So crazy it just might work!
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Angioplasty, Balloon, Coronary↗
Biomedical subjects
Richard R Heuser
Publications and source records attributed to Richard R Heuser.
Embolic protection devices in saphenous vein graft interventions.
Saphenous vein grafts (SVGs) are widely used as aortocoronary conduits during coronary artery bypass surgery and are critical in the high early success of coronary bypass revascularization. Saphenous vein grafts tend to be more prone than native coronary arteries to accelerated atherosclerosis and intimal fibrosis and thus frequently lead to recurrent symptoms and require further revascularization. Percutaneous coronary interventions (PCI) have become the prime means of SVG mechanical revascularization but are plagued by higher complication rates than PCI on native coronaries, largely due to embolic debris mobilized from around the target lesion in the SVG. Several mechanical devices and techniques have been developed to capture this friable material during the PCI before it can embolize; these devices have shown great promise in reducing the morbidity and mortality of these interventions and should be employed routinely.
Angioplasty, Balloon, Coronary↗
Review of interventional repair for abdominal aortic aneurysm.
Abdominal aortic aneurysm is associated with high mortality rate. For over 50 years, open surgical repair was the standard approach for large aneurysms. However, over the past decade, endovascular aneurysm repair (EVAR) has emerged as a viable alternative. EVAR is associated with lower operative and short-term morbidity and mortality and similar long-term survival (up to 4 years) compared with surgical repair. Endoleak remains a significant limitation associated with aneurysm expansion and reintervention. With newer, more versatile endograft designs, improvements in durability, and better surveillance techniques, the utilization of EVAR is likely to continue to expand.
Aortic Aneurysm, Abdominal↗
Devices for chronic occlusion.
Interventional cardiology has advanced into domains once believed to be beyond the reach of percutaneous procedures. As technologic advances continue to push the limits of the interventionalist's capabilities, several areas still exert considerable resistance to this forward momentum. These technically difficult frontiers include bifurcated lesions, small-vessel disease, multivessel disease, diffuse disease, and chronic total occlusions.
Angioplasty, Balloon, Coronary↗
Filters ... not just for coffee and carotids.
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Arteriosclerosis↗
Two-year clinical follow-up of 90Sr/90 Y beta-radiation versus placebo control for the treatment of in-stent restenosis.
BACKGROUND: It is an ongoing concern that intracoronary brachytherapy may possibly just delay the problem of in-stent restenosis ("late catch up"). For gamma-radiation, 3 placebo-controlled studies have shown the maintenance of the initially positive effect after 2 years, but similar data do not exist for beta-radiation. STents And Restenosis Trial (START) was the first placebo-controlled randomized trial for in-stent restenosis with beta-radiation; herein, we report the 2-year clinical follow-up. METHODS AND RESULTS: Two hundred and forty-four patients were randomized to active treatment, 232 patients to placebo (nonactive source train) treatment. The primary end point of efficacy was target vessel revascularization (TVR); primary safety end point was any major adverse cardiac event (MACE) at 8 months and 2 years. Two-year clinical outcome in patients receiving brachytherapy was based on 195 of 244 original patients (79.9%) and in the placebo arm on 183 of 232 original patients (78.9%). TVR was significantly reduced by 25%; from 36.6% (placebo) to 27.5% (brachytherapy) remained significant after 2 years (RR .7 [.57-.98], 95% CI -9.2 [-17.5-0.8]). The Kaplan-Meier analysis for TVR and MACE showed improvement beginning approximately 90 days after radiation and remained almost constant for the 2 following years. Freedom from TVR was significantly increased from 62.4% +/- 3.8% to 71.6% +/- 3.3% (P = .027) and freedom from MACE from 58.9% +/- 3.7% to 68.0% +/- 3.4% (P = .035). CONCLUSIONS: The START trial shows for the first time that the initial beneficial effects of intracoronary brachytherapy with beta-radiation using 90 Sr/ 90 Y are maintained at 2-year clinical follow-up period.
Aged↗
Distal embolic protection for SVG interventions: can we afford not to use it?
The development of atherosclerosis in saphenous vein grafts (SVGs) is one of the limiting factors in coronary artery bypass surgery. Approximately one half of vein conduits are significantly diseased or occluded at 10 years. A surgical revascularization strategy is often not pursued secondary to the incremental risks associated with a repeat bypass procedure. For this reason, percutaneous treatment of SVG disease is often the first option for a majority of patients. However, catheter-based treatment of SVG disease is associated with increased morbidity and mortality compared with native coronary arterial percutaneous intervention. This is often the result of distal embolization of atherothrombotic disease, leading to the phenomenon of "no-reflow." Intraprocedural pharmacological therapy has historically been the mainstay of treatment for these patients. However, more recently, the development of a mechanical embolic protection device has shown to be beneficial for the prevention of these complications. This article will review the types of embolic protection devices and the clinical studies that have proven their necessity in percutaneous SVG intervention.
Angioplasty, Balloon, Coronary↗
Usefulness of optical coherent reflectometry with guided radiofrequency energy to treat chronic total occlusions in peripheral arteries (the GRIP trial).
Optical coherent reflectometry, a forward-looking, fiberoptic-guided device was used in 72 patients to direct radiofrequency energy across the central intraluminal portion of 75 chronic total occlusions in peripheral arteries (iliac, femoral, and popliteal) that failed attempts with conventional guidewires. The system was successful in crossing 76% of the chronic total occlusions with no clinical perforations or distal embolizations, and complications consisted of a single dissection greater than or equal to grade C.
Aged↗
Embolic protection pas de deux.
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Angioplasty, Balloon, Coronary↗
New approaches to long lesions.
Long coronary lesions, comprising up to 20% of the interventional practice, pose a significant challenge to the interventionalist. Several approaches have been described to treat long coronary lesions with long-term suboptimal outcomes. Atherectomy and laser treatments with or without adjunctive balloon angioplasty have not been shown to be superior to conventional balloon angioplasty alone. Preliminary data with the use of drug-eluting stents in the treatment of long coronary lesions appears to be promising even in small vessels and may eventually become the mainstay treatment of long lesions.
Angioplasty, Balloon↗
Abdominal aortic aneurysm: a review of endoluminal treatment.
Abdominal aortic aneurysm (AAA) carries a high mortality if left untreated. Until recently, most patients with AAA were treated with surgical repair. However, endoluminal graft treatment is rapidly becoming an alternative to surgical repair due to lower morbidity and comparable perioperative mortality rates. Despite this optimism patients and operators should keep in mind the palliative nature of these endovascular repairs and the lifelong need for surveillance, before embarking on these procedures. Endoleaks remain to be a significant problem leading to aneurysm expansion and occasionally rupture. Durability of the existing endograft devices remains to be seen. Careful patient selection is critical to success with these procedures. With future advancements in the endograft device technology, methods of patient surveillance, and patient care, there may be a shift from conventional surgical approaches to endovascular repair for the treatment of AAA.
Aortic Aneurysm, Abdominal↗
Randomized trial of 90Sr/90Y beta-radiation versus placebo control for treatment of in-stent restenosis.
BACKGROUND: After conventional treatment of in-stent restenosis, the incidence of recurrent clinical restenosis may approach 40%. We report the first multicenter, blinded, and randomized trial of intracoronary radiation with the use of a 90Sr/90Y beta-source for the treatment of in-stent restenosis. METHODS AND RESULTS: After successful catheter-based treatment of in-stent restenosis, 476 patients were randomly assigned to receive an intracoronary catheter containing either 90Sr/90Y (n=244) or placebo (n=232) sources. The prescribed dose 2 mm from the center of the source was 18.4 Gy for vessels between 2.70 and 3.35 mm in diameter and 23.0 Gy for vessels between 3.36 and 4.0 mm. The primary end point, ie, clinically driven target-vessel revascularization by 8 months, was observed in 56 (26.8%) of the patients assigned to placebo and 39 (17.0%) of the patients assigned to radiation (P=0.015). The incidence of the composite including death, myocardial infarction, and target-vessel revascularization was observed in 60 (28.7%) of the patients assigned to placebo and 44 (19.1%) of the patients assigned to radiation (P=0.024). Binary 8-month angiographic restenosis (> or =50% diameter stenosis) within the entire segment treated with radiation was reduced from 45.2% in the placebo-treated patients to 28.8% in the 90Sr/90Y-treated patients (P=0.001). Stent thromboses occurred in 1 patient assigned to placebo <24 hours after the procedure and in 1 patient assigned to 90Sr/90Y at day 244. CONCLUSIONS: The results of this study demonstrated that beta-radiation using 90Sr/90Y is both safe and effective for preventing recurrence in patients with in-stent restenosis.
Beta Particles↗
Embolic protection devices.
The limiting factor in coronary artery bypass surgery is the relatively rapid progression of atheromatous disease in the saphenous vein grafts. Greater than one-half of these vein grafts will fail by 10 years, and the risks associated with repeat coronary artery bypass surgery are significantly greater than that of the initial surgery. Yet, catheter-based interventional treatment of saphenous vein grafts is hindered by distal embolization of friable lipidrich plaque. This is one mechanism responsible for reduced antegrade flow (i.e., "no-reflow" phenomenon), including spasm of the distal microcirculation and platelet clumping. This complication increases the risk of a major adverse clinical event (i.e., myocardial infarction or late mortality). Distal protection devices are designed to provide protection of the distal microcirculation during percutaneous intervention. One device type is a balloon occlusive system that temporarily occludes the distal vessel during the intervention followed by the aspiration of liberated atheromatous and thrombotic material before it reaches the arteriolar and capillary bed. The other device type is a nonocclusive, filter-based system that preserves coronary blood flow through tiny pores, as low as 100 microns. Atheromatous and thrombotic material is trapped in the filter-based systems and then removed with the retrieval of the device through a retrieval catheter. This article discusses the current distal protective devices.
Angioplasty, Balloon, Coronary↗
Guiding catheter aspiration to prevent embolic events during saphenous vein graft intervention.
UNLABELLED: Percutaneous coronary interventions (PCI) in saphenous vein graft (SVG) stenosis carries 10%-20% risk of major adverse clinical events (MACE) or reduced antigrade flow (No-reflow Phenomena). The PercuSurge device is not available at all United States hospitals and sometimes anatomically cannot be placed (distal stenosis). We developed a simple technique for use in patients who could not have the PercuSurge device placed during PCI of SVG. METHODS: The basic concept of this technique is the use of guiding catheter aspiration during PCI. Over a two-year period, seven patients underwent PCI in SVG, using this technique for symptomatic stenosis. They were all males, average SVG age was 14 +/- 6 years, 43% were degenerated SVG's, four (57%) had new stents placed, and three (43%) had percutaneous transluminal coronary angioplasty (PTCA) or cutting balloon therapy. All patients were pretreated with aspirin and clopidogrel and had baseline preprocedure serum creatine kinase (CK) and ECG. Following the procedure, patients had repeat serum CK and ECG eights hours post-procedure. No patients received glycoprotein platelets inhibitors. RESULTS: Twenty to 60 mL of blood with gross macroscopic material was recovered during aspiration. None of the patients experienced no-reflow phenomena or had major elevated CKs during the procedure as defined as 5 x normal baseline. Thirty-day MACE in all patients was zero. CONCLUSION: The pilot study suggests that guiding catheter aspiration may be effective in reducing MACE is some patients undergoing PCA in SVG.
Aged↗