Percutaneous implantation of endoprostheses in the carotid arteries.

OBJECTIVE: To assess the in-hospital evolution of patients undergoing percutaneous stent placement in the carotid arteries. METHODS: From August 1996 to April 2001, we studied 86 patients with carotid arterial obliterative lesions > 70% who were treated with percutaneous stent placement in the carotid arteries. We assessed the rate of success of the implantation and of the procedure, the types of stents used, mortality rate, and neurological complications. RESULTS: Successful implantation was obtained in 98.9% of the cases, and the procedure was successful in 91.8%. The Wallstent was the most frequently used stent (73 patients - 77%). Cerebral strokes occurred as follows: 3 (3.2%) transient ischemic attacks, 1 (1.1%) minor stroke, and 3 (3.1%) major strokes. One (1.1%) patient died during hospitalization. CONCLUSION: The high rate of success of stent implantation (98.9%) in addition to the low rate of cerebral stroke/death (4.2%) showed the efficiency and safety of percutaneous stent placement in carotid arteries.

Randomized comparison of distal and proximal cerebral protection during carotid artery stenting.

OBJECTIVES: This study sought to randomly compare cerebral protection with ANGIOGUARD (Cordis Corporation, Bridgewater, New Jersey) with Mo.Ma (Invatec/Medtronic Vascular Inc, Santa Rosa, California) during carotid artery stenting (CAS), using diffusion-weighted magnetic resonance imaging (DW-MRI) to detect new ischemic cerebral lesions. The number, size, and location of lesions were analyzed. BACKGROUND: The choice of the type of cerebral protection during CAS is controversial. METHODS: From July 2008 to July 2011, 60 patients undergoing CAS were randomized to ANGIOGUARD or Mo.Ma, distributed by chance, 30 patients for each group. All patients underwent DW-MRI before and after CAS. An independent neuroradiologist blinded to the cerebral protection used analyzed the images. Univariate and multivariate logistic models were fitted to analyze new ischemic lesions. Alternatively, a propensity score approach was used to reduce the bias due to differences between the groups. For the number of lesions, we used Poisson regression models. RESULTS: New ischemic lesions seen on DW-MRI were present in 63.3% of the ANGIOGUARD group versus 66.7% of the Mo.Ma cohort (p = 0.787). The number of ischemic cerebral lesions per patient, when present, was significantly lower in the Mo.Ma group (a median of 6 lesions per patient vs. a median of 10 in the ANGIOGUARD, p < 0.001). Most lesions were small (<0.5 mm) and localized in the ipsilateral territory. One patient in the ANGIOGUARD group had a minor stroke during CAS (1.66%). CONCLUSIONS: New ischemic lesions seen on DW-MRI were present in both groups in >60%, but the number of lesions per patient was greater in the ANGIOGUARD group. No death or disabling stroke occurred during at least 1 year of follow-up in both cohorts.

Comparison of the very long term (>1 year) outcomes of drug-eluting stents for the treatment of bare-metal and drug-eluting stent restenosis.

AIMS: Drug-eluting stents (DES) have become the first choice to treat BMS restenosis (ISR), replacing brachytherapy and all other available percutaneous approaches. Although markedly reduced, DES ISR still occurs and has been frequently treated with another DES, despite the lack of robust data supporting the safety and efficacy of this approach. We sought to compare the long term clinical outcomes of patients with BMS and DES ISR treated with another DES deployment. METHODS AND RESULTS: Between May 2002 and January 2008 a total of 158 patients with BMS restenosis and 58 patients with DES restenosis were treated with a DES and enrolled in this registry. Primary endpoint included the cumulative occurrence of major adverse cardiac events (MACE=cardiac death, myocardial infarction and target-vessel revascularisation) and stent thrombosis. Baseline clinical aspects did not significantly differ between the groups. There was a trend toward a higher incidence of DM in the DES cohort (36.1% vs. 32.9%, p=0.1). Mean time between first procedure and restenosis was significant longer in the DES population (178+/-61 days vs. 140+/-38 days, p=0.02). At the end of the follow-up period, 92.6% of the patients with BMS-ISR and 86.3% of those with DES-ISR were free of MACE (p<0.001). Patients with DES ISR had significant more recurrence of ISR but equivalent rates of cardiac death, MI and stent thrombosis. CONCLUSIONS: Percutaneous treatment of BMS or DES ISR with the implant of a DES represents a simple and safe approach with sustained long term results. However, the relatively high rate of ISR recurrence among patients with prior DES ISR demand the developing of more effective strategies for that subset of individuals.

Impacto da Curva de Aprendizado na Seleção de Pacientes e nos Resultados Clínicos do Implante por Cateter de Prótese Aórtica / Impact of Transcatheter Aortic Valve Implantation Learning Curve on Patient Selection and Clinical Outcomes

Introdução: O implante por cateter de prótese aórtica (TAVI, do inglês transcatheter aortic valve implantation) constitui tratamento alternativo para pacientes com estenose aórtica de alto risco cirúrgico ou inoperáveis. Para adquirir competência, o grupo multidisciplinar deve receber treinamento específico e acumular experiência na execução do TAVI. Contudo, sua curva de aprendizado não está bem estabelecida. Nosso objetivo foi analisar o impacto da curva de aprendizado na seleção de pacientes, nos aspectos técnicos e nos resultados clínicos do TAVI. Métodos: Estudo observacional e prospectivo dos primeiros 150 pacientes submetidos a TAVI por via femoral, entre janeiro de 2009 e dezembro de 2013 divididos em tercis (n = 50) de acordo com a data do procedimento. Os desfechos foram definidos conforme os critérios Valve Academic Research Consortium-2 (VARC-2). Resultados: A idade foi de 82,5 ± 6,7 anos, sendo 44% homens e 75% em classe NYHA III/IV. O EuroSCORE (24,2 ± 13% vs. 21,2 ± 10,8% vs. 23,4 ± 14,3%) e o STS Score (5,9 ± 2,9% vs. 6,7 ± 4,3% vs. 5,8 ± 3,1%) foram similares entre os grupos. Observou-se redução gradativa nos tempos do procedimento (107,2 ± 48,1 minutos vs. 90,3 ± 42,2 minutos vs. 76,6 ± 37,7 minutos; p < 0,01) e de fluoroscopia (31,3 ± 9,6 minutos vs. 25,4 ± 8,7 minutos vs. 17,2 ± 6,2 minutos; p = 0,01), e no ...

Background: Transcatheter aortic valve implantation (TAVI) is an alternative treatment for high-risk or inoperable patients with aortic stenosis. The multidisciplinary team must undergo specific training and accumulate experience to achieve optimal results. However, its learning curve is not well established. Our objective was to investigate the impact of learning curve on patient selection, technical aspects and clinical outcomes of TAVI. Methods: Observational, prospective analysis of the first 150 patients undergoing transfemoral TAVI between January 2009 and December 2013. Patients were divided into tertiles (n = 50), according to the procedure date. Outcomes were defined according to Valve Academic Research Consortium-2 (VARC-2) criteria. Results: Mean age was 82.5 ± 6.7 years, 44% were male and 75% were in NYHA class III/IV. EuroS-CORE (24.2 ± 13% vs. 21.2 ± 10.8% vs. 23.4 ± 14.3%) and STS Score (5.9 ± 2.9% vs. 6.7 ± 4.3% vs. 5.8 ± 3.1%) were similar between groups. A gradual decrease was observed in procedure times (107.2 ± 48.1 minutes vs. 90.3 ± 42.2 minutes vs. 76.6 ± 37.7 minutes; p < 0.01), fluoroscopy times (31.3 ± 9,6 minutes vs. 25.4 ± 8.7 minutes vs. 17.2 ± 6.2 minutes; p = 0.01) and contrast volume (145.5 ± 70.9 mL vs. 123.2 ± 87.8 mL vs. 101.1 ± 50 mL; p = 0.01). Mortality decreased gradually (20% vs. 10% vs. 4%; p = 0,047), and lower bleeding and moderate-to-severe aortic regurgitation were ...

Drug-eluting stents in the elderly: long-term (> one year) clinical outcomes of octogenarians in the DESIRE (Drug-Eluting Stents In the REal world) registry.

BACKGROUND: Despite the increasing number of elderly people, this high-complexity subset of patients is often excluded from randomized trials of percutaneous coronary intervention (PCI) and, therefore, limited data are available about their outcomes after drug-eluting stent (DES) implantation. We sought to compare the very long-term (> 1 year) clinical follow up of octogenarians treated with DES compared to younger individuals. METHODS: The DESIRE registry is a prospective, nonrandomized, single-center registry with consecutive patients treated solely with DES between May 2002 and May 2007. The only exclusion criteria were the treatment of patients in the setting of acute myocardial infarction (MI) (< 72 hours) and lesions located in non-native coronary arteries. The primary endpoint was the occurrence of combined major adverse cardiac events (MACE) (cardiac death, non-fatal MI and target vessel revascularization) in-hospital and in very long term (> 1 year) follow up. Patients were clinically evaluated at 1, 3 and 6 months and then annually up to 5 years. Stent thrombosis was classified according to the ARC definition. RESULTS: A total of 1,364 patients matched the inclusion/exclusion criteria and were sorted into 3 groups according to their ages: Group I = patients < 70 years of age (n = 914); Group II = patients greater than or equal to 70 and < 80 years of age (n = 334); and Group III = patients greater than or equal to 80 years old (n = 116). As expected, octogenarians had significantly more comorbid and complex anatomic lesion presentation. Nevertheless, in-hospital success was comparable among the 3 groups. Long-term (2.6 +/- 1.2 years) follow up was obtained from 97% of the total population and showed equivalent cumulative MACE in all age ranges (7.6% for < 70 years old vs. 5.4% for septuagenarians and 6.0% for octogenarians, p = 0.7). However, octogenarians had markedly more cardiac death, reflecting the severity of their comorbidity and the natural evolution of coronary disease. Of note, very few cases of stent thrombosis were noticed in the overall population (20 patients, 1.5%), with no difference among the groups. CONCLUSIONS: PCI with DES represents an efficient and safe approach to treat coronary artery disease in the elderly, with low rates of combined MACE comparable to other age ranges.

Impacto do uso rotineiro de stents farmacológicos na prática intervencionista contemporânea de um centro terciário: experiência de uma década do registro DESIRE / Impact of routine drug-eluting stents in contemporary interventional cardiology at a tertiary center: one-decade experience of the DESIRE registry

INTRODUÇÃO: Os stents farmacológicos (SFs) modificaram a prática intervencionista contemporânea, permitindo abordar cenários clínicos e angiográficos progressivamente mais complexos. O objetivo deste estudo foi demonstrar as modificações ocorridas nos últimos 10 anos na forma de indicar e de realizar a intervenção coronária percutânea (ICP) em um hospital privado, terciário, do Estado de São Paulo. MÉTODOS: O DESIRE é um registro unicêntrico, prospectivo, com o objetivo de acompanhar os desfechos agudos e tardios de pacientes consecutivos tratados com SFs. RESULTADOS: No período de 2002 a 2011, foram incluídos 4.229 pacientes, com média de idade de 64,3 ± 11,2 anos, 23% eram do sexo feminino e 30,5%, diabéticos. Foram tratadas 6.518 lesões, das quais 61,5% eram do tipo B2/C. Os SFs foram utilizados em proporção crescente, alcançando penetração de 88,4% em 2011. A complexidade das ICPs aumentou, sendo tratada no último ano 1,76 lesão por paciente, com média de 1,89 SF. O escore SYNTAX, no período de 2002-2006, foi de 12,3 ± 4,4, enquanto entre 2007-2011 elevou-se para 15,7 ± 4,7. O seguimento clínico foi obtido em 98,2% dos pacientes, com mediana de 5,2 anos, sendo observada, nesse período, revascularização da lesão-alvo em 5%, infarto do miocárdio em 6,7% e óbito cardiovascular em 4,1% dos pacientes. A trombose do stent ocorreu em 2,4% dos casos. CONCLUSÕES: Nossos resultados demonstram marcante incremento no perfil de complexidade dos pacientes tratados nos últimos 10 anos e, ao mesmo tempo, confirmam a efetividade a longo prazo dos SFs, a despeito dos perfis clínico e angiográfico tratados.

BACKGROUND: Drug-eluting stents (DES) have changed contemporary interventional cardiology practice, enabling the approach of increasingly more complex clinical and angiographic scenarios. The objective of this study was to demonstrate the changes observed in the last 10 years in the indication and practice of percutaneous coronary intervention (PCI) at a tertiary private hospital in the State of São Paulo. METHODS: DESIRE is a single-center prospective registry aiming at following the acute and late outcomes of consecutive patients treated by DES. RESULTS: From 2002 to 2011, 4,299 patients were included, with mean age of 64.3 ± 11.2 years, 23% were female and 30.5 were diabetic. The total number of lesions treated was 6,518 of which 61.5% were type B2/C. During the course of the study, DES were progressively more used, reaching a penetration of 88.4% in 2011. The complexity of PCIs has increased and in the past year 1.76 lesions per patient were treated with an average of 1.89 DES. The SYNTAX score increased from 12.3 ± 4.4 (2002-2006) to 15.7 ± 4.7 (2007-2011). Clinical follow-up was obtained in 98.2% of the patients, with a median of 5.2 years, and during this period target-lesion revascularization rate was 5%, myocardial infarction was 6.7% and cardiovascular death was 4.1%. Stent thrombosis was observed in 2.4% of the cases. CONCLUSIONS: Our results showed a marked increment in the complexity profile of patients treated in the last 10 years and at the same time confirm the long-term effectiveness of DES, despite the clinical and angiographic profile of patients.

Evolução tardia de pacientes com infarto agudo do miocárdio tratados com stents farmacológicos na prática diária do mundo real: subanálise do registro DESIRE (drug-eluting stent in the real world) / Late follow-up of patients with acute myocardial infarction treated with drug-eluting stents in the daily practice of the real world: a sub-analysis of the DESIRE registry (drug-eluting stent in the real world)

Introdução: Estudos prévios comparando stents farmacológicos (SFs) e stents não-farmacológicos sugerem eficácia e segurança dos SFs no tratamento de pacientes com infarto agudo do miocárdio (IAM). No entanto, a evolução tardia de pacientes com IAM tratados com SFs na prática diária permanece desconhecida. Este estudo teve como objetivo investigar o seguimento tardio de pacientes com IAM recente tratados com SFs na prática diária do mundo real. Métodos: Entre maio de 2002 e junho de 2009, 3.018 pacientes não-selecionados com indicação de intervenção percutânea eletiva ou de emergência foram consecutivamente tratados com SFs em uma instituição clínica. O seguimento tardio de até sete anos foi realizado em 98%, com mediana de 3,4 anos. Os pacientes foram divididos em dois grupos: pacientes com IAM recente (< 30 dias) e pacientes sem IAM recente. Resultados: Os pacientes com IAM recente tinham menos comorbidades e mais doença multiarterial (68,1% vs. 60,7%; P < 0,001), lesões com trombo (13,6% vs. 1,3%; P < 0,001), fluxo TIMI 0/1 (8,3% vs. 1,1%; P < 0,001) e disfunção moderada/grave do ventrículo esquerdo (23,2% vs. 10,9%; P < 0,001), comparativamente aos pacientes sem IAM recente. O grupo IAM recente recebeu 1,6 ± 0,8 stent/ paciente e mais inibidores da glicoproteína IIb/IIIa (19,6% vs. 2%; P < 0,001), mas o sucesso angiográfico foi similar nos dois grupos (> 99%). No seguimento tardio, a incidência de óbito cardíaco (6,4% vs. 2,7%; P < 0,001) e de trombose de stent (3,6% vs. 1,3%; P < 0,001) foi significativamente maior no grupo IAM recente. O IAM recente permaneceu como preditor independente de trombose de stent na análise multivariada (RR 2,96, IC 95% 1,62-5,41; P < 0,001). Conclusões: Pacientes com IAM < 30 dias tratados com SFs apresentaram pior prognóstico quando comparados aos pacientes sem IAM recente, incluindo aumento significativo do óbito cardíaco até sete anos de acompanhamento, e ocorrência 2,5 vezes maior das taxas de trombose de stent.

BACKGROUND: Previous studies comparing drug-eluting stents (DES) and bare-metal stents suggest efficacy and safety of the DES in the treatment of patients with myocardial infarction (MI). However, the late evolution of patients with MI treated with DES in the daily practice remains unknown. Our goal was to investigate the late follow-up of patients with MI recently treated with DES in the real world. METHODS: Between May 2002 and June 2009, 3,018 non-selected patients with indication for elective or urgent percutaneous coronary intervention have been consecutively treated with DES in a clinical institution. The 7-year follow-up was performed in 98% of these patients, with a median of 3.4 years. The patients were divided in two groups: patients with recent MI (< 30 days) and patients without recent MI. RESULTS: Patients with recent MI had less co-morbidities, but more multiarterial disease (68.1% vs. 60.7%; P < 0.001), lesions with thrombus (13.6% vs. 1.3%; P < 0.001), TIMI flow 0/1 (8.3% vs. 1.1%; P < 0.001), and moderate/severe LV dysfunction (23.2% vs. 10.9%; P < 0.001) when compared with patients without MI. The recent MI group received 1.6 ± 0.8 stents/patient and more glycoprotein IIb/IIIa inhibitors (19.6% vs. 2%; P < 0.001), but the angiographic success (> 99%) was similar between groups. In the late follow-up, the incidence of cardiac death (6.4% vs. 2.7%; P < 0.001) and stent thrombosis (3.6% vs. 1.3%; P < 0.001) was significantly greater in the recent MI group. Recent MI remained an independent predictor of stent thrombosis in multivariate analysis (HR 2.96, 95% CI 1.62-5.41; P < 0,001). CONCLUSIONS: Patients with MI < 30 days treated with DES had a worse prognosis when compared with patients without recent MI, including a higher incidence of cardiac death and a 2.5 times greater occurrence of stent thrombosis rate up to 7-year follow-up.

Terapia de recanalização endovascular de oclusão da artéria carótida em paciente com acidente vascular cerebral agudo / Percutaneous recanalization of carotid artery occlusion in patient with and acute stroke

Relatamos o caso de uma paciente de 69 anos, que, após a realização de arteriografia carotídea apresentou trombose sintomática da bifurcação carotídea. A paciente foi submetida imediatamente a reperfusão endovascular mecânica, com implante bem-sucedido de stent carotídeo, obtendo reversão completa do déficit neurológivo.

A 69 year-old woman developed symptomatic internal carotid artery thrombosis after carotid angiography. She was immediately submitted to mechanical endovascular reperfusion with successful carotid stent implantation and complete neurological recovery.

Influência dos sintomas pré-procedimentos na evolução hospitalar e tardia das angioplastias carotídeas com implante de stent e sistemas de proteção cerebral / Influence of symptoms pre-procedure in hospital and late evolution of carotid angioplasty with stent implantation and cerebral protection systems

Introdução: A doença carotídea aterosclerótica (DCA) é responsável por 40 por cento dos acidentes vasculares cerebrais (AVC). Apesar de a intervenção carotídea percutânea (ICP) ser uma alternativa à endarterectomia, ainha há poucos dados disponíveis comparando a ICP em pacientes assintomáticos (PAS) versus sintomáticos (PS). O objetivo desta análise foi avaliar essa questão em um grupo consecutivo de pacientes. Métodos: Foram realizadas 262 ICP em 230 pacientes consecutivos, 61 (26,5 por cento) PAS versus 169 (73,5 por cento) PS. A angioplastia carotídea quantitativa (ACQ) foi realizada pré e pós-procedimento e o seguimento clínico, na fase hospitalar e aos 6 e 12 meses. Resultados: As características demográficas foram similares entre os dois grupos, sendo 31 por cento diabéticos. Obtivemos sucesso primário em 100 por cento dos casos, com ausência de complicações maiores em ambos os grupos. Na análise com ACQ, o diâmetro de estenose foi maior no grupo PAS (83,4 maior ou menos 7,6 por cento vs. 74,9 mais ou menos 12,5 por cento; p menor 0,01), mas o grupo PS apresentou lesões mais longas (18,3 mais ou menos 5,7 por cento vs. 21,7 mais ou menos 7,4 por cento; p menor 0,01). Aos 30 dias não houve diferença na incidência de AVC maior...

Background: Carotid atherosclerotic disease (CAD) is responsible for 40% of strokes. Despite percutaneous carotid intervention (PCI) is an alternative to endarterectomy, there is little data available comparing the PCI in asymptomatic vs. symptomatic patients. The purpose of this analysis was to evaluate this issue in a consecutive group of cases. Methods: 262 PCIs were conducted on 230 consecutive patients, 61 (26.5%) in asymptomatic vs. 169 (73.5%) in symptomatic patients. Quantitative carotid angiography (QCA) was performed before and after the procedure and the clinical follow-up obtained in-hospital and at 6 and 12 months. Results: The demographic characteristics were similar between groups; 31% were diabetics. Primary success was obtained in all cases, with no major complications in both groups. QCA analysis revealed a higher diameter stenosis in asymptomatics (83.4% ± 7.6% vs. 74.9% ± 12.5%; p < 0.01), but symptomatic patients had longer lesions (18.3% ± 5.7% vs. 21.7% ± 7.4%; p < 0.01). At 30 days there was no difference in the incidence of major (1.8% vs. 2.0%; p = 0.45) or minor strokes (0 vs. 1.4%; p = 0.19) for both groups. Between 1 and 12 months there have been no additional strokes. A late target vessel revascularization was observed in symptomatic patients but no neurologic deaths in both groups. Conclusion: PCI is safe and effective, with low incidence of complications at 1 and 12 months. The incidence of death, stroke and target vessel revascularization was similar between groups.

Evolução tardia após intervenção coronária percutânea com stents farmacológicos em pacientes diabéticos do Registro DESIRE (Drug-Eluting Stents in the Real World) / Long-Term results after percutaneous coronary intervention with drug eluting stents in diabetic patients in the DESIRE (Drug-Eluting Stents in the Real World)

Fundamentos: O diabetes melito está relacionado à ocorrência de desfechos desfavoráveis após intervenções coronárias percutâneas. Os stents farmacológicos podem conferir melhor evolução tardia a esse subgrupo de pacientes. O objetivo deste estudo foi avaliar o desempenho desses instrumentais em pacientes diabéticos. Métodos: O DESIRE é um registro unicêntrico, prospectivo, que inclui 2,365 pacientes tratados consecutivamente com stents farmacológicos, entre maio de 2002 e janeiro de 2008. Para a presente análise foram excluídos pacientes com diagnóstico de infarto do miocárdio, aqueles com lesão tratada em ponte de safena e os com período de evolução inferior a 6 meses. Resultados: Assim 1.705 pacientes foram divididos em dois grupos: não-diabéticos (n igual 1.211 pacientes, 71,1 por cento) e diabéticos (n igual 494 pacientes, 28,9 por cento),sendo 109 (6,4 por cento) pacientes em uso de insulina. Dentre os diabéticos havia mais idosos (64,8 mais ou menos 9,8 anos vs. 63,4 mais ou menos11,7 anos; p igual 0,025), mulheres (28,9 por cento vs. 22,5 por cento; p igual 0,005), obesos (35,2 por cento vs. 23,5 por cento; p menor 0,001)...

Background: Diabetes mellitus is related to the occurrence of unfavorable outcomes after percutaneous coronary interventions. Drug-eluting stents can confer a better late evolution to this subgroup. The aim of this study was to assess the performance of these devices in diabetic patients. Methods: The DESIRE is a single-center, prospective registry that included 2,365 consecutive patients treated with drug-eluting stents between May 2002 and January 2008. For the present analysis, patients with a diagnosis of acute myocardial infarction, those with saphenous vein grafts lesions and those within 6 months of the index procedure, were excluded. Results: Therefore, 1,705 patients were divided into two groups: non-diabetics (n = 1,211 P/71.1%) and diabetics (n = 494 P/28.9%), of which 109 P (6.4%) were insulin-dependent. Among the diabetics there was a higher number of older people (64.8 ± 9.8 years old vs. 63.4 ± 11.7 years old; p = 0.025), females (28.9 vs. 22.5%; p = 0.005), patients with obesity (35.2 vs. 23.5%; p < 0.001), hypertension (86.6 vs. 73.7%; p < 0.001), multi-vessel disease (63.4 vs. 54.4%; p = 0.001), small-vessel disease (2.70 ± 0.51 mm vs. 2.75 ± 0.42 mm; p < 0.001) and calcified lesions (32.3 vs. 27.1%; p = 0.009).In the late clinical follow up (2.2 ± 1.1 years), the combined cardiac events occurred more frequently in the diabetic patients (9.8 vs. 7.0%; p = 0.048). The multivariate analysis showed that diabetes mellitus (OR = 1.45; 95% confidence interval 1.0 to 2.1) and the presence of a calcified lesion

Impacto dos stents famacológicos no tratamento percutâneo de lesões coronárias em bifurcação: resultados clínicos tardios de um estudo comparativo incluindo pacientes do "mundo-real" / The impact of drug-eluting stents in the percutaneous treatment of bifurcation coronary lesions: late clinical outcomes of a comparative study including

Fundamentos: Historicamente, as intervenções coronárias percutâneas (ICP) em lesões de bifurcação associam-se com elevadas taxas de complicações, principalmente em decorrência dos resultados subótimos no ramo lateral (RL) e da necessidade de revascularização da lesão-alvo (RLA) durante seguimento tardio. Avaliamos o impacto dos stents farmacológicos (SF) na evolução clínica tardia de pacientes não-selecionados provenientes da prática clínica diária com lesão envolvendo bifurcação. Método: A partir de maio de 2002, 195 pacientes com lesão de bifurcação foram consecutivamente tratados em dois centros clínicos (grupo SF = 89 pacientes; grupo stent não-farmacológico [SNF] = 106), e o seguimento clínico foi completo até dois anos. Resultados: Os dois grupos apresentavam perfis clínicos semelhantes, incluindo média das idades de 63 anos, e 25% de diabetes melito. A maioria das lesões tinha comprometimento significativo dos dois ramos (78% vs. 76%; p = 0,82), a estratégia de stent provisional RL foi utilizada na maioria dos casos (75% vs. 89% de SNF; p = 0,45), e o sucesso angiográfico no RL (fluxo TIMI 3, estenose residual < 50%, sem dissecção) foi atingido em 80% vs. 78% (p = 0,56), nos grupos SF e SNF, respectivamente. Aos 24 meses de seguimento, o grupo SF apresentou maior sobrevida livre de RLA (97,8% vs. 82,1%; p < 0,0001), com conseqüente maior sobrevida livre de eventos cardíacos adversos maiores (ECAM) (93,3% vs. 77,4%; p = 0,003). A trombose de stent ocorreu em 2 pacientes em cada grupo...

Background: Historically, percutaneous coronary interventions (PCI) in bifurcation lesions are associated with high rates of complications, especially due to suboptimal results in the lateral branch (LB) and the need for target lesion revascularization (TLR) during long-term follow-up. We assess the impact of drug-eluting stents in the late clinical follow-up of non-selected patients with bifurcation lesions coming from the daily clinical practice. Methods: Since May, 2002, 195 patients with bifurcation lesions were treated consecutively at two clinical centers [drugeluting stent (DES) group = 89; non drug-eluting stent (NDES) group = 106] and followed up for two years. Results: The two groups presented similar clinical profiles including mean age of 63 years and 25% with diabetes mellitus. The majority of lesions had significant involvement of the two branches (78% vs. 76%; p = 0.82), the provisional LB stent strategy was used in the majority of cases (75% DES vs. 89% NDES; p = 0.45), and the angiographic success in the lateral branch (TIMI 3 flow, residual stenosis < 50% without dissection) was achieved in 80% vs. 78% (p = 0.56) in the DES and NDES groups, respectively. After 24 months of follow-up, the DES group showed a higher survival free of TLR (97.8% vs. 82.1%; p < 0.0001), resulting in higher survival free of major adverse cardiac events (MACE) (93.3% vs. 77.4%; p = 0.003). Stent thrombosis occurred in 2 patients in each group...

Intervenção nas artérias carótidas / Intervention in the carotid artery

O acidente vascular cerebral é uma das doenças de maior prevalência nos dias atuais, No Brasil,representa a terceira causa de óbito na população geral. A cirurgia de endarterectomia de carótidas em pacientes portadores de lesão aterosclerótica carotídea tem sido mais eficiente na diminuição do risco de acidente vascular cerebral quando comparada ao tratamento clínico. Os resultados de estudos observacionais e ensaios clínicos revelaram ser otratamento endovascular com implante percutâneo de stent carotídeo seguro e eficaz. Acredita-se que esse procedimento (implante percutâneo de stent carotídeo) represente uma alternativa à cirurgia de endarterectomia de carótidas, principalmente em pacientes considerados de alto risco para a cirurgia. O aperfeiçoamento das endopróteses e dos materiais e a utilização de sistemas de proteção distal têm contribuído substancialmente para a melhoria dos resultados do implante percutâneo de stent carotídeo...

Cateterismo cardíaco ambulatorial: análise da experiência acumulada em 10 meses / Outpatient Cardiac Catheterization. Analysis of a 10 Month Experience

Objetivo - Identificar pacientes que se prestem à estratégia do cateterismo cardíaco ambulatorial, com base nos aspectos sociais, riscos e complicações, por um período de 24 h. Métodos - Dos 2.126 casos submetidos a ca-teterismo cardíaco, no Instituto Dante Pazzanese de Cardiologia, no período de setembro de 1990 a junho de 1991, excluíramse: a) aqueles com idade superior a 75 anos; b) os com síndromes isquêmicas agudas; c) os com descompensação cardíaca classe IV (NYHA); d) os estudados pela técnica femoral com sistemas introdutores de alto perfil; e) os submetidos à anestesia geral, estudos eletrofisiológicos ou biópsias endomiocárdicas. Após a realização do exame, seguia-se período de observação de 3 h e, na ausência de complicacões, os pacientes re-cebiam alta com orientação de retorno obrigatório no dia seguinte, para reavaliação clínica. As eventuais complicacões deste período foram anotadas. Resultados - Dos 719pacientes elegíveis, 68% eram do sexo masculino, e a idade média era de 55,3 anos. Sessenta e um por cento estavam em classefuncional I da NYHA e a maioria (80,8%) foi estudada pela via braquial. Em 83% dos casos realizou-se a coronariografia, dos quais, 52%exibiam aterosclerose coronária. Quatrocentos e quatorze casos não receberam alta, pela seguintes razões: 217 por término do exame após as 18 h, 111 por razões sócio-econômicas, 23 por recusa do médico assistente, 8 devido à lesão do tronco da coronária esquerda e 55 por complicacões diversas. Todos os 305 pacientes que receberam alta ambulatorial não mostraram qualquer complicação na avaliação clínica do dia seguinte. Conclusão - O cateterismo ambulatorial demonstrou ser seguro em pacientes selecionados, viabilizando grande número de exames, com relativa economia de leitos e outros recursos hospitalares

Purpose - To identify patients suitable for out-patient cardiac catheterization strategy, based on social aspects, risks and complications, for a 24 hour period. Methods - In a series of 2.126 cases submitted to cardiac catheterization at the Instituto Dante Pazzanese de Cardiologia, between September 1990 and June 1991, were excluded: a) those over 75 years of age; b) the acute ischemic syndroms; c) those in NYHA functional class IV; d) patients who used 7 or 8 French femoral angiographtc catheters; e) patients who had undergone general anesthesia, electrophysiological study or endomyocardial biopsy. After the procedure, the patients were observed for a 3 hour period and in the absence of any complication, they were discharged from the hospital, returning the next day for clinical evaluation. If any complication occurred it was registered. Results - In a cohort of 719 eligible patients, 68% were male, with a mean age of 55,3 years. Sixty one per cent were in NYHA functional class I and most of them (80,8%) were studied by the brachial approach. Eigthy-three per cent of the patients were submitted to coronary angiography, with 52% of them having coronary artery disease. Four hundred and fourteen patients were not discharged on the same day: 217 did not have their procedures finish after 6p.m., 111forsocial-economical reasons, 23 because of theirphysician's refuse, 8 because of left main coronary disease, 55 because of any kind of complication. All the 305 patients who were discharged on the same day, did not have shown any complication in the next day evaluation. Conclusion - Outpatient cardiac catheterization is a safe technique in selected patients, making possible the accomplishment of a greater number of procedures improving bed utilization and decreasing hospitalar costs

Tratamento näo-cirúrgico de fístula artério-venosa coronária pulmonar / Nonsurgical treatment of Arterio-venous coronary - pulmonary fístula

Paciente de 58 anos de idade, do sexo masculino, portador de dispnéia, fadiga e angina do peito progressiva aos esforços. Grande fístula artério-venosa coronária pulmonar foi demonstrada através da cinecoronariografia que se originava da artéria circunflexa. A oclusäo da fístula, por técnica percutânea, foi realizada com sucesso. A evoluçäo clínica foi excelente e o resultado angiográfico, 6 meses após, evidenciou manutençäo do resultado

Fifty eight year old man, with dispneia, fatigue and progressive angina underwent cinecoronariography, which showed an arterio-venous coronary-pulmonary fistula originating from the circumflex artery to the pulmonary circulation. We decided to oclude it percutaneously, using a detachable balloon technic. The occlusion was accomplished successfully. Clinical evolution was excellent and the follow-up cinecoronariography 6 months later showed the maintainance of the initial results

Oclusäo de ramos secundários após angioplastia da artéria coronária descendente anterior / Occlusion of secondary branches after angioplasthy of the left descending coronary artery

Avaliar a incidência de oclusäo de ramos secundários em pacientes com lesäo única da artéria descendente anterior, em que a angioplastia coronária foi aplicada pela primeira vez e com sucesso. Duzentos e treze casos com ramos secundários em pacientes com lesäo única da ar considerados " em risco" por estarem envolvidos na lesäo (grupo I - GI; 85 casos - 39,9%); ou por terem sido atingidos pela insuflaçäo do baläo (grupo II - GII, 128 casos - 61,5%). Corresponderam a: GI - 54 ramos septais (S) e 31 ramos diaggonais (Dg), sendo que 36% tinham evidência angiográfica de doença ostial; GII - 77 S e 51 Dg, com 7,8% de doença ostial. Oclusäo de 7 (3,3%) ramos secundários " em "em risco", 4 (4,7%) do GI e 3 (2,3%) do GII. Na evoluçäo clínica destes 7 casos observaram-se angina de peito em 57% e alteraçöes isquêmicas discretas ao eletrocardiograma em 28.6%. Näo houve qualquer alteraçäo enzímica. A oclusäo foi clinicamente silenciosa em 43% dos casos. A oclusäo de ramos secundários é de baixa incidência, ocorre com maior freqüência nos septais, que nascem da lesäo e nos que têm doença ostial, sendo silenciosa em quase metade dos pacientes ou acompanhada de alteraçeos isquêmicas.

Purpose: To evaluate the incidence and clinical presentation of the occlusion of such secondary branches in patients with single vessel coronary artery disease in the left anterior descending artery, who underwent a first elective and successful PTCA. Material and Methods: Two hundred and thirteen side branches of 121 patients considered to be at risk. They were divided into group I (GI85 side branches, 39.9%), if they originated from the atherosclerotic site; and group II (GII120 side branches, 61.5%), if their origin would be involved during the balloon inflation. In the GI there were 54 septal branches and 3.1 diagonal branches, and 36& had angiographic evidence of ostium disease. GII was constituted by 77 septal and 51 diagonal branches, and 7.8% of them had evidence of ostium disease. Results: Seven side branches (3.3%) at risk occluded, 4 from GI (4.7%) and 3 (2.3%) from GII. As for the clinical presentation, 57% of them had angina, where as 28.6% showed minor abnormalities in the ECG. No patient elevated its serum CK-MB, and silent occlusion cccurred in 43% if them. Conclusion: Occlusion of side branches is a low incidence phenomenon, which happens more often in septal branches with ostium disease that originates from the atherosclerotic site; that about half of the patient had silent occlusion (43%) or mild ischemic manifestations

Implante percutâneo de endopróteses nas artérias carótidas / Percutaneous implantation of endoprostheses in the carotid arteries

OBJECTIVE: To assess the in-hospital evolution of patients undergoing percutaneous stent placement in the carotid arteries. METHODS: From August 1996 to April 2001, we studied 86 patients with carotid arterial obliterative lesions > 70 percent who were treated with percutaneous stent placement in the carotid arteries. We assessed the rate of success of the implantation and of the procedure, the types of stents used, mortality rate, and neurological complications. RESULTS: Successful implantation was obtained in 98.9 percent of the cases, and the procedure was successful in 91.8 percent. The Wallstent was the most frequently used stent (73 patients - 77 percent). Cerebral strokes occurred as follows: 3 (3.2 percent) transient ischemic attacks, 1 (1.1 percent) minor stroke, and 3 (3.1 percent) major strokes. One (1.1 percent) patient died during hospitalization. CONCLUSION: The high rate of success of stent implantation (98.9 percent) in addition to the low rate of cerebral stroke/death (4.2 percent) showed the efficiency and safety of percutaneous stent placement in carotid arteries

A intervenção coronária percutânea para o tratamento dos coronarianos estáveis: evidências e tomada de decisão / Coronary percutaneous intervention for the threatment of stable coronary patients: evidences and decision making

A angina estável, forma mais comum de apresentação clínica da doença aterosclerótica coronária, ainda hoje responde por elevados índices de morbidade e mortalidade na população mundial, fato que continuamente tem estimulado os cardiologistas a pesquisarem novas formas de combatê-los, quer por meio do desenvolvimento de novos fármacos como do aprimoramento das técnicas de revascularização percutânea e cirúrgica. A Cardiologia intervencionista, ao longo de seus 25 anos de existência, vem oferecendo opções de tratamento percutâneo cada vez mais eficientes e menos invasivas para os portadores de doença coronária crônica, desde a era dos balões até os atuais stents eluídos em medicação, sendo hoje capaz de modificar de forma segura e eficaz a história natural dessa afecção.