New devices enhance hospital results of coronary angioplasty

Coronary angiography through the radial or the femoral approach: The CARAFE study

In a previous study, the radial approach for coronary angiography was shown to be associated with a lower success rate and longer procedural and X-ray times compared to the femoral approach. However, this approach is associated with a steep learning curve. A series of 210 consecutive nonselected patients were randomized to femoral versus right radial approach or femoral versus left radial approach by two experienced operators. Clinical characteristics were similar in the three groups. Technical failure occurred in one patient in the right radial group with subsequent crossover to left radial artery. The number of coronary catheters used was lower in the right radial group (1.4 +/- 0.7 vs. 2.1 +/- 0.4 for the two other groups). The procedural duration was longer with left radial (14.2 +/- 3.3 min; P < 0.05) approach than with right radial (12.4 +/- 5.8 min) and femoral (11.2 +/- 3.3 min) without significant differences between femoral and right radial. X-ray exposure was shorter in the femoral group (3.1 +/- 1.7 min) than in both radial groups (right: 3.8 +/- 2.2 min; left: 4.2 +/- 1.7 min). The angiographic quality was not different between the three groups for RCA, but was less good for LCA through right radial approach. Bed rest and hospital stay were shorter in the two radial groups. The comfort was judged better with the transradial approach. An ad hoc PTCA was performed in 45.7% of femoral patients, 41.4% of right radial, and 44.3% of left radial with immediate sheath withdrawal (closure device for femoral group). There were no severe complications in the three groups, but two patients from the femoral group were discharged later because of vascular complications. The total cost of coronary angiography was higher in the femoral group. In conclusion, after the learning period, transradial coronary angiography can be performed with a high success rate, low rate of complication, and good angiographic quality. It is associated with a slight increase in procedural (LR) and fluoroscopy times, but permits earlier ambulation and discharge, improves patient comfort, and reduces the cost.

Neuroprotective "agents" in surgery. Secret "agent" man, or common "agent" machine?

The search for clinically-effective neuroprotective agents has received enormous support in recent years--an estimated $200 million by pharmaceutical companies on clinical trials for traumatic brain injury alone. At the same time, the pathophysiology of brain injury has proved increasingly complex, rendering the likelihood of a single agent "magic bullet" even more remote. On the other hand, great progress continues with technology that makes surgery less invasive and less risky. One example is the application of endovascular techniques to treat coronary artery stenosis, where both the invasiveness of sternotomy and the significant neurological complication rate (due to microemboli showering the cerebral vasculature) can be eliminated. In this paper we review aspects of intraoperative neuroprotection both present and future. Explanations for the slow progress on pharmacologic neuroprotection during surgery are presented. Examples of technical advances that have had great impact on neuroprotection during surgery are given both from coronary artery stenosis surgery and from surgery for Parkinson's disease. To date, the progress in neuroprotection resulting from such technical advances is an order of magnitude greater than that resulting from pharmacologic agents used during surgery. The progress over the last 20 years in guidance during surgery (CT and MRI image-guidance) and in surgical access (endoscopic and endovascular techniques) will soon be complemented by advances in our ability to evaluate biological tissue intraoperatively in real-time. As an example of such technology, the NASA Smart Probe project is considered. In the long run (i.e., in 10 years or more), pharmacologic "agents" aimed at the complex pathophysiology of nervous system injury in man will be the key to true intraoperative neuroprotection. In the near term, however, it is more likely that mundane "agents" based on computers, microsensors, and microeffectors will be the major impetus to improved intraoperative neuroprotection.

Frequency of major adverse cardiac events within one month of coronary angioplasty: a useful measure of operator performance

OBJECTIVES

To test one-month outcomes in a single center for their statistical power to corroborate conclusions derived from large multicenter databases.

BACKGROUND

Only with large, multicenter databases has it been possible to demonstrate more frequent occurrences of complications in patients treated by "low-volume operators." Critics feel that such analyses mask excellent performance by many "low-volume operators."

METHODS

In a high-volume cardiac catheterization laboratory in a large, nonuniversity teaching hospital, baseline clinical and angiographic characteristics were collected for a consecutive series of 1,029 patients treated by 37 percutaneous transluminal coronary intervention (PTCI) operators over a four-month period. One-month follow-up was obtained in 967 (94%) patients who form the basis for this analysis.

RESULTS

Only the group of operators performing <50 cases annually had a major adverse cardiac event (MACE) (death, myocardial infarction or symptom-driven revascularization) rate at one month significantly greater than predicted from baseline characteristics. (Observed rate: 15.1%, expected: 9.7%, 95% confidence interval [CI]: 4.7%, 14.6%.) The difference was driven by the significantly more frequent rate at which repeat revascularization was performed in patients treated by that group of operators (observed: 13.8%, expected: 7.1%, 95% CI: 2.8%, 11.4%).

CONCLUSIONS

As is true of analyses of large multicenter databases, lower volume operators as a group have less good outcomes than those performing more. The greater statistical power provided by one-month MACE rate offers advantages over the use of in-hospital complications for the analysis of operator performance.

Prognostic value of the modified american college of Cardiology/American heart association stenosis morphology classification for long-term angiographic and clinical outcome after coronary stent placement

Background-The modified American College of Cardiology/American Heart Association (ACC/AHA) lesion morphology criteria are predictive of early outcome after various coronary catheter interventions. Their potential prognostic value after stent implantation and, in particular, for restenosis and long-term clinical outcome has not been studied. We assessed the prognostic value of the modified ACC/AHA criteria for the long-term angiographic and clinical outcome of patients after coronary stenting. Methods and Results-This study includes 2944 consecutive patients with symptomatic coronary artery disease treated with coronary stent placement. Modified ACC/AHA lesion morphology criteria were used to qualitatively assess the angiograms; type A and B1 lesions were categorized as simple, and type B2 and C lesions were designated complex. Primary end points were angiographic restenosis and 1-year event-free survival. Restenosis rate was 33.2% in complex lesions and 24.9% in simple lesions (P<0.001). It was 21. 7% for type A, 26.3% for type B1, 33.7% for type B2, and 32.6% for type C lesions. One-year event-free survival was 75.6% for patients with complex lesions and 81.1% for patients with simple lesions (P<0. 001). It was 85.2% for patients with type A, 79.4% for type B1, 75. 9% for type B2, and 75.2% type C lesions. The higher risk for restenosis and an adverse outcome associated with complex lesions was also maintained after multivariate adjustment for other clinical and angiographic characteristics. Conclusions-The modified ACC/AHA lesion morphology scheme has significant prognostic value for the outcome of patients after coronary stent placement. Lesion morphology is able to influence the restenosis process and thus the entire 1-year clinical course of these patients.

Procedural results of coronary angioplasty but not late mortality have improved in patients with depressed left ventricular function

BACKGROUND

Published experience with coronary angioplasty in patients with severely depressed left ventricular (LV) ejection fraction indicates that procedural complications are more frequent in such patients than in those with normal or near normal LV function. Although the immediate outcomes of transcatheter revascularization in unselected populations have improved substantially since the procedures upon which these reports were based were performed, outcomes with this subset of patients has not been recently reviewed.

HYPOTHESIS

This study was undertaken to document the results of the application of current transcatheter technology to this patient subset.

METHODS

We analyzed data from 194 consecutive patients with a visually estimated LV ejection fraction < 30%, who underwent coronary angioplasty in this institution between January 1, 1995, and April 30, 1996, and compared their outcomes with those of 1,390 patients with normal LV function treated concurrently.

RESULTS

Angiographic success in the two groups was similar. The hospital mortality of the patients with low ejection fraction was higher (2.6 vs. 0.6%, p = 0.02) than in concurrently treated patients with normal LV function. Other procedural complications were no more frequent than in such patients. Late mortality in patients with low ejection fraction was 16%, a similar value to that in older reports.

CONCLUSION

Compared with older reports, current hospital outcomes of coronary angioplasty are improved in patients with severely depressed LV function. Unfortunately, late outcomes are not demonstrably better.