Técnica de pull-back para implante de stent em lesões de bifurcação com envolvimento único de óstio do ramo lateral: avaliação dos resultados iniciais e aos seis meses pós-implante / Pull-back technique for stent implantation in coronary bifurcation lesions involving isolated ostial side branch: early and 6-month follow-up results

Introdução: Lesões coronárias em bifurcação ainda representam um desafio ao tratamento percutâneo, com sucesso do procedimento abaixo do esperado e altas taxas de reestenose. A técnica de pull-back é uma opção no tratamento de lesões coronárias de bifurcações que apresentam acometimento isolado do óstio de ramos laterais, embora seus resultados a médio prazo ainda não sejam conhecidos. O objetivo deste estudo foi avaliar os resultados angiográficos iniciais e aos seis meses com essa técnica em nossa casuística. Método: A técnica consiste no posicionamento de duas guias, seguido do stent no ramo lateral e do balão no vaso principal encobrindo a origem do ramo. Após a insuflação do balão no vaso principal, o stent é tracionado em direção ao vaso principal até contato com o balão e, então, liberado. Resultados: Foram tratados 37 pacientes consecutivos. Os ramos diagonais foram os mais freqüentemente abordados (70,3%). O diâmetro de referência dos ramos laterais foi de 2,51 ± 0,37 mm e a extensão da lesão, de 11,1 ± 3,7 mm. A pressão de liberação dos stents no ramo lateral foi de 12,8 ± 1,9 atm e a pressão de insuflação do balão no vaso principal, de 7,8 ± 0,9 atm. O sucesso do implante ocorreu em todos os procedimentos. Foram submetidos a coronariografia tardia 22 (59,5%) pacientes, tendo sido observada reestenose no ramo lateral em nove (40,9%) pacientes e desenvolvimento de lesões > 50% no vaso principal em sete (31,8%). Conclusão: Lesões isoladas localizadas no óstio de ramos laterais tratadas com stent pela técnica de pull-back apresentaram elevadas taxas de sucesso do procedimento. No seguimento a médio prazo, entretanto, observou-se elevada taxa de reestenose no ramo lateral e alto risco de desenvolvimento de uma nova obstrução no vaso principal.

Introduction: Bifurcated coronary lesions are still a challenge to the percutaneous treatment, with a lower than expected success rate and high rates of restenosis. The pull-back technique is an option for the treatment of coronary lesions in bifurcations that compromises exclusively the ostium of lateral branches, but its middle term results are still not known. The aim of this study is to assess the initial and 6-month angiographic results of this technique in our casuistic. Method: The technique consists in the positioning of two guide-wires, followed by the stent in the lateral branch and the balloon in the main vessel, covering the origin of the branch. After insufflating the balloon in the main vessel, the stent is pulled back towards the main vessel until it touches the balloon, and then implanted. Results: Thirty-seven consecutive patients were treated. The diagonal branches were the most commonly treated (70.3%). The reference diameter of the lateral branches was 2.51 ± 0.37 mm and the extension of the lesion 11.1 ± 3.7 mm. The release pressure of the stents within the lateral branch was 12.8 ± 1.9 atm and the insufflation pressure of the balloon in the main vessel was 7.8 ± 0.9 atm. The stent was successfully implanted in all procedures. Twenty-two (59.5%) patients were submitted to late coronariography and restenosis was observed in the lateral branch in 9 (40.9%) patients, and the development of lesions > 50% in the main vessel was observed in 7 (31.8%) patients. Conclusion: Isolated lesions found in the ostial of lateral branches treated with the “pull-back” stent implantation technique presented high rates of procedural success. However, in the middle term follow-up, a high restenosis rate in the lateral branch was observed, as well as a high risk of developing a new obstruction in the main vessel.

Avaliação do custo do implante programado de múltiplos stents em mais de uma intervenção percutânea em pacientes com doença coronária multiarterial / Cost evaluation of scheduled multiple stents implantation in multivessel coronary disease patients

Fundamentos: O Sistema Único de Saúde estabelece que a angioplastia coronária com implante de dupla prótese intraluminal não deverá exceder o total de 20% das angioplastias realizadas, resultando na necessidade de escalonar a maioria dos procedimentos nos pacientes com doença coronária multiarterial. O objetivo deste estudo foi comparar os custos do escalonamento estabelecido pelo SUS para implante de stent ao planejamento de implante de stent considerado ideal pela equipe de cardiologia intervencionista, em pacientes com doença coronária multiarterial, com indicação de implante de mais um stent por procedimento. Método: Os custos foram comparados em uma série consecutiva de 100 pacientes com doença multiarterial com indicação de revascularização completa por intervenção coronária percutânea com o implante de dois ou mais stents por paciente. As coronariografias foram previamente avaliadas pela equipe de cardiologia intervencionista, que indicou o escalonamento considerado ideal para o tratamento das estenoses coronárias em cada paciente. Em seguida, foram realizados os procedimentos de acordo com os critérios do SUS e os custos das duas estratégias comparados. O valor do procedimento de implante de um stent pela tabela SUS é de R$4.298,00. Resultados: A idade média foi 61,5±10,7 anos, 66% eram do sexo masculino, 43% eram diabéticos e 67% tinham angina estável. Ocorreu concordância em relação ao escalonamento estabelecido pelo SUS em 44% e discordância em 56%. Foram realizados 58 procedimentos a mais do que o considerado ideal pela equipe de cardiologia intervencionista, gerando um custo adicional de R$131.298,00. Conclusões: O escalonamento estabelecido pelo SUS, com parado ao considerado ideal pela equipe de cardiologia intervencionista, ocasiona um aumento no número de procedimentos de implante de stent coronário e, consequentemente, uma elevação de gastos públicos.

Background: The Brazilian Public Health System (SUS)establishes that coronary ngioplasties with implantation of two stents must not exceed 20% of the total amount of angioplasties performed, resulting in the necessity of staged procedures in the majority of the patients with multivessel coronary disease. The objective of this study was to compare the costs of the staged stent implantation policy, imposed by SUS, with the stent implantation approach considered ideal by the interventional cardiology team, in patients with multivessel coronary disease. Methods: Costs were compared in a consecutive cohort of 100 patients with multivessel disease with indication of complete revascularization by percutaneous coronary intervention. Coronary angiographies had been previously evaluated by the interventional cardiology team that had individualized the approach considered ideal for the treatment of each patient. Procedures were then performed in accordance to SUS multistage policy and the costs of the two treatment strategies were compared. Of note, a single stent implantation procedure costs R$4,298.00 according to the SUS price list. Results: Mean age was 61.5±10.7 years, 66% were male, 43% diabetics and 67% had stable angina. Agreement in relation to the SUS staged procedures occurred in 44% and discordance in 56%. An excess of 58 procedures was detected, generating an additional cost of R$131,298.00. Conclusions: The multistaged approach imposed by SUS increases the number of procedures for coronary stent implantation in patients with multivessel disease and consequently increments the public expenses.

Late coronary thrombosis secondary to implantation of paclitaxel-eluting stent without restenosis of conventional stents.

A male 39 year-old patient with post-infarction angina. The coronary angiography showed total proximal obstruction of right coronary artery (RCA), obstructive lesions of 95% of the anterior descending artery (ADA), 80% of the second left marginal branch (LM2), and 95% of the circumflex artery (CXA). The patient was successfully implanted with a Taxus 3.0 x 24 mm stent and an Express 2.75 x 24 mm stent in the proximal and distal thirds of the RCA, respectively, and with an Infinnium 3.0 x 24 mm stent in the ADA. After seven months, the patient had an anterior acute myocardial infarct (AMI) due to thrombosis of the Infinnium stent and restenosis of the Taxus stent, with no loss of results in the conventional stents.

Randomized comparative study of diamond-like carbon coated stainless steel stent versus uncoated stent implantation in patients with coronary artery disease.

OBJECTIVE: To compare restenosis and major cardiac event rates at one and six months after DLC-coated stent implantation with those of uncoated stents. METHODS: Randomized, prospective, comparative study of 180 patients with coronary insufficiency undergoing DLC coated stent (Phytis) or uncoated stent (Penta) implantation, from January, 2003 to July, 2004. Inclusion criteria were: de novo lesion with >50% diameter stenosis in a coronary artery with reference diameter > or = 2.5 mm and < or = 4 mm, and length < 20 mm. Exclusion criteria were: left main coronary artery and bifurcation lesions, chronic total occlusion, and in-stent restenosis. RESULTS: Clinical and angiographic baseline characteristics of the groups were similar. Procedural success was achieved in 98.9% of the patients in both groups. One cardiac death occurred in each group during hospitalization. Reference diameter and acute gain were greater in the Penta group (3.21 +/- 0.37 mm vs. 3.34 +/- 0.8 mm, p=0.02 and 2.3 +/- 0.5 vs. 2.49 +/- 0.5, p=0.009, respectively). Angiographic follow-up at six months showed similar rates of restenosis (24.3% vs. 21.8%, p=0.84) and of major cardiac events (16.8% vs. 17.5%, p=1). CONCLUSION: DLC coated stents did not provide better outcomes in relation to uncoated stents.

Trombose coronariana tardia secundária a implante de stent com paclitaxel sem reestenose dos stents convencionais / Late coronary thrombosis secondary to implantation of paclitaxel-eluting stent without restenosis of conventional stents

Homem de 39 anos com angina pós-infarto. Coronariografia demonstrou: obstrução total proximal da artéria coronária direita (ACD), lesões obstrutivas de 95 por cento na artéria descendente anterior (ADA), 80 por cento no 2° ramo marginal esquerdo (ME) e 95 por cento na artéria circunflexa (ACX). O paciente foi submetido a implante de stent TAXUS 3,0 x 24 mm e stent EXPRESS 2,75 x 24 mm nos terços proximal e distal da ACD, respectivamente, e stent INFINNIUM 3,0 x 24 mm na ADA com sucesso. Após 7 meses, apresentou IAM anterior por trombose do stent INFINNIUM e reestenose do stent TAXUS, sem perda de resultado nos stents convencionais.

A male 39 year-old patient with post-infarction angina. The coronary angiography showed total proximal obstruction of right coronary artery (RCA), obstructive lesions of 95 percent of the anterior descending artery (ADA), 80 percent of the second left marginal branch (LM2), and 95 percent of the circumflex artery (CXA). The patient was successfully implanted with a Taxus 3.0 x 24 mm stent and an Express 2.75 x 24 mm stent in the proximal and distal thirds of the RCA, respectively, and with an Infinnium 3.0 x 24 mm stent in the ADA. After seven months, the patient had an anterior acute myocardial infarct (AMI) due to thrombosis of the Infinnium stent and restenosis of the Taxus stent, with no loss of results in the conventional stents.

Estudo comparativo randomizado do implante de Stent de aço inoxidável recoberto por carbono semelhante ao diamante versus não recoberto em pacientes com doença arterial coronariana / Randomized comparative study of diamond-like carbon coated stainless steel stent versus uncoated stent implantation in patients with coronary artery disease

OBJETIVO: Comparar as taxas de reestenose e de eventos cardíacos maiores em um e seis meses pós-implante de stents recobertos com CSD com os não-recobertos. MÉTODOS: Estudo comparativo, prospectivo, randomizado, de 180 pacientes com diagnóstico de insuficiência coronária, submetidos a implante de stent recoberto com CSD (Phytis®) ou stent não-recobertos (Penta®), no período de janeiro de 2003 a julho de 2004. Foram critérios de inclusão: lesão de novo com porcentual de estenose em diâmetro > 50 por cento em artéria coronária com diâmetro de referência > 2,5 mm e < 4 mm e extensão < 20 mm; e de exclusão: lesões localizadas no TCE, bifurcações, oclusões crônicas e reestenose intra-stent. RESULTADOS: As características basais dos grupos foram clinica e angiograficamentemente semelhantes. O sucesso do procedimento foi obtido em 98,9 por cento dos pacientes nos dois grupos. Ocorreu uma morte cardíaca na fase hospitalar em cada grupo. O diâmetro de referência e o ganho agudo foram maiores no grupo Penta® (3,21±0,37 mm vs 3,34±0,8 mm, p=0,02 e 2,3±0,5 vs 2,49±0,5, p=0,009, respectivamente). O seguimento angiográfico aos seis meses mostrou taxas semelhantes de reestenose (24,3 por cento vs 21,8 por cento, p=0,84) e de eventos cardíacos maiores (16,8 por cento vs 17,5 por cento, p=1). CONCLUSÃO: Os stents recobertos com CSD não apresentaram resultados superiores em relação aos stents não-recobertos.

OBJECTIVE: To compare restenosis and major cardiac event rates at one and six months after DLC-coated stent implantation with those of uncoated stents. METHODS: Randomized, prospective, comparative study of 180 patients with coronary insufficiency undergoing DLC coated stent (Phytis™) or uncoated stent (Penta™) implantation, from January, 2003 to July, 2004. Inclusion criteria were: de novo lesion with >50 percent diameter stenosis in a coronary artery with reference diameter > 2,5 mm and < 4 mm, and length < 20 mm. Exclusion criteria were: left main coronary artery and bifurcation lesions, chronic total occlusion, and in-stent restenosis. RESULTS: Clinical and angiographic baseline characteristics of the groups were similar. Procedural success was achieved in 98.9 percent of the patients in both groups. One cardiac death occurred in each group during hospitalization. Reference diameter and acute gain were greater in the Penta™ group (3.21±0.37 mm vs. 3.34±0.8 mm, p=0.02 and 2.3±0.5 vs. 2.49±0.5, p=0.009, respectively). Angiographic follow-up at six months showed similar rates of restenosis (24.3 percent vs. 21.8 percent, p=0.84) and of major cardiac events (16.8 percent vs. 17.5 percent, p=1). CONCLUSION: DLC coated stents did not provide better outcomes in relation to uncoated stents.