2801
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Palmaz JC. Future Direction with Drug Delivery and Stent Design. J Vasc Interv Radiol 2003. [DOI: 10.1016/s1051-0443(03)70107-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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2802
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Gunn J, Morton AC, Wales C, Newman CMH, Crossman DC, Cumberland DC. Drug eluting stents: maximising benefit and minimising cost. Heart 2003; 89:127-31. [PMID: 12527654 PMCID: PMC1767559 DOI: 10.1136/heart.89.2.127] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A policy of selective implantation of drug eluting stents, in a minority of lesions most likely to benefit, seems to be a rational way to employ this new and currently costly technology.
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Affiliation(s)
- J Gunn
- Cardiovascular Research Group, Division of Clinical Sciences (Northern General Hospital), University of Sheffield, Sheffield,
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2803
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Green NE, Maddux JT, Burchenal J. Coronary Angioplasty. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2003; 5:13-24. [PMID: 12686015 DOI: 10.1007/s11936-003-0011-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Percutaneous revascularization is a widely accepted procedure to treat patients with coronary artery disease. Since its first description in the 1970s, significant technological and pharmaceutical advances have occurred and subsequently reduced the complications associated with the procedure. Large, randomized controlled trials have provided additional evidence that percutaneous revascularization improves morbidity and mortality in patients with coronary artery disease. Over the last decade, devices designed to treat patients with more complex coronary artery disease have expanded the available therapeutic options and will likely contribute to a further decline in adverse events. Despite these advances, the management of patients with acute myocardial infarction, in-stent restenosis, and multivessel coronary artery disease remains challenging. The majority of evidence supports an early, aggressive approach in patients with acute ST-elevation and non-ST-elevation myocardial infarction. Ongoing clinical trials should help to further define the role of percutaneous interventions in the optimal management of patients with coronary artery disease.
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Affiliation(s)
- Nathan E. Green
- Cardiac Catheterization Laboratory, University of Colorado Health Science Center, 4200 East 9th Avenue, Denver, CO 80262, USA.
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2804
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Abstract
Animal models of stenting probably predict human responses as the stages of healing are remarkably similar. What is characteristically different is the temporal response to healing, which is substantially prolonged in humans. The prevention of restenosis in recent clinical trials of drug eluting stents may represent a near absent or incomplete phase of intimal healing. Continued long term follow up of patients with drug eluting stents for major adverse cardiac events and angiographic restenosis is therefore imperative.
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Affiliation(s)
- R Virmani
- Department of Cardiovascular Pathology, Armed Forces Institute of Pathology, Washington DC 20306-6000, USA.
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2805
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Affiliation(s)
- Martin R Bennett
- Addenbrooke's Centre for Clinical Investigation, Box 110, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK.
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2806
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Ferreira AC, Peter AA, Salerno TA, Bolooki H, de Marchena E. Clinical impact of drug-eluting stents in changing referral practices for coronary surgical revascularization in a tertiary care center. Ann Thorac Surg 2003; 75:485-9. [PMID: 12607658 DOI: 10.1016/s0003-4975(02)04367-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The long-term benefits of angioplasty are limited by the occurrence of restenosis. Drug-eluting stents with a projected restenosis rate of close to 0% are soon to become available. The short- and long-term consequences of this advance to the cardiac surgical volume remain unclear. METHODS A total of 196 consecutive coronary angiograms and medical records of patients referred for coronary bypass surgery were reviewed. Considering the hypothetical premise of having drug-eluting stents with a near zero restenosis rate, we reviewed each case to determine if surgical revascularization was still the preferred option for revascularization. RESULTS The mean age was 60 (+/-10.6) years. Seventy-two percent of patients were male. Considering the availability of drug-eluting stents 154 (79%) would still have been sent to surgery, representing a 21% decrease in the number of surgical revascularizations. Angiographic characteristics predicting coronary bypass revascularization were the presence of chronic total occlusion (odds ratio [OR]: 9.1; confidence interval [CI]: 2.1 to 39), left main coronary artery stenosis (OR: 9.6; CI: 1.27 to 73), and need for valvular surgery (OR: 7.38; CI: 1.3 to 157). The most common predictors of a change in clinical management from surgical to percutaneous revascularization if drug-eluting stents were available were diffuse coronary narrowing (OR: 15.78), restenotic lesions (OR: 27.86), and small coronary arteries (OR: 26). CONCLUSIONS Drug-eluting stents may have a significant impact on cardiac surgery volume (approximately a 21% decrease in our center). It may also direct patients with small vessels, diffuse narrowing, or restenotic lesions and diabetic patients to percutaneous therapy.
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Affiliation(s)
- Alexandre C Ferreira
- Department of Medicine, Division of Cardiology, University of Miami School of Medicine, Miami, Florida, USA.
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2807
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Fischmann Magee M, A Taiwo A, Howard BV. Management of Diabetes with Coronary Artery Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2003; 5:75-88. [PMID: 12686020 DOI: 10.1007/s11936-003-0016-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Persons with cardiovascular disease (CVD) and diabetes consistently have worse clinical outcomes than those without diabetes. Treatment of diabetes with CVD must target blood pressure, cholesterol, and glycemic targets. Control of blood pressure to pound 130/80 mm Hg and low-density lipoprotein cholesterol to less than 100 mg/dL is key to preventing and managing CVD with diabetes. Optimal glucose control should be a goal in treating diabetes and CVD, in both hospital and outpatient settings. This article focuses on the oral antihyperglycemic agents and insulins available for diabetes pharmacotherapy. Effective glucose management using these agents when interventional procedures and cardiac surgery are to be performed is possible. Practical strategies include combination therapies and use of insulins subcutaneously or by intravenous infusion. Emerging therapies may impact outcomes for diabetes with CVD, including use of insulin sensitizers, drug-eluting stents, and brachytherapy. Attention is currently focused on the insulin sensitizers (metformin and thiazolidinediones), as they appear to impact processes related to the insulin resistance syndrome and the vascular pathophysiologic changes of atherosclerosis. It remains to be seen whether or not the insulin-sensitizing agents will confer a definitive advantage in treating the patient with diabetes for the prevention of or intervention for CVD.
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2808
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2809
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Abstract
The techniques and modalities provided by interventional pulmonology play a major role in the management of patients with symptomatic airways obstruction. The majority of these obstructions are part of pulmonary involvement by primary lung neoplasms or metastatic lesions from other organs. Benign lesions, although capable of producing similar symptoms, are more rare. Performance of successful interventional pulmonology is dependent on the skill and dexterity of the operator paired with a highly trained and dedicated ancillary team of nurses, anesthetists, and respiratory therapists. Successful endobronchial management of airway obstruction not only provides significant improvement in patients' quality of life, it also adds to their survival time. Both results fulfill the stated goals of appropriate and desired palliative therapy. Interventional pulmonology also contributes to research of the process of lung carcinogenesis and the introduction of targeted therapy for early minimally invasive cancer and the potential chemotherapy of premalignant lesions.
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Affiliation(s)
- Michael Unger
- Fox Chase Cancer Center, 7701 Burholme Avenue, Philadelphia, PA 19111, USA.
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2810
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Abstract
During the last two decades, several advances have resulted in marked improvement in medium-term survival, with excellent quality of life, in children undergoing cardiac transplantation. Improved outcomes reflect better selection of donors and recipients, increased surgical experience in transplantation for complex congenital heart disease, development of effective surveillance for rejection, and wider choice of immunosuppressive medications. Despite all of these advances, recipients continue to suffer from the adverse effects of non-specific immunosupression, including infections, induction of lymphoproliferative disorders and other malignancies, renal dysfunction, and other important end-organ toxicities. Furthermore, newer immunosuppressive regimes, thus far, appear to have had relatively little impact on the incidence of chronic rejection. Progress in our understanding of the immunologic mechanisms of rejection and graft acceptance should lead to more targeted immunosuppressive therapy and avoidance of non-specific immunosupression. The ultimate goal is to induce a state of tolerance, wherein the recipient will accept the allograft indefinitely, without the need for long-term immunusupression, and yet remain immuno-competent to all non-donor antigens. This quest is currently being realized in many animal models of solid organ transplantation, and offers great hope for the future.
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Affiliation(s)
- Steven A Webber
- Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, PA 15213, USA.
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2811
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Sousa JE, Costa MA, Sousa AGMR, Abizaid AC, Seixas AC, Abizaid AS, Feres F, Mattos LA, Falotico R, Jaeger J, Popma JJ, Serruys PW. Two-year angiographic and intravascular ultrasound follow-up after implantation of sirolimus-eluting stents in human coronary arteries. Circulation 2003; 107:381-3. [PMID: 12551858 DOI: 10.1161/01.cir.0000051720.59095.6d] [Citation(s) in RCA: 223] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The safety and efficacy of sirolimus-eluting stenting have been demonstrated, but the outcome of patients treated with this novel technology beyond the first year remains unknown. We sought to evaluate the angiographic, intravascular ultrasound (IVUS), and clinical outcomes of patients treated with sirolimus-eluting stents 2 years after implantation. METHODS AND RESULTS This study included 30 patients treated with sirolimus-eluting Bx Velocity stenting (slow release [SR], n=15, and fast release [FR], n=15) in São Paulo, Brazil. Twenty-eight patients underwent 2-year angiographic and IVUS follow-up. No deaths occurred during the study period. In-stent late loss was slightly greater in the FR group (0.28+/-0.4 mm) than in the SR group (-0.09+/-0.23 mm, P=0.007). No patient had in-stent restenosis. At 2-year follow-up, only 1 patient (FR group) had a 52% diameter stenosis within the lesion segment, which required repeat revascularization. The target-vessel revascularization rate for the entire cohort was 10% (3/30) at 2 years. All other patients had < or =35% diameter stenosis. Angiographic lumen loss at the stent edges was also minimal (in-lesion late loss was 0.33+/-0.42 mm [FR] and 0.13+/-0.29 mm [SR]). In-stent neointimal hyperplasia volume, as detected by IVUS, remained minimal after 2 years (FR= 9.90+/-9 mm3 and SR=10.35+/-9.3 mm3). CONCLUSIONS This study demonstrates the safety and efficacy of sirolimus-eluting Bx Velocity stents 2 years after implantation in humans. In-stent lumen dimensions remained essentially unchanged at 2-year follow-up in the 2 groups, although angiographic lumen loss was slightly higher in the FR group. Restenosis "catch-up" was not found in our patient population.
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2812
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Abstract
CONTEXT Restenosis is the most important long-term limitation of stent implantation for coronary artery disease, occurring in 15-60% of patients. In-stent restenosis, a refractory coronary lesion resulting from neointimal hyperplasia, challenges both vascular biologist and interventional cardiologist. Various drugs and devices have been used tried to overcome restenosis but are not particularly successful. Over 1500000 percutaneous coronary interventions are done annually. Restenosis is not only important clinically but also for its impact on health-care costs. STARTING POINT Growth and migration of vascular smooth-muscle cells result in neointimal proliferation after vascular injury and are the key mechanism of in-stent restenosis. The rationale of the most recent approaches to restenosis (eg, brachytherapy and immunosuppressive agents) arises from the similarity between tumour-cell growth and the benign tissue proliferation which characterises intimal hyperplasia. Several immunosuppressants have been tested for their potential to inhibit restenosis, with the novel strategy of administering the drug via a coated stent platform. Local drug delivery achieves higher tissue concentrations of drug without systemic effects, at a precise site and time. The first multicentre trial with stents coated with sirolimus was by Marie-Claude Morice and colleagues (N Engl J Med 2002; 346: 1773-80). In a trial of 238 patients, restenosis of 50% or more at 6 months was 0% and 27% with sirolimus or normal stents (p<0.001), respectively, after percutaneous revascularisation. Muzaffer Degertekin and colleagues (Circulation 2002; 106: 1610-13) present data on 2-year follow-up of 15 patients who had been implanted with the sirolimus stent in another study, and confirm persistent inhibition of restenosis and an absence of unexpected adverse events. WHERE NEXT? Local application of antiproliferative agents is a promising technique and research is developing. Other agents with potential benefits (eg, statins, local gene-therapy, adenovirus-mediated arterial gene-transfer, L-arginine, abciximab, angiopeptin, recombinant pegylated hirudin, and hiloprost) as well as improvements in polymer technology (biodegradable smart polymers, coatings for multiple-drug release) are under evaluation. The clinical impact of the elimination of restenosis may influence the approach to coronary artery disease, the future of cardiac surgery, and health-care economics in cardiology.
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Affiliation(s)
- Rossella Fattori
- Department of Radiology, Cardiovascular Unit, University Hospital S Orsola, 40138, Bologna, Italy.
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2813
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Degertekin M, Regar E, Tanabe K, Smits PC, van der Giessen WJ, Carlier SG, de Feyter P, Vos J, Foley DP, Ligthart JMR, Popma JJ, Serruys PW. Sirolimus-eluting stent for treatment of complex in-stent restenosis: the first clinical experience. J Am Coll Cardiol 2003; 41:184-9. [PMID: 12535805 DOI: 10.1016/s0735-1097(02)02704-3] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES In this study, we assess the value of sirolimus eluting stent (SES) implantation in patients with complex in-stent restenosis (ISR). BACKGROUND The treatment of ISR remains a therapeutic challenge, since many pharmacological and mechanical approaches have shown disappointing results. The SESs have been reported to be effective in de-novo coronary lesions. METHODS Sixteen patients with severe, recurrent ISR in a native coronary artery (average lesion length 18.4 mm) and objective evidence of ischemia were included. They received one or more 18 mm Bx VELOCITY SESs (Cordis Waterloo, Belgium). Quantitative angiographic and three-dimensional intravascular ultrasound (IVUS) follow-up was performed at four months, and clinical follow-up at nine months. RESULTS The SES implantation (n = 26) was successful in all 16 patients. Four patients had recurrent restenosis following brachytherapy, and three patients had totally occluded vessels preprocedure. At four months follow-up, one patient had died and three patients had angiographic evidence of restenosis (one in-stent and two in-lesion). In-stent late lumen loss averaged 0.21 mm and the volume obstruction of the stent by IVUS was 1.1%. At nine months clinical follow-up, three patients had experienced four major adverse cardiac events (two deaths and one acute myocardial infarction necessitating repeat target vessel angioplasty). CONCLUSIONS The SES implantation in patients with severe ISR lesions effectively prevents neointima formation and recurrent restenosis at four months angiographic follow-up.
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2814
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Bauters C, Lamblin N, Mc Fadden EP, Van Belle E, Millaire A, de Groote P. Influence of diabetes mellitus on heart failure risk and outcome. Cardiovasc Diabetol 2003; 2:1. [PMID: 12556246 PMCID: PMC149427 DOI: 10.1186/1475-2840-2-1] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2002] [Accepted: 01/08/2003] [Indexed: 12/17/2022] Open
Abstract
Our aim is to summarize and discuss the recent literature linking diabetes mellitus with heart failure, and to address the issue of the optimal treatment for diabetic patients with heart failure. THE STUDIES LINKING DIABETES MELLITUS (DM) WITH HEART FAILURE (HF) : The prevalence of diabetes mellitus in heart failure populations is close to 20% compared with 4 to 6% in control populations. Epidemiological studies have demonstrated an increased risk of heart failure in diabetics; moreover, in diabetic populations, poor glycemic control has been associated with an increased risk of heart failure. Various mechanisms may link diabetes mellitus to heart failure: firstly, associated comorbidities such as hypertension may play a role; secondly, diabetes accelerates the development of coronary atherosclerosis; thirdly, experimental and clinical studies support the existence of a specific diabetic cardiomyopathy related to microangiopathy, metabolic factors or myocardial fibrosis. Subgroup analyses of randomized trials demonstrate that diabetes is also an important prognostic factor in heart failure. In addition, it has been suggested that the deleterious impact of diabetes may be especially marked in patients with ischemic cardiomyopathy. TREATMENT OF HEART FAILURE IN DIABETIC PATIENTS : The knowledge of the diabetic status may help to define the optimal therapeutic strategy for heart failure patients. Cornerstone treatments such as ACE inhibitors or beta-blockers appear to be uniformly beneficial in diabetic and non diabetic populations. However, in ischemic cardiomyopathy, the choice of the revascularization technique may differ according to diabetic status. Finally, clinical studies are needed to determine whether improved metabolic control might favorably influence the outcome of diabetic heart failure patients.
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Affiliation(s)
- Christophe Bauters
- Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037 Lille cedex, France
| | - Nicolas Lamblin
- Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037 Lille cedex, France
| | - Eugène P Mc Fadden
- Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037 Lille cedex, France
| | - Eric Van Belle
- Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037 Lille cedex, France
| | - Alain Millaire
- Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037 Lille cedex, France
| | - Pascal de Groote
- Centre Hospitalier Universitaire de Lille, Place de Verdun, 59037 Lille cedex, France
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2815
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Sousa JE, Costa MA, Abizaid A, Sousa AGMR, Feres F, Mattos LA, Centemero M, Maldonado G, Abizaid AS, Pinto I, Falotico R, Jaeger J, Popma JJ, Serruys PW. Sirolimus-eluting stent for the treatment of in-stent restenosis: a quantitative coronary angiography and three-dimensional intravascular ultrasound study. Circulation 2003; 107:24-7. [PMID: 12515737 DOI: 10.1161/01.cir.0000047063.22006.41] [Citation(s) in RCA: 155] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We have previously reported the safety and effectiveness of sirolimus-eluting stents for the treatment of de novo coronary lesions. The present investigation explored the potential of this technology to treat in-stent restenosis. METHODS AND RESULTS Twenty-five patients with in-stent restenosis were successfully treated with the implantation of 1 or 2 sirolimus-eluting Bx VELOCITY stents in São Paulo, Brazil. Nine patients received 2 stents (1.4 stents per lesion). Angiographic and volumetric intravascular ultrasound (IVUS) images were obtained after the procedure and at 4 and 12 months. All vessels were patent at the time of 12-month angiography. Angiographic late loss averaged 0.07+/-0.2 mm in-stent and -0.05+/-0.3 mm in-lesion at 4 months, and 0.36+/-0.46 mm in-stent and 0.16+/-0.42 mm in-lesion after 12 months. No patient had in-stent or stent margin restenosis at 4 months, and only one patient developed in-stent restenosis at 1-year follow-up. Intimal hyperplasia by 3-dimensional IVUS was 0.92+/-1.9 mm(3) at 4 months and 2.55+/-4.9 mm(3) after 1 year. Percent volume obstruction was 0.81+/-1.7% and 1.76+/-3.4% at the 4- and 12-month follow-up, respectively. There was no evidence of stent malapposition either acutely or in the follow-up IVUS images, and there were no deaths, stent thromboses, or repeat revascularizations. CONCLUSION This study demonstrates the safety and the potential utility of sirolimus-eluting Bx VELOCITY stents for the treatment of in-stent restenosis.
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2816
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Grube E, Silber S, Hauptmann KE, Mueller R, Buellesfeld L, Gerckens U, Russell ME. TAXUS I: six- and twelve-month results from a randomized, double-blind trial on a slow-release paclitaxel-eluting stent for de novo coronary lesions. Circulation 2003; 107:38-42. [PMID: 12515740 DOI: 10.1161/01.cir.0000047700.58683.a1] [Citation(s) in RCA: 602] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The TAXUS NIRx stent (Boston Scientific Corp) provides local delivery of paclitaxel via a slow-release polymer coating. The TAXUS I trial was the first in-human experience evaluating safety and feasibility of the TAXUS NIRx stent system compared with bare NIR stents (control) (Boston Scientific Corp) for treatment of coronary lesions. METHODS AND RESULTS METHODS AND RESULTS The TAXUS I trial was a prospective, double-blind, three-center study randomizing 61 patients with de novo or restenotic lesions (< or =12 mm) to receive a TAXUS (n=31) versus control (n=30) stent (diameter 3.0 or 3.5 mm). Demographics, lesion characteristics, clinical outcomes were comparable between the groups. The 30-day major adverse cardiac event (MACE) rate was 0% in both groups (P=NS). No stent thromboses were reported at 1, 6, 9, or 12 months. At 12 months, the MACE rate was 3% (1 event) in the TAXUS group and 10% (4 events in 3 patients) in the control group (P=NS). Six-month angiographic restenosis rates were 0% for TAXUS versus 10% for control (P=NS) patients. There were significant improvements in minimal lumen diameter (2.60+/-0.49 versus 2.19+/-0.65 mm), diameter stenosis (13.56+/-11.77 versus 27.23+/-16.69), and late lumen loss (0.36+/-0.48 versus 0.71+/-0.48 mm) in the TAXUS group (all P<0.01). No evidence of edge restenosis was seen in either group. Intravascular ultrasound analysis showed significant improvements in normalized neointimal hyperplasia in the TAXUS (14.8 mm3) group compared with the control group (21.6 mm3) (P<0.05). CONCLUSIONS In this feasibility trial, the TAXUS slow-release stent was well tolerated and showed promise for treatment of coronary lesions, with significant reductions in angiographic and intravascular ultrasound measures of restenosis.
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Affiliation(s)
- Eberhard Grube
- Department of Cardiology/Angiology, Heart Center Siegburg, Siegburg, Germany.
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2817
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2818
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Blanco-Colio LM, Tuñón J, Martín-Ventura JL, Egido J. Anti-inflammatory and immunomodulatory effects of statins. Kidney Int 2003; 63:12-23. [PMID: 12472764 DOI: 10.1046/j.1523-1755.2003.00744.x] [Citation(s) in RCA: 234] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Anti-inflammatory and immunomodulatory effects of statins. 3-Hydroxy-3-methyl-gutaryl coenzyme A (HMG-CoA) reductase inhibitors or statins constitute the most powerful class of lipid-lowering drugs. Clinical trials have demonstrated a marked reduction in cardiovascular mortality in patients treated with statins. However, the benefits observed with statin therapy appear to be related, at least in part, with their cholesterol-lowering independent effects. Extensive research carried out mainly in the last decade suggests that the clinical benefits of these drugs could be related to an improvement in endothelial dysfunction, a reduction in blood thrombogenicity, anti-inflammatory properties, and, recently, immunomodulatory actions. In this sense, statins decrease T cell activation, the recruitment of monocytes and T cells into the arterial wall, and enhance the stability of atherosclerotic lesions. Many of these effects are related with the inhibition of isoprenoid synthesis, which serve as a lipid attachment for a variety of proteins implicated in intracellular signaling. In fact, small G proteins, whose proper membrane localization and function are dependent on isoprenylation, may play an important role in the lipid-lowering independent effects of HMG-CoA reductase inhibitors. This article summarizes the anti-inflammatory and immunomodulatory effects of statins and their participation in the different steps of atherosclerotic lesion formation.
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2819
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Tripuraneni P. The future of CART in the era of drug eluting stents: “It's not over until it's over.”. Brachytherapy 2003; 2:74-6. [PMID: 15062143 DOI: 10.1016/s1538-4721(03)00104-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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2820
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Stankovic G, Orlic D, Di Mario C, Corvaja N, Airoldi F, Chieffo A, Amato A, Orecchia R, Colombo A. Beta-radiation therapy for long lesions in native coronary vessels: a matched comparison between de novo and in-stent restenotic lesions. CARDIOVASCULAR RADIATION MEDICINE 2003; 4:18-24. [PMID: 12892768 DOI: 10.1016/s1522-1865(03)00122-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate effectiveness and to compare clinical outcome of intracoronary beta-radiation to treat long lesions (>20 mm) in patients with de novo stenosis vs. patients with in-stent restenosis (ISR). METHODS A matched comparison of 44 patients with 63 de novo lesions and 48 patients with 63 ISR lesions (>20 mm) treated with intracoronary beta-radiation was performed. RESULTS Stents were implanted in 65.1% of de novo and 19% of ISR lesions (P=.001). Radiation doses delivered were 17.2+/-3.0 vs. 20.3+/-3.0 Gy at 2 mm from the source center for de novo and ISR lesions. There was no difference in the incidence of in-hospital events. Clinical follow-up at 16.4+/-6.7 months showed no difference in major adverse cardiac events (MACE) between de novo and ISR patients (27.3% vs. 25%, P=.8). Late total occlusions (LTOs) occurred in eight patients (four in each group) treated with stents at the time of radiation and after discontinuation of ticlopidine. By multivariate analysis, stent implantation was the only predictor of late occlusions (OR 8.25, 95% CI 1.73-38.46, P<.008). Restenosis rates were similar for de novo and ISR lesions (29.3% vs. 23.2%, P=.46), as well as target lesion revascularization (TLR) and target vessel revascularization (TVR) rates (22.7% vs. 22.9% and 29.5% vs. 29.2%, respectively). CONCLUSIONS Intracoronary beta-radiation gives comparable results when used to treat de novo or ISR lesions provided new stent implantation can be avoided. Long-term combined antiplatelet therapy is mandatory for patients who receive new stents at the time of radiation treatment.
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Affiliation(s)
- Goran Stankovic
- Centro Cuore Columbus, Via M. Buonarroti 48, 20145 Milan, Italy
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2821
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2822
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Abstract
Restenosis limits the success of percutaneous transluminal coronary interventions. Coronary artery stenting decreases restenosis, improves outcomes, and is currently the most commonly used percutaneous coronary intervention in the United States. However, in-stent restenosis continues to occur at an unacceptable rate. In-stent restenosis is a neointimal hyperplastic response resulting primarily from vascular smooth muscle cell proliferation. Treatment with anti-proliferative agents presents a logical approach to eradicating restenosis, however, these drugs are highly toxic. Coating stents with anti-proliferative agents allows local delivery of high doses and avoids systemic side effects. In 2001, the results of two clinical trials, RAVEL and ELUTES, using sirolimus- and paclitaxil-coated stents demonstrated nearly complete elimination of in-stent restenosis. These dramatic results represent a tremendous advance in the treatment of coronary heart disease.
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Affiliation(s)
- Dorie W Schwertz
- Department of Medical Surgical Nursing, University of Illinois, Chicago, Illinois, USA
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2823
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Paszkowiak JJ, Dardik A. Arterial wall shear stress: observations from the bench to the bedside. Vasc Endovascular Surg 2003; 37:47-57. [PMID: 12577139 DOI: 10.1177/153857440303700107] [Citation(s) in RCA: 212] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Shear stress is the tangential force of the flowing blood on the endothelial surface of the blood vessel. Shear is described mathematically or ideal fluids, and in vitro models have enabled researchers to describe the effects of shear on endothelial cells. High shear stress, as found in laminar flow, promotes endothelial cell survival and quiescence, alignment in the direction of flow, and secretion of substances that promote vasodilation and anticoagulation. Low shear stress, or changing shear stress direction as found in turbulent flow, promotes endothelial proliferation and apoptosis, shape change, and secretion of substances that promote vasoconstriction, coagulation, and platelet aggregation. The precise pathways by which endothelial cells sense shear stress to promote their quiescent or activated pathways are currently unknown. Clinical applications include increasing shear stress via creation of an arteriovenous fistula or vein cuff to promote bypass graft flow and patency. Since an abnormal level of shear stress is implicated in the pathogenesis of atherosclerosis, neointimal hyperplasia, and aneurysmal disease, additional research to understand the effects of shear stress on the blood vessel may provide insight to prevent vascular disease.
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2824
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Sianos G, Hofma S, Ligthart JMR, Saia F, Hoye A, Lemos PA, Serruys PW. Stent fracture and restenosis in the drug-eluting stent era. Catheter Cardiovasc Interv 2003; 61:111-6. [PMID: 14696169 DOI: 10.1002/ccd.10709] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Georgios Sianos
- Department of Interventional Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
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2825
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Campistol JM. Sirolimus: a potential option for the prevention of chronic allograft nephropathy. Transplant Rev (Orlando) 2003. [DOI: 10.1053/trre.2003.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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2826
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Obradović S, Rusović S, Dincić D, Gligić B, Baskot B, Balint B, Stamatović D, Romanović R, Ristić A, Trifunović Z. Autologous pluripotent progenitor cells in the treatment of ischemic heart disease. VOJNOSANIT PREGL 2003; 60:725-31. [PMID: 14737893 DOI: 10.2298/vsp0306725o] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
<zakljucak> Studije na zivotinjama i prva klinicka iskustva na ljudima pokazuju da nakon primene progenitornih celija mioblasta ili poreklom iz kostne srzi dolazi do poboljsanja srcane funkcije. Pomenute metode jos nose sa sobom veoma veliki broj pitanja. Da li je zaista moguce regenerisati miokard ?nekim? novim mioblastima, za koje se ocekuje da se diferenciraju u patoloskim uslovima u plemenito visoko diferentovano, funkcionalno tkivo miokarda? Kada je u pitanju ishemijska bolest srca ne treba zaboraviti osnovni problem - koronarnu insuficijenciju, koja se samom kardiomioplastikom ne resava. Kombinacija revaskularizacionih procedura sa celijskom kardiomioplastikom je sine qua non za prezivljavanje i transplantovanih celija. Da li je veca debljina oziljka na miokardu i njegova elasticnost dovoljna korist da bi se ove celije transplantovale kod bolesnika sa teskim oziljnim promenama na srcu? Koji su bolesnici pravi kandidati za ovaj vid terapije, koji je optimalan broj mioblasta koji treba transplantovati i koji je najbolji nacin za transplantaciju? Ovo su samo neka od ozbiljnih pitanja na koje je sada tesko dati odgovor. Sa druge strane, transplantacija progenitornih celija iz kostne srzi ili njihova mobilizacija faktorima rasta u perifernu krv su metode za pospesivanje arteriogeneze i angiogeneze, koja moze biti veoma brza i efikasna u smislu spasavanja ugrozenog miokarda u akutnim koronarnim sindromima, a dovoljna u sprecavanju ishemije kod teskih hronicnih koronarnih bolesnika. Visednevna primena faktora rasta omogucava dugotrajnu mobilizaciju velikog broja progenitora mezenhimskih celija iz kostne srzi, tj. pospesuje proces koji se i inace dogadja pod uticajem ishemije i nekrozom potaknutane imunske reakcije. Medjutim, koje faktore rasta, kada i u kojoj dozi, treba dati za mobilizaciju endotelnih i mioblastnih progenitora? Da li neki od njih mogu da pospese reperfuziono ostecenje miokarda? Koliko dugo treba primenjivati takvu terapiju? Da li je treba dati samo bolesnicima sa no reflow fenomenom? Dakle, brojna su pitanja koja se namecu i kada je u pitanju ovaj vid celijske terapije. U svakom slucaju dosadasnja istrazivanja otvaraju nove puteve i potrebne su vece, dobro kontrolisane randomizovane studije koje ce lagano da odgovaraju na jedno po jedno od pomenutih pitanja! Kardiologija se spusta na novi nivo, nivo osnovnih bioloskih procesa, diferencijacije, regeneracije, gensku terapiju, terapiju koja je usmerena na razvijanje mikrocirkulacije. Kao i u svemu ranije, bice potrebno puno godina da osetimo korist od istine za kojom tragamo.
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Affiliation(s)
- Slobodan Obradović
- Vojnomedicinska akademija, Klinika za urgentnu internu medicinu, Beograd
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2827
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Modern management of acute myocardial infarction. Curr Probl Cardiol 2003. [DOI: 10.1016/s0146-2806(03)70001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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2828
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2829
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Indolfi C, Torella D, Coppola C, Curcio A, Rodriguez F, Bilancio A, Leccia A, Arcucci O, Falco M, Leosco D, Chiariello M. Physical training increases eNOS vascular expression and activity and reduces restenosis after balloon angioplasty or arterial stenting in rats. Circ Res 2002; 91:1190-7. [PMID: 12480821 DOI: 10.1161/01.res.0000046233.94299.d6] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The effects of dynamic exercise on restenosis after vascular injury are still unknown. The consequences of balloon dilation-induced injury on neointimal hyperplasia, vascular negative remodeling, and reendothelialization were assessed in sedentary and trained rats. Ex vivo eNOS vascular expression and activity were investigated in carotid arteries isolated from sedentary and exercised rats. The in vivo effects of eNOS inhibition by L-NMMA on vessel wall after balloon dilation were evaluated in sedentary and exercised rats. We also investigated the effects of exercise on neointimal formation in a rat stent model of vascular injury. Compared with sedentary group, the arteries isolated from trained rats showed higher levels of eNOS protein expression and activity 7 days after balloon dilation. A significant reduction of both neointimal hyperplasia and negative remodeling was observed 14 days after balloon injury in trained compared with sedentary rats. Moreover, we demonstrated that exercise training produced accelerated reendothelialization of the balloon injured arterial segments compared with sedentary. L-NMMA administration eliminated the benefits of physical training on vessel wall after balloon dilation. Finally, a decrease of neointimal hyperplasia as well as of platelet aggregation was observed after stent deployment in trained rats compared with sedentary. In conclusion, physical exercise could favorably affect restenosis after balloon angioplasty and stenting. Increase in eNOS expression and activity might contribute to the potential beneficial effects of exercise on the vessel wall after vascular injury.
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MESH Headings
- Adenosine Diphosphate/pharmacology
- Angioplasty, Balloon/adverse effects
- Animals
- Carotid Stenosis/etiology
- Carotid Stenosis/pathology
- Carotid Stenosis/prevention & control
- Cell Division/physiology
- Disease Models, Animal
- Endothelium, Vascular/enzymology
- Endothelium, Vascular/injuries
- Endothelium, Vascular/pathology
- Enzyme Activation/drug effects
- Enzyme Inhibitors/pharmacology
- Graft Occlusion, Vascular/etiology
- Graft Occlusion, Vascular/pathology
- Graft Occlusion, Vascular/prevention & control
- Hyperplasia/pathology
- Hyperplasia/prevention & control
- Immunoblotting
- Immunohistochemistry
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/enzymology
- Muscle, Smooth, Vascular/pathology
- Nitric Oxide Synthase/antagonists & inhibitors
- Nitric Oxide Synthase/metabolism
- Nitric Oxide Synthase Type III
- Physical Conditioning, Animal
- Physical Exertion
- Platelet Aggregation/drug effects
- Rats
- Rats, Wistar
- Stents/adverse effects
- Swimming/physiology
- Tunica Intima/drug effects
- Tunica Intima/enzymology
- Tunica Intima/injuries
- Tunica Intima/pathology
- omega-N-Methylarginine/pharmacology
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Affiliation(s)
- Ciro Indolfi
- Division of Cardiology, Magna Graecia University, Catanzaro, Italy.
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2830
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2831
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Drenth DJ, Veeger NJGM, Winter JB, Grandjean JG, Mariani MA, Boven van AJ, Boonstra PW. A prospective randomized trial comparing stenting with off-pump coronary surgery for high-grade stenosis in the proximal left anterior descending coronary artery: three-year follow-up. J Am Coll Cardiol 2002; 40:1955-60. [PMID: 12475455 DOI: 10.1016/s0735-1097(02)02536-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study was done to identify the best treatment for an isolated high-grade stenosis of the proximal left anterior descending coronary artery (LAD). BACKGROUND Percutaneous transluminal coronary angioplasty with stenting (PCI) and off-pump coronary artery bypass grafting (surgery) are used to treat single-vessel disease of a high-grade stenosis of the proximal LAD. Midterm results of both treatments are compared in this prospective randomized study. METHODS In a single-center prospective trial, we randomly assigned 102 patients with a high-grade stenosis of the proximal LAD (American College of Cardiology/American Heart Association classification type B2 or C) to PCI (n = 51) or surgery (n = 51). Primary composite end point was freedom from Major Adverse Cardiac and Cerebrovascular Events (MACCE) at follow-up, including death, myocardial infarction, cerebrovascular accident, and repeat target vessel revascularization (TVR). Secondary end points were angina pectoris class and need for antianginal medication at follow-up. Analysis was by intention-to-treat (ITT) and received treatment (RT). RESULTS Mean follow-up time was three years (90% midrange, two to four years). Incidence of MACCE was 23.5% after PCI and 9.8% after surgery; p = 0.07 ITT (24.1% vs. 8.3%; p = 0.04 RT). After surgery a significantly lower angina pectoris class (p = 0.02) and need for antianginal medication (p = 0.01) was found compared to PCI. Target vessel revascularization was 15.7% after PCI and 4.1% after surgery (p = 0.09). CONCLUSIONS At three-year follow-up (range, two to four years), a trend in favor of surgery is observed in regard to MACCE-free survival with a significantly lower angina pectoris status and significantly lower need for antianginal medication.
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Affiliation(s)
- Derk J Drenth
- Thoraxcentre of the Groningen University Hospital, Groningen, The Netherlands
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2832
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Versaci F, Gaspardone A, Tomai F, Ribichini F, Russo P, Proietti I, Ghini AS, Ferrero V, Chiariello L, Gioffrè PA, Romeo F, Crea F. Immunosuppressive Therapy for the Prevention of Restenosis after Coronary Artery Stent Implantation (IMPRESS Study). J Am Coll Cardiol 2002; 40:1935-42. [PMID: 12475452 DOI: 10.1016/s0735-1097(02)02562-7] [Citation(s) in RCA: 166] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study tested the effect of oral prednisone on clinical and angiographic restenosis rate after successful stent implantation in patients with persistent elevation of systemic markers of inflammation after the procedure. BACKGROUND Experimental studies have shown that corticosteroids have the potential to reduce the inflammatory response associated with stent implantation. METHODS Eighty-three patients undergoing successful stenting with C-reactive protein (CRP) levels >0.5 mg/dl 72 h after the procedure were randomized to receive oral prednisone or placebo for 45 days. The primary clinical end point was 12-month event-free survival rate (defined as freedom from death, from myocardial infarction, and from recurrence of symptoms requiring additional revascularization). The angiographic end points were restenosis rate and late loss at six months. RESULTS Twelve-month event-free survival rates were 93% and 65% in patients treated with prednisone and placebo, respectively (relative risk [RR] 0.18, 95% confidence intervals [CI], 0.05 to 0.61, p = 0.0063). Six-month restenosis rate and late loss were lower in prednisone-treated than in placebo-treated patients (7% vs. 33%, p = 0.001, and 0.39 +/- 0.6 mm vs. 0.85 +/- 0.6 mm, p = 0.001, respectively). CONCLUSIONS In patients with persistently high CRP levels after successful coronary artery stent implantation, oral immunosuppressive therapy with prednisone results in a striking reduction of clinical events and angiographic restenosis rate.
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Affiliation(s)
- Francesco Versaci
- Cattedra di Cardiochirurgia, Divisione di Cardiochirurgia, Università Tor Vergata, European Hospital, Rome, Italy.
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2833
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Kim TH, Skelding KA, Nabel EG, Simari RD. What can cardiovascular gene transfer learn from genomics: and vice versa? Physiol Genomics 2002; 11:179-82. [PMID: 12464691 DOI: 10.1152/physiolgenomics.00063.2002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The field of gene transfer has developed in an era of expanding biomedical knowledge. The potential for gene transfer to treat cardiovascular disease is great, yet identified and unidentified barriers remain. Gene transfer and its ultimate application, gene therapy, require extensive details of not only the mechanism of disease but the biological implications of the vectors used to deliver the therapeutic genes as well. Many of these details are becoming available via the study of genomics. Genomics, the study of complete genetic sequences, holds the potential for enabling and amplifying the therapeutic hopes for gene transfer. Identification of new therapeutic genes, new regulatory sequences, and establishing the patterns of gene expression from tissues exposed to vectors and transgenes will rapidly advance the application of gene transfer. Finally, there are historical and ongoing lessons learned from the development of gene transfer that may be applicable to the challenging field of genomics and may enable its future success.
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Affiliation(s)
- Tae Ho Kim
- Division of Cardiovascular Disease, Department of Internal Medicine, Chung-Ang University Hospital, Seoul 140-757, Korea
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2834
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De Feyter PJ, Smits PC, Rensing BJ, Vos J, Van der Giessen WJ, Sianos G, Serruys PW. Sirolimus-eluting coronary stents. J Interv Cardiol 2002; 15:467-70. [PMID: 12476649 DOI: 10.1111/j.1540-8183.2002.tb01090.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- P J De Feyter
- Thoraxcenter, Room Bd 410, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
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2835
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Brueck M, Scheinert D, Wortmann A, Bremer J, von Korn H, Klinghammer L, Kramer W, Flachskampf FA, Daniel WG, Ludwig J. Direct coronary stenting versus predilatation followed by stent placement. Am J Cardiol 2002; 90:1187-92. [PMID: 12450596 DOI: 10.1016/s0002-9149(02)02832-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Direct stenting without antecedent dilatation may reduce procedural time, costs, and radiation exposure, and may result in less vessel injury. The purpose of this investigation was to compare immediate and long-term clinical and angiographic outcomes of direct stenting with stent placement after initial balloon dilation. Three hundred thirty-five symptomatic patients with single or multiple coronary lesions (diameter reduction 60% to 95%) of < or =30 mm length and with a vessel diameter of 2.5 to 4.0 mm were randomized either to direct stenting (group A, n = 171) or stenting after predilation (group B, n = 164). Patients with vessels with excessive calcification, severe proximal tortuosity, or occlusion were excluded. All patients were asked to return for routine repeat angiography at 6 months, irrespective of symptoms. Feasibility of direct stenting was 95% in group A, with 5% requiring crossover to predilation. Successful stent placement after predilation was performed in all 164 patients in group B. Direct stenting was associated with less procedural duration (group A 42.1 +/- 18.7 minutes vs group B 51.5 +/- 23.8 minutes, p = 0.004), radiation exposure time (group A 10.3 +/- 7.7 minutes vs group B 12.5 +/- 6.4 minutes, p = 0.002), amount of contrast dye used (group A 163 +/- 69 ml vs group B 197 +/- 84 ml, p <0.0001), and lower procedural costs (group A 845 +/- 167 vs group B 1,064 +/- 175, p <0.0001). Immediate angiographic results and in-hospital clinical outcomes (death, Q-wave myocardial infarction, repeat revascularization) were not significantly different between both strategies. However, at 6-month follow-up, direct stenting was associated with a lower angiographic restenosis (group A 20% vs group B 31%, p = 0.048) and target lesion revascularization rates (group A 18% vs group B 28%; p = 0.03). This study demonstrates the feasibility, safety, and outcomes of direct stenting in eligible coronary lesions. In appropriately selected cases, direct stenting has a lower rate of angiographic restenosis up to 6 months after the procedure, resulting in fewer coronary reinterventions compared with the conventional strategy of stenting with antecedent dilatation.
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Affiliation(s)
- Martin Brueck
- University of Erlangen-Nuernberg, Department of Cardiology, Erlangen, Germany.
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2836
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Lamfers ML, Aalders MC, Grimbergen JM, de Vries MR, Kockx MM, van Hinsbergh VW, Quax PH. Adenoviral delivery of a constitutively active retinoblastoma mutant inhibits neointima formation in a human explant model for vein graft disease. Vascul Pharmacol 2002; 39:293-301. [PMID: 14567067 DOI: 10.1016/s1537-1891(03)00043-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intimal hyperplasia resulting from vascular injury remains a major obstacle in the long-term success of coronary artery bypass grafts. Inhibition of smooth muscle cell (SMC) proliferation using adenoviral gene transfer of cell cycle inhibitors resulted in reduced neointima formation in various animal models. However, little is known about the effect on human SMCs and neointima formation. Here we report the effects of infection with an adenoviral vector encoding a constitutively active form of the retinoblastoma gene (Ad. delta Rb) on proliferation of human saphenous vein SMCs (HSVSMCs) and neointima formation in organ cultures of human saphenous vein. Proliferation of SMCs was inhibited dose-dependently after infection with Ad. delta Rb. A near-total inhibition was found at an Ad. delta Rb concentration of 10(8) pfu/ml. Organ cultures of human saphenous vein segments were used to evaluate the effect of Ad. delta Rb infection on neointima formation and vein graft disease. Segments cultured for 4 weeks develop a neointima that is morphologically highly similar to early initimal lesions found in pathological vein grafts in vivo. Infection of saphenous vein segments with 2 x 10(9) pfu/ml Ad. delta Rb resulted in a 59% reduction of neointimal area when compared to uninfected counterparts, whereas infection with control adenovirus, Ad.LacZ, had no significant effect. The results of this study show that Ad. delta Rb gene transfer might be an efficient approach to prevent neointima formation in human saphenous vein grafts.
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MESH Headings
- Adenoviridae/genetics
- Cell Division/physiology
- Cells, Cultured
- Coronary Artery Bypass
- Graft Occlusion, Vascular/genetics
- Graft Occlusion, Vascular/pathology
- Heterozygote
- Humans
- Hyperplasia/pathology
- Image Processing, Computer-Assisted
- Immunohistochemistry
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/physiology
- Mutation/genetics
- Organ Culture Techniques
- RNA, Messenger/biosynthesis
- RNA, Messenger/genetics
- Retinal Neoplasms/genetics
- Retinoblastoma/genetics
- Reverse Transcriptase Polymerase Chain Reaction
- Saphenous Vein/cytology
- Saphenous Vein/growth & development
- beta-Galactosidase/metabolism
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Affiliation(s)
- Martine L Lamfers
- Gaubius Laboratory, TNO-PG, P.O. Box 2215, 2301 CE Leiden, The Netherlands
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2837
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Abstract
PURPOSE OF REVIEW To provide an update on clinical trials of gene therapy for atherosclerotic cardiovascular disease published since 1 August 2001 and summarize the general advantages and potential problems of gene transfer in these disorders. RECENT FINDINGS There are two major areas in which gene therapy has entered clinical trials. The first is angiogenesis for coronary and peripheral arterial disease. Two relatively small placebo-controlled trials for coronary disease were reported, one using intramyocardial plasmid VEGF-2 gene, the other using intracoronary adenoviral FGF-4 gene. The VEGF-2 study in no-option patients showed reduced angina, and significant improvement in perfusion and function, whereas the FGF-4 study in less severely affected patients showed promising results in some subsets. In peripheral artery disease two phase 1 studies of adenoviral NV1FGF and VEGF showed some objective improvement in pain, ulcer size and ankle:brachial index in one study and endothelial function in the other. Both adenoviral and plasmid VEGF gene transfer at angioplasty increased vascularity in a phase 2 double-blind study. The other major area is the prevention of graft disease and restenosis using antisense oligodeoxynucleotides. E2F decoy led to a significant reduction in venous graft complications after ex-vivo transfection at the time of coronary bypass surgery, whereas the c-Myc oligodeoxynucleotide was ineffective in preventing in-stent coronary restenosis. SUMMARY There are more reviews of gene therapy for atherosclerosis in the literature than publications with original data or trials, but in the past year the imbalance is being redressed, with some promising results from controlled studies.
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Affiliation(s)
- Saul Benedict Freedman
- Department of Cardiology, University of Sydney, Concord Repatriation General Hospital, Australia.
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2838
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2839
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Rizik DG, Barman NC, Bouhasin A, Villegas BJ. T-stenting with drug-eluting stents for the treatment of bifurcation in-stent restenosis. J Interv Cardiol 2002; 15:519-20. [PMID: 12476657 DOI: 10.1111/j.1540-8183.2002.tb01098.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- David G Rizik
- Scottsdale Heart Group, 9755 North 90th St., Suite A100, Scottsdale, AZ 85258, USA.
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2840
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Derntl M, Syeda B, Beran G, Schukro C, Denk S, Glogar D. Prevention of stent thrombosis following brachytherapy and implantation of drug-eluting stents. J Interv Cardiol 2002; 15:477-83. [PMID: 12476651 DOI: 10.1111/j.1540-8183.2002.tb01092.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The implementation of coronary brachytherapy and especially the application of drug-eluting stents for the prevention of in-stent restenosis are of vital importance in the field of interventional cardiology. Despite undeniable benefits of these new methods a potential increased risk for the occurrence of stent thrombosis as a result of the mode of action of these new methods has to be taken into consideration. The prevention of stent thrombosis following coronary brachytherapy and implantation of drug-eluting stents is therefore of particular importance to assure the success of these forward-looking technologies. This article provides an overview of current data regarding the incidence of stent thrombosis following brachytherapy and implantation of drug-eluting stents and it's implication for clinical practice.
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Affiliation(s)
- Michael Derntl
- Department of Internal Medicine II/Division of Cardiology, University of Vienna, Vienna, Austria
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2841
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Affiliation(s)
- Mohan N Babapulle
- Division of Cardiology, Montreal General Hospital/McGill University, Montreal, Quebec, Canada
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2842
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Virmani R, Liistro F, Stankovic G, Di Mario C, Montorfano M, Farb A, Kolodgie FD, Colombo A. Mechanism of late in-stent restenosis after implantation of a paclitaxel derivate-eluting polymer stent system in humans. Circulation 2002; 106:2649-51. [PMID: 12438288 DOI: 10.1161/01.cir.0000041632.02514.14] [Citation(s) in RCA: 201] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We recently reported delayed angiographic restenosis in 15 patients who received 7-hexanoyltaxol (QP2)-eluting polymer stents (QuaDS) for the treatment of in-stent restenosis. This study presents the histological findings of atherectomy specimens from a subset of these patients receiving implants. METHODS AND RESULTS Between October and December 2001, 5 patients treated with QuaDS-QP2 stents underwent directional coronary atherectomy at 11.2+/-1.0 months for recurrent in-stent restenosis. Restenotic lesion composition was assessed with special stains, immunohistochemistry with quantitative image analysis, and, in one specimen, transmission electron microscopy. Atherectomy specimens contained fibrin interspersed in a smooth muscle cell-rich neointima with proteoglycan matrix. In 2 of 5 specimens, large aggregates of macrophages and T-lymphocytes were noted. These areas of active inflammation demonstrated a relatively high proliferation index by Ki-67 antibody staining, whereas the proliferation index in smooth muscle cell-rich restenotic areas was low. CONCLUSION Restenotic lesions from QuaDS-QP2-eluting stents at 12 months show persistent fibrin deposition with varying degrees of inflammation. These pathological changes, representing delayed healing, are usually observed up to only 3 months in human coronary arteries with stainless steel balloon-expandable stents. The nonreabsorbable polymer alone may have induced chronic inflammation.
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Affiliation(s)
- Renu Virmani
- Catheterization Laboratories, Ospedale San Raffaele and Emo Centro Cuore Columbus, Milan, Italy.
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2843
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Mauri L, Bonan R, Weiner BH, Legrand V, Bassand JP, Popma JJ, Niemyski P, Prpic R, Ho KKL, Chauhan MS, Cutlip DE, Bertrand OF, Kuntz RE. Cutting balloon angioplasty for the prevention of restenosis: results of the Cutting Balloon Global Randomized Trial. Am J Cardiol 2002; 90:1079-83. [PMID: 12423707 DOI: 10.1016/s0002-9149(02)02773-x] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The cutting balloon (CB) is a specialized device designed to create discrete longitudinal incisions in the atherosclerotic target coronary segment during balloon inflation. Such controlled dilatation theoretically reduces the force needed to dilate an obstructive lesion compared with standard percutaneous transluminal coronary angioplasty (PTCA). We report a multicenter, randomized trial comparing the incidence of restenosis after CB angioplasty versus conventional balloon angioplasty in 1,238 patients. Six hundred seventeen patients were randomized to CB treatment, and 621 to PTCA. The mean reference vessel diameter was 2.86 +/- 0.49 mm, mean lesion length 8.9 +/- 4.3 mm, and prevalence of diabetes mellitus in patients was 13%. The primary end point, the 6-month binary angiographic restenosis rate, was 31.4% for CB and 30.4% for PTCA (p = 0.75). Acute procedural success, defined as the attainment of <50% diameter stenosis without in-hospital major adverse cardiac events, was 92.9% for CB and 94.7% for PTCA (p = 0.24). Freedom from target vessel revascularization was slightly higher in the CB arm (88.5% vs 84.6%, log-rank p = 0.04). Five coronary perforations occurred in the CB arm only (0.8% vs 0%, p = 0.03). At 270 days, rates of myocardial infarction, death, and total major adverse cardiac events for CB and PTCA were 4.7% versus 2.4% (p = 0.03), 1.3% versus 0.3% (p = 0.06), and 13.6% versus 15.1% (p = 0.34), respectively. In summary, the proposed mechanism of controlled dilatation did not reduce the rate of angiographic restenosis for the CB compared with conventional balloon angioplasty. CB angioplasty should be reserved for difficult lesions in which controlled dilatation is believed to provide a better acute result compared with balloon angioplasty alone.
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Affiliation(s)
- Laura Mauri
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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2844
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Freedman SB. Global cardiology comes to Australia: 14th World Congress of Cardiology, Sydney, 5-9 May 2002. Med J Aust 2002; 177:473-5. [PMID: 12405887 DOI: 10.5694/j.1326-5377.2002.tb04913.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2002] [Accepted: 09/09/2002] [Indexed: 11/17/2022]
Affiliation(s)
- Saul B Freedman
- Department of Cardiology, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2139, Australia.
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2845
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Dzau VJ, Braun-Dullaeus RC, Sedding DG. Vascular proliferation and atherosclerosis: new perspectives and therapeutic strategies. Nat Med 2002; 8:1249-56. [PMID: 12411952 DOI: 10.1038/nm1102-1249] [Citation(s) in RCA: 636] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Victor J Dzau
- Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA.
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2846
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Alonso JJ, Durán JM, Gimeno F, Ramos B, Serrador A, Fernández-Avilés F. [Coronary angioplasty in diabetic patients. Current and future perspectives]. Rev Esp Cardiol 2002; 55:1185-200. [PMID: 12423576 DOI: 10.1016/s0300-8932(02)76782-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
It has been estimated that 15-25% of patients who undergo percutaneous or surgical coronary angioplasty are diabetics. The indications for coronary revascularization and initial results of the procedure do not differ substantially between patients with diabetes mellitus and non-diabetics. However, the long-term results of both percutaneous and surgical coronary angioplasty are less favorable in diabetics in terms of mortality and the need for new revascularization procedures. The development and widespread use of stents and glycoprotein IIb/IIIa receptor inhibiting drugs have improved the clinical evolution of diabetics treated with angioplasty. Currently available data show that the administration of glycoprotein IIb/IIIa inhibitors to patients undergoing coronary angioplasty is especially useful in diabetics and improves short-term and long-term results, decreasing one-year mortality by 45%. There seem to be indications for the routine use of glycoprotein IIb/IIIa inhibitors in diabetics treated with angioplasty. While the use of stents has improved long-term and short-term results in diabetics, the success rates of angioplasty in diabetics are still lower than in non-diabetics. Diabetes is still an independent predictor of restenosis and long-term events after stenting interventions. Analysis of the studies comparing percutaneous and surgical revascularization in diabetic patients with multivessel disease shows that surgery is superior in terms of long-term mortality and need for new revascularization procedures. Stenting has improved, but not substantially, the results of multivessel angioplasty in diabetics. Therefore, the indications for angioplasty in multivessel diabetics should be evaluated individually. Factors that contribute to the less favorable post-angioplasty evolution of diabetic patients are more rapid progression of atherosclerosis and, especially, a higher rate of restenosis. New angioplasty techniques, such as brachytherapy and drug-eluting stents, are likely to significantly improve the results of percutaneous interventions in diabetics, thus allowing the indications for angioplasty in diabetics to be extended even further in the near future.
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Affiliation(s)
- Joaquín J Alonso
- Instituto de Ciencias del Corazón (ICICOR). Hospital Universitario de Valladolid. Valladolid. España.
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2847
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Abstract
The pathophysiology of restenosis involves early elements of direct injury to smooth muscle cells, deendothelialization, and thrombus deposition. Over time, this leads to smooth muscle cell proliferation/migration and extracellular matrix deposition. There is an increasing body of evidence to suggest that inflammation plays a pivotal role linking early vascular injury to the eventual consequence of neointimal growth and lumen compromise. The widespread use of coronary stents has fundamentally altered the vascular response to injury by causing a more intense and prolonged inflammatory state. Many of the cellular and molecular elements responsible for leukocyte recruitment have been elucidated, providing potential therapeutic targets for restenosis. This review seeks to provide an integrated view of the pathophysiology of restenosis that explains the central role of inflammation.
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Affiliation(s)
- Frederick G P Welt
- Department of Medicine, Cardiac Catheterization Laboratory and Coronary Care Unit, Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA.
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2848
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Tanabe K, Serruys PW, Degertekin M, Regar E, van Domburg RT, Sousa JE, Wülfert E, Morice MC. Fate of side branches after coronary arterial sirolimus-eluting stent implantation. Am J Cardiol 2002; 90:937-41. [PMID: 12398958 DOI: 10.1016/s0002-9149(02)02657-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The sirolimus-eluting stent (SES) is emerging as a potential solution for the prevention of restenosis. Although the outcome of side branches after stenting with an uncoated metal stent (UMS) has been reported, the fate of side branches after SES implantation is unknown. Furthermore, the absence of spontaneous recanalization of occluded side branches following intracoronary brachytherapy has been previously described and has been related to a delayed healing process. We assessed the procedural and 6-month follow-up angiograms of 238 patients enrolled in the RAVEL study, a double-blind controlled trial of the SES versus the UMS. Any side branch seen on the preprocedure angiogram and subsequently covered by the stent was evaluated. The side branch Thrombolysis In Myocardial Infarction (TIMI) flow grade was assessed at baseline and at follow-up by 2 observers. One hundred twenty-eight patients with > or =1 side branches were identified (63 patients in the SES group with 118 side branches, 65 patients in the UMS group with 124 side branches). Side branch occlusion occurred after stenting in 12 branches (10%) in the SES group and in 9 branches (7%) in the UMS group (p = NS). Of these occluded branches, spontaneous recanalization was observed in 11 branches (92%) in the SES group and in 6 branches (67%) in the UMS group at follow-up angiography (p = NS). Thus, the fate of side branches after SES implantation is favorable and at least as good as after UMS implantation.
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2849
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Abstract
There has been an increasing focus on renovascular disease, particularly in renal failure, and on the role of renal angioplasty and stenting. Significant improvements have occurred in non-invasive imaging techniques. This review concentrates on the recent developments in imaging that specifically targets the renal artery and renal artery stenosis. It also discusses how these techniques may facilitate better selection of cases that will respond to intervention.
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Affiliation(s)
- John F Reidy
- Radiology Department, Guy's Hospital, London, UK.
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2850
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Topol EJ. Economics and quality of care for patients with acute coronary syndromes: the impending crisis. Clin Cardiol 2002; 25:I9-15. [PMID: 12428814 PMCID: PMC6653940 DOI: 10.1002/clc.4960251304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Several factors are placing significant financial burdens on the health care system today. These include the growing older population, the obesity and type II diabetes epidemics, and the attendant increased prevalence of heart disease, which remains the leading cause of death in the United States. In response, cardiovascular medicine is undergoing sweeping change in the use of advanced technology and interventions. In addition, biomarkers, such as troponin, are emerging as critical predictors of responses to therapy, particularly for coronary stenting. Future trends in the treatment of acute coronary syndromes (ACS) will embrace the use of genomic solutions, such as gene expression profiling, to predict therapeutic outcomes. Careful consideration will need to be given to these innovative approaches to ensure they are cost effective.
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Affiliation(s)
- Eric J Topol
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Ohio 44195-0001, USA.
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