Outcome of carotid artery stenting in asymptomatic and asymptomatic carotid artery stenosis patients in Siriraj Hospital.

BACKGROUND: Carotid artery stenosis represents one of the most common etiologies of stroke. One of current treatment modalities available for the treatment of carotid artery stenosis is carotid artery stenting (CAS). CAS is a less invasive revascularization strategy than carotid endarterectomy (CEA) in carotid artery stenosis. OBJECTIVE: To determine outcome of CAS in symptomatic and asymptomatic carotid artery stenosis patients in Siriraj Hospital. MATERIAL AND METHOD: The authors enrolled 82 patients with carotid artery stenosis that underwent carotid artery stenting between January 2006 and January 2010. Baseline characteristics were collected. Comorbid medical conditions (age > or = 80 years, congestive heart failure class III/IV angina pectoris class III/IV left main or > or = 2 vessels coronary artery disease, urgent heart surgery < 30 days, left ventricular ejection fraction < 30%, recent myocardial infarction < 30 days, severe chronic lung disease, severe renal disease) and anatomic features (lesion at second cervicle or higher; lesion below clavicle, prior radical neck surgery or radiation, prior ipsilateral CEA, contralateral laryngeal nerve palsy, tracheostomy) that are associated with increased complications after CEA were analyzed. Primary endpoint of the present study was the cumulative incidence of a major adverse cardiovascular event (MACE) at 30 days (a composite of death, stroke or myocardial infarction within 30 days after the intervention). RESULTS: There were 60 male (73.20%). Majority of age group (60-79 years) was 64 patients (78.0%). Symptomatic patients accounted for 69.5%. Eight patients (9.7%) developed a major cardiovascular event which was observed at 30 days. No correlation existed between either comorbid medical conditions or anatomic features to major cardiovascular event. Univariate and multivariate analysis showed that age > or = 80 years (p = 0.04) and history of transient ischemic attack (TIA) (p = 0.03) increased unfavorable outcomes. CONCLUSION: CAS is the alternative treatment to CEA for carotid artery stenosis. Risk factor for unfavorable outcomes at 30 days were age > or = 80 years and history of TIA.

Transcatheter aortic valve implantation (TAVI): first case in Thailand.

Aortic valve replacement (AVR) is the standard treatment for patients with symptomatic severe aortic stenosis (AS). However many patients are not offered surgery due to high surgical risk for open AVR. Transcatheter aortic valve implantation has been an alternative to open heart surgery in patients with symptomatic severe aortic stenosis (AS) who are not suitable for open surgery. The first transcatheter aortic valve implantation in Thailand via the transapical route is described. An 87-year-old woman with symptomatic severe AS, calcified aorta and peripheral arterial disease, who was at high surgical risk, was successfully treated, and had good functional and haemodynamic results at six-months follow-up.

D-dimer plasma levels in NSTE-ACS patient.

BACKGROUND: Acute Coronary Syndrome (ACS) occurs when a vulnerable plaque ruptures and induces platelet aggregation and coagulation process at the rupture. Thrombogenesis is the final process that forms a clot in the coronary lumen causing myocardial injury. Plasma D-dimer, a primary degradation product and circulating marker offibrin turnover, serves as a direct marker of ongoing fibrinolysis in site of coronary artery occlusion. OBJECTIVE: To determine the correlation between plasma D-dimer levels and severity of coronary artery obstruction based on angiographic data that is composed of the number of coronary arteries affected and the percentage of maximum stenosis of coronary artery lumen in non-ST elevation ACS (NSTE-ACS) patients. MATERIAL AND METHOD: NSTE-ACS patients who admitted in Siriraj hospital duringJune 2009 and March 2010 were enrolled. Conditions that increased plasma D-dimer other than NSTE-ACS were excluded. Demographic characteristics were assessed by a standardized questionnaire. Plasma D-dimer was measured and coronary angiography was performed to evaluate severity of coronary artery stenosis. RESULTS: Total of 74 NSTE-ACS patients were enrolled (29 in unstable angina and 45 in non-ST elevation myocardial infarction). Mean age of these patients (54.1% in female and 45.9% in male) were 66 years. D-Dimer was significantly increased with the number of coronary arteries affected (p = 0.03). In non-significant and single coronary artery disease (CAD) patients, median D-dimer was 406 (178-2,788) mcg/L. In multivessel CAD, median D-dimer was 941 (131-7,110) mcg/L. D-dimer levels had a trend to be increased with percentage of maximum stenosis of coronary artery lumen; atheromatosis, (p = 0.30). In mild and moderate atheromatosis (coronary artery stenosis < 70%), median D-dimer was 479 (182-5902) mcg/L while median D-dimer was 789 (131-7110) mcg/L in severe atheromatosis (coronary artery stenosis > 70%). Moreover plasma D-dimer levels correlated with complication of NSTE-ACS (Congestive heartfailure; p < 0.001, arrhythmia; p = 0.007 and death; p = 0.009) and was increased in patients who underwent treatment with CABG more often than those who received PCI and medication treatment alone. D-dimer also correlated with serum creatinine (r = 0.517, p < 0.001), creatinine clearance (r = -0.463, p < 0.001), troponin-T level (r = 0.381, p < 0.001) and left ventricular ejection fraction (r = -0.368, p = 0.002). CONCLUSION: D-dimer is useful coagulation marker use to evaluate extent of coronary affected and may predict in-hospital CV complication. However, other conditions that increased plasma D-dimer also excluded.

Correlation between peripheral arterial disease and stage of chronic kidney disease.

BACKGROUND: Atherosclerotic disease is the most common disease in clinical practice. Risk factors for the disease include diabetes, hypertension, dyslipidemia, smoking and chronic kidney disease (CKD). However, few studies have reported the correlation between peripheral arterial disease (PAD) and stages of CKD. Ankle brachial index (ABI) is a non-invasive method for detecting PAD with high sensitivity and specificity. OBJECTIVE: We studied the prevalence of asymptomatic PAD in patients with each stage of CKD using ABI measurement. MATERIAL AND METHOD: We conducted a study of patients with CKD classified by the Kidney Disease Outcomes Quality Initiative classification (K/DOQI classification) who attended at outpatient clinics. The patients with symptomatic PAD will be excluded. The participants will be sent to ABI measurement for the diagnosis of PAD, defined as ABI less than 0.9 RESULTS: The total number of patients who had been enrolled in the study was 201; Male 55%. Mean age was 65.16 +/- 11.3 years. 22.4% of the patients have ABI less than 0.9 which was associated with older age, being female, and having lower diastolic blood pressure (p = 0.002, < 0.001, < 0.0001, respectively) . Diabetes and coronary artery disease were higher in patients with abnormal ABI but with no statistical significance. No difference in other risk factors, for example, hypertension, dyslipidemia and smoking, was detected. Abnormal ABI was frequently seen in the patients with more advanced CKD and mean ABI was lower in patients with more advanced CKD stage. The meanABI of stage 4 and 5 CKD patients was lower than that of stage 1 and 2 (p < 0.05). CONCLUSION: The prevalence of asymptomatic PAD increased with more advanced stage of CKD.

Prediction of contrast-induced nephropathy in diabetic patients undergoing elective cardiac catheterization or PCI: role of volume-to-creatinine clearance ratio and iodine dose-to-creatinine clearance ratio.

OBJECTIVE: To assess a role of volume-to-creatinine clearance ratio (V/CrCl) and iodine dose-to-creatinine clearance ratio (I-dose/CrCl) in predicting contrast- induced nephropathy (CIN) in diabetic patients undergoing elective cardiac catheterization or percutaneous coronary intervention (PCI). BACKGROUND: In diabetic patients undergoing cardiac catheterization or PCI, the incidence of CIN is higher than in non-diabetic patients. High doses of contrast media also increase the likelihood of renal dysfunction. The ratio of the volume of contrast media to creatinine clearance (V/CrCl) and iodine dose-to-creatinine clearance (I-dose/CrCl) has been shown to correlate with the area under the curve of contrast media concentration over time and was used to predict the occurrence of CIN in unselected patients. No study has been conducted specifically in diabetic patients undergoing cardiac catheterization or PCI before. MATERIAL AND METHOD: We conducted a prospective, single center study. The V/CrCl and I-dose/CrCl were calculated in diabetic patients undergoing elective cardiac catheterization or PCI. An increase in serum creatinine of > 0.5 mg/dl or > 25% by 7 days from baseline was considered CIN. The incidence of CIN was determined. The predictive value of V/CrCl and I-dose/CrCl for CIN were assessed using multivariable logistic regression. RESULTS: The total number of patients that had been enrolled in the study was 248; Male 50.8%. The overall incidence of CIN was 5.2%. The mean age for the entire population was 65 +/- 9 years; the mean body mass index was 25.6 +/- 4.0 kg/m2; and the mean creatinine clearance was 60.6 +/- 27.4 ml/min. The mean values of V/CrCl for patients with and without CIN were 3.7 +/- 2.9 and 2.2 +/- 1.7 (p = 0.041). The mean values of I-dose/CrCl for patients with and without CIN were 1.31 +/- 0.94 and 0.82 +/- 0.63 (p = 0.042). The receiver-operator characteristic curve analysis indicated that a V/CrCl ratio of 2.60 and I-dose/CrCl of 0.98 were fair predictors of CIN. After adjusting for other known predictors of CIN, a V/CrCl ratio > or = 2.60 remained the only significant predictor of CIN (Odds ratio 5.8; 95% confidence interval 1.7-19.4, p = 0.005). CONCLUSIONS: A V/CrCl ratio > or = 2.60 was a significant predictor of CIN in diabetic patients undergoing elective cardiac catheterization or PCI.

The effectiveness of "Siriraj Leg Lock" brace on back pain after percutaneous coronary intervention: PCI.

BACKGROUND: The most common problem experienced by patients after Percutaneous Coronary Intervention (PCI) is back pain. After the procedure, patients are restricted to complete bed rest with no hip flexion for up to 10 hours, causing much discomfort, especially back pain. In some patients, anxiety arises due to limited movement, with the belief that movement might cause re-bleeding from the wound. To alleviate these problems, the "Siriraj Leg Lock" brace or SLL was initiated to confine the hip while allowing patients to freely move other parts of their body without complicating the wound. Hence, anxiety is relieved and mobility can lower the chance of getting back pain with more comfort. OBJECTIVE: The aims of this experimental study were to investigate the effect and satisfaction of SLL on back pain in post-PCI patients, and to compare bleeding and/or hematoma occurrences at the site of incision between experimental and control groups. MATERIAL AND METHOD: The randomized controlled trial (RCT) was conducted in 100 patients who underwent coronary angioplasty and/or stent placement interventions and received post procedural care at the intermediate cardiac care ward, Her Majesty Cardiac Center from December 2006 to February 2007. The control group (49 patients) was to get standard care after the intervention, whereas the experimental group (51 patients) was fitted with the SLL device to allow free mobility right after the procedure. RESULTS: Lower maximum back pain scores and mean back pain scores in the experimental group than in the control group, with statistical significance (p < 0.001). Back pain score reduced from the day of admission in the experimental group after applying SLL, but increased in the control group. The occurrence of hematoma in both groups was not significantly different (p = 0.114). The experimental group with the SLL could freely change positions from upright to decubitus without any effects to the wound, feeling more comfortable and experiencing less back pain. Patients' satisfaction towards the SLL from 1 to 5 scale was 4.3. The satisfaction was evident especially in patients who had previous PCI experience, and desired to ask for SLL application if a future procedure to be needed. CONCLUSION: Using SLL after sheath removal post PCI allows the patient to freely change position without any effects to the wound and reduces back pain with more patients' satisfaction.

Evaluation of the firebird sirololimus eluting stent in all comers with coronary artery stenosis.

OBJECTIVE: Percutaneous coronary intervention (PCI) has been widely used to treat obstructive coronary artery disease. With the advent of drug-eluting stent (DES) in real world registry was proved as promising therapy. The limitation of the use of DES is the limited health care expenditure. We propose the use of Chinese made DES among Thai patients and that this will solve the cost issue. The clinical result of this DES has not been well known. METHODS: Prospective study from November 2005 to March 2007 using the structured registry form to evaluate the safety and efficacy of new Chinese made Firebird sirolimus eluting stent (Firebird SES) on clinical parameters from in-hospital, 30 days and 12 months or longer term follow-up. End point is major adverse cardiac event (MACE) including death, MI, TLR and CABG at 30 day and cumulative MACE at 12 month follow-up. RESULTS: Ninety consecutive patients who were treated with Firebird stent implantation (107 target lesions) were analyzed. Angiographic success (defined as < 30% diameter stenosis) was 85%. Procedure success was 77.8%. MACE at 30 day was 16.6%, cumulative MACE at 12 months was 18.8%. There were total 9 deaths during the study period, two deaths occurred at before 30 days, 3 deaths occurred before 12 months and other 4 deaths occurred after 12 months to 1305 days. Eighty patients (88.9%) had either office visit or telephone call follow-up after 12 months, 38 patients (42.2%) underwent clinical driven coronary arteriography, binary restenosis was 26.3%. Shock and smoking history was the analyzed predictor of MACE at follow-up. CONCLUSION: The implantation of Firebird DES in unselected patients (all comers) is safe, effective and could be an alternative choice of stent for Thai patients.

Early and intermediate outcomes of left main coronary intervention.

OBJECTIVE: We examined the immediate and long-term outcomes after stenting of all comers for left main coronary artery (LMCA) stenoses. BACKGROUND: Left main coronary artery disease is regarded as an absolute contraindication for coronary angioplasty. Recently, several reports on protected or unprotected LMCA stenting, or both, suggested the possibility of percutaneous intervention for this prohibited area. MATERIAL AND METHOD: Eighty-one consecutive patients with LMCA stenoses were treated with stents. The post-stent antithrombotic regimens were aspirin and clopidogrel. The major adverse cardiac events (MACE) including death, Q-wave myocardial infarction, or repeat target lesion revascularization were followed. Patients were followed very closely and all attended office visit at 12 months. RESULTS: The procedural success rate was 86.4%, with no episodes of acute thrombosis. Follow-up angiography was performed in 30 of 65 eligible patients (46.2%). Angiographic restenosis occurred in eight patients (9.9%). Cumulative death occurred in 16 patients (19.7%). MACE at 30 day and 12-month was 12.3% and 33.3% respectively. From multivariate analysis, dialysis (HR =3.22, p = 0.048), urgent PCI (HR =2.39, p = 0.036), post-procedure TIMI flow < 3 (HR =25.99, p = 0.001) and final kissing balloon inflation (HR = 0.30, p = 0.04) were independent predictors of MACE at 12-month. There was one definite late stent thrombosis (1.2%). CONCLUSION: Stenting of LMCA stenosis may be a safe and effective alternative to CABG in carefully selected patients. Further studies in larger patient populations are needed to assess late outcome.

Effectiveness of manual pressure hemostasis following transfemoral coronary angiography in patients on therapeutic warfarin anticoagulation.

We evaluated the effectiveness of manual pressure hemostasis after transfemoral coronary angiography in patients on therapeutic warfarin anticoagulation (international normalized ratio [INR] 2.0 to 3.0) compared with discontinuing warfarin > or =48 hours before the procedure (INR <2.0). There was a low incidence of small hematomas with either strategy (no significant difference) and no major vascular complications. No prolonged hospital stay due to an access site complication was observed, and no thromboembolic events occurred. In conclusion, transfemoral coronary angiography appears to be safe in patients on warfarin with an INR of 2.0 to 3.0).

Extraction of challenging intracoronary thrombi: multi-device strategies using guide catheters, distal vascular protection devices and aspiration catheters.

Patients with large intracoronary thrombi represent a difficult management problem for the interventional cardiologist. We report 10 cases of challenging thrombi treated percutaneously using varying combinations of deep guide catheter engagement, guide aspiration, dedicated catheter aspiration and withdrawal of a distal filter vascular protection device. These cases demonstrate interventional options which may be considered for such patients.

Rapid ventricular pacing to lower blood pressure during endograft deployment in the thoracic aorta.

Controlled hypotension is critical to the accurate deployment of aortic endografts and safe balloon post-dilation. We describe the use of rapid ventricular pacing during 15 aortic stenting procedures. An immediate and sustained reduction in both phasic and mean blood pressure was achieved in all patients. This procedure has advantages over pharmacologic or other methods of blood pressure reduction.

Stenting coronary trifurcation lesions: is "ménage à trois" the solution?

Percutaneous treatment of coronary stenoses involving important side branches remains a challenge to the interventionist. We describe two cases of stent deployment in coronary trifurcation lesions. Triple kissing balloon inflation appears important for achieving an optimal angiographic and clinical result.