Emergent saphenous vein graft stenting for acute occlusion during percutaneous transluminal coronary angioplasty

Effect of Percutaneous Interventions within the Coronary Sinus on the Success Rate of the Implantations of Resynchronization Pacemakers

BACKGROUND

Cardiac resynchronization therapy (CRT) becomes a "gold standard" in therapy of selected patients with advanced heart failure. We set out to evaluate the feasibility and safety of percutaneous interventions within coronary sinus (CS) and their effect on the success rate of left ventricular (LV) lead implantation during CRT.

METHODS

The study analyzed eight consecutive patients with the indications for CRT, who needed additional procedures within CS to overcome technical problems during left ventricular (LV) electrode implantation. The analyzed group consisted of three subgroups: patients in whom percutaneous balloon angioplasty within CS was needed (n = 4); patients with acute instability of the lead, requiring stenting of the vein to fix the electrode (n = 2); and patients with the stenting of CS due to late dislocation of the lead (n = 2). Success rate, procedure duration, fluoroscopy, complications, and electrical parameters of leads were analyzed.

RESULTS

Success rate of the procedures was 87.5%; additional interventions increased overall efficacy of CRT implantation at our center from 88% to 98% (P < 0.05). Procedure duration (155.0 minute) and fluoroscopy time (42.5 minute) remained acceptable for the patient and operator; however, both were higher than in the procedures performed routinely in our hospital. Electrical properties of the LV leads were stable and within normal ranges during the observation period. We noted two local dissections of CS during the procedure, which remained clinically silent.

CONCLUSION

Percutaneous interventions within CS seem to be feasible and safe treatment options, which can improve the short- and long-term success rates of CRT.

Clinical, angiographic, and procedural correlates of abrupt vascular closure during coronary intervention: a 10-year experience at Mayo Clinic

A large matched-cohort study was carried out to determine correlates of in-hospital abrupt vascular closure (AC). Univariate analysis identified current cigarette smoking (P = 0.021), myocardial infarction within 24 hr prior to procedure (P = 0.0035), emergency procedure (P = 0.02), lesion thrombus (P = 0.0001), and lesion angulation (P = 0.021) as significant clinical and angiographic variables. Relative to balloon angioplasty (PTCA), use of atherectomy (P = 0.015) and laser devices (P = 0.018) but not elective stent placement (P = 0.97) were associated with increased risk of AC. In the multivariate model, current cigarette smoking (P = 0.0474), lesion thrombus (P = 0.0001), lesion angulation (P = 0.0124), use of atherectomy devices (P = 0.001), and laser devices (P = 0.0037) remained as significant correlates of increased AC events. In conclusion, the risk of AC appears associated primarily with lesion characteristics and use of nonballoon devices other than stents. Elective stent placement did not appear to reduce AC risk over conventional PTCA; the small number of patients studied may have prevented any benefit from being observed.

How good are experienced interventional cardiologists in predicting the risk and difficulty of a coronary angioplasty procedure? A prospective study to optimize surgical standby

The prediction of the risk of a percutaneous transluminal coronary angioplasty has either been based on coronary lesion morphology or on clinical parameters, but a combined angiographic and clinical risk assessment system has not yet been evaluated prospectively. Five experienced interventionalists categorized 7,144 patients with 10,081 stenoses (1.4 lesion/patient) for both the risk and the difficulty of the procedure. Risk categories are as follows: 1 = low risk; 2 = intermediate risk; 3 = high risk. This division was made for percutaneous transluminal coronary angioplasty planning purposes. Category 1 patients denotes those in whom surgical standby is not required; category 2 patients, surgical standby not required but available within 1 hr; category 3 patients, surgical standby required. Difficulty categories are as follows: 1 = easy lesion; 2 = moderately difficult lesion; 3 = difficult lesion. Success was defined as a reduction of the degree of stenosis to less than 50%, without acute myocardial infarction, emergency redilatation, emergency bypass grafting, or death within 1 week. The procedure was not successful in difficulty category 1 in 1.6%, in category 2 in 3.5%, and in category 3 in 9.9%. Complications occurred in risk category 1 in 3.5%, in category 2 in 5.2%, and in category 3 in 12.4%. All differences were statistically significant (P < 0.05). Experienced cardiologists can well predict the risk and success of a coronary angioplasty procedure. This helps to optimize surgical standby, although even in the lowest-risk category complications can occur.

Successful limb salvage after recanalization of an occluded infrapopliteal artery utilizing a balloon expandable (Palmaz-Schatz) stent

This case describes the first reported successful management of an infrapopliteal artery intimal dissection utilizing the Palmaz-Schatz balloon expandable stent. Stent deployment relieved the compromised blood flow caused by the intimal flap which could not be corrected by prolonged balloon inflation or removed with directional atherectomy, and averted any emergency surgical procedure.

Changing incidence and management of abrupt closure following coronary intervention in the new device era

Abrupt closure of the dilated segment occurs in approximately 4 to 7% of cases following conventional percutaneous coronary angioplasty. Additional balloon angioplasty reverses roughly 40% of these closures, to yield an overall 1.6 to 3.4% rate of emergent surgery. The impact of new devices on the incidence and reversal rate of abrupt closure has not been examined. Abrupt closure occurred in 80 (4.2%) of 1,919 consecutive coronary angioplasties performed in our single center, 389 (20%) of which were performed using newer interventions (208 Palmaz-Schatz stents, 170 directional coronary atherectomies, and 11 elective laser balloon angioplasties). Abrupt closure was less frequent following newer coronary interventions (1.8%) compared to standard balloon angioplasty (4.9%, P < 0.01), possibly reflecting case selection. When abrupt closure did occur, percutaneous rescue was successful in 53 (66%) patients, including 42 (53%) who were rescued using standard or perfusion balloon angioplasty, and 11 (13%) who were rescued using laser balloon balloon angioplasty after failure of additional angioplasty attempts. Medical therapy alone was used in 8 (10%), while emergent coronary bypass surgery was performed in 18 (23%), yielding an overall emergent surgery rate of 0.9%. Q-wave myocardial infarction was significantly less frequent (0.2%) following percutaneous rescue, compared to either medical therapy (25%) or emergent surgery (33%, P < 0.001). In our catheterization laboratory, use of these 3 new coronary interventional devices coincides with a trend towards a lower incidence of abrupt closure, a higher percutaneous rescue rate with reduced incidence of myocardial infarction, and a lower emergent bypass surgery rate.

Angiographic and clinical outcome of intracoronary stenting: immediate and long-term results from a large single-center experience

OBJECTIVES

The purpose of this study was to determine the immediate and long-term angiographic and clinical results of coronary stenting.

BACKGROUND

Although preliminary trials of endovascular stenting have demonstrated promising results, lack of long-term follow-up has limited the critical evaluation of the role of coronary stenting in the treatment of obstructive coronary artery disease.

METHODS

A total of 250 procedures using the Palmaz-Schatz stent, performed in 220 patients between June 1988 and July 1991, were examined. Minimal lumen diameter of the treated segments was measured on angiograms obtained before, after and 6 months after intervention.

RESULTS

Stent placement was successful in 246 (98%) of 250 lesions, reducing diameter stenosis from 77% to -2.5%. There were no deaths or Q wave myocardial infarctions. One patient (0.4%) required emergency bypass surgery and one (0.4%) developed subacute thrombosis. Femoral vascular complications occurred in 36 patients (16%). Six-month angiographic follow-up was obtained in 91% of eligible patients. The overall angiographic restenosis rate (stenosis greater than or equal to 50%) was 25%. By univariable analysis, the rate of restenosis was significantly higher for stents in the left anterior descending versus the right coronary artery (44% vs. 12%; p = 0.002); in diabetic patients (56% vs. 20%; p = 0.006), and in vessels with post-stent lumen diameter less than 3.31 mm (34% vs. 16%; p = 0.05). Stenting of the left anterior descending artery was the strongest predictor (p = 0.01) of restenosis in a multivariable model. Total survival was 97% and event-free survival (freedom from death, myocardial infarction or revascularization) was 70% at 36 months.

CONCLUSIONS

Palmaz-Schatz stents can be placed successfully with a low incidence of major complications. The angiographic restenosis rate was 25%, and 70% of patients remained free of cardiovascular events at 3 years. Diabetes, small postprocedure lumen diameter and stenting of the left anterior descending artery are associated with higher rates of restenosis.

Vascular pathology of balloon-expandable flexible coil stents in humans

The morphologic changes in atherosclerotic coronary arteries and saphenous vein bypass grafts after placement of a balloon-expandable flexible coil stent (Cook) are described. In each case, the vessels were patent despite morphologic evidence of injury and dissection in the vessel wall. The stented region was reendothelialized and the tissue overlying the stent wires consisted primarily of smooth muscle cells. There was minimal inflammatory reaction to the stent wires. These findings suggest that the balloon-expandable flexible coil stent can effectively maintain vessel patency even in the setting of postangioplasty lumen disruption. In addition, the vessels tolerate the metal prosthesis with little evidence of tissue inflammatory reaction.