Treatment of in-stent restenosis with sirolimus-eluting-stents—

[Acute coronary syndrome - a challenge for the cooperation between outpatient and inpatient care]

Acute coronary syndrome (ACS) summarizes all phases of coronary heart disease, which are imminently life-threatening. In clinical practice, these are unstable angina pectoris, acute myocardial infarction, and sudden cardiac death. As the transitions between these clinical entities are smooth, it has been established during the last years to distinguish patients based on ECG findings in groups with (STEMI) and without ST segment elevation (NSTEMI/unstable angina pectoris). Because of the life-threatening character of this disease, continuous monitoring and immediate diagnostic evaluation are mandatory in all patients with suspected ACS. Regularly, this has to be done in the emergency department of a hospital. As the diagnostic and therapeutic management of ACS necessitates rapid decision-making, an optimal cooperation between outpatient and inpatient departments is essential for maximal therapeutic performance. However, it has been shown that only 20-30% of patients admitted to an emergency department with acute chest pain have ACS and only 10-15% have acute myocardial infarction. About 50% of patients presenting with acute chest pain are part of a low-risk group and do not need hospital admission. On the other hand, 2-8% of patients with acute myocardial infarction are misdiagnosed in interdisciplinary emergency departments and discharged too early in spite of an ongoing life-threatening risk. Therefore, chest pain units (CPUs) were founded in many hospitals to optimize the diagnosis and treatment of ACS and the related consumption of financial resources. A task force of the German Society of Cardiology is presently preparing a consensus paper on the basic requirements for CPUs in Germany. The positioning of CPUs at the gateway between outpatient and inpatient care and the additional need for short-term outpatient exercise testing (stress ECG, stress echocardiography, scintigraphy, stress MRI) after ruling out ACS and myocardial infarction, predestine these facilities for new models of managed care including cardiologists in private practice.

Midterm outcomes of paclitaxel-eluting stents for the treatment of intracranial posterior circulation stenoses

OBJECT

Symptomatic intracranial vertebral and basilar artery atherosclerotic stenoses carry a high risk of stroke and permanent disability if refractory to maximal medical therapy. The authors conducted a study to determine the technical feasibility and midterm clinical and angiographic outcomes in patients in whom paclitaxel-eluting stents were placed for the treatment of symptomatic intracranial posterior circulation stenoses.

METHODS

A retrospective review of medical records and imaging studies was performed for 13 consecutive patients in whom paclitaxel-coated stents were used to treat symptomatic posterior circulation intracranial stenoses between 2002 and 2005. Clinical follow-up data were supplemented by telephone interviews. The technical success rate for stent placement was 100%. One patient (8%) suffered a periprocedural stroke. Twelve patients (92%) underwent clinical follow up for a minimum of 3 months postsurgery, and 11 (92%) of these patients remained asymptomatic after a mean period of 10.9 months. Nine patients (69%) underwent catheter angiographic follow up, and no patient had significant in-stent recurrence of stenosis after a mean period of 5.4 months.

CONCLUSIONS

Treatment of intracranial posterior circulation stenoses with drug-eluting stents is technically feasible, and the rate of clinically significant periprocedural complications is low. Rates of stenosis recurrence are reduced compared with those of bare-metal stents in the midterm. Midterm clinical outcome is excellent; no symptom recurrence was observed in this patient cohort.