[Results of the French register of renal stenting: the Esternal study]. / Résultats du registre français du stenting rénal: étude Esternal.

Renal artery angioplasty using the same techniques employed for coronary arteries has developed considerably. A register was set up in France to evaluate the efficacy of this treatment for improving renal function and lowering blood pressure in cardiac patients. Between 2001 and 2005, 205 patients (234 lesions) were treated in 14 centres (mean age: 69.2 +/- 10.4 years, 59% male). All of the patients had hypertension and the majority of them (171) had renal failure (creatinine clearance<90 ml/min). Direct implantation of a stent was performed in 75.2% of the cases, successfully in 196 patients (96%) with 220 lesions (95.2%). The complications encountered were segmental renal infarction in two patients (0.9%), and four cases of minor vascular complications at the puncture site (2%). The mean value for pre-implantation creatinine clearance was 54.6 +/- 32.8 ml/min and 58.1 +/- 36.0 post- implantations. The duration of follow up was 5.9 +/- 2.7 months. Mortality was 3.5% (seven patients, of whom two died from renal causes). The mean systolic and diastolic blood pressure was 142.2 +/- 16.2 and 78.9 +/- 9.5 respectively versus 164.9 +/- 25.2 and 89.1 +/- 14.8 before treatment (p<0.0001). A non-significant improvement in creatinine clearance at six months was also observed in patients with renal failure prior to treatment: 48.7 +/- 17.1 ml/min vs. 69.2 +/- 160.3. Renal artery stenting in cardiac patients with renal artery stenosis is associated with a very high success rate, with few complications and an improvement in hypertension and renal function.

Indications of coronary angioplasty and stenting in 2003: what is left to surgery?

UNLABELLED: For many years, coronary artery by-pass graft (CABG) remained the only effective treatment of multivessel disease compared to medical treatment. The first technical revolution was in 1977 when Gruentzig introduced balloon percutaneous transluminal coronary angioplasty (PTCA), the 2nd in the 90's with the developments of stents and antiaggregant protocols. The equipment for PTCA became more and more sophisticated, and the skill of cardiologists greater. In the 90's, interventional cardiology played a predominant role in revascularization as the number of CABG decreased at the same time, and emergency CABG for bail out almost disappeared (0% to 0.5%). Systematic stenting decreased the need for repeat revascularization to about 18-20% nowadays in the majority of centers, except in diabetic patients. Despite this fact restenosis remains the pitfall of angioplasty, mostly in diabetic patients presenting multivessel disease in which surgery with "all arterial grafts" gives good long term RESULTS: The first studies comparing PTCA and CABG are favourable to surgery (BARI), then late ones using stents (ARTS, ERACI 2) showed that stenting was at least equivalent to CABG, in terms of mortality or serious complications (major acute coronary events, MACE), despite a higher target vessel revascularisation (TVR) mainly due to restenosis in the angioplasty cohort. The same results are observed by stenting a high risk lesion as the unprotected left main stenosis can be, until then treated surgically. However, high volume centers studies treating by PTCA+stent the unprotected left main artery (LMA) shows that the 1 year survival rate is similar to surgery, but always related to a restenosis rate of 20% at 6 months in the stent group, which represents the only significant difference in terms of MACE; the new drug eluting stents lead us to expect, according to SIRIUS and TAXUS II studies, to reduce the restenosis rate, and by the way, the MACE could be dramatically lowered from 50% to 60%. Randomised studies would be necessary, but the extrapolation of the actual data, more particularly results of subgroups with a high risk of restenosis, diabetic patients and small vessels, lead us to think that stenting could come in first intention before surgery if TVR is significantly reduced. A complex anatomy, failed attempted chronic occlusion, several lesions on tortuous vessels, would remain the last surgical indication if CABG provides a more complete revascularization. The impact of these new drugs seems promising. However, we should await early results of studies in diabetic patients and bifurcations. But in high volume experienced centers, CABG indications would be reduced in the future to the technical pitfalls of stenting (complex or tortuous anatomy, chronic occlusions) or to the adverse additional cost of this device, unless reduction of restenosis or TVR could also cancel this extra cost. We expect randomised studies CABG versus stented angioplasty using drug eluting stents to confirm these preliminary data.

[Complete revascularisation of multivessel coronary artery disease during acute myocardial infarction. Results following hospitalization and after 30 months. Series of 86 interventions carried out with 167 multivessel disease patients; causes of failure]. / Revascularisation complète des patients multitronculaires en phase aiguë d'infarctus du myocarde. Résultats en fin de période hospitaliere et à 30 mois. Série de 86 cas effectués sur 167 patients multitronculaires consécutifs; causes d'échec.

This series studied 167 patients with multivessel disease, admitted consecutively for acute myocardial infarction (excluding cardiogenic shock), who underwent systematic angioplasty and stenting before the 12th hour of the culprit artery and the other vessels with >70% (QCA) angiographic stenosis, and followed up for a period of 8 to 68 months with an average follow-up of 2.5 years. The criteria of evaluation were: numbers of asymptomatic patients, deaths, new infarctions, residual ischaemias, cardiac failure, angioplasties or bypass surgeries. On admission, 43.1% of infarcts were anterior, 48.5% inferior or postero-inferior and 8.3% lateral wall infarcts. One hundred and twenty-two consecutive patients had double vessel disease and 45 has triple vessel disease. The failures of revascularisation of the culprit artery were excluded from the study. The feasibility rate of complete multivessel revascularisation in a single procedure was over half the cases (86 out of 167, 51.5%): 60.6% of double vessel disease and 26.9% of triple vessel disease, a simple favorable anatomical presentation being necessary to accomplish this objective. During the hospital period (30 days), 95.3% of patients who were completely revascularised remained totally asymptomatic, 2 (2.3%) had recurrent infarction, 1 (1%) had cardiac failure and 1 (1%) died of a non-cardiac cause. No cardiac deaths were observed in this series. Of the multivessel disease patients who could not be completely revascularised (N=81) (poor clinical state or complicated anatomical presentation), 83.6% were asymptomatic: there were 7.7% cases of cardiac failure, 2.4% of recurrent infarction; 1.2% died of non-cardiac causes and 1.2% died of a cardiac cause. The statistical difference was significant in favour of the patients who had successful complete revascularisation with respect to the others in terms of numbers of asymptomatic patients (p=0.004) and of numbers of cardiac failure (p=0.002). The follow-up rate of patients who had complete revascularisation in a single procedure was 98.8%. After two and a half years of follow-up, 74.1% of patients were totally asymptomatic; the cumulative major cardiac adverse event rate (death, infarction, angioplasty or bypass surgery) was 29.4% and the reoperation rate by angioplasty or bypass surgery was 27%.

[Primary angioplasty associated with systemic coronary stenting in acute myocardial infarction. Results at the end of the hospitalization period and at 24 months]. / Angioplastie primaire associée à la mise en place systématique d'une endoprothèse en phase aiguë d'infarctus du myocarde. Résultats en fin de période hospitalière et à 24 mois.

A series of 149 consecutive patients admitted for myocardial infarction (excluding cardiogenic shock), dilated and systematically stented in the acute phase before the 12th hour and followed up for a period from 30 days to 2 years, was studied. The criteria of follow-up were: number of asymptomatic patients, deaths, reinfarction, residual ischaemia, cardiac failure, angioplasty or bypass surgery. On admission, 40.9% of the infarcts were anterior, 44.3% inferior and 14.8% lateral. One hundred and eighty-three stents with a diameter of over 3 mm were inserted. The angioplasty success rate was 98.6%. During the hospital period, 90.6% of patients were asymptomatic. 4.7% had recurrent infarction, 4% had cardiac failure, 0.7% had residual ischaemia, and there were 0.7% of cardiac deaths. The survival rate was 97.2% at 2 years: 69.8% of patients were totally asymptomatic: the cumulative major cardiac event rate (death, reinfarction, angioplasties or bypass graft) was 25.9% and the reoperation rate on the culprit vessel was 20.1%. These results show the short and long-term value of angioplasty associated with coronary stenting over other techniques in the acute phase of infarction based on the criteria studied. The long-term results of larger randomised studies using glycoprotein inhibitors (Gp IIb IIIa) associated with angioplasty and stenting are expected for validating the use of these products.

Long-term results with the Palmaz stent in the superficial femoral artery.

PURPOSE: Femoral stenting has demonstrated inconsistent and often disappointing long-term results. To compare out experience, we retrospectively analyzed a series of patients who had Palmaz balloon-expandable stents placed exclusively for superficial femoral artery (SFA) lesions. METHODS: From January 1990 to November 1993, 39 patients were evaluated for claudication (79%) or critical ischemia in 42 limbs. The culprit lesions were confined to the SFA: 24 (57%) occlusions and 18 (43%) stenoses, including 3 restenotic lesions. Stenting was elective in 12 (29%) cases: the 3 restenoses and 9 chronic, calcified occlusions. The remaining stents were applied for postangioplasty residual stenosis or angioscopic findings of thrombogenic luminal irregularities. A total of 55 prostheses were successfully implanted. All patients were maintained on ticlopidine and followed by routine duplex scanning. Follow-up angiography was performed in 28 (72%) patients between 4 and 45 months. RESULTS: In the postprocedural period, two acute thromboses (4.8%) occurred within 48 hours in patients who had long occlusions and poor runoff; no other major complications were encountered, for a clinical success rate of 95%. Follow-up evaluation ranged from 4 months to 4 years with a mean of 25 months. The restenosis rate was 19% (34% in occlusions; 10% in stenotic lesions, p = NS). At 24 months, cumulative primary patency was 77% and secondary patency 89%. CONCLUSIONS: Palmaz stents performed will in the SFA, demonstrating a low acute thrombosis rate and good long-term patency. The incidence of restenosis is likely to be greater in occlusions than in stenoses.

[Primary results of laser recanalization in the endovascular treatment of arterial stenosis and occlusion of the lower limbs. Apropos of 45 treated cases]. / Résultats primaires de la recanalisation par laser dans le traitement endovasculaire des sténoses et occlusions artérielles des membres inférieurs. A propos de 45 lésions traitées.

Forty-five lower limb arterial lesions were treated by Nd Yag laser angioplasty using 1.4 and 2 mm hybrid catheters in 31 patients. This population comprised 28 men and 3 women (average age 63.8 +/- 3 years) 20 were in Stage II, 5 in Stage III and 6 in Stage IV of Fontaine's classification. The arteriographic lesions were 22 occlusions with an average length of 12.3 cm and 23 stenoses averaging 87% luminal reduction a few millimeters long to a maximum of a string of stenoses. Seventeen of these lesions were very calcified. The stenoses were situated on the iliac artery (7 cases), superficial femoral artery (28 cases), popliteal artery (9 cases) and the tibio-peroneal artery (1 case). There were no fatalities or recourse to emergency surgery. All patients underwent complementary balloon dilatation. The immediate patency rate was 91% in stenotic and 72% in occlusive lesions. At one week, the patency rate for stenotic lesions was unchanged but it had fallen to 59% for occlusive lesions (arteriographic evaluation). Angioscopy was used 22 times: it was indissociable to laser angioplasty as it enabled diagnosis and controlled the result. The use of thermal laser with hybrid catheters (metallic window tip) in endovascular procedures is a safe and effective method of treating stenosis and occlusion of lower limb arteries.

Long-term peripheral stent evaluation using angioscopy.

To evaluate incorporation of peripheral artery stents into the arterial wall, we performed angioscopy on 13 patients fitted with Palmaz endoluminal stents. Of the 15 stents inspected, 5 were in the iliac artery, 9 in the femoral artery and 1 in the popliteal artery. The indications for placement were occlusion in 4 cases and high-grade stenosis in 11 cases including 3 restenosis after balloon dilatation and 1 restenosis after surgery. In 9 cases prosthesis insertion was preceded by laser treatment (Trimedyne Nd:YAG Cardiolase 4000). The decision to use a stent was based on radiologic findings in 3 cases (residual stenoses, dissections) and on angioscopic visualization in 7 cases (2 dissections, 5 flaps). In the remaining cases stent placement was performed electively. The only postoperative treatment was antiplatelet therapy (Ticlopidin). At the time of examination, the mean duration of placement was 6 months (extremes: 2 and 12 months). Inspection was made using Sopro-Meadox angioscope with a 0.75 mm probe mounted on an occlusive balloon for stents in the iliac artery and with a 2.2 mm probe with a working channel and sometimes a deflecting device for stents in the femoral or popliteal artery. Angioscopy was successful in all cases. Angiography was always performed at the same time as endoscopy. Endothelialization was observed in all cases. It appeared as a uniform and smooth whitish layer with a thickness proportional to the duration of placement. Endothelialization was most rapid in femoropopliteal arteries, total coverage being achieved within 4 months. Endothelialization took the longest on medial side of the iliac artery which may remain partially exposed after 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Early angiographic assessment of coronary revascularizations using the internal mammary artery. Apropos of a consecutive and prospective series of 180 bypass grafts]. / Contrôle angiographique précoce des revascularisations coronaires par l'artère mammaire interne. A propos d'une série consécutive et prospective de 180 pontages.

This report describes a consecutive and prospective series of 136 patients, who underwent coronary bypass using the internal mammary arteries. Coronary angiography was routinely performed on all patients 8 days after surgery. A total of 137 operations (1 reoperation) were performed on 180 coronary arteries using 132 left internal mammary arteries and 25 right internal mammary arteries. Direct bypass was performed 133 times (73.8%), sequential bypass 23 times (25.5%) and free graft once. Bypass involved 1 coronary artery 89 times (65.4%), 2 coronary arteries 46 times (33.8%) and 3 coronary arteries in 1 case. The overall early success rate of internal mammary bypass in this series was 94.8% including 2 bypasses which were patent but non-functional. Of the 23 sequential bypasses, only 1 anastomosis out of 46 was not patent for a success rate of 97.3%. These good results are attributed to the large diameter of the mammary artery. Early postsurgical imaging is valuable for several reasons. It allows detection of surgical errors and improvement of the procedure. It enables distinction between residual primary surgical stenosis and secondary stenosis or genuine restenosis. It allows analysis of perioperative complications allows. No correlations between myocardial infarction and bypass obstruction were found. Finally, it permits endoluminal therapies such as thrombolysis (1 case in this series) and dilatation (2 cases). In conclusion, although we do not perform angiography routinely, our policy is to perform imaging in all cases of postoperative complications and after certain procedures such as sequential bypass.

Current status of vascular grafting in supraaortic trunks. Personal experience.

Two-hundred forty-nine patients underwent prosthesis implantation for supraaortic trunk disease. The most frequently used technique for lesions of the innominate artery was direct repair via sternotomy. Mortality was very low (2.8%) and at 97.3% late patency was excellent (mean follow-up: six years). Extra-anatomical bypasses were reserved for all other lesions of the subclavian and common carotid arteries or contraindications to the direct approach. Patency for carotido-subclavian bypass (81 patients) and subclavio-subclavian bypass (134 patients) was 71% (mean follow-up: 4.6 years) with one operative death. Indications are decided on the basis of the extent and aspect of the lesions.