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OBJECTIVES: The purpose of the current study was to use intravascular ultrasound (IVUS) to clarify anatomical and morphological lesion characteristics of uncrossable lesions. BACKGROUND: Uncrossable lesions are not always severely calcified. The prevalence of uncrossable lesions that are nonseverely calcified as well as other mechanisms for uncrossability has not been well clarified. METHODS: A total of 252 de novo uncrossable lesions in native coronary arteries that underwent either rotational or orbital atherectomy due to inability of any balloon to cross the lesion and 38 lesions with severe calcium in which IVUS crossed preatherectomy were included. Severe calcium is defined as maximum arc of calcium ≥270°. RESULTS: Severe calcification was absent in 16% of uncrossable lesions, 83% of which had a significant vessel bend. Compared with crossable lesions with severe calcium, uncrossable lesions with severe calcium more often had a bend in the vessel (71% vs. 21%, p < 0.001) and a longer length of continuous severe calcium (median length of calcium ≥270° 3.8 mm vs. 1.9 mm, p = 0.001). Other than severe calcium (especially long continuous calcium) or a bend in the vessel, anatomical factors associated with uncrossabilty were aorto-ostial lesion location and small vessels. CONCLUSIONS: Uncrossable lesions are not always severely calcified. The interaction of lesion morphology (continuous long and large arcs of calcium) and vessel geometry (bend in the vessel or ostial lesion location) affect lesion crossability.
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Aterectomia Coronária , Doença da Artéria Coronariana , Calcificação Vascular , Aterectomia Coronária/efeitos adversos , Cálcio , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Humanos , Resultado do Tratamento , Ultrassonografia de Intervenção , Calcificação Vascular/diagnóstico por imagemRESUMO
OBJECTIVES: We sought to determine the 1-year outcomes of patients receiving successful chronic total occlusion (CTO) percutaneous coronary intervention (PCI) procedures comparing subintimal versus intraplaque wire tracking patterns. BACKGROUND: CTO PCI utilizes both intraluminal and subintimal wire tracking to achieve successful percutaneous revascularization. Intravascular ultrasound (IVUS) can be used to precisely determine the path of wire tracking. METHODS: From 2014 to 2016, data from patients undergoing CTO PCI were collected in a single-center database. The primary composite endpoint was target vessel failure (TVF) defined as cardiovascular death, target vessel myocardial infarction (MI), or target vessel revascularization (TVR). RESULTS: In total 157 patients with successful CTO PCI and concomitant IVUS imaging completed 1-year follow-up. Subintimal tracking was detected in 53.5% of cases and those patients had a higher incidence of prior PCI, prior coronary artery bypass grafting, and higher J-CTO score. At 1-year, the unadjusted rate of TVF in the subintimal tracking group was higher than the intraplaque group (17.9 vs. 6.9%, HR 2.74, 95% CI 1.00-7.54, P = 0.04), driven by numerically higher rates of TVR and peri-procedural MI. After multivariable adjustment, no significant differences in the rates of the TVF between subintimal vs. intraplaque groups were present at 1-year (TVF: HR 1.51, 95% CI 0.38-6.00, P = 0.55). Landmark analysis excluding in-hospital events showed no significant differences in TVF to 1-year. CONCLUSIONS: IVUS-detected subintimal tracking was observed in over half of successful CTO PCI cases and correlated with baseline and angiographic factors that contributed to the overall rate of TVF at 1-year.
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Angioplastia Coronária com Balão , Oclusão Coronária/terapia , Vasos Coronários/diagnóstico por imagem , Placa Aterosclerótica , Ultrassonografia de Intervenção , Idoso , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/mortalidade , Doença Crônica , Angiografia Coronária , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/mortalidade , Oclusão Coronária/fisiopatologia , Vasos Coronários/fisiopatologia , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
AIMS: The feasibility, safety, and clinical utility of percutaneous coronary intervention (PCI) without radio-contrast medium in patients with advanced chronic kidney disease (CKD) are unknown. In this series, we investigated a specific strategy for 'zero contrast' PCI with the aims of preserving renal function and preventing the need for renal replacement therapy (RRT) in patients with advanced CKD. METHODS AND RESULTS: A total of 31 patients with advanced CKD [creatinine = 4.2 mg/dL, inter-quartile range (IQR) 3.1-4.8, estimated glomerular filtration rate = 16 ± 8 mL/min/1.73 m2] who had clinical indication for PCI based on a prior minimal contrast coronary angiogram were included. Zero contrast PCI was performed at least 1 week after diagnostic angiography using real-time intravascular ultrasound (IVUS) guidance, with pre- and post-PCI measurements of fractional flow reserve and coronary flow reserve to confirm physiological improvement. This approach resulted in successful PCI, no major adverse cardiovascular events and preservation of renal function without the need for RRT within a follow-up time of 79 days (IQR 33-207) in all patients. CONCLUSION: In patients with advanced CKD who require revascularization, PCI may safely be performed without contrast using IVUS and physiological guidance with high procedural success and without complications.
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Intervenção Coronária Percutânea , Angiografia Coronária , Creatinina , Humanos , Insuficiência Renal Crônica , Resultado do TratamentoRESUMO
OBJECTIVES: To describe our experience, at a large pediatric heart transplant center, with percutaneous coronary interventions (PCI) for cardiac allograft vasculopathy (CAV). BACKGROUND: CAV is a leading cause of late graft failure, mortality, and re-transplantation in pediatric heart transplant (HTx) recipients. Studies of PCI in adult patients have shown some short-term improvements, but no significant change in long-term outcomes. There are limited data on PCI for CAV in pediatric patients. We describe the largest single-center experience to date. METHODS: We performed a retrospective chart review of all pediatric HTx recipients who underwent PCI for a diagnosis of CAV from 2005 to 2014. RESULTS: Twenty-three procedures were performed in 13 patients, at a median age of 16.4 years (range 5.6-21.2) and median time from HTx to first PCI of 8.3 years (range 2.9-20.3). Three cases consisted of angioplasty alone, two cases had bare metal stents implanted, and the remaining 18 had drug-eluting stents implanted. There was acute procedural success in all but one case, and there was only one procedure-related complication (rebleeding from access site). During the follow-up interval (median 10.4 months, range 0.2-111.8), 7/13 patients had repeat PCI performed, two patients died (at 1.8 and 5.8 months post-PCI), and five were re-transplanted (range 0.2-18 months post-PCI). Freedom from death or retransplant by Kaplan-Meier analysis was 54% at 1 year. CONCLUSIONS: PCI can be performed safely and effectively in pediatric HTx recipients with CAV. Similar to the adult experience, there remains a high rate of disease progression and graft failure. © 2016 Wiley Periodicals, Inc.
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Doença da Artéria Coronariana/cirurgia , Stents Farmacológicos , Transplante de Coração/efeitos adversos , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias , Adolescente , Adulto , Criança , Pré-Escolar , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/etiologia , Progressão da Doença , Feminino , Seguimentos , Transplante de Coração/mortalidade , Humanos , Lactente , Masculino , New York/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Adulto JovemRESUMO
Background: While not available for clinical use in the United States, dedicated drug-coated balloons (DCB) are currently under investigation for the management of coronary in-stent restenosis (ISR). Peripheral drug-coated balloons (P-DCB) have been used off-label for coronary ISR. Further data regarding this practice are needed. We aimed to describe outcomes in patients who underwent off-label P-DCB angioplasty for coronary ISR. Methods: We analyzed data on P-DCB angioplasty for coronary ISR at a single high-volume center between April 1, 2015, and December 30, 2017. Demographic and procedural details were collected, with systematic follow-up as clinically indicated. Results: Data from 31 patients treated with P-DCB angioplasty (mean age 68.0 ± 10.7 years) with coronary ISR (17 recurrent and 14 first time) were analyzed. Most patients presented with high-grade angina (81%) or myocardial infarction (13%). Treated ISR lesions were in native coronary arteries (68%), saphenous vein grafts (SVG, 23%), and the left internal mammary artery (10%). Diffuse intrastent ISR was common (69%) with a mean lesion length of 21.7 ± 12.4 mm. No postprocedural myocardial infarction occurred and 1 nonprocedural mortality occurred during index admission. At follow-up (median: 283, interquartile range [IQR]: 354 days), repeat angiography was performed in 19 patients (median: 212, IQR: 188 days), and 11 patients had target lesion recurrent ISR (Kaplan-Meier event-free survival estimate: 44.7%, 95% CI, 26.1%-76.5%). Conclusions: In the absence of availability of dedicated coronary DCB, treatment of coronary ISR using P-DCB angioplasty was feasible, although follow-up demonstrated continued risk for recurrent ISR in this high-risk population.
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BACKGROUND: Outcomes after percutaneous coronary intervention (PCI) for de novo ostial right coronary artery (RCA) lesions are poor. AIMS: We used intravascular ultrasound (IVUS) to clarify the morphological patterns of de novo ostial RCA lesions and their associated clinical outcome. METHODS: Among 5,102 RCA IVUS studies, 170 de novo ostial RCA stenoses (within 3 mm from the aorto-ostium) were identified. These were classified as 1) isolated ostial lesions (no disease extending beyond 10 mm from the ostium and without a calcified nodule [CN]); 2) ostial CN, typically with diffuse disease (disease extending beyond 10 mm); and 3) ostial lesions with diffuse disease but without a CN. The primary outcome was target lesion failure (TLF: cardiac death, target vessel myocardial infarction, definite stent thrombosis, and ischaemia-driven target lesion revascularisation). RESULTS: The prevalence of an isolated ostial lesion was 11.8% (n=20), 47.6% (n=81) were ostial CN, and 40.6% (n=69) were ostial lesions with diffuse disease. Compared to ostial lesions with diffuse disease, isolated lesions were more common in women (75.0% vs 42.0%; p=0.01), and CN were associated with older age (median [first, third quartile] 76 [70, 83] vs 69 [63, 81] years old; p=0.002). The Kaplan-Meier rate of TLF at 2 years was significantly higher in patients with CN (21.6%) compared to diffuse lesions (8.2%) (p=0.04), and patients with isolated lesions had no events. A multivariable Cox proportional hazard model revealed that CN were significantly associated with TLF (hazard ratio 6.63, 95% confidence interval: 1.28-34.3; p=0.02). CONCLUSIONS: Ostial RCA lesions have specific morphologies - detectable by IVUS - that may be associated with long-term clinical outcomes.
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Doença da Artéria Coronariana , Stents Farmacológicos , Intervenção Coronária Percutânea , Humanos , Feminino , Idoso de 80 Anos ou mais , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Doença da Artéria Coronariana/etiologia , Intervenção Coronária Percutânea/efeitos adversos , Resultado do Tratamento , Fatores de Risco , Angiografia CoronáriaRESUMO
BACKGROUND: Intravascular ultrasound (IVUS) studies show that one-quarter of left anterior descending (LAD) arteries have a myocardial bridge. An MB may be associated with stent failure when the stent extends into the MB. OBJECTIVES: The aim of this study was to investigate: 1) the association between an MB and chronic total occlusion (CTO) in any LAD lesions; and 2) the association between an MB and subsequent clinical outcomes after percutaneous coronary intervention in LAD CTOs. METHODS: A total of 3,342 LAD lesions with IVUS-guided percutaneous coronary intervention (280 CTO and 3,062 non-CTO lesions) were included. The primary outcome was target lesion failure (cardiac death, target vessel myocardial infarction, definite stent thrombosis, and ischemic-driven target lesion revascularization). RESULTS: An MB by IVUS was significantly more prevalent in LAD CTOs than LAD non-CTOs (40.4% [113/280] vs 25.8% [789/3,062]; P < 0.0001). The discrepancy in CTO length between angiography and IVUS was greater in 113 LAD CTOs with an MB than 167 LAD CTOs without an MB (6.0 [Q1, Q3: 0.1, 12.2] mm vs 0.2 [Q1, Q3: -1.4, 8.4] mm; P < 0.0001). Overall, 48.7% (55/113) of LAD CTOs had a stent that extended into an MB after which target lesion failure was significantly higher compared to a stent that did not extend into an MB (26.3% vs 0%; P = 0.0004) or compared to an LAD CTO without an MB (26.3% vs 9.6%; P = 0.02). CONCLUSIONS: An MB was more common in LAD CTO than non-CTO LAD lesions. If present, approximately one-half of LAD CTOs had a stent extending into an MB that, in turn, was associated with worse outcomes.
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Oclusão Coronária , Infarto do Miocárdio , Intervenção Coronária Percutânea , Humanos , Oclusão Coronária/diagnóstico por imagem , Oclusão Coronária/terapia , Resultado do Tratamento , Intervenção Coronária Percutânea/efeitos adversos , Angiografia Coronária , Doença CrônicaRESUMO
OBJECTIVES: This study sought to evaluate the safety and feasibility of a magnetic medical positioning system (MPS) to determine the three-dimensional (3D) position and orientation of intracoronary wires and catheters and to guide angiography and percutaneous coronary intervention (PCI). BACKGROUND: Coronary angiography relies on fluoroscopy for catheter navigation and often fails to accurately portray vessel tortuosity, overlap, and length because of complex anatomy and foreshortening of curved coronary segments. METHODS: Forty adult participants underwent coronary angiography and/or PCI with MPS guidance. Two interventional cardiologists independently scored (1-5) the accuracy of MPS catheter tracking projected on live fluoroscopy, recorded cine loops, and 3D vessel reconstructions. Measurements from MPS reconstructions were compared to conventional two-dimensional (2D) quantitative coronary angiography (QCA) measurements. Device procedural success was defined as the ability of the MPS-enabled catheter to reach the target vessel, perform the intended operations, and be retrieved without major adverse cardiac events. RESULTS: Diagnostic coronary angiography was performed in 19 (47.5%) and PCI in 21 patients (52.5%). MPS procedural success was achieved in 36 (90%) of the cases. MPS accuracy was highest with the MPS superimposed on live fluoroscopy (4.9 ± 0.2/5) and the 3D vessel reconstruction (4.7 ± 0.5/5). MPS length measurements were more accurate than conventional QCA. CONCLUSIONS: This study demonstrates the feasibility and safety of magnetic catheter tracking with 3D positional data during diagnostic angiography and PCI. Catheter position was accurately projected on real-time fluoroscopy, recorded cine loops, and 3D reconstructions. An MPS may serve as a platform for device navigation and positioning during PCI.
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Angiografia Coronária/métodos , Vasos Coronários/diagnóstico por imagem , Magnetismo/métodos , Intervenção Coronária Percutânea/métodos , Radiografia Intervencionista/métodos , Terapia Assistida por Computador/métodos , Idoso , Cateteres Cardíacos , Angiografia Coronária/efeitos adversos , Angiografia Coronária/instrumentação , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Fluoroscopia , Alemanha , Humanos , Imageamento Tridimensional , Magnetismo/instrumentação , Imãs , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/instrumentação , Valor Preditivo dos Testes , Interpretação de Imagem Radiográfica Assistida por Computador , Radiografia Intervencionista/instrumentação , Terapia Assistida por Computador/instrumentaçãoRESUMO
Acute coronary syndromes (ACS) remain one of the leading causes of cardiovascular morbidity and mortality in the United States and around the world. Because of the acute nature of ACS presentations, timely identification, risk stratification, and intervention are of the utmost importance. Twenty years ago, we published the first iteration of our institutional chest pain clinical pathway in this journal, which separated patients presenting with chest pain into one of the 4 levels of decreasing acuity, with associated actions and interventions for providers based on the level. This chest pain clinical pathway has undergone regular review and updates under a collaborative team of cardiologists, emergency department physicians, cardiac nurse practitioners, and other associated stakeholders in the treatment of patients presenting with chest pain. This review will discuss the key changes that our institutional chest pain algorithm has undergone over the last 2 decades and what the future holds for chest pain algorithms.
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Síndrome Coronariana Aguda , Cardiologistas , Humanos , Dor no Peito , Coração , AlgoritmosRESUMO
Clinical pathways are useful tools for conveying and reinforcing best practices to standardize care and optimize patient outcomes across myriad conditions. The NewYork-Presbyterian Healthcare System has utilized a clinical chest pain pathway for more than 20 years to facilitate the timely recognition and management of patients presenting with chest pain syndromes and acute coronary syndromes. This chest pain pathway is regularly updated by an expanding group of key stakeholders, which has extended from the Columbia University Irving Medical Center to encompass the entire regional healthcare system, which includes 8 hospitals. In this 2023 update of the NewYork-Presbyterian clinical chest pain pathway, we present the key changes to the healthcare system-wide clinical chest pain pathway.
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Síndrome Coronariana Aguda , Humanos , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Procedimentos Clínicos , Dor no Peito/diagnóstico , Dor no Peito/etiologia , Dor no Peito/terapia , Atenção à SaúdeRESUMO
BACKGROUND: Despite a high rate of in-stent restenosis (ISR) after stenting the right coronary artery (RCA) ostium, the mechanism of ostial RCA ISR is not well understood. AIMS: We aimed to clarify the cause of ostial RCA ISR using intravascular ultrasound (IVUS). METHODS: Overall, 139 ostial RCA ISR lesions were identified with IVUS, pre-revascularisation. Primary ISR mechanisms were classified as follows: 1) neointimal hyperplasia (NIH); 2) neoatherosclerosis; 3) ostium not covered by the stent; 4) stent fracture or deformation; 5) stent underexpansion (old minimum stent area <4.0 mm2 or stent expansion <50%); or 6) a protruding calcified nodule. RESULTS: The median duration from prior stenting was 1.2 (first quartile 0.6, third quartile 3.1) years. The primary mechanisms of ISR were NIH in 25% (n=35) of lesions, neoatherosclerosis in 22% (n=30), uncovered ostium in 6% (n=9) (biological cause 53%, n=74), stent fracture or deformation in 25% (n=35), underexpansion in 11% (n=15), and protruding calcified nodules in 11% (n=15) (mechanical cause 47%, n=65). Including secondary mechanisms, 51% (n=71) of ostial RCA ISRs had stent fractures that were associated with greater hinge motion of the ostial-aorta angle during the cardiac cycle. The Kaplan-Meier rate of target lesion failure at 1 year was 11.5%. When the mechanically caused ISRs were treated without new stents, they suffered a higher subsequent event rate (41.4%) compared with non-mechanical causes or mechanical causes treated without restenting (7.8%, unadjusted hazard ratio 6.44, 95% confidence interval: 2.33-17.78; p<0.0001). CONCLUSIONS: Half of the ostial RCA ISRs were due to mechanical causes. Subsequent event rates were high, especially in mechanically caused ISRs treated without the implantation of a new stent.
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Reestenose Coronária , Humanos , Reestenose Coronária/diagnóstico por imagem , Reestenose Coronária/etiologia , Reestenose Coronária/terapia , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , Angiografia Coronária/efeitos adversos , Resultado do Tratamento , Stents/efeitos adversosRESUMO
BACKGROUND: Although the presence of severe stenosis in the left main coronary artery (LMCA) is a well-established predictor of mortality, whether this extends to nonobstructive atherosclerosis in the LMCA is unknown. OBJECTIVES: The aim of this study was to evaluate the association between LMCA disease by intravascular ultrasound (IVUS) and long-term mortality. METHODS: Between 2005 and 2013, 3,239 patients with LMCA IVUS imaging without LMCA revascularization (either before angiography or scheduled based on index angiography or IVUS) were included. The primary and secondary endpoints were all-cause and cardiac mortality at a minimum of 5 years obtained from the National Death Index. RESULTS: The IVUS-measured LMCA minimum lumen area (MLA) and plaque burden were 13.1 ± 5.0 mm2 and 41.7% ± 15.6%, respectively. The median follow-up was 8.2 years. The Kaplan-Meier estimated 12-year all-cause and cardiac death rates were 37.5% and 17.0%, respectively. Greater plaque burden (unadjusted HR per 10%: 1.17; 95% CI: 1.12-1.22; P < 0.0001) and smaller IVUS MLA (unadjusted HR per 1 mm2: 0.98; 95% CI: 0.96-0.99; P = 0.0008) were associated with all-cause death. After adjusting for clinical, angiographic, and IVUS factors, plaque burden (adjusted HR per 10%: 1.12; 95% CI: 1.04-1.21; P = 0.003) but not MLA (adjusted HR per 1 mm2: 1.02; 95% CI: 0.99-1.04; P = 0.18) was associated with long-term all-cause death. These findings were also consistent for long-term cardiac mortality. CONCLUSIONS: In the present large-scale study with a 12-year follow-up, increasing LMCA plaque burden was associated with long-term all-cause and cardiac mortality in patients not undergoing LMCA revascularization, even when the lumen area was preserved.
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Aterosclerose , Doença da Artéria Coronariana , Placa Aterosclerótica , Humanos , Vasos Coronários/diagnóstico por imagem , Angiografia Coronária/métodos , Ultrassonografia de Intervenção/métodos , Resultado do Tratamento , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapiaRESUMO
[Figure: see text].
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Aterectomia Coronária , Doença da Artéria Coronariana , Intervenção Coronária Percutânea , Calcificação Vascular , Cálcio , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/terapia , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Stents , Resultado do Tratamento , Ultrassonografia de Intervenção , Calcificação Vascular/diagnóstico por imagem , Calcificação Vascular/terapiaRESUMO
OBJECTIVES: To evaluate the outcome of patients with coronary perforations who were treated with the dual catheter approach. BACKGROUND: Coronary artery perforation is a grave complication of percutaneous coronary intervention (PCI) with high mortality and morbidity. Treating a coronary artery perforation with two catheters through dual access enables a rapid delivery of covered stent or coils to the vessel, without losing control of the perforation site. METHODS: We retrospectively reviewed all patients who had a severe coronary perforation during a PCI in our center, and compared outcomes of patients treated with the dual versus the traditional single guiding catheter approach. RESULTS: Between April 2004 and October 2008, 13,466 PCI's were performed in Columbia University - New York Presbyterian Medical Center. There were 33 documented cases of coronary perforations during that period of time (0.245%), among these, 26 were angiographically severe (Ellis type 2 or 3 perforations). Eleven patients were treated acutely with a dual catheter technique whereas the other fifteen patients were treated using a single guiding catheter. In the dual catheter group one patient expired after emergent CABG (9.1%), and four patients underwent emergent paricardiocentesis (36.4%). In patients treated with single catheter, there were three deaths (20%), two surgical explorations (13.3%), eight emergent pericardiocenthesis (53.3%), and one event of severe anoxic brain damage (6.7%). CONCLUSION: The dual catheter technique is a relatively safe and reproducible approach to treat a PCI induced severe coronary artery perforation, and may improve outcome compared to historical series.
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Angioplastia Coronária com Balão/efeitos adversos , Oclusão com Balão/métodos , Cateterismo Cardíaco/métodos , Vasos Coronários/lesões , Doença Iatrogênica , Ferimentos Penetrantes/terapia , Centros Médicos Acadêmicos , Idoso , Oclusão com Balão/efeitos adversos , Oclusão com Balão/instrumentação , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/instrumentação , Angiografia Coronária , Feminino , Humanos , Masculino , Cidade de Nova Iorque , Estudos Retrospectivos , Ruptura , Índice de Gravidade de Doença , Stents , Resultado do Tratamento , Ferimentos Penetrantes/diagnóstico por imagem , Ferimentos Penetrantes/etiologiaRESUMO
Percutaneous treatment of saphenous vein graft (SVG) lesions has been associated with higher rates of periprocedural complications and restenosis compared with non-SVG lesions. Whether these outcomes are similar in contemporary clinical practice, particularly when drug-eluting stents are used, is unknown. We evaluated outcomes of 110 consecutive patients who were treated with stent-assisted percutaneous coronary intervention for 145 SVG lesions (drug-eluting stents used in 91.0% of lesions). Embolic protection devices were used in 52.1% of treated grafts. Adverse events were recorded up to 1 year. Major or minor periprocedural myocardial necrosis occurred in 11 patients (10.9%). At 1-year clinical follow-up, we observed 13 myocardial infarctions (13.7%), 8 target lesion revascularizations (8.4%), 18 target vessel revascularizations (19.0%), 2 stent thromboses (2.1%), and 7 deaths (7.4%). The incidence of major adverse cardiac events, defined as death, myocardial infarction, or target vessel revascularization, was 30.5% at 1 year. By multivariable analysis, the presence of thrombus inside the graft before the procedure and the length of the stented segment were independent predictors of major adverse cardiac events at 1 year (hazard ratio for thrombus 4.07, 95% confidence interval 1.90 to 8.68, p = 0.0003; hazard ratio per millimeter of stented length 1.02, 95% confidence interval 1.01 to 1.03, p = 0.025). In conclusion, our data show that patients with SVG lesions remain a high-risk subgroup with worse outcomes after percutaneous coronary intervention compared with native vessel disease even in the era of drug-eluting stents.
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Angioplastia Coronária com Balão , Oclusão de Enxerto Vascular/terapia , Veia Safena/transplante , Stents , Trombose/terapia , Idoso , Angiografia Coronária , Ponte de Artéria Coronária , Feminino , Seguimentos , Oclusão de Enxerto Vascular/mortalidade , Humanos , Masculino , Análise Multivariada , Infarto do Miocárdio/epidemiologia , Miocárdio/patologia , Necrose , Paclitaxel/administração & dosagem , Estudos Prospectivos , Desenho de Prótese , Sistema de Registros , Retratamento , Sirolimo/administração & dosagem , Trombose/mortalidadeAssuntos
Marcadores Fiduciais , Órgãos em Risco/diagnóstico por imagem , Proteção Radiológica/instrumentação , Radiodermite/diagnóstico por imagem , Radiodermite/etiologia , Radiografia Intervencionista/efeitos adversos , Radiografia Intervencionista/instrumentação , Desenho de Equipamento , Análise de Falha de Equipamento , Fluoroscopia/efeitos adversos , Fluoroscopia/instrumentação , Humanos , Radiodermite/prevenção & controleRESUMO
American archeology has long been polarized over the issue of a human presence in the Western Hemisphere earlier than Clovis. As evidence of early sites across North and South America continues to emerge, stone tool assemblages appear more geographically and temporally diverse than traditionally assumed. Within this new framework, the prevailing models of Clovis origins and the peopling of the Americas are being reevaluated. This paper presents age estimates from a series of alluvial sedimentary samples from the earliest cultural assemblage at the Gault Site, Central Texas. The optically stimulated luminescence age estimates (~16 to 20 thousand years ago) indicate an early human occupation in North America before at least ~16 thousand years ago. Significantly, this assemblage exhibits a previously unknown, early projectile point technology unrelated to Clovis. Within a wider context, this evidence suggests that Clovis technology spread across an already regionalized, indigenous population.
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Arqueologia , Fósseis/história , História Antiga , Atividades Humanas/história , Humanos , América do Norte , Tecnologia , TexasRESUMO
BACKGROUND: Angiographic assessment of a left main coronary artery stenosis (LMCS) is often difficult and unreliable. We aimed to evaluate the severity of ambiguous LMCSs by intravascular ultrasound (IVUS) and to clarify how frequently significant stenosis occurs in the "real world". METHODS: We retrospectively found 115 consecutive patients in our clinical IVUS database with a de novo, angiographically ambiguous, intermediate LMCS who underwent IVUS evaluation. Quantitative coronary angiography (QCA) and IVUS analyses were performed. We define a significant LMCS as a diameter stenosis >50% by QCA and a minimal lumen area <6.0 mm2 by IVUS. RESULTS: Ostial, mid, and distal LMCSs were seen in 44 (38.3%), 6 (5.2%), and 65 (56.5%) lesions. Overall, IVUS minimal lumen area and plaque burden measured 6.8 +/- 2.6 mm2 and 63% +/- 14%. A significant LMCS was seen in 51 (44.3%) lesions by IVUS but in only 15 (13.0%) lesions by QCA. In particular, only 36.4% of ostial lesions had a significant IVUS stenosis, and minimal lumen diameter by QCA was less well correlated with IVUS in ostial lesions than in other lesion locations. CONCLUSIONS: This real-world IVUS analysis showed that less than half of intermediate LMCSs had significant stenoses by IVUS assessment, especially for lesions located at the left main ostium. Such patients deserve IVUS assessment or physiologic assessment before blindly proceeding to revascularization.
Assuntos
Estenose Coronária/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Ultrassonografia de Intervenção/métodos , Idoso , Angiografia Coronária , Feminino , Seguimentos , Humanos , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
Importance: Although much less frequent than in adults, coronary artery disease requiring revascularization may develop in children because of homozygous familial hypercholesterolemia or other underlying conditions. Percutaneous coronary intervention (PCI) with a bioresorbable scaffold (BRS) may have advantages over metallic coronary stents in this population. Objective: To present a case of the successful treatment of unstable, multivessel coronary artery disease in a child with PCI with BRS implantation. This case highlights the limitations of conventional metal stents and the potential benefits of using BRSs in children. Design, Setting, and Participants: This is a case report from an academic tertiary care institution of a 3-year-old boy with homozygous familial hypercholesterolemia and unstable coronary artery disease requiring revascularization. We also briefly review the related literature. Interventions/Exposures: Intravascular imaging-guided PCI of the proximal right coronary artery and the left main and proximal left circumflex arteries was performed with BRSs. Main Outcomes and Measures: The primary outcomes were acute procedural success and survival to liver transplant (3 months after PCI). Results: Following BRS implantation, the patient recovered and remained free of cardiovascular symptoms 3 months after PCI. He subsequently underwent an orthotopic liver transplant for definitive treatment of homozygous familial hypercholesterolemia but died of noncardiac complications. A postmortem examination, including a histological assessment, revealed both BRSs to be patent with nonobstructive neointimal hyperplasia. Conclusions and Relevance: To our knowledge, this is the first report of PCI with BRSs in a child. This represents an application of a BRS with potentially important implications for the future treatment of coronary artery disease in children and warrants further study.
Assuntos
Implantes Absorvíveis , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/cirurgia , Intervenção Coronária Percutânea/métodos , Alicerces Teciduais , Pré-Escolar , Doença da Artéria Coronariana/diagnóstico , Vasos Coronários/diagnóstico por imagem , Humanos , Masculino , Ultrassonografia de IntervençãoRESUMO
Simple pebble tools, ephemeral cultural features, and the remains of maritime and terrestrial foods are present in undisturbed Late Pleistocene and Early Holocene deposits underneath a large human-made mound at Huaca Prieta and nearby sites on the Pacific coast of northern Peru. Radiocarbon ages indicate an intermittent human presence dated between ~15,000 and 8000 calendar years ago before the mound was built. The absence of fishhooks, harpoons, and bifacial stone tools suggests that technologies of gathering, trapping, clubbing, and exchange were used primarily to procure food resources along the shoreline and in estuarine wetlands and distant mountains. The stone artifacts are minimally worked unifacial stone tools characteristic of several areas of South America. Remains of avocado, bean, and possibly cultivated squash and chile pepper are also present, suggesting human transport and consumption. Our new findings emphasize an early coastal lifeway of diverse food procurement strategies that suggest detailed observation of resource availability in multiple environments and a knowledgeable economic organization, although technologies were simple and campsites were seemingly ephemeral and discontinuous. These findings raise questions about the pace of early human movement along some areas of the Pacific coast and the level of knowledge and technology required to exploit maritime and inland resources.