Stenting within a stent: treatment for repeat in-stent restenosis in a venous graft.
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Aged↗
Biomedical subjects
J C Stauffer
Publications and source records attributed to J C Stauffer.
Late in-stent restenosis in coronary arteries and in grafts.
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[Immediate and mid-term clinical and angiographic results after implantation of AVE intracoronary micro-stents in 140 consecutive cases. An experience in Lausanne].
Two hundred AVE (Arterial Vascular Engineering) microstents measuring 4 to 30 mm were implanted in 140 patients aged 62 +/- 10 years with Class II to IV angina of the Canadian Cardiovascular Society Classification. The indications were: de novo lesions (30%), suboptimal angioplasty results (54%), acute occlusion (8%) or restenosis (8%). The stents of 3.0 to 4.0 mm diameter were implanted in the left main coronary artery (1%) the left anterior descending artery (20%), the left circumflex artery (19%), the right coronary artery (44%) or a venous bypass graft (7%) after intravenous injection of 15,000 IU of heparin. Daily treatment with aspirin 100 mg and ticlopidine 500 mg was instituted from the day of the procedure. The success rate was 98.5% with only 3 technical failures. The minimal luminal diameter and percentage stenosis ranged from 0.80 +/- 0.2 mm and 74 +/- 13% before to 2.66 +/- 0.38 mm and 15 +/- 7% after the procedure in vessels with an average reference diameter of 3.05 +/- 0.35 mm. There were 3% of stent-related immediate clinical complications. In February 1996, 97 patients had survived 6 months. With a 97% follow-up rate, the clinical event rate was 18%. The angiographic follow-up rate was 70% and the restenosis rate was 27%. The authors conclude that the AVE microstents are easy to implant and provide excellent immediate angiographic results with a low complication rate.
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[Coronary angioplasty in elderly patients].
Percutaneous transluminal coronary angioplasty (PTCA) is a widely accepted treatment of symptomatic coronary heart disease providing prompt and prolonged clinical, improvement in most patients. We have examined the value of this therapy in a group of 91 patients in their eighth decade treated by 133 consecutive angioplasties. Most patients had refractory or instable angor in spite of optimal pharmacotherapy. Multivessel disease was present in 67% and maintained left-ventricular function in 92% of the patients. The angiographic success rate of PTCA was 84%; technical failures occurred in 12% and adverse events in 14%. Two patients died. The rate of symptomatic restenosis was 24%. Survival and patients free of myocardial events were at 89% and 60%, respectively, estimated by Kaplan-Meier analysis. PTCA is an efficient and acceptable treatment for the elderly patient with severe and drug-resistant angina. Two years after PTCA the majority of patients was asymptomatic.
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Placement of multiple and different stent types for very long dissections during coronary angioplasty.
We have been investigating the safety and efficacy of multiple and different stent types placed in the unfavorable situation of a very long dissection (> 20 mm) after coronary angioplasty. We report our preliminary experience in 20 patients who were treated by the following combinations: Palmaz-Schatz and Micro stent (14 patients). Wallstent and Micro stent (4 patients); Wiktor and Micro stent (1 patient); and Palmaz-Schatz, Micro and Wallstent (1 patient). Normal distal flow was restored in all except one (no reflow phenomenon) patient and complete covering of the dissection was obtained in all but two patients. Event-free survival at 30 days was 90% (18 of 20 patients). During follow-up (mean period: 8 +/- 3 months), two patients died. Of the 18 other patients, 16 remained asymptomatic and free of complications. Symptomatic restenosis was treated by standard angioplasty in the two remaining patients. In conclusion, placement of different stent types seems a feasible, safe, and efficient treatment for very long dissections caused by standard angioplasty.
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Comparison of elective Wiktor stent placement with conventional balloon angioplasty for new-onset lesions of the right coronary artery.
This study compared the clinical and angiographic outcome, during a 6-month follow-up period, of 84 patients with new-onset lesions of the right coronary artery randomized to either Wiktor stent implantation (42 patients) or conventional balloon angioplasty (42 patients). At hospital discharge, three patients in each group (7%, p = not significant [NS]) reached a clinical end point. At 6 months, these proportions were 24% (10 patients with stents) and 29% (12 patients with angioplasty) (p = NS). There were no incidents of death or myocardial infarction. Despite a larger minimal luminal diameter after stenting (2.87 mm [95% confidence interval; 2.66 to 2.96 mm] vs 2.37 mm [2.23 to 2.61 mm for angioplasty] [p = 0.001]), no difference was observed at 6 months of follow-up (1.75 mm [1.43 to 2.18 mm] vs 1.74 mm [1.45 to 2.03 mm] [p = NS], respectively). Accordingly, angiographic restenosis rates were 47.5% (19 of 40 patients with stents) and 35% (14 of 40 patients with angioplasty) (p = NS). Elective stenting with the Wiktor stent and conventional balloon angioplasty are safe and immediately effective therapeutic options for symptomatic, obstructive right coronary artery disease. At 6 months of follow-up, clinical and angiographic outcome did not differ. The role of Wiktor stent placement in primary restenosis prevention remains to be determined for lesions of the right coronary artery.
Angioplasty, Balloon, Coronary↗
Emergency endoluminal stenting for abrupt vessel closure following coronary angioplasty: a randomized comparison of the Wiktor and Palmaz-Schatz stents.
In order to compare the efficacy of two different stent types in case of bailout stenting, 65 patients, with abrupt or threatened vessel closure following coronary angioplasty, were randomly assigned to either Wiktor (Medtronic Inc., Minneapolis, MN, 33 patients) or Palmaz-Schatz (Johnson & Johnson Interventional, Warren, NJ, 32 patients) stent implantation. Stenting was technically feasible in all except one patient and immediately successful in reverting ischemia and vessel closure in 60 patients (92%). At hospital discharge, complication rates were comparable: early vessel closure, 18% (Wiktor) versus 13% (Palmaz-Schatz) (P = 0.53); any clinical event (such as death, myocardial infarction, and surgical revascularization): 18% (Wiktor) versus 22% (Palmaz-Schatz) (P = 0.71). At 6 months follow-up, these complication rates remained equal: restenosis, 38% (Wiktor) versus 27% (Palmaz-Schatz) (P = 0.42); any clinical and angiographic (vessel closure and restenosis) event: 45% (Wiktor) and 41% (Palmaz-Schatz) (P = 0.69). Baseline, direct postprocedural, and follow-up quantitative coronary analysis data were similar, with, however, an exception for the postprocedural residual stenosis [28% (24-32%) (Wiktor) and 21% (18-23%) (Palmaz-Schatz] (means and 95% confidence intervals). In conclusion, despite a discrete postprocedural angiographic benefit observed with the Palmaz-Schatz stent, the long-term clinical and angiographic outcome is similar in both treatment groups. The choice whether to implant a Wiktor or Palmaz-Schatz stent may probably be left to the discretion of the operator and his experience with one particular device.
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Unplanned use of intracoronary stents for the treatment of a suboptimal angiographic result after conventional balloon angioplasty.
This observational single-center trial examines the safety and efficacy of unplanned endoluminal stenting for the treatment of a suboptimal angiographic result (defined as a residual stenosis after angioplasty of 40% to 50% without delayed runoff as estimated by visual assessment) after conventional coronary angioplasty in native, new-onset, coronary artery stenoses. Between October 1991 and April 1994, 101 patients with suboptimal results after coronary angioplasty in new-onset lesions were treated by endoluminal Wiktor (41 patients) and Palmaz-Schatz (60 patients) stent implantation. Stenting was a technical and angiographic success in all cases. In-hospital complications were subacute closure (2%) and vascular complications at puncture site necessitating surgery (12%) or blood transfusion (3%). No myocardial infarction occurred, nor was any urgent bypass surgery performed. At follow-up restenosis was detected in 16 (20%, 80% angiographic follow-up rate) patients requiring repeat angioplasty (8%) and elective bypass grafting (4%). Myocardial infarction was not documented. However, one patient died suddenly at 5 months of follow-up. The unplanned use of intracoronary stents is a safe and effective therapeutic option for the treatment of a suboptimal angiographic result after conventional angioplasty in new-onset lesions. This approach guarantees a high immediate angiographic success but implies a considerable incidence of vascular complications at puncture site.
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Stand-by versus stent-by during percutaneous transluminal coronary angioplasty.
To evaluate the impact of a more liberal use of endoluminal stenting on the incidence of emergency coronary artery by-pass grafting, we analyzed our attitude toward abrupt or threatened closure after percutaneous transluminal coronary angioplasty from 1986 through 1993. In 3083 procedures performed, 204 (6.6%) patients had abrupt or threatened closure. The incidence of closure or threatened closure remained stable during the 8 years, ranging between 5% (1986) and 8% (1987) (p = 0.89). Endoluminal stent implantation was attempted in 92 patients and successfully achieved in 90 (98%), and emergency bypass grafting had to be performed in 41 patients. The proportion without adverse end point (death or myocardial infarction) was higher in the patients treated by endoluminal stenting than in patients treated with bypass grafting (71/90 (79%) patients vs 17/41 (40%) patients, respectively; p < 0.0001). The use of bailout stenting gradually increased from 0.4% (1986) to 5.6% (1993) of all procedures (p = 0.0001), whereas the incidence of emergency bypass grafting decreased from 2.7% (1986) to 0.7% (1993) (p = 0.04). Meanwhile, the incidence of myocardial infarction remained stable between 5.6% (1988) and 1.8% (1992) (p = 0.1), and death rates decreased from 1.4% (1988) to 0.2% (1993) (p = 0.05). It is concluded that "stent-by" is a highly effective therapeutic approach (79% in the present study) toward closure after coronary angioplasty and that, although surgical "stand-by" is certainly mandatory for selected cases, routine stand-by is questionable.
Angioplasty, Balloon, Coronary↗
Initial experience with the "Big-Skinny" angioplasty catheter.
We describe our initial experience with the "Big Skinny" angioplasty catheter, currently only available as an investigational device and in sizes of 4.5, 5, and 6 mm. Six patients with severe angina pectoris were successfully dilated with this angioplasty catheter and have remained asymptomatic up until a mean follow-up period of 6 months. However, because of the large profile of the catheter, sufficient back-up with an adequate guiding catheter should be obtained and predilation with a smaller angioplasty catheter should be performed. The use of this catheter may be a more simple alternative for the treatment of oversized vessel stenosis than the "hugging balloon" technique or directional atherectomy. Otherwise, it may be considered as an adjunct technique in order to optimize the angiographic result after stenting or directional arthrectomy in this particular indication.
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Can early closure and restenosis after endoluminal stenting be predicted from clinical, procedural, and angiographic variables at the time of intervention?
OBJECTIVES: To develop a statistical model to assess the risk of early closure and restenosis on the basis of the information available at the time of stent implantation. DESIGN: An exploratory forward, stepwise multivariate logistic regression for each adverse event and multivariate polychotomous analysis for both events. SETTING: Tertiary referral centre for interventional treatment of coronary artery disease. PATIENTS: 243 consecutive, successful stenting procedures between 1986 and 1993 with the Wallstent, the Palmaz-Schatz and Wiktor stents with analysis of clinical, procedural, and angiographic variables. MEAN OUTCOME MEASURES: Early closure was defined as angiographically documented stent thrombosis within the first 3 weeks after implantation and restenosis according to the 50% reference diameter reduction criterion. RESULTS: Overall early closure and restenosis rates were 14.4% (35/243) and 19.2% (40/208, for a 97% repeat angiography rate). The statistical model predicted a worse outcome for male patients, with less restenosis in female patients. The only risk factor in female patients was the presence of collaterals to the target lesion. For male patients the following risk factors for closure and restenosis were retained: multiple stent implantation during the same session, the presence of collaterals to the target lesion, stenting of the left anterior descending artery or of the left circumflex artery, and bailout stenting. Only bailout stenting implied a decreased restenosis risk. CONCLUSIONS: Clinical, procedural and angiographic variables increase the risk for early closure and restenosis after endoluminal stenting. The prediction models described above need to be validated prospectively.
Angina Pectoris↗
Major dissection during coronary angioplasty: outcome using prolonged balloon inflation versus coronary stenting.
BACKGROUND: Abrupt or threatened closure is the major acute complication following conventional coronary angioplasty with a persistent incidence of 2% to 10%. OBJECTIVES: In order to evaluate the safety and efficacy of endoluminal stenting and autoperfusion balloon angioplasty in the setting of abrupt or threatened closure following coronary angioplasty, the short- and long-term clinical and angiographic follow-up of respectively 45 and 51 patients treated by either method were compared. METHODS: From August 1986 through August 1992, consecutive patients treated by either endoluminal stenting or autoperfusion balloon angioplasty for abrupt closure following coronary angioplasty, were entered into an observational trial that requested clinical follow-up and repeat angiography at 6 months. RESULTS: Except for vessel localization, baseline clinical, angiographic and procedural characteristics were comparable. The in-hospital clinical and angiographic outcome was similar (p = 0.85) with 69% event-free patients in both treatment groups. The postprocedural minimal luminal diameter was larger following stenting: 2.67 +/- 0.76mm versus 2.07 +/- 0.70mm (autoperfusion balloon) (p = 0.0002). At follow-up, there were less events in the stent group: 11% versus 34% for the autoperfusion balloon angioplasty group, (p = 0.03). Restenosis rates were 5% (2/37 patients, stent) versus 27% (11/41 patients, autoperfusion balloon) (p = 0.02). CONCLUSIONS: Autoperfusion balloon angioplasty and endoluminal stenting are effective and safe therapeutic options for abrupt or threatened closure following coronary angioplasty with a comparable short-term clinical and angiographic outcome. However, during follow-up, more complications occur following autoperfusion balloon angioplasty. This is explained by a higher restenosis rate in this treatment group.
Adult↗
[Balloon angioplasty for restenosis of coronary endoprostheses].
Between March 1991 and June 1994, the authors treated restenosis (> or = 50%) of coronary endoprostheses in 17 men aged 39 to 72 years by balloon angioplasty. The stents had been implanted for de novo stenosis in 14 patients, restenosis in 1 patient and for acute occlusion in 2 patients. The vessels treated were the left anterior descending artery (1 case), the left circumflex artery (2 cases), the right coronary artery (7 cases) and venous bypass grafts (7 cases). The endoprostheses used were 5 Wallstents in 4 patients, 13 Wiktor stents in 11 patients and 2 Palmaz-Schatz in 2 patients. Clinically, the patients with restenosis presented with class II angina (6 patients), class III (8 patients) and class IV (3 patients) of the Canadian Cardiovascular Society Classification. Conventional balloon angioplasty was performed 17 months (range: 3 to 87 months) after stent implantation and resulted in immediate clinical and angiographic success (residual stenosis < or = 50% on quantitative analysis) in all patients. In particular, there were no dissections. The minimal lumenal diameter (MLD) and percentage stenosis changed from 1.04 mm (range: 0.87 to 1.20) and 72% (range: 68 to 76) respectively before stent implantation to 2.83 mm (range: 2.46 to 3.20) and 23% (range: 20 to 27) after stent implantation. Restenosis resulted in a MLD and percentage stenosis of 0.89 mm (range: 0.77 to 1.01) and 73% (range: 69 to 78) respectively. After angioplasty of the stent, they returned to 2.68 mm (range: 2.29 to 3.06) and 27% (range: 23 to 30) respectively. The patients were not anticoagulated after angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Comparison of the Wallstent, Palmaz-Schatz stent, and Wiktor stent late after intracoronary stenting.
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Coronary Vessels↗
Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis.
Coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are more effective than medical treatment for the management of ischaemic heart disease. However, patients with single-vessel involvement have been excluded from prospective comparisons of the two methods. We have carried out such a comparison in patients with isolated proximal left anterior descending artery stenosis, conserved left ventricular function, and documented ischaemia. Eligible patients presenting to a single centre were randomly assigned PTCA (68 patients) or left internal mammary grafting (66). The procedures were technically feasible in all cases. The incidence of in-hospital complications was 2% (perioperative myocardial infarction) for CABG and 3% (emergency CABG for acute closure) for PTCA. Clinical and functional status improved similarly in both groups. However, patients in the PTCA group took more antianginal drugs. At median follow-up of 2.5 years, 86% of CABG-treated and 43% of PTCA-treated patients were free from adverse events (p < 0.01; relative risk 2.0 [95% CI 1.7-2.3]). The adverse events that explain this difference were restenosis (32%) requiring subsequent surgical (16%) or percutaneous (15%) revascularisation (1% had medical therapy). Rates of cardiac death and myocardial infarction did not differ between the groups. Both CABG and PTCA improve the clinical status of symptomatic patients with single-vessel coronary artery disease. If patient and physician accept the risk of restenosis and reintervention associated with PTCA, this procedure remains a suitable option and a simpler initial alternative to CABG.
Angioplasty, Balloon, Coronary↗
[Paradoxical pulse].
Pulsus paradoxus is one of the cardinal signs of cardiac tamponade and must be looked for at bedside examination of any patient who presents a clinical picture of low cardiac output. This paper reviews the definition of pulsus paradoxus and the way to measure it noninvasively. We then discuss the physiological fluctuation of systemic blood pressure during respiration and the various mechanisms which lead to an exaggeration of this phenomenon during tamponade. The sensitivity and specificity of this sign are also discussed. Finally, the role of echocardiography in the diagnosis of cardiac tamponade is shortly presented, as this method appears to be very accurate and sensitive in evaluating the hemodynamic embarrassment associated with pericardial effusion.
Blood Pressure↗
Stent shortening and elongation: pitfalls with the Wiktor coronary endoprosthesis.
This report demonstrates two specific complications that occurred during implantation of a Wiktor (Medtronic, Inc., Minneapolis, MN) coronary stent: stent shortening and elongation were observed and attributed to the unique coil structure of the device. Major cardiac events occurred during follow-up as a consequence of this stent deformation. Therefore, semiurgent bypass surgery should be considered to treat this complication.
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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.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗