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Xenogiannis I, Tajti P, Burke MN, Brilakis ES. Staged revascularization in patients with acute coronary syndromes due to saphenous vein graft failure and chronic total occlusion of the native vessel: A novel concept. Catheter Cardiovasc Interv 2018; 93:440-444. [DOI: 10.1002/ccd.27978] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/19/2018] [Accepted: 10/23/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Iosif Xenogiannis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation; Abbott Northwestern Hospital; Minneapolis Minnesota
| | - Peter Tajti
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation; Abbott Northwestern Hospital; Minneapolis Minnesota
- University of Szeged; Division of Invasive Cardiology, Second Department of Internal Medicine and Cardiology Center; Szeged Hungary
| | - M. Nicholas Burke
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation; Abbott Northwestern Hospital; Minneapolis Minnesota
| | - Emmanouil S. Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation; Abbott Northwestern Hospital; Minneapolis Minnesota
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2
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Douglas JS. Percutaneous coronary intervention in patients with prior coronary bypass surgery in 2012. Interv Cardiol 2012. [DOI: 10.2217/ica.11.96] [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] Open
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3
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Davlouros P, Damelou A, Karantalis V, Xanthopoulou I, Mavronasiou E, Tsigkas G, Hahalis G, Alexopoulos D. Evaluation of Culprit Saphenous Vein Graft Lesions With Optical Coherence Tomography in Patients With Acute Coronary Syndromes. JACC Cardiovasc Interv 2011; 4:683-93. [DOI: 10.1016/j.jcin.2011.02.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 11/17/2010] [Accepted: 02/04/2011] [Indexed: 10/18/2022]
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4
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Adgey AA, Mathew TP, Harbinson MT. Periprocedural creatine kinase-MB elevations: long-term impact and clinical implications. Clin Cardiol 2009; 22:257-65. [PMID: 10198735 PMCID: PMC6655971 DOI: 10.1002/clc.4960220403] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Since the introduction of percutaneous transluminal coronary angioplasty (PTCA), percutaneous intervention with balloon catheters, stents, and atherectomy devices has become a widely accepted practice. The persistent complication of non-Q-wave myocardial infarction (MI), as evidenced by increased cardiac enzyme levels after intervention, has aroused only moderate concern because its incidence was perceived to be small and not clinically relevant. With more systematic assessments of cardiac enzymes--specifically, creatine kinase (CK) and its MB isoform--evidence has begun to clarify both the incidence and the prognosis of periprocedural non-Q-wave MI: It appears to occur nearly three times more often than is clinically evident across all device types (8 to 9% of all interventions) and is directly and continuously associated with adverse outcomes, including late death. Although directional and rotational atherectomy improve angiographic outcome compared with PTCA, periprocedural infarction occurs at least twice as often with these newer technologies; the incidence associated with stent placement is comparable to and possibly higher than that of PTCA. Factors that may cause elevated CK-MB levels include distal embolization, side branch occlusion, thrombus, and coronary spasm. Analyses of the major trials of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors, a class of potent antiplatelet agents, show striking effectiveness of these drugs in reducing the incidence of "enzyme-only" or "silent" MI and in improving long-term clinical outcomes. The findings implicate platelet mediation in the occurrence of periprocedural infarction and suggest an important role for antiplatelet therapy, particularly GP IIb/IIIa receptor inhibition, in protecting patients undergoing percutaneous intervention.
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Affiliation(s)
- A A Adgey
- Royal Victoria Hospital, Belfast, Northern Ireland
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5
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Brunetti ND, Quagliara D, Di Biase M. Troponin ratio and risk stratification in subjects with acute coronary syndrome undergoing percutaneous coronary intervention. Eur J Intern Med 2008; 19:435-42. [PMID: 18848177 DOI: 10.1016/j.ejim.2007.04.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2006] [Revised: 04/23/2007] [Accepted: 04/23/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cardiac enzyme release after percutaneous coronary intervention (PCI) seems to play a role in risk stratification. After PCI, CK-MB plasmatic concentrations three times above the upper level of normal (ULN) are currently the most used risk stratification parameters. We sought to assess whether peak cardiac troponin I (cTn-I) concentration/base concentration ratio (PBTR) may act as a predictor of major adverse cardiac events (MACEs) after PCI, regardless of cTn-I ULN. METHODS We evaluated 326 consecutive patients with acute coronary syndrome (ACS) who underwent PCI. Baseline and post-PCI cTn-I values were evaluated over serial blood samples every 6h for at least 72h. Patients were further divided into four groups according to their PBTR values (<1, 1-4, 4-10, >10). MACEs were recorded over a 6-month follow-up period. Patients with primary PCI or unsuccessful PCI were excluded from the study. RESULTS Higher values of PBTR significantly correlated with a worse prognosis at 6 months (<1, 16.30% of MACEs; 1-4, 19.42%; 4-10, 24.39%; >10, 35.63%; p<0.05), both in Q-wave myocardial infarction (MI) and unstable angina (UA) subgroups. The correlation remained statistically significant, even considering subjects with peak cTn-I less than three times the ULN (p < 0.05) and after correction for age, gender, risk factors, diagnosis (MI versus UA), and peak cTn-I levels in a multiple Cox' regression analysis (HR 1.62, p<0.05). CONCLUSIONS PBTR is an independent predictor of MACEs after PCI in a 6-month follow-up period. This risk stratification tool may be useful to predict adverse events in PCI patients, even in the case of apparently non-elevated peak cTn-I concentrations.
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6
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Kirtane AJ, Heyman ER, Metzger C, Breall JA, Carrozza JP. Correlates of Adverse Events During Saphenous Vein Graft Intervention With Distal Embolic Protection. JACC Cardiovasc Interv 2008; 1:186-91. [DOI: 10.1016/j.jcin.2008.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Revised: 12/13/2007] [Accepted: 01/23/2008] [Indexed: 11/27/2022]
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7
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Coolong A, Baim DS, Kuntz RE, O’Malley AJ, Marulkar S, Cutlip DE, Popma JJ, Mauri L. Saphenous Vein Graft Stenting and Major Adverse Cardiac Events. Circulation 2008; 117:790-7. [PMID: 18212287 DOI: 10.1161/circulationaha.106.651232] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Treatment of saphenous vein graft (SVG) stenosis with percutaneous coronary intervention has a 15% to 20% incidence of major adverse cardiac events (MACE) within 30 days. Although MACE rates are reduced significantly by the use of embolic protection devices (EPDs), neither the level of baseline risk nor the benefit provided by EPDs has been well characterized.
Methods and Results—
Data from 5 randomized controlled trials and 1 registry evaluating EPDs in SVG percutaneous coronary intervention (n=3958 patients) were pooled for analysis. MACE was defined as a composite of death, myocardial infarction, and target vessel revascularization. Baseline variables and 2 summary angiographic variables (an SVG degeneration score and an estimate of lesion plaque volume) were included in a multivariable logistic regression model to predict 30-day MACE, with adjustment for the type of device used and inter-study variation. The angiographic variables were potent predictors of MACE (increasing SVG degeneration score,
P
<0.0001; larger estimated plaque volume,
P
<0.0001), with significant contributions from the presence of thrombus (
P
<0.01), increasing patient age (
P
<0.01), glycoprotein IIb/IIIa inhibitor use (
P
=0.02), and current tobacco abuse (
P
=0.03). The treatment benefit of EPDs was preserved across all categories of risk as categorized by SVG degeneration or plaque volume.
Conclusions—
The strongest predictors of 30-day MACE in SVG percutaneous coronary intervention are angiographic estimates of plaque volume and SVG degeneration. Identification of these predictors of 30-day MACE allows reliable prediction of patient outcomes and confirms consistent treatment benefit with the use of EPDs across the range of patients tested in randomized trials.
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Affiliation(s)
- Alanna Coolong
- From the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (A.C., L.M.); Boston Scientific, Natick, Mass (D.S.B.); Medtronic, Minneapolis, Minn (R.E.K.); and Department of Health Care Policy, Harvard Medical School (A.J.O.), Beth Israel-Deaconess Medical Center (D.E.C.), St Elizabeth’s Medical Center (J.J.P.), and Harvard Clinical Research Institute (A.C., S.M., D.E.C., L.M.), Boston, Mass
| | - Donald S. Baim
- From the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (A.C., L.M.); Boston Scientific, Natick, Mass (D.S.B.); Medtronic, Minneapolis, Minn (R.E.K.); and Department of Health Care Policy, Harvard Medical School (A.J.O.), Beth Israel-Deaconess Medical Center (D.E.C.), St Elizabeth’s Medical Center (J.J.P.), and Harvard Clinical Research Institute (A.C., S.M., D.E.C., L.M.), Boston, Mass
| | - Richard E. Kuntz
- From the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (A.C., L.M.); Boston Scientific, Natick, Mass (D.S.B.); Medtronic, Minneapolis, Minn (R.E.K.); and Department of Health Care Policy, Harvard Medical School (A.J.O.), Beth Israel-Deaconess Medical Center (D.E.C.), St Elizabeth’s Medical Center (J.J.P.), and Harvard Clinical Research Institute (A.C., S.M., D.E.C., L.M.), Boston, Mass
| | - A. James O’Malley
- From the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (A.C., L.M.); Boston Scientific, Natick, Mass (D.S.B.); Medtronic, Minneapolis, Minn (R.E.K.); and Department of Health Care Policy, Harvard Medical School (A.J.O.), Beth Israel-Deaconess Medical Center (D.E.C.), St Elizabeth’s Medical Center (J.J.P.), and Harvard Clinical Research Institute (A.C., S.M., D.E.C., L.M.), Boston, Mass
| | - Sachin Marulkar
- From the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (A.C., L.M.); Boston Scientific, Natick, Mass (D.S.B.); Medtronic, Minneapolis, Minn (R.E.K.); and Department of Health Care Policy, Harvard Medical School (A.J.O.), Beth Israel-Deaconess Medical Center (D.E.C.), St Elizabeth’s Medical Center (J.J.P.), and Harvard Clinical Research Institute (A.C., S.M., D.E.C., L.M.), Boston, Mass
| | - Donald E. Cutlip
- From the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (A.C., L.M.); Boston Scientific, Natick, Mass (D.S.B.); Medtronic, Minneapolis, Minn (R.E.K.); and Department of Health Care Policy, Harvard Medical School (A.J.O.), Beth Israel-Deaconess Medical Center (D.E.C.), St Elizabeth’s Medical Center (J.J.P.), and Harvard Clinical Research Institute (A.C., S.M., D.E.C., L.M.), Boston, Mass
| | - Jeffrey J. Popma
- From the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (A.C., L.M.); Boston Scientific, Natick, Mass (D.S.B.); Medtronic, Minneapolis, Minn (R.E.K.); and Department of Health Care Policy, Harvard Medical School (A.J.O.), Beth Israel-Deaconess Medical Center (D.E.C.), St Elizabeth’s Medical Center (J.J.P.), and Harvard Clinical Research Institute (A.C., S.M., D.E.C., L.M.), Boston, Mass
| | - Laura Mauri
- From the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass (A.C., L.M.); Boston Scientific, Natick, Mass (D.S.B.); Medtronic, Minneapolis, Minn (R.E.K.); and Department of Health Care Policy, Harvard Medical School (A.J.O.), Beth Israel-Deaconess Medical Center (D.E.C.), St Elizabeth’s Medical Center (J.J.P.), and Harvard Clinical Research Institute (A.C., S.M., D.E.C., L.M.), Boston, Mass
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EL-JACK SEIFS, SUWATCHAI PORNRATANARANGSI, STEWART JAMEST, RUYGROK PETERN, ORMISTON JOHNA, WEST TEENA, WEBSTER MARKWI. Distal Embolization during Native Vessel and Vein Graft Coronary Intervention with a Vascular Protection Device: Predictors of High-Risk Lesions. J Interv Cardiol 2007; 20:474-80. [DOI: 10.1111/j.1540-8183.2007.00308.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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9
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Niccoli G, De Vita M, Maria Leone A, Biscione C, Mongiardo R, Rebuzzi A, Crea F. Delayed stenting of a thrombotic saphenous vein graft after intravenous tirofiban pretreatment. Int J Cardiol 2006; 110:108-9. [PMID: 16005993 DOI: 10.1016/j.ijcard.2005.05.064] [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] [Received: 05/16/2005] [Accepted: 05/28/2005] [Indexed: 10/25/2022]
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10
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Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB, Morrison DA, O'Neill WW, Schaff HV, Whitlow PL, Williams DO, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). J Am Coll Cardiol 2006; 47:e1-121. [PMID: 16386656 DOI: 10.1016/j.jacc.2005.12.001] [Citation(s) in RCA: 309] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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11
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Abstract
During the past three decades, percutaneous coronary intervention has become one of the cardinal treatment strategies for stenotic coronary artery disease. Technical advances, including the introduction of new devices such as stents, have expanded the interventional capabilities of balloon angioplasty. At the same time, there has been a decline in the rate of major adverse cardiac events, including Q-wave acute myocardial infarction, emergency coronary artery bypass grafting, and cardiac death. Despite these advances, the incidence of post-procedural cardiac marker elevation has not substantially decreased since the first serial assessment 20 years ago. As of now, these post-procedural cardiac marker elevations are considered to represent peri-procedural myocardial injury (PMI) with worse long-term outcome potential. Recent progress has been made for the identification of two main PMI patterns, one near the intervention site (proximal type, PMI type I) and one in the distal perfusion territory of the treated coronary artery (distal type, PMI type II) as well as for preventive strategies. Integrating these new developments into the wealth of clinical information on this topic, this review aims at giving a current perspective on the entity of PMI.
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Affiliation(s)
- Joerg Herrmann
- Department of Internal Medicine, Mayo Clinic Rochester, 200 First Street S.W., Rochester, MN 55905, USA.
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12
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Kurowski V, Toelg R, Jain D, Richter C, Wiegand UKH, Richardt G, Khattab AA. Effect of adjunctive treatment with tirofiban on troponin T elevation during stenting of critically stenosed aortocoronary saphenous vein grafts. Am J Cardiol 2005; 96:681-4. [PMID: 16125495 DOI: 10.1016/j.amjcard.2005.04.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Revised: 04/22/2005] [Accepted: 04/22/2005] [Indexed: 11/21/2022]
Abstract
In this pilot study, we show that periprocedural administration of tirofiban during stenting of critically stenosed saphenous vein grafts, significantly reduces the occurrence of postprocedural minor myocardial necroses.
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Affiliation(s)
- Volkhard Kurowski
- Medizinische Klinik II, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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13
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Lanzieri M. Percutaneous intervention of a bifurcating saphenous vein graft with simultaneous dual-limb filter wire protection. Catheter Cardiovasc Interv 2004; 63:307-9. [PMID: 15505854 DOI: 10.1002/ccd.20168] [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: 11/08/2022]
Abstract
Distal embolization during saphenous vein graft angioplasty may result in myocardial infarction. The use of dual nonocclusive filter wire during angioplasty in a bifurcating saphenous vein graft is described.
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Affiliation(s)
- Mark Lanzieri
- Department of Medicine, Central Maine Medical Center, Lewiston, Maine 04240, USA.
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14
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Bicknell CD, Cheshire NJW. The relationship between carotid atherosclerotic plaque morphology and the embolic risk during endovascular therapy. Eur J Vasc Endovasc Surg 2003; 26:17-21. [PMID: 12819643 DOI: 10.1053/ejvs.2002.1859] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- C D Bicknell
- Regional Vascular Unit, St Mary's Hospital and Department of Surgical Oncology and Technology, Imperial College, London, UK
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15
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Ghazzal Z, Ashfaq S, Morris DC, Douglas JS, Marshall JJ, King SB, Weintraub WS. Prognostic implication of creatine kinase release after elective percutaneous coronary intervention in the pre-IIb/IIIa antagonist era. Am Heart J 2003; 145:1006-12. [PMID: 12796756 DOI: 10.1016/s0002-8703(03)00095-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The significance of mild elevations in cardiac enzymes after an elective percutaneous coronary intervention (PCI) still remains controversial. We evaluated the significance of creatine phosphokinase level (CPK) elevations in a large cohort of patients who had undergone an elective PCI before the IIb/IIIa receptor antagonist era. METHODS All patients enrolled in the Emory databank from 1981 to 1996 who had an elective PCI were evaluated. We identified 15,637 patients who met our inclusion and exclusion criteria. Patients were divided into 4 groups on the basis of the magnitude of the CPK elevation noted in the post-PCI period: group I (CPK <250 mg/dL, n = 14,512); group II (CPK 250-500 mg/dL, n = 715); group III (CPK 500-750 mg/dL, n = 164); and group IV (CPK >750 mg/dL, n = 246). RESULTS CPK elevations were associated with a significant increase in the periprocedure angiographic complications. Angiographic complication rates were 14.6%, 30.5%, 40.2%, and 43.5% in groups I, II, III, and IV, respectively (P <.001). Long-term survival also correlated inversely with the magnitude of CPK elevations. The 10-year survival rates were 73%, 71%, 69%, and 55% in groups I, II, III, and IV, respectively (P <.0001). After multivariate analysis to correct for clinical factors, a CPK elevation of at least 3-times normal (group IV) was found to be an independent predictor of diminished 30-day and long-term survival (hazard ratio 1.84, 95% CI 1.41-2.41, P <.0001). Elevations in CPK <3-times normal (groups II and III) were not independently predictive of poor long-term survival. CONCLUSION A CPK level >3-times normal after an elective PCI is a strong independent predictor of poor long-term prognosis.
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Affiliation(s)
- Ziyad Ghazzal
- Andreas Gruentzig Cardiovascular Center of Emory University School of Medicine, Division of Cardiology, Atlanta, GA, USA.
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16
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López-Palop R, Pinar E, Lozano I, Carrillo P, Saura D, Cortés R, Picó F, Valdés M. [Angiographic results of thrombectomy performed with two new devices in lesions with intracoronary thrombus]. Rev Esp Cardiol 2003; 56:271-80. [PMID: 12622957 DOI: 10.1016/s0300-8932(03)76863-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVE The presence of intracoronary thrombus is associated with less favorable results of percutaneous coronary interventions. In recent years, new devices have been designed to improve the outcome of these procedures when an intracoronary thrombus is present. The results of two new systems of thrombectomy used in a single center are analyzed. METHODS Prospective observational registry of the use of two thrombectomy devices, X-SIZER (EndiCOR Medical Inc., San Clemente, California, USA) and RESCUE (Boston Scientific Scimed, Inc., Maple Grove, Minnesota, USA), between 1 June 2000 and 15 February 2002. RESULTS. One hundred thirty-nine devices were used in 137 patients (112 RESCUE and 27 X-SIZER). The main indication was primary angioplasty for acute myocardial infarction (80%). In 7 patients (5%), unscheduled thrombectomy was performed for unexpected complications that appeared during the procedure. In 75% of patients, IIb/IIIa inhibitors were given. In 10 cases (7%) the device did not reach the lesion. Complications derived from the use of the device were recorded in 3 cases (2.1%). TIMI flow improved from 1.28 1.1 before thrombectomy to 2.31 1.2 after the procedure. Improvement in the thrombus image was observed in 86%. The intervention was successful in 86%. CONCLUSIONS Thrombectomy with X-Sizer and Rescue improved the angiographic thrombus image in most cases and was associated to a low complication rate. Its efficacy compared to the conventional technique should be assessed in future trials.
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Affiliation(s)
- Ramón López-Palop
- Servicio de Cardiología. Hospital Universitario Virgen de la Arrixaca. Murcia. España.
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17
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Block PC. CABG caveats. Catheter Cardiovasc Interv 2001; 54:325-6. [PMID: 11747156 DOI: 10.1002/ccd.1291] [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: 11/11/2022]
Affiliation(s)
- P C Block
- Emory University Hospital, Atlanta, Georgia, USA
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18
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Sdringola S, Assali AR, Ghani M, Moustapha A, Achour H, Yusuf SW, Fujise K, Rosales O, Schroth GW, Anderson HV, Smalling RW. Risk assessment of slow or no-reflow phenomenon in aortocoronary vein graft percutaneous intervention. Catheter Cardiovasc Interv 2001; 54:318-24. [PMID: 11747155 DOI: 10.1002/ccd.1290] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Slow or no-reflow phenomenon (SNR) complicates 10%-15% of cases of percutaneous intervention (PCI) in aortocoronary saphenous vein grafts (SVG). At present, there are no uniform, effective strategies to predict or prevent this common and potentially serious complication. The purpose of our study was to characterize variables correlated with the risk of SNR in SVG PCI in the era of stenting and glycoprotein IIb/IIIa receptor inhibitors. We identified 2,898 consecutive patients who had PCI, of whom 163 underwent PCI of at least one SVG. The clinical and angiographic characteristics of patients who developed SNR (SNR group) were compared with those who did not (no-SNR group). A total of 23 patients experienced SNR and 140 did not. Using a stepwise multivariate logistic regression analysis, four independent predictors for SNR were detected: probable thrombus (OR 6.9; 95% CI, 2.1-23.9; P = 0.001), acute coronary syndromes (OR 6.4; 95% CI, 2.0-25.3; P = 0.003), degenerated vein graft (OR 5.2; 95% CI, 1.7-16.6; P = 0.003), and ulcer (OR 3.4; 95% CI, 0.99-11.6; P = 0.04). The risk of developing SNR could be estimated according to the number of predictors found: low-grade risk (1%-10%) if < or = one variable was present, moderate risk (20%-40%) if two variables were present, and high risk (60%-90%) if three or more variables were present. We identified and quantified current risk factors for SNR and concluded that the risk of developing SNR during PCI in SVG can be predicted by simple clinical and angiographic variables obtained before PCI. This information may be useful when the risk of PCI has to be balanced against alternative strategies such as medical therapy or redo-bypass surgery or in the selection of those patients that will most benefit from the use of protection devices during PCI.
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Affiliation(s)
- S Sdringola
- Cardiology Division, Department of Medicine, University of Texas Medical School, Houston, Texas 77030, USA
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19
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Smith SC, Dove JT, Jacobs AK, Ward Kennedy J, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO, Gibbons RJ, Alpert JP, Eagle KA, Faxon DP, Fuster V, Gardner TJ, Gregoratos G, Russell RO, Smith SC. ACC/AHA guidelines for percutaneous coronary intervention (revision of the 1993 PTCA guidelines)31This document was approved by the American College of Cardiology Board of Trustees in April 2001 and by the American Heart Association Science Advisory and Coordinating Committee in March 2001.32When citing this document, the American College of Cardiology and the American Heart Association would appreciate the following citation format: Smith SC, Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO. ACC/AHA guidelines for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1993 Guidelines for Percutaneous Transluminal Coronary Angioplasty). J Am Coll Cardiol 2001;37:2239i–lxvi.33This document is available on the ACC Web site at www.acc.organd the AHA Web site at www.americanheart.org(ask for reprint no. 71-0206). To obtain a reprint of the shorter version (executive summary and summary of recommendations) to be published in the June 15, 2001 issue of the Journal of the American College of Cardiology and the June 19, 2001 issue of Circulation for $5 each, call 800-253-4636 (US only) or write the American College of Cardiology, Educational Services, 9111 Old Georgetown Road, Bethesda, MD 20814-1699. To purchase additional reprints up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1,000 or more copies, call 214-706-1466, fax 214-691-6342, or E-mail: pubauth@heart.org(ask for reprint no. 71-0205). J Am Coll Cardiol 2001. [DOI: 10.1016/s0735-1097(01)01345-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Kuroda Y, Hara K, Nakajima H, Ikari Y. Short-term outcome of stent implantation in saphenous vein grafts: predictors of distal embolization and restenosis. JAPANESE CIRCULATION JOURNAL 2001; 65:265-70. [PMID: 11316120 DOI: 10.1253/jcj.65.265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The present study, which aimed to determine the predictors of distal embolization and restenosis after stenting for vein graft disease, retrospectively analyzed 51 consecutive patients who underwent stent implantation for diseased saphenous vein grafts. Follow-up angiography was performed 6 months after the procedure and the clinical and angiographic variables were analyzed by multivariate logistic regression to determine the predictors of distal embolization and restenosis. Initial clinical success was achieved in 49 patients, 44 of whom underwent follow-up angiography and were enrolled in the retrospective analysis. Distal embolization occurred in 6 grafts (13.6%). Multivariate analysis showed that the lesion length and the total cholesterol level were independent predictors of distal embolization. Angiographic restenosis occurred in 13 (26.5%) of 49 lesions. The minimum luminal diameter and the percent diameter stenosis after stenting were associated with the occurrence of restenosis. Multivariate analysis of lesions located in the graft body identified graft age as an independent predictor of restenosis. Distal embolization can occur after vein graft stenting, especially in patients with hypercholesterolemia and diffuse stenosis. The post-stenting minimum luminal diameter and the percent diameter stenosis are predictors of restenosis. In particular, graft age is associated with the restenosis of graft body lesions.
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Affiliation(s)
- Y Kuroda
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
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21
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Khan MA, Liu MW, Chio FL, Yates VB, Chapman GD, Misra VK, Sweeney A, Dean LS. Effect of abciximab on cardiac enzyme elevation after transluminal extraction atherectomy (TEC) in high-risk saphenous vein graft lesions: comparison with a historical control group. Catheter Cardiovasc Interv 2001; 52:40-4. [PMID: 11146520 DOI: 10.1002/1522-726x(200101)52:1<40::aid-ccd1010>3.0.co;2-f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Saphenous vein graft (SVG) intervention has been associated with an increased incidence of distal embolization. Long lesions and lesions associated with thrombus are particularly at increased risk. This study was performed to determine whether abciximab may decrease this risk in high risk SVG angioplasty. From June 1994 to June 1998, 84 patients with at least one high risk factor, i.e., lesion length >20 mm or angiographic evidence of thrombus, underwent Transluminal extraction atherectomy (TEC) procedure followed by balloon dilatation or stenting. Of these 84 patients, 37 who had procedure after September 1995 underwent TEC with abciximab (Abciximab Group) and 47 who had their procedure before that date had TEC without abciximab thereby serving as historic control (Non-Abciximab Group). All patients had normal pre-procedure CK and CK-MB. Total creatine kinase (CK) and CK-MB were measured every 8 hr post-procedure for 24 hr. Baseline demographics, angiographic characteristics, incidence of LV dysfunction and triple vessel disease were similar between the two groups. Graft age was similar between two groups (122 +/- 70 vs. 117 +/- 54 months). Graft diameter, pre and post-procedure percent stenoses were not different between the two groups. Stents were used in 65% in the Abciximab group and 45% in Non-Abciximab group (P = 0. 14). There was no in-hospital repeat PTCA, urgent bypass surgery, or cardiac death. There was no difference between the two groups in regards to the incidence of any elevation of total CK (27% vs. 21. 3%) or CK-MB (54% vs. 51%). When used in conjunction with TEC in treating high risk vein graft lesions, abciximab did not reduce post procedure CK-MB elevation in this patient population.
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Affiliation(s)
- M A Khan
- Department of Medicine, Division of Cardiovascular Disease, The University of Alabama at Birmingham, 35294-0012m USA
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22
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Fasseas P, Orford JL, Denktas AE, Berger PB. Distal protection devices during percutaneous coronary and carotid interventions. CURRENT CONTROLLED TRIALS IN CARDIOVASCULAR MEDICINE 2001; 2:286-291. [PMID: 11806815 PMCID: PMC64830 DOI: 10.1186/cvm-2-6-286] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Distal embolization of particulate matter complicates percutaneous coronary and peripheral interventions more often than had been recognized until recently. A number of distal protection devices are under development. The PercuSurge GuardWiretrade mark is a balloon occlusion thrombectomy device approved by the United States Food and Drug Administration for saphenous vein graft intervention. A number of filter devices utilize an expandable filter mounted on the angioplasty guidewire to facilitate entrapment of particles and safe removal. The Parodi Anti-Emboli Systemtrade mark is an example of a catheter occlusion device that establishes protection by reversing blood flow in the target vessel.
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Affiliation(s)
- Panayotis Fasseas
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
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23
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Bhargava B, Kornowski R, Mehran R, Kent KM, Hong MK, Lansky AJ, Waksman R, Pichard AD, Satler LF, Leon MB. Procedural results and intermediate clinical outcomes after multiple saphenous vein graft stenting. J Am Coll Cardiol 2000; 35:389-97. [PMID: 10676686 DOI: 10.1016/s0735-1097(99)00564-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We evaluated the early and mid-term (18-month) clinical events in a consecutive series of patients undergoing a nonstaged multiple saphenous vein grafting (SVG) intervention with stents as compared with a single SVG stent procedure. BACKGROUND Saphenous vein graft angioplasty has been limited by high rates of distal embolization, myocardial infarction, restenosis and late mortality. It is unknown whether stenting of multiple, different SVGs at the same setting is associated with higher risk. METHODS We evaluated in-hospital and mid-term clinical outcomes (death, Q wave myocardial infarction [MI] and repeat revascularization rates up to 18 months) in 70 consecutive patients treated with coronary stents in 2 (93% of patients) or 3 SVGs, as compared with 649 patients undergoing stenting of a single SVG between January 1, 1994 and December 31, 1997. RESULTS Overall procedural success was obtained in 97% of patients with 2 or 3 SVGs and 97% of patients with a single SVG (p = 0.94). Procedural complications were also similar (2.8% for multiple SVGs vs. 2.7% for a single SVG, p = 0.94). There was a higher prevalence of periprocedural non-Q wave MI (28% vs. 16%, p = 0.009) in the multiple SVG group. During follow-up (18 months), target lesion revascularization was 11% in multiple SVG and 15% in single SVG interventions (p = 0.19), and repeat revascularization (calculated per treated patient) was also similar for both groups (19% vs. 18%, p = 0.94). There was no difference in death (5.6% vs. 5.3%, p = 0.92) and Q wave MI rate (4.3% vs. 2.9%, p = 0.55) after the multiple SVG intervention. Overall cardiac event-free survival was similar for both groups (62% vs. 60%, p = 0.75). The study was powered to detect a clinically meaningful difference of 10% in mortality; smaller differences could not be evaluated on the basis of this sample size. CONCLUSIONS Simultaneous stenting of multiple SVGs in carefully selected patients has similar in-hospital procedural success and major complications rates, as well as mid-term (18-month) clinical outcomes, as compared with single SVG stenting. Thus, multiple SVG interventions using stents may be a viable revascularization strategy for carefully selected patients and suitable lesions in multiple SVG disease.
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Affiliation(s)
- B Bhargava
- Cardiac Catheterization Laboratory, Division of Cardiology, Washington Hospital Center, Washington, DC, USA
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24
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Webb JG, Carere RG, Virmani R, Baim D, Teirstein PS, Whitlow P, McQueen C, Kolodgie FD, Buller E, Dodek A, Mancini GB, Oesterle S. Retrieval and analysis of particulate debris after saphenous vein graft intervention. J Am Coll Cardiol 1999; 34:468-75. [PMID: 10440161 DOI: 10.1016/s0735-1097(99)00196-5] [Citation(s) in RCA: 152] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study was designed to evaluate the composition and quantity of particulate debris resulting from vein graft intervention. BACKGROUND Distal embolization and "no reflow" are frequent and important complications resulting from angioplasty of diseased saphenous vein grafts. Little is known about the composition and quantity of embolic particulate debris associated with vein graft intervention, and no intervention has been shown to protect against its clinical consequences. METHODS A catheter system, designed to contain, retrieve and protect against distal embolization of this material, was evaluated during 27 percutaneous interventional saphenous vein graft procedures. Clinical, angiographic and pathologic analyses were performed. RESULTS The duration of distal graft occlusion required to allow intervention and subsequent debris removal was 150 +/- 54 s, decreasing as experience was gained. Thrombolysis in Myocardial Infarction trial (TIMI) flow grade increased from 2.6 +/- 0.8 to 3.0 +/- 0.0. Creatine kinase (CK) rose above normal in three patients (11.1%) exceeding 3x normal in one (3.7%) resulting in the diagnosis of non-Q-myocardial infarction. Particulate material was identified following 21 of 23 procedures suitable for analysis. Particle size was 204 +/- 57 microm in the major axis and 83 +/- 22 microm in the minor axis. Particles consisted predominantly of soft acellular atheromatous material, such as that typically found under a fibrous cap. Semiquantitative analysis suggested that the quantity of particulate material was less following stenting than following balloon dilation. CONCLUSIONS Particulate matter is commonly present following routine angioplasty and stenting of saphenous vein grafts. Containment, retrieval and analysis of this particulate debris are all feasible. Comparison to prior clinical experience is limited by small sample size. However, to the extent that these particles may contribute to distal embolization, no-reflow and infarction, such a system may contribute to the reduction of complications following vein graft intervention.
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Affiliation(s)
- J G Webb
- St. Paul's Hospital, University of British Columbia, Vancouver, Canada.
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25
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Abstract
BACKGROUND Previous studies in humans have indicated that there is less ischemic dysfunction during PTCA when ischemic preconditioning is elicited. However, the clinical relevance of these observations remains unclear. The present study design tests the hypothesis that PTCA performed to elicit the preconditioning response would result in less myocardial necrosis as assessed by postprocedure creatine kinase (CK) levels. METHODS AND RESULTS Patients (n=150) undergoing PTCA for unstable ischemic syndromes were randomly assigned to receive a previously validated approach to PTCA-mediated preconditioning (PC) or an unrestricted approach to balloon angioplasty (UC). CK levels were determined at 8, 12, and, if necessary, 24 hours. Clinical success rates were equivalent for the 2 groups. However, the frequency of any CK elevation was significantly higher in the UC group (25%) than in the PC group (7. 1%) (P<0.005). Multivariable analysis confirmed a significant effect of preconditioning on CK release. CONCLUSIONS A standardized protocol to elicit preconditioning during PTCA results in a significant reduction in the rate of CK elevation in a high-risk population. These observations support the clinical relevance of ischemic preconditioning in humans.
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Affiliation(s)
- W K Laskey
- Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.
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26
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SHUBROOKS SAMUELJ. Update on Interventions in Saphenous Vein Grafts. J Interv Cardiol 1998. [DOI: 10.1111/j.1540-8183.1998.tb00186.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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27
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Silva JA, White CJ, Collins TJ, Ramee SR. Morphologic comparison of atherosclerotic lesions in native coronary arteries and saphenous vein graphs with intracoronary angioscopy in patients with unstable angina. Am Heart J 1998; 136:156-63. [PMID: 9665233 DOI: 10.1016/s0002-8703(98)70196-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Coronary vein grafts develop accelerated atherosclerosis after aortocoronary bypass surgery. Previous pathologic studies have suggested that the morphologic appearance of atherosclerotic lesions in saphenous vein grafts may have subtle differences compared with those of native coronary arteries and may be more prone to disruption and thrombus formation. However, a comparative in vivo assessment of the angioscopic morphology differences between these two types of vessels has not been reported previously. We compared the angioscopic lesion morphology of native coronary arteries and saphenous vein grafts in patients with unstable angina. METHODS AND RESULTS Percutaneous coronary angioscopy was performed in 60 consecutive patients with unstable angina. Plaque color, texture, friability, and the presence of atherosclerotic plaque ulceration or intracoronary thrombus were noted in the culprit lesion. The culprit lesion was located in native coronary arteries in 42 (70%) patients and in a saphenous vein graft in 18 (30%) patients. There were no significant differences in age, sex, and coronary risk factors including tobacco use, hypertension, hypercholesterolemia, or diabetes mellitus between the two populations. There were also no significant differences between the two groups in terms of plaque color, surface texture, or the incidence of complex plaque morphology (plaque ulceration and intracoronary thrombosis). Loosely adherent, friable plaque, detected by angioscopy, was absent in native coronary arteries and was present in 44% of the saphenous vein grafts (p < 0.0001). CONCLUSIONS The results of our angioscopic study indicate that other than a high incidence of plaque friability in vein grafts, the surface morphology of culprit lesions in unstable angina patients is quite similar for saphenous vein grafts and native coronary arteries.
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Affiliation(s)
- J A Silva
- Department of Internal Medicine, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, LA 70121, USA
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28
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Califf RM, Abdelmeguid AE, Kuntz RE, Popma JJ, Davidson CJ, Cohen EA, Kleiman NS, Mahaffey KW, Topol EJ, Pepine CJ, Lipicky RJ, Granger CB, Harrington RA, Tardiff BE, Crenshaw BS, Bauman RP, Zuckerman BD, Chaitman BR, Bittl JA, Ohman EM. Myonecrosis after revascularization procedures. J Am Coll Cardiol 1998; 31:241-51. [PMID: 9462562 DOI: 10.1016/s0735-1097(97)00506-8] [Citation(s) in RCA: 360] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The detection of elevated cardiac enzyme levels and the occurrence of electrocardiographic (ECG) abnormalities after revascularization procedures have been the subject of recent controversy. This report represents an effort to achieve a consensus among a group of researchers with data on this subject. Creatine kinase (CK) or CK-MB isoenzyme (CK-MB) elevations occur in 5% to 30% of patients after a percutaneous intervention and commonly during coronary artery bypass graft surgery (CABG). Although Q wave formation is rare, other ECG changes are common. The rate of detection is highly dependent on the intensity of enzyme and ECG measurement. Because most events occur without the development of a Q wave, the ECG will not definitively diagnose them; even the ECG criteria for Q wave formation signifying an important clinical event have been variable. At least 10 studies evaluating > 10,000 patients undergoing percutaneous intervention have demonstrated that elevation of CK or CK-MB is associated not only with a higher mortality, but also with a higher risk of subsequent cardiac events and higher cost. Efforts to identify a specific cutoff value below which the prognosis is not impaired have not been successful. Rather, the risk of adverse outcomes increases with any elevation of CK or CK-MB and increases further in proportion to the level of intervention. This information complements similar previous data on CABG. Obtaining preprocedural and postprocedural ECGs and measurement of serial cardiac enzymes after revascularization are recommended. Patients with enzyme levels elevated more than threefold above the upper limit of normal or with ECG changes diagnostic for Q wave myocardial infarction (MI) should be treated as patients with an MI. Patients with more modest elevations should be observed carefully. Clinical trials should ensure systematic evaluation for myocardial necrosis, with attention paid to multivariable analysis of risk factors for poor long-term outcome, to determine the extent to which enzyme elevation is an independent risk factor after considering clinical history, coronary anatomy, left ventricular function and clinical evidence of ischemia. In addition, tracking of enzyme levels in clinical trials is needed to determine whether interventions that reduce periprocedural enzyme elevation also improve mortality.
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Affiliation(s)
- R M Califf
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA.
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29
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van Ommen VG, van den Bos AA, Pieper M, den Heyer P, Thomas MR, Ozbeck S, Bär FW, Wellens HJ. Removal of thrombus from aortocoronary bypass grafts and coronary arteries using the 6Fr Hydrolyser. Am J Cardiol 1997; 79:1012-6. [PMID: 9114756 DOI: 10.1016/s0002-9149(97)00039-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study evaluates the feasibility and safety of a 6Fr hydrodynamic thrombectomy catheter, the Hydrolyser, in native coronary arteries and aortocoronary bypass grafts. With use of a conventional contrast injector, saline solution is injected into the narrow lumen of the catheter which makes a 180 degrees bend at the tip. The resultant high-velocity jet (150 km/hour) is directed over a sidehole near the tip into a wide exhaust lumen. As a consequence of the Venturi effect, thrombus is sucked into that sidehole, fragmented, and removed through the wide exhaust lumen into a collection bag. Thirty-one thrombotic lesions were treated in 31 patients. The culprit vessel was a venous graft in 21 patients (15 with Thrombolysis in Myocardial Infarction Trial [TIMI] grade 0 or 1 flow) and a coronary artery in 11 patients (9 with grade 0 or 1 flow). Twenty-six patients had angina New York Heart Association functional class III or IV heart failure and 5 an acute myocardial infarction. In 26 patients, Hydrolyser therapy was the primary treatment, whereas in 5 patients coronary angioplasty preceded Hydrolyser therapy. In 1 patient the Hydrolyser could not reach the lesion. Thrombus was removed in 29 of the 31 patients. Successful reperfusion (TIMI grade 2 or 3 flow) by Hydrolyser therapy alone was achieved in 14 of the 24 patients with TIMI grade 0 or 1 flow before the procedure. Adjunctive therapy (coronary angioplasty, stent, or thrombolysis) was performed in 28 of the 31 patients. At the end of the total procedure 24 patients had TIMI grade 3 flow. Distal embolization during thrombectomy occurred in 2 patients, which led to a non-Q-wave infarction in 1. No patient died or needed emergency coronary bypass due to the Hydrolyser procedure. Thus, thrombectomy using the 6Fr Hydrolyser is feasible and was performed safely in 31 patients.
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Affiliation(s)
- V G van Ommen
- Department of Cardiology, Academic Hospital Maastricht, The Netherlands
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30
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INOUE TERUO, HOSHI KAZUHIRO, MIZOGUCHI KEIICHI, SHIMIZU MINORU, SAKAI YOSHIHIKO, MOROOKA SHIGENORI. Cutting Balloon Angioplasty for a Restenosis Lesion at the Distal Anastomosis of a Saphenous Vein Graft. J Interv Cardiol 1997. [DOI: 10.1111/j.1540-8183.1997.tb00019.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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31
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Gurbel PA, Criado FJ, Curnutte EA, Patten P, Secada-Lovio J. Percutaneous revascularization of an extensively diseased saphenous vein bypass graft with a saphenous vein-covered Palmaz stent. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1997; 40:75-8. [PMID: 8993819 DOI: 10.1002/(sici)1097-0304(199701)40:1<75::aid-ccd13>3.0.co;2-t] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A 68-year-old man developed unstable angina 12 years following coronary artery bypass surgery. Angiography revealed an extensive area of severe stenosis and diminished distal flow in a right coronary artery vein bypass graft. Given the high distal embolism rate associated with conventional catheter-based treatment of old degenerated vein grafts, the diseased area was "relined" with a composite autologous saphenous vein-covered stent. The procedure was performed using modifications of standard PTCA methods and resulted in a widely patent, smooth lumen. This initial case demonstrates that a degenerated saphenous vein graft can be successfully revascularized with an autologous saphenous vein-covered stent in an attempt to minimize the potential complications of standard catheter-based revascularization methods.
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MESH Headings
- Aged
- Angina, Unstable/diagnosis
- Angina, Unstable/etiology
- Angina, Unstable/therapy
- Angioplasty, Balloon, Coronary/instrumentation
- Angioplasty, Balloon, Coronary/methods
- Cardiac Catheterization
- Coronary Artery Bypass/adverse effects
- Follow-Up Studies
- Graft Occlusion, Vascular/diagnosis
- Graft Occlusion, Vascular/etiology
- Graft Occlusion, Vascular/therapy
- Humans
- Male
- Saphenous Vein/transplantation
- Stents
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Affiliation(s)
- P A Gurbel
- Division of Cardiology, Union Memorial Hospital, Baltimore, Maryland, USA
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32
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Misumi K, Matthews RV, Sun GW, Mayeda G, Burstein S, Shook TL. Reduced distal embolization with transluminal extraction atherectomy compared to balloon angioplasty for saphenous vein graft disease. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 39:246-51. [PMID: 8933966 DOI: 10.1002/(sici)1097-0304(199611)39:3<246::aid-ccd8>3.0.co;2-e] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Extraction atherectomy utilizes suction aspiration as an attempt to limit distal emboli during atherectomy. We sought to test the hypothesis that extraction atherectomy produces less distal embolization than balloon angioplasty when treating saphenous vein grafts. Among 163 consecutive, nonrandomized patients, 103 patients underwent transluminal extraction catheter (TEC) atherectomy with or without adjunctive balloon angioplasty, and 60 patients had conventional balloon angioplasty. Both groups showed comparably high procedural success rates (TEC 90.3%, angioplasty 83.3%, P = NS). TEC cases had a significantly lower incidence of angiographic distal embolization, compared with angioplasty (3.9% vs. 16.7%, P = 0.005). In cases with angiographic evidence of thrombus in the grafts, TEC maintained a significantly lower incidence of distal embolization than angioplasty (5.6% vs. 31.8%, P = 0.004). There were no statistical differences between the two groups regarding the incidence of other procedure-related complications, including death, myocardial infarction, or emergency coronary artery bypass grafting. TEC atherectomy appears to have a significantly lower incidence of distal embolization than balloon angioplasty when treating saphenous vein grafts, particularly in the presence of angiographically apparent thrombus.
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Affiliation(s)
- K Misumi
- Heart Institute, Good Samaritan Hospital, Los Angeles, CA 90017, USA
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33
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Kaplan BM, Safian RD, Grines CL, Goldstein JA, Marsalese DL, Ajluni S, O'Neill WW. Usefulness of adjunctive angioscopy and extraction atherectomy before stent implantation in high-risk aortocoronary saphenous vein grafts. Am J Cardiol 1995; 76:822-4. [PMID: 7572663 DOI: 10.1016/s0002-9149(99)80235-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- B M Kaplan
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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34
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Cardenas JR, Strumpf RK, Heuser RR. Rotational atherectomy in restenotic lesions at the distal saphenous vein graft anastomosis. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1995; 36:53-7; discussion 58. [PMID: 7489594 DOI: 10.1002/ccd.1810360113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Restenotic lesions at distal saphenous vein graft (SVG) anastomoses have been notoriously difficult to treat with standard angioplasty techniques. We explored the potential of rotational atherectomy in three patients with nonthrombotic, focal restenoses at the SVG touch down. The Rotablator safely and successfully recanalized the lesions, allowing further treatment with dilation or stenting or both. Rotational atherectomy may warrant investigation as a treatment for nonthrombotic restenotic SVG lesions.
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Affiliation(s)
- J R Cardenas
- Department of Cardiology, Arizona Heart Institute and Foundation, Phoenix 85006, USA
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35
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Lefkovits J, Holmes DR, Califf RM, Safian RD, Pieper K, Keeler G, Topol EJ. Predictors and sequelae of distal embolization during saphenous vein graft intervention from the CAVEAT-II trial. Coronary Angioplasty Versus Excisional Atherectomy Trial. Circulation 1995; 92:734-40. [PMID: 7641351 DOI: 10.1161/01.cir.92.4.734] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The purpose of this study was to identify the predictors and sequelae of distal embolization from a multicenter, randomized trial of saphenous vein graft intervention. The CAVEAT-II trial demonstrated that saphenous vein graft directional coronary atherectomy (DCA) was associated with greater angiographic success and less need for repeat intervention compared with percutaneous transluminal coronary angioplasty (PTCA) but at the cost of more acute complications--notably distal embolization. METHODS AND RESULTS In CAVEAT-II, 305 patients were randomly assigned to DCA (149 patients) or PTCA (156 patients) for lesions with > 60% diameter stenosis in vein grafts > or = 3 mm in diameter. Distal embolization occurred in 20 patients (13.4%) assigned to DCA and 8 patients (5.1%) assigned to PTCA (P = .011). Independent predictors of distal embolization were use of DCA (71% in distal embolization patients versus 47% in patients without distal embolization, P = .011) and presence of thrombus (39% in distal embolization patients versus 14% in patients without distal embolization, P < .00). In-hospital adverse events were more frequent after distal embolization; 71% versus 20%, odds ratio plus (95% confidence intervals) 9.87 (4.65, 20.94). At 12-month follow-up, adverse event rates were also higher in patients with distal embolization (odds ratio, 3.05 [1.95, 4.76]). CONCLUSIONS In this first prospective multicenter trial of saphenous vein graft intervention, distal embolization was more common after DCA than PTCA and in lesions containing thrombus. It also was associated with worse in-hospital and 12-month outcomes. The risk and sequelae of distal embolization should be considered when choosing a treatment strategy for vein graft disease.
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Affiliation(s)
- J Lefkovits
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA
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36
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Strauss BH, Natarajan MK, Batchelor WB, Yardley DE, Bittl JA, Sanborn TA, Power JA, Watson LE, Moothart R, Tcheng JE. Early and late quantitative angiographic results of vein graft lesions treated by excimer laser with adjunctive balloon angioplasty. Circulation 1995; 92:348-56. [PMID: 7634448 DOI: 10.1161/01.cir.92.3.348] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Percutaneous excimer laser coronary angioplasty (PELCA) has been approved for treatment of diseased saphenous vein bypass grafts. However, detailed and complete quantitative angiographic analysis of immediate procedural and late follow-up results has not been performed. METHODS AND RESULTS PELCA using the CVX-300 excimer laser system was performed in 125 bypass lesions (mean graft age, 96 +/- 53 months; range, 2 to 240 months) in 106 consecutive patients at eight centers. Quantitative analyses of the procedural and follow-up angiograms were done with the Cardiac Measurement System. Stand-alone PELCA was done in 21 lesions (17%). Lesions were located at the ostium (20%), body (67%), or distal anastomosis (13%). The graft reference diameter was 3.26 +/- 0.79 mm (mean +/- SD). Minimal lumen diameter increased from 1.09 +/- 0.52 mm before treatment to 1.61 +/- 0.69 mm after laser and 2.18 +/- 0.63 mm after adjunctive balloon dilation (P < .001) but had declined at follow-up to 1.40 +/- 1.17 mm. Dissections were evident in 45% of lesions after laser treatment (types A and B, 27%; types C through F, 18%), including 7% occlusions. Angiographic success (< or = 50% diameter stenosis [% DS]) was 54% after laser and 91% after adjunctive PTCA, with an overall clinical success rate of 89%. In-hospital complications were death, 0.9%; myocardial infarction (Q-wave and non-Q-wave), 4.5%; and bypass surgery, 0.9%. Independent predictors of % DS after laser were reference diameter, lesion length, and minimal lumen diameter before laser. At angiographic follow-up in 83% of eligible patients, the restenosis rate per lesion (DS > 50%) was 52%, including 23 occlusions (24%). The only independent predictor of increased % DS at follow-up was lesion symmetry. Logistic regression indicated that smaller reference diameter was an independent predictor of late occlusion. Overall 1-year mortality was 8.6%. Actuarial event-free survival (freedom from death, myocardial infarction, bypass surgery, or target vessel percutaneous transluminal coronary angioplasty) was 48.2% at 1 year. CONCLUSIONS Excimer laser angioplasty with adjunctive balloon angioplasty can be safely and successfully performed in diseased, old saphenous vein bypass graft lesions considered at high risk for reintervention. The extent of laser ablation remains limited by the diameter and effectiveness of the catheters. Late restenosis and, in particular, total occlusion mitigate the early benefits of the procedure. Other approaches such as the routine use of additional anticoagulation (eg, warfarin) should be considered to reduce the risk of late occlusions and restenosis after laser angioplasty of bypass grafts.
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Affiliation(s)
- B H Strauss
- Division of Cardiology, St Michael's Hospital, University of Toronto, Ontario, Canada
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Safian RD. Lesion specific approach to coronary intervention. J Interv Cardiol 1995; 8:143-80. [PMID: 10155226 DOI: 10.1111/j.1540-8183.1995.tb00528.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- R D Safian
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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Tan KH, Henderson RA, Sulke N, Cooke RA, Karani S, Sowton E. Percutaneous transluminal coronary angioplasty in patients with prior coronary artery bypass grafting: ten years' experience. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1994; 32:11-7. [PMID: 8039212 DOI: 10.1002/ccd.1810320104] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We evaluated the acute and long-term results of percutaneous transluminal coronary angioplasty in 140 patients with prior coronary artery bypass grafting treated over a 10-year period (1981-1991). Angioplasty was technically successful in 85% of 122 nonoccluded native vessels and in 86% of 50 saphenous vein grafts. Two patients (1.4%) had a myocardial infarction and there were three procedure-related deaths (2.1%). The cumulative probability of survival was 91.5% and 74.5% at 1 and 5 years, respectively. Survival free from myocardial infarction and repeat bypass grafting at 1 and 5 years was 77.3% and 53.9%, respectively. At census, 31% of the 117 survivors were asymptomatic, and 47% were improved by at least two angina grades. Coronary angioplasty provides an apparently safe and effective alternative method of revascularization in selected patients with prior coronary artery bypass grafting. This treatment strategy potentially avoids reoperation with its attendant risks.
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Affiliation(s)
- K H Tan
- Department of Cardiology, Guy's Hospital, London, United Kingdom
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