Showing papers in "Catheterization and Cardiovascular Interventions in 2004"
TL;DR: The risk of device erosion with ASO is low and complications can be decreased by identifying high‐risk patients and following them closely, as well as identifying high-risk cases, early recognition, and prompt intervention.
Abstract: The objectives of this study were to identify possible risk factors that may lead to erosion of the Amplatzer septal occluder (ASO) and recommend ways to minimize future risk. There have been rare occurrences of adverse events with development of pericardial effusion after ASO placement. Identification of high-risk cases, early recognition, and prompt intervention may minimize the future risks of adverse events. In all patients who developed hemodynamic compromise after ASO placement, echocardiograms (pre-, intra-, and postprocedure), atrial septal defect (ASD) size (nonstretched, stretched), size of the device used, cineangiograms, and operative records were reviewed by a panel selected by AGA Medical Corporation. The findings were compared to the premarket approval data obtained from FDA-approved clinical trials that were conducted in the United States, before the device was approved. A total of 28 cases (14 in United States) of adverse events were reported to AGA Medical. All erosions occurred at the dome of the atria, near the aortic root. Deficient aortic rim was seen in 89% and the defect described as high ASD, suggesting deficient superior rim. The device to unstretched ASD ratio was significantly larger in the adverse event group when compared to the FDA trial group. The incidence of device erosion in the United States was 0.1%. The risk of device erosion with ASO is low and complications can be decreased by identifying high-risk patients and following them closely. Patients with deficient aortic rim and/or superior rim may be at higher risk for device erosion. Oversized ASO may increase the risk of erosion. The defect should not be overstretched during balloon sizing. Patients with small pericardial effusion at 24 hr should have closer follow-up.
507 citations
TL;DR: These results document that interventional cardiologists commonly suffer orthopedic disease, frequently leading to lost work days, as well as radiation‐associated problems (cataracts and cancers).
Abstract: Invasive cardiologists generally consider radiation to be the chief occupational hazard. Heavy leaded aprons worn to reduce this risk may be associated with orthopedic complications. This study was designed to characterize the prevalence of these occupational health problems. The Interventional Committee of the Society for Cardiac Angiography and Interventions (SCAI) sent to its Internet-registered members a Web-based survey. Inquiries included age, years of invasive practice, and diagnostic/interventional cases/year. Questions (yes/no) focused on orthopedic (spine, hips, knees, and ankles) and radiation-associated problems (cataracts and cancers). The survey was sent to over 1,600 members with 424 responses. Responders were on average busy and experienced, performing catheterization > 10 years in 62% of cases and > 20 years in 24% others. Average annual diagnostic-only case load was > 200/year in 72%, > 300/year in 43%, and > 500/year in 18% of responders. Reported annual interventional caseload was > 100/year in 83%, > 200/year in 37%, and > 300/year in 15% of operators. Orthopedic problems included spine problems in 42% of responders (of these, 70% were lumbosacral and 30% cervical). Hip, knee, or ankle problems were noted in 28% of operators. Spine problems were related to the annual procedural caseload and the number of years in practice. Over one-third reported spine problems had caused them to miss work. The results of the radiation queries were inconclusive. These results document that interventional cardiologists commonly suffer orthopedic disease, frequently leading to lost work days.
243 citations
TL;DR: The optimal timing for elective noncardiac surgery (NCS) after coronary stenting is uncertain and six of the seven patients in whom thienopyridine antiplatelet therapy was discontinued died postoperatively in a manner suggestive of stent thrombosis.
Abstract: The optimal timing for elective noncardiac surgery (NCS) after coronary stenting is uncertain. We identified 47 patients who underwent elective NCS within 90 days of coronary stent placement between January 1995 and December 2000. Twenty-seven patients had NCS within 3 weeks of coronary stenting. Six of the seven in whom thienopyridine antiplatelet therapy was discontinued died postoperatively in a manner suggestive of stent thrombosis. In contrast, only 1 of the 20 patients in whom the thienopyridine was continued through the NCS died. The frequency of perioperative hemorrhage was similar whether or not the antiplatelet agent was continued. Only 1 perioperative death occurred in the 20 patients with NCS more than 3 weeks following stenting.
222 citations
TL;DR: This work reports two cases of treatment failure with sirolimus-eluting stents (SESs) related to stent fractures.
Abstract: Coronary stents, initially reserved for bailout situations, are now used in more than 80% of all cases. However, their efficacy is limited by the occurrence of in-stent restenosis, ranging from 15% to 35% of cases, depending on lesion morphology [1–3]. Recently, drugeluting stents have been proven very effective in suppressing neointimal proliferation and reduced restenosis to single digit numbers [4–6]. We report two cases of treatment failure with sirolimus-eluting stents (SESs) related to stent fractures.
206 citations
TL;DR: It is concluded that percutaneous device closure of postinfarction VSDs using the Amplatzer PIMVSD occluder appears to be safe and effective.
Abstract: The objective of this study was to assess the immediate and mid-term results of transcatheter closure of postinfarct muscular ventricular septal defects (VSDs) using the new Amplatzer postinfarct muscular VSD device (PIMVSD). Ventricular septal rupture occurs in 0.2% of myocardial infarcts and remains associated with very high morbidity and mortality. Data were prospectively collected for 18 patients who underwent attempted device closure of postinfarction VSDs between 2000 and 2003. Five patients underwent the closure in the acute phase (within 6 days from the infarct); the remaining patients underwent closure on day 14-95 after the diagnosis of the infarct. Outcome parameters included procedural success, evidence of residual shunts on echocardiography, and occurrence of procedure-related complications. The procedure was successful in deploying a device across the VSD in 16 of 18 patients. The 30-day mortality was 28%. Eleven patients are still alive and have been followed up for a median of 332 days. Two patients required a second procedure to close a residual VSD. At the most recent outpatient follow-up, the VSD was completely closed in two patients, six patients had a trivial or small residual shunt, and two patients had a moderate residual shunt. We conclude that percutaneous device closure of postinfarction VSDs using the Amplatzer PIMVSD occluder appears to be safe and effective. Further trials are required to assess long-term efficacy and compare the results with those of surgical closure.
191 citations
TL;DR: Because the incidence of ASO embolization is about 1 in 200 in the most experienced hands, all operators should be prepared with the techniques and equipment required for percutaneous ASO retrieval.
Abstract: Embolization and percutaneous retrieval of the Amplatzer septal occluder (ASO) after release have been reported However, the incidence, the causes of embolization, and the methods for effective retrieval have not been systematically described In a survey of the ASO company-designated proctors, the incidence of ASO embolization in this group's experience was 055% (21 embolizations in 3824 device placements) with a wide range of patient demographics, atrial septal defect (ASD) sizes, and device sizes Most embolizations occurred because of inadequate rim or undersized devices Of the 21 embolizations, 15 of the devices were retrieved percutaneously with a gooseneck snare without morbidity or mortality Six were retrieved at surgery Of the 21 patients, 12 had ASO closure of their ASDs, and 9 had surgical ASD closure In vitro, all devices could be retrieved with sheathes 2 Fr sizes larger than their recommended delivery sheath Any device larger than 26 mm could be retrieved with its delivery sheath The ability to pull the snared button into a sheath was variable and was assisted by pulling the device from above with a bioptome and by using a rigid notched sheath Because the incidence of ASO embolization is about 1 in 200 in the most experienced hands, all operators should be prepared with the techniques and equipment required for percutaneous ASO retrieval
160 citations
TL;DR: The Amplatzer membranous septal occluder was suitable to close a wide range of perimembranous VSD sizes and morphologies with good short‐term outcomes.
Abstract: Percutaneous closure of perimembranous ventricular septal defects (VSDs) has been feasible, safe, and effective with the new Amplatzer membranous septal occluder We report further experience with this device with emphasis on morphological aspects of the VSDs and technical issues Ten patients (median age and weight, 14 years and 345 kg, respectively) with volume-overloaded left ventricles underwent closure under general anesthesia and transesophageal guidance (TEE) The VSD diameter was 71 +/- 40 mm by angiography and 78 +/- 37 mm by TEE Three patients had defects associated with aneurysm-like formations (two with multiple exit holes), four had defects shrouded by extensive tricuspid valve tissue, two had defects with little or no tricuspid valve involvement, and one had a right aortic cusp prolapse with trivial aortic regurgitation Implantation was successful in all patients, although in two the initial device had to be changed for a larger one Kinkings in the delivery sheath, inability to position the sheath near the left ventricular apex, and device prolapse through the VSD prompted modifications in the standard technique of implantation Device orientation was excellent except in one case Nine patients had complete occlusion within 1-3 months Device-related aortic or tricuspid insufficiency, arrhythmias, and embolization were not observed Two patients had slight gradients across the left ventricular outflow tract, normalizing after 3 months The Amplatzer membranous septal occluder was suitable to close a wide range of perimembranous VSD sizes and morphologies with good short-term outcomes Longer follow-up is required
138 citations
TL;DR: This work aimed to investigate the performance of drug‐eluting stent (DES) platforms with the crush technique, to identify deployment pitfalls, and to clarify the best deployment strategies.
Abstract: Sirolimus-eluting stents appear to reduce substantially restenosis following percutaneous coronary bifurcation intervention. The crush technique was devised to reduce restenosis further by improving stent and drug application to the side-branch ostium. We aimed to investigate the performance of drug-eluting stent (DES) platforms with the crush technique, to identify deployment pitfalls, and to clarify the best deployment strategies. Each stage of the crush technique was photographed in a bifurcation phantom. Simultaneous side- and main-branch dilatation (kissing balloons) fully expanded the stent in the side-branch ostium, widened the gaps between stent struts covering the side branch, and eliminated main-branch distortion. With side branches angled at > 70 degrees , sequential (side- then main-branch) inflations may be needed to achieve best results. Postdilatation of the main branch with a balloon of narrower diameter than the deploying balloon caused main-branch stent distortion. These principles applied to all the bifurcation strategies and stent designs tested.
136 citations
TL;DR: A transcatheter technique is likely to have more acceptance and may expand the indications for early intervention for right ventricular outflow tract dysfunction and the risk of cardiopulmonary bypass, infection, bleeding, and ventricular dysfunction remains.
Abstract: Percutaneous transcatheter interventions for valve replacement or implantation is one of the most exciting developments in the field of interventional cardiology. Valvular stenosis has been treated by balloon dilatation with early and late results; however, treatment for valvular regurgitation has remained surgical until now. Most new designs have been investigated for implantation of valves in the left or right ventricular outflow tracts. Patients with surgery on the right ventricular outflow tract for congenital heart disease constitute the most common group for reoperations during late follow-up. Surgical pulmonary valve replacement can be performed with low mortality; however, it sets up a substrate for future operations. Also, the risk of cardiopulmonary bypass, infection, bleeding, and ventricular dysfunction remains. A transcatheter technique is likely to have more acceptance and may expand the indications for early intervention for right ventricular outflow tract dysfunction.
130 citations
TL;DR: A new system for PCI called the five‐in‐six system is presented, which increases backup support of a 6 Fr guiding catheter and was tried on eight chronic total occlusion cases.
Abstract: A 6 Fr guiding catheter is commonly used in the percutaneous coronary intervention (PCI). However, one of the limitations of the 6 Fr guiding catheter is its weak backup support compared to a 7 or an 8 Fr guiding catheter. In this article, we present a new system for PCI called the five-in-six system. Between March 2003 and September 2003, this system was tried on eight chronic total occlusion cases. The advantage of the five-in-six system is that it increases backup support of a 6 Fr guiding catheter.
120 citations
TL;DR: Closure of a large ASD associated with a lack of support in the inferior rim may warrant alternative strategies to position the device successfully, according to Catheter Cardiovasc Interv 2004.
Abstract: Outcomes of device closure of large and small secundum atrial septal defects (ASDs) as related to rim anatomy with the Amplatzer atrial septal occluder were compared. Rim adequacy (≥ 5mm) of the anterior, inferior, posterior, and superior rims was determined using transesophageal echocardiography. Balloon-stretched defect size defined patients into two groups: group 1, ≤ 25 mm (n = 138); group 2, > 25 mm (n = 34). Rim deficiency (n = 62) was more frequent in group 2 compared to group 1 (50% vs. 33%; P = 0.07), especially inferior rim deficiency (35% vs. 2%; P = 0.005). Device deployment was successful in group 1 and group 2 (100% vs. 91%; P = 0.007). Unsuccessful deployment was associated with an ASD of > 25 mm (P = 0.007) and inferior rim deficiency (P = 0.001). At first follow-up (54 ± 16 days), right ventricular systolic pressure had improved in both groups (P < 0.001). Closure of a large ASD associated with a lack of support in the inferior rim may warrant alternative strategies to position the device successfully. Catheter Cardiovasc Interv 2004;61:131–139. © 2004 Wiley-Liss, Inc.
TL;DR: Cutting balloon angioplasty is a safe and feasible option for the treatment of popliteal and infrapopliteal vessels and after mean follow‐up of 1 year, 89.5% of threatened limbs were salvaged.
Abstract: Options for lower limb percutaneous revascularization are limited especially for complex vessel obstruction. Cutting balloon angioplasty (CBA) has been described in the coronary literature as effective for complex disease. We analyzed our peripheral vascular database and report procedural outcomes along with the clinical success at a mean of 1-year follow-up in 73 patients with symptomatic lower limb ischemia undergoing CBA. CBA was successfully completed in all 73 patients (93 vessels; 100%) with predilation necessary in 4% of vessels. Severe intimal dissection or inadequate hemodynamic result necessitated in adjunctive stenting in 20%. There were no incidents of vessel perforation or surgical target vessel revascularization. One patient (1.5%) died during the periprocedural period due to renal failure. After mean follow-up of 1 year (6-21 months), 89.5% of threatened limbs were salvaged. CBA is a safe and feasible option for the treatment of popliteal and infrapopliteal vessels.
TL;DR: Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement.
Abstract: Despite the increasing use of percutaneous transluminal coronary angioplasty and intracoronary stent placement for the treatment of obstructive coronary artery disease, a large subset of coronary lesions cannot be adequately treated with balloon angioplasty and/or intracoronary stenting alone. Such lesions are often heavily calcified or fibrotic and undilatable with the present balloon technology and attempts to treat them with balloon angioplasty or intracoronary stent placement often lead to vessel dissection or incomplete stent deployment with resultant adverse outcomes. Rotational atherectomy remains a useful niche device for the percutaneous treatment of such complex lesions, usually as an adjunct to subsequent balloon angioplasty and/or intracoronary stent placement. In contrast to balloon angioplasty or stent placement that widen the coronary lumen by displacing atherosclerotic plaque, rotational atherectomy removes plaque by ablating the atherosclerotic material, which is dispersed into the distal coronary circulation. Other lesion subtypes amenable to treatment with this modality include ostial and branch-ostial lesions, chronic total occlusions, and in-stent restenosis. This review discusses the technique and principles of rotational atherectomy, the various treatment strategies for its use (including adjunctive pharmacotherapy), the lesion-specific applications for this device, and the complications unique to this modality. Recommendations are also made for its use in the current interventional era.
TL;DR: The results in both groups were as good as the surgical groups in previous studies comparing PCI and CABG in MVD, indicating that PCI in those with one or two hemodynamically significant lesions as identified by an FFR < 0.75 yields a similar favorable outcome as CabG in thoseWith three or more culprit lesions despite a similar angiographic extent of disease.
Abstract: The optimal revascularization strategy, percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG), for patients with multivessel coronary artery disease (MVD) remains controversial. The aim of the present study was to compare the long-term outcomes after selective PCI of only hemodynamically significant lesions (fractional flow reserve, or FFR < 0.75) to CABG of all stenoses in patients with MVD. In 150 patients with MVD referred for CABG, FFR was determined in 381 coronary arteries considered for bypass grafting. If the FFR was less than 0.75 in three vessels or in two vessels including the proximal left anterior descending (LAD) artery, CABG was performed (CABG group). If only one or two vessels were physiologically significant (not including the proximal LAD), PCI of those lesions was performed (PCI group). Of the 150 patients, 87 fulfilled the criteria for CABG and 63 for PCI. There were no significant differences in the angiographic or other baseline characteristics between the two groups. At 2-year follow-up, no differences were seen in adverse events, including repeat revascularization (event-free survival 74% in the CABG group and 72% in the PCI group). A similar number of patients were free from angina (84% in the CABG group and 82% in the PCI group). Importantly, the results in both groups were as good as the surgical groups in previous studies comparing PCI and CABG in MVD. In patients with multivessel disease, PCI in those with one or two hemodynamically significant lesions as identified by an FFR < 0.75 yields a similar favorable outcome as CABG in those with three or more culprit lesions despite a similar angiographic extent of disease.
TL;DR: Standard MAP calculations for MAP can easily be improved by inclusion of a heart rate factor, and the new formula showed a much closer correlation with the computer‐derived values for MAP.
Abstract: Mean arterial pressure (MAP) has traditionally been derived from systolic and diastolic pressures, weighted 1/3 systolic and 2/3 diastolic. No correction is made for the increasing time dominance of systole with increasing heart rates. In a previous study, we developed a new and more accurate heart rate-corrected MAP formula from central aorta pressure determinations in a large number of patients: MAP = DP + [0.33 + (HR x 0.0012)] x [PP] where SP and DP are systolic and diastolic pressure and HR is heart rate. The current study validates the new MAP formula in the same patient at increasing paced heart rates. A central aorta catheter was used to obtain computer-determined systolic, diastolic, and MAP in 12 patients. Values were obtained at baseline and then at increasing right atrial paced heart rates. The new and standard MAP formula-derived values were compared with computer-determined values. The new formula showed a much closer correlation with the computer-derived values for MAP. Standard MAP calculations for MAP can easily be improved by inclusion of a heart rate factor.
TL;DR: A novel image‐based gating method called Intelligate is described, which features automatic retrospective selection of end‐diastolic frames from videotaped or digitally stored ICUS studies, and shows that there are no quantitative differences between analysis results of hardware ECG‐gated and Intelligated IC US studies.
Abstract: Quantitative analysis of intracoronary ultrasound (ICUS) studies is performed on a series of tomographic cross-sectional ICUS images acquired during a motorized 0.5 mm/sec catheter pullback. Catheter displacement in the vascular lumen during the cardiac cycle causes an anatomically shuffled ICUS study, which results in a sawtooth-shaped appearance of the coronary segment in longitudinal reconstructed views in quantitative coronary ultrasound software packages. This hampers contour detection and leads to a laborious time-consuming semiquantitative analysis process that may produce inaccurate results. To solve these problems, in the past, online ECG-gated acquisition hardware has been applied. This article describes a novel image-based gating method called Intelligate, which features automatic retrospective selection of end-diastolic frames from videotaped or digitally stored ICUS studies. Our evaluation shows that there are no quantitative differences between analysis results of hardware ECG-gated and Intelligated ICUS studies.
TL;DR: In patients with AMI and occluded infarct‐related artery treated with primary PCI, intracoronary abciximab given just before PCI downstream of the occlusion is associated to a greater degree of myocardial salvage than the usual abcximab protocol.
Abstract: In this prospective randomized trial on patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI), we hypothesized that abciximab administered intracoronarily, downstream of the coronary occlusion, leads to a greater degree of myocardial salvage and better left ventricular function recovery compared with the usual abciximab administration. Forty-five consecutive patients with first AMI and infarct-related artery TIMI flow 0-1 undergoing primary PCI were enrolled. Twenty-two patients were randomly assigned to the intracoronary treatment and 23 to the usual treatment. The initial perfusion defect, final infarct size, myocardial salvage, salvage index, and left ventricular function recovery were assessed by serial scintigraphic scans performed at admission and 7 days and 1 month after PCI. Angiographic myocardial blush grade, corrected TIMI frame count, and electrocardiographic ST segment elevation reduction were also assessed as markers of myocardial reperfusion. Final infarct size was significantly smaller (P = 0.043) and salvage index significantly higher (P = 0.003) in the intracoronary treatment group as a result of a greater degree of myocardial salvage (P = 0.0001). The increase of left ventricular ejection fraction at 1 month was significantly higher in the intracoronary treatment patients (P = 0.013). The markers of myocardial reperfusion were also significantly better in the intracoronary treatment group. In patients with AMI and occluded infarct-related artery treated with primary PCI, intracoronary abciximab given just before PCI downstream of the occlusion is associated to a greater degree of myocardial salvage than the usual abciximab protocol. This benefit is mainly related to a substantial reduction in final infarct size, which leads to an improvement in left ventricular ejection fraction.
TL;DR: It is suggested that SSA is predictable, safe, and durable, with age and male gender representing important predictors of all‐cause long‐term mortality and the strong association of increased mortality with hypothyroidism is difficult to discard and raises the question of a yet to be described thyroid steal phenomena.
Abstract: This study provides extended follow-up of a nonrandomized series of symptomatic patients who underwent subclavian stent-supported angioplasty (SSA) with emphasis on preprocedure factors that may have influenced outcome. The endpoints of mortality and restenosis were analyzed using backward stepwise logistic regression with the following clinical variables: coronary artery disease, hypertension, hyperlipidemia, smoking, diabetes mellitus, chronic obstructive pulmonary disease, chronic renal insufficiency/failure, and hypothyroidism. Restenosis is reported based on prospective serial noninvasive studies and/or angiography. Mortality was evaluated by retrospective database review and inquiry to the State Department of Health and Human Services' statistical registry in patients who were lost to follow-up. Over a 9-year period (mean follow-up, 36.1 +/- 30.4 months; maximum observation, 109.5 months), 101 stents were placed in 91 consecutive patients (37 male, 54 female). The mean age at intervention was 62.03 +/- 9.3. The procedure was technically successful in 89 patients 97% (mean pre- and postoperative stenosis and pressure gradients were 90.2% +/- 9.4% vs. 3.7% +/- 6.6%, P 0.05), but the same were less likely to die during follow-up (P > 0.001). Also, the presence of hypothyroidism (P = 0.004) and increasing age (P = 0.068) were positively correlated with all-cause mortality. This study suggests that SSA is predictable, safe, and durable. The diagnosis of symptomatic subclavian disease is of prognostic importance, with age and male gender representing important predictors of all-cause long-term mortality. The strong association of increased mortality with hypothyroidism is difficult to discard and raises the question of a yet to be described thyroid steal phenomena.
TL;DR: In patients with acute myocardial infarction treated with primary angioplasty and abciximab, the transradial access is efficacious with fewer major access site complications than transfemoral access, although with longer times of radiation and higher dose‐area product.
Abstract: Compared to the femoral approach, the use of radial arterial access has been demonstrated to reduce the incidence of access site bleeding complications in staged procedures. The purpose of this study was to evaluate clinical outcomes comparing radial and femoral approaches in the treatment of acute myocardial infarction with primary angioplasty and the GP IIb/IIIa inhibitor abciximab. Between 15 September 1999 and 15 September 2002, we prospectively enrolled 119 consecutive patients undergoing primary angioplasty with abciximab comparing radial (n = 64) and femoral (n = 55) access. In this nonrandomized study, freedom from major cardiac events at 1-month follow-up occurred in 62 (97%) and 52 (94.5%) patients in the radial and the femoral groups, respectively (P = 0.19). There were no major access site bleeding complications in the radial group, as opposed to three (5.5%) in the femoral group (P = 0.03), all requiring transfusions, with surgical repair necessary in two. Uncomplicated clinical course occurred in 62 (97%) of patients in the radial group and 49 (89%) in the femoral group (P = 0.04). Total hospital length of stay was significantly higher in the femoral group (5.9 +/- 2.1 vs. 4.5 +/- 1.2 days; P = 0.05). Cannulation time (from patient arrival at the catheterization laboratory to the effective placement of arterial sheath) and procedural time were not significantly different in the radial and the femoral group (respectively 8.5 +/- 5.2 vs. 9.0 +/- 5.8 min, P = 0.81, and 42 +/- 28 vs. 44 +/- 27 min, P = 0.74). Nevertheless, time of radiation (23.1 +/- 11 vs. 16.5 +/- 10.9 min; P = 0.01) and dose-area product (28,616 +/- 16,571 vs. 18,819 +/- 10,739 R. cm2; P = 0.01) were significantly higher in the radial group. In patients with acute myocardial infarction treated with primary angioplasty and abciximab, the transradial access is efficacious with fewer major access site complications than transfemoral access. Transradial approach produces a shorter length of stay, as compared to the transfemoral approach, although with longer times of radiation and higher dose-area product.
TL;DR: In many patients with cyanotic CHD, especially in those with ductal pulmonary perfusion and additional forward flow from the right ventricle, ductal stenting is an effective transcatheter approach, and some patients can be cured by the intervention alone.
Abstract: Indications for catheter-based interventions in patent ductus arteriosus (PDA)-dependent pulmonary blood flow have yet to be defined. The aim of this study was to assess the acute and midterm outcome after stent implantation in the PDA. Between 1996 and 2002, ductal stenting was performed in 21 neonates and infants (14 females/7 males) to maintain pulmonary blood supply in cyanotic congenital heart disease (CHD). Balloon-expandable stents were implanted in the PDA with a final diameter of 4-5 mm without procedural deaths. Stent patency was achieved for 8-1,130 days (median, 142). Reintervention was necessary in nine patients. Overall survival rate after 6 years was 86%. Two neonates died a few days after the procedure due to right heart failure not related to PDA stenting. Corrective surgery was possible in six patients. An additional aortopulmonary shunt was needed in three patients; Fontan type operations were performed in six. One patient died after bidirectional Glenn shunt, another five reached palliation by additional perforation of the atretic valve/balloon valvuloplasty, and two are awaiting surgery. We conclude that in many patients with cyanotic CHD, especially in those with ductal pulmonary perfusion and additional forward flow from the right ventricle, ductal stenting is an effective transcatheter approach. Morphology of the PDA predicts the risk of restenosis and necessity of reintervention. Growth of the pulmonary vascular bed allows corrective or palliative surgery, and some patients can be cured by the intervention alone.
TL;DR: A prospective trial of 100 calcified and/or balloon‐resistant lesions where a new 0.9 mm excimer laser coronary catheter was used at standard or higher energy level to facilitate angioplasty seems to be safe and effective for management of calcification and nondilatable lesions.
Abstract: This study was designed to evaluate safety and effectiveness of the 0.9 mm excimer laser coronary catheter with increased laser parameters. We report a prospective trial of 100 calcified and/or balloon-resistant lesions where a new 0.9 mm excimer laser catheter was used at standard or higher energy level to facilitate angioplasty. Standard in-hospital clinical and angiographic parameters were collected and measured. Laser technical success was obtained in 87 lesions (92%), procedural success was reached in 88 lesions (93%), and clinical success in 82 lesions (86%). Increased laser parameters were used for 29 resistant lesions. This new 0.9 mm excimer laser coronary catheter using higher energy parameters seems to be safe and effective for management of calcified and nondilatable lesions.
TL;DR: Rotational coronary angiography can be rapidly performed in any patient and provides a significant reduction in contrast and radiation utilization while at the same time providing adequate angiographic data to complement or replace standard coronaryAngiography in the evaluation of coronary artery disease.
Abstract: This study evaluates the safety and clinical utility of rotational angiography in the diagnosis of coronary artery disease. High-speed rotational angiography is a newly available angiographic modality that gives a dynamic multiple-angle perspective of the coronary tree during a single contrast injection. We prospectively randomized 56 patients referred for diagnostic coronary angiography to either standard or rotational angiography. Contrast and radiation utilization were compared between the two groups. The number of additional cine acquisitions needed was used to determine adequacy of the diagnostic study protocol. Rotational angiography was successfully completed in all subjects. There was a 33% reduction in contrast utilization in the rotational group as compared to the standard group (35.6 ± 12.6 vs. 52.8 ± 10.7 ml, respectively; P < 0.0001). Additionally, there was a 28% reduction in total radiation exposure in the rotational group as compared to the standard group (39.0 ± 18.5 vs. 53.9 ± 23.4 Gycm2, respectively; P = 0.01). Total whole-body radiation exposure to the primary operator was 144 mrem with rotational angiography and 170 mrem with standard angiography. Procedure time tended to be shorter for rotational angiography (353.9 ± 146.7 vs. 396.8 ± 165.8 s; P = 0.3). Rotational coronary angiography can be rapidly performed in any patient and provides a significant reduction in contrast and radiation utilization while at the same time providing adequate angiographic data to complement or replace standard coronary angiography in the evaluation of coronary artery disease. Catheter Cardiovasc Interv 2004;62:167–174. © 2004 Wiley-Liss, Inc.
TL;DR: It is reported on two cases of IVUS‐guided wiring technique performed on chronic total occlusion using stiffer wires and low‐profile intracoronary ultrasound catheter, which helped improve a success rate of chronic total Occlusion case.
Abstract: We report on two cases of IVUS-guided wiring technique performed on chronic total occlusion using stiffer wires and low-profile intracoronary ultrasound catheter. This technique helped improve a success rate of chronic total occlusion case.
TL;DR: In patients with contraindications to the femoral approach, transradial cardiac catheterization can be performed successfully and with a low risk of major complications, though difficulties are minimized both with increasing operator experience and smaller sheath diameter.
Abstract: The transradial approach to coronary angiography is considered by some to be a route of choice, by others to be a route that should be used only where there are relative contraindications to the femoral approach. We present the largest series to date of patients in whom transradial coronary angiography was undertaken specifically because of contraindications to the femoral approach. Since 1995, patients at this cardiothoracic center have been considered for a transradial approach to coronary angiography if there were relative contraindications to the femoral route. Data from 500 patients was prospectively collected. Patients were aged 66 +/- 9 years; 72% were male. Indications for the radial approach included peripheral vascular disease (305), therapeutic anticoagulation (77), musculoskeletal (59), and morbid obesity (32). Sixty-eight patients (14%) required a radial procedure following a failed femoral approach. Access was right radial 291 (58%), left radial 209 (42%). Eighteen operators were involved, but two operators undertook 355 (71%) of the cases. Catheter gauge was 6 Fr (n = 243; 49%), 5 Fr (219; 43%), and 4 Fr (29; 6%). The procedure was successful in 463 cases [92.6%; 88.2% for nonmajority vs. 94.4% (P < 0.05) for the two majority operators]. Success in males (93.6%) significantly exceeded that in females (90.1%; P < 0.05). In-catheter-laboratory duration was 45 +/- 17 min; fluoroscopy time, 7.5 +/- 6 min; radiation dose, 40 +/- 23 CGy. The procedure was without incident in 408 cases (82%). There were procedural difficulties in 18% of cases, including radial artery spasm (12%) and vasovagal response (5%). The incidence was higher with 6 Fr catheters (23%) than with 5/4 Fr (15%; P < 0.05). Major procedural complications occurred in three cases: brachial artery dissection in one and cardiac arrest in two. Postprocedure major vascular complications numbered three: claudicant pain on handgrip in one, ischemic index finger (with subsequent terminal phalanx amputation due to osteomyelitis) in one, and ischemic hand for 4 hr in one. Patients with contraindications to the femoral approach form a high-risk group. In these patients, transradial cardiac catheterization can be performed successfully and with a low risk of major complications. Minor adverse features remain frequent, occurring in one in five cases, though difficulties are minimized both with increasing operator experience and smaller sheath diameter.
TL;DR: Assessment of the pharmacokinetic response to intravenous (IV) enoxaparin given 8–12 hr after subcutaneous (SC) dosing in patients undergoing percutaneous coronary intervention found anti‐Xa levels were within the target range in 98% of patients 2–8 hr after the last SC dose.
Abstract: The objective of this study was to evaluate the pharmacokinetic response to intravenous (IV) enoxaparin given 8-12 hr after subcutaneous (SC) dosing in patients undergoing percutaneous coronary intervention (PCI). Fifty-five patients received SC enoxaparin (1 mg/kg every 12 hr) followed by an IV bolus (0.3 mg/kg) 8-12 hr after the last SC dose, at the start of PCI or during catheterization. Anti-Xa levels were within the target range in 98% of patients 2-8 hr after the last SC dose, in 96% of patients following the IV bolus, and in 91% of patients for a further 2 hr. Subcutaneous enoxaparin (1 mg/kg every 12 hr) provides sufficient anti-Xa levels for PCI 2-8 hr after the last dose. An additional 0.3 mg/kg enoxaparin dose given IV 8-12 hr after the last SC dose reliably maintains anti-Xa levels within the target for at least 2 additional hr.
TL;DR: The P‐PS technique is safe and effective using either UK or TNK, offering several potential advantages over monotherapy, including more rapid revascularization, decreases systemic lytic exposure and bleeding complications while facilitating both CT and RT capacity and efficacy.
Abstract: The novel power-pulse spray (P-PS) technique maximizes and combines the advantages and minimizes the disadvantages of both chemical thrombolysis (CT) and rheolytic thrombectomy (RT). Forty-nine consecutive patients with iliofemoral thrombotic occlusion were treated via P-PS technique. Using a 6 Fr RT catheter, saline prime was exchanged for thrombolytic solution [group 1, 10-20 mg tenecteplase (TNK)/50 cc saline, n = 25; group 2, 1,000,000 urokinase (UK)/50 cc saline, n = 24]. The outflow port was closed, then the catheter was advanced at 1 mm increments while pulsing lytic agent. After 30-min lysis time, RT and definitive treatment of the underlying stenosis were performed. Procedure success was 23/25 (92%) and 22/24 (91.6%) for group 1 and 2, respectively. The mean total procedure time was 72 and 75 min in group 1 and 2, respectively. Thirty-day limb salvage was 91% in both groups. There were no major surgical complications. The P-PS technique is safe and effective using either UK or TNK, offering several potential advantages over monotherapy, including more rapid revascularization, decreases systemic lytic exposure and bleeding complications while facilitating both CT and RT capacity and efficacy.
TL;DR: Percutaneous intervention of the CFA can be performed with a rate of high technical success and a low complication rate and appears to be a reasonable alternative to surgical therapy in patients at high risk for surgery.
Abstract: We performed percutaneous transluminal intervention in 20 consecutive patients (21 limbs) with common femoral artery (CFA) lesions causing symptomatic limb ischemia. In 12 limbs, concurrent additional percutaneous intervention proximal or distal to the target CFA lesion was performed. Angiographic success was obtained in 100%, with procedural success (angiographic success without a major in-hospital complications) in 90% and clinical success (procedural success and in-hospital improvement by at least one Fontaine functional class) in 81% of the limbs. The in-hospital Fontaine class improved by at least one functional class in 17 of 19 patients (89%), and the overall in-hospital event-free survival was 90% (18 of 20 patients). At follow-up (11.4 ± 6 months), the overall event-free survival was 90% (18 of 20 patients) and 17 of 19 patients (89%) continue to show improvement by at least one functional (Fontaine) class. Percutaneous intervention of the CFA can be performed with a rate of high technical success and a low complication rate. It provides excellent clinical results at mid-term follow-up and appears to be a reasonable alternative to surgical therapy in patients at high risk for surgery. Catheter Cardiovasc Interv 2004;62:230–233. © 2004 Wiley-Liss, Inc.
TL;DR: The IC bolus route of abciximab may be superior to the intravenous route, and Prospective randomized trials are warranted to validate these findings.
Abstract: There have been animal and human studies looking at intracoronary (IC) use of abciximab with good short-term clinical outcomes There exists no data comparing intracoronary with intravenous (IV) administration of abciximab beyond 30 days We compared the clinical outcomes between the IC (n = 101) and IV (n = 72) group of patients Patients who had coronary stenting and received abciximab were included in the study All the patients received the standard systemic bolus dose of abciximab 025 mg/kg either via the IC or IV route, followed by a 12-hr IV infusion at 0125 microg/kg/min The 6-month composite endpoint of death or myocardial infarction was slightly higher in the IV (139%) than in the IC group (59%; P = 004) The frequency of bleeding complications was similar in both groups The IC bolus route of abciximab may be superior to the intravenous route Prospective randomized trials are warranted to validate these findings
TL;DR: Intravascular ultrasound (IVUS) is useful in evaluating coronary stent deployment and provides a more accurate assessment of stent dimensions, expansion, and apposition than angiography, which is associated with a higher risk of stroke.
Abstract: Intravascular ultrasound (IVUS) is useful in evaluating coronary stent deployment. The aim of this study was to assess the safety and utility of IVUS in carotid artery stenting (CAS). Ninety-eight consecutive high-risk patients (107 arteries) underwent CAS. IVUS was performed prior to predilatation in 87 of the 107 vessels and in all 107 following stent deployment when an optimal angiographic appearance was obtained. Quantitative carotid angiography (QCA) and IVUS analysis were performed offline. Procedural success was 97%. Combined stroke or death at 30 days was 5.6%. IVUS measurements of the minimum lumen diameter (MLD) of the distal internal carotid artery (ICA) reference segment were similar to QCA (4.60 +/- 0.74 vs. 4.74 +/- 0.71 mm; P = 0.21). The ICA stent MLD was significantly smaller by IVUS compared to QCA (3.65 +/- 0.68 vs. 4.31 +/- 0.76 mm; P < 0.001). IVUS detected stent malapposition in 11%. IVUS findings, after an optimal angiographic result, necessitated additional treatment in 9% of procedures. Calcium was detected in more arteries with IVUS than angiography (61% vs. 46%; P < 0.05). Arteries with superficial lesion calcification subtending three or four quadrants by IVUS had a 31% incidence of stroke compared with a 1% incidence in arteries without severe superficial calcium (P < 0.001). We found IVUS imaging in CAS to be safe even prior to plaque dilatation. IVUS provides a more accurate assessment of stent dimensions, expansion, and apposition than angiography. Severe calcification by IVUS was associated with a higher risk of stroke.
TL;DR: The use of stents as an adjunct to balloon angioplasty in selected patients with coarctation can be performed with low complication rates and provides excellent immediate relief of obstruction with promising follow‐up.
Abstract: Balloon angioplasty as treatment for coarctation of the aorta is increasingly performed Endovascular stents have been proposed as a means of improving the efficacy and safety of the procedure In this report, we describe one institution's immediate results and clinical follow-up after implantation of endovascular stents Retrospective analysis for endovascular stent placement for coarctation of the aorta between 1993 and 2002 was made The immediate hemodynamic results and clinical follow-up were reviewed Thirty-two patients underwent attempted stent placement for coarctation Twenty-three patients had postoperative recurrent coarctation and nine had native coarctation The systolic gradient decreased from 31 to 18 mm Hg (P = 0001) and the diameter was increased 81 to 135 mm (P-0001) Mean follow-up was 15 years The mean follow-up gradient as assessed by sphygomomanometry was 131 mm Hg Eight patients underwent 10 successful further dilations Complications included one stent migration and one aortic dissection The use of stents as an adjunct to balloon angioplasty in selected patients with coarctation can be performed with low complication rates and provides excellent immediate relief of obstruction with promising follow-up Further dilation of these stents is possible Long-term follow-up is warranted