Bilateral carotid stenting combined with three-vessel percutaneous coronary intervention in single setting.

We describe a patient who underwent bilateral internal carotid artery stenting and three-vessel percutaneous coronary intervention during the same procedure. Stenting of carotid arteries was performed employing our innovative technique combining coronary and peripheral devices. No complications occurred. The patient was discharged home 1 day after the intervention and remains asymptomatic, leading a fully active life. To our knowledge, unstaged bilateral carotid stenting combined with three-vessel coronary intervention has not been reported previously.

Local delivery of enoxaparin to decrease restenosis after stenting: results of initial multicenter trial: Polish-American Local Lovenox NIR Assessment study (The POLONIA study).

BACKGROUND: Enoxaparin inhibits smooth muscle cell proliferation in experimental models. Intimal hyperplasia has been found to be the principal cause of restenosis after coronary stent implantation. We sought to determine whether the intramural delivery of enoxaparin before stenting of de novo lesions decreases restenosis. METHODS AND RESULTS: One hundred patients who were undergoing stenting were randomly assigned to either local administration of enoxaparin during predilation with reduced systemic heparinization or stenting with standard, systemic heparinization. All patients were treated with the same type of stent (NIR). The primary study end point was late luminal loss. The secondary end points were major adverse cardiac events, target lesion revascularization, and angiographic restenosis at 6 months. Angiographic follow-up at 6 months was completed in all except 1 patient. Late luminal loss was reduced to 0.76+/-0.42 mm in the local enoxaparin delivery group versus 1. 07+/-0.49 mm in the systemic heparinization group (P:<0.001). Restenosis, using a binary definition, occurred in 10% of patients in the enoxaparin group and in 24% of patients in the systemic heparinization group (P:<0.05). Target lesion revascularization rates occurred in 8% of the enoxaparin group and 22% of the systemic heparinization group (P:<0.05). There were no deaths and no emergent CABGs were performed. The only subacute stent closure and non-Q-wave infarction occurred in a patient assigned to the systemic heparinization group. CONCLUSIONS: This is the first prospective randomized trial in which the local delivery of a drug, enoxaparin, resulted in significant reduction in late luminal loss and restenosis after stent implantation in de novo coronary lesions.

Novel approach to rotational atherectomy results in low restenosis rates in long, calcified lesions: long-term results of the San Antonio Rotablator Study (SARS).

Ablation technique and adjunctive strategy may affect restenosis after rotational atherectomy. To minimize trauma to the vascular wall, we changed the technique of rotablation as follows: the RPM range was decreased to 140,000-160,000 RPM, the ablation was performed using a repetitive pecking motion, avoiding a decrease in the rotational speed of the burr greater than 3,000 RPM, long lesions were divided into segments and each segment was separately ablated, and the burr-to-artery ratio was intended to be approximately 0.75. To prevent coronary spasm, before and after each pass, 100-200 microg nitroglycerin and 100-200 microg verapamil i.c. boluses were administered. Adjunctive PTCA was performed using a closely sized 1.1:1 balloon-to-artery ratio with a noncompliant balloon at low pressures for 120 sec. The study incorporated 111 patients with a combined total of 146 calcified lesions. Results. A total of 31.5% of patients underwent a multivessel procedure. No deaths occurred. Q-wave MI and/or creatine kinase elevation greater than three times baseline levels occurred in 4.5% of patients. By quantitative coronary angiography (QCA), the reference vessel diameter was 3.13+/-0.59 mm, mean lesion length was 33.41+/-18.58 mm. Percent stenosis and mean luminal diameter were as follows: at baseline 75.7%+/-10.8%, or 0.76+/-0.41mm, Post-rotational atherectomy 41.5%+/-3.6%, or 1.83+/-0.43 mm, Post-PTCA 18.2%+/-11.9%, or 2.56+/-0.50 mm. Six-month angiographic follow-up was available in 64 (57.7%) pts. Net luminal gain was 1.15+/-0.76 mm, with a late luminal loss of 0.65+/-0.84 mm. The mean diameter stenosis at follow-up was 37.6%+/-28.5%, with MLD 1.91+/-1.21 mm. The binary restenosis rate was 28.1%. Therefore, modification of rotational atherectomy technique with adjunctive PTCA resulted in a favorable restenosis rate in long, calcified lesions. Cathet. Cardiovasc. Intervent. 48:48-53, 1999.

Acute directional coronary atherectomy prior to stenting in complex coronary lesions: ADAPTS Study.

The purpose of this study was to determine the results of directional coronary atherectomy (DCA) combined with stenting in a high-risk patient population. The use of stenting or DCA alone for aorto-ostial lesions, total chronic occlusions, long lesions, and lesions containing thrombus is associated with lowered success and a relatively high restenosis rate. Between July 1993 and October 1996, we treated 89 lesions with the combined approach of DCA and stenting in 60 consecutive patients. Thirty-one (51.7%) patients were treated because of unstable angina, 11 (18.3%) for post-myocardial infarction (MI) angina, 3 (5.0%) for acute MI, and 15 (25.0%) patients for stable angina. A total of 43 (71.7%) patients had multivessel disease, 19 (31.7%) had undergone previous coronary artery bypass graft (CABG), and 17 (28.3%) patients had undergone multivessel revascularization. The procedure was successful in all patients; and no postprocedural deaths or emergent CABG occurred. Two patients (3.3%) had non-Q-wave MI after the procedure and 1 patient (1.7%) experienced Q-wave MI due to subacute stent closure 7 days after the procedure. During follow-up ranging from 6 months to 3 years, 2 (3.3%) patients died, 2 (3.3%) required CABG surgery, 1 (1.7%) patient had an MI, and 6 patients (10.0%) required target vessel revascularization. By the quantitative coronary angiography, the initial minimal luminal diameter (MLD) averaged 0.91+/-0.45 mm (74.7+/-11.8% stenosis) increasing to 3.80+/-0.44 mm (-6.7+/-12.1%) after the combined approach procedure. Thirty patients (50.0%) met criteria for late (> or =6 months) angiographic follow-up. Late MLD loss averaged 1.13+/-1.07 mm, for a mean net gain of 1.61+/-1.23 mm. Available angiographic follow-up evaluation showed a restenosis rate of 13.3%. A combined approach, defined as the use of both DCA and stenting, is safe and yields a low restenosis rate in high-risk patients who have lesions known to respond less favorably to stenting or DCA alone.

Intracoronary adenosine and papaverine do not increase myocardial systolic thickening.

STUDY OBJECTIVE: The aim was to determine if myocardial systolic thickening increases when coronary flow is augmented by infusing intracoronary vasodilators (adenosine and papaverine). DESIGN: Systolic thickening fraction was measured with pulsed Doppler crystals and sonomicrometer crystals before and during the intracoronary infusion of adenosine and papaverine. SUBJECTS: Sixteen anaesthetized mongrel dogs were studied. MEASUREMENTS AND MAIN RESULTS: Intracoronary adenosine did not alter systemic haemodynamics, but did induce a three- to fourfold increase in myocardial blood flow. Intracoronary papaverine caused a slight decrease in systemic arterial pressure and rise in heart rate. Neither intracoronary adenosine nor intracoronary papaverine increased systolic thickening: control thickening fraction (TF%) = 20 (SEM 1)%, adenosine TF% = 18(1)%; control TF% = 22(2)%, papaverine TF% = 20(2)%. CONCLUSIONS: These experiments do not support the hypothesis that an increase in myocardial blood flow induced by intracoronary vasodilators causes an increase in myocardial systolic function.