Appraising failure of surgical and percutaneous revascularization: long term outcomes from an observational registry.

AIM: Many randomized trials have compared coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in terms of efficacy, but data comparing outcomes of patients in which these two techniques have failed are lacking. METHODS: We included patients undergoing PCI at our center between July 2002 and December 2004. Subjects were distinguished in 2 groups: those with at least one occluded or stenotic saphenous vein graft (CABG failure), and those with at least one stent with angiographically documented restenosis (PCI failure). The primary endpoint was the long-term rate of major adverse clinical events. RESULTS: Two hundred and thirthy four patients were included, with a medium follow up of 61±13 months; 134 were assigned to the CABG failure group, and 104 to the PCI failure group, sharing high rates of baseline risk factors. At long term rates of death were higher in post CABG group (22.1% vs. 9.9%; P=0.015, RR 2.24 C.I. 95% 1.14-4.40) while death rates in patients with diagnosis of diabetes mellitus (24.0% vs. 23.5%; P=0.969, RR 1.020 C.I. 95% 0.38-2.74) were not different CONCLUSION: PCI can be safely offered to both these kinds of patients: as recently demonstrated post CABG outcomes seem to be more favorable in patients with diabetes mellitus.

Very long-term outcome of peripheral arterial disease in patients undergoing percutaneous coronary revascularization: a retrospective analysis.

AIM: Peripheral arterial disease (PAD) in patients undergoing percutaneous coronary intervention (PCI) with stent implantation is a well known risk factor leading to an increased rates of stroke, cardiovascular death and myocardial infarction. Anyway there are few data on very-long term outcome (more than 1 year follow up) of PAD after stent implantation. We thus aimed to evaluate the influence of PAD on very long-term outcome of our PCI-population. METHODS: We retrospectively identified all patients undergoing PCI with stent implantation at our center between July 2002 and June 2004, and thus eligible for at least 4 years of follow-up. For the purpose of this study, we considered a diagnosis of PAD based on clinical evaluation and/or angiographic documentation. We adjudicated the following clinical events: death, myocardial infarction, repeat revascularization, and their composite (i.e. major adverse cardiac events, MACE). RESULTS; A total of 1008 patients were included, 109 with PAD and 899 Without PAD. Those with had more often diabetes (35% vs. 25%, P=0.002), hypertension (83% vs. 68%, P=0.001) and unfavorable basal clinical condition at the start of this study: past-Percutaneous Coronary Intervention (PCI) (30% vs. 22%, P=0.005), past-Coronary Artery Bypass Graft (CABG) (24% vs. 14%, P=0.001), ejection fraction (EF) <35% (14% vs. 7%, P=0.02) and chronic renal failure (CRF) (15% vs. 6%, P=0.002). In addiction patient with PAD were more likely to have chronic total occlusion (CTO) (36% vs. 25%, p=0.02) and unprotected left main (16% vs. 8%,P=0.01). Clinical outcome at the time of follow-up (4,42 ± 1,66 years) was as follow: Revascularization (53% vs. 37%, P=0.002), Cardiac death (21% vs. 13%, P=0.04), MACE (69% vs. 49%, p<.001). Independent predictors of MACE according to our survival analysis were: PAD (HR 1.31; 95% CI 1.01-1.69), Age >75 (HR 1.23; 95% CI 1-1.51), Chronic heart failure (HR1.72; 95% CI 1.19-2.5), Unprotected left main (HR 1.48; 95% CI 1.12-1.96). CONCLUSION: This long-term registry shows that PAD remains an important clinical condition that negatively influences the outcome of patients undergoing PCI with stent implantation in a very long-term follow-up period.

Short and long-term outcomes of percutaneous revascularization in patients with prior coronary artery bypass graft.

AIM: Patients with prior coronary artery bypass grafting (CABG) represent a sizable portion of those undergoing percutaneous coronary intervention (PCI): in many instances, it is unclear whether performing PCI on the bypass graft or in the native coronary vessels can offer the best risk-benefit balance. METHODS: We included patients with prior CABG undergoing PCI at our center between July 2002 and June 2004 and we distinguished them in three groups. Those in whom PCI was performed on stenotic saphenous vein graft (SVG group), those in whom PCI was performed on native vessels despite the presence of potentially treatable SVG disease (optional native group), and those in whom PCI had to be performed mandatorily in the native vessels because of chronic SVG occlusions or disease in non-bypassed segments (mandatory native group). The primary end-point was long-term rate of major adverse clinical events (MACE, i.e. death, myocardial infarction, or target vessel revascularization). RESULTS: We identified 109 patients: 28 were in the SVG group, 25 in the optional native group, and 56 in the mandatory native group. Early major adverse cardiac events (MACE) occurred with similar frequency in the three groups (respectively, 9.1%, 0% and 5.7%, P=0.35). After more than three years of follow-up, MACE occurred in 39.3% vs. 28 and 39.4% (P=0.59), death occurred in 27.2 vs. 24.0% vs. 13.5% (P=0.30), and TVR in 27.3% vs. 8.0% vs. 28.8% (P=0.14). CONCLUSION: In selected patients, PCI of native coronary vessels despite the presence of apparently treatable SVG lesions can be envisioned.

Clopidogrel treatment in a patient with ticlopidine-induced hepatitis following percutaneous coronary stenting.

Thienopyridines are commonly prescribed antiplatelets drugs, extremely useful for the acute and chronic management of patients with cerebrovascular and cardiovascular diseases. The occurrence of their side effects is fortunately uncommon, although unpredictable. We thereby describe a case of prescription of clopidogrel in a patient with ticlopidine-induced hepatitis confirmed by liver biopsy that had undergone multiple percutaneous coronary stenting procedures necessitating subsequent compulsory antiplatelets treatment. The description of this exceptional clinical case is of relevant knowledge to orientate a physician treating a patient with absolute need of antiplatelets and history of previous drug-induced reactions.

Percutaneous aortic valve replacement in two cases at high surgical risk: procedural details and implications for patient selection.

The morbidity and mortality burden of heart valve disease is increasing in the developing world, especially among the elderly. Whereas surgery remains the standard of care in fit patients with degenerative aortic stenosis, percutaneous aortic valve replacement could become an effective alternative to surgery in selected higher risk patients. The authors report on two women with aortic stenosis, both at high surgical risk (an 81-year-old female with coronary artery and cerebro-vascular disease, and a 70-year-old female with end-stage cirrhosis), in whom percutaneous valve replacement was effectively performed by means of transfemoral access and retrograde CoreValve Re-valving System implantation. Two major post-procedural complications occurred, both effectively managed, in the second patient: a third degree atrio-ventricular block (requiring permanent pace-maker implantation) and bleeding from the right femoral artery access (requiring implantation of two covered stents and blood transfusion). Despite the increased baseline risk, both patients were discharged asymptomatic, the first twelve days and the other three weeks after admission. In the authors' experience percutaneous aortic valve replacement can be performed with reasonable safety in patient with severe aortic stenosis at high surgical risk.

Percutaneous unprotected left main angioplasty with drug-eluting stents in a nonagenarian: feasible and safe despite recurrent restenosis.

The management of severe coronary artery disease in the very elderly is challenging and the most appropriate revascularization strategy highly debated. To date, coronary artery bypass surgery has been the treatment of choice for significant stenosis of unprotected left main (ULM) coronary. Whether this holds true also in very old patients is unknown. The Authors hereby report the case of a 91-year-old diabetic man who underwent coronary angiography in June 2005 for subacute unstable angina. Angiography disclosed a critical stenoses in the distal unprotected left main, left anterior descending, and distal left circumflex, which were treated with a paclitaxel-eluting stent and a bare-metal stent (BMS), respectively. Four months later, recurrent angina lead to a second angiography which showed critical restenosis in the left anterior descending and significant ostial stenosis in the left circumflex. Another paclitaxel-eluting stent was implanted in the left anterior descending, followed by kissing balloon in the left main, achieving a good angiographic result. Six months later angina recurred again: at angiography diffuse restenosis in the left main, left anterior descending and left circumflex was documented. A crushing technique was thus employed to deliver 2 sirolimus-eluting stents, achieving a satisfactory final result. Since then, and to date for more than 17 months since the last procedure, this nonagenarian has remained free from anginal chest. This case highlights the potentials and drawbacks of percutaneous coronary intervention for unprotected left main disease, suggesting nonetheless, that this revascularization strategy can be safely repeated even in elderly patients.

Telecardiogram: still of matter in the modern cardiac imaging era?

The modern cardiovascular imaging era has seen the introduction in clinical practice of highly innovative and performing diagnostic features. The negative side of this outstanding evolution risks to be an under-assessment of well-established classical diagnostic techniques. Thereby, to support the actual relevance of a properly executed chest X-ray, this article describes two paradigmatic cases of exceptional cardiac abnormalities, in which X-rays played a key diagnostic role.

C-reactive protein and coronary composition in patients with percutaneous revascularization.

BACKGROUND: C-Reactive Protein (CRP) is considered a predictive factor for cardiovascular events and its serum levels have been shown to correlate with thin cap coronary plaques in sudden coronary death. Whether serum CRP levels are associated with in vivo atherothrombotic features is unclear. We thus analysed samples from coronary atherectomy specimens obtained during percutaneous coronary intervention. MATERIALS AND METHODS: Patients with coronary artery disease undergoing directional atherectomy, distinguished by unstable versus stable coronary syndrome diagnosis, provided coronary specimens from culprit lesions. Assessment was conducted by means of conventional histology, morphometry and immunohistochemistry. Specific antibodies against erythrocyte-specific protein glycophorin A, endothelial and macrophage antigens were also used. RESULTS: There were 51 patients with unstable coronary disease and 47 patients with stable angina. Serum CRP levels >/= 1 mg L(-1) were detected in 24/98 patients, and were significantly associated with hypercellularity, macrophage infiltrates, neoangiogenesis and intraplaque haemorrhage (all P < 0.05). Furthermore, coronary plaques from patients with unstable angina contained larger atheromas, more hypercellular plaques, with abundant macrophages, neoangiogenesis and intraplaque haemorrhages and lesser fibrous tissue (all P < 0.05). CONCLUSIONS: We observed a positive correlation between increased serum CRP levels and typical pathological features of complex atherothrombotic coronary disease, confirming in vivo the mechanistic role of CRP in coronary atherothrombosis.

Low testosterone levels are associated with coronary artery disease in male patients with angina.

Historically, high androgen levels have been linked with an increased risk for coronary artery disease (CAD). However, more recent data suggest that low androgen levels are associated with adverse cardiovascular risk factors, including an atherogenic lipid profile, obesity and insulin resistance. The aim of the present study was to evaluate the relationship between plasma sex hormone levels and presence and degree of CAD in patients undergoing coronary angiography and in matched controls. We evaluated 129 consecutive male patients (mean age 58+/-4 years, range 43-72 years) referred for diagnostic coronary angiography because of symptoms suggestive of CAD, but without acute coronary syndromes or prior diagnosis of hypogonadism. Patients were matched with healthy volunteers. Out of 129 patients, 119 had proven CAD; in particular, 32 of them had one, 63 had two and 24 had three vessel disease, respectively. Patients had significantly lower levels of testosterone than controls (9.8+/-6.5 and 13.5+/-5.4 nmol/l, P<0.01) and higher levels of gonadotrophin (12.0+/-1.5 vs 6.6+/-1.9 IU/l and 7.9+/-2.1 vs 4.4+/-1.4, P<0.01 for follicle-stimulating hormone and luteinizing hormone, respectively). Also, both bioavailable testosterone and plasma oestradiol levels were lower in patients as compared to controls (0.84+/-0.45 vs 1.19+/-0.74 nmol/l, P<0.01 and 10.7+/-1.4 vs 13.3+/-3.5 pg/ml, P<0.05). Hormone levels were compared in cases with one, two or three vessel disease showing significant differences associated with increasing severity of coronary disease. An inverse relationship between the degree of CAD and plasma testosterone levels was found (r=-0.52, P<0.01). In conclusion, patients with CAD have lower testosterone and oestradiol levels than healthy controls. These changes are inversely correlated to the degree of CAD, suggesting that low plasma testosterone may be involved with the increased risk of CAD in men.

Evolving standard in the treatment of coronary artery disease. Drug-eluting stents.

Coronary stent implantation is the predominant method of percutaneous coronary interventions (PCI). This is to be attributed to the ease of use beside the better short and long term clinical outcome as compared to balloon angioplasty. Nevertheless, improvements in operator skill and stent technology together with better use of adjunctive pharmacological therapy have contributed to the improvement in clinical outcome. However, the main limitation of coronary stenting is still represented by in-stent restenosis (ISR) with an estimated rate of 17-32%. Thus, compared to coronary bypass surgery, the major adverse cardiac events following stent implantation are still higher and mainly represented by the need for re-intervention. The advent of drug eluting stents (DES) has led the experts to predict that with DES there will be little or no difference between PCI and coronary bypass surgery in terms of long-term outcome leading to a further expansion of indications. The clinical trial programs of the 2 available DES for clinical use (sirolimus-eluting stent, SES - Cypher and paclitaxol-eluting stent - Taxus) have been able to demonstrate the safety and clinical efficacy of both. Nevertheless, off-label use in patients on high risk for restenosis confirmed these data. At least for SES as was demonstrated by 2 "real world" registries. Thus, the introduction of DES represents a remarkable evolution for new standards in coronary artery disease treatment and offers hope to those patients considered to be "high risk" such as diabetics, patients with ISR, diffuse disease in whom surgery was previously the only therapeutic option. This paper will discuss the main results of the clinical trial programs of the DES (mentioned above) available for clinical use in the present time and analyze technical and procedural aspects which could affect long term outcome.

Drug-eluting stent: the emerging technique for the prevention of restenosis.

Percutaneous coronary interventions (PCI) have surpassed coronary artery bypass grafting as the most common means for treating coronary artery disease, because of materials improvement, the use of stent and pharmacotherapy. However, despite the variety of mechanical techniques such as dilatation, debulking or conventional stent implantation, the incidence of restenosis on short and mid-term follow-up is still representing an important limitation to PCI. Restenosis is mainly due to elastic recoil, negative vessel remodelling and neointimal proliferation, as a response to vessel injury induced by angioplasty devices. The use of conventional stents has provided an efficient method to avoid elastic recoil and negative vessel remodelling, thus partially reducing restenosis as compared to conventional balloon dilatation. However, neointimal proliferation (biological vessel response to injury caused by stent implantation) is not affected by stenting technique. Thus, the extensive use of coronary stent, even in complex lesions, have produced again a "new" disease: the in-stent restenosis especially in some patients' subset (diabetics) or in some lesion subset (bifurcations, long lesions, small vessels, total occlusions, diffuse disease). Therefore, the main target of today's interventional cardiologists is to resolve this problem. The combination between mechanical control of elastic recoil and negative remodelling (stent) and the control of neointimal proliferation - biological response to vessel injury - (antiproliferative drugs) is the emerging approach against restenosis. This emerging approach consists in using the stent as drug carrier to the target site. Local delivery of antiproliferative or immunosuppressive agents using a drug-coated stent is supposed to inhibit in stent restenosis. The first antiproliferative agents being used successfully in clinical trials are sirolimus and paclitaxel and, so far, the data available of these trials demonstrated a marked reduction of restenosis using sirolimus- and paclitaxel-coated stents as compared to conventional stents. However, many questions are still to be answered and several other clinical trials with drug-eluting stents are ongoing, evaluating safety and efficacy of sirolimus and paclitaxel in a larger number of patients and in different subset of coronary lesions type and morphology. Based on the very impressive results available at the present time, we can expect, in the very near future, remarkable changes in our clinical practice and the beginning of a new "era" of interventional cardiology.

Emergency stenting to treat neurological complications occurring after carotid endarterectomy.

OBJECTIVES: The purpose of this study was to assess the efficacy of emergency stent implantation for the treatment of perioperative stroke after carotid endarterectomy (CEA). BACKGROUND: Carotid endarterectomy has been proven safe and effective in reducing the risk of stroke in symptomatic and asymptomatic patients with >60% carotid artery stenosis. However, perioperative stroke has been reported in 1.5% to 9% of CEA cases. The management of such a complication is challenging. Recently, percutaneous transluminal carotid angioplasty with stent deployment has emerged as a valuable and alternative strategy for the treatment of carotid artery disease. METHODS: Between April 1998 and February 2000, 18 of the 995 patients (1.8%) who had CEA in our institution experienced perioperative major or minor neurological complications. Of these, 13 patients underwent emergency carotid angiogram and eventual stent implantation, whereas the remaining five had surgery re-exploration. RESULTS: Carotid angiogram was performed within 20+/-10 min and revealed vessel flow-limiting dissection (five cases) or thrombosis (eight cases). Percutaneous transluminal carotid angioplasty with direct stenting (self-expandable stent) was performed in all 13 cases. Angiographic success was 100%. Complete remission of neurological symptoms occurred in 11 of the 13 patients treated by stent implantation and in one of the five patients treated by surgical re-exploration (p = 0.024). CONCLUSIONS: Stent implantation seems to be a safe and effective strategy in the treatment of perioperative stroke complicating CEA, especially when carotid dissection represents the main anatomic problem.

Acute electrophysiologic effect of estradiol 17beta in menopausal women.

Sixteen postmenopausal women underwent electrophysiologic study before and 20 minutes after the administration of sublingual estradiol 17beta or placebo. Estradiol 17beta significantly affected electrophysiologic parameters, thereby suggesting its role in the development of palpitations in women.

Predictors of long-term clinical outcome in patients undergoing multiple vessel stenting for coronary artery disease.

BACKGROUND: Coronary artery stenting reduces the restenosis rate compared to coronary angioplasty alone. With the increased number of procedures completed with stent placement there has been a parallel increase in the number of procedures performed in patients with multivessel disease and therefore a rise in the number of patients receiving multiple stents. The clinical outcome and the predictors of the outcome of patients receiving multiple stents are not known. METHODS: To evaluate the clinical outcome of patients with multivessel coronary artery disease undergoing multiple stenting we studied 133 consecutive patients who had received > 1 stent in at least two vessels. A total of 375 coronary stents (2.8 stent per patient) were implanted in elective procedure situations. Clinical follow-up was complete in 100%. RESULTS: During follow-up 2 patients (1.5%) died (1 cardiac death), 4 patients (3%) had acute myocardial infarction, 96 patients (72.1%) remained angina-free, and 31 patients (23.3 %) had recurrence of angina. Repeat revascularization procedure was performed in 45 patients (33.8%); 43 patients (32.3%) underwent coronary angioplasty; 2 patients (1.5%) underwent coronary artery bypass grafting. The female gender and the presence of diabetes were significant (p < 0.05) predictors for coronary angioplasty or coronary artery bypass grafting procedures during follow-up. Recurrence of angina was also significantly (p < 0.05) associated with unstable angina at the time of the first procedure as well as diabetes and the female gender. Diabetes, the female gender and unstable angina were highly predictive factors of major adverse cardiac events during follow-up. CONCLUSIONS: Multiple vessel stenting in patients with multivessel coronary artery disease is associated with an acceptable immediate and long-term clinical outcome and could be considered as an alternative therapeutic option in these patients. Predictors of an adverse long-term outcome are the female gender and the presence of diabetes mellitus.

Direct coronary stenting without predilation.

OBJECTIVES: Coronary stenting is the primary therapeutic option for percutaneous treatment of many coronary lesions, after the risk of subacute stent thrombosis and bleeding complications has been reduced by improved antithrombotic regimens and high pressure stent expansion. BACKGROUND: Direct stent implantation (without predilation) has been considered a promising new technique that may reduce the procedure time, radiation exposure time and cost. METHODS: After having reviewed all cases of stent implantation from February to June 1998 (n = 585), 185 (32%) of these patients were retrospectively considered candidates for direct stent implantation without predilation, according to prespecified criteria (i.e., absence of severe coronary calcifications and/or tortuosity of the lesion or the segment proximal to the lesion). By operator preference, direct coronary stent implantation was actually attempted in 123 (21%) of the 585 patients (100 men, 60 +/- 10 years old) on 123 lesions. The impact of direct stenting in terms of cost, procedure time, radiation exposure time and amount of contrast dye used was assessed by comparing the two groups of patients who underwent single-vessel stenting without (n = 69) and with (n = 46) predilation. RESULTS: Direct stenting was successful in 118 patients (96%). No acute or subacute complications occurred in these patients. Procedure time, radiation exposure time and cost were significantly lower in the group of patients who had single-vessel direct versus conventional stenting (45 +/- 31 vs. 64 +/- 46 min, 12 +/- 9 vs. 16 +/- 10 min and 1,305 +/- 363 vs. 2,210 +/- 803 Euro, respectively; p < 0.05 for all). CONCLUSIONS: Direct stenting without predilation in selected lesions seems to be a safe and successful procedure that provides a way to contain cost and to shorten radiation exposure time.

Intraoperative stenting of the internal carotid artery after unsuccessful eversion endarterectomy.

Stenting of the internal carotid artery (ICA) has been shown to be feasible in atherosclerotic lesions, in restenosis after carotid endarterectomy, and in spontaneous carotid dissections. To correct an intimal flap that detached distal occlusion of the ICA after eversion carotid endarterectomy, as shown with intraoperative completion angiography, we successfully used stenting of the ica with a self-expandable stainless steel stent placed during surgery through the common carotid artery.

Prevention of distal embolization during saphenous vein graft lesion angioplasty. Experience with a new temporary occlusion and aspiration system.

BACKGROUND: Repeat coronary artery bypass graft surgery (CABG) is associated with a high morbidity and mortality, rendering percutaneous treatment of saphenous vein graft (SVG) lesions an attractive alternative. However, percutaneous interventions of degenerated SVGs carries high risk of distal embolization. METHODS AND RESULTS: This study reports our initial experience with the PercuSurge GuardWire, a new device developed to prevent embolization during treatment of degenerated SVG. This device consists of a 190-cm-long, hollow 0.014-in guidewire with a central lumen connected to a distal occlusion balloon. A dedicated inflation device (the MicroSeal Adapter) was used to inflate the distal balloon and maintain complete lumen occlusion during balloon dilatation and stent implantation. A monorail aspiration catheter, connected to a vacuum syringe, was used to evacuate atherosclerotic and thrombotic debris. Angioplasty with stent implantation was performed in 15 degenerated SVGs (18 lesions). Procedural success was achieved in all patients with normal postprocedure flow (Thrombolysis in Myocardial Infarction grade 3). No distal embolization was observed. There were no major in-hospital adverse clinical events, including Q-wave or non-Q-wave myocardial infarction, emergency CABG, or death. All patients were asymptomatic at discharge. CONCLUSIONS: This preliminary series supports the feasible use of the PercuSurge GuardWire for retrieval of plaque debris and prevention of embolization in degenerated SVGs. The good tolerance of temporary occlusions without angiographic or clinical evidence of distal embolization represents encouraging early findings.

Effect of acute administration of estradiol 17 beta on aortic blood flow in menopausal women.

Acute administration of estradiol 17beta increases aortic blood flow velocity in menopausal women. This suggests that the effect of the ovarian hormone on cardiac dynamics is mainly dependent on a reduction in peripheral vascular resistances.