Safety and efficacy of elective carotid artery stenting in high-risk patients.

OBJECTIVES: We sought to evaluate the safety and efficacy of carotid artery stenting (CAS) in high risk patients. BACKGROUND: Carotid endarterectomy (CE) has been shown to be more effective than medical therapy, but it has limitations. Carotid artery stenting may be a reasonable alternative, particularly in high-risk patients. METHODS: We prospectively evaluated the safety and efficacy of CAS in 170 consecutive patients who underwent the procedure in 192 carotid arteries. Of the patients enrolled, 129 (76%) would have been excluded from the major trials of CE and 54 (32%) were referred by vascular surgeons. This series represents a very high-risk group that included patients with unstable angina, previous ipsilateral CE, contralateral carotid artery occlusion and other severe comorbid illnesses. Only 25 (24%) of 104 symptomatic patients would have met the North American Symptomatic Carotid Endarterectomy Trial (NASCET) entry criteria. The patients' mean age was 73 +/- 8 years (95 confidence interval [CI] 57 to 89), and 42 patients (25%) were > or = 80 years old. Patients had an independent neurologic examination before and after the procedure. RESULTS: The procedural success rate was 99%, including 73 patients who had a coronary intervention. Mean carotid artery stenosis was 78 +/- 10% before (95 CI 58 to 98) and 2 +/- 3% after the procedure (95 CI -4 to 8). During the initial hospital period and 30 days after CAS, there was one major and two category 2 minor strokes, as well as two category 1 minor strokes (total 30-day stroke rate was 2.9% for treated patients or 2.6% for treated arteries). There were no myocardial infarctions or deaths during or within 30 days of CAS. None of the NASCET-eligible patients had a stroke. At a mean follow-up of 19 +/- 11 months, three patients (2%) had asymptomatic restenosis. No other major strokes or neurologic deaths occurred. CONCLUSIONS: Carotid artery stenting is feasible, can be performed even in high-risk patients and is associated with a low restenosis rate.

Procedural results and early clinical outcome of percutaneous transluminal myocardial revascularization.

A substantial number of patients present with medically refractory angina who are not candidates for angioplasty or bypass surgery. The creation of channels between the myocardium and the ventricular blood pool has been performed after thoracotomy with excellent relief of symptoms but has been associated with high perioperative mortality. We investigated the safety of a nonoperative, percutaneous technique for channel creation. Twenty-seven patients with angina and coronary anatomy not amenable to revascularization with coronary angioplasty or bypass surgery underwent percutaneous transluminal myocardial revascularization (PTMR). Energy from a Holmium:yttrium-aluminum-garnet (YAG) laser was directed through a fiber enclosed in a catheter to the ventricular myocardium creating channels between the blood pool and the myocardium. On average, 17 +/- 4 channels were formed per patient. There were no procedure-related deaths, episodes of tamponade, or other complications except for an increase in creatine phosphokinase in 1 patient. Immediately after the procedure, there was no worsening of regional wall motion function in any patient, but rather improvement in some. All patients were discharged alive after a hospital stay of 1.8 +/- 1.5 days. Mean Canadian Cardiovascular Society functional class declined from 3.6 +/- 0.5 before the procedure to 0.65 +/- 0.8 at 30 days after the procedure (p < 0.01). For 12 patients eligible for 6-month follow-up, mean functional class was 0.94 +/- 0.97. At 6-month stress testing, 9 of these 12 had no electrocardiographic evidence of ischemia. Thus, PTMR can be performed safely in the cardiac catheterization laboratory with a complication rate lower than that reported in surgical series and with excellent near-term symptomatic relief. The long-term effect of PTMR on mortality and relief of angina as well as its safety and effectiveness compared with the surgical approach remains to be defined.

Significance of cryptococcal antigen titers in patients with AIDS.

We have described a patient with AIDS and cryptococcal antigen titers of 1:262,144 in CSF and 1:268,435,456 in serum. Although the prognosis is poor in AIDS patients with high cryptococcal antigen titers, this patient responded well to treatment and has been free of clinical recurrence of cryptococcal infection for 2 years.