Primary PCI for the treatment of ectatic infarct-related coronary artery.

AIM: There is lack of information on the outcome of patients treated with primary angioplasty for lesions located in an ectatic coronary artery segment in the setting of acute myocardial infarction. The aim of this study was to analyse the 2-year follow-up of this specific patient population. METHODS: By means of a systematic review of the databases and cine-films of 5912 primary angioplasties performed in eight Italian cardiac centers we identified 101 patients with infarct-related coronary artery ectasia. Ectasia was defined as a dilatation exceeding the 1.5-fold of normal adjacent segment and was classified according to its severity. The primary end point was the composite rate of cardiac death, recurrence of acute myocardial infarction and a new revascularisation at 2-year. RESULTS: The procedure was successful in 70.3% of cases, unsuccessful or complicated in 29.7%. The primary endpoint was met in 6.9% of cases during hospitalization (95% CI: 2.0-11.8), in 17.8% (95% CI: 10.3-25.3) at 1 year, and in 38.5% (95% CI: 29.0-48.0) at 2 years. Nine patients had a stent thrombosis: 3 acute and 6 sub-acute. A statistically significant correlation between the dimensions of the stent and stent thrombosis was observed (P=0.005). CONCLUSION: In subjects undergoing primary angioplasty for acute myocardial infarction the rate of patients treated on lesions located in an ectatic coronary artery segment is very small (1.7%). The procedural success was low, whereas the rate of events at follow-up was quit high reflecting the complexity of this disease.

Angioplasty of below-the-elbow arteries in critical hand ischaemia.

BACKGROUND: Critical hand ischaemia (CHI) due to pure below-the-elbow (BTE) artery obstruction is a disabling disease and there is still no consensus concerning the most appropriate revascularisation strategy. The aim of this study was to assess the feasibility, safety and outcomes of percutaneous transluminal angioplasty (PTA) in the treatment of CHI due to pure BTE artery disease. METHODS AND RESULTS: Twenty-eight patients (age 62 ± 11 years; three females) with a total of 34 hands affected by CHI (one pain at rest; 18 non-healing ulcer; 15 gangrene) due to pure BTE artery disease underwent PTA. Most of the patients were males with a long history of diabetes mellitus, end-stage renal disease (ESRD) on haemodialysis and systemic atherosclerosis. The interosseous artery was free of disease in all cases, whereas the radial and ulnar arteries were simultaneously involved in 31/34 hands with long stenosis/occlusions (91%; mean length 155 ± 64 mm). The technical success rate was 82% (28/34), with only three minor complications. In the three cases with a functioning radial arteriovenous fistula, we successfully treated the ulnar artery. PTA was unsuccessful in 18% (6/34) hands due to inability to cross severely calcified lesions. The hand-healing rate was 65% (22/34). The predictors of hand healing were PTA technical success (odds ratio (OR) 0.5, confidence interval (CI) 0.28-0.88; p ≤ 0.0001) and digital run-off (OR 0.37, CI 0.19-0.71; p ≤ 0.003). The mean follow-up period was 13 ± 9 months. Six patients (18%) underwent secondary procedures due to symptomatic restenosis. In all these cases, a successful re-PTA was performed at a mean 6 months after the index procedure, and there were no major procedure-related events. Ten patients (36%) died during follow-up. CONCLUSIONS: Angioplasty of BTE vessels for CHI is a feasible and safe procedure with acceptable rates of technical success and hand healing. Poor digital run-off due to obstructive disease of the digital vessels can reduce the hand-healing rate after a successful PTA. Pure isolated BTE vessel disease seems to characterise patients with ESRD and diabetes mellitus.

Nobori™ drug eluting stent system: clinical evidence update.

Drug eluting stents (DES) have changed the landscape of interventional cardiology with their high efficacy in preventing restenosis. Several DES are available for clinical use with different drugs, polymers and platforms. The Nobori™ is a novel generation drug eluting stent. The drug, Biolimus A9™, a sirolimus analogue, is immersed in a biodegradable polymer which is applied solely to the abluminal surface of a flexible stainless steel stent platform. The drug-polymer matrix is designed to release the drug simultaneously with the polymer degradation in a process lasting between 6-9 months. The coating design along with the lipophilicity of the drug is expected to optimize drug distribution and to reduce its release into the peripheral circulation. The drug free luminal surface might reduce negative impact on endothelization observed with DES with circumferential coating and durable polymers. Nobori™ stent is extensively studied in the comprehensive NOBORI clinical program. This stent showed superiority versus Taxus Liberte stent for in-stent late loss at 9 months in NOBORI 1 study, similarity to Cypher stent in NOBORI CORE study and superior performance versus both Taxus and Cypher stent in the study indirectly assessing endothelial function at 6-9 months after stent implantation. The landmark of NOBORI trials is very low rate of late and very late stent thrombosis along with exceptionally low target lesion revascularization rate.

Long-term outcomes after angioplasty of isolated, below-the-knee arteries in diabetic patients with critical limb ischaemia.

BACKGROUND: It has been shown that concomitant percutaneous transluminal angioplasty (PTA) of above-the-knee (ATK) and below-the-knee (BTK) arteries is highly beneficial for limb salvage in patients with critical limb ischaemia (CLI), but few published studies have specifically investigated outcomes in diabetic patients with CLI associated with isolated small BTK-vessel disease. This study aimed to evaluate the long-term results of successful PTA for limb salvage in such patients. MATERIALS AND METHODS: From among the 634 patients with CLI in our database, we retrospectively selected a consecutive series of 101 diabetics (16%) with 107 critically ischaemic limbs (33 Rutherford 5 and 74 Rutherford 6) and no critical ATK lesion, who underwent PTA on isolated BTK lesions. RESULTS: The limb salvage rate was 93% after a mean follow-up of 1048+/-525 days (2.9+/-1.4 years). Transcutaneous oxygen tension significantly increased after 1 month (18.1+/-11.2 vs. 39.6+/-15.1; p<0.05). After 1 year, target-vessel re-stenosis had occurred in 42% of the non-amputated limbs, nine patients (9%) had died because of medical conditions unrelated to PTA and three patients had undergone repeat PTA for recurrent CLI. CONCLUSIONS: In our selected patient population with ischaemic diabetic foot and isolated BTK lesions, a successful endovascular procedure led to a high percentage of limb salvage at long-term follow-up.

Left ventricular diastolic impairment during coronary arteriography with a non-ionic contrast medium.

AIM: The aim of this study was to assess the influence of coronary arteriography with the use of a non-ionic low molecular monomer (iopromide) on left ventricular function. METHODS: Fifty consecutive patients with coronary artery disease (CAD) and normal left ventricular ejection fraction were studied by coronary arteriography for a stable or unstable coronary syndrome by using iopromide. They were divided into 2 groups: group 1, patients with one vessel disease; group 2, patients with multiple vessel disease. A >50% reduction of the lumen diameter by on-line quantitative angiography was considered a significant coronary stenosis. Coronary arteriography was performed by hand injection of 5 ml of iopromide avoiding the use of nitrates during the procedure. Doppler echocardiography monitoring was performed immediately before the coronary arteriography and at the end of the last coronary injection. The following parameter were recorded: E peak velocity (E) (cm/s), A peak velocity (A) (cm/s), E/A ratio, E deceleration time (EDT) (ms), isovolumic relaxation time (IRT) (ms), and left ventricular ejection fraction (EF) (%). RESULTS: No complications were observed during the procedures. A mean amount of 40+/-8 ml of iopromide was used. No significant variation of heart rate and arterial pressure was shown during coronary arteriography. No changes were observed either for E, A, E/A ratio or for left ventricular EF in any group of patients. A significant increase of EDT and IRT in comparison with baseline values was documented only in group 2 (from 140+/-77 to 199+/-44 and from 98+/-33 to 144+/-44, p<0.01), returning to baseline values after 10+/-3 minutes. A positive correlation was observed between EDT and IRT shift from baseline values (r=0.77; p<0.01). CONCLUSION: In conclusion, iopromide temporarily impairs left ventricular diastolic dynamics during selective coronary angiography, but only in patients with multivessel CAD.

Percutaneous closure of patent foramen ovale: pathophysiology, indications, and technique.

The percutaneous closure of patent forame ovale (PFO) is currently performed in patients with cryptogenic stroke or paradoxical systemic embolism. The availability of new user friendly devices and the increase in knowledge of the pathophysiology, epidemiology, and follow-up of these patients has broadened the indications and drastically reduced the morbidity related to the intervention. This review considers the main pathophysiological and epidemiological features of PFO and discusses the indications and results of the intervention.

Restenosis after NIR stent implantation.

The NIR stent is a "second-generation" slotted-tube stent that was developed after the Palmaz Schatz and the Gianturco-Roubin stents, and introduced into clinical practice in 1992. This review of the literature describes its clinical performance and the long-term outcomes after implantation in different anatomical and clinical subsets of patients. It also considers clinical experience with the gold-plated NIR stent.

A randomised comparison of the use of 4 and 6 French diagnostic catheters: the limits of downsizing.

BACKGROUND: The use of small catheters for coronary angiography can reduce the risk of vascular complications and allow early ambulation, but excessive downsizing may lead to poor quality imaging. The aim of this study was to assess the feasibility of performing coronary angiography using 4 French (4 F) femoral catheters. METHODS: In total, 400 consecutive elective patients were randomised to undergo coronary angiography with 4 F or 6 F catheters. The puncture site was manually compressed and inspected before and after ambulation, and 24 h later. The handling difficulty of the catheters was semi-quantitatively evaluated using a three grade scoring system; angiogram quality was evaluated by two independent physicians. RESULTS: No major procedure-related complications were observed. Coronary arteriography with 4 F catheters was possible in all of the attempted cases. There were no statistical differences between the two groups in terms of procedural or fluoroscopy time, the amount of contrast medium used, or the incidence of vascular complications, while compression time was significantly shorter in the patients studied using the smaller catheter (3.4 vs. 9.9 min; P<0.0001). Catheter stability was similar in the two groups, whereas catheter torque and the quality of the coronary angiograms were statistically better in the patients studied using six French catheters. CONCLUSIONS: Coronary angiography with 4 F catheters is technically feasible and permits early ambulation after the procedure. Although the radiological resolution of the images obtained using 4 F catheters was always adequate for clinical decision-making, the angiogram quality and catheter handling were significantly better using the 6 F system.

[New coronary imaging modality. I. Digital angiography (cineless) and low-energy digital fluoroangioscopy systems]. / Nuove modalità di imaging coronarico I. Angiografia digitale (cineless) e sistemi fluorangioscopici digitali a bassa energia.

The advent of digital medical imaging offered unique new possibilities of analyzing, visualizing and communicating medical images. This article reviews the impact of the digital technology in the cardiac catheterization laboratory and covers a range of topics such as the standard DICOM, the transition to cineless angiography, the digital cardiac archive, the network system for imaging exchange and the role of the cardiac digital mobile imaging systems.

Stent implantation without predilation in patients with a single, noncalcified coronary artery lesion.

The purpose of this study was to assess the feasibility of stent implantation without predilation in patients with a single, noncalcified coronary artery lesion. A total of 122 patients were randomized to receive a stent with or without predilation; direct stent placement was possible in 59 of the 61 patients (97%) with an immediate and long-term clinical follow-up similar to that observed in the group of patients treated conventionally.

[The hemodynamics laboratory without cine film. A comparison between the production costs of 35-mm film and the recordable compact disk]. / Il laboratorio di emodinamica cineless. Confronto tra costi di produzione del film 35 mm e del compact disk recordable.

BACKGROUND: For more than 35 years, cine film has been used as the standard recording medium for coronary angiography. At present, the DICOM and the CD-R format have been established as the standard media for the transport of cardiac angiographic images in place of cine angiographic film. The aim of the study was to compare the media production costs between two cardiac catheterization laboratories, with and without cine film. METHODS: We collected data from two different laboratories in the same geographic area which perform about 1000 procedures/year, using a similar digital x-ray imaging system. In one lab, images are recorded on 35-mm film at 25 frames/sec. In the other one, the image support is based on a CD-R. For each laboratory we considered both direct patient and variable equipment costs. Direct patient costs in the film-lab include: cine film, processing chemicals, processing labor, chemical disposal, maintenance; in the digital lab: CD-R costs and masterization time. Equipment costs in the film-lab include: cine camera, cine film processor and cine projector; in the filmless lab a DICOM formatter and a review workstation. The equipment amortization costs are considered over a three-year period. RESULTS: Total direct patient costs are 90,000 lira for the film and 14,000 lira for the CD-R. Equipment costs are 193,000,000 lira in the film-lab and 150,000,000 lira in the filmless one. Overall cost per patient is 154,300 lira for the cine film and 64,000 lira for the CD-R. CONCLUSIONS: This study shows that the media costs per patient for a digital DICOM CD-R format system are substantially less than for 35-mm film, permitting savings of more than 90,000,000 Italian lira per year in a mid-volume cardiac catheterization laboratory.

Which variable of stenosis severity best describes the significance of an isolated left anterior descending coronary artery lesion? Correlation between quantitative coronary angiography, intracoronary Doppler measurements and high dose dipyridamole echocardiography.

OBJECTIVES: This study sought to investigate the angiographic or intracoronary Doppler variables of stenosis severity that best correlate with the results of dipyridamole echocardiography. BACKGROUND: Quantitative coronary angiography and intracoronary Doppler flow velocity assessments are the commonly used techniques for the objective identification of significant coronary artery stenosis. METHODS: Thirty patients with an isolated lesion of the left anterior descending coronary artery (LAD) were studied by means of on-line quantitative coronary arteriography, intracoronary Doppler flow velocity measurements and dipyridamole echocardiography 6 months after percutaneous transluminal coronary angioplasty. The quantitative arteriographic analyses were performed on-line; post-stenotic Doppler flow velocities were measured at baseline and after adenosine infusion. Angiographic and Doppler measurements were compared with the corresponding dipyridamole echocardiographic data and analyzed by discriminant analysis. RESULTS: The dipyridamole echocardiographic response was positive in 11 patients (37%). The best cutoff values for predicting an abnormal echocardiographic response were 1) stenotic flow reserve of 2.8 (p = 0.0001); 2) 59% diameter stenosis (p = 0.0001); 3) minimal lumen diameter of 1.35 mm (p = 0.001); 4) coronary flow reserve of 2.0 (p = 0.0002); and 5) maximal peak velocity of 60 cm/s during hyperemia (p = 0.04). Multivariate analysis identified stenotic flow reserve as the only independent predictor of ischemia during dipyridamole echocardiography. CONCLUSIONS: Stenotic flow reserve is the variable that best describes the functional significance of an isolated LAD lesion, and a value of 2.8 is the best predictor of a positive dipyridamole echocardiographic response. Furthermore, angiographic variables of stenosis severity relate to echocardiographic test results better than intracoronary Doppler variables.

Dipyridamole thallium-201 imaging very early after uncomplicated acute myocardial infarction in patients treated with thrombolytic therapy.

The aim of this study was to assess the safety and prognostic value of dipyridamole 201T1 imaging very early after acute myocardial infarction in patients treated with thrombolytic therapy. Fifty-two consecutive patients with an uncomplicated clinical course underwent quantitative planar dipyridamole 201T1 imaging 2 5 days after acute myocardial infarction. The patients were followed for 14 +/- 7 months after discharge. No major complications occurred during the test. Of the 30 patients with redistribution, five (16.6%) developed in-hospital unstable angina as against none of the 22 patients without redistribution. During follow-up, a total of live late cardiac events were observed: two deaths and two cases of unstable angina in the group with reversible defects and one reinfarction in the group with fixed defects. The 1-year actuarial probability of being free of cardiac events was, respectively, 66 +/- 10% and 94 +/- 5% in the patients with and without redistribution (P < 0.01). In conclusion, in patients treated with thrombolysis, dipyridamole-201T1 imaging very early after uncomplicated acute myocardial infarction is a feasible and safe test. Patients with fixed defects appear to be at low risk and may be candidates for early discharge; the presence of redistribution identifies a subgroup of patients who may benefit from further careful clinical evaluation.