Right coronary artery arising from the pulmonary trunk.

The right coronary artery (RCA) abnormally originating from the pulmonary trunk (PT) is a rare congenital anomaly. Our patient is a 62-year-old woman with longstanding systemic arterial hypertension and angina pectoris. Angiographic images documented the RCA arising from the PT, and coronary angiography showed severe stenosis (70%) on the distal tract of the left anterior descending artery. The primary treatment of the anomalous origin of RCA from the pulmonary artery is surgical technique. Our surgeons opted for coronary reimplantation; 6-month follow-up has shown very good results, with complete disappearance of symptoms.

Variability in extent of platelet function inhibition after administration of optimal dose of glycoprotein IIb/IIIa receptor blockers in patients undergoing a high-risk percutaneous coronary intervention.

The Ultegra Rapid Platelet Function Assay was used to measure the inhibition of platelet aggregation at baseline and 10 minutes and 8 hours after starting therapy in 114 patients undergoing high-risk percutaneous coronary intervention with the planned use of a glycoprotein IIb/IIIa inhibitor. The abciximab-treated patients received a 0.25 mg/kg bolus, followed by a 0.125 microg/kg/min infusion for 12 hours; the eptifibatide-treated patients received 2 boluses of 180 microg/kg administered 10 minutes apart, followed by a 2 microg/kg/min infusion for 24 hours; the tirofiban-treated patients received a 25 microg/kg bolus, followed by a 0.15 microg/kg/min infusion for 18 hours. Ten minutes after starting therapy, the mean level of platelet inhibition was 86 +/- 9% for abciximab, 92 +/- 6% for eptifibatide, and 95 +/- 5% for tirofiban (p <0.001); > or =95% platelet inhibition was achieved in 29% of the patients treated with abciximab, 44% of those receiving eptifibatide, and 68% of the those receiving tirofiban (p = 0.02). In conclusion, at the evaluated doses, tirofiban seemed to be the most effective drug in achieving "optimal" platelet inhibition very early after percutaneous coronary intervention.

Downstream administration of a high-dose tirofiban bolus in high-risk patients with unstable angina undergoing early percutaneous coronary intervention.

BACKGROUND: The best treatment option for high-risk patients with unstable coronary syndrome is an early invasive strategy accompanied by intensive anti-platelet therapy. We tested the effect on clinical outcome of early coronary angioplasty using a high-dose bolus of tirofiban in patients with non-ST segment elevation acute coronary syndrome. METHODS: One hundred and forty consecutive patients with unstable coronary syndrome who underwent an immediate percutaneous coronary intervention with the administration of a high (25 microg/kg) dose bolus of tirofiban followed by an 18-h infusion of 0.15 microg kg(-1) min(-1) were compared with a matched control group of 162 patients treated with abciximab. The primary endpoint of the study was the 30-day incidence of major adverse cardiac events; the secondary endpoints were the incidence of major and minor bleeding. RESULTS: The time from admission to PCI was slightly shorter in the tirofiban group (3.9+/-4.8 vs. 4.5+/-4.4 h; P=0.26). The 30-day rate of major adverse cardiac events was similar in the two groups (6% with tirofiban and 8.6% with abciximab: OR=1.37, 95% CI=0.58-3.29, P=0.52). No major bleeding episodes were observed; the incidence of minor bleeding was 3.6% in the tirofiban group and 2.5% in the abciximab group (OR=0.68, 95% CI=0.18-2.59, P=0.74). CONCLUSIONS: In this preliminary study, the beneficial effect of the administration of a high-dose tirofiban bolus on 30-day clinical outcomes was similar to that of abciximab in high-risk patients with unstable angina undergoing immediate percutaneous coronary intervention. The results of this therapeutic strategy should be tested in a larger randomised study.

Case report: a very large dissection in the left anterior descending coronary artery of a 56-year-old man.

Spontaneous coronary artery dissection (SCAD) is a rare condition that usually occurs in relatively young patients who are predominantly female. Seldom it could be a cause of acute myocardial ischemia leading to a sudden cardiac death. SCAD consists of intramural hematoma formation or, rarely, intimal tears that initiate and propagate the dissection in the vessel wall. In rare cases, the SCAD occurs in male patients. We report the case of a 56-year-old man with acute myocardial infarction who was successfully treated via systemic thrombolysis in a peripheral hospital. Associated conditions were thrombosis of right femoral artery in the past and high platelet count (800,000/mm3). After 1 month, elective coronary angiography revealed a very diffuse spiral dissection of the left anterior descending artery; hence, our choice of medical treatment consisted of double oral antiplatelet therapy (clopidogrel 75 mg plus aspirin 325 mg once daily). After a 2-year follow-up, there was absence of both angina and myocardial ischemia and there was a decrease in platelet count. Many strategies could be considered in patients with SCAD, such as PCI, bypass surgery, or conservative medical management. In general, the long-term prognosis of patients with SCAD is considered favorable if they survive the acute phase.

Endovascular treatment of a symptomatic aneurysm of the left subclavian artery.

Upper extremity ischemia is a rare entity usually due to emboli of arterial origin. Such thromboemboli produce acute symptoms of sufficient severity as to necessitate early surgical intervention. We report the case of a patient with severe ischemia in his left hand, in whom the embolic source was a mural thrombus localized at the level of a saccular aneurysm of the subclavian artery. After having excluded the presence of a thoracic outlet syndrome, the lesion was successfully treated by means of percutaneous implantation of a stent graft with the exclusion of the aneurysm and the sealing of the thrombus.

Compression repair versus low-dose thrombin injection for the treatment of iatrogenic femoral pseudoaneurysm: a retrospective case-control study.

BACKGROUND: It has been shown that thrombin injection is a safe and effective technique for the treatment of iatrogenic femoral pseudoaneurysm. The aim of this study was to evaluate and compare the use of ultrasound-guided low-dose thrombin injections with ultrasonographically-guided compression repair in the treatment of iatrogenic femoral arterial pseudoaneurysm. METHODS: We compared two cohorts of patients treated for iatrogenic femoral pseudoaneurysm: the first included 38 patients who underwent ultrasonographically-guided compression repair as a first-step approach between January 1998 and November 2002; the second included 21 patients treated with ultrasound-guided low-dose thrombin injection between December 2002 and December 2003. RESULTS: Both groups had similar demographic characteristics and aneurysm sizes (p = 0.72). Compression was successful in 24/38 patients (63%); the 14 persistent aneurysms were surgically repaired (37%). The primary thrombin injection of a mean dose of 185+/-95 U/ml (range 100-400 U/ml) successfully obliterated all of the 21 pseudoaneurysms (success rate 100 vs 63% in the compression group, p = 0.004). Thrombosis occurred within an average of 12+/-15 s of thrombin injection. Sedation was used in 42% of the patients undergoing compression and in none of those receiving thrombin (p = 0.001). The duration of hospitalization was significantly longer in patients undergoing compression therapy (9.8+/-5.6 vs 5.6+/-1.4 days, p = 0.001). CONCLUSIONS: Ultrasound-guided low-dose thrombin injection appears to be more effective in reducing the need for surgical repair when used to treat iatrogenic femoral pseudoaneurysm, is better tolerated by the patients, and requires a shorter hospital stay.

Effect of hypnotic sedation during percutaneous transluminal coronary angioplasty on myocardial ischemia and cardiac sympathetic drive.

Forty-six patients were randomized to receive drug (group 1) or hypnotic sedation (group 2) during percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery. Intracoronary and standard electrocardiograms were continuously registered, and heart rate spectral variability was studied. Normalized units of low- and high-frequency components and the ratio of low to high frequency were measured during balloon inflations. The ST segment shifted at the first balloon inflation from 0.02 +/- 0.01 to 0.09 +/- 0.6 mm in group 1 and from 0.02 +/- 0.08 to 0.1 +/- 0.6 in group 2 mm (p <0.05). In group 1, the low-frequency band and the ratio of low to high frequency increased significantly during the first balloon inflation (from 59 +/- 10 to 75 +/- 10 normalized units and from 2.4 +/- 1.4 to 7.3 +/- 4.7, respectively; p <0.001). The increase of the ratio of low to high frequency was significantly related to ST shift (r = 0.706; p <0.01). In contrast, no significant variation of spectral parameters was found in group 2. The increase in cardiac sympathetic activity associated with balloon inflation and myocardial ischemia during percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery was selectively eliminated by hypnosis but not by drug sedation.

Comparison in patients having primary coronary angioplasty of abciximab versus tirofiban on recovery of left ventricular function.

In patients treated with primary coronary angioplasty, the use of abciximab improves microvascular perfusion and enhances the recovery of contractile function. This study compared the effects of the new dose regimen of tirofiban (25-microg/kg bolus followed by an 18-hour infusion at 0.15 microg/kg/min) on left ventricular function with those of abciximab in patients who underwent direct angioplasty. One hundred patients who underwent primary coronary angioplasty were randomized to receive a standard dose of abciximab or a large-dose bolus of tirofiban. The primary end point of the study was change in the infarct-zone wall motion score index between the initial and 30-day follow-up echocardiographic studies. The secondary end points were procedural evaluations before and after Thrombolysis In Myocardial Infarction (TIMI) grade flow, TIMI grade myocardial perfusion, and corrected TIMI frame count. Baseline global and regional ventricular functions were similar in the 2 treatment groups. After the procedure, a TIMI grade 3 flow was obtained in 86% of patients treated with abciximab and 88% of those receiving tirofiban (p = 1.0), whereas TIMI grade 3 myocardial perfusion was present in 70% and 76%, respectively (p = 0.65); corrected TIMI frame count was 22.5 +/- 1.9 and 22.1 +/- 2.5 (p = 0.37). After 30 days, we obtained 87 paired echocardiographic studies. The infarct-zone wall motion score index decreased from 2.20 +/- 0.3 to 1.99 +/- 0.2 in the abciximab group and from 2.18 +/- 0.3 to 1.95 +/- 0.3 in the tirofiban group (p = 0.67). Thus, in patients who had primary coronary angioplasty, abciximab, and the large-dose bolus of tirofiban showed similar effects on the initial angiographic results and 30-day recovery of left ventricular function.

Preliminary experience with a high bolus dose of tirofiban during percutaneous coronary intervention.

BACKGROUND: In the TARGET study, sub-optimal platelet inhibition with tirofiban was held responsible for the higher incidence of periprocedural CK-MB release compared to abciximab. Since then, a new, higher bolus dose of tirofiban has been proposed to increase blood concentrations very soon after the start of treatment. OBJECTIVE: The aim of this study was to explore the bleeding risk and clinical outcome at 30 days in a series of patients undergoing percutaneous coronary intervention (PCI) with the new dosing regimen of tirofiban (25 microg/kg bolus followed by a 0.15 microg kg(-1) min(-1) infusion for 18 h). METHODS: A total of 133 consecutive patients underwent a PCI and received a high bolus dose of tirofiban. Platelet function inhibition was measured using the Ultegra RPFA (Accumetrics) 10 min and 8 and 24 h after the start of therapy in the first 38 cases. RESULTS: The procedural success rate was 98.5%. The mean level of platelet inhibition 10 min after the start of therapy was 94.7 +/- 5.9%. No major bleedings, no need for red blood cell transfusion and no episodes of severe thrombocytopoenia were recorded. Groin haematoma was observed in seven patients (5.3%). The cumulative incidence of 30-day major adverse cardiovascular events was 4.6% (five myocardial infarctions and one repeat PTCA for sub-acute stent thrombosis). CONCLUSIONS: The use of a high bolus dose of tirofiban in patients undergoing PCI seems to be safe and not associated with an increased risk of major bleeding. This high bolus dose may help to further reduce the rate of periprocedural adverse events.

Six-month clinical and angiographic outcomes of the Tecnic Carbostent coronary system: the phantom IV study.

The aim of this multicenter, prospective, non-randomized study was to examine the procedural, in-hospital, and mid-term clinical and angiographic outcome of patients undergoing coronary angioplasty with the Tecnic Carbostent system. Between October 2001 and March 2002, 123 consecutive patients were treated with coronary implantation of the Tecnic Carbostent. Stable angina (54%), unstable angina (37%) and silent ischemia (9%) were clinical indications for revascularisation. The baseline lesion morphology was complex (Type B2 or C) in 59% of the cases, and the mean lesion length was 15+/-8 mm. A total of 179 stents were implanted in 149 lesions. The procedural success rate was 100%. Mean percent diameter of the stenosis decreased after the intervention from 75%+/-11% to 8%+/-4%. The mean cross-sectional area stent recoil was 8.8%+/-7.3%. No in-hospital or 30-day major adverse cardiac events were observed. During the 6-month follow-up period, there were no deaths or myocardial infarctions, whereas the incidence of target lesion revascularisation was 12.7%. The angiographic restenosis rate was 14.1%: a focal or limited pattern (class I or II) was found in 83% of cases, whereas the remaining 17% had a proliferative morphology (class III or IV). In conclusion, this study indicates that a good clinical and angiographic outcome may be obtained with the Tecnic Carbostent coronary system in consecutive patients with de novo coronary lesions.

Safety and efficacy of low-dose unfractionated heparin during percutaneous coronary revascularisation and the relationship between activated clotting time and haemorrhagic or ischaemic complications: our results.

OBJECTIVE: An inverse relation between the degree of heparin anticoagulation and the subsequent risk of postprocedural thrombotic complications was observed in the era of conventional balloon angioplasty, but the optimal dose of heparin during percutaneous coronary intervention (PCI) using newer interventional equipment and glycoprotein IIb/IIIa receptor inhibition has not been clearly defined. Previous studies did not assess the increased risk of adverse cardiac events with an activated clotting time of <200 s using strategies of routine stent placement and glycoprotein IIb/IIIa receptor inhibition. We hypothesised that the efficacy and safety of PCI would be maintained, if not improved, especially when performed in conjunction with glycoprotein IIb/IIIa receptor inhibitors (abciximab, tirofiban or eptifibatide as a bolus plus infusion for 12-18 h) and oral antiplatelet therapy (clopidogrel 75 mg plus aspirin 325 mg/day) associated with low doses (5000-10 000 U) of unfractionated heparin using a target activated clotting time of

Safety of a high bolus dose of tirofiban in patients undergoing coronary stent placement.

To overcome the suboptimal platelet inhibition induced by tirofiban in the first hour after a percutaneous coronary intervention, a new regimen of 25 microg/kg bolus followed by an 18-hr infusion of 0.15 microg/kg/min has been proposed. The aim of this study was to compare the effects of this high bolus dose of tirofiban with those of abciximab on bleeding risk and 30-day clinical outcome in patients undergoing coronary stenting. We compared two cohorts of patients who underwent coronary stent placement between January 2000 and December 2002. In the first cohort, the only available IIb/IIIa receptor inhibitor was abciximab, which was given to 280 (34.9%) out of 802 stented patients; in the second cohort, tirofiban was administered to 274 (38.3%) out of 716 treated patients. The primary endpoints were the proportion of patients with major bleeding and the rate of site access complications; the 30-day incidence of major adverse cardiac events (MACE) was also assessed. After the procedure, the patients were given ticlopidine for 4 weeks and aspirin indefinitely. Major bleeding episodes were observed in four patients receiving abciximab and in none receiving tirofiban (1.4% vs. 0%; P = 0.12); the rates of site access complications were similar (3.6% vs. 3.3%; P = 0.96). The 30-day incidence of MACE was 7.1% in the abciximab group and 5.8% in the tirofiban group (P = 0.65). In patients undergoing coronary stenting, the high bolus dose of tirofiban is safe and not associated with an increased risk of major bleeding or site access complications in comparison with abciximab.

Nonionic low-osmolar contrast media have no impact on major adverse cardiac events in patients undergoing coronary stenting with appropriate antiplatelet therapy.

The aim of this study was to assess the impact of two nonionic low-osmolar monomers (iopamidol and iopromide) and one ionic low-osmolar dimeric contrast medium (ioxaglate) on 30-day major adverse cardiac events in patients undergoing coronary interventions involving the use of new-generation stents and appropriate antiplatelet agents. Thirteen hundred and eight patients treated with stent implantation were randomized to receive ioxaglate (438 patients), iopamidol (442 patients), or iopromide (428 patients). Most of them (55%) had an acute coronary syndrome. Glycoprotein IIb/IIIa inhibitors were used in 37% of cases. All of the patients were on aspirin and ticlopidine for 1 month after the procedure. There was no significant between-group difference in the incidence of the primary composite endpoint of major adverse cardiac events 30 days after stenting (ioxaglate 3.6%; iopamidol 2.3%; iopromide 4.2%; P = 0.27). Adverse drug reactions were more frequent in the ioxaglate group (4.6% vs. 1.1% vs. 0.5%; P = 0.001). Multivariate analysis showed that intracoronary thrombus (P = 0.002), diabetes mellitus (P = 0.01), and postprocedure minimum lumen diameter (P = 0.04) independently correlated with an adverse outcome after 1 month. In conclusion, no significant differences in 30-day major ischemic complications were observed in this unselected population of patients undergoing coronary stenting who received ioxaglate, iopamidol, or iopromide. These data seem to suggest that the use of nonionic low-osmolar contrast media does not adversely affect stent patency.

Preliminary experience with the Tsunami coronary stent: immediate and six-month clinical and angiographic results.

The Tsunami is a new, balloon-expandable, stainless steel, tubular coronary stent whose design is based on a number of radial, diamond-shaped cells joined by double connectors. The aim of this two-centre, prospective, nonrandomized study was to examine the procedural, in-hospital, and long-term clinical and angiographic outcomes of patients undergoing angioplasty with the Tsunami stent. Sixty-one consecutive unselected patients were treated by means of the implantation of 74 Tsunami stents in 72 coronary lesions. Most of the patients (64%) had unstable angina or acute myocardial infarction. The baseline lesion morphology was complex in 76% of cases, and the mean lesion length was 14 +/- 6 mm. The procedural success rate was 98%. Mean percentage diameter of the stenosis decreased after the intervention from 79 +/- 12% to 10 +/- 6%. The in-hospital major adverse cardiac event rate was 3.3%. During the six-month follow-up, there was one cardiac death and nine subjects (14.5%) underwent target vessel revascularization. The six-month event-free survival rate was 80%. The angiographic restenosis rate was 17%: a focal or limited pattern (class I or II) was found in 43% of cases, whereas the remaining 57% had a proliferative morphology (class III or IV). In conclusion, this study indicates the good clinical and angiographic performance of the Tsunami coronary stent system in consecutive unselected patients.

Patterns of in-stent restenosis after placement of NIR gold-coated stents in unselected patients.

The aim of this study was to assess the incidence and angiographic patterns of in-stent restenosis 6 months after the implantation of NIR gold-coated stents in an unselected patient population. One hundred and sixteen consecutive patients were treated with the implantation of 149 NIR gold-coated stents. The majority of the patients (52%) had unstable angina or acute myocardial infarction. The baseline lesion morphology was complex in 78% of cases; the mean lesion length was 18 +/- 5 mm. The procedural success rate was 97%. Subacute stent thrombosis occurred in three patients (2.6%). During the 6-month follow-up, there were 2 deaths and 22 subjects (19.5%) underwent target vessel revascularization. The 6-month event-free survival was 60%. The angiographic restenosis rate was 32%. In 83% of the cases, the morphology of the restenosis was proliferative; in the remaining 17%, it presented as total occlusion. In conclusion, the restenosis rate after NIR gold-coated stent implantation in high-risk patients is similar to that reported using other stent designs. However, restenosis was always diffuse, involving the overall stent length and extending beyond the margins, thus indicating a greater proliferative neointimal response to this device.