[Pathophysiology and therapeutic concepts in coronary restenosis]

Clinical outcomes after the endovascular treatments of pulmonary vein stenosis in patients with congenital heart disease

BACKGROUND

Pulmonary vein stenosis (PVS) is a condition with challenging treatment and leads to severe cardiac failure and pulmonary hypertension. Despite aggressive surgical or catheter-based intervention, the prognosis of PVS is unsatisfactory. This study aimed to assess the prognosis and to establish appropriate treatment strategies.

METHODS

We retrospectively reviewed endovascular treatments for PVS (2001-2017) from the clinical database at the Okayama University Hospital.

RESULTS

A total of 24 patients underwent PVS associated with total anomalous pulmonary venous connection and 7 patients underwent isolated congenital PVS. In total, 53 stenotic pulmonary veins were subjected to endovascular treatments; 40 of them were stented by hybrid (29) and percutaneous procedures (11) (bare-metal stent, n = 34; drug-eluting stent, n = 9). Stent size of hybrid stenting was larger than percutaneous stenting. Median follow-up duration from the onset of PVS was 24 months (4-134 months). Survival rate was 71 and 49% at 1 and 5 years, respectively. There was no statistically significant difference between stent placement and survival; however, patients who underwent bare-metal stent implantation had statistically better survival than those who underwent drug-eluting stent implantation or balloon angioplasty. Early onset of stenosis, timing of stenting, and small vessel diameter of pulmonary vein before stenting were considered as risk factors for in-stent restenosis. Freedom from re-intervention was 50 and 26% at 1 and 2 years.

CONCLUSIONS

To improve survival and stent patency, implantation of large stent is important. However, re-intervention after stenting is also significant to obtain good outcome.

“How to Do It”

Pulmonary vein stenosis (PVS) is often progressive and severe. Surgical and percutaneous angioplasty are acutely successful; however, restenosis is common and many patients require multiple reinterventions. We perform intraoperative “hybrid” stent placement to deliver larger, stronger stents. Hybrid stent placement is well described for pulmonary arterial stenosis (PAS). The PAS data demonstrate that smaller stents are associated with rapid in-stent restenosis. Data from PVS in adults demonstrate superior outcomes with larger stents. Hybrid stent placement requires a strong collaborative effort between congenital heart surgeons and interventional cardiologists.

Intracranial stenting of severe symptomatic intracranial stenosis: results of 100 consecutive patients

BACKGROUND AND PURPOSE

There are a few reports regarding the outcome evaluation of balloon-expandable intracranial stent placement (BEICS). The purpose of our study was to evaluate the outcome and factors related to the adverse events (AEs) of BEICS.

MATERIALS AND METHODS

We evaluated 100 consecutive patients who underwent BEICS. We assessed the procedural success (residual stenosis < 50%), AEs (minor strokes, major strokes, and death), clinical outcome, and restenosis (> 50%) at 6 months. We also analyzed 18 factors including symptom patterns related to AE rate. Symptom patterns revealed 1) stable patients (n = 73) with improving, stationary, or resolved symptoms; and 2) unstable patients (n = 27) with gradual worsening or fluctuating symptoms (National Institutes of Health Stroke Scale [NIHSS] > or = 4) within 2 days before stent placement.

RESULTS

The procedural success rate was 99%. Overall, there were 10 (10%) AEs within the 6 months: 4 (4%) minor strokes, 3 (3%) major strokes, and 3 (3%) deaths including a death from myocardial infarction. AE rate was 4.1% in stable and 25.9% in unstable patients. Restenosis at 6 months revealed 0% (0/59). Good outcome (modified Rankin Scale < or = 2) at 6 months was 97% (71/73) in stable and 67% (18/27) in unstable patients. Stepwise logistic regression model revealed that symptom pattern (unstable versus stable) was the only significant risk factor (OR, 8.167; 95% CI, 1.933-34.500; P = .004).

CONCLUSION

BEICS revealed a low AE and good outcome rate at 6 months, especially in the stable patients. Midterm outcome was also favorable in the unstable patient group.

Bifurcation Coronary Lesions Treated With the “Crush” Technique

OBJECTIVES

We report intravascular ultrasound (IVUS) findings after crush-stenting of bifurcation lesions.

BACKGROUND

Preliminary results with the crush-stent technique are encouraging; however, isolated reports suggest that restenosis at the side branch (SB) ostium continues to be a problem.

METHODS

Forty patients with bifurcation lesions underwent crush-stenting with the sirolimus-eluting stent. Postintervention IVUS was performed in both branches in 25 lesions and only the main vessel (MV) in 15 lesions; IVUS analysis included five distinct locations: MV proximal stent, crush area, distal stent, SB ostium, and SB distal stent.

RESULTS

Overall, the MV minimum stent area was larger than the SB (6.7 +/- 1.7 mm2 vs. 4.4 +/- 1.4 mm2, p < 0.0001, respectively). When only the MV was considered, the minimum stent area was found in the crush area (rather than the proximal or MV distal stent) in 56%. When both the MV and the SB were considered, the minimum stent area was found at the SB ostium in 68%. The MV minimum stent area measured <4 mm2 in 8% of lesions and <5 mm2 in 20%. For the SB, a minimum stent area <4 mm2 was found in 44%, and a minimum stent area <5 mm2 in 76%, typically at the ostium. "Incomplete crushing"--incomplete apposition of SB or MV stent struts against the MV wall proximal to the carina--was seen in >60% of non-left main lesions.

CONCLUSIONS

In the majority of bifurcation lesions treated with the crush technique, the smallest minimum stent area appeared at the SB ostium. This may contribute to a higher restenosis rate at this location.

Clinical and angiographic results of coronary artery stenting using PURA-VARIO (PUVA) stents

BACKGROUND

Many different stent types are available for intracoronary placement. No clinical trial has demonstrated clearly the superiority of any stent design over another.

METHODS

This study was designed to analyze clinical and angiographic results after using intracoronary PURA-VARIO (Devon Medical, Hamburg, Germany) (PUVA) stents. A total of 306 implanted stents were investigated in a series of 217 unselected patients (61.2 +/- 10.7 years, 74.3% male). Stenting was performed electively and during acute coronary syndromes. Stents were manually mounted on angioplasty balloons and expanded in the target lesion. Angiographic measurements were carried out by quantitative coronary angiography.

RESULTS

Stenting was successful in 214/217 patients (98.8%). During hospitalization (median three days) 206 patients (94.9%) were free from adverse cardiac events. Stent thrombosis occurred in five patients (2.3%), Q-wave infarction in one (0.5%) and urgent percutaneous target vessel revascularization in four (1.8%). Follow-up angiography, performed in 170 patients (78.3%) showed a restenosis (>/=50% diameter stenosis) in 44/170 patients (25.9%), requiring angioplasty in 29 (17.2%). A surgical revascularization was recommended in 13 patients (7.6%). One patient died during follow-up from an unknown cause; however, sudden cardiac death was most likely.

CONCLUSIONS

PUVA stents are characterized by a high level of safety and efficacy. Clinical and angiographic results are comparable with those of other approved stents.