Coronary rotational atherectomy in current practice: acute and mid-term results in high- and low-volume centers.

We conducted a prospective observational study to evaluate the indications, technique, in-hospital and 9-month results of consecutive patients treated with rotational atherectomy (RA) in 12 centers during 1 year, as well as their relationship with volume of RA activity. The study included 345 lesions in 289 patients treated (4.4% +/- 2.6% of procedures at the participating centers). The lesions were mostly calcified (63%) and type B2 or C (74%). Procedural success was obtained in 94% of patients, with a major adverse cardiac event (MACE) rate of 4.5%. At 9 months, MACE occurred in 17.3%. Multivariate analysis identified multivessel disease and slow flow as negative predictors of procedural success, whereas balloon pressure

Iatrogenic aortic dissection during coronary intervention.

Iatrogenic acute dissection of the ascending aorta following coronary angiography and percutaneous intervention is rare. Localized aortic dissections have been treated by sealing the entry with a coronary stent. Extensive dissections may require a surgical intervention. We describe a coronary dissection with retrograde extension to the ascending aorta that occurred during angioplasty of the right coronary artery. The extensive dissection, which was limited to the ascending aorta, was successfully treated by stenting of the right coronary artery and monitoring the aortic dissection by means of transesophageal echocardiography.

Intracoronary beta-radiation for the treatment of patients at very high risk for recurrence of in-stent restenosis: a single center experience.

BACKGROUND: Intracoronary brachytherapy has significantly reduced the recurrence of in-stent restenosis. The aim of this study was to evaluate the feasibility, safety and efficacy of intracoronary beta-radiation in patients at very high risk for recurrence of in-stent restenosis. METHODS: We analyzed 42 patients with 50 lesions submitted to catheter-based beta-radiation (Beta-Cath System, Novoste Corporation, Norcross, GA, USA) for in-stent restenosis. Thirty-eight lesions were at the second restenosis, 8 at the third, and 4 at the fourth; a diffuse pattern was present in 78%. RESULTS: Balloon angioplasty was performed for 30 lesions (60%) and the cutting balloon technique for 20 (40%). In 12 lesions further 14 stents had to be deployed (28%). The delivery catheter was successfully positioned in 96% of the procedures. The mean dwell time was 179 +/- 50 s with a radiation dose ranging from 18.4 to 25.3 Gy, depending on the vessel size. A complete angiographic success without coronary dissection and without any additional stenting after radiation delivery was achieved in 86%. At follow-up (7.2 +/- 2.1 months), the overall restenosis rate was 30.4% (14 lesions). A recurrence was detected in 1/11 lesions with initial focal pattern and in 13/39 lesions with initial diffuse pattern. The restenosis rate was higher in patients in whom a geographic miss had occurred (p < 0.05 vs lesions without geographic miss) and in those in whom a new stent had been deployed (p < 0.05 vs lesions treated without a stent). CONCLUSIONS: Brachytherapy reduces the in-stent restenosis rate in patients who are at very high risk of recurrence. The restenosis pattern, geographic miss and new stent deployment seem to be negative prognostic factors for recurrence of restenosis.

Immediate and late results of coronary angioplasty in patients with severe left ventricular dysfunction.

BACKGROUND: Severe coronary artery disease in patients with a markedly depressed left ventricular function is associated with a poor prognosis. Even though coronary angioplasty (PTCA) has been offered as an alternative to bypass surgery, the role of PTCA in the treatment of patients with severe left ventricular dysfunction has not been well defined. The aim of the present study was to evaluate the immediate and long-term results in patients with severe left ventricular dysfunction < or = 35% who underwent PTCA. METHODS: One hundred and twenty-five patients with a left ventricular ejection fraction < or = 35% who underwent PTCA were analyzed. RESULTS: The mean left ventricular ejection fraction was 29.7%. Eighty-seven patients (69.6%) had multivessel disease and 41 (32.8%) had previous coronary artery bypass graft. Intra-aortic balloon pumping was used in 12% of cases. Angiographic success was achieved in 96% of patients. Complete revascularization was achieved in 56 patients (44.8%). Major complications occurred in 4% of the population and 2 patients died (1.6%). During the long-term follow-up re-PTCA due to angiographic restenosis was performed in 41 patients (34%); 12 patients (10.4%) died. The only parameter which significantly correlated with death was the presence of an occluded left anterior descending coronary artery not recanalized neither with PTCA nor with coronary artery bypass graft. CONCLUSIONS: These data suggest that PTCA may be an effective treatment for coronary artery disease in patients with left ventricular dysfunction and is associated with high procedural success rate and low complications; however, the long-term follow-up seems not to be influenced by the PTCA procedure.

Elective stenting in small coronary arteries: results of the Italian prospective multicenter registry MICROSCOPE.

BACKGROUND: The role of stent implantation in small coronary arteries is still controversial. The MICROSCOPE study (Ministenting in small coronary arteries, a prospective evaluation) is a multicenter registry addressed to prospectively evaluate the immediate and mid-term clinical and angiographic results of elective stenting of lesions located in coronary arteries with an angiographic reference diameter < or = 2.75 mm. METHODS: A total of 146 patients (160 lesions) were included in the study. The percentage of complex lesions (B2 and C lesions) was 49.3%. The clinical indications for stent implantation were: stable angina (55.0%), unstable angina (24.6%), and clinical evidence of myocardial ischemia in asymptomatic patients (20.4%); 60% of patients had multivessel disease. Stent deployment could be performed in 96.2% of lesions. The baseline reference diameter was 2.12 +/- 0.36 mm. In all cases the Ministent (Cordis, a J&J Company, Miami, FL, USA), specifically designed for small coronary arteries, was employed. The stent was pre-mounted on low profile balloons available in three different diameters (2.25, 2.50 and 2.75 mm) and three different lengths (11, 15 e 26 mm). RESULTS: The primary endpoint of successful stent-assisted angioplasty in all study vessels without major adverse cardiac events was achieved in 95.8% of the patients. The minimal lumen diameter increased from 0.64 +/- 0.24 to 2.02 +/- 0.43 mm and the dimensions of the stenosis (expressed as a percentage of the diameter of the coronary vessel) decreased from 68.6 +/- 10.8 to 16.2 +/- 10.7% (< 30% standard deviation in all cases). After the procedure all the patients received double antiplatelet therapy for 4 weeks. Post-procedural complications were limited to 2 patients (1.3%) who had a non-Q wave myocardial infarction at 6 months of follow-up; 13 patients (11%) required target lesion revascularization. No patient died following the procedure. Angiographic control was performed in 44% of lesions. The minimal lumen diameter decreased to 1.12 +/- 0.47 mm and the percent stenosis increased to 45.9 +/- 23.2%. The incidence of binary restenosis (stenosis > or = 50%) was 41%. CONCLUSIONS: Elective stenting of small coronary arteries with the Ministent can be safely performed and is associated with a low incidence of acute or subacute stent thrombosis. The mid-term results indicate a high rate of angiographic restenosis but a low need of target vessel revascularization. These data suggest that stenting cannot be considered the treatment of choice for unselected lesions located in coronary arteries with a small reference diameter, but represents a safe solution if unsatisfactory results are obtained with balloon angioplasty alone.