A novel strategy for stent deployment in the treatment of acute or threatened closure complicating balloon coronary angioplasty. Use of short or standard (or both) single or multiple Palmaz-Schatz stents.

OBJECTIVES: The purpose of this study was to determine the immediate and long-term angiographic and clinical results of coronary stenting as a specific therapy for intracoronary dissection associated with acute or threatened closure complicating percutaneous transluminal coronary angioplasty. BACKGROUND: Published reports contain conflicting results with regard to the benefit of stent insertion for coronary dissection. In particular, there is a wide range in the reported rates of subacute occlusion. METHODS: Palmaz-Schatz stents were inserted in 56 patients who had significant dissections and acute or threatened closure complicating coronary angioplasty. An attempt was made to cover the entire site of the dissection with short or standard single or multiple Palmaz-Schatz stents. The use of the short stent allowed complete coverage of the dissection, specifically in situations such as marked vessel tortuosity or the need to place a stent distal to a deployed stent. RESULTS: A single stent was implanted in 24 patients and multiple stents were implanted in 32 patients. A total of 138 stents (78 standard, 60 short stents) were implanted. The primary clinical success rate was 88% (49 of 56 patients). Complications occurred in seven patients (12.5%): Three patients (5%) required urgent bypass surgery; two patients (4%) had a myocardial infarction; and two patients (4%) died. Subacute occlusion occurred in one patient (2%). Clinical follow-up was available in all patients at a mean of 10 +/- 4 months. Thirty-nine (80%) of 49 patients were clinically asymptomatic. Angiographic restenosis was found in 15 (36%) of 42 patients on angiographic follow-up performed a mean of 5 months (median 6) after the procedure in 86% of the eligible patients. Nine patients had successful repeat angioplasty, and two had elective bypass surgery. CONCLUSIONS: The strategy of coronary stenting to completely cover the lesion is an effective treatment for large coronary dissection complicating angioplasty. A total major complication rate of 12.5% may be acceptable for this high risk group.

Intracoronary stent insertion after balloon angioplasty of chronic total occlusions.

OBJECTIVES: This retrospective analysis was performed to assess the medium-term effectiveness of implanting intracoronary stents into chronic total occlusions that are successfully opened by balloon angioplasty. BACKGROUND: The value of percutaneous transluminal coronary angioplasty of chronic total occlusions is limited by a very high restenosis rate of 50% to 68%. Intravascular stents have been shown to reduce restenosis in a subset of patients with subtotal stenoses. It has not been demonstrated that the placement of stents into successfully opened chronic total coronary artery occlusions leads to lower rates of restenosis. METHODS: A consecutive series of patients with chronic total coronary occlusions successfully opened by balloon angioplasty received Palmaz-Schatz stents. Patients underwent clinical and angiographic follow-up at a mean of 6 months after stent insertion. Angiographic and clinical results were retrospectively analyzed. RESULTS: Fifty-nine patients underwent stenting of 60 chronic total coronary occlusions, with a 98% rate of successful stent deployment. Complications occurred in 5% of cases, all with subacute thrombosis. Angiographic follow-up was obtained in 88% of patients at a mean of 6 months and demonstrated an angiographic restenosis rate of 20%, with only one reocclusion. Among several variables examined, only the presence of a procedure-related moderate to severe dissection was associated with higher follow-up percent diameter stenoses and clinical events. At a mean of 14 months after stent insertion, 77% of patients remained free of symptoms or clinical events. CONCLUSIONS: The implantation of intracoronary stents into vessels with opened chronic total coronary occlusions is associated with favorable rates of angiographic restenosis and relief of symptoms. A randomized clinical trial comparing balloon angioplasty with stent-assisted balloon angioplasty in the treatment of chronic total coronary occlusions is indicated.

High pressure assisted coronary stent implantation accomplished without intravascular ultrasound guidance and subsequent anticoagulation.

OBJECTIVES: The purpose of this study was to determine the efficacy of treatment with antiplatelet therapy and no anticoagulation after high pressure assisted coronary stent implantation performed without intravascular ultrasound (IVUS) guidance. BACKGROUND: Previous studies have shown that during IVUS-guided Palmaz-Schatz coronary stenting, it is safe to withhold anticoagulation when stent expansion has been optimized by high pressure balloon dilation. METHODS: Patients that had successful coronary stenting without IVUS guidance were treated with ticlopidine, 500 mg/day, and aspirin, 325 mg/day, for 1 month and then received only aspirin, 325 mg/day, indefinitely. Patients were not treated with warfarin (Coumadin) or heparin after successful stenting. Clinical and angiographic events were assessed at 1 month. RESULTS: A total of 201 intracoronary stents were implanted in 127 patients with 137 lesions. The average number of stents per lesion was 1.4 +/- 0.8, and the average number of stents per patient was 1.6 +/- 1.1. Stent deployment was performed for elective indications in 79% of procedures and for emergency indications in 21%. There were four stent thrombosis events for a per patient event rate of 3.1% and a per lesion event rate of 2.9%. CONCLUSIONS: After high pressure assisted stenting performed without IVUS guidance, there was an acceptable incidence of 3.1% of stent thrombosis with the combination of short-term ticlopidine and aspirin therapy and no anticoagulation. Although the study involved only 127 patients, the results support the relative safety of stenting without IVUS guidance and with antiplatelet therapy only in comparison to historical trials on stenting performed with postprocedure anticoagulation.

Benefit of intracoronary ultrasound in the deployment of Palmaz-Schatz stents.

OBJECTIVES: This study was designed to evaluate the changes in intrastent and angiographic dimensions when intravascular ultrasound imaging is used to direct the deployment of balloon-expandable Palmaz-Schatz stents in coronary arteries and saphenous vein grafts. BACKGROUND: Intravascular ultrasound provides more information than angiography in the imaging of intravascular structures. Previous studies have shown that obtaining a larger lumen (greater "acute gain") with coronary interventions such as stenting leads to less restenosis and subacute thrombosis. It is not clear whether the information obtained by intravascular ultrasound can be used to obtain a greater acute gain in lumen dimensions. METHODS: Forty consecutive patients undergoing Palmaz-Schatz stent implantation had intravascular ultrasound imaging performed after a good angiographic appearance was obtained. If the stent did not appear adequately expanded by intravascular ultrasound, or if the struts were poorly apposed to the arterial wall, further stent dilation with larger balloons or higher pressure inflations were performed. Twenty-nine patients had subsequent intravascular ultrasound imaging. Intrastent diameters and areas were compared from the initial to the final intravascular ultrasound studies. RESULTS: Of the 40 patients studied, only 5 (13%) had an adequate result by intravascular ultrasound despite an acceptable angiographic appearance in all patients. Six additional patients did not undergo subsequent intravascular ultrasound imaging. The other 29 patients all demonstrated a significant increase in intrastent minimal diameter (mean 19%), major diameter (11%) and cross-sectional area (34%) (p < 0.001 for all measurements). CONCLUSIONS: The use of intravascular ultrasound imaging in the deployment of balloon-expandable Palmaz-Schatz stents leads to a significant increase in intrastent dimensions (greater "acute gain").

Dipyridamole technetium-99m-2-methoxy isobutyl isonitrile tomoscintigraphic imaging for identifying diseased coronary vessels: comparison with thallium-201 stress-rest study.

A same-day double injection protocol employing 99mTc-methoxyisobutyl isonitrile (MIBI) and myocardial single-photon emission computed tomography (SPECT) for detecting coronary artery disease (CAD) was assessed in 30 patients. SPECT was performed 1 hr after a first injection (250 MBq) of 99mTc-MIBI, given after 0.56 mg/kg dipyridamole (DPD) infusion. Patients were then reinjected at rest (750 MBq) and were reimaged 1 hr later. Within 1 wk, all patients underwent a complete stress-rest SPECT thallium study. Of the 330 myocardial segments evaluated, 25 were judged ischemic by both techniques, while persistent defects were demonstrated in 50 and in 47 with 99mTc-MIBI and 201TI, respectively. Six regions were considered for diseased vessels identification. Sensitivity and specificity for CAD were 100% and 75%, respectively, for both 201TI and 99mTc-MIBI. Sensitivity for identification of diseased vessels by 201TI was 68% for LAD, 89% for RCA, and 80% for LCX as opposed to 75%, 89% and 80%, respectively, by 99mTc-MIBI. Specificity was 93% in both cases for LAD, 73% and 63% for RCA, and 53% and 46% for LCX.

Usefulness of nicorandil in congestive heart failure.

Rest and exercise hemodynamic and hormonal effects of nicorandil, a nicotinamide-nitrate vasodilator, were assessed in 9 patients with New York Heart Association class II or III congestive heart failure (CHF) and left ventricular ejection fraction less than or equal to 40%. Single oral doses of placebo and 40 and 60 mg of nicorandil were given in a double-blind, randomized trial. Hemodynamic measurements were assessed at rest, up to 8 hours after dose and at peak exercise performed on an upright cycloergometer 1 hour after the dose. Forearm blood flow and venous capacitance were measured by plethysmography 45 minutes after dose. Plasma noradrenaline and plasma renin activity were assessed 1 hour and 2 hours after dose, respectively. Data were analyzed by analysis of variance. Peak effects were observed between 30 and 60 minutes after dose. Mean blood pressure decreased from 86 +/- 7 mm Hg after placebo to 78 +/- 7 mm Hg after 40 mg (p less than 0.05) and to 78 +/- 7 mm Hg after 60 mg (p less than 0.05) of nicorandil. Mean pulmonary artery pressure decreased from 24 +/- 11 to 15 +/- 17 mm Hg (p less than 0.05) and to 17 +/- 7 mm Hg (p less than 0.05) and mean pulmonary wedge pressure decreased from 15 +/- 8 to 9 +/- 4 mm Hg (p less than 0.05) and to 10 +/- 5 mm Hg (p less than 0.05). The changes were significant up to 6 to 8 hours after both doses.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and hemodynamic effects of long-term administration of gallopamil in patients with coronary artery disease and normal or impaired left ventricular function.

The hemodynamic and clinical profiles of gallopamil, a new calcium antagonist, were evaluated in 20 patients with severe coronary artery disease in a placebo-controlled, single-blind study. The patients were divided into 2 groups depending on baseline ejection fraction (greater than 45 or less than or equal to 45%) and underwent nuclear ventriculography, both at rest and during bicycle exercise under electrocardiographic monitoring, after 3 weeks of therapy (50 mg 3 times daily) and the 1-week run in and washout placebo periods. The mean anginal weekly frequency per patient was significantly reduced, from 3.4 to 0.5 (p less than 0.001). The left ventricular ejection fraction, cardiac volumes, ejection and filling indexes at rest and for the same workload were not altered in the population as a whole or in each of the 2 groups. The rate pressure product during exercise was reduced for the same workload from 18.0 +/- 5.0 X 10(3) to 16.8 +/- 4.7 X 10(3), while the regional ejection fraction in ischemic regions was not significantly changed. Individual variations of ventriculographic parameters in both groups were not related to basal values. Gallopamil increased the total duration of exercise from 432 +/- 201 to 537 +/- 188 s (p less than 0.001). Six patients did not complain of angina and their exercise was interrupted because of muscular weakness. The hemodynamic and clinical responses did not differ when the results in the population as a whole and in each of the 2 groups were compared. Gallopamil was effective and well tolerated, even in patients with very depressed cardiac function.

Intracoronary stent implantation in native coronary arteries and saphenous vein grafts: a consecutive experience with six types of stents without prolonged anticoagulation.

OBJECTIVE: To analyze the results of implantation of six different intracoronary stents without the use of prolonged anticoagulation. MATERIAL AND METHODS: Between Mar. 30, 1993, and Jun. 30, 1995, 889 patients with 1,194 coronary or vein graft lesions underwent implantation of one of six types of stents-Palmaz-Schatz, Gianturco-Roubin, Wiktor, Micro, Cordis, or Wallstent. The patients were classified into seven groups on the basis of the type of stent that was implanted, including one group with combined use of two or more types of stents. Among the 851 patients with successful stent delivery and without major complications, 801 received only antiplatelet therapy, and 50 received a standard anticoagulation regimen. One-month clinical followup data were obtained in all patients, and clinical events were investigated. RESULTS: The mean number of stents was 1.8 per lesion and 2.4 per patient. Procedural success was achieved in 93% of the lesions. The clinical success rate at 1 month was 90%. Intravascular ultrasound assessment was performed in 90% of the lesions. The final minimal luminal cross-sectional area of the stent increased from 6.8 to 7.8 mm2 after intravascular ultrasound-guided optimization. Within 1 month, 16 stent thrombosis events (1.9%) occurred. No significant differences were noted in stent thrombosis rates among the various stent cohorts. Multivariate logistic regression analysis revealed that the final stent minimal luminal diameter measured by intravascular ultrasonography was the only variable associated with stent thrombosis. CONCLUSION: This study showed that six different stents could possibly be inserted without subsequent anticoagulation if optimal stent expansion and total lesion coverage were achieved.

Results of coronary angioplasty in patients aged 75 years and older.

We studied a group of 47 patients greater than or equal to 75 years old. The mean age was 77 +/- 1.5 years and there were 28 (60 percent) male patients. Multivessel disease was present in 72 percent. Angioplasty was successful in 93 percent of 90 stenoses and in 30 percent of ten total occlusions. Single vessel angioplasty was done in 53 percent of patients, double vessel in 28 percent and triple vessel in 19 percent. Incomplete or absent revascularization was present in 47 percent and 9 percent, respectively. Primary clinical success was accomplished in all patients with single vessel disease; in 85 percent of patients with double vessel disease, and in only 52 percent of patients with triple vessel disease. Complications were highest in patients with triple vessel disease: 14 percent mortality and 5 percent emergency CABG. The follow-up at one year showed 91 percent survival. The PTCA is a valid alternative method of revascularization in elderly patients with single and double vessel disease. The results in triple vessel disease are less encouraging.

Survival after percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction.

To assess the effects of coronary angioplasty in patients with severe left ventricular dysfunction, the results of procedures, performed between 1987 and 1991, in 100 patients (90 male) with left ventricular function < or = 0.35 (range, 0.20 to 0.35) and anginal symptoms were analyzed. Mean age was 62 +/- 10 years (range, 38 to 85 years). Ninety-five patients had previous myocardial infarction and 27 patients had previous coronary artery bypass grafting. Unstable angina was present in 81 percent of patients. Single-vessel disease was present in 6 patients, double vessel was present in 31 patients, and triple-vessel disease was present in 63 patients. Percutaneous transluminal coronary angioplasty (PTCA) was attempted on 164 vessels, 27 of these with chronic total occlusion. The overall angiographic success rate was 84 percent. Myocardial infarction occurred in four patients, six patients underwent urgent coronary bypass surgery, and seven patients died of cardiac causes. There was a 9 percent incidence of total in hospital mortality. Major complications were significantly more frequent in patients with triple-vessel disease. Clinical success was achieved in 75 patients, 55 of these with incomplete revascularization. Long-term follow-up (mean, 19 +/- 7 months) was available in all patients with clinical success. Thirteen patients had repeated PTCA, 8 patients had coronary surgery, and 13 patients died. In conclusion, in patients with severe left ventricular dysfunction, acute complications and late mortality rate are high. Patients with triple-vessel disease are a higher risk subset and have no long-term benefits by PTCA.

Percutaneous transluminal coronary angioplasty in patients aged 70 years and older: immediate and long-term results.

We analyzed all coronary angioplasty procedures performed in patients aged greater than 70 yr since 1987. There were a total of 92 patients with a mean age of 74 +/- 4 yr (range 70-82). The clinical diagnosis was unstable angina in 79%. Single-vessel disease was present in 41%, double-vessel in 29% and triple-vessel in 30% of patients. A left ventricular ejection fraction of less than 40% was present in 18 patients. Angioplasty was attempted on one vessel in 52 patients (56%), on two vessels in 29 patients (32%) and in three vessels in 10 patients (11%). Angiographic success was achieved in 96% of stenoses and in 53% of chronic total occlusions attempted. Complete revascularization was achieved in 56% of patients. Complications included three patients (3.2%) who underwent emergency coronary artery bypass grafting, 1 patient (1.1%) who sustained a myocardial infarction and 5 patients (5.4%) who died. During hospitalization, which averaged 3 +/- 2 days, 1 patients sustained reversible renal failure and 5 patients required blood transfusion for a large groin hematoma. Clinical success at discharge was 83%. At a mean follow-up of 13 months (range 3-45 months), symptomatic improvement was observed in 59 of the 76 patients who had achieved clinical success, with 42 of these patients (55%) being asymptomatic. The following clinical events occurred: myocardial infarction in 1 patient, new percutaneous transluminal coronary angioplasty in 9 and 3 patients died of cardiac reasons.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and angiographic outcome after Palmaz-Schatz stent implantation guided by intravascular ultrasound.

Intracoronary stents can be implanted with a low incidence of stent thrombosis (< 1%) when the stent procedure is guided by intravascular ultrasound. The long-term clinical and angiographic effects, however, have not been reported. This study assesses the 6 month clinical and angiographic results of a consecutive series of patients with intravascular ultrasound guided Palmaz-Schatz stent deployment that were not treated with subsequent anticoagulation after a successful stent implantation procedure. From March, 1993 to April 1994, 411 patients underwent Palmaz-Schatz stent implantation. There were 26 patients that had uncomplicated Palmaz-Schatz stent implantation that were treated with a standard anticoagulation regimen that are not evaluated in this study. Thus, this study includes an assessment of 385 patients that had either a successful intravascular ultrasound guided stent implantation procedure and did not receive post procedure anticoagulation or had a procedural complication. Procedural success was achieved in 369 patients (96%). Clinical success (procedure success without early post procedure event) was achieved in 363 patients (94%). There were 2 acute stent thrombosis events (0.5%) and 1 subacute stent thrombosis (0.3%) in the group of 369 patients with 454 lesions treated without anticoagulation. At 6 month clinical follow-up the incidence of myocardial infarction was 4.9% and the rate of coronary bypass surgery was 6.2%. There was a 2.1% incidence of death. Emergency intervention (emergency angioplasty or bailout stent implantation was necessary in 3 patients (0.8%). The total incidence of repeat percutaneous intervention was 11.4%. By 6 months clinical follow-up, major events had occurred in 19.2% of patients. The angiographic lesion restenosis rate, according to 50% diameter stenosis criteria, was 19%. The incidence of restenosis per patient was 22%. In conclusion, intravascular ultrasound guided Palmaz-Schatz can be performed without subsequent anticoagulation with a low incidence of stent thrombosis and acceptable clinical and angiographic outcome at 6 month clinical follow-up.

Italian BiodivYsio open registry (BiodivYsio PC-coated stent): study of clinical outcomes of the implant of a PC-coated coronary stent.

UNLABELLED: Rapid technological developments have made new materials available for percutaneous coronary intervention procedures. The coronary stent in particular has undergone progressive structural improvements leading to the recent availability of a third generation of stents, namely, coated stents. The rapid evolution of the stent has often made its evaluation problematical, since trials are frequently confined to small groups of patients in single centers. The purpose of this registry was to verify the safety and efficacy of the BiodivYsio stent (a stent coated with phosphorylcholine polymer) in a broad population of patients who reflect the daily reality of coronary intervention in a cardiac catheterization laboratory. METHODS AND RESULTS: The registry was designed to collect the principal angiographic and clinical data of a consecutive series of Oreal worldO patients. Patients were treated with a BiodivYsio stent (Biocompatibles, Galway, United Kingdom) in 12 centers (11 Italian and 1 Swiss) between January 1998 and January 1999. Procedural, in-hospital, 30-day and six-month follow-up data were collected. The monitoring, data entry and statistical analyses were carried out by an independent center. During the study, 218 patients were enrolled; 165 (76%) male and 53 (24%) female, with an average age of 61.6 +/- 9.4 years (range, 36Eth 84 years). A total of 258 stents were implanted in 233 lesions (1.1 stents per lesion), of which 233 (90%) were the BiodivYsio PC coated stent, the remaining 25 implants were of other stent types. The percutaneous transluminal coronary angioplasty and stenting procedure were carried out in 109 (50%) patients with unstable angina, 65 (30%) with stable angina, 29 (13%) with acute myocardial infarction, and 15 (7%) patients with silent ischemia. Procedural success was achieved in 217/218 (99.5%) patients. Optimal results were achieved in 212 (97.7%) patients. In 34 (15.6%) cases, patients were treated with periprocedural abciximab. During the hospitalization period, one (0.4%) death occurred on day 7 due to subacute occlusion of the stent, and 3 (1.4%) myocardial infarctions were reported. At 30-day follow-up, 211 (97.2%) patients were asymptomatic, as were 189 (87%) patients at clinical follow-up at 6 months. CONCLUSIONS: This study evaluated the safety and efficacy of a third-generation stent. The results demonstrate a high procedural success rate and a low incidence of major adverse cardiac events at short- and medium-term follow-up. It appears that the BiodivYsio stent should be considered safe in clinical and/or anatomical situations with a high risk of complications, confirming the hypothesis that PC may have non-thrombogenic properties. To corroborate these results, an appropriately designed study would be required to measure the stentOs efficacy in the most suitable clinical context, i.e., clinical situations that are at the highest risk of ischemic relapse.

"Hybrid" percutaneous and surgical coronary revascularization: selection criteria from a single-center experience.

BACKGROUND: The association of minimally invasive direct coronary artery bypass (MIDCAB) to percutaneous transluminal coronary angioplasty (PTCA) of large arteries with focal lesions can be an alternative therapeutic method for patients with multivessel coronary artery disease. We reviewed our experience regarding 42 patients treated at our Institute. METHODS: MIDCAB and PTCA of the circumflex or right coronary arteries > 3 mm were performed in 42 patients from September 1997 to December 1999. RESULTS: One patient died after MIDCAB in the operating room because of rupture of the left anterior descending anastomosis. Postoperative angiography confirmed patency of the internal mammary artery (IMA) graft in 92.3% of cases: 3 early IMA graft failures occurred. The success rate for PTCA was 98%: in 1 case the wire just would not cross a chronically and totally occluded right coronary artery. The in-hospital morbidity was 12.2%: 2 patients required urgent sternotomy respectively for cardiac tamponade and coronary artery bypass grafting on cardiopulmonary bypass. One patient developed atheroembolism after PTCA with recurrence of symptoms, progressive multiorgan failure and death. Two patients required PTCA on the IMA anastomosis because of early failure of the arterial graft. At a medium follow-up of 535 days, all 40 survivors are in Canadian Cardiovascular Society class I. CONCLUSIONS: Hybrid revascularization appears to be an effective treatment for selected patients with multivessel coronary artery disease. The immediate success seems related to the learning curve for MIDCAB.

Percutaneous transluminal coronary revascularization in women: higher risk of dissection and need for stenting.

BACKGROUND: Even though success rates of percutaneous transluminal coronary angioplasty (PTCA) are influenced by gender, women are at higher risk for adverse procedural events. Plaque dissection has been demonstrated to cause more adverse cardiac events during PTCA in the female gender than the male, but it is not clear how much it could influence stent implantation and procedural complications in the stent era. This study sought to evaluate whether the prevalence of dissection is equal in men and women with similar vessel size, which factors are associated with the risk of this complication and whether stenting has modified the immediate outcome. METHODS: Three hundred thirty-nine lesions were studied in 100 consecutive women and 128 men with a vessel diameter < or = 3.5 mm, who underwent PTCA in our catheterization laboratory between March 1998 and March 1999. RESULTS: Procedural success rates were similar in the two groups (93.9% women vs 97.6% men). Complications were one coronary artery bypass graft and five acute myocardial infarctions. In the group of women, however, there was a significant increase in the incidence of plaque dissection during the procedure (37.9 vs 21.7%, p = 0.001), with consequent increased need for stenting (70.4 vs 52.2%, p < 0.05) to achieve adequate final results. Moreover, dissection was strongly associated (p = 0.03) with procedural complications. Multivariate analysis of the whole patient cohort showed the risk of dissection to be associated only with the female gender (p = 0.009), diabetes (p = 0.029), and type C lesion morphology (p = 0.019). CONCLUSIONS: Women are at higher risk of plaque dissection, which is associated with adverse procedural events and an increased need for stenting.

[The evaluation of the acute recoil of the Palmaz-Schatz stent using echography. A case report]. / Valutazione del "recoil" acuto dello stent di Palmaz-Schatz mediante ecografia. Descrizione di un caso.

Intravascular ultrasound, performed using a 0.018 in guide wire with a 30 MHz ultrasound transducer, allows to study the acute recoil of Palmaz-Schatz stent. This case showed that the acute recoil of the Palmaz-Schatz stent occurs immediately after stent implantation. The analysis of diameter and lumen cross-sectional area at the stent site was performed at different levels of dilatation. A 20% reduction of cross-sectional area was found immediately after stent expansion and balloon deflation.

Techniques for Palmaz-Schatz stent deployment in lesions with a large side branch.

Palmaz-Schatz coronary stent implantation in lesions with a large side branch are reported. The first case describes how to manage plaque shifting after stent implantation. The second and third cases demonstrate a kissing balloon predilatation and stent dilatation technique of a bifurcational lesion. The final case demonstrates a stent implantation technique through the stent struts of a previously deployed stent.

[Percutaneous coronary angioplasty in the elderly: a report of 2 cases in patients over 90]. / Angioplastica coronarica percutanea nei vecchi: descrizione di due casi in pazienti ultranovantenni.

Percutaneous transluminal coronary angioplasty is a validated method for coronary revascularization over coronary surgery in elderly patients. We describe two cases in patients in their nineties. Case n. 1: a 95-year-old patient with post-infarction angina that was not controlled well by medical therapy. On admission to our department, the patient was in good hemodynamic condition and a transthoracic echocardiographic examination confirmed normal left ventricular systolic function. Coronary angiography showed a severe calcified stenosis of the left anterior descending coronary artery, which was successfully treated with coronary angioplasty and stenting. After three months, the patient was readmitted because of angina. A new coronary angiogram showed diffuse in-stent restenosis, which was successfully treated with rotational atherectomy and angioplasty. The patient was asymptomatic at follow-up after 6 months. Case n. 2: a 91-year-old patient was admitted for an unstable angina. On admission to our department the patient was in good hemodynamic condition. Coronary angiography showed a severe stenosis of the left anterior descending coronary artery that was successfully treated with angioplasty and stenting. The patient was asymptomatic at 6-month follow-up. These cases show that coronary revascularization can successfully be performed even in patients in their nineties when medical therapy is unsuccessful and the patients are considered at high risk for surgery.

Favourable results of treatment of narrowed saphenous vein grafts with Palmaz-Schatz stent implantation.

Although conventional balloon angioplasty of saphenous vein grafts can be performed with an acceptable acute success and complication rate, restenosis remains a major problem. However, this may be overcome by the implantation of Palmaz-Schatz stents. Palmaz-Schatz stent deployment was performed in our institution in 43 patients who were referred for PTCA of stenosed saphenous vein grafts. Thirty-seven were located at the mid-portion of the graft, seven at the ostium and six at the distal anastomosis. Overall, we used 59 standard length (15 mm) Palmaz-Schatz stents and 22 short (7 mm) stents. In 15 lesions (30%) multiple stents were implanted in tandem to treat diffuse disease. Angiographic success was achieved in 47 of the 50 attempted lesions (94%). Major cardiac complications occurred in three patients. Two patients had procedures complicated by the development of a Q wave myocardial infarction, one of whom underwent urgent CABG. One patient died. There was no episode of subacute thrombosis. The angiographic follow-up of 37 lesions (80% of eligible lesions) at a mean time of 5 +/- 2 months (range 1-8) showed a restenosis rate of 11% and residual post-stent diameter stenosis was associated with a significantly higher restenosis rate. However, no restenosis occurred in lesions receiving multiple stents. Clinical follow-up was performed in all patients, and at a mean of 25 months after the procedure, 64% were free from clinical events, including recurrent angina. Palmaz-Schatz stent implantation is an effective and safe procedure to treat narrowed vein grafts.(ABSTRACT TRUNCATED AT 250 WORDS)