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PubMedDate not supplied

Lessons from intravascular ultrasonography: observations during interventional angioplasty procedures.

This article reviews many of the applications of intravascular ultrasonic imaging for coronary and peripheral arterial disease. In vitro studies demonstrate an excellent correlation between ultrasound measurements of lumen and plaque cross-sectional area compared with histologic sections. In vivo clinical studies reveal the enhanced diagnostic capabilities of this technology compared with angiography. Ultrasonic imaging also permits visualization of the atherosclerotic plaque itself for the first time in vivo. In addition to accurately describing the plaque morphology, ultrasonography can identify some of the tissue characteristics of the plaque. During interventional procedures, ultrasonic imaging has been shown to be beneficial for enhanced diagnosis as well as improvement of our understanding of the mechanism of newer interventional devices such as directed atherectomy, rotational or TEC atherectomy, or excimer laser. Initial studies suggest that ultrasound guidance of intravascular stent deployment may be critical for optimizing stent placement. Randomized studies are currently in progress to determine whether the guidance provided by intravascular ultrasonic imaging will alter the results of interventional procedures so that the restenosis rate can be improved.

Angioplasty↗

PubMed1997

Atherosclerosis studies by intracoronary ultrasound.

Intravascular ultrasound (IVUS) is a new technique of tomographic visualization of the coronary arteries: its lumen, wall and pathology. Three dimensional (3D) reconstruction shows the tubular structure of the arterial wall and its pathology. IVUS has many advantages over coronary angiography: it has better resolution and shows many hidden lesions. IVUS has helped uncover the underlying mechanisms of percutaneous transluminal coronary angioplasty (PTCA), restenosis, the use and value of other interventional techniques such as directional coronary atherectomy (DCA), rotational atherectomy and stent implantation, and has great value in planning complex interventional procedures. The new American Heart Association (AHA) classification of coronary atherosclerosis pathology can be demonstrated by IVUS. IVUS is sensitive for studies of atheroma regression and progression and shows the coronary artery lesions after cardiac transplantation.

Animals↗

PubMed1998

[Perforation and rupture of coronary arteries].

Spontaneous rupture of coronary arteries as well as coronary perforation during percutaneous interventions are rare but potentially life-threatening incidents often resulting in emergency surgery. Frequency of acute perforation due to therapeutic catheterization varies according to the devices employed. With conventional balloon angioplasty it is estimated to be 0.1 to 0.2% whereas substantially higher rates of up to 3% have been reported with the use of so-called "new devices" (i.e. directional atherectomy, rotablation, excimer laser angioplasty or extractional atherectomy). Interventional strategies for nonsurgical treatment of acute coronary perforations during catheterization procedures have been developed. In recent times, availability of coronary stent-grafts allows for a percutaneous resolution of acute perforations while maintaining vessel patency. Whereas iatrogenic perforations in the catheterization laboratory may thus be treated immediately at the site of their occurrence, rupture of pre-existing but potentially unknown coronary pathology frequently is associated with a diagnostic interval, giving rise to serious clinical events (i.e. myocardial infarction, cardiac tamponade, malign arrhythmias or sudden death). It may be warranted to advocate prophylactic treatment of rupture-prone coronary conditions even on incidental diagnosis. This can either be performed by cardiothoracic surgery or, in suitable cases, by interventional therapy. Implantation of coronary stent-grafts could prove to become the therapy of choice due to its technical facility, safety and the short length of hospital stay associated with it. Before general recommendations can be made, however, as to the extension of indication for these novel coronary devices, further clinical studies encompassing long-term clinical and angiographic follow-up are needed.

Angioplasty, Balloon, Coronary↗

PubMed2004

Classification and current treatment options of in-stent restenosis. Present status and future perspectives.

Coronary stent implantation is currently performed in > 80% of percutaneous coronary interventions. Its main late complication is the development of in-stent restenosis (ISR), occurring in 10-80% of lesions treated in daily practice. The classification by Mehran et al. is most commonly used. Current therapeutic options to treat ISR include repeat balloon angioplasty, repeat stenting, cutting balloon angioplasty, directional coronary atherectomy, rotational coronary atherectomy, brachytherapy, and drug-eluting stents (DES). DES have been effective in reducing binary restenosis in de novo lesions in randomized controlled trials. The novel use of DES to treat ISR has been shown to be safe and effective in multiple studies involving sirolimus- and paclitaxel-eluting stents. As DES implantation becomes more widespread, ISR in DES is emerging as a new problem. The use of debulking techniques to treat ISR in DES is to be cautioned against. In this new era, the optimal treatment of this new problem is currently unknown. We await further data to see whether repeat DES implantation may help solve this vexing clinical problem.

Administration, Topical↗

PubMed1991

Intracoronary ultrasound evaluation of interventional technologies.

The feasibility and applicability of intravascular ultrasound (IVUS) of the coronary arteries were evaluated in 65 patients undergoing 70 coronary interventional procedures. Morphologic and quantitative analyses were performed with a mechanically rotated IVUS catheter (4.8Fr, 20 MHz) and with orthogonal view cineangiography. A semiautomated edge-detection algorithm was used for cineangiographic quantification. Coronary interventions included 45 percutaneous transluminal coronary angioplasties, 9 excimer lasers, 11 directional coronary atherectomies, 3 rotational atherectomies and 2 stents. Most lesions consisted of a mixture of plaque composition (hard, n = 30; soft, n = 64). Other unique morphologic data by IVUS were plaque topography (eccentric, n = 34; concentric, n = 36) and vessel dissection (IVUS [n = 29] versus angiography [n = 14], p less than 0.05). Postprocedure minimal lumen diameter and cross-sectional area measured by IVUS were larger and poorly correlated with angiography (r = 0.28, standard error of the estimate = 0.52 mm; r = 0.08, standard error of the estimate = 1.0 cm2, respectively). IVUS is more sensitive than angiography when assessing postintervention lesion characteristics including vessel dissection and plaque morphology. Catheter-based ultrasound appears to be a useful adjunct to contrast angiography when evaluating and comparing the therapeutic impact of conventional percutaneous transluminal coronary angioplasty with new technologies.

Algorithms↗

PubMed1992

Target lesion calcification in coronary artery disease: an intravascular ultrasound study.

OBJECTIVES: The purpose of this study was to evaluate the frequency, amount and distribution of target lesion calcification in patients undergoing transcatheter therapy for symptomatic coronary artery disease. BACKGROUND: Coronary artery target lesion calcification may be an important determinant of response to transcatheter therapy: balloon angioplasty causes dissections in calcified lesions, directional atherectomy cuts calcium poorly, rotational atherectomy causes preferential ablation of calcium and laser irradiation effect may vary. Intravascular ultrasound imaging is a highly sensitive technique for detection of plaque calcification in vivo. METHODS: We performed intravascular ultrasound imaging before or after, or both, various transcatheter therapies in 110 patients. These 84 men and 26 women had a mean age of 60 years and a duration of angina of 22 +/- 34 months. Forty-nine patients had one-vessel, 29 had two-vessel, 25 had three-vessel and 7 had left main coronary disease. Vessels treated and imaged were the left main (n = 7), left anterior descending (n = 47), left circumflex (n = 18) and right (n = 38) coronary arteries. RESULTS: Eighty-four patients (76%) had target lesion calcification; 29 patients had one-quadrant, 25 had two-quadrant, 17 had three-quadrant and 13 had four-quadrant calcification. The calcification was superficial in 42 patients, deep in 13 and both superficial and deep in 31. The axial length of calcium could be measured in 29 patients; it was < or = 5 mm in 11 and > or = 6 mm in 18. Fluoroscopy detected calcification in 50 patients (48%, p < 0.001 vs. detection by ultrasound); this proportion increased to 74% in patients with calcification of two or more quadrants and to 86% in patients with calcification > or = 6 mm in length of two or more quadrants. Calcification was more common in patients who smoked and tended to be more common in patients with multivessel disease or previous coronary artery bypass graft surgery. CONCLUSIONS: We conclude that target lesion calcification occurs in 75% of patients with symptomatic coronary artery disease requiring angioplasty. Target lesion calcification is best detected, localized and quantified by intravascular ultrasound. These observations may be important in selecting devices for transcatheter therapy.

Adult↗

PubMed1994

Proliferation and extracellular matrix synthesis of smooth muscle cells cultured from human coronary atherosclerotic and restenotic lesions.

OBJECTIVES: The purpose of this study was to examine the proliferative capacity and extracellular matrix synthesis of human coronary plaque cells in vitro. BACKGROUND: Common to both primary atherosclerosis and restenosis are vascular smooth muscle cell proliferation and production of extracellular matrix proteins. The applicability to humans of experimental animal models of these processes has been questioned. METHODS: Primary atherosclerotic and restenotic lesions were excised by percutaneous directional coronary atherectomy in 93 patients. Smooth muscle cells were cultivated by an explant technique and identified by their morphology in culture, ultrastructural features under electron microscopy and immunostaining using monoclonal antibodies to smooth muscle cell alpha-actin. Proliferation in secondary culture was assessed with growth curves and the synthesis of collagen and sulfated glycosaminoglycans by the incorporation of 3H-proline and 35S-sulfate, respectively. These studies were also performed in cells derived from human umbilical artery media. RESULTS: Success rates for primary (45%) and secondary (12%) culture of coronary cells were not influenced by clinical variables or lesion category. Primary culture success was improved by the presence of organized thrombus in the plaque and in relation to increased maximal cell density of the atherectomy specimen. Restenotic cells displayed more rapid growth than did cells of primary atherosclerotic origin, which grew in a manner similar to that of umbilical artery cells. Mean calculated population-doubling times for the three cell groups were 52 h (95% confidence interval [CI] 48 to 58 h), 71 h (95% CI 62 to 83 h) and 74 h (95% CI 65 to 84 h), respectively. Restenotic and primary atherosclerotic cells did not differ in the synthesis of collagen ([mean +/- SEM] 0.034 +/- 0.004 vs. 0.033 +/- 0.004 nmol isotope.microgram protein-1, p = NS) or sulfated glycosaminoglycans (11.47 +/- 1.07 vs. 15.37 +/- 3.10 nmol isotope.microgram protein-1, p = NS), but the coronary cells synthesized significantly more collagen and sulfated glycosaminoglycans than did umbilical artery cells (0.019 +/- 0.004 and 5.43 +/- 1.00 nmol isotope.microgram protein-1, respectively, both p < 0.05). CONCLUSIONS: These data indicate that increased smooth muscle cell proliferation contributes to coronary restenosis in humans and support the concept that the extracellular matrix synthesis of adult smooth muscle cells is important to lesion formation.

Cell Division↗

PubMed2006

Accuracy of in vivo coronary plaque morphology assessment: a validation study of in vivo virtual histology compared with in vitro histopathology.

OBJECTIVES: The goal of the present study was to compare the accuracy of in vivo tissue characterization obtained by intravascular ultrasound (IVUS) radiofrequency (RF) data analysis, known as Virtual Histology (VH), to the in vitro histopathology of coronary atherosclerotic plaques obtained by directional coronary atherectomy. BACKGROUND: Vulnerable plaque leading to acute coronary syndrome (ACS) has been associated with specific plaque composition, and its characterization is an important clinical focus. METHODS: Virtual histology IVUS images were performed before and after a single debulking cut using directional coronary atherectomy. Debulking region of in vivo histology image was predicted by comparing pre- and post-debulking VH images. Analysis of VH images with the corresponding tissue cross section was performed. RESULTS: Fifteen stable angina pectoris (AP) and 15 ACS patients were enrolled. The results of IVUS RF data analysis correlated well with histopathologic examination (predictive accuracy from all patients data: 87.1% for fibrous, 87.1% for fibro-fatty, 88.3% for necrotic core, and 96.5% for dense calcium regions, respectively). In addition, the frequency of necrotic core was significantly higher in the ACS group than in the stable AP group (in vitro histopathology: 22.6% vs. 12.6%, p = 0.02; in vivo virtual histology: 24.5% vs. 10.4%, p = 0.002). CONCLUSIONS: Correlation of in vivo IVUS RF data analysis with histopathology shows a high accuracy. In vivo IVUS RF data analysis is a useful modality for the classification of different types of coronary components, and may play an important role in the detection of vulnerable plaque.

Aged↗

PubMed2007

Plaque excision with the Silverhawk catheter: early results in patients with claudication or critical limb ischemia.

OBJECTIVE: This study was conducted to detail the early experience after infrainguinal atherectomy using the Silverhawk plaque excision catheter for the treatment of symptomatic peripheral vascular disease. METHODS: A prospective database was established in August 2004 in which data for operations, outcomes, and follow-up were recorded for patients undergoing percutaneous plaque excision for peripheral arterial occlusive disease. Society for Vascular Surgery (SVS) ischemia scores and femoropopliteal TransAtlantic Inter-Society Consensus (TASC) criteria were assigned. A follow-up protocol included duplex ultrasound surveillance at 1, 3, and 6 months and then yearly thereafter. Standard statistical analyses were performed. RESULTS: During a 17-month period, 66 limbs of 60 patients (37 men [61.7%]) underwent 70 plaque excisions (four repeat procedures). Indications included tissue loss based on SVS ischemia at grades 5 and 6 (25/70), rest pain at grade 4 (22/70), and claudication at grades 2 to 3 (23/70). The mean lesion length was 8.8 +/- 0.7 cm. The technical success rate was 87.1% (61/70). Adjunctive treatment was required in 17 procedures (24.3%), consisting of 14 balloon angioplasties and three stents. Femoropopliteal TASC criteria included 5 TASC A lesions, 14 TASC B lesions, 32 TASC C lesions, and 19 TASC D lesions. Although 17 plaque excisions included a tibial vessel, no patient underwent isolated tibial atherectomy. The mean increase in ankle-brachial index was 0.27 +/- 0.04 and in toe pressure, 20.3 +/- 6.9 mm Hg. Mean duplex ultrasound follow-up was 5.2 months (range, 1 to 17 months). One-year primary, primary assisted, and secondary patency was 61.7%, 64.1%, and 76.4%, respectively. Restenosis or occlusion developed in 12 patients (16.7%) and was detected at a mean of 2.8 +/- 0.7 months. Restenosis or occlusion was significantly more common (P < .05) in patients with TASC C and D lesions compared with patients with TASC A and B lesions. Six (8.3%) of 12 patients underwent reintervention on the basis of duplex ultrasound surveillance results. Four (33.3%) of 12 patients experienced reocclusion during the same hospitalization, and amputation and open revascularization were required in two patients each. CONCLUSIONS: Percutaneous plaque excision is a viable treatment option for lower extremity revascularization. Outcomes are related to ischemia and lesion severity. Patency and limb salvage rates are equivalent to other endovascular modalities.

Catheterization, Peripheral↗

PubMed2002

Device selection in the treatment of in-stent restenosis with and without radiation (from the Gamma Radiation Trials).

In-stent restenosis (ISR) is a major limitation of coronary stenting and is associated with high recurrence rates after intervention with all available devices. Intracoronary gamma (gamma) radiation was proved to reduce the recurrence rate after conventional therapy. The purpose of this study was to compare the different devices utilized for the treatment of ISR with and without gamma radiation. To search for the optimal device for the treatment of ISR, 685 patients from the radiation trials for ISR who were randomized to either iridium-192 gamma radiation (559 patients) or placebo (126 patients) following intervention were evaluated. Devices used included balloon percutaneous transluminal coronary angioplasty, excimer laser coronary angioplasty (ELCA), rotational atherectomy, and additional stent implantation. Baseline clinical and angiographic characteristics were similar between the gamma radiation and placebo groups. One- and 6-month clinical and angiographic outcomes were compared. The use of stenting compared with other devices was associated with increased late loss. Device selection used as adjunctive therapy did not influence the 30-day outcome. Patients treated with gamma radiation and placebo therapy had similar rates of composite major adverse coronary events (MACE) (death, Q-wave myocardial infarction, target vessel revascularization) (3% vs 2%, p = NS). At 6 months, MACE rates in irradiated patients were similar among POBA (29%), ELCA (28%), rotational atherectomy (18%), and additional stent implantation (30%, p = NS), and were significantly lower compared with placebo for the entire cohort and for each device subgroup. The overall recurrence rate of ISR was lower in patients treated with gamma radiation using iridium-192 compared with placebo. Device selection did not influence late clinical outcomes in irradiated and nonirradiated groups.

Aged↗

PubMed1998

In-stent restenosis: the Washington Hospital Center experience.

In-stent restenosis has become a significant clinical problem. In 1997 alone, it is estimated that up to 100,000 patients world-wide with in-stent restenosis were treated. Serial intravascular ultrasound (IVUS) analysis has shown that tubular-slotted stents almost never chronically recoil and that neointimal hyperplasia is responsible for in-stent restenosis. With the rapid recent explosion in stent use, information about in-stent restenosis has lagged behind, especially on the impact of new stent designs. For example, the true prevalence of in-stent restenosis (1) varies with the lesion and patient subset, being much higher in the "real world" than in the selected patients typically enrolled in many studies; and (2) depends on its definition (i.e., clinical vs angiographic, intralesion vs in-stent). "Conventional" catheter-based treatments have included percutaneous transluminal coronary angioplasty (PTCA), rotational atherectomy, excimer laser coronary angioplasty, directional coronary atherectomy, and additional stent implantation. Rates of recurrence with these approaches are not known and vary considerably among series; however, certain lesions seem likely to recur regardless of the treatment modality. Recently, brachytherapy has emerged as the most promising way to treat in-stent restenosis.

Angioplasty, Balloon, Coronary↗

PubMed1997

Predictors of CABG within one year of successful PTCA: a retrospective, case-control study.

BACKGROUND: We previously have established characteristics predictive of the need for coronary artery bypass grafting (CABG) over many years after successful percutaneous transluminal coronary angioplasty (PTCA). In this study, we examined the factors associated with the need for CABG within 1 year of successful PTCA, and the recent impact of newer, catheter-based technologies. METHODS: From January 1982 through December 1995, 234 patients underwent CABG within 1 year of a successful "index" PTCA at our hospital. Emergency operations within 12 hours of index PTCA were excluded. These cases were matched with 234 controls who underwent a successful index PTCA but did not require a subsequent CABG during the next year. Cases were matched by the date of their index PTCA, and 1-year follow-up was complete for all patients. RESULTS: Before index PTCA there were no differences between the groups in terms of age, sex, diabetes, prior myocardial infarction, ejection fraction, duration of anginal symptoms, hypertension, hyperlipidemia, family history, or obesity (all nonsignificant). At index PTCA the cases had a greater mean number of lesions measuring 70% or greater compared with the controls (2.8 versus 1.8, respectively; p < 0.0001). The cases were more likely to have critical (70% or greater) proximal left anterior descending artery, proximal first obtuse marginal artery, and right posterior descending artery stenoses. The use of stents or atherectomy devices was not significantly more common among the controls (21% of controls versus 17.1% of cases; p = 0.35). Complete revascularization was achieved in significantly fewer of the cases than the controls (91 versus 156, respectively; p < 0.0001). The cases underwent CABG at a mean of 3 months (86% within 6 months) after PTCA. Among those who had a diagnostic catheterization, 52% of the patients had both restenosis of a dilated lesion and progression of other disease. Only 5 of 75 patients who had restenosis of a dilated lesion had a stent or an atherectomy device used at index PTCA. Of note, 13% (30 of 234) required an emergency operation, with an overall operative mortality rate of 3% (7 of 234). CONCLUSIONS: Although the likelihood of local restenosis is decreased by newer interventional techniques, the need for CABG within 1 year after successful PTCA is not diminished. The number of critical lesions and their location are the best predictors of the need for early CABG. If early post-PTCA CABG is to be avoided, patients who cannot be completely revascularized by PTCA should be revascularized by CABG.

Angioplasty, Balloon, Coronary↗

PubMed2000

Monitoring plasma cardiac troponin I for the detection of myocardial injury after percutaneous transluminal coronary angioplasty.

The objective of this study was to detect myocardial injury defined by an increase of plasma cardiac troponin I (cTnI) following percutaneous transluminal coronary angioplasty (PTCA) and compare plasma cTnI with the risk of cardiac complications at 30 days. Plasma cTnI, creatine kinase (CK) MB, and total CK were determined in 83 patients before (baseline) and 6, 12 and 24 h after PTCA. Thirty-eight patients underwent conventional PTCA, 39 PTCA-stent and six rotational atherectomy. Patients with acute myocardial infarction (AMI) and increased pre-procedural cTnI >0.8 microg/l were categorized into group 1 (n=23). The remaining 60 patients (pre-procedural cTnI=0.8 microg/l) were categorized as follows: group 2 (n=15) AMI; group 3 (n=20) unstable angina (UA); group 4 (n=25) coronary artery disease (CAD). Twelve hours post-procedure, all three cardiac markers were more frequently increased over baseline in group 2 patients (40-60%) compared to patients in group 3 (5-29%, P<0.03) or group 4 (0.5-5%, P<0.01). This was also true for patients undergoing PTCA-stent compared to conventional PTCA or rotational atherectomy (27-40 vs. 4-14%, P<0.02). cTnI was more sensitive (60%) to detect release of myocardial protein after PTCA compared to total CK (47%) or CKMB (43%). A moderate increase of cTnI (0.8-1.5 microg/l) in groups 2, 3 and 4 was associated with higher risk of complications 30 days post-procedure.

Aged↗

PubMed2002

Nuclear factor-kappaB immunoreactivity is present in human coronary plaque and enhanced in patients with unstable angina pectoris.

BACKGROUND: Nuclear factor-kappaB (NF-kappaB) is a transcription factor which plays a coordinating role in inflammation and cellular proliferation and is thought to be involved in the pathogenesis of atherosclerosis. Its role in unstable coronary plaque in humans is unknown. METHODS AND RESULTS: Coronary atherectomy plaque was obtained via directional coronary atherectomy from 32 patients [16 with unstable angina pectoris (UAP) and 16 with stable angina pectoris (SAP)]. The predominant pathology in UAP consisted of richly cellular areas with atheromatous gruel or loose intimal proliferative tissue within a myxoid matrix (P<0.05 compared with SAP). By contrast, SAP plaques showed more dense fibrosis (P<0.01 compared with UAP). Sections were then stained with a monoclonal antibody to the activated p65 subunit of NF-kappaB and this staining was present in 31/32 specimens, localized to smooth muscle cells, macrophages and foam cells. Staining was then graded semiquantitatively by three independent observers. Immunostaining grades for activated NF-kappaB were significantly higher in UAP compared with SAP (2.60+/-0.1 vs. 1.98+/-0.18; P<0.01). CONCLUSIONS: NF-kappaB immunoreactivity is present in coronary atherosclerotic plaque and is increased among patients with unstable coronary syndromes. These data support a role for NF-kappaB in the pathogenesis of acute coronary syndromes in humans.

Adult↗

PubMed2000

[Spanish Registry of the Section of Hemodynamic and Interventional Cardiology Activity for 1999].

The results of the Spanish Registry of Hemodynamic and Interventional Cardiology in 1999 are presented. The activity of 90 centers representing all the cardiac catheterization laboratories in Spain is reported, with 83 centers performing mainly adult cardiac catheterization and 7 centers exclusively carrying out pediatric cardiac catheterization. In 1999, a total of 82,805 diagnostic catheterization procedures, 79% being coronary angiographies (65,234; 1,637 per million inhabitants), were performed, representing a total increase of 11.4% compared to 1998. Compared to 1998, coronary intervention increased by 14.2%, with a total number of 23,010 procedures. The ratio of coronary interventions per million inhabitants was 590. Success rates for coronary interventions (94%) and complications (2.2%) were similar to those registered in previous years, and in 12.4% of the cases IIb-IIIa glycoprotein inhibitors were used. Ten point two per cent of the procedures were performed to treat acute myocardial infarction. Coronary stenting is the main device for coronary intervention. In 1999, coronary stents were used in 17,783 cases (23% increase compared to 1998), representing 77.3% of all coronary revascularization procedures. A total of 22,946 prostheses were implanted, 87% electively and 21.4% as a primary stenting procedure, with a low rate of complications (0.85% subacute closure, 1.95% myocardial infarction and 0.9% mortality). Compared to 1998, both directional coronary atherectomy (52 procedures) and rotational atherectomy (473 procedures) showed a slight decrease.A slight increase (4% compared to 1998) was reported in adult valvuloplasties (525 vs 505)while pediatric interventional procedures increased by 21% (678 vs 557 procedures) compared to 1998. In conclusion, we would like to underline the high degree of laboratory participation in the Registry, and despite the increase in activity, the current rates remain lower than European figures.

Adult↗

PubMed1997

[Registry of activities of the Hemodynamics and Interventional Cardiology Section in the year 1996].

The results of the Spanish Registry of Hemodynamic and Interventional Cardiology in 1996 are presented. The Registry collects the activity of 81 centers which constitutes all of the cardiac catheterization laboratories in Spain. The main activity was adult cardiac catheterization in 73 centers and exclusively pediatric cardiac catheterization in 8. A total of 63,961 diagnostic catheterization procedures were performed, which represents a 10.7% increase compared to 1995. This was mainly due to the increase in coronary angiographies. Coronary interventions increased by 21.4%, for a total number of 15,009 procedures. The ratio of coronary interventions per million inhabitants was 375. Success rates of coronary interventions (94%) and complications (2.9%) were similar to those registered in preceding years. In the specific field of revascularization devices, there has been a sustained and spectacular increase in the use of intracoronary stents in the last 3 years. In 1996, coronary stents were employed in 7,104 cases (47.3% of all coronary revascularization procedures) and 8,873 prosthesis were implanted, increasing two-fold the activity in that field when compared to 1995. Stent implantation was elective in 58% cases, and the complication rate was very low (1% subacute closure; 1.8% myocardial infarction and 0.9% mortality). Directional coronary atherectomy decreased by 47% in the last year whereas rotational atherectomy increased by 10% despite a reduction in the number of centers performing this technique. As in previous years, a slight decrease in adult valvuloplasties was noted. Pediatric interventional procedures (607) increased by 30% compared to the 1995 Registry.

Adult↗

PubMed1999

Implications of small reference vessel diameter in patients undergoing percutaneous coronary revascularization.

OBJECTIVES: The purpose of this study was to determine whether small reference diameter of the culprit coronary artery influences the outcome of an attempted percutaneous revascularization procedure in the current era of interventional cardiology. BACKGROUND: Although the interventional strategy is largely determined by the size of the culprit coronary artery, earlier quantitative studies have not shown a worse acute outcome for small reference vessel diameter (< or =2.5 mm). METHODS: A total of 2,306 patients undergoing percutaneous coronary revascularization was divided in groups with reference diameters < or =2.5 mm (n = 813) or >2.5 mm (n = 1,493). Success and in-hospital major adverse cardiac event (death, Q-wave myocardial infarction and emergency coronary artery bypass graft) rates between both groups were compared. RESULTS: Patients with lesions in small vessels were older and presented more frequently with female gender, diabetes mellitus, heart failure, peripheral vascular, multivessel coronary disease and American Heart Association/American College of Cardiology (AHA/ACC) lesion type C (p < or = 0.01, each). Further, utilization of interventional devices differed markedly. In contrast to stents (18.5% vs. 41.9%) and directional atherectomy (3.7% vs. 13.5%), conventional balloon angioplasty (73% vs. 50%) and rotational atherectomy (16.1% vs. 8.3%) were used more often in smaller vessels (p < or = 0.0001, each). Success rate was lower in the small vessel group (92% vs. 95%; p = 0.006). Major adverse cardiac events occurred more frequently in small than large vessels (univariate 3.4% vs. 2.0%, p = 0.03; multivariate odds ratio 2.1, p = 0.02), particularly when proximal coronary segments were compared. CONCLUSIONS: Lesions in vessels with small reference diameter represent a distinct group with respect to clinical and morphologic characteristics as well as device utilization. These lesions have lower chances of successful percutaneous intervention and carry relatively higher risks, specifically when located in proximal coronary segments.

Aged↗

PubMed1997

Revascularization procedures in patients with transplant coronary artery disease.

OBJECTIVE: To assess the efficacy of revascularization in cardiac transplant patients who developed de novo coronary artery disease. METHODS: Eighteen patients underwent one or more of four methods of revascularization: percutaneous transluminal coronary angioplasty (PTCA), percutaneous transluminal coronary rotational atherectomy (PTCRA), coronary artery bypass grafting (CABG), and transmyocardial laser revacularization (TMLR). Eleven PTCA procedures were performed in 10 patients 55.3 +/- 6.6 months after transplantation. Six patients underwent PTCRA 83.3 +/- 11.2 months after transplantation. Five patients underwent CABG 54.0 +/- 12.6 months after transplantation; the mean left ventricular ejection fraction was 49.6 +/- 16.9 (20-65%); hypertrophy was present in two of these patients. One patient with distal coronary artery disease and New York Heart Association class IV symptoms underwent TMLR only. One patient underwent both CABG and TMLR because of triple vessel proximal disease, diffuse distal disease, and New York Heart Association class IV symptoms. RESULTS: PTCA was successful in 10 procedures with decrease in mean stenosis from 87.7 +/- 2.7 to 24.3 +/- 6.0%. Follow-up, at 16.9 +/- 4.0 months, showed restenosis in two patients. PTCRA was successful in all patients with a decrease in mean stenosis from 83.4 +/- 4.4 to 11.7 +/- 1.9%. Short-term follow-up did not reveal reocclusion. Two CABG patients who had hypertrophy died of heart failure 2 and 9 days after their operations. One CABG patient with excellent cardiac function died after 15 days because of pulmonary failure. In one patient, left ventricular ejection fraction improved from 35 to 50%, and he is alive 64 months later. Six months after TMLR, the New York Heart Association class in one patient improved from IV to II, and his left ventricular ejection fraction improved from 29 to 42%. The ejection fraction in the patient who underwent both CABG and TMLR improved from 20 to 56% but the patient expired 7 weeks later. CONCLUSIONS: It appears that revascularization procedures can be effective in patients with coronary artery disease after cardiac transplantation and that coronary angioplasty or atherectomy would be a therapy of choice for single proximal lesions. CABG should be used cautiously and only reserved for patients with multi-vessel disease without hypertrophy. Laser revascularization with or without bypass grafting has potential to become the therapy of choice for transplant coronary artery disease.

Angioplasty, Balloon, Coronary↗