Coronary Calcification and Long-Term Outcomes According to Drug-Eluting Stent Generation

ObjectivesThe aim of this study was to evaluate the long-term impact of coronary artery calcification (CAC) on outcomes after percutaneous coronary intervention and the respective performance of first- and second-generation drug-eluting stents (DES).BackgroundWhether contemporary DES have improved the long-term prognosis after percutaneous coronary intervention in lesions with severe CAC is unknown.MethodsIndividual patient data were pooled from 18 randomized trials evaluating DES, categorized according to the presence of angiography core laboratory–confirmed moderate or severe CAC. Major endpoints were the patient-oriented composite endpoint (death, myocardial infarction [MI], or any revascularization) and the device-oriented composite endpoint of target lesion failure (cardiac death, target vessel MI, or ischemia-driven target lesion revascularization). Multivariate Cox proportional regression with study as a random effect was used to assess 5-year outcomes.ResultsA total of 19,833 patients were included. Moderate or severe CAC was present in 1 or more target lesions in 6,211 patients (31.3%) and was associated with increased 5-year risk for the patient-oriented composite endpoint (adjusted hazard ratio [adjHR]: 1.12; 95% confidence interval [CI]: 1.05 to 1.20) and target lesion failure (adjHR: 1.21; 95% CI: 1.09 to 1.34), as well as death, MI, and ischemia-driven target lesion revascularization. In patients with CAC, use of second-generation DES compared with first-generation DES was associated with reductions in the 5-year risk for the patient-oriented composite endpoint (adjHR: 0.88; 95% CI: 0.78 to 1.00) and target lesion failure (adjHR: 0.73; 95% CI: 0.61 to 0.87), as well as death or MI, ischemia-driven target lesion revascularization, and stent thrombosis. The relative treatment effects of second-generation compared with first-generation DES were consistent in patients with and without moderate or severe CAC, although outcomes were consistently better with contemporary devices.ConclusionsIn this large-scale study, percutaneous coronary intervention of target lesion moderate or severe CAC was associated with adverse patient-oriented and device-oriented adverse outcomes at 5 years. These detrimental effects were mitigated with second-generation DES.     

Fatal subclavian stent infection remote from implantation.

We report the unusual case of a 66-year-old alcoholic male who presented with acute arm ischemia 4 months following ipsilateral subclavian artery stenting. The patient had a petechial rash and Janeway lesions in the distribution of the affected subclavian artery. He had been treated for an infected dialysis graft 10 days prior to entry into the hospital. Subsequent angiogram confirmed a patent stent with intraluminal filling defects and occlusion of the brachial artery. Thrombectomy yielded material that was consistent with septic emboli and CT scan of the chest was suggestive of a mycotic aneurysm around the stent. The subclavian stent was removed surgically and the aneurysm was repaired. Unfortunately, the patient had multiple comorbidities and died of complications during recovery. This is the first case of a subclavian stent infection following septicemia remote from implantation.     

Hepatic venous outflow obstruction after right lateral sector living-donor liver transplantation,treated by insertion of an expandable metallic stent

Hepatic venous outflow obstruction is a relatively uncommon but important and devastating complication occurring after liver transplantation. Recently, right lateral sector liver grafts have sometimes been used in living-donor liver transplantation (LDLT), but, to our knowledge, early hepatic venous outflow obstruction has never been reported in right lateral sector LDLT. A 58-year-old woman was diagnosed with liver cirrhosis and hepatocellular carcinoma and underwent right lateral sector LDLT. Postoperatively, she developed liver dysfunction. Doppler ultrasound examination revealed flat waveforms and low-flow velocity in the right hepatic vein (RHV). A computed tomography (CT) scan revealed a ventrally distorted RHV due to hypertrophy of the liver graft. Hepatic venous obstruction was suspected and a hepatic venogram was performed. The venogram revealed stenosis of the RHV due to the distortion of the vein. We performed percutaneous transfemoral balloon dilatation, but this was not effective. We then inserted an expandable metallic stent (EMS) into the RHV. After the EMS placement, the condition of the patient improved. Venogram and CT data suggested that the obstruction of the RHV developed because of distortion of the RHV to the ventral side during liver regeneration.     

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.     

药物支架晚期血栓

药物支架很大程度上解决了支架内再狭窄的问题。但最近药物支架晚期血栓的问题倍受关注。现就可能导致药物支架晚期血栓的因素及支架的发展前景做一简要综述。     

Transjugular intrahepatic portal-systemic shunts (TIPS) – initial experience and clinical outcome

Background: The clinical role of the transjugular intrahepatic portal-systemic shunt (TIPS) has not been fully defined.
Aims: To determine the technical results of TIPS and the clinical outcome of patients undergoing the procedure.
Methods: Retrospective audit of the results of the first 31 procedures performed in Melbourne.
Results: Thirty procedures were performed for variceal haemorrhage, one procedure was for ascites. The aetiology of the liver disease was cirrhosis due to alcohol in 20, cryptogenic in five, chronic viral infection in four, and autoimmune chronic active hepatitis in one. Nodular regenerative hyperplasia was present in one patient. Seventy-seven per cent of procedures were considered successful based on the angiographic demonstration of shunt patency at the end of the procedure. The in-hospital mortality in all patients undergoing TIPS was 45% and was 42% in patients undergoing technically successful TIPS. Only age could be identified as predictive of death in hospital. In patients leaving hospital, we found a rebleeding rate of 57% with one patient dying of bleeding, one requiring balloon tamponade and two requiring variceal sclerotherapy. Hepatic trauma was documented in six cases, shunt thrombosis in four cases, stent displacement in two cases and severe hepatic encephalopathy in one case.
Conclusions: TIPS has the potential to decompress the portal venous system, but the procedure is technically complex and should be performed in the knowledge that mortality and morbidity can be relatively high, particularly in patients whose condition is poor.     

Stenting the distal anastomotic site of the left internal mammary artery graft: a case report

The major problem associated with the long-term patency of the internal mammary artery graft is the early occurrence of stenosis usually at its distal anastomotic site; its management by balloon angioplasty has been associated with a high success rate. We report the case of an unsuccessful balloon angioplasty of an anastomotic stenosis of a left internal mammary artery graft that was successfully managed by stenting with one-half of a Palmaz-Schatz stent. © 1994 Wiley-Liss,Inc..     

Randomized Comparison Between Everolimus-Eluting Bioresorbable Scaffold and Metallic Stent: Multimodality Imaging Through 3 Years

ObjectivesThe aim of this study was to investigate the vascular responses and fates of the scaffold after bioresorbable vascular scaffold (BVS) implantation using multimodality imaging.BackgroundSerial comprehensive image assessments after BVS implantation in the context of a randomized trial have not yet been reported.MethodsIn the ABSORB Japan trial, 400 patients were randomized to a BVS (n = 266) or a cobalt-chromium everolimus-eluting stent (n = 134). Through 3 years, patients underwent serial angiography and intravascular ultrasound or optical coherence tomography (OCT).ResultsLuminal dimension at 3 years was consistently smaller with the BVS than with the cobalt-chromium everolimus-eluting stent (mean angiographic minimal luminal diameter 2.04 ± 0.63 mm vs. 2.40 ± 0.56 mm, mean difference −0.37 mm [95% confidence interval: −0.50 to −0.24 mm]; p < 0.001), mainly because of smaller device area (6.13 ± 2.03 mm² vs. 7.15 ± 2.16 mm², mean difference −1.04 mm² [95% confidence interval: −1.66 to −0.42 mm²]; p < 0.001), and larger neointimal area (2.10 ± 0.61 mm² vs. 1.86 ± 0.64 mm², mean difference 0.24 mm² [95% confidence interval: 0.06 to 0.43 mm²]; p = 0.01) by OCT. BVS-treated vessels did not show previously reported favorable vessel responses, such as positive vessel remodeling, late luminal enlargement, and restoration of vasomotion, although the OCT-based healing score was on average zero (interquartile range: 0.00 to 0.00). At 3 years, intraluminal scaffold dismantling (ISD) was observed in 14% of BVS. On serial OCT, ISD was observed in 6 lesions at 2 years, where the struts had been fully apposed at post-procedure, while ISD was observed in 12 lesions at 3 years, where 8 lesions were free from ISD on 2-year OCT. In 5 cases of very late scaffold thrombosis, strut discontinuities were detected in all 4 cases with available OCT immediately before reintervention.ConclusionsIn this multimodality serial imaging study, luminal dimension at 3 years was smaller with the BVS than with the cobalt-chromium everolimus-eluting stent. ISD, suspected to be one of the mechanisms of very late BVS thrombosis, was observed in a substantial proportion of cases at 3 years, which developed between post-procedure and 2 years and even beyond 2 years. (AVJ-301 Clinical Trial: A Clinical Evaluation of AVJ-301 [Absorb™ BVS] in Japanese Population [ABSORB JAPAN]; NCT01844284)     

Experience with the Gianturco-Roubin stent for abrupt vessel closure complicating percutaneous transluminal coronary angioplasty

Background: Emergency coronary artery bypass grafting (CABG) has previously been the only option in the treatment of refractory abrupt vessel closure complicating percutaneous transluminal coronary angioplasty (PTC A), and has been associated with high rates of morbidity and mortality. Intracoronary stenting now provides an alternative to emergency CABG. Aim: To assess our initial experience with emergency coronary artery stenting as a new technique. Methods: Retrospective case study review with clinical and angiographic follow-up. Results: The Gianturco-Roubin (GR) stent was deployed in 13 patients in whom PTCA was complicated by abrupt vessel closure refractory to standard balloon techniques. Indications for PTCA were unstable angina (six), stable angina (six) and acute myocardial infarction (MI) (one). The arteries stented included left anterior descending (LAD) artery lesions (eight) and right coronary artery lesions (five). Two patients required urgent CABG, one due to failed stent deployment and one for inadequate control of vessel dissection. In seven of the stented patients the creatine kinase rose to greater than twice the upper limit or normal. Three patients had subacute thrombotic occlusion at seven to 19 days post stent deployment, managed with intravenous thrombolysis or repeat PTCA. At seven months follow-up, 11 patients were free of angina, two patients had Canadian Heart Association class II angina and there were no deaths. Eleven patients had repeat angiography at mean six months post stent. Five patients had evidence of restenosis managed with repeat PTCA in four and CABG in one. Conclusions: The GR stent is an effective alternative to urgent CABG in the treatment of refractory abrupt vessel closure complicating PTCA.