Natural history of small and medium-sized side branches after coronary stent implantation.

OBJECTIVE: Our purpose was to identify angiographic and procedural predictors for acute and late side branch occlusion after coronary stent implantation. METHODS: We evaluated 185 patients with 185 lesions with 255 side branches with a mean reference diameter of 1.45 +/- 0.38 mm; the lesions were covered by 240 stents. Angiographic follow-up was completed in 99 patients with 133 side branches 206 +/- 120 days after stent implantation and clinical follow-up was available in 136 patients. Side branch occlusion (SBO) was defined as a Thrombolysis In Myocardial Infarction (TIMI) flow < or =1. RESULTS: Acute SBO affected 54 side branches in 49 patients and was not associated with death or Q-wave infarction. By logistic regression, independent predictors for acute SBO were (1) the reference side branch diameter (RLD) at baseline (OR [odds ratio] 0.217, 95% CI 0.07-0.67, P =.008); (2) an ostial side branch stenosis before stenting (OR 2.96, 95% CI 1.26-6.95, P =.013); (3) the involvement of the side branch origin within the lesion of the parent vessel (OR 2.77, 95% CI 1.17-6.57, P =.021); and (4) the balloon-to-artery ratio (OR 4.66, 95% CI 1.18-18.42, P =.028). Among the initially occluded side branches, 81.8% were spontaneously reperfused at follow-up. Late SBO involved 12% of the side branches without impaired antegrade flow after stenting and was predicted by the initial RLD of the side branch (OR 0.07, 95% CI 0.01-0.8, P =.032). Chronic SBO occurred in 13.5% of cases and was also predicted by the baseline RLD (OR 0.13, 95% CI 0.02-0.8, P =.028). CONCLUSIONS: Acute SBO after stenting occurred in 21.2% of cases and had a benign course. Most acutely occluded side branches underwent late spontaneous reperfusion. A baseline side branch diameter >1.4 mm predicted a preserved antegrade flow immediately after stent implantation, as well as during follow-up.

Utilization of eptifibatide for treatment of severe dissections as a bail-out procedure.

BACKGROUND: It has been shown in several large trials that the inhibition of glycoprotein (GP) IIb/IIIa receptors of platelets can reduce the rate of ischemic complications following percutaneous transluminal coronary angioplasty (PTCA). We sought to determine the efficacy of eptifibatide in patients with severe dissections or threatened vessel closure after PTCA in small coronary arteries (< 2.5 mm). METHODS: Eptifibatide was used in 51 patients after conventional balloon angioplasty complicated by severe dissections with or without threatened vessel occlusion. Eptifibatide was administered as a double-bolus of 180 microg/kg bodyweight, followed by a continuous infusion at a dosage of 2.0 microg/kg min over a time period of 20 h. In this situation, the implantation of a coronary stent was avoided if a prompt antegrade flow of contrast dye could be maintained. RESULTS: Using the GP IIb/IIIa antagonist eptifibatide, it was possible to increase or to maintain antegrade blood flow in 28 (55%) patients. In 45% of the patient population, however, repeat PTCA was needed, and in four patients (7.8%) an intracoronary stent had to be implanted. During hospitalization three (6%) patients underwent target lesion revascularization (two Re-PTCAs, one coronary bypass graft operation). There were no myocardial infarctions and there was no intrahospital death. The cumulative event rate including acute and long term events was 25%. CONCLUSIONS: The findings of our study indicate that eptifibatide is able to prevent vessel occlusion after PTCA complicated by severe dissections with or without threatened vessel occlusion associated with a low-in-hospital complication rate.