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McFadden EP, Stabile E, Regar E, Cheneau E, Ong ATL, Kinnaird T, Suddath WO, Weissman NJ, Torguson R, Kent KM, Pichard AD, Satler LF, Waksman R, Serruys PW. Late thrombosis in drug-eluting coronary stents after discontinuation of antiplatelet therapy. Lancet 2004; 364:1519-21. [PMID: 15500897 DOI: 10.1016/s0140-6736(04)17275-9] [Citation(s) in RCA: 986] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although the safety profiles of coronary stents eluting sirolimus or paclitaxel do not seem to differ from those of bare metal stents in the short-to-medium term, concern has arisen about the potential for late stent thromboses related to delayed endothelialisation of the stent struts. We report four cases of angiographically-confirmed stent thrombosis that occurred late after elective implantation of polymer-based paxlitaxel-eluting (343 and 442 days) or sirolimus-eluting (335 and 375 days) stents, and resulted in myocardial infarction. All cases arose soon after antiplatelet therapy was interrupted. If confirmed in systematic long-term follow-up studies, our findings have potentially serious clinical implications.
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Rha SW, Kuchulakanti PK, Pakala R, Cheneau E, Fournadjiev JA, Pinnow E, Gebreeyesus A, Aggrey G, Wang Z, Pichard AD, Satler LF, Kent KM, Lindsay J, Waksman R. Bivalirudin versus heparin as an antithrombotic agent in patients treated with a sirolimus-eluting stent. Am J Cardiol 2004; 94:1047-50. [PMID: 15476623 DOI: 10.1016/j.amjcard.2004.06.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Revised: 06/30/2004] [Accepted: 06/30/2004] [Indexed: 10/26/2022]
Abstract
Bivalirudin (Angiomax) is increasingly used as a substitute for heparin in a variety of percutaneous coronary interventions. This retrospective, observational study aimed to evaluate the efficacy and safety of bivalirudin compared with heparin as an antithrombotic regimen in patients treated with sirolimus-eluting stents (Cypher) and found that bivalirudin is clinically safe and feasible, with fewer vascular and ischemic complications compared with heparin.
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Stabile E, Cheneau E, Kinnaird T, Suddath WO, Weissman NJ, Torguson R, Kent KM, Pichard AD, Satler LF, Waksman R. Late thrombosis in cypher stents after the discontinuation of antiplatelet therapy. ACTA ACUST UNITED AC 2004; 5:173-6. [PMID: 16237987 DOI: 10.1016/j.carrad.2004.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Drug-eluting stents, since their approval in the United States, have become the treatment of choice for de novo coronary artery narrowing due to their ability to reduce restenosis and the need for repeat revascularization. We present two patients who underwent percutaneous coronary intervention for the treatment of multivessel coronary artery disease; both patients were treated with sirolimus-eluting stents (SES) and bare metal stents (BMS).
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Cheneau E, Mintz GS, Leborgne L, Kotani JI, Satler LF, Ajani AE, Weissman NJ, Waksman R, Pichard AD. Intravascular ultrasound predictors of subacute vessel closure after balloon angioplasty or atherectomy. THE JOURNAL OF INVASIVE CARDIOLOGY 2004; 16:572-4. [PMID: 15505353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND Factors leading to subacute vessel closure after percutaneous coronary intervention (PCI) have not been well established in lesions treated with balloon angioplasty or atherectomy. METHODS AND RESULTS We used intravascular ultrasound (IVUS) to determine the pre- and post-PCI characteristics involved in subacute vessel closure after PCI. Of 3,403 patients undergoing IVUS imaging during coronary balloon angioplasty or atherectomy, 8 patients (0.2%) developed angiographically documented subacute vessel closure within 1 week post-PCI and were compared to a group matched by procedure date (within 6 months), age, gender, stable or unstable angina, lesion location and treatment (balloon angioplasty or atherectomy). IVUS identified at least one cause for subacute vessel closure in 87% of patients (vs 25% in matched lesions, p < 0.01). Causes were all procedure-related and included inadequate final lumen (60%), dissection (50%) and thrombus (25%). Pre-procedure lesion characteristics were not different from matched lesions. CONCLUSIONS Subacute vessel closure after balloon angioplasty or atherectomy is mostly related to insufficient post-procedure lumen dimension or dissection.
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Cheneau E, Canos D, Kuchulakanti PK, Rha SW, Satler LF, Suddath WO, Kent KM, Pichard AD, Waksman R. Value of monitoring activated clotting time when bivalirudin is used as the sole anticoagulation agent for percutaneous coronary intervention. Am J Cardiol 2004; 94:789-92. [PMID: 15374791 DOI: 10.1016/j.amjcard.2004.05.068] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2004] [Revised: 05/21/2004] [Accepted: 05/21/2004] [Indexed: 11/30/2022]
Abstract
Anticoagulation during percutaneous coronary intervention (PCI) requires the monitoring of activated clotting time (ACT) to protect from periprocedural ischemic and bleeding complications; however, the optimal ACT values have not been established when PCI is performed with bivalirudin. After 495 consecutive patients treated for coronary artery disease with PCI received bivalirudin as a single anticoagulation agent, it was found that ACT is reproducible when bivalirudin is used during PCI and does not correlate with clinical events.
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Waksman R, Fournadjiev J, Baffour R, Pakala R, Hellinga D, Leborgne L, Yazdi H, Cheneau E, Wolfram R, Seabron R, Horton K, Kolodgie F, Virmani R, Rivera E. Transepicardial autologous bone marrow-derived mononuclear cell therapy in a porcine model of chronically infarcted myocardium. ACTA ACUST UNITED AC 2004; 5:125-31. [PMID: 15721847 DOI: 10.1016/j.carrad.2004.10.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Accepted: 10/18/2004] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Cell therapy is becoming a viable strategy to improve revascularization and myocardial function after myocardial injury. We evaluated the effect of bone marrow-derived mononuclear cell (BMMNC) transplantation on collateral vessel development and myocardial function in a porcine model of chronically infarcted heart. METHODS Myocardial infarction was produced in 13 domestic swine. At 4 weeks, animals were randomized to receive transepicardial injections of autologous BMMNCs (approximately 24x10(6) cells, n=8) or phosphate buffered saline (PBS; control, n=5) into infarcted and border regions. Collateral growth, angiogenesis, and infarct size were assessed by angiography, immunohistochemistry, and histomorphometry. RESULTS Regional contractility was assessed by transepicardial echocardiography at baseline and 4 weeks following treatment. Angiography revealed a trend toward increased collateral growth in the BMMNC group. Wall motion score index (myocardial function) was similar in both groups at baseline (1.63+/-0.16 vs. 1.25+/-0.25, P=.21) and at 4 weeks (1.83+/-0.22 vs. 1.63+/-0.38, P=.62). alpha-Actin-positive smooth muscle cells (SMCs) and Factor VIII positive endothelial cells were significantly greater in the BMMNC-injected animals (314.8+/-37.4/0.1 vs. 167.1+/-11.9/0.1 mm(2) in controls, P=.02, and 363.3+/-28.2 cells/0.1 mm(2) vs. 254.4+/-28.1 cells/0.1 mm(2) in controls, P=.03, respectively). The number of blood vessels >50 mum in diameter was significantly increased in the BMMNC group (317.9+/-54.9 vs. 149.1+/-6.1, P<.05). The size of the infarct area was smaller in the BMMNC-transplanted group than in the controls (P=.015). CONCLUSION BMMNC transplantation appears to improve angiogenesis and reduce infarct size yet results in no improvement in left ventricular function in a chronically infarcted heart.
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Pakala R, Kuchulakanti P, Rha SW, Cheneau E, Baffour R, Waksman R. Peroxisome proliferator-activated receptor γ: Its role in metabolic syndrome. ACTA ACUST UNITED AC 2004; 5:97-103. [PMID: 15464947 DOI: 10.1016/j.carrad.2004.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Revised: 03/25/2004] [Accepted: 03/25/2004] [Indexed: 10/26/2022]
Abstract
Here we review PPARgamma function in relation to human adipogenesis, insulin sensitization, lipid metabolism, blood pressure regulation and prothrombotic state to perhaps provide justification for this nuclear receptor remaining a key therapeutic target for the continuing development of agents to treat human metabolic syndrome.
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Rha SW, Waksman R, Kuchulakanti PK, Ajani AE, White LR, Canos DA, Cheneau E, Mattox V, Abbott MC, Pinnow E, Pichard AD, Satler LF, Kent KM, Lindsay J. 880-6 Three-year follow-up after intracoronary gamma radiation for in-stent restenosis in saphenous vein grafts. J Am Coll Cardiol 2004. [DOI: 10.1016/s0735-1097(04)90434-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Leborgne L, Cheneau E, Wolfram R, Pinnow EE, Canos DA, Pichard AD, Suddath WO, Satler LF, Lindsay J, Waksman R. Comparison of baseline characteristics and one-year outcomes between African-Americans and Caucasians undergoing percutaneous coronary intervention. Am J Cardiol 2004; 93:389-93. [PMID: 14969608 DOI: 10.1016/j.amjcard.2003.10.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2003] [Revised: 10/14/2003] [Accepted: 10/14/2003] [Indexed: 11/19/2022]
Abstract
The objectives of this study were to determine whether there are race-based differences in baseline characteristics and in short- or long-term outcomes after percutaneous coronary intervention (PCI). African-Americans have a higher incidence of coronary artery disease but are less likely to undergo coronary revascularization than Caucasians. Little is known about the profiles and outcomes of African-Americans who undergo PCI. Consecutive series of 1,268 African-Americans and 10,561 Caucasians with symptomatic coronary artery disease who underwent PCI between January 1994 and June 2001 were analyzed. Patients hospitalized for acute myocardial infarction were excluded. African-Americans were older, were more likely to be women, and had more co-morbid baseline conditions compared with Caucasians. Preprocedure lesion characteristics were similar with regard to vessel size, length, and complexity. The rate of clinical success did not differ between the groups. African-Americans experienced more in-hospital combined events of death and Q-wave myocardial infarction (p = 0.03). After propensity score adjustment, African-American race was not an independent predictor for in-hospital events. At 1 year, African-Americans had a slightly lower rate of target lesion revascularization and a 50% higher rate of death (9.8% vs. 6.4%, p <0.001), with a relative risk of 1.52 (95% confidence interval 1.22 to 1.89). In multivariate analysis, African-American race remained a significant predictor of increased 1-year mortality (hazard ratio 1.35, 95% confidence interval 1.06 to 1.71, p = 0.01). African-Americans undergoing angioplasty have more co-morbid baseline conditions than Caucasians. Despite similar clinical success, 1-year outcomes are impaired in African-Americans.
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Ajani AE, Waksman R, Sharma AK, Lew R, Pinnow E, Canos DA, Cheneau E, Castagna M, Cha DH, Leborgne L, Satler LF, Pichard AD, Kent KM, Lindsay J. Usefulness of periprocedural creatinine phosphokinase-MB release to predict adverse outcomes after intracoronary radiation therapy for in-stent restenosis. Am J Cardiol 2004; 93:313-7. [PMID: 14759380 DOI: 10.1016/j.amjcard.2003.10.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2003] [Revised: 10/06/2003] [Accepted: 10/06/2003] [Indexed: 11/18/2022]
Abstract
We aimed to analyze periprocedural creatinine phosphokinase (CPK)-MB elevation in patients treated with intracoronary radiation therapy (IRT) for in-stent restenosis (ISR) to risk stratify these patients. The clinical significance of periprocedural CPK-MB elevation after IRT for ISR is unknown. An elevated CPK-MB has been associated with increased mortality after conventional angioplasty. We evaluated 1,326 patients who were enrolled in radiation trials for ISR at the Washington Hospital Center using gamma- and beta-emitters. Patients were analyzed according to degree of CPK-MB increase within 24 hours of the index IRT procedure (normal CPK-MB, CPK-MB 1 to 3 times the upper limit of normal, or CPK-MB >3 times the upper limit of normal). Patients with CPK-MB >3 times the upper limit of normal were older (64 +/- 12 years, p = 0.04), more likely to be smokers (64%, p = 0.04), hypertensive (85%, p <0.01), and diabetic (49%, p = 0.04). The cohort with the highest CPK-MB release (CPK-MB >3 times the upper limit of normal) had significantly higher rates of adverse clinical events at 12 months (major adverse cardiac events 40%, p <0.01), including death (9.3%, p <0.01) and late thrombosis (6.3%, p <0.01). Periprocedural CPK-MB elevation is of prognostic importance in patients treated with IRT for ISR, and its analysis appears to be mandatory to risk stratify these patients. The impact of glycoprotein IIb/IIIa antagonists in reducing periprocedural CPK-MB release awaits evaluation.
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Cheneau E, Canos D, Pinnow E, Ajani AE, Satler LF, Pichard AD, Kent KM, Lindsay J, Waksman R. Impact of radiation dose on late clinical outcome after intracoronary radiation therapy: Three-year follow-up of Long WRIST. Catheter Cardiovasc Interv 2004; 62:318-22. [PMID: 15224297 DOI: 10.1002/ccd.20072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To determine the safety and efficacy, including the impact, on the late recurrence rate of an incremental gamma-radiation dose from 15 to 18 Gy, we report the 3-year clinical outcome of Washington Radiation for In-Stent Restenosis Trial for Long Lesions (Long WRIST). One hundred eighty patients with recurrent in-stent restenosis (ISR) were enrolled in the Long WRIST series and treated with (192)Ir with 1 month of antiplatelet therapy. Between 6 months and 3 years, the need for repeat revascularization was low and similar among the three groups. At 3 years, target lesion revascularization (TLR) and major adverse cardiac events (MACE) were less frequent in the 18 Gy group than in the 15 Gy group (P = 0.12 for TLR, P < 0.05 for MACE) and less frequent in the 15 Gy group as compared to the placebo group (P < 0.05 for TLR and MACE). At 3 years, a higher dose of 18 Gy with (192)Ir continues to improve the outcome of patients treated for ISR when compared to patients treated with 15 Gy or placebo.
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Cheneau E, Pichard AD, Stabile E, Waksman R. Asymptomatic late stent thrombosis after sirolimus stent implantation. CARDIOVASCULAR RADIATION MEDICINE 2004; 5:57-8. [PMID: 15495372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Cheneau E, Leborgne L, Canos D, Pichard AD, Satler LF, Suddath WO, Kent KM, Lindsay J, Weissman N, Waksman R. Impact of intravascular ultrasound-guided direct stenting on clinical outcome of patients treated for native coronary disease. ACTA ACUST UNITED AC 2004; 5:15-9. [PMID: 15275627 DOI: 10.1016/j.carrad.2004.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Accepted: 03/22/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Despite the fact that in animal models direct stenting (DS) reduces the vessel injury, in clinical practice this treatment strategy did not reduce late restenosis as compared to conventional strategy with balloon predilatation (PD). However, the influence of DS was not evaluated when stent expansion is optimized by intravascular ultrasound (IVUS) assessment. METHODS We analyzed the in-hospital and 1-year outcomes of patients at Washington Hospital Center who were treated with percutaneous coronary interventions and stent implantation when percutaneous intervention was guided by IVUS. Only patients treated for single de novo lesions were included. RESULTS In 1386 patients, 251 (18.1%) were treated with DS and 1135 (71.9%) were treated with PD. Pre- and postprocedure characteristics by angiography and IVUS were similar in both groups. Postprocedure non-Q-wave myocardial infarction (MI) occurred in 4.9% of the DS group and in 12.5% of the PD group (P = .005). At 1-year follow-up, target lesion revascularization (TLR) rate was 4.9% in the DS group and 14.8% in the PD group (P = .005). DS strategy (odds ratio = .46, confidence interval = .25-.85, P = .013) was independently correlated to lower risk for revascularization in multivariate analysis. CONCLUSION When DS is implemented by IVUS assessment, it is associated with low in-hospital and long-term events.
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Wolfram R, Cheneau E, Lew R, Chan R, Pichard AD, Satler LF, Kent KM, Dilcher C, Pinnow E, Bui A, Waksman R. Effects of gamma radiation on the noninjured and unprotected left main. Catheter Cardiovasc Interv 2004; 61:477-81. [PMID: 15065141 DOI: 10.1002/ccd.10745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The aim of this study was to evaluate the effect of gamma radiation on the noninjured, unprotected left main coronary artery. Noninjured vessel segments are often radiated during treatment of in-stent restenosis with PCI and gamma radiation. Angiographic analysis using QCA methods was performed on 55 left main arteries of patients (32 with radiation of the left main compared to 23 controls) who participated in the Washington Radiation for In-Stent Restenosis Trials (WRIST). Baseline demographics and follow-up were comparable between the two groups, concluding that gamma radiation with long radiation safety margins is feasible and safe. Gamma radiation of noninjured irradiated left main vessels when used to facilitate wide radiation margins for proximal irradiated injured LAD and LCx is safe and does not compromise the vessel integrity and its lumen.
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Wolfram R, Leborgne L, Cheneau E, Pinnow EE, Canos DA, Hellinga D, Satler LF, Pichard AD, Kent KM, Waksman R. Comparison of effectiveness and safety of three different antithrombotic regimens (bivalirudin, eptifibatide, and heparin) in preventing myocardial ischemia during percutaneous coronary intervention. Am J Cardiol 2003; 92:1080-3. [PMID: 14583359 DOI: 10.1016/j.amjcard.2003.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this retrospective, observational analysis was to compare the efficacy and safety of 3 antithrombotic regimens: bivalirudin, eptifibatide plus heparin, and heparin alone, with emphasis on preventing interventional procedural creatinine kinase-MB fraction (CK-MB) release, and consequently, myocardial necrosis.
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Wolfram R, Leborgne L, Cheneau E, Pichard A, Satler L, Kent K, Waksman R. Comparison of creatine kinase elevation and outcome of comparison of percutaneous coronary intervention for saphenous vein graft in-stent restenosis versus de novo stenosis. Am J Cardiol 2003; 92:980-3. [PMID: 14556879 DOI: 10.1016/s0002-9149(03)00984-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Percutaneous coronary intervention of saphenous vein grafts is associated with distal embolization. We aimed to compare potential differences in patients undergoing percutaneous coronary intervention for in-stent restenosis with de novo saphenous vein graft lesions. Myocardial necrosis was associated with higher mortality regardless of lesion type.
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Kuchulakanti P, Rha SW, Cheneau E, Satler L, Pichard A, Kent K, Waksman R. Identification of “vulnerable plaque” using virtual histology in angiographically benign looking lesion of proximal left anterior descending artery. ACTA ACUST UNITED AC 2003; 4:225-7. [PMID: 15329976 DOI: 10.1016/j.carrad.2004.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Leborgne L, Cheneau E, Pichard A, Ajani A, Pakala R, Yazdi H, Satler L, Kent K, Suddath WO, Pinnow E, Canos D, Waksman R. Effect of direct stenting on clinical outcome in patients treated with percutaneous coronary intervention on saphenous vein graft. Am Heart J 2003; 146:501-6. [PMID: 12947370 DOI: 10.1016/s0002-8703(03)00309-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with frequent postprocedural enzyme elevation and late cardiac events. New strategies are proposed to minimize distal embolization and to improve the outcome of patients treated with stenting for SVG lesions. The objectives of the current study were to examine direct stenting (DS) strategy of PCI in SVG lesions and its effects on creatine-kinase (CK) release, major adverse cardiac events (MACE), and late outcome when compared to conventional stenting (CS). METHODS A consecutive series of 527 patients treated with stent implantation for SVG stenosis was analyzed. In this cohort, 170 patients with 229 lesions were treated with DS and 357 patients with 443 lesions were treated with CS. The inhospital and 12-month follow-up events were recorded and reported. RESULTS Baseline clinical and postprocedural angiographic characteristics were similar between the 2 groups except for higher preprocedural prevalence of thrombus-containing lesions in the DS group. Patients in the DS group had less CK-MB release (P <.001), and less non-Q-wave myocardial infarction (P =.024). Multivariate analysis detected unstable angina (odds ratio [OR] = 1.8, P =.03) as a correlate for non-Q-wave MI; DS was inversely associated with non-Q-wave myocardial infarction (OR = 0.65, P =.04). At 1 year, the target lesion revascularization-MACE was significantly lower in the DS group (P =.021). Multivariate analysis showed that DS (OR = 0.47, P =.007) was associated with reduction of the target lesion revascularization-MACE. CONCLUSIONS When feasible, DS may be the best approach for treating SVG stenosis.
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Cheneau E, Leborgne L, Mintz GS, Kotani JI, Pichard AD, Satler LF, Canos D, Castagna M, Weissman NJ, Waksman R. Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. Circulation 2003; 108:43-7. [PMID: 12821553 DOI: 10.1161/01.cir.0000078636.71728.40] [Citation(s) in RCA: 343] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Factors leading to subacute stent thrombosis after percutaneous coronary intervention (PCI) have not been well established. We assessed the pre- and post-PCI intravascular ultrasound (IVUS) characteristics of subacute stent thrombosis. METHODS AND RESULTS We analyzed 7484 consecutive patients without acute myocardial infarction who were treated with PCI and stenting and underwent IVUS imaging during the intervention. Twenty-seven (0.4%) had angiographically documented subacute closure <1 week after PCI (median time to subacute closure, 24 hours). Subacute closure lesions were compared with a control group (selected to be 3 times the abrupt closer group) matched by procedure date (within 6 months), age, gender, stable or unstable angina, lesion location, and additional treatment (balloon angioplasty or atherectomy). Postintervention IVUS did not identify a cause in 22% and did identify at least 1 cause for abrupt closure in 78% of patients (versus 33% in matched lesions, P=0.0002). In 48% of the patients, there were multiple causes in 48% (versus 3% in matched lesions, P<0.0001). Causes included dissection (17%), thrombus (4%), and tissue protrusion within the stent struts leading to lumen compromise lumen (4%). A total of 83% of patients with >1 of these abnormal morphologies also had reduced lumen dimensions post-PCI (final lumen <80% reference lumen). Preprocedural lesion characteristics were not different from matched lesions. CONCLUSIONS Subacute stent thrombosis is infrequently related to the preintervention lesion characteristics. Inadequate postprocedure lumen dimensions, alone or in combination with other procedurally related abnormal lesion morphologies (dissection, thrombus, or tissue prolapse), contribute to this phenomenon.
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Cheneau E, Wu Z, Leborgne L, Ajani AE, Weissman N, Pichard AD, Satler LF, Kent KM, Mintz G, Waksman R. Additional stenting promotes intimal proliferation and compromises the results of intravascular radiation therapy: an intravascular ultrasound study. Am Heart J 2003; 146:142-5. [PMID: 12851623 DOI: 10.1016/s0002-8703(03)00147-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Vascular brachytherapy (VBT) reduces in-stent restenosis (ISR). However, additional stenting at the time of radiation may be associated with a worse outcome. METHODS AND RESULTS Intravascular ultrasound (IVUS) was performed after VBT and at 6 months follow-up in 79 native artery ISR patients treated with gamma-radiation who participated in the Washington Radiation for In-Stent restenosis Trial (WRIST), Gamma-1, and Angiorad Radiation Technology for In-Stent restenosis Trial in Coronaries (ARTISTIC) trials. Patients were treated with (192)Ir at 14 or 15 Gy at 2 mm from the source. Additional stents were used to treat the ISR lesions in 45 patients; these patients were then compared with the 34 patients treated without restenting. Paired measurements included stent, lumen, and intimal hyperplasia volumes. After the VBT procedure, intimal hyperplasia volume was smaller in the group treated with additional stents (54 +/- 33 mm(3) vs 34 +/- 33 mm(3), P =.012), but minimal lumen area was similar between the 2 groups (4.3 +/- 1.5 mm(2) vs 4.7 +/- 1.4 mm(2) respectively, P = NS). Between the time of the VBT procedure and follow-up, intimal hyperplasia volume increased by 27 +/- 19 mm(3) in the restented group and by 9 +/- 21 mm(3) in the group treated without additional stents (P =.014). At 6 months, intimal volume was similar in the 2 groups, but minimal lumen area was slightly smaller in the group treated with additional stents (3.4 +/- 1.8 mm(2) vs 4.2 +/- 1.7 mm(2), P =.053). Patients treated with additional stents had more target lesion revascularizations than the group treated without additional stents (38% vs 15%, P =.02). CONCLUSIONS Additional stenting reduces intimal hyperplasia within the stents acutely. However, it compromises the benefit of VBT by promoting higher intimal regrowth within months after radiation.
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Pakala R, Leborgne L, Cheneau E, Chan RC, Yazdi H, Fournadjiev J, Weber D, Hellinga D, Kolodgie F, Virmani R, Waksman R. Radiation-Induced Atherosclerotic Plaque Progression in a Hypercholesterolemic Rabbit. ACTA ACUST UNITED AC 2003; 4:146-51. [PMID: 14984715 DOI: 10.1016/s1522-1865(03)00182-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Human observations provide rich soil for making hypotheses, but good animal models are essential for understanding the disease and to test treatment modalities. Currently, there is no standard animal model of vulnerable plaque; therefore, the purpose of this study is to develop a pathophysiologically relevant vulnerable plaque model. METHODS New Zealand White rabbits were fed with 1% hypercholesterolemic (HC) diet for 7 days, followed by balloon denudation of both the iliac arteries, and continued on 1% HC diet. Four weeks later, in 12 rabbits one of the iliac arteries was radiated (192-Ir, 15 Gy), and in five rabbits both the iliac arteries were sham treated. Following that, rabbits were fed with 0.15% HC diet. Four weeks later, arteries were processed for histomorphometry or immunohistochemistry. RESULTS Serum cholesterol levels were similar in all the groups. In radiated arteries, plaque area was significantly larger (32% larger then in sham). Macrophage-positive area in radiated arteries was 2.4 times greater than the macrophage-positive area in the nonradiated arteries. The area positive for macrophages is also positive for metalloproteinases (MMP)-1. The extent of alpha-actin positive area was significantly less (2.3-fold) in radiated arteries. CONCLUSION The atherosclerotic plaque developed in the current model is predominantly composed of macrophages expressing metalloproteinases with few smooth muscle cells (SMC)--a characteristic of vulnerable plaque. The animal model presented in this study can elucidate at least part of the mechanism of plaque vulnerability and could be used to test treatment modalities to test plaque stability.
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Cha DH, Malik IA, Cheneau E, Ajani AE, Leborgne L, Wolfram R, Porrazzo M, Satler LF, Kent KM, Pichard AD, Pinnow E, Lindsay J, Waksman R. Use of restenting should be minimized with intracoronary radiation therapy for in-stent restenosis. Catheter Cardiovasc Interv 2003; 59:1-5. [PMID: 12720231 DOI: 10.1002/ccd.10490] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Restenting at the time of intracoronary radiation therapy (IRT) for in-stent restenosis (ISR) potentially increases the risk of late total occlusion (LTO) of the treated vessel. Prolonged antiplatelet therapy with clopidogrel (6 months) has been shown to be effective in reducing LTO risk. The purpose of this study was to assess the impact of restenting on clinical outcomes following IRT for ISR with 6 months of clopidogrel. We retrospectively evaluated 1,275 patients with 6-months clinical follow-up who were enrolled in radiation trials for ISR using gamma- and beta-emitters conducted at Washington Hospital Center. Patients were analyzed according to whether additional stents were deployed at the time of IRT. The predominant indication for restenting was to optimize the final angiographic result in the event of tissue prolapse or to cover edge dissections. All patients received a minimum of 6 months of clopidogrel. Baseline clinical and angiographic characteristics were similar between the restented and nonrestented groups. Radiation was delivered successfully in all cases. At 6 months, patients treated with additional stents and IRT had a significantly higher rate of target vessel revascularization than patients without additional stents (24.6% vs. 18.7%; P = 0.011). Restenting caused more frequent late thrombosis, late total occlusion, and Q-wave myocardial infarction than no restenting (4.0% vs. 2.2%, P = 0.09; 6.1% vs. 4.3%, P = 0.14; and 1.9% vs. 0.4%, P = 0.009, respectively). Restenting for the treatment of ISR is associated with increased adverse events and should be avoided after intracoronary radiation therapy for in-stent restenosis, as restenting results in a higher recurrence rate and the potential for increased late total occlusion.
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Cheneau E, John MC, Fournadjiev J, Chan RC, Kim HS, Leborgne L, Pakala R, Yazdi H, Ajani AE, Virmani R, Waksman R. Time course of stent endothelialization after intravascular radiation therapy in rabbit iliac arteries. Circulation 2003; 107:2153-8. [PMID: 12695306 DOI: 10.1161/01.cir.0000062648.39025.09] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Late total occlusion after vascular brachytherapy (VBT) continues to be a serious complication. Delayed reendothelialization was suggested as a pivotal cause, but the time course for complete healing is unknown. METHODS AND RESULTS Seventy-two rabbit iliac arteries underwent stent implantation and were treated with gamma-radiation using 192Ir. The prescribed doses were 0 Gy (controls, n=24 arteries), 15 Gy (n=24), or 30 Gy (n=24) at 2 mm. Animals were killed at 1 month (n=24), 3 months (n=24), or 6 months (n=24) and were analyzed for histomorphometry or scanning electron microscopy. Intimal area was reduced after VBT at 3 months with 15 and 30 Gy (0.66+/-0.07 and 0.66+/-0.04 mm2, respectively) compared with controls (1.01+/-0.11 mm2, P<0.05) and at 6 months with 30 Gy (0.75+/-0.09 versus 1.28+/-0.26 mm2 in controls, P<0.01). Intimal area was similar at 6 months between 15 Gy and controls. At 1 month, 92+/-4% of the control stented segment was covered with endothelial cells, whereas only 37+/-4% and 37+/-8% was covered in the 15- and 30-Gy arteries, respectively. Similarly, at 3 and 6 months, there was a difference in the extent of reendothelialized areas (at 3 months, 95+/-2%, 32+/-12%, and 29+/-13%; and at 6 months, 98+/-2%, 40+/-8%, and 35+/-12% in control, 15-Gy, and 30-Gy arteries, respectively). Excess platelets and leukocytes were seen in irradiated arteries without complete coverage of endothelium. CONCLUSIONS Reendothelialization after VBT is not completed at 6 months after VBT. Special care with prolonged antiplatelet therapy should be considered beyond that time point.
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Waksman R, Cheneau E, Ajani AE, White RL, Pinnow E, Torguson R, Deible R, Satler LF, Pichard AD, Kent KM, Teirstein PS, Lindsay J. Intracoronary radiation therapy improves the clinical and angiographic outcomes of diffuse in-stent restenotic lesions: results of the Washington Radiation for In-Stent Restenosis Trial for Long Lesions (Long WRIST) Studies. Circulation 2003; 107:1744-9. [PMID: 12665490 DOI: 10.1161/01.cir.0000060497.91775.6d] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Washington Radiation for In-Stent Restenosis Trial for long lesions (Long WRIST) was designed to determine the safety and efficacy of vascular brachytherapy for the treatment of diffuse in-stent restenosis. METHODS AND RESULTS A total of 120 patients with diffuse in-stent restenosis in native coronary arteries (lesion length, 36 to 80 mm) were randomized for either radiation with 192Ir with 15 Gy at 2 mm from the source axis or placebo. After enrollment, 120 additional patients with the same inclusion criteria were treated with 192Ir with 18 Gy and included in the Long WRIST High Dose registry. Antiplatelet therapy was initially prescribed for 1 month and was extended to 6 months in the last 60 patients of the Long WRIST High Dose registry. At 6 months, the binary angiographic restenosis rate was 73%, 45%, and 38% in the placebo, 15 Gy, and 18 Gy radiated groups, respectively (P<0.05). At 1 year, the primary clinical end point of major cardiac events was 63% in the placebo group and 42% in the radiated group with 15 Gy (P<0.05). The major cardiac event rate was further reduced with 18 Gy (22%; P<0.05 versus 15 Gy). Late thrombosis was 12%, 15%, and 9% in the placebo group, 15 Gy group with 1 month of antiplatelet therapy, and 18 Gy group with 6 months of antiplatelet therapy, respectively. CONCLUSIONS Vascular brachytherapy with 192Ir is safe and reduces the rate of recurrent restenosis in diffuse in-stent restenosis. The efficacy of vascular brachytherapy on angiographic and clinical outcomes is enhanced with a radiation dose of 18 Gy and prolonged antiplatelet therapy.
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Sharma AK, Ajani AE, Garg N, Cheneau E, Wolfram R, Chan R, Pinnow E, Canos D, Pichard AD, Satler LF, Kent KM, Lindsay J, Waksman R. Usefulness of gamma intracoronary radiation for totally occluded in-stent restenotic coronary narrowing. Am J Cardiol 2003; 91:595-7. [PMID: 12615269 DOI: 10.1016/s0002-9149(02)03315-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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