FFR), calculated by coronary pressure measurement, is the invasive gold standard to assess the hemodynamic significance of a coronary stenosis. FFR reliably indicates whether a stenosis is responsible for inducible ischemia and if percutaneous coronary intervention is appropriate. False positive or negative FFR is rare. Occasionally, however, a clinical or angiographic condition is encountered in which in first instance the FFR measurement contradicts the intuitive feeling of the interventionalist. Further examination in such cases, however, often reveals a clear physiologic explanation and in this manner FFR “lifts the veil”. Two such patients are presented in this case report and the reasons for apparent or actual false positive or negative FFR are discussed. © 2008 Wiley‐Liss, Inc.     

How to manage no reflow phenomenon with local drug delivery via a rapid exchange catheter

We describe two cases of no reflow phenomenon in the setting of primary PCI for ST elevation myocardial infarction successfully managed with intracoronary vasodilator therapy via a Clearway? balloon catheter, where vasodilator therapy via the guiding catheter had been ineffective. Traditionally, if not given via the guiding catheter, vasodilators have been administered via an over‐the‐wire balloon catheter, which can be cumbersome and time consuming. The Clearway catheter is a rapid exchange balloon catheter affording rapid delivery of vasodilators to the distal infarct related artery without risk of loss of wire position. © 2010 Wiley‐Liss, Inc.     

Wandering coronary stenoses: Adrenaline‐induced coronary artery spasm in a patient resuscitated from cardiac arrest

A 68‐year‐old ex‐smoker man with history of allergy, presented to the emergency department with progressive dyspnea one hour following self‐medication with aspirin for troublesome headache. Examination revealed diffuse sibilant rhonchi over both lungs. Electrocardiogram showed signs of ischemia. In the intensive care unit, he received bronchodilators, nitroglycerin, and aspirin. Bronchospasm increased, and then the patient was shocked, and developed cardiac arrest. After resuscitation, he was kept on mechanical ventilation and adrenaline infusion. He was sceduled for coronary angiography. The left system demonstrated stenosis of the mid‐segment of the left anterior descending artery (LAD), which was totally occluded distally, stenosis of the left circumflex (LCx) with a mild plaque in its marginal branch. The right system demonstrated stenosis of the mid‐segment of the right coronary artery (RCA), with diffusely diseased posterior descending artery (PDA) and posterolateral left ventricular branch (PLLV). Successful direct stenting was performed to the RCA. Angiography demonstrated worsening of the distal stenosis in the PLLV and complete occlusion of the PDA. Balloon dilatation of the PLLV was adequate, but dilatation of the PDA failed. Repeat angiography of the left system revealed an occluded LCx with critical stenosis of its marginal branch; nevertheless, the LAD was as before. Balloon dilatation of the distal LAD was attempted without improvement, yet, angiography therein, demonstrated “migration” of the stenoses in the LCx. The procedure was halted, adrenaline infusion discontinued, and an intra‐aortic balloon pump inserted. The patient was discharged one day later. Follow‐up angiography 6 months later demonstrated mild atherosclerotic coronary irregularities. © 2010 Wiley‐Liss, Inc.     

Four‐year clinical follow‐up of the XIENCE V everolimus‐eluting coronary stent system in the treatment of patients with de novo coronary artery lesions: The SPIRIT II trial

This report describes the 4‐year clinical outcomes of the SPIRIT II study, which randomized 300 patients to treatment with the XIENCE V everolimus‐eluting stent (EES), or the TAXUS paclitaxel‐eluting stent. At 4‐year clinical follow‐up, which was available in 256 (85.3%) patients, treatment with EES lead to a trend for lower rates of ischemia‐driven major adverse cardiovascular events, a composite of cardiac death, myocardial infarction, and ischemia‐driven target lesion revascularization (EES 7.7% vs. paclitaxel‐eluting stent 16.4%, P = 0.056). Treatment with EES also resulted in a trend toward lower rates of cardiac death and numerically lower rates of myocardial infarction, ischemia‐driven target lesion revascularization, and stent thrombosis. Overall, this study reports numerically fewer clinical events in patients treated with EES at 4‐year follow‐up, which is consistent with results from earlier follow‐up. © 2010 Wiley‐Liss, Inc.     

Percutaneous treatment of multiple fistulas associated with a giant aneurysm

Coronary fistulas are not common in patients undergo coronary angiography. It is described, even less frequently, that coronary fistulas may be associated with giant aneurysms along their course. These cases classically are treated surgically. We present a case treated fully percutaneously in a novel fashion.