Postclose technique for large sheath arterial access using perclose(TM) in emergency endovascular repair.

The "Preclose technique" using a perclose device has recently become widely used in various percutaneous procedures requiring a large access sheath. However, the post-procedural application of the perclose(TM) to the large sheath arteriotomy is more challenging because of the risk of bleeding and difficulty of device application. This report introduces a novel post-procedural closing technique of large 22 Fr arterial sheath access using perclose devices.

Large false lumen area is a predictor of failed false lumen volume reduction after stent-graft repair in type B aortic dissection.

PURPOSE: To investigate the predictors of failed false lumen (FL) volume reduction at 12 months after stent-graft implantation in patients with type B aortic dissection. METHODS: The retrospective analysis comprised 38 patients (25 men; mean age 60±12 years) with double-barrel type B aortic dissection (9 acute) treated with thoracic endovascular aortic repair (TEVAR) and evaluated with serial computed tomography (CT) scans up to 12 months. Aortic volume changes were determined. Based on FL volume change at 1 year after stent-graft implantation, patients were dichotomized according to the presence or absence of FL volume reduction. Clinical and CT variables were compared between groups to determine risk factors of failed FL volume reduction. A major adverse event (MAE) was defined as death or reintervention. RESULTS: Patients were followed for 4.2±2.8 years. FL volume reduction (+FLVR) occurred in 27 (71%) patients, whereas 11 (29%) patients had no FL volume reduction (-FLVR). The MAE-free survival rate was significantly higher in the +FLVR patients than in the -FLVR group (88.9% vs. 27.3%, respectively; p=0.001). Chronicity of dissection, location of tear site, or the maximum total aortic lumen area was not associated with failure to achieve FL volume reduction. However, the maximum preprocedure FL area was significantly lower in the +FLVR group than in the -FLVR group (12.6±6.6 vs. 21.0±11.4 cm(2), respectively; p=0.041) and was an independent predictor for failed FL volume reduction (odds ratio 1.3, 95% confidence interval 1.02 to 1.70, p=0.031). CONCLUSION: Failed FL volume reduction after TEVAR was associated with a significantly increased rate of mortality or reintervention during follow-up. A larger preprocedure maximum FL area was a predictor of failed FL volume reduction after TEVAR in type B dissection.

Hybrid endovascular repair for aortic arch pathology: intermediate outcomes and complications: a retrospective analysis.

OBJECTIVES: To evaluate the outcomes of hybrid endovascular repair for aortic arch pathology. METHODS: This study was a retrospective analysis involving patients who underwent hybrid endovascular repair for aortic arch pathologies. RESULTS: Twenty-one patients (16 men; mean age, 64.7 ± 16.2 years) with aortic arch pathologies were treated by hybrid endovascular repair. The indications for treatment included increased aneurysm size in 16 cases (71.4%), rupture or impending aneurysmal rupture in 5 cases (23.8%), and rapid growth of aortic dissection (≥ 10 mm/y) in 1 case (4.8%). Supra-aortic vessel transposition and stent-graft implantation were achieved in all cases. Two types of stent-graft was used, as follows: the Seal thoracic stent-graft in 14 patients (66.7%); and the Valiant stent grafts in 7 patients (33.3%). Perioperative complications affected 5 patients (23.8%), as follows: bleeding (n = 4, 19.0%); stroke (n = 3, 14.3%); renal failure (n = 2, 9.5%); vascular injury (n = 1, 4.8%), and respiratory failure (n = 1, 4.8%). Two patients died within 30 days (9.5%). Technical success was achieved in 15 patients (71.5%). Early endoleaks were noted in 4 patients (19.0%). One patient died during follow-up (mean, 21.3 ± 11.6 months) due to a de novo intramural hematoma. Persistent early endoleaks were noted in 4 patients (19.0%); 2 of the 4 patients were successfully managed with implantation of additional stent-grafts. No late onset endoleaks were noted. The death-free survival and reintervention-free survival rates during follow-up were 85.7% and 90.5%, respectively. CONCLUSION: Hybrid treatment with supra-aortic vessel transposition and endovascular repair may be an option in frail patients in who open procedures is too risky.

Efficacy of stent-supported subintimal angioplasty in the treatment of long iliac artery occlusions.

BACKGROUND: Subintimal angioplasty (SA) is becoming increasingly accepted as a revascularization technique for chronic arterial occlusive disease. However, its efficacy in iliac artery occlusions has not been established. Therefore, we investigated the procedural and clinical outcomes of subintimal angioplasty in long iliac artery occlusions and compared them with those of intraluminal angioplasty (IA) in nonocclusive stenotic iliac artery lesions. METHODS: We retrospectively analyzed data from 151 consecutive patients with long (>5 cm) iliac artery lesions (204 limbs) who underwent angioplasty with primary stent implantation from October 2004 through July 2008. Among them, 100 lesions in 100 patients were treated with intentional SA, and 104 lesions in 82 patients were treated with IA. We compared the baseline characteristics and immediate and long-term outcomes of iliac artery lesions treated with SA versus IA. RESULTS: Baseline characteristics showed that longer lesions and critical limb ischemia were found more frequently in the SA group, whereas diabetes and combined femoropopliteal lesions were present more often in the IA group. The technical success rate of SA was lower than that of IA (93.0% vs 99.0%; P = .048). However, there was no significant difference in the procedure-related complications between the SA and IA groups (4.0% vs 4.8%; P = .779). Primary patency rates for SA and IA were 96.8% and 98.0% at 1 year, and 93.9% and 90.6% at 2 years, respectively (log rank P = .656). CONCLUSION: Stent-supported SA in occlusive iliac lesions was safe and showed a high long-term patency rate comparable to that of IA performed in nonocclusive iliac lesions despite longer lesion length. Thus, SA with implantation of stents is an effective technique for the treatment of chronic long iliac artery occlusion.

Outcomes of endovascular treatment of chronic total occlusion of the infrarenal aorta.

BACKGROUND: Few reports have been published on the outcomes of endovascular therapy in chronic total occlusion of the aorta. METHODS: Endovascular treatment was attempted in 49 patients (40 men and nine women; aged 64.1 ± 10.9 years) with infrarenal aortic occlusion between January 1995 and December 2009. The first attempt at wire passage and balloon angioplasty was usually performed by an antegrade approach through the brachial artery. Stents were implanted with or without intra-arterial administration of thrombolytic agents. We investigated the immediate and midterm outcomes of endovascular therapy for chronic infrarenal aortic occlusions. RESULTS: Technical success was achieved in 40 patients (81.6%). Procedural failures were due to wire passage failure in eight patients and to embolization and spinal cord infarction in one. Stents were implanted in 97.5% of patients. Major complications occurred in eight patients (16.3%): two neurologic events (spinal and cerebral infarction), two cases of jailed renal artery after stenting, and one case each of periprocedural death from pneumonia, distal embolization requiring embolectomy, iliac artery rupture requiring implantation of covered stents, and access site pseudoaneurysm treated with surgery. In patients treated successfully, the primary patency rate was 88.4% at 1 year and 80.1% at 3 years. The major amputation rate was 0%. Seven patients (17.5%) required repeat intervention (n = 5) or bypass surgery (n = 2) during the follow-up period. CONCLUSION: Endovascular therapy of infrarenal aortic occlusion was feasible in most cases, and midterm patency was favorable. However, because of relatively high procedurally related complication rates, cautious selection of patients and appropriate preventive measures are necessary to improve immediate outcomes.

Treatment of type I endoleaks after endovascular aneurysm repair of infrarenal abdominal aortic aneurysm: usefulness of N-butyl cyanoacrylate embolization in cases of failed secondary endovascular intervention.

PURPOSE: To evaluate the technical feasibility and effectiveness of N-butyl cyanoacrylate (NBCA) embolization using a percutaneous transabdominal or a transarterial approach in the failed secondary endovascular treatment of type I endoleaks after endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms. MATERIALS AND METHODS: From 2000-2007, seven patients with failed secondary endovascular treatment of type I endoleaks (five patients with type Ia endoleak, one patient with type Ib endoleak, and one patient with type Ia and Ib endoleaks) were treated with embolization using NBCA with or without a coil. Embolizations were performed using either a percutaneous transabdominal (n = 5) or a transarterial (n = 5) approach. Four patients underwent a single session of embolization, and three underwent two sessions of embolization. The duration between EVAR and endoleak treatment was 9.6 months ± 15.3 (mean ± standard deviation; range 0-42 months). Follow-up computed tomography (CT) scans were evaluated for changes in size and shape of the aneurysm sac and presence or resolution of endoleaks. The follow-up period after endoleak treatment was 18.0 months ± 20.4 (mean ± standard deviation; range 0-53 months). RESULTS: Technical success was achieved in six patients with complete resolution of the endoleak confirmed by follow-up CT scans. One technical failure was observed in a patient who eventually underwent surgical conversion. There were no procedure-related complications. CONCLUSIONS: Embolization with NBCA by a percutaneous transabdominal or a transarterial approach for the treatment of type I endoleaks after EVAR was technically feasible and clinically effective, with no major complications.

Hybrid endovascular repair of thoracic aortic aneurysm in a patient with Behçet's disease following right to left carotid-carotid bypass grafting.

Endovascular repair of inflammatory aortic aneurysms has been reported as an alternative to open surgical treatment. In selective cases, adjunctive bypass surgery may be required to provide an adequate landing zone. We report a case of endovascular repair of an inflammatory aortic aneurysm in a patient with Behçet's disease using a carotid-carotid bypass graft to provide an adequate landing zone. A 45-yr-old man with a voice change was referred to our hospital with the diagnosis of saccular aneurysm of the distal aortic arch resulting from vasculitis. Computed tomography showed a thoracic aortic aneurysm with thrombosis. Right to left carotid-carotid bypass grafting was performed. After 8 days, the patient underwent an endovascular stent graft placement distal to the origin of the innominate artery. The patient was discharged with medication and without postoperative complications after 5 days. Hybrid endovascular treatment may be suitable a complementary modality for repairing inflammatory aortic aneurysms.

Incidence and natural history of coronary artery aneurysm developing after drug-eluting stent implantation.

AIMS: There is a growing concern about the occurrence of coronary artery aneurysms (CAAs) after drug-eluting stent (DES) implantation and their long-term course. We assessed the occurrence and the factors affecting the long-term outcome of DES-associated CAA. METHODS AND RESULTS: We analyzed 3,612 consecutive patients (4,419 lesions) who underwent follow-up angiography after DES implantation. All 34 CAAs (0.76% per lesion) in 29 patients (0.8% per patient) were detected at follow-up, and the mean elapsed time from DES implantation to CAA diagnosis was 414 ± 213 days. Angiographically, CAAs developed almost exclusively in complex (type B2/C) de novo lesions (30 [88.2%] of 34 lesions), and lesion length was significantly greater in patients with CAA than without CAA (26.9 ± 9.03 vs 23.1 ± 7.14 mm; P = .004). Myocardial infarction with stent thrombosis occurred in 5 patients with CAA (17.2%), 4 of whom were on aspirin only without clopidogrel. CONCLUSION: Although CAAs rarely develop after DES implantation and show mostly favorable clinical courses, long-term maintenance of clopidogrel therapy might be required to minimize occurrence of adverse clinical events resulting from stent thrombosis.

Soluble fms-like tyrosine kinase-1 and the progression of carotid intima-media thickness ­ 24-month follow-up study ­.

BACKGROUND: The relationship between fms-like tyrosine kinase-1 (sFlt-1), a soluble receptor for vascular endothelial growth factor (VEGF), and vascular disease has not been established, so this study aimed to elucidate the association between sFlt-1 and the progression of carotid intima - media thickness (IMT) in hypertensive patients. METHODS AND RESULTS: The 120 hypertensive patients under medical control were enrolled and 112 completed the study (age 59 ± 9 years, 57 females). Plasma VEGF and sFlt-1 levels were measured at enrollment. At baseline and 24-month visit, carotid IMT was measured and the association between sFlt-1 and IMT progression was assessed by linear regression. At baseline, age (r=0.186) and low level of high-density lipoprotein-cholesterol (HDL-C <40 mg/dl, r=0.214) were significantly related to carotid IMT. Over the 24 months, carotid IMT increased from 0.670 ± 0.089 mm to 0.696 ± 0.095 mm. There was a positive correlation between sFlt-1 tertiles and IMT change (P=0.05 by ANOVA). Upon multivariate analysis, log-transformed sFlt-1 level (ß=0.137, P=0.003) and low HDL-C (ß=0.048, P=0.04) were identified as predictors of IMT progression, independent of other confounding variables. CONCLUSIONS: High sFlt-1 level is predictive of carotid IMT progression in hypertensive patients. Low HDL-C level was also associated with IMT change. These observations support a high sFlt-1 level being indicative of progression of atherosclerosis.

Effect of baseline glomerular filtration rate on renal function following stenting for atherosclerotic renal artery stenosis.

OBJECTIVE: Percutaneous transluminal renal artery angioplasty and stenting (PTRAS) is one treatment option for atherosclerotic renal artery stenosis (ARAS). However, factors predicting the outcome remain controversial. This study investigated the effect of the baseline glomerular filtration rate (GFR) on renal function after PTRAS in patients with ARAS. MATERIAL AND METHODS: Patients who underwent PTRAS due to significant ARAS (luminal narrowing > or = 60%) were enrolled. The patients were divided into control (n = 57; estimated GFR (eGFR) > or = 60 ml/min/1.73 m(2)) and chronic renal failure (CRF) groups (n = 53; eGFR < 60 ml/min/1.73 m(2)), according to the baseline eGFR. RESULTS: The mean age at the time of PTRAS was 62 +/- 9 years, and the mean duration of follow-up was 50 +/- 26 months. There was a significant decrease in eGFR after PTRAS in the control group, whereas the CRF group showed no significant change in eGFR. The percentage change in eGFR was negatively correlated with the baseline eGFR (r = -0.274, p = 0.004). Multivariate linear regression revealed that only baseline eGFR predicted the change in eGFR (p = 0.032). CONCLUSIONS: PTRAS was more effective at preserving renal function in patients with moderately impaired renal function. Thus, baseline GFR may indicate the expected renal function outcome after PTRAS.

Correlates of the severity of coronary atherosclerosis in long-term kidney transplant patients.

Coronary artery disease remains the leading cause of early death and graft loss in renal transplant patients. The aim of this study was to identify clinical and echocardiographic parameters independently associated with the angiographically-determined severity of coronary atherosclerosis in long-term kidney transplant patients. Fifty-two kidney transplant recipients who underwent elective coronary angiography were reviewed retrospectively. Angiographic severity was evaluated using the modified Gensini index (MGI). The mean age at coronary angiography was 52.5+/-7.9 yr with a mean prior transplant duration of 118.1+/-58.8 months. Pearson correlation analysis demonstrated a positive correlation of MGI with transplant duration before coronary angiography and chronic allograft nephropathy, whereas an inverse correlation was demonstrated with ejection fraction and statin use. On subsequent multivariate linear regression analysis, transplant duration before coronary angiography, statin use, and ejection fraction were independently associated with the severity of coronary atherosclerosis in long-term kidney transplant patients. In summary, our study demonstrates that statin use, ejection fraction, and transplant duration before coronary angiography are independent parameters associated with the severity of coronary atherosclerosis in long-term kidney transplant patients. Further investigation is required to reduce the atherosclerotic burden in kidney transplant patients.

Central aortic pressure in aortic aneurysm and aortic dissection: a novel prognostic marker.

BACKGROUND: Some aortic aneurysm (AA) or aortic dissection (AD) patients can be observed to detect disease progression if optimal blood pressure is achieved. However, in another group of patients, disease progression occurs despite well-controlled blood pressure. The aim of this study was to determine the prognostic value of central aortic pressure in AA and AD. METHODS: Fifty-six newly diagnosed AA or AD patients (37 men, age: 60.3 +/- 12.9 years) who did not need urgent surgery or interventional treatment were enrolled. All patients achieved brachial SBP < or = 120 mm Hg with beta-blocker-based treatment within 1 month. Then, central aortic pressure parameters were noninvasively checked with radial tonometry (SphygmoCor Px Pulse Wave Analysis System, AtCor Medical, Sydney, Australia). All patients were monitored for at least 6 months and for up to 5 years. RESULTS: Thirty-three patients did well without disease progression. However, disease progression was noted despite well-controlled brachial blood pressure in 23 patients. In intergroup comparisons, central aortic systolic pressure (112.7 +/- 3.5 mm Hg vs. 104.3 +/- 7.5 mm Hg) and aortic augmentation index (AI: 33.4 +/- 13.5% vs. 23.4 +/- 8.7%) were significantly high in the disease progression group (P < 0.05). CONCLUSION: In some AA or AD patients, central aortic pressure and AI can be considered as surrogate prognostic markers.

Efficacy of Xience/promus versus Cypher in rEducing Late Loss after stENTing (EXCELLENT) trial: study design and rationale of a Korean multicenter prospective randomized trial.

BACKGROUND: The everolimus-eluting stent (EES) is a newly developed drug-eluting stent using the MULTILINK VISION stent platform combined with the drug everolimus contained in a polymer coating. Recently reported randomized trials have shown the noninferiority and subsequent superiority of the EES compared with the paclitaxel-eluting stent regarding in-stent late loss (LL) at 180 days. However, there have been no studies comparing head to head the EES with the sirolimus-eluting stent (SES), which has shown the least amount of LL among the previously released drug-eluting stent (DES). In addition, adjunctive antiplatelet therapy is a critical factor in optimizing long-term DES safety. Despite the recommendation of the American Heart Association/American College of Cardiology to maintain 12 months of dual antiplatelet therapy, there have been no prospective randomized trials comparing the efficacy and safety of different durations. STUDY DESIGN: In the Efficacy of Xience/promus versus Cypher in rEducing Late Loss after stENTing (EXCELLENT) trial, approximately 1,400 patients are being prospectively and randomly assigned in a 2 x 2 factorial design according to the type of stent (EES vs SES) and the duration of dual antiplatelet therapy (6 vs 12 months). The primary end point is in-segment LL at 9 months for comparison of type of stent, and the coprimary end point is target vessel failure at 12 months for comparison of dual antiplatelet therapy duration. SUMMARY: The EXCELLENT trial is the largest study yet performed to directly compare the efficacy and safety of the EES versus the SES. In addition, this study will also address the issue of a 6- versus 12-month duration of dual antiplatelet therapy for post-percutaneous coronary intervention management.

Effectiveness and safety of endovascular aneurysm treatment in patients with vasculo-Behçet disease.

PURPOSE: To compare long-term outcomes of endovascular and surgical treatment of arterial aneurysms in patients with vasculo-Behçet disease (VBD). METHODS: The medical records of 912 patients with Behçet disease who were seen between May 1995 and January 2007 were reviewed. Among them, 34 (3.7%) patients with 39 non-cerebral aneurysmal lesions were diagnosed with VBD. Between February 1998 and November 2006, 16 VBD patients (14 men; mean age 39.2+/-9.2 years, range 25-63) were treated for 20 arterial aneurysms with an endovascular technique (stent-graft and/or coil embolization). All patients received immunosuppressive therapy (prednisolone 60 mg/d) before endovascular therapy to induce remission. From February 1993 to January 2007, 8 arterial aneurysms in 7 patients (all men; mean age 33.0+/-7.9 years, range 25-51) were treated with surgical graft interposition over 31.5+/-23.2 months. RESULTS: The endovascular procedure was successful in all lesions. The mean follow-up was 47.6+/-41.8 months, during which 4 complications in 3 patients (3/16, 18.8%) occurred (2 occluded stent-grafts and 2 access site pseudoaneurysm). There were no deaths. The cumulative primary patency rate in the endovascular group was 89% at 24 months. In the 7 patients undergoing graft interposition for 8 arterial aneurysms, 3 (42.9%) events occurred in follow-up: 2 recurrent pseudoaneurysms and 1 aneurysm-related death. CONCLUSION: In Behçet disease, aneurysm treatment is performed whenever possible because of the high risk of rupture. Endovascular treatment of arterial aneurysms was effective and safe, with an acceptable vascular complication rate and excellent patency of the treated site.

Blood eicosapentaenoic acid and docosahexaenoic acid as predictors of all-cause mortality in patients with acute myocardial infarction--data from Infarction Prognosis Study (IPS) Registry.

BACKGROUND: Although omega-3 polyunsaturated fatty acids are known to have beneficial effects on cardiovascular diseases, their prognostic value has not been studied prospectively in patients with acute myocardial infarction (AMI). METHODS AND RESULTS: The plasma levels of phospholipids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) (% of total fatty acids), were measured in 508 patients (365 males; mean age, 63 years) with AMI. Clinical and biomarker predictors of all-cause and cardiovascular mortality were identified by stepwise Cox regression model. During a mean follow-up of 16.1 months, 36 (7.1%) patients died. After controlling for confounding variables, age (hazard ratio (HR): 1.09, P<0.001), renal insufficiency (HR: 2.84, P=0.01) and EPA level (HR: 0.29, P=0.004) were identified as independent predictors of all cause-mortality. When stratified by gender, age (HR: 1.08, P=0.001) and renal insufficiency (HR: 4.49, P=0.003) were predictors of all-cause-mortality in males, whereas EPA level (HR: 0.18, P=0.009) and angiotensin-converting enzyme inhibitor use (HR: 0.24, P=0.03) were identified as predictive of all-cause-mortality in females. CONCLUSIONS: Lower plasma level of EPA, but not DHA, was an independent predictor for all-cause-mortality in patients with AMI, but this relationship was significant only in female patients.

Effects of hemoglobin concentration and creatinine clearance in pro-B-type natriuretic peptide-based left ventricular filling pressure prediction in patients with preserved left ventricular systolic function.

Although N-terminal pro-B-type natriuretic peptide (pro-BNP) has been shown to correlate with left ventricular (LV) filling pressure, pro-BNP-based LV filling pressure prediction has some limitations due to several factors that affect pro-BNP. The aim of this study was to evaluate the effects of blood hemoglobin concentration and creatinine clearance (CCr) on pro-BNP-based LV filling pressure prediction in patients with preserved LV systolic function. A total of 421 consecutive patients referred for coronary angiography underwent LV pressure measurement by fluid-filled catheters. Patients with plasma creatinine levels>or=1.5 mg/dl and LV ejection fractions<50% were excluded. LV diastolic pressures and echocardiographic parameters were compared with pro-BNP levels in 281 patients. Blood hemoglobin levels and CCr were measured simultaneously. Log pro-BNP was independently correlated with hemoglobin concentration (beta=-0.261, p<0.001), CCr (beta=-0.230, p<0.001) and LV pre-A-wave pressure (beta=0.384, p<0.001). A pro-BNP level of 124 pg/ml was the optimal cutoff for LV pre-A-wave pressure>15 mm Hg in all patients (sensitivity 67%, specificity 67%, p<0.001). However, by subclassification according to hemoglobin and CCr tertiles, optimal cut-off values varied significantly, and their predictive accuracies could be improved (from 89 to 331 pg/dl, with diagnostic accuracy up to 79%). In conclusion, in the pro-BNP-based prediction of elevated LV filling pressure, subclassification on the basis of hemoglobin concentration and CCr should be considered in patients with preserved LV systolic and renal function.

A paclitaxel-eluting stent for the prevention of coronary restenosis.

BACKGROUND: Intimal hyperplasia and resulting restenosis limit the efficacy of coronary stenting. We studied a coronary stent coated with the antiproliferative agent paclitaxel as a means of preventing restenosis. METHODS: We conducted a multicenter, randomized, controlled, triple-blind study to evaluate the ability of a paclitaxel-eluting stent to inhibit restenosis. At three centers, 177 patients with discrete coronary lesions (<15 mm in length, 2.25 to 3.5 mm in diameter) underwent implantation of paclitaxel-eluting stents (low dose, 1.3 microg per square millimeter, or high dose, 3.1 microg per square millimeter) or control stents. Antiplatelet therapies included aspirin with ticlopidine (120 patients), clopidogrel (18 patients), or cilostazol (37 patients). Clinical follow-up was performed at one month and four to six months, and angiographic follow-up at four to six months. RESULTS: Technical success was achieved in 99 percent of the patients (176 of 177). At follow-up, the high-dose group, as compared with the control group, had significantly better results for the degree of stenosis (mean [+/-SD], 14+/-21 percent vs. 39+/-27 percent; P<0.001), late loss of luminal diameter (0.29+/-0.72 mm vs. 1.04+/-0.83 mm, P<0.001), and restenosis of more than 50 percent (4 percent vs. 27 percent, P<0.001). Intravascular ultrasound analysis demonstrated a dose-dependent reduction in the volume of intimal hyperplasia (31, 18, and 13 mm3, in the high-dose, low-dose, and control groups, respectively). There was a higher rate of major cardiac events in patients receiving cilostazol than in those receiving ticlopidine or clopidogrel. Among patients receiving ticlopidine or clopidogrel, event-free survival was 98 percent and 100 percent in the high-dose and control groups, respectively, at one month, and 96 percent in both at four to six months. CONCLUSIONS: Paclitaxel-eluting stents used with conventional antiplatelet therapy effectively inhibit restenosis and neointimal hyperplasia, with a safety profile similar to that of standard stents.

Incremental value of measuring the time difference between onset of mitral inflow and onset of early diastolic mitral annulus velocity for the evaluation of left ventricular diastolic pressures in patients with normal systolic function and an indeterminate E/E'.

This study sought to evaluate the incremental value of the time interval between the onset of early transmitral flow velocity (E) and the onset of early diastolic velocity (E') of the mitral annulus for the prediction of left ventricular (LV) end-diastolic pressure (EDP) in the presence of a "gray zone" value for E/E'. An E/E' ratio of 8 to 15 is classified as the "gray zone" for the estimation of LVEDP. Recently, it was suggested that prolongation of the time interval between the onset of E and E' (T(E'-E)) might indicate elevated filling pressure. Simultaneous left-sided cardiac catheterization and Doppler echocardiography were performed in 74 patients with normal systolic function. T(E'-E) was calculated as the time interval between the peak of the R wave and the onset of E' and between the peak of the R wave and the onset of E. Of the 74 patients enrolled, 55 (27 men, mean age 59 years) who had E/E' ratios of 8 to 15 were analyzed. LVEDP was elevated (>18 mm Hg) in 34 patients (62%). There was no significant difference in Doppler echocardiographic parameters and N-terminal pro-brain natriuretic peptide levels between those with normal and high LVEDP, except T(E'-E), which was significantly longer in the latter (19.0 +/- 17.8 vs 35.0 +/- 17.0 ms, p = 0.002). The receiver-operating characteristic curves for the prediction of high LVEDP showed the largest area under the curve (0.760) for T(E'-E). In multivariate analysis, T(E'-E) added significant information to the other parameters in the prediction of high LVEDP (p = 0.029). In conclusion, T(E'-E) may have an incremental value in the estimation of LVEDP in patients with normal systolic function and indeterminate E/E' ratios.

Comparison of long-term outcome after mitral valve replacement or repeated balloon mitral valvotomy in patients with restenosis after previous balloon valvotomy.

Symptomatic mitral stenosis (MS) develops in 7% to 21% of patients after percutaneous mitral balloon valvotomy (PMV). Treatment options for these patients are surgical mitral valve replacement (MVR) or repeated PMV. However, no comparisons were made between these 2 procedures regarding long-term outcome. This retrospective study compares the long-term outcome of 888 patients with symptomatic MS after MVR or repeated PMV who underwent PMV from April 1988 to December 2003. Thirty-two patients subsequently underwent repeated PMV, and 59 patients underwent MVR for symptomatic MS. Mean follow-up was 85 +/- 43 months with a maximum follow-up of 15 years. Patients with MVR have more unfavorable clinical characteristics, including a higher incidence of atrial fibrillation and severe mitral regurgitation. Event-free survival was similar between the 2 groups up to 40 months after the procedure; 3-year event-free survival rates were 96.6% for MVR patients and 90.0% for repeated PMV patients (p = 0.215). However, after 40 months, the outcome was more favorable for MVR. Comparing MVR versus PMV, 6-year event-free survival rates were 93.0% versus 75.9% (p = 0.036), and 9-year event-free survival rates were 90.4% versus 36.0% (p <0.001). In conclusion, the long-term outcome of patients with symptomatic MS after previous PMV was more favorable after MVR than after repeated PMV. These data suggest that MVR may be the preferred mode of therapy in patients with unfavorable valve morphologic characteristics and no co-morbid disease.

Kilt Technique as an Angle Modification Method for Endovascular Repair of Abdominal Aortic Aneurysm with Severe Neck Angle.

PURPOSE: Kilt technique can be useful for overcoming the severe angle in endovascular abdominal aortic repair. Thus, we investigate the utility of the Kilt technique as an angle modification method. METHODS: This study included 16 patients with abdominal aortic aneurysm having severe neck angle (over 60°). Of these, eight were treated using Kilt technique, whereas the remaining eight were by the conventional endovascular method. We investigated the pre- and post-procedural differences in neck angle between the two groups using aortic computed tomography (CT) angiography. RESULTS: Mean pre-procedural neck angles in the conventional group and the Kilt group were 70° ± 13° and 93° ± 14° (p = 0.007) and supra-renal neck angles were 54° ± 16° and 89° ± 26°, respectively (p = 0.016). However, the angle differences disappeared between the two groups after the procedure. Consequently, the Kilt group showed greater angle change than the conventional group (p value for ∆ supra-renal angle and ∆ neck angle were 0.015 and 0.021, respectively). There was no type 1 endoleak during 16 ± 16 months of CT follow-up. CONCLUSION: Kilt technique may be an effective tool for modifying the neck angle without leaving increased risk of type 1 endoleak in this subset of patients.