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Batyraliev TA, Pershukov IV, Niyazova-Karben ZA, Karaus A, Calenici O, Guler N, Eryonucu B, Temamogullari A, Ozgul S, Akgul F, Sengul H, Dogru O, Demirbas O, Timoshin IS, Gaigukov AV, Petrakova LN, Peresypko MK, Sidorenko BA. Current Role of Laser Angioplasty of Restenotic Coronary Stents. Angiology 2016; 57:21-32. [PMID: 16444453 DOI: 10.1177/000331970605700104] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Treatment of in-stent restenosis (ISR) with conventional percutaneous transluminal coronary angioplasty (PTCA) causes significant recurrent neointimal tissue growth in 30-85%. Therefore, laser ablation of intrastent neointimal hyperplasia before balloon dilation can be an attractive alternative. However, the long-term outcomes of such treatment have not been studied thoroughly enough. This prospective case-control study evaluated angiographic and clinical outcomes of PTCA alone and a combination of excimer laser coronary angioplasty (ELCA) and adjunct PTCA in 125 patients with ISR. ELCA was performed before balloon dilation in 67 patients, PTCA alone was performed in 58 patients. Basic demographic and clinical data were comparable in both groups. Lesions included in ELCA group were longer (17.1 ±9.9 vs 13.6 ±9.1 mm; p=0.034), more complex (36.5% type C stenoses vs 14.3%; p=0.006), and more frequently had reduced distal blood flow (TIMI <3: 18.9% vs 4.8%; p=0.025) compared to lesions in the PTCA group. Immediate angiographic results of PTCA and ELCA + PTCA appeared to be comparable. PTCA alone was successful in 57 patients (98.3%), ELCA + PTCA, in 66 patients (98.5%). The rates of hospital complications were comparable (3.0% in ELCA group vs 8.6% in PTCA group). The 1-year follow-up showed that the rates of major adverse cardiac events (MACE) were comparable in the 2 groups (37.3% in ELCA group vs 46.6% in PTCA group). The rates of target vessel revascularization (TVR) within 1 year after the intervention were also similar in the 2 groups (32.8% vs 34.5%). The data mean that ELCA in patients with complex ISR is efficient and safe. Despite a higher complexity of lesions in the ELCA group, no increase in the rate of complications was registered.
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Mukhopadhyay S, Vyas A, Yusuf J. Accidental retrieval of a fully deployed stent: A case report. Catheter Cardiovasc Interv 2015; 86:E153-7. [PMID: 25729007 DOI: 10.1002/ccd.25906] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 02/26/2015] [Indexed: 11/08/2022]
Abstract
We describe a case of accidental retrieval of a fully deployed stent in ostial left anterior descending (LAD) artery. This occurred while attempting stent delivery in obtuse marginal (OM) artery due to entrapment of a wire which inadvertently had passed through the struts of ostial LAD stent. The proposed mechanism and recommendations to avoid this rare complication are discussed.
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Affiliation(s)
- Saibal Mukhopadhyay
- Professor, Department of Cardiology, Govind Ballabh Pant Hospital, Maulana Azad Medical College, New Delhi, India
| | - Aniruddha Vyas
- Senior Resident, Department of Cardiology, Govind Ballabh Pant Hospital, Maulana Azad Medical College, New Delhi, India
| | - Jamal Yusuf
- Professor, Department of Cardiology, Govind Ballabh Pant Hospital, Maulana Azad Medical College, New Delhi, India
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Cheema JK, Shroff AR, Vidovich MI. Unintentional extraction of an endothelialized bare metal stent. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2013; 14:187-90. [DOI: 10.1016/j.carrev.2012.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Revised: 12/13/2012] [Accepted: 12/17/2012] [Indexed: 10/27/2022]
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4
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Kim JW, Kim W. Unintentional extraction of a coronary stent deployed two months prior during a dislodged left main stent retrieval. Int J Cardiol 2012; 156:e45-8. [DOI: 10.1016/j.ijcard.2011.08.841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Accepted: 08/26/2011] [Indexed: 10/17/2022]
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5
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Pershukov IV, Vural A, Batyraliev TA, Niyazova-Karben ZA, Karaus A, Calenici O, Petrakova LN, Peresypko MK, Preobrazhenskii DV, Sidorenko BA. Clinical and Angiographic Results of Percutaneous Excimer Laser Versus Balloon Angioplasty for Coronary Intra-Stent Restenosis. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2004. [DOI: 10.29333/ejgm/82232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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6
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Airoldi F, Di Mario C, Stankovic G, Briguori C, Bramucci E, Reimers B, Ardissino D, Aurier E, Tavano D, Colombo A. Effectiveness of treatment of in-stent restenosis with an 8-French compatible atherectomy catheter. Am J Cardiol 2003; 92:725-8. [PMID: 12972119 DOI: 10.1016/s0002-9149(03)00839-7] [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: 11/16/2022]
Abstract
The study reports the results of directional atherectomy with an 8Fr guiding catheter-compatible atherectomy catheter in a series of 31 in-stent restenotic lesions. This preliminary experience indicates a favorable safety profile, with events limited to non-Q-wave myocardial infarction occurring in 3.6% of patients. The secondary end point regarding the incidence of angiographic restenosis at 6 months showed a high restenosis rate (65%).
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Affiliation(s)
- Flavio Airoldi
- EMO Centro Cuore, Columbus Clinic, Via Buonarroti 48-20145 Milan, Italy.
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7
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Abstract
Stent restenosis, especially the diffuse pattern, has developed into a significant clinical and economical problem. It has been estimated that up to 250,000 patients developed in-stent restenosis in 2,000 alone, two thirds of them can be expected to have diffuse in-stent restenosis, which is difficult to treat because of high recurrence rates. None of the conventionally available interventional treatment modalities provides optimal long-term results. Intravascular radiation therapy is currently the only effective percutaneous therapy for combating in-stent restenosis. Late thrombotic complications have largely been eliminated by extended antiplatelet regimens. Geographical miss, a major reason for recurrence of in-stent restenosis after brachytherapy, can be reduced by an improved radiation technique. The first preliminary data on drug-eluting stents, showing only minimal neointimal proliferation at 6-month postimplantation, could represent a major breakthrough in the quest to solve restenosis.
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Affiliation(s)
- H Störger
- Red Cross Hospital Cardiology Center, Pfingstweidstr. 11, 60316 Frankfurt, Germany.
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8
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Harb TS, Ling FS. Inadvertent stent extraction six months after implantation by an entrapped cutting balloon. Catheter Cardiovasc Interv 2001; 53:415-9. [PMID: 11458426 DOI: 10.1002/ccd.1193] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We report a case of extraction of a restenosed aorto-ostial stent by an entrapped cutting balloon that had inadvertently been passed through a protruding stent cell. Cathet Cardiovasc Intervent 2001;53:415-419.
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Affiliation(s)
- T S Harb
- Cardiology Unit, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642-8679, USA
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9
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Islam MA, Blankenship JC, Iliadis EA. Effectiveness of transluminal extraction atherectomy for debulking saphenous vein graft in-stent restenosis. Am J Cardiol 2001; 87:785-8, A8. [PMID: 11249906 DOI: 10.1016/s0002-9149(00)01506-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Treatment of in-stent restenosis in saphenous vein grafts often requires initial debulking, but transluminal extraction catheter (TEC) atherectomy is seldom used for this purpose, and most discussions omit this option. Our experience with 6 episodes of TEC used successfully for saphenous vein graft in-stent restenosis and review of 7 other reported cases suggests TEC may be safe and effective for debulking saphenous vein graft restenosis lesions.
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Affiliation(s)
- M A Islam
- Department of Cardiology, Geisinger Medical Center, Danville, Pennsylvania 17822, USA
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10
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Grantham JA, Tiede DJ, Holmes DR. Technical considerations when intervening with coronary device catheters in the vicinity of previously deployed stents. Catheter Cardiovasc Interv 2001; 52:214-7. [PMID: 11170332 DOI: 10.1002/1522-726x(200102)52:2<214::aid-ccd1051>3.0.co;2-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
As stent use increases, interventional cardiologists are increasingly faced with patients that require procedures in the vicinity of previously deployed stents. We present two cases of side-branch interventions in the vicinity of previously deployed stents where devices were trapped by the stent. In each case, traction on the device resulted in stent dislodgment. The stents were successfully extracted and replaced without complications.
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Affiliation(s)
- J A Grantham
- Cardiovascular Consultants, P.C., Mid-America Heart Institute, Kansas City, Missouri, USA
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11
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Giri S, Ito S, Lansky AJ, Mehran R, Margolis J, Gilmore P, Garratt KN, Cummins F, Moses J, Rentrop P, Oesterle S, Power J, Kent KM, Satler LF, Pichard AD, Wu H, Greenberg A, Bucher TA, Kerker W, Abizaid AS, Saucedo J, Leon MB, Popma JJ. Clinical and angiographic outcome in the laser angioplasty for restenotic stents (LARS) multicenter registry. Catheter Cardiovasc Interv 2001; 52:24-34. [PMID: 11146517 DOI: 10.1002/1522-726x(200101)52:1<24::aid-ccd1007>3.0.co;2-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In-stent restenosis (ISR), when treated with balloon angioplasty (PTCA) alone, has an angiographic recurrence rate of 30%-85%. Ablating the hypertrophic neointimal tissue prior to PTCA is an attractive alternative, yet the late outcomes of such treatment have not been fully determined. This multicenter case control study assessed the angiographic and clinical outcomes of 157 consecutive procedures in 146 patients with ISR at nine institutions treated with either PTCA alone (n = 64) or excimer laser assisted coronary angioplasty (ELCA, n = 93)) for ISR. Demographics were similar except more unstable angina at presentation in ELCA-treated patients (74.5% vs. 63.5%; P = 0.141). Lesions selected for ELCA were longer (16.8 +/- 11.2 mm vs. 11.2 +/- 8.6 mm; P < 0.001), more complex (ACC/AHA type C: 35.1% vs. 13.6%; P < 0.001), and with compromised antegrade flow (TIMI flow < 3: 18.9% vs. 4.5%; P = 0.008) compared to PTCA-treated patients. ELCA-treated patients had similar rate of procedural success [93 (98.9% vs. 62 (98.4%); P = 1.0] and major clinical complications [1 (1.1%) vs. 1 (1.6%); P = 1.0]. At 30 days, repeat target site coronary intervention was lower in ELCA-treated patients (1.1% vs. 6.4% in PTCA-treated patients; P = 0.158), but not significantly so. At 1 year, ELCA-treated patients had similar rate of major cardiac events (39.1% vs. 45.2%; P = 0.456) and target lesion revascularization (30.0% vs. 32.3%; P = 0.646). These data suggest that ELCA in patients with complex in-stent restenosis is as safe and effective as balloon angioplasty alone. Despite higher lesion complexity in ELCA-treated patients, no increase in event rates was observed. Future studies should evaluate the relative benefit of ELCA over PTCA alone for the prevention of symptom recurrence specifically in patients with complex in-stent restenosis.
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Affiliation(s)
- S Giri
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts 02215, USA
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12
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Tversky J, Yamamoto H, Brinker JA. The pump, grind, and heat of in-stent restenosis. Catheter Cardiovasc Interv 2000; 51:414-6. [PMID: 11108671 DOI: 10.1002/1522-726x(200012)51:4<414::aid-ccd8>3.0.co;2-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Köster R, Kähler J, Terres W, Reimers J, Baldus S, Hartig D, Berger J, Meinertz T, Hamm CW. Six-month clinical and angiographic outcome after successful excimer laser angioplasty for in-stent restenosis. J Am Coll Cardiol 2000; 36:69-74. [PMID: 10898415 DOI: 10.1016/s0735-1097(00)00704-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study evaluated the clinical and angiographic six-month follow-up after excimer laser coronary angioplasty (ELCA) for restenosed coronary stents. BACKGROUND Excimer laser coronary angioplasty has recently been shown to be safe and efficient for the treatment of in-stent restenosis. METHODS Ninety-six consecutive patients successfully treated with ELCA within 141 stents were included in a six-month clinical and angiographic follow-up. RESULTS During follow-up there was one sudden death and one patient with documented myocardial infarction. Angina pectoris classified as > or = Canadian Cardiovascular Society II reoccurred in 49 patients. Follow-up angiography was obtained in 89 patients (93%) with 133 stents. Quantitative coronary angiography revealed a mean diameter stenosis of 77 +/- 10% before intervention, 41 +/- 12% after laser treatment and 11% +/- 12% after adjunctive percutaneous transluminal coronary angioplasty (p < 0.001). Six months after ELCA the mean diameter stenosis had increased to 60 +/- 26% (p < 0.001). A > or =50% diameter stenosis was present in 48 patients (54%); in 24 of these patients diameter stenosis was > or =70%. Total occlusions occurred in an additional 10 patients (11%). There was a trend toward an increased recurrent restenosis rate in patients with diabetes mellitus and long lesions or total occlusions (p = 0.059). Forty-eight patients (50%) received medical treatment after six months. Reinterventions were necessary in 30 patients (31%), and coronary artery bypass surgery was performed in 17 patients (18%). Event-free survival was 50%. CONCLUSIONS Excimer laser angioplasty for in-stent restenosis was associated with a high incidence of recurrent restenosis in this group of patients, suggesting that this technique is unlikely to reduce recurrent in-stent restenosis and that other approaches are necessary.
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Affiliation(s)
- R Köster
- University Hospital Eppendorf, Medical Clinic, Department of Cardiology, Hamburg, Germany
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14
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HABERBOSCH WERNER, WAAS WOLFGANG, WALDECKER BERND, HEIZMANN HEINRICH, HÖLSCHERMANN HANS, RAU MATTHIAS, TILLMANNS HARALD. Directional Coronary Atherectomy of In-stent Restenosis: A Two-Center Experience. J Interv Cardiol 2000. [DOI: 10.1111/j.1540-8183.2000.tb00271.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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15
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Radke PW, Klues HG, Haager PK, Hoffmann R, Kastrau F, Reffelmann T, Janssens U, vom Dahl J, Hanrath P. Mechanisms of acute lumen gain and recurrent restenosis after rotational atherectomy of diffuse in-stent restenosis: a quantitative angiographic and intravascular ultrasound study. J Am Coll Cardiol 1999; 34:33-9. [PMID: 10399989 DOI: 10.1016/s0735-1097(99)00151-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This quantitative angiographic and intravascular ultrasound study determined the mechanisms of acute lumen enlargement and recurrent restenosis after rotational atherectomy (RA) with adjunct percutaneous transluminal coronary angioplasty in the treatment of diffuse in-stent restenosis (ISR). BACKGROUND In-stent restenosis remains a significant clinical problem for which optimal treatment is under debate. Rotational atherectomy has become an alternative therapeutic approach for the treatment of diffuse ISR based on the concept of "tissue-debulking." METHODS Rotational atherectomy with adjunct angioplasty of ISR was used in 45 patients with diffuse lesions. Quantitative coronary angiographic (QCA) analysis and sequential intravascular ultrasound (IVUS) measurements were performed in all patients. Forty patients (89%) underwent angiographic six-month follow-up. RESULTS Rotational atherectomy lead to a decrease in maximal area of stenosis from 80+/-32% before intervention to 54+/-21% after RA (p < 0.0001) as a result of a significant decrease in intimal hyperplasia cross-sectional area (CSA). The minimal lumen diameter after RA remained 15+/-4% smaller than the burr diameter used, indicating acute neointimal recoil. Additional angioplasty led to a further decrease in area of stenosis to 38+/-12% due to a significant increase in stent CSA. At six-month angiographic follow-up, recurrent restenosis rate was 45%. Lesion and stent length, preinterventional diameter stenosis and amount of acute neointimal recoil were associated with a higher rate of recurrent restenosis. CONCLUSIONS Rotational atherectomy of ISR leads to acute lumen gain by effective plaque removal. Adjunct angioplasty results in additional lumen gain by further stent expansion and tissue extrusion. Stent and lesion length, severity of ISR and acute neointimal recoil are predictors of recurrent restenosis.
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Affiliation(s)
- P W Radke
- Medical Clinic I, RWTH University Hospital, Aachen, Germany.
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16
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Sakamoto T, Kawarabayashi T, Taguchi H, Tanaka A, Nishida Y, Shimada K, Yoshikawa J. Intravascular ultrasound-guided balloon angioplasty for treatment of in-stent restenosis. Catheter Cardiovasc Interv 1999; 47:298-303. [PMID: 10402282 DOI: 10.1002/(sici)1522-726x(199907)47:3<298::aid-ccd9>3.0.co;2-8] [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: 11/12/2022]
Abstract
We investigated the usefulness of intravascular ultrasound (IVUS)-guided balloon angioplasty for in-stent restenosis in 37 lesions of 34 consecutive patients. We divided these patients into two groups: a group in which the balloon size was determined by quantitative coronary angiography (QCA group; 17 patients, 19 lesions) and a group in which the balloon size was determined by IVUS (IVUS group; 17 patients, 18 lesions). We compared short-term and 6-month outcomes for these groups. In the IVUS group, we used a balloon of a size equal to 95% of the media-to-media diameter at the distal to the stent, as determined by IVUS. No significant differences were observed in patient or lesion characteristics between the two groups. The clinical success rate was 100% in both groups, and no clinical events were observed in either of the groups. The balloon/artery ratio was larger in the IVUS group than in the QCA group (1.33 +/- 0.35 vs. 1.16 +/- 0.13, P < 0.05), and the recurrent restenosis rate was lower (17% vs. 53%, P < 0.05). These results suggest that repeat balloon angioplasty using a balloon size determined by IVUS is useful for in-stent restenosis. Cathet. Cardiovasc. Intervent. 47:298-303, 1999.
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Affiliation(s)
- T Sakamoto
- Department of Cardiology, Baba Memorial Hospital, Sakai, Japan
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17
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Radke PW, vom Dahl J, Klues HG. [Stent restenosis: therapy concepts and possibilities for prevention]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1999; 94:88-92. [PMID: 10194953 DOI: 10.1007/bf03044706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND In-stent restenosis has become a significant problem for interventional cardiologists. Due to different pathogenic causes it remains unclear whether a uniform therapeutic regimen is appropriate. TREATMENT Redilatation has predominantly been used for the treatment of instent restenosis, however, in long and diffuse restenotic stents, long-term results are reported to be poor. Therefore, tissue-debulking techniques may have beneficial effects in complex cases of in-stent restenosis. The therapeutic benefit of intracoronary radiation, local drug delivery or gene transfer has not been evaluated so far. PREVENTION Therefore, prevention of the iatrogenic entity in-stent restenosis has become more important.
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Affiliation(s)
- P W Radke
- Medizinische Klinik I, Universitätsklinikum der RWTH Aachen.
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Mahdi NA, Pathan AZ, Harrell L, Leon MN, Lopez J, Butte A, Ferrell M, Gold HK, Palacios IF. Directional coronary atherectomy for the treatment of Palmaz-Schatz in-stent restenosis. Am J Cardiol 1998; 82:1345-51. [PMID: 9856917 DOI: 10.1016/s0002-9149(98)00639-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Management of in-stent restenosis has become a significant challenge in interventional cardiology. The results of balloon angioplasty have been disappointing due to the high recurrence of restenosis at follow-up. Debulking of the restenotic tissue within the stents using directional coronary atherectomy (DCA) may offer a therapeutic advantage. We report the immediate clinical and angiographic outcomes and long-term clinical follow-up results of 45 patients (46 lesions), mean age 63+/-12 years, 73% men, with a mean reference diameter of 2.9+/-0.6 mm, treated with DCA for symptomatic Palmaz-Schatz in-stent restenosis. DCA was performed successfully in all 46 lesions and resulted in a postprocedural minimal luminal diameter of 2.7+/-0.7 mm and a residual diameter stenosis of 17+/-10%. There were no in-hospital deaths, Q-wave myocardial infarctions, or emergency coronary artery bypass surgeries. Four patients (9%) suffered a non-Q-wave myocardial infarction. Target lesion revascularization was 28.3% at a mean follow-up of 10+/-4.6 months. Kaplan-Meier event-free survival (freedom from death, myocardial infarction, and repeat target lesion revascularization) was 71.2% and 64.7% at 6 and 12 months after DCA, respectively. Thus, DCA is safe and efficacious for the treatment of Palmaz-Schatz in-stent restenosis. It results in a large postprocedural minimal luminal diameter and a low rate of both target lesion revascularization and combined major clinical events at follow-up.
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Affiliation(s)
- N A Mahdi
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
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McKenna CJ, Wilson SH, Camrud AR, Berger PB, Holmes DR, Schwartz RS. Neointimal response following rotational atherectomy compared to balloon angioplasty in a porcine model of coronary in-stent restenosis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 45:332-6. [PMID: 9829900 DOI: 10.1002/(sici)1097-0304(199811)45:3<332::aid-ccd27>3.0.co;2-r] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In-stent restenosis remains a clinical therapeutic challenge. Rotational atherectomy (RA) is an attractive treatment option as it may cause less vascular injury than balloon angioplasty (BA) and, therefore, limit further neointimal response. In an animal model of coronary in-stent restenosis, thermal injury and stenting created neointima (old NI). The treatment of in-stent restenosis with either BA (n = 9) or RA (n = 11) also generated neointima (new NI). The average areas (mm2) of old NI in the BA and RA groups were similar (3.77 +/- 0.40 vs. 3.67 +/- 0.53; P = 0.32). However, new NI formed after treatment of in-stent restenosis was significantly less in the RA as compared to the BA group (0.33 +/- 0.12 vs. 0.73 +/- 36, P < 0.01). In this porcine coronary artery model of in-stent restenosis, treatment with rotational atherectomy resulted in significantly less recurrent neointimal hyperplasia than balloon angioplasty. This animal study, thus, provides a rationale for the clinical use of rotablation in the treatment of in-stent restenosis.
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Affiliation(s)
- C J McKenna
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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21
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Eltchaninoff H, Koning R, Tron C, Gupta V, Cribier A. Balloon angioplasty for the treatment of coronary in-stent restenosis: immediate results and 6-month angiographic recurrent restenosis rate. J Am Coll Cardiol 1998; 32:980-4. [PMID: 9768721 DOI: 10.1016/s0735-1097(98)00333-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The purpose of this prospective study was to evaluate the immediate results and the 6-month angiographic recurrent restenosis rate after balloon angioplasty for in-stent restenosis. BACKGROUND Despite excellent immediate and mid-term results, 20% to 30% of patients with coronary stent implantation will present an angiographic restenosis and may require additional treatment. The optimal treatment for in-stent restenosis is still unclear. METHODS Quantitative coronary angiography (QCA) analyses were performed before and after stent implantation, before and after balloon angioplasty for in-stent restenosis and on a 6-month systematic coronary angiogram to assess the recurrent angiographic restenosis rate. RESULTS Balloon angioplasty was performed in 52 patients presenting in-stent restenosis. In-stent restenosis was either diffuse (> or =10 mm) inside the stent (71%) or focal (29%). Mean stent length was 16+/-7 mm. Balloon diameter of 2.98+/-0.37 mm and maximal inflation pressure of 10+/-3 atm were used for balloon angioplasty. Angiographic success rate was 100% without any complication. Acute gain was lower after balloon angioplasty for in-stent restenosis than after stent implantation: 1.19+/-0.60 mm vs. 1.75+/-0.68 mm (p=0.0002). At 6-month follow-up, 60% of patients were asymptomatic and no patient died. Eighteen patients (35%) had repeat target vessel revascularization. Angiographic restenosis rate was 54%. Recurrent restenosis rate was higher when in-stent restenosis was diffuse: 63% vs. 31% when focal, p=0.046. CONCLUSIONS Although balloon angioplasty for in-stent restenosis can be safely and successfully performed, it leads to less immediate stenosis improvement than at time of stent implantation and carries a high recurrent angiographic restenosis rate at 6 months, in particular in diffuse in-stent restenosis lesions.
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Affiliation(s)
- H Eltchaninoff
- Department of Cardiology, Hôpital Charles Nicolle, University of Rouen, France
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22
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Schiele F, Meneveau N, Vuillemenot A, Gupta S, Bassand JP. Treatment of in-stent restenosis with high speed rotational atherectomy and IVUS guidance in small <3.0 mm vessels. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1998; 44:77-82. [PMID: 9600530 DOI: 10.1002/(sici)1097-0304(199805)44:1<77::aid-ccd19>3.0.co;2-m] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The management of in-stent restenosis remains a subject for debate because no one revascularization option is considered the most appropriate. Since a high restenosis rate still occurs after repeat balloon angioplasty, new techniques are attempted in order to reduce this rate. A combination of high speed rotational atherectomy (HSRA) and adjunctive balloon angioplasty is likely to achieve good results. In small (<3.0 mm diameter) vessels, the risk of interaction between the burr and the stent increases. We thus used intravascular ultrasound (IVUS) guidance in the treatment of in-stent restenosis with HSRA in small <3.0 mm small diameter vessels. Nine patients with in-stent restenosis in small vessels were referred for repeat angioplasty. Initial IVUS examination was used to assess the minimal stent struts diameter and to guide the burr size selection. A combination of HSRA and additional balloon angioplasty was performed under IVUS and angiographic guidance. Mean angiographic reference diameter was 2.25 +/- 0.35 mm and mean stent struts diameter was 2.38 +/- 0.20 mm. Burr size was selected approximately 0.5 mm smaller than stent struts diameter and ranged from 1.75 to 2.5 mm, with a 0.88 +/- 0.12 mean burr/artery ratio (range 0.71, 1.08). In two patients, a second larger burr was used. In 4/9 patients, the burr size chosen under IVUS guidance was close to angiographic MLD at stent implantation and thus larger than what would be used without IVUS guidance. Additional balloon angioplasty was decided in all cases, using a 1.1 +/- 0.15 balloon/artery ratio. No complication occurred. Mean relative gain in minimal lumen diameter (MLD) was 94 +/- 90% after HSRA and 54 +/- 34% after balloon angioplasty (total relative gain 180 +/- 100%). IVUS guidance allowed safe management of in-stent restenosis in small vessels using combination of HSRA and balloon angioplasty. Long-term follow-up and comparison with other techniques are necessary to assess whether this technique should be used routinely.
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Affiliation(s)
- F Schiele
- Hôpital Saint-Jacques, Besançon, France
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23
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Klues HG, Radke PW, Hoffmann R, vom Dahl J. [Pathophysiology and therapeutic concepts in coronary restenosis]. Herz 1997; 22:322-34. [PMID: 9483438 DOI: 10.1007/bf03044283] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Demonstration of a reduced restenosis rate after stent implantation (Benestent, STRESS) has initiated rapid increase in stent implantation rates with widening indications. At present, the majority of stents are implanted in "none-Benestent/STRESS-lesions" with the consequence of a higher restenosis rate as previously expected. Stent restenosis has therefore become a relevant problem in interventional cardiology. In contrast to balloon angioplasty, where acute and subacute recoil represents the major mechanism of restenosis, stent restenosis is exclusively attributed to neointima proliferation. Morphological studies have demonstrated that neointima is caused by early smooth muscle cell ingrowth with a maximum after 7 days which is then gradually replaced by extracellular matrix. Systematic clinical, angiographic and intravascular ultrasound studies have identified several risk factors for increased stent restenosis such as: diabetes mellitus, treatment of restenosis, serial stent implantation, small and calcified vessels, ostial lesions, venous bypass grafts and complex stenosis morphology. In addition, there is increasing evidence that aggressive implantation techniques with high pressures and oversized balloons may also induce higher restenosis rates. Optimal treatment of instent restenosis has not been determined so far. Balloon angioplasty is at present considered the therapeutic option of choice. Several small studies have shown, that in short, discrete lesions (< 10 mm) results of simple PTCA are acceptable with re-restenosis rates between 15 and 35%. The intervention is considered safe with low complication rates. In 10 to 15% additional stent implantation is necessary, usually due to dissections proximal or distal to the treated stent. In long, diffuse stent restenosis (> or = 10 mm), however, PTCA results in high re-restenosis rates up to > 80%. This is most likely due to insufficient early balloon angioplasty results with minimal luminal diameters (MLD) significantly below the previous stent diameter. Therefore, debulking techniques have been used to reduce neointima burden within the stent. At present 3 techniques are available: directional coronary atherectomy (DCA), Excimerlaser angioplasty (ELCA) or high frequency rotablation. All of these techniques achieve a significant reduction in plaque volume within the stent and in combination with balloon angioplasty allow larger MLDs than PTCA alone. Limited experiences with ELCA and rotablation have shown that the techniques are safe without major periinterventional complications. DCA, however, has been accompanied with stent destruction and therefore should be considered with large care, especially in stents with coil design. At present, no randomized controlled trials for the comparison of debulking techniques with or without balloon angioplasty versus balloon angioplasty alone are available. Three multicenter trials have been initiated (LARS, ARTIST and TWISTER) to compare debulking techniques versus balloon angioplasty in diffuse stent restenosis. Adjunct medical treatment after interventions for stent restenosis is usually limited to ASS alone, indications for additional application of Ticlopidine have not been verified so far. Positive results are expected for the use of local radiation therapy either by radioactive stent implantation or afterloading techniques. With increasing stent implantation rates and indications, about 400,000 stents will be implanted in 1997 worldwide. Considering a low restenosis rate of 20%, 80,000 stent restenosis will occur within one year. Final recommendations for optimal treatment of these patients are not yet available.
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Affiliation(s)
- H G Klues
- Medizinische Klinik I, Universitätsklinikum der RWTH Aachen.
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Köster R, Hamm CW, Terres W, Koschyk DH, Reimers J, Kähler J, Meinertz T. Treatment of in-stent coronary restenosis by excimer laser angioplasty. Am J Cardiol 1997; 80:1424-8. [PMID: 9399715 DOI: 10.1016/s0002-9149(97)00703-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We evaluated the efficacy and safety of excimer laser angioplasty (ELCA) with adjunctive balloon angioplasty in patients with restenotic or occluded coronary stents. ELCA was performed in 70 patients (60 +/- 9 years), who had previously been treated with Micro Stents (n = 65), Palmaz-Schatz (n = 38), Wiktor, NIR, Freedom, and Multi-Link stents (n = 1 each). Restenosis (> or =50% diameter stenosis) was documented in 90 stents, another 17 stents were occluded. Laser energy was delivered to the lesions with catheters 1.4, 1.7 (eccentric), and 2.0 mm in diameter. Procedural success was controlled by intravascular ultrasound in a subgroup. Laser catheters crossed all restenotic or occluded stents and decreased diameter stenosis from 80 +/- 13% to 44 +/- 11% (p <0.001). Adjunctive balloon angioplasty further reduced diameter stenosis to 13 +/- 13% (p <0.001). In 13 patients with 21 stents, serial intravascular ultrasound imaging revealed a reduction of plaque area within the stent by 34 +/- 22% (from 4.2 +/- 1.8 mm2 to 2.7 +/- 1.1 mm2) after ELCA and a reduction by 65 +/- 16% (to 1.5 +/- 0.7 mm2) after balloon angioplasty (p <0.01). There were 4 patients with an increase of creatine kinase levels, 8 patients with major dissections (in 7 patients they were related to adjunctive balloon angioplasty), 1 patient with distal embolization, 2 with minor perforations, and 1 patient with stent dislocation. Reintervention during hospitalization was necessary in 3 patients. ELCA is an efficient and safe technique to debulk tissue in restenotic lesions and total occlusions within stents. The incidence of procedure related complications was low.
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Affiliation(s)
- R Köster
- Medical Clinic, Department of Cardiology, University Hospital Eppendorf, Hamburg, Germany
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25
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Reimers B, Moussa I, Akiyama T, Tucci G, Ferraro M, Martini G, Blengino S, Di Mario C, Colombo A. Long-term clinical follow-up after successful repeat percutaneous intervention for stent restenosis. J Am Coll Cardiol 1997; 30:186-92. [PMID: 9207641 DOI: 10.1016/s0735-1097(97)00142-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES This study evaluated the long-term clinical outcome of successful repeat percutaneous intervention after in-stent restenosis. BACKGROUND Recurrence of symptoms and angiographic restenosis after stent implantation are observed in 15% to 35% of cases. Repeat percutaneous treatment for in-stent restenosis has been shown to be safe, with high immediate success, but little is known about the long-term clinical outcome. METHODS Clinical follow-up (minimum 9 months) was obtained in a consecutive series of 124 patients (127 vessels) presenting with stent restenosis who were successfully treated with repeat percutaneous intervention. RESULTS Clinical follow-up was obtained in all 124 patients at a mean [+/-SD] of 27.4 +/- 14.7 months (range 9 to 66); a stress test was available in 88 patients (71%). Recurrence of clinical events occurred in 25 patients (20%) and included death from any cause in 2 patients (2%), target vessel revascularization in 14 (11%), myocardial infarction in 1 (1%) and positive stress test results or recurrence of symptoms (Canadian Cardiovascular Society class I to IV) treated medically in 8 (6%). Cumulative event-free survival at 12 and 24 months was 86.2% and 80.7%, respectively. Significant predictive factors of recurrence of clinical events were repeat intervention in saphenous vein grafts, multivessel disease, low ejection fraction and a < or = 3-month interval between stent implantation and repeat intervention. CONCLUSIONS In-stent balloon angioplasty for stent restenosis in native vessels seems to be an effective method in terms of a low long-term clinical event rate.
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26
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Chow WH, Chan TF. Pullback atherectomy for the treatment of intrastent restenosis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 41:94-5. [PMID: 9143776 DOI: 10.1002/(sici)1097-0304(199705)41:1<94::aid-ccd21>3.0.co;2-p] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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27
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Belli G, Whitlow PL. Should we spark interest in rotational atherectomy for in-stent restenosis? CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 40:150-1. [PMID: 9047053 DOI: 10.1002/(sici)1097-0304(199702)40:2<150::aid-ccd5>3.0.co;2-a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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28
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Ceceña FA. Stenting the stent: alternative strategy for treating in-stent restenosis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 39:377-82. [PMID: 8958427 DOI: 10.1002/(sici)1097-0304(199612)39:4<377::aid-ccd12>3.0.co;2-a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Several approaches have been taken to relieve restenosis inside a vascular stent. In a patient with a complicated history of coronary artery disease, a restenotic lesion inside a Gianturco-Roubin flex stent was relieved by angioplasty and deployment of three 10 mm Palmaz P-104 "biliary" stents, with urokinase and verapamil used to prevent thromboembolism and the no-reflow phenomenon. An angiographic study 6 months later showed a patient graft with no residual stenosis.
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Affiliation(s)
- F A Ceceña
- Charles A. Barrow Heart Lung Center, St. Luke's Medical Center, Phoenix, Arizona, USA
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29
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Eisenhauer AC, Piemonte TC, Gossman DE, Ahmed AL. Extraction of fully deployed coronary stents. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 38:393-401. [PMID: 8853150 DOI: 10.1002/(sici)1097-0304(199608)38:4<393::aid-ccd15>3.0.co;2-g] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Coronary stents are often used because of their potential to improve the acute and long-term results of balloon angioplasty. The Palmaz-Schatz stent has been approved for use by the U.S. Food and Drug Administration largely because of a demonstrated reduction in the incidence of restenosis following its primary implantation. The Gianturco-Roubin design has been approved for use when balloon angioplasty results in threatened or acute vessel closure. In practice, both stent types are being used in settings when the results of balloon angioplasty are either potentially or actually unacceptable. In such circumstances it is imperative that stents be placed accurately and carefully. Occasionally, stent misplacement, embolization, or disruption can occur, and the need arises to recover and/or reposition the wayward prosthesis. This review describes the removal and recovery of fully deployed Gianturco-Roubin stents using an intracoronary snare technique.
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Affiliation(s)
- A C Eisenhauer
- Lahey Hitchcock Medical Center, Burlington, Massachusetts 01805, USA
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30
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Patel JJ, Meadaa R, Cohen M, Adiraju R, Kussmaul WG. Transluminal extraction atherectomy for aortosaphenous vein graft stent restenosis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 38:320-4. [PMID: 8804772 DOI: 10.1002/(sici)1097-0304(199607)38:3<320::aid-ccd24>3.0.co;2-j] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The optimal strategy to manage in-stent saphenous vein graft (SVG) restenosis has not been studied. We present two cases in which transluminal extraction atherectomy (TEC) was used successfully for the treatment of SVG stent restenosis. TEC atherectomy may provide an alternative to conventional balloon angioplasty for such patients.
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Affiliation(s)
- J J Patel
- Department of Medicine, Hahnemann University, Philadelphia, Pennsylvania, USA
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31
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Abstract
As demonstrated by the two recent randomized studies of elective, single stent placement versus balloon angioplasty of de novo lesions in the coronary arteries, angiographic restenosis occurs significantly less after stent implantation. However, reported stent restenosis rate varies from 14% to more than 60%, depending on patient characteristics, stent design, number of stents implanted, vessel treated, location of the lesion, and acute luminal gain. The lowest rate of stenosis occurs in de novo lesions. The highest rate of stent restenosis is encountered in multiple stents and in ostial saphenous vein graft lesions. Stent restenosis can be treated with balloon angioplasty with very high success rates. This treatment is associated with remarkably low incidence of complications. Focal stenoses within the stent are more easily treated than are diffuse occlusions. Atherectomy of intrastent stenosis is not recommended. Excimer and holmium: YAG lasers can be applied for revascularization of intrastent lesions considered "not ideal" for balloon angioplasty. Unless thrombus is present or significant dissection detected or angioplasty performed within 2 months following stenting, patients do not require anticoagulants following balloon angioplasty of stent restenosis.
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Affiliation(s)
- O Topaz
- Cardiac Catheterization Laboratories, McGuire VA Medical Center, Richmond 23249, USA
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32
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Goods CM, Jain SP, Liu MW, Babu RB, Roubin GS. Intravascular ultrasound-guided transluminal extraction atherectomy for restenosis after Gianturco-Roubin coronary stent implantation. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 37:317-9. [PMID: 8974816 DOI: 10.1002/(sici)1097-0304(199603)37:3<317::aid-ccd23>3.0.co;2-d] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Two patients with restenosis following implantation of the Gianturco-Roubin stent were successfully treated with the transluminal extraction atherectomy device, with the assistance of intravascular ultrasound guidance and adjunctive balloon angioplasty. The optimal management strategy of in-stent restenosis remains unclear, but the transluminal extraction atherectomy device may be an option for the management of restenosis within the Gianturco-Roubin stent.
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Affiliation(s)
- C M Goods
- Department of Interventional Cardiology, University of Alabama at Birmingham, USA
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33
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Bailey SR, Stefan Kiesz R. Intravascular stents: Current applications. Curr Probl Cardiol 1995. [DOI: 10.1016/s0146-2806(06)80018-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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34
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Macander PJ, Roubin GS, Agrawal SK, Cannon AD, Dean LS, Baxley WA. Balloon angioplasty for treatment of in-stent restenosis: feasibility, safety, and efficacy. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 32:125-31. [PMID: 8062366 DOI: 10.1002/ccd.1810320206] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Sixty patients with 1 or 2 stainless steel intracoronary stents (Cook, Inc.) underwent balloon angioplasty for in-stent restenosis 1.5-13.5 months after stenting. Seventy-five in-stent redilatation procedures were performed. Seventy-three restenotic lesions (97%) were successfully recrossed and dilated, reducing the mean pre-angioplasty intrastent diameter stenosis from 77 +/- 12% to 20 +/- 11% residual. Although one angioplasty (1.3%) was complicated by non-Q-wave infarction, no angioplasty-related death, acute closure, need for additional stenting, emergent coronary bypass surgery, side branch occlusion, or vascular sequelae occurred. Post-procedure heparin was not used in 83% of successful cases. Most patients were discharged the day following redilatation (mean in-hospital stay 1.7 +/- 1.3 days). At 5.4 +/- 3.4 months following in-stent angioplasty, 84% of patients were in Canadian Cardiovascular Society class 0 or I. In conclusion, balloon dilatation in this stent for restenosis appears simple and efficacious in the short term, and may entail less risk than dilatation of unprotected coronary vessels.
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Affiliation(s)
- P J Macander
- Department of Medicine, University of Alabama at Birmingham
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35
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Timmis GC. Interventional Cardiology: A Comprehensive Bibliography. J Interv Cardiol 1993. [DOI: 10.1111/j.1540-8183.1993.tb00864.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Baim DS, Levine MJ, Leon MB, Levine S, Ellis SG, Schatz RA. Management of restenosis within the Palmaz-Schatz coronary stent (the U.S. multicenter experience. The U.S. Palmaz-Schatz Stent Investigators. Am J Cardiol 1993; 71:364-6. [PMID: 8427190 DOI: 10.1016/0002-9149(93)90813-r] [Citation(s) in RCA: 144] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- D S Baim
- Charles A. Dana Research Institute, Boston, Massachusetts
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