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Sadr-Ameli M, Mousavi H, Heidarali M, Maadani M, Ghelich Y, Ghadrdoost B. Early and midterm major adverse cardiac events in patient with saphenous vein graft using direct stenting or embolic protection device stenting. Res Cardiovasc Med 2014; 3:e13012. [PMID: 25478526 PMCID: PMC4253743 DOI: 10.5812/cardiovascmed.13012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/24/2013] [Accepted: 11/15/2013] [Indexed: 11/16/2022] Open
Abstract
Background: The treatment of an occluded saphenous vein graft (SVG) with percutaneous coronary intervention may encounter major adverse cardiac events (MACE). MACE rates have been reduced significantly by using the embolic protection device (EPD). Objectives: The aim of this study was to clarify the risks and the benefits of embolic protection devices. Patients and Methods: In a prospective, non-randomized observational study, patients aged 33 to 85 years old who underwent elective percutaneous coronary intervention due to SVG stenosis at our tertiary care center were enrolled between 2009 and 2011. The incidence rates of adverse events, including MACE, were obtained during the patients’ hospitalization and at 30-day and 6-month follow-up. MACE included death, Q-wave and non-Q-wave myocardial infarction, in-stent thrombosis, target lesion revascularization, and target vessel revascularization. Results: From 150 patients enrolled to the study, 128 (85.3%) patients underwent direct stenting and the rest underwent the EPD procedure. In-hospital MACE occurred in 17.2% of the patients in the direct stenting group versus only 9.1% in the EPD group (P = 0.530). MACE incidence was gradually increased at one and 6-month follow-up periods in the direct stenting group (19.5% and 21.9%, respectively), and remained unchanged in the EPD group (9.1% at six-month follow-up). Multivariate logistic regression model showed that the stenting procedure type could not predict early and midterm MACE with the presence of baseline characteristics as cofounders. Conclusions: Despite the considerable lower early and midterm MACE rates, numerically following the EPD procedure compared to direct stenting, the difference in the MACE rates between the two groups was not significant.
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Affiliation(s)
- Mohammadali Sadr-Ameli
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Hossein Mousavi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mona Heidarali
- Cardiac Electrophysiology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mohsen Maadani
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Mohsen Madaani, Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Vali-e-Asr St., Niayesh Blvd, Tehran, IR Iran. Tel: +98-2123923017, Fax: +98-2122663217, E-mail:
| | - Yones Ghelich
- Department of Intervention, 502 Military Hospital, Tehran, IR Iran
| | - Behshid Ghadrdoost
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
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Badr S, Dvir D, Waksman R. Distal anastomotic lesions after coronary artery bypass surgery: incidence, pathogenesis, and treatment approach. Catheter Cardiovasc Interv 2013; 81:1162-8. [PMID: 22888036 DOI: 10.1002/ccd.24582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 07/17/2012] [Indexed: 11/11/2022]
Abstract
Distal anastomotic lesions are the most common reason for venous and arterial graft failure. Redo coronary artery bypass surgery carries a higher risk for mortality and non-fatal myocardial infarction. Many operators therefore consider percutaneous coronary intervention as a good alternative for relieving angina symptoms in this subset of patients with anastomotic lesions. However, the best percutaneous method for treating these lesions is still controversial. Here we review reported data on the incidence, pathogenesis, and treatment of distal anastomotic lesions in both venous and arterial bypass grafts.
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Affiliation(s)
- Salem Badr
- Interventional Cardiology, MedStar Washington Hospital Center, Washington Hospital Center, Washington, District of Columbia 20010, USA
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3
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Hoyt JR, Gurm HS. Drug-Eluting Stents Versus Bare Metal Stents in Saphenous Vein Graft Intervention. Interv Cardiol Clin 2013; 2:283-305. [PMID: 28582136 DOI: 10.1016/j.iccl.2012.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with higher adverse event rates, lower procedural success, and inferior longterm patency rates compared with native vessel PCI. The ability to comply with dual antiplatelet therapy, and whether the patient will need an interruption in dual antiplatelet therapy, should be considered when deciding whether to implant a drug-eluting stent (DES) or bare metal stent (BMS) in an SVG. DES should be used for SVG PCI because they seem to reduce target vessel revascularization. This article reviews the evolution and contemporary evidence regarding use of DES versus BMS in SVG PCI.
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Affiliation(s)
- John R Hoyt
- Division of Cardiovascular Disease, Department of Internal Medicine, University of Michigan Cardiovascular Center, University of Michigan, 1500 East Medical Center Drive, 2381 CVC SPC 5853, Ann Arbor, MI 48109-5853, USA
| | - Hitinder S Gurm
- Division of Cardiovascular Disease, Department of Internal Medicine, University of Michigan Cardiovascular Center, University of Michigan, 1500 East Medical Center Drive, Room 2A394, Ann Arbor, MI 48109-5853, USA.
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Mohan S, Dhall A. A comparative study of restenosis rates in bare metal and drug-eluting stents. Int J Angiol 2012; 19:e66-72. [PMID: 22477592 DOI: 10.1055/s-0031-1278368] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
BACKGROUND Various studies have been performed throughout the world on the rate of restenosis using bare metal stents (BMS) and drug-eluting stents (DES). The prohibitive costs associated with DES generally dictate the type of stent used, especially in developing countries. Therefore, there was a need for a study to assess the effect of various risk factors on restenosis in BMS and DES in the Indian context. A study was performed in the premier institution of the Indian Armed Forces, the Army Hospital (Research and Referral), New Delhi, India, under the aegis of the Indian Council of Medical Research (New Delhi). The profile of patients in the armed forces is inherently diverse in terms of demography, ethnicity, genetics, etc, which reflects the diverse and varied nature of the population in India. METHODS AND RESULTS A total of 130 patients were included in the present study. Follow-up after stent implantation was scheduled for six to nine months following the procedure to assess symptoms, drug compliance, and treadmill test and coronary angiography results, and to ascertain the incidence of restenosis. However, only 80 patients returned for follow-up and, therefore, the final analysis was based on these patients. They were segregated into BMS (n=41) and DES (n=39) groups. Restenosis occurred in 29 patients (36.3%). Nine of 39 patients with DES (23.1%) and 20 of 41 patients with BMS (48.8%) developed restenosis. There was a statistically significant relationship between restenosis and female sex, clinical presentation before intervention and at the time of follow-up evaluation (unstable angina), hypertension, positive stress test and compliance with medical therapy (P<0.05). No statistically significant relationship was observed between restenosis and age, diabetes, smoking, obesity and diet (P>0.05). CONCLUSIONS DES appear to reduce the restenosis rate and clinical end points, and appear to be more cost effective than BMS. Patient-related factors (eg, sex, hypertension and unstable angina) are important variables that affect the restenosis rate. Noninvasive stress testing had high positive and negative predictive values. Therefore, based on the present study, noninvasive stress testing is suggested before routine angiography at follow-up, which will reduce the need for repeat coronary angiography.
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Affiliation(s)
- Shilpi Mohan
- Department of Cardiology, Army Hospital (Research and Referral), and Indian Council of Medical Research, New Delhi, India
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5
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Porto I, Belloni F, Niccoli G, Larosa C, Leone AM, Burzotta F, Trani C, De Maria GL, Hamilton-Craig C, Crea F. Filter no-reflow during percutaneous coronary intervention of saphenous vein grafts: incidence, predictors and effect of the type of protection device. EUROINTERVENTION 2011; 7:955-61. [DOI: 10.4244/eijv7i8a151] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ziakas A, Klinke P, Mildenberger R, Fretz E, Williams M, Della Siega A, Kinloch D, Hilton D. A comparison of the radial and the femoral approach in vein graft PCI. A retrospective study. ACTA ACUST UNITED AC 2009; 7:93-6. [PMID: 16093218 DOI: 10.1080/14628840510011270] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Transradial PCI is a safe and effective method of percutaneous revascularization. However, there is limited data on the efficacy of the transradial approach for saphenous vein graft (SVG) PCI. METHODS We studied 334 patients who underwent SVG PCI between January 2000 and December 2003, and compared the radial (132 patients) and the femoral (202 patients) approach. RESULTS Mean EF (55.6+/-18.6% radial versus 58.1+/-16.8% femoral), lesion location (proximal, mid, distal: 22.6/50.6/26.7% versus 22.6/44.5/32.9% respectively) and lesion type (B1/B2/C: 3.4/4.1/92.5% versus 0.4/3.1/96.5%) were similar in both groups (P>0.05). Five patients had a failed radial attempt (3.8%) and were switched to the femoral approach. Mean fluoroscopy time (20.4+/-12.2 versus 18.4+/-10.2 min), procedural time (60.0+/-27.2 versus 61.6+/-24.9 min) and the use of contrast (223+/-91 versus 234+/-91 ml) IIB/IIIA inhibitors (27.2 versus 33.2%), and stenting (81.5 versus 81.3%) were similar in both groups, whereas 5 or 6 French sheaths were used more often in the radial group (83.4 versus 64.9%, P<0.01). Angiographic success (93.9 versus 92.9%), in hospital MACE (radial:5 MI (3.8%) versus femoral: 1 death (0.5%) and 7 MI (3.5%) and major vascular complications (0.7 versus 0.5%) were also similar. CONCLUSIONS The radial approach in SVG PCI is as fast and successful as the femoral.
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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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MINUTELLO ROBERTM, BHAGAN SHERRITA, SHARMA ATUL, SLOTWINER ALEXANDERJ, FELDMAN DMITRIYN, CUOMO LINDAJ, WONG SCHIU. Long-Term Clinical Benefit of Sirolimus-Eluting Stents Compared to Bare Metal Stents in the Treatment of Saphenous Vein Graft Disease. J Interv Cardiol 2007; 20:458-65. [DOI: 10.1111/j.1540-8183.2007.00301.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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10
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Interventional treatment of vein graft disease. Eur Surg 2007. [DOI: 10.1007/s10353-007-0318-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Uchida T, Bakhai A, Almonacid A, Shibata T, Cox B, Kuntz RE. A meta-analysis of randomized controlled trials of intracoronary gamma- and beta-radiation therapy for in-stent restenosis. Heart Vessels 2006; 21:368-74. [PMID: 17143713 DOI: 10.1007/s00380-006-0919-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2005] [Accepted: 03/31/2006] [Indexed: 10/23/2022]
Abstract
We assessed the effectiveness of intracoronary brachytherapy and compared treatment effects for the two radiation sources as well as the performance of the procedure in saphenous vein grafts (SVG) and native coronary arteries. Five randomized controlled trials comparing intracoronary brachytherapy with placebo involving a total of 1310 patients were reviewed for a meta-analysis. Risk differences (RD) for major adverse cardiac events (MACE), target vessel revascularization, target lesion revascularization, and angiographic binary restenosis at 6-12 months were computed, and a meta-regression analysis of MACE was performed. For MACE, the RD was 0.19 (95% confidence interval [CI], 0.09%-0.29%; P value, 0.00); there was significant between-study variance of 0.2395. In univariate meta-regression analyses, diabetes was a significant factor for the between-study variance (P value, 0.000). In multivariate meta-regression analyses adjusted for diabetes and lesion length, neither gamma-radiation source nor SVG was a significant factor for the between-study variance (P value, 0.675 and 0.433, respectively); the adjusted between-study variance was 0.000. Intra-coronary brachytherapy is effective compared with placebo at mid-term follow up. Neither procedure in SVG (gamma radiation) nor difference in radiation source (beta or gamma) in native coronary arteries was a significant factor in brachytherapy effectiveness compared to placebo.
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Hara H, Nakamura M, Palmaz JC, Schwartz RS. Role of stent design and coatings on restenosis and thrombosis. Adv Drug Deliv Rev 2006; 58:377-86. [PMID: 16650911 DOI: 10.1016/j.addr.2006.01.022] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2005] [Accepted: 01/31/2006] [Indexed: 10/24/2022]
Abstract
More than 15 years have passed since stent technology was introduced by Sigwart et al. [U. Sigwart, J. Puel, V. Mirkovitch, F. Joffe, et al. Intravascular stents to prevent occlusion and restenosis after transluminal angioplasty. N. Engl. J. Med. 316 (1987) 701-706.] among interventional cardiologists. Recently drug eluting stents have assumed dominance in the interventional world as positive trial results revealed their efficacy for preventing restenosis. Stent design, delivery-vehicle materials, and drug properties affect the function of these stents. Stainless steel stents with tubular and multicellular design have proven superior to coil or hybrid stent models. This chapter describes stents which have subtle influences of modular design, metal coverage, strut thickness, strut shape, surface smoothness, and coating materials like an alloy composition.
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Affiliation(s)
- Hidehiko Hara
- Minnesota Cardiovascular Research Institute, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, 920 East 28th Street Suite 620, Minneapolis, MN, 55407, USA
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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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Abstract
The introduction and widespread use of coronary stents have been the most important advancement in the percutaneous treatment of coronary artery disease since the introduction of balloon angioplasty. Coronary artery stents reduce the rate of angiographic and clinical restenosis compared to balloon angioplasty. This angiographic restenosis was further reduced with the introduction of drug-eluting stents and hence further reduction in the frequency of major adverse cardiac events. Herein we present a comprehensive and up-to-date review about the use of drug-eluting stents in the treatment of coronary artery disease.
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Rha SW, Kuchulakanti P, Ajani AE, Cheneau E, Pinnow EE, Canos DA, Torguson R, Pichard AD, Satler LF, Kent KM, Ramee S, Teirstein P, Lindsay J, Waksman R. Three-year follow-up after intravascular γ-radiation for in-stent restenosis in saphenous vein grafts. Catheter Cardiovasc Interv 2005; 65:257-62. [PMID: 15864805 DOI: 10.1002/ccd.20372] [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: 11/06/2022]
Abstract
The Washington Radiation for In-Stent Restenosis Trial in Saphenous Vein Grafts (SVG WRIST) demonstrated safety and efficacy of intravascular radiation therapy (IRT) for the treatment of in-stent restenosis (ISR) in SVG at 12 months. In this study, we aimed to examine whether the safety and efficacy of IRT is durable up to 36 months. One hundred twenty patients with diffuse ISR in SVG underwent balloon angioplasty, laser or atherectomy ablation, and/or additional stenting. After successful intervention, patients were randomly assigned in a double-blind fashion to intravascular treatment with a ribbon containing either iridium (Ir)-192 (n = 60) or nonradioactive seeds (n = 60). The prescribed dose at 2 mm from the source was either 14 or 15 Gy in vessels 2.5-4.0 mm or 18 Gy in vessels > 4.0 mm in diameter. At 36 months, target lesion revascularization (TLR; 43% vs. 66%; P = 0.02) and target lesion revascularization-major adverse cardiac event (TLR-MACE; 49% vs. 71%; P = 0.02) rates continued to be lower in the IRT group, but both target vessel revascularization (TVR; 59% vs. 71%; P = 0.17) and TVR-MACE (63% vs. 77%; P = 0.11) rates were not. In SVG WRIST, patients with ISR treated with IRT had a marked reduction in the need for repeat TLR at 36 months, with sustained clinical benefit at 3 years despite late recurrences, which were more pronounced in the radiation group.
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Affiliation(s)
- Seung-Woon Rha
- Division of Cardiology, Washington Hospital Center, Washington, District of Columbia 20010, USA
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Ge L, Iakovou I, Sangiorgi GM, Chieffo A, Melzi G, Cosgrave J, Montorfano M, Michev I, Airoldi F, Carlino M, Corvaja N, Colombo A. Treatment of saphenous vein graft lesions with drug-eluting stents. J Am Coll Cardiol 2005; 45:989-94. [PMID: 15808752 DOI: 10.1016/j.jacc.2004.11.060] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2004] [Revised: 10/29/2004] [Accepted: 11/02/2004] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The purpose of the present report was to evaluate clinical and angiographic outcomes of drug-eluting stent (DES) implantation in saphenous vein graft (SVG) lesions. BACKGROUND The safety and efficacy of DES implantation for the treatment SVG lesions remains uncertain. METHODS We evaluated in-hospital and six-month outcomes in 61 consecutive patients treated with DES in SVG lesions from March 2002 to March 2004 (DES group), as compared to 89 consecutive patients treated with bare-metal stents (BMS) in the 24 months immediately before the introduction of DES (BMS group). Major adverse cardiac events (MACE) including death, myocardial infarction, target lesion revascularization (TLR), and target vessel revascularization (TVR) were recorded in-hospital and at six-month follow-up. RESULTS The rate of in-hospital MACE was similar between the two groups (6.6% vs. 5.6%, p = 1.0). Cumulative MACE at six months was 11.5% in the DES group and 28.1% in the BMS group (p = 0.02). The DES group had a significantly lower incidence of in-segment restenosis (10.0% vs. 26.7%, p = 0.03), TLR (3.3% vs. 19.8%, p = 0.003), and TVR (4.9% vs. 23.1%, p = 0.003). By Cox regression analysis, diabetes (hazard ratio [HR]: 3.03; 95% confidence interval [CI]: 1.33 to 6.90; p = 0.008), usage of BMS (HR: 2.53; 95% CI: 1.07 to 5.97; p = 0.03), and age of SVG (HR: 1.10; 95% CI: 1.02 to 1.19; p = 0.02) were identified as predictors of MACE at six-month follow-up. CONCLUSIONS Compared to BMS implantation, DES implantation in SVG lesions appears safe with favorable and improved mid-term outcomes.
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Affiliation(s)
- Lei Ge
- EMO Centro Cuore Columbus, 48 Via M. Buonarroti, 20145 Milan, Italy.
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Lozano Í, López-Palop R, Pinar E, Saura D, Fuertes J, Rondán J, Suárez E, Valdés M, Morís C. Implante de stent directo en puentes de safena. Resultados inmediatos y a largo plazo. Rev Esp Cardiol 2005. [DOI: 10.1157/13072474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Bejarano J. Mechanical protection of cardiac microcirculation during percutaneous coronary intervention of saphenous vein grafts. Int J Cardiol 2005; 99:365-72. [PMID: 15771915 DOI: 10.1016/j.ijcard.2004.05.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Revised: 04/30/2004] [Accepted: 05/05/2004] [Indexed: 10/26/2022]
Abstract
Saphenous vein bypass grafts permeability is one of the most important limitations of open heart surgery. The risks associated with surgical re-intervention are greater than those associated with the initial procedure. While native coronary arteries usually have fixed, fibrotic or calcified atherosclerotic plaques, the disease in the vein grafts contains soft material. When this material is compressed during percutaneous angioplasty, there is an unfavorable immediate outcome due to distal embolization of thrombus and plaque debris. In addition, the risk of post-procedure adverse events are higher when the grafts have a long time of implantation, due to a greater risk of branch occlusion or no-reflow at the adjacent microcirculation. The clinical consequence is a Non-Q-Wave Myocardial Infarction that is reflected in the increased serum cardiac enzymes. It is because of this complication that the distal protection devices were developed. The purpose of this paper is to review and discuss the current data on the distal protection devices available now for the treatment of degenerative saphenous vein graft disease. Currently, there are two distal protection devices approved in the United States: the Guardwire Balloon and Aspiration (Export) System and the Filter Wire EX. Other devices like the Triactiv System, Angioguard XP/ECW, DOW, MedNova Cardioshield, Medtronic-AVE DPD and the E-Trap Filter are still being studied. The first observational studies showed the safety and efficacy of the approved devices. A large randomized trial initially confirmed a significant decrease of in-hospital and 30-day cardiac adverse events, mainly Non-Q-Wave Myocardial Infarction, when angioplasty was performed with the assistance of the Guardwire System. Subsequently, another randomized study showed an equivalence between the Guardwire System and the Filter Wire EX. Distal protection devices have an acceptable performance, however, further technological improvements are warranted for a quick preparation, delivery and/or retrieval of these devices.
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Affiliation(s)
- Jorge Bejarano
- Miami Heart Institute, Cardiovascular Laboratory, 4701 North Meridian Avenue, Suite 3303, Miami Beach, FL 33140, USA.
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Laarman GJ, Kiemeneij F, Mueller R, Guagliumi G, Cobaugh M, Serruys PW. Feasibility, safety, and preliminary efficacy of a novel ePTFE-covered self-expanding stent in saphenous vein graft lesions: The Symbiot II trial. Catheter Cardiovasc Interv 2005; 64:361-8. [PMID: 15736242 DOI: 10.1002/ccd.20282] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Compared with percutaneous interventions in native coronary arteries, revascularization of saphenous vein graft (SVG) lesions is associated with increased rates of immediate and long-term major adverse cardiac events (MACE). The Symbiot II trial was a multicenter prospective study designed to evaluate the feasibility and safety of a novel self-expanding polytetrafluoroethylene (ePTFE)-covered stent in the treatment of de novo and restenotic SVG lesions. The primary endpoint was MACE through 30 days postprocedure. Successful Symbiot stent deployment was achieved in 75 of 77 patients (97.4%) with SVG lesions < or = 35 mm in length (visual assessment). The procedural success rate (defined as < 30% residual stenosis at the target site and no clinical complications) was 83%, and all study device procedures provided grade 3 TIMI flow postprocedure. Within the first 30 days postprocedure, four patients (5.2%) experienced MACE (defined as death, Q-wave or non-Q-wave myocardial infarction, and clinically driven target vessel revascularization), of whom three patients (3.9%) experienced periprocedural non-Q-wave myocardial infarction. No subacute stent thrombosis was observed over the 6-month follow-up period. No relevant luminal loss at the target site (mean, 0.3 +/- 0.9 mm) was observed in the 58 patients (77.3% of enrolled patients) who underwent quantitative coronary angiography at 6 months. The incidences of binary in-stent restenosis, in-segment restenosis, and target vessel failure (defined as acute and late-term MACE through 6 months postprocedure) were low (7.0%, 8.6%, and 14.3%, respectively). The Symbiot self-expanding ePTFE membrane-covered stent was associated with a high procedural success rate (97.4%), low incidences of MACE at 30 days (5.2%) and 6 months (14.3%), suggesting that it is safe and effective in the treatment of SVG disease.
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Affiliation(s)
- Gerrit J Laarman
- Amsterdam Department of Interventional Cardiology, OLVG, Amsterdam, The Netherlands.
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20
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Hoye A, Lemos PA, Arampatzis CA, Saia F, Tanabe K, Degertekin M, Hofma S, McFadden E, Sianos G, Smits PC, van der Giessen WJ, de Feyter P, van Domburg RT, Serruys PW. Effectiveness of the sirolimus-eluting stent in the treatment of patients with a prior history of coronary artery bypass graft surgery. Coron Artery Dis 2004; 15:171-5. [PMID: 15096998 DOI: 10.1097/00019501-200405000-00006] [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] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Percutaneous coronary intervention in patients with a history of previous coronary artery bypass grafting (CABG) is associated with an increased rate of subsequent adverse events compared to those without prior CABG. We evaluated the impact of utilizing the sirolimus-eluting stent (SES) in this high-risk population. METHODS Since April 2002, SES implantation was utilized as the default strategy for all percutaneous procedures in our hospital. Consecutive patients with a history of previous CABG and de novo lesions (n=47) treated exclusively with SES, were compared to 66 patients who received bare stents in the 6-month period just before SES introduction. RESULTS There were no significant differences between the groups (SES and bare stent) with respect to baseline clinical or lesion characteristics. The only difference between the groups related to the nominal diameter of stent utilized, which was smaller in the SES group than the bare stent group. (The maximum diameter of SES available was 3.0 mm). At 1 year, the cumulative incidence of major adverse events (defined as death, myocardial infarction, or target vessel revascularization) was significantly lower in the SES group than the bare stent group [8.5 versus 30.3%, hazard ratio 0.37 (95% confidence interval 0.15-0.91); P=0.03]. CONCLUSIONS The utilization of the sirolimus-eluting stent for percutaneous intervention in a high-risk population with a history of previous CABG surgery is associated with a significant reduction in the rate of major adverse cardiac events at 1 year.
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Affiliation(s)
- Angela Hoye
- Department of Cardiology, Thoraxcenter, Erasmus Medical Centre, Rotterdam, The Netherlands
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21
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Abstract
PURPOSE OF REVIEW Despite numerous advances in coronary interventional techniques, the frequent occurrence of restenosis continues to plague interventional cardiology. With the widespread use of drug-eluting stents, there is a need to reexamine critically the roles of the various interventional techniques currently available. RECENT FINDINGS Drug-eluting stents have dramatically reduced the rates of restenosis and target vessel revascularization in a wide spectrum of patients with varying lesion morphologies. However, when restenosis does occur, it still tends to be dependent on the same factors that predict restenosis with bare metal stenting. The routine use of drug-eluting stents entails high initial costs to the health care system. Debulking as a means to improve outcomes after angioplasty has not lived up to expectations. Gene therapy is rapidly evolving into a viable means to reduce neointimal proliferation after angioplasty. SUMMARY Careful patient selection and attention to the procedure of stent deployment optimize the results of angioplasty with drug-eluting stents. Because of cost considerations, drug-eluting stents should be used in patients who are expected to have the greatest absolute benefit. In this context, when judiciously used, conventional balloon angioplasty and bare metal stenting still have a definite role in the management of patients with obstructive coronary artery disease.
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Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, Cardiothoracic Sciences Center, All India Institute of Medical Sciences, New Delhi, India
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22
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Costa MA, Gigliotti OS, Zenni MM, Gilmore PS, Bass TA. Synergistic use of sirolimus-eluting stents and intravascular ultrasound for the treatment of unprotected left main and vein graft disease. Catheter Cardiovasc Interv 2004; 61:368-75. [PMID: 14988898 DOI: 10.1002/ccd.10782] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Treating unprotected left main disease and degenerated saphenous vein grafts by percutaneous intervention remains one of the more challenging situations facing interventional cardiologists. We present two cases showing how the use of sirolimus-eluting stents in combination with other novel techniques might alter treatment paradigms in the future.
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Affiliation(s)
- Marco A Costa
- Division of Cardiology, Shands Hospital, University of Florida Health Science Center, Jacksonville, Florida 32209, USA
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23
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Hanekamp CEE, Koolen JJ, Den Heijer P, Schalij MJ, Piek JJ, Bär FWHM, De Scheerder I, Bonnier HJRM, Pijls NHJ. Randomized study to compare balloon angioplasty and elective stent implantation in venous bypass grafts: the Venestent study. Catheter Cardiovasc Interv 2004; 60:452-7. [PMID: 14624420 DOI: 10.1002/ccd.10692] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of the study was to compare acute and long-term angiographic and clinical outcome of balloon angioplasty and elective stenting in de novo lesions in the body of a saphenous vein graft (SVG). A total of 150 patients, with de novo lesions in SVG, were randomly assigned to balloon angioplasty or elective Wiktor I stent implantation. The angiographic restenosis rate at 6-month follow-up was 32.8% in the balloon group and 19.1% in the stent group (P = 0.069). At 1-year follow-up, target vessel revascularization rate was 31.4% vs. 14.5% (P < 0.05), and event-free survival was 60.0% vs. 76.3% (P < 0.05) for the balloon and stent group, respectively. Elective stent implantation in de novo SVG lesions is associated with a significant lower target vessel revascularization rate and a significant higher event-free survival at 1-year follow-up as compared to balloon angioplasty.
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Affiliation(s)
- Clara E E Hanekamp
- Department of Cardiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
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Abstract
Percutaneous coronary interventions represent an attractive alternative to surgical revascularization; nevertheless, these techniques continue to be characterized by their propensity to elicit restenosis. Despite an exhaustive search for an effective pharmacotherapy to treat or prevent restenosis, hundreds of clinical trials have failed to identify an agent with proven therapeutic benefit. Recently, however, the Food and Drug Administration approved intracoronary radiation (brachytherapy) as a viable therapeutic option for in-stent stenosis. In addition, recent randomized trials have shown encouraging results for drug-eluting stents. This article reviews the pathophysiology of restenosis, along with current and future treatment options.
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Affiliation(s)
- Vivek Rajagopal
- Division of Cardiovascular Medicine, Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, California 94305, USA
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25
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Stone GW, Mehran R, Midei M, Waksman R, Schaer GL, Negoita M, Lansky AJ, Buchbinder M. Usefulness of beta radiation for de novo and in-stent restenotic lesions in saphenous vein grafts. Am J Cardiol 2003; 92:312-4. [PMID: 12888142 DOI: 10.1016/s0002-9149(03)00635-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Following successful angioplasty of 49 saphenous vein graft lesions, a novel, self-centering phosphorus-32 solid foil beta source encapsulated within a dual-balloon membrane was used to deliver 20 Gy 1 mm into the vessel wall. Clinical and angiographic recurrence rates at 12 months were low, especially in de novo lesions.
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Affiliation(s)
- Gregg W Stone
- Cardiovascular Research Foundation and Lenox Hill Heart and Vascular Institute, New York, New York 10022, USA.
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26
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Stankovic G, Colombo A, Presbitero P, van den Branden F, Inglese L, Cernigliaro C, Niccoli L, Bartorelli AL, Rubartelli P, Reifart N, Heyndrickx GR, Saunamäki K, Morice MC, Sgura FA, Di Mario C. Randomized evaluation of polytetrafluoroethylene-covered stent in saphenous vein grafts: the Randomized Evaluation of polytetrafluoroethylene COVERed stent in Saphenous vein grafts (RECOVERS) Trial. Circulation 2003; 108:37-42. [PMID: 12821546 DOI: 10.1161/01.cir.0000079106.71097.1c] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment of lesions located in saphenous vein grafts (SVGs) is associated with increased procedural risk and a high rate of restenosis. METHODS AND RESULTS We conducted a randomized, multicenter trial to evaluate the usefulness of a polytetrafluoroethylene (PTFE)-covered stent compared with a bare stainless steel (SS) stent for prevention of restenosis and major adverse cardiac events (MACE) in patients undergoing SVG treatment. The primary end point was angiographic restenosis at 6 months. Secondary end points were 30-day and 6-month MACE rates, defined as the cumulative of death, myocardial infarction (MI), and target lesion revascularization. Between September 1999 and January 2002, 301 patients with SVG lesions were randomized to either the PTFE-covered JoStent coronary stent graft (PTFE group, n=156) or the SS JoFlex stent (control group, n=145). Angiographic and procedural success rates were similar between the 2 groups (97.4% versus 97.9% and 87.3% versus 93.8%, respectively). The incidence of 30-day MACE was higher in the PTFE group (10.9% versus 4.1%, P=0.047) and was mainly attributed to MI (10.3% versus 3.4%, P=0.037). The primary end point, the restenosis rate at 6-month follow-up, was similar between the 2 groups (24.2% versus 24.8%, P=0.237). Although the 6-month non-Q-wave MI rate was higher in the PTFE group (12.8% versus 4.1%, P=0.013), the cumulative MACE rate was not different (23.1% versus 15.9%, P=0.153). CONCLUSIONS The study did not demonstrate a difference in restenosis rate and 6-month clinical outcome between the PTFE-covered stent and the SS stent for treatment of SVG lesions. However, a higher incidence of nonfatal myocardial infarctions was found in patients treated with the PTFE-covered stent.
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27
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Schiele TM, Regar E, Silber S, Eeckhout E, Baumgart D, Wijns W, Colombo A, Rutsch W, Meerkin D, Gershlick A, Bonan R, Urban P. Clinical and angiographic acute and follow up results of intracoronary beta brachytherapy in saphenous vein bypass grafts: a subgroup analysis of the multicentre European registry of intraluminal coronary beta brachytherapy (RENO). Heart 2003; 89:640-4. [PMID: 12748220 PMCID: PMC1767684 DOI: 10.1136/heart.89.6.640] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess clinically and angiographically the feasibility, safety, and effectiveness of vascular brachytherapy (VBT) in saphenous vein bypass grafts (SVG). PATIENTS AND METHODS 67 of 1098 (6.1%) consecutive patients of the European registry of intraluminal coronary beta brachytherapy underwent treatment for 68 SVG lesions by VBT using a Sr/Y(90) source train (BetaCath). Clinical follow up data were obtained for all of them after a mean (SD) of 6.3 (2.4) months and angiographic follow up was performed in 61 patients (91.0%) after 6.9 (2.0) months. RESULTS 58 (86.6%) patients were men, their mean (SD) age was 66 (10) years, 28 (41.8%) had unstable angina, and 21 (31.3%) had diabetes. Fifty three (77.9%) lesions were in-stent restenosis, 13 (19.1%) de novo lesions, and 2 (3.0%) non-stented restenotic lesions. Mean (SD) reference diameter before the intervention was 4.19 (0.52) mm, mean (SD) lesion length was 23.56 (20.38) mm, and mean (SD) minimum lumen diameter measured 0.73 (0.62) mm. Mean (SD) acute gain was 3.02 (0.88) mm. The prescribed radiation dose was 20.1 (3.2) Gy. Pullback manoeuvres were performed in 17 (25.0%) of cases. Most patients received combined aspirin and thienopyridin treatment for 6 or 12 months after the procedure. Technical success was obtained in 62 (91.2%) treated lesions and in-hospital major adverse cardiac events occurred in 4.5%. At follow up, mean (SD) reference diameter was 4.20 (0.53) mm, minimum lumen diameter 2.94 (1.50) mm, and late loss 0.86 (1.25) mm. The overall major adverse cardiac events rate was 26.7%. CONCLUSION VBT of SVG is feasible and safe. At follow up the reintervention rate and cardiac morbidity and mortality seem to be favourable, considering that interventions in SVG usually are associated with the highest risks.
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Affiliation(s)
- T M Schiele
- Medizinische Klinik-Innenstadt, University Hospital, Munich, Germany.
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Ajani AE, Waksman R, Cheneau E, Cha DH, Leborgne L, Sharma AK, Pinnow E, Canos DA, Satler LF, Pichard AD, Kent KM, Torguson R, Lindsay J. Comparison of intracoronary gamma radiation for in-stent restenosis in saphenous vein grafts versus native coronary arteries. Am J Cardiol 2003; 91:22-6. [PMID: 12505566 DOI: 10.1016/s0002-9149(02)02992-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Intracoronary gamma radiation is effective in reducing recurrent in-stent restenosis (ISR) involving native coronary arteries. This study compares the effectiveness and safety of intracoronary gamma radiation for the treatment of ISR in saphenous vein grafts (SVGs) versus native coronary arteries. In the Washington Radiation for In-Stent restenosis Trial (WRIST) series of gamma radiation trials, 1,142 patients with ISR (230 in SVG and 912 in native coronary arteries) completed 6-month clinical follow-up. All patients underwent balloon angioplasty, atherectomy, and/or restenting. Different ribbon lengths containing 6 to 23 seeds of iridium-192 were used to cover lesion lengths <80 mm. The prescribed radiation doses were 14 or 15 Gy at 2-mm radial distance from the center of the source. Baseline demographics showed that patients with SVGs were older (65 +/- 13 vs 61 +/- 11 years, p <0.001), more likely male (79% vs 64%, p <0.001), had more multivessel coronary disease (81% vs 50%, p <0.001), and less diffuse lesions (17 +/- 10 vs 24 +/- 12 mm, p <0.001). At 6 months, event-free survival was similar for patients with SVG ISR and native coronary ISR (82% vs 84%, p = 0.35). The SVG ISR population had a low rate of late total occlusion (4.6%) and late thrombosis (3.5%). Thus, treatment of ISR with gamma radiation in SVGs had similar outcome to native coronary arteries. The use of gamma radiation for the treatment of ISR should expand to SVGs.
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Affiliation(s)
- Andrew E Ajani
- Cardiovascular Research Institute, Washington Hospital Center, Washington, DC 20010, USA
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29
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Affiliation(s)
- Dale T Ashby
- Cardiovascular Research Foundation, New York, New York 10022, USA
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30
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Waksman R, Ajani AE, White RL, Chan RC, Satler LF, Kent KM, Pichard AD, Pinnow EE, Bui AB, Ramee S, Teirstein P, Lindsay J. Intravascular gamma radiation for in-stent restenosis in saphenous-vein bypass grafts. N Engl J Med 2002; 346:1194-9. [PMID: 11961147 DOI: 10.1056/nejmoa012579] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intracoronary radiation therapy is effective in reducing the recurrence of in-stent stenosis in native coronary arteries. We examined the effects of intravascular gamma radiation in patients with in-stent restenosis of saphenous-vein bypass grafts. METHODS A total of 120 patients with in-stent restenosis in saphenous-vein grafts, the majority of whom had diffuse lesions, underwent balloon angioplasty, atherectomy, additional stenting, or a combination of these procedures. If the intervention was successful, the patients were randomly assigned in a double-blind fashion to intravascular treatment with a ribbon containing either iridium-192 or nonradioactive seeds. The prescribed dose, delivered at a distance of 2 mm from the source, was 14 to 15 Gy in vessels that were 2.5 to 4.0 mm in diameter and 18 Gy in vessels with a diameter that exceeded 4.0 mm. The primary end points were death from cardiac causes, Q-wave myocardial infarction, revascularization of the target vessel, and a composite of these events at 12 months. RESULTS Revascularization and radiation therapy were successfully accomplished in all patients. At six months, the restenosis rate was lower in the 60 patients assigned to the iridium-192 group than in the 60 assigned to the placebo group (21 percent vs. 44 percent, P=0.005). At 12 months, the rate of revascularization of the target lesion was 70 percent lower in the iridium-192 group than in the placebo group (17 percent vs. 57 percent, P<0.001), and the rate of major cardiac events was 49 percent lower (32 percent vs. 63 percent, P<0.001). CONCLUSIONS The results of our study support the use of gamma-radiation therapy for the treatment of in-stent restenosis in patients with bypass grafts.
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Affiliation(s)
- Ron Waksman
- Division of Cardiology, Washington Hospital Center and the Washington Cancer Institute, Washington, DC 20010, USA.
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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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Rodés J, Tanguay JF, Bertrand OF, Malekianpour M, Lespérance J, Côté G, Théroux P. Late (> 48 hr) myocardial infarction after PTCA: clinical and angiographic characteristics of infarction related or not to the angioplasty site. Catheter Cardiovasc Interv 2001; 53:155-62. [PMID: 11387598 DOI: 10.1002/ccd.1142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Since late myocardial infarctions after percutaneous coronary interventions have not been well characterized, we intended to evaluate the characteristics of myocardial infarctions occurring > 48 hr after balloon angioplasty of native coronary arteries or saphenous vein grafts. The Montreal Heart Institute database (1985-1996) was interrogated for all patients readmitted with a diagnosis of MI more than 48 hr after successful percutaneous transluminal coronary angioplasty (PTCA). We compared the clinical, procedural, and angiographic variables between MIs related or not to the index PTCA site. One hundred and ninety-three patients presented with late myocardial infarction (MI) following balloon angioplasty. The median time elapsed between PTCA and MI was 55 days compared to 968 days when MI was unrelated to the PTCA site. MIs related to the PTCA site were more likely non-Q-wave (76% vs. 35%, P = 0.0001) with less marked CK-MB rise. Angiography showed less complex lesions (63% vs. 90%, P = 0.001) and better thrombolysis in myocardial infarction (TIMI) grade flow (TIMI II to III, 66% vs. 56%, P = 0.01) when the culprit lesion was at the PTCA site. Independent predictors of MI at the PTCA site were vein graft dilation, female sex, and residual stenosis post-PTCA. Myocardial infarctions occurring late after PTCA have a distinct time course and present specific characteristics according to their relationship or not to the previously dilated site.
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Affiliation(s)
- J Rodés
- Interventional Cardiology Laboratories, Montreal Heart Institute, Quebec, Canada
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33
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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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34
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Heidland UE, Heintzen MP, Michel CJ, Strauer BE. Risk factors for the development of restenosis following stent implantation of venous bypass grafts. Heart 2001; 85:312-7. [PMID: 11179274 PMCID: PMC1729656 DOI: 10.1136/heart.85.3.312] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To analyse the variables involved in the high restenosis rate following stent implantation in coronary artery bypass grafts. DESIGN A retrospective analysis of a consecutive group of patients attending a tertiary centre. PATIENTS The long term angiographic outcome of 219 stent implantations for individual lesions performed in 191 patients was investigated. Multivariate analysis correlated clinical, procedural, and angiographic variables with the incidence of angiographic restenosis, defined as diameter stenosis > 50% at follow up. RESULTS Angiographic restenosis was observed in 34% of lesions treated. Multiple logistic regression analysis defined diabetes mellitus (odds ratio 6.91, 95% confidence interval (CI) 2.43 to 9.69), graft recanalisation (2.89, 95% CI 1.18 to 6.63), lesion at the aortic anastomosis (6.98, 95% CI 2.77 to 21.31), lesion at the coronary anastomosis (3.01, 95% CI 1.19 to 7.69), high diameter stenosis after stent placement (7.21, 95% CI 2.66 to 16.81), placement of long stents (2.73, 95% CI 1.09 to 7.39), and implantation of more than one stent (7.31, 95% CI 2.08 to 19.96) as independent predictors of graft in-stent restenosis. CONCLUSIONS There appears to be a specific risk factor constellation contributing to the high restenosis rate following stent implantation in venous bypass grafts. Critical consideration of these variables may help identify patients who are poor candidates for stent implantation and who may benefit from a different approach.
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Affiliation(s)
- U E Heidland
- School of Internal Medicine, Department of Cardiology, Pneumology and Angiology, Heinrich-Heine-University, Moorenstrasse 5, D-40225 Düsseldorf, Germany.
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Chandrasekar B, Bourassa MG. Incidence and risk factors predictive of unstable angina resulting from restenosis after percutaneous angioplasty of saphenous vein grafts. Am Heart J 2000; 140:827-33. [PMID: 11099984 DOI: 10.1067/mhj.2000.110768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The current study was designed to determine the incidence and risk factors for unstable angina resulting from restenosis in patients undergoing percutaneous transluminal coronary angioplasty (PTCA) of saphenous vein graft (SVG), about which little data are available. METHODS AND RESULTS A retrospective analysis of a consecutive series of 212 patients undergoing PTCA of SVG was performed. Procedural success was achieved in 200 patients (94.3%) who formed the study group. During a follow-up of 16.8 +/- 10.2 months, 24.5% of patients presented with unstable angina resulting from restenosis. There was a higher prevalence of dyslipidemia (81. 6% vs 51.2%, P <.0002) and greater postprocedural residual stenosis (14.2% +/- 12.6% vs 7.1% +/- 11.0%, P =.007) in patients with unstable angina caused by restenosis compared with the remaining patient population. By multivariate analysis, dyslipidemia (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.64-8.39, P <.002) and to a lesser extent postprocedural residual stenosis (OR 1.04, 95% CI 1.01-1.07, P <.05) were predictive of unstable angina resulting from restenosis. Among dyslipidemic patients, those not on lipid-lowering drugs during the index procedure had a significantly higher incidence of unstable angina caused by restenosis than did those on lipid-lowering drugs (P <.05). CONCLUSION Unstable angina caused by restenosis presents in as many as one fourth of patients undergoing PTCA of SVG. Dyslipidemia strongly, and to a lesser extent postprocedural residual stenosis, predicts its occurrence. Scrupulous attention to these modifiable risk factors may help reduce the incidence of unstable angina after SVG angioplasty.
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Affiliation(s)
- B Chandrasekar
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
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Ahmed JM, Hong MK, Mehran R, Pichard AD, Satler LF, Kent KM, Mintz GS, Wu H, Leon MB. Assessing a strategy of initial stand-alone extractional atherectomy followed by staged stent placement in degenerated saphenous vein graft lesions. Am J Cardiol 2000; 86:923-6. [PMID: 11053700 DOI: 10.1016/s0002-9149(00)01123-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
To assess whether a staged strategy (initial stand alone transluminal extraction atherectomy and coumadin therapy followed by stenting six weeks later) could reduce ischemic complications in degenerated saphenous vein graft (SVG) interventions, we studied 72 patients undergoing percutaneous interventions of degenerated SVG. Patients were divided into two groups; 28 were treated with a staged strategy (group I) and 44 with similar lesion characteristics were treated with a definitive initial procedure with transluminal extraction atherectomy +/- adjunctive balloon angioplasty and stenting (group II). Procedural success, major in-hospital complications (death, Q-wave myocardial infarction, and emergent coronary bypass surgery), and incidence of distal embolization were compared between the 2 groups. Procedural success was lower (92% vs 100%, p = 0.14) and major in-hospital complications were higher (0% vs 11%, p = 0.14) in group II. Distal embolization occurred in 11% of the patients in group I compared with 23% of the patients in group II (p = 0.19). At 6 week follow-up (group I), 9 patients (33%) had negative symptoms, 11 (41%) underwent stent implantation, 3 (11%) did not require any further therapy (without significant stenosis), and 4 (14%) had total occlusions. We therefore conclude that this staged strategy in degenerated SVG appears to reduce distal embolization but most importantly avoids major in-hospital complications, including any deaths either at the time of initial procedure or during the 6-week follow-up period.
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Affiliation(s)
- J M Ahmed
- Cardiac Catheterization Laboratory, Washington Hospital Center, DC, USA
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Abstract
Stenting lesions with favorable characteristics as required for inclusion in the STRESS/BENESTENT trials have yielded superior results to that of PTCA alone. Results for less favorable lesions such as in small vessels, diffuse disease, ostial disease, and saphenous vein grafts are less well established. This review seeks to analyze available data for stent placement in this subset of non-STRESS/BENESTENT lesions.
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Affiliation(s)
- P Wong
- Department of Cardiology, National Heart Center, Singapore.
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38
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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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Hong MK, Mehran R, Dangas G, Mintz GS, Lansky A, Kent KM, Pichard AD, Satler LF, Stone GW, Leon MB. Comparison of time course of target lesion revascularization following successful saphenous vein graft angioplasty versus successful native coronary angioplasty. Am J Cardiol 2000; 85:256-8. [PMID: 10955387 DOI: 10.1016/s0002-9149(99)00634-7] [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: 10/16/2022]
Abstract
We studied 1,267 patients with 2,186 saphenous vein graft (SVG) lesions to determine the time course of target lesion revascularization (TLR) after successful SVG angioplasty. We found that the time course of TLR in SVG appears prolonged, with only 54% occurring within the first 6 months and continued TLR even after 1 year.
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Affiliation(s)
- M K Hong
- Division of Cardiology, Cornell--New York Presbyterian Hospital, USA.
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40
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Gruberg L, Hong MK, Mehran R, Mintz GS, Kornowski R, Lansky AJ, Kent KM, Pichard AD, Satler LF, Dangas G, Wu H, Stone GW, Leon MB. In-hospital and long-term results of stent deployment compared with balloon angioplasty for treatment of narrowing at the saphenous vein graft distal anastomosis site. Am J Cardiol 1999; 84:1381-4. [PMID: 10606108 DOI: 10.1016/s0002-9149(99)00580-9] [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: 11/25/2022]
Abstract
Disease at the distal anastomosis site of saphenous vein grafts (SVGs) has been successfully treated with balloon angioplasty, with a lower restenosis rate than at sites of the aortoostial or proximal portion of the SVG. The role of stents for these lesions has not been well defined. To compare the in-hospital and long-term outcome of patients who underwent treatment at this site by either balloon angioplasty or tubular stent implantation, we studied 182 consecutive patients who underwent balloon angioplasty and 77 patients who underwent stenting between January 1994 and August 1997. Baseline clinical characteristics for both groups were similar. Angiographically, SVG stenoses treated with stents were older, longer in lesion length, and more restenotic. The in-hospital outcome was similar for both groups, with 98% procedural success rates and 1% major ischemic complications. Long-term follow-up was obtained for 93% of the patients, for an average of 17 +/- 14 months. The mortality rates were similar for patients who underwent balloon angioplasty and stenting (11.6% vs 13%, p = NS). The Q-wave myocardial infarction rates were also similar (1% vs 0%, p = NS). There was a trend toward a higher rate of target lesion revascularization in the balloon angioplasty group (25% vs 14%, p = 0.058). We conclude that percutaneous revascularization of the SVG distal anastomosis site by either balloon angioplasty or stenting can be performed with a high rate of procedural success and favorable in-hospital and long-term outcomes. Stent deployment may further improve the long-term outcome of these patients by reducing the need for repeat revascularization.
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Affiliation(s)
- L Gruberg
- Cardiac Catheterization Laboratory and the Cardiovascular Research Foundation, Washington Hospital Center, Washington, DC 20010, USA
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Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O'Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert JS, Eagle KA, Garson A, Gregoratos G, Russell RO, Smith SC. ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999; 34:1262-347. [PMID: 10520819 DOI: 10.1016/s0735-1097(99)00389-7] [Citation(s) in RCA: 329] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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42
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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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BENREY JAIME, MESA ANDRES, JAIN SURENDRA, GARCIA-GREGORY JORGEA. Successful Rotational Atherectomy of Mid-Saphenous Vein Graft Lesions. J Interv Cardiol 1999. [DOI: 10.1111/j.1540-8183.1999.tb00233.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Moses JW, Moussa I, Popma JJ, Sketch MH, Yeh W. Risk of distal embolization and infarction with transluminal extraction atherectomy in saphenous vein grafts and native coronary arteries. NACI Investigators. New Approaches to Coronary Interventions. Catheter Cardiovasc Interv 1999; 47:149-54. [PMID: 10376493 DOI: 10.1002/(sici)1522-726x(199906)47:2<149::aid-ccd3>3.0.co;2-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Lower success rates have been reported when treating high-risk lesions in saphenous vein grafts (SVGs) and native coronary arteries with balloon angioplasty. The transluminal extraction atherectomy catheter (TEC) has been proposed to reduce the incidence of distal embolization (DE) in subsets of high-risk lesions. To define the utility of TEC in reducing the incidence of DE, all patients who were enrolled in the New Approaches to Coronary Interventions (NACI) Registry and had TEC planned as the sole treatment were studied (329 patients with 381 lesions). Of the lesions treated, 75.9% were in SVGs; 37.5% were thrombotic; and 15% were total occlusions. Adjunctive percutaneous transluminal coronary angioplasty (PTCA) was performed in 87.4% of lesions. Multivariate predictors of DE were: noncardiac disease, stand alone TEC, thrombus, and larger vessel size. DE was associated with an 18.5% in-hospital mortality vs. 3.0% without DE (P < 0.01) and a 25.9% MI rate vs. 5.0% without DE (P < 0.01). In conclusion, in this high-risk subset of patients, TEC is associated with an 8.3% incidence of DE with thrombotic and SVGs lesions. DE associated with TEC appears to carry high morbidity and mortality. Additional techniques to control DE are needed to reduce the frequency of complications in these patients.
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Affiliation(s)
- J W Moses
- Department of Cardiology, Lenox Hill Hospital, New York, NY 10021, USA.
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Abstract
A coaxial catheter system for containment of distal embolization is described. Utilizing a novel 0.014" hypotube with a distal elastomeric occlusion balloon, the PercuSurge GuardWire functions as a guidewire while trapping distal embolization resulting from more proximal intervention. The particulate debris is evacuated with a single operator exchange aspiration catheter (Export catheter) prior to deflation of the distal occlusion balloon. This animal study confirmed the feasibility of concept. The system was easily delivered through tortuous coronary anatomy. The GuardWire served as an adequate rail for delivery of dilatation balloons and a multitude of stents. There was no evidence of deep wall damage from low-pressure inflation and apposition of the distal occlusion balloon.
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Affiliation(s)
- S N Oesterle
- Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
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46
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Brizolara AA, Stouffer GA. Interesting cases from the University of Texas Medical Branch. Cardiol Clin 1999; 17:401-14. [PMID: 10384835 DOI: 10.1016/s0733-8651(05)70083-7] [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: 11/18/2022]
Abstract
This article discusses the cases for four patients with unstable angina. The first case is an example of the "high-risk" patient with widespread ECG changes, heart failure, and enzymatic elevations during an episode of chest pain. The second patient illustrates an unusual cause of unstable angina in a young women. The third patient had a large thrombus visible on angiography and management strategies for dealing with intracoronary thrombus are discussed. The final patient had an extensive past cardiac history with two prior coronary artery bypass operations and we discuss the recent advances made in the treatment of degenerative vein graft disease.
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Affiliation(s)
- A A Brizolara
- Division of Cardiology, University of Texas Medical Branch, Galveston, USA
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Gao W, Koh TH. Retrograde embolization during saphenous vein graft angioplasty. Catheter Cardiovasc Interv 1999; 46:205-9. [PMID: 10348546 DOI: 10.1002/(sici)1522-726x(199902)46:2<205::aid-ccd20>3.0.co;2-r] [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: 11/07/2022]
Abstract
Angioplasty of degenerated saphenous vein grafts is not infrequently complicated by distal embolization of atheromatous debris. We describe an uncommon case in which balloon angioplasty of an old vein graft to a second diagonal branch of the left anterior descending coronary artery was followed by distal embolization. However, the embolization occurred in a retrograde fashion distal to the anastomotic site, resulting in occlusion of the upstream first diagonal branch. The reasons for its occurrence are discussed, together with suggestions for its recognition.
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Affiliation(s)
- W Gao
- Department of Cardiology, National Heart Centre, Singapore General Hospital, Singapore
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48
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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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Brown M, D'Haem C, Berkompas D, Cohn JM. Acute interventions for myocardial reperfusion. Emerg Med Clin North Am 1998; 16:565-81, viii. [PMID: 9739775 DOI: 10.1016/s0733-8627(05)70018-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The primary goal of treatment in acute myocardial infarction is reperfusion of the infarct-related artery in as short a time as possible. Present strategies for acute reperfusion include the use of thrombolytic agents and a variety of catheter-based interventions. This article presents a brief review of these strategies and discusses the patient subsets better served by a particular type of intervention.
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Affiliation(s)
- M Brown
- Department of Internal Medicine, Michigan State University, East Lansing, USA
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50
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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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