Recurrent minor strokes/TIA with a right to left shunt.

A patient came to our institution for evaluation and closure of suspected patent foramen ovale actively manifesting as cerebrovascular accident. Through further studies, we found the presence of a pulmonary arteriovenous fistula, which was subsequently and successfully closed through non-invasive percutaneous selective segmental pulmonary artery embolisation.

Drug-eluting stent: a review and update.

The development of stent has been a major advance in the treatment of obstructive coronary artery disease since the introduction of balloon angioplasty. However, neointimal hyperplasia occurring within the stent leading to in-stent restenosis is a main obstacle in the long-term success of percutaneous coronary intervention (PCI). The recent introduction of drug-eluting stents (DES) contributes a major breakthrough to interventional cardiology. Many large randomized clinical trials using DES have shown a remarkable reduction in angiographic restenosis and target vessel revascularization when compared with bare metal stents. The results of these trials also appear to be supported by evidence from everyday practice and non-controlled clinical trials. However, the expanded applications of DES, especially in treating complex lesions such as left main trunk, bifurcation, saphenous vein graft lesions, or in-stent restenosis, are still under evaluation with ongoing studies. With the availability of different types of DES in the market, the issue of cost should not be a deterrent and DES will eventually be an economically viable option for all patients. The adoption of DES in all percutaneous coronary intervention may become a reality in the near future. In this review article, we summarize the recent development and progress of DES as well as compare and update the results of clinical trials.

Effectiveness of elective stenting of common carotid artery lesions in preventing stroke.

We report our experience with elective stenting of lesions only involving the origin and proximal common carotid arteries. In 37 patients (42 vessels), procedural success was 95% (40 of 42 vessels) with 2 minor strokes (4.70%) and no major strokes. Follow-up for a mean of 24 months showed 1 transient ischemic attack, 2 contralateral minor strokes, 1 cerebral hemorrhage associated with long-term warfarin therapy, and a 5.1% restenosis rate. This technique is an excellent alternative for treating proximal and ostial lesions of the common carotid artery.

Predictors of restenosis after successful carotid artery stenting.

This study was performed to determine the risk factors for restenosis after successful carotid stenting. Of 222 patients who underwent successful carotid stenting, 179 (81%) had a follow-up study (carotid ultrasound and/or angiogram). Restenosis rate was 6.7% (14 of 195) for vessels. By univariate analysis, restenosis rates were significantly different between men and women (4% vs 15.4%, p = 0.018) and age < or =75 versus >75 years (3.8% vs 16%, p = 0.013). By multivariate analysis, older age (odds ratio [OR] 1.107, p = 0.015), female sex (OR 3.519, p = 0.001), implantation of multiple stents (OR 2.363, p = 0.019), and postprocedural percent stenosis (OR 1.067, p = 0.054) were associated with increased incidence of restenosis.

Long-term clinical outcome after implantation of medium Palmaz (biliary) stents in very large native coronary arteries.

Intracoronary stenting has been shown to improve acute and long-term clinical results compared with coronary angioplasty. However, clinical outcome after medium Palmaz biliary (PB) stent implantation in very large native coronary arteries (> 4 mm in diameter) is unknown. This study evaluated restenosis and long-term clinical outcome after PB stenting in large native coronary arteries. Between June 1993 and December 1998, 55 patients with 56 lesions were treated with PB stents. Intracoronary stent deployment was successful in all 56 vessels attempted (100%). The mean stenosis was reduced from 65% +/- 10% to 4% +/- 14%. In 48 of the 56 vessels (86%), vessel size was greater than 4.0 mm in diameter and the mean reference vessel diameter was 4.73 +/- 0.7 mm after stenting. Angiographic success was achieved in 100%. Five patients had postprocedural cardiac enzyme elevation. There was no periprocedural death, emergency coronary artery bypass surgery, repeat target lesion revascularization, or acute stent thrombosis. Long-term clinical follow-up at mean of 28 +/- 15 months was obtained in 96% of the patients. Clinical restenosis rate occurred in 18% of ostial (6/34) and 0% of nonostial (0/22) lesions (P < 0.0001) with an overall clinical restenosis rate of 11%. Repeat angioplasty were performed in these six patients. There were three cardiac and three noncardiac deaths. The overall event-free survival at 1 and 3 years was 92% +/- 4% and 80% +/- 6%, respectively. PB stent implantation in very large native coronary arteries can be performed with a high degree of procedural success and low in-hospital complications. The long-term clinical outcome of patients undergoing PB stenting is associated with excellent event-free survival. However, stenting of ostial lesions remains as an important factor for restenosis even in very large coronary artery stenting.