Angiographic Success Rate Research Articles

328 Long term clinical outcomes following adjunctive percutaneous transluminal rotational atherectomy during percutaneous stenting procedures in complex native coronary lesions

Revascularization by percutaneous coronary intervention (PCI) has become the predominant mode of symptom relief in patients with ischemic heart disease. However, certain lesion subsets still require surgical revascularization, including those that cannot be successfully crossed or dilated because of a heavy calcium burden. Percutaneous transluminal rotational atherectomy (PTRA) is a technique which can be used to ‘de-bulk' lesions to assist both balloon dilatation and stent expansion. We retrospectively studied our outcomes when using adjunctive PTRA prior to stent insertion. Using institutional and provincial databases, 145 consecutive Nova Scotia patients were identified to have undergone 146 attempted PTRA procedures with stent insertion at our centre between November 2003 and January 2009. Major adverse cardiac events (MACE), comprising death, myocardial infarction (MI) and target vessel revascularization (TVR) were determined at 12 month follow-up. Indications for PTRA included heavily calcified lesions, ostial lesions or prior failure of balloon dilatation. Femoral arterial access predominated (77%). Most cases used 7Fr guides (37%) and combination heparin/glycoprotein IIb/IIIa inhibitor therapy (83%). An average of 2 stents per vessel were deployed, with 57% of cases receiving at least one DES. Average stented length was 39 mm (range 8-137 mm), with a mean stent diameter of 3.0 mm and a final angiographic success rate of 98%. Average procedure time was 114 min (range 37-244 min). There were 4 procedural failures. Three patients died in hospital (2.0%), two of whom required emergency CABG and one who developed refractory CHF. The overall one year MACE rate was 20% (death 6.9%, acute myocardial infarction 4.1% and TVR 7.5%). In our experience, PTRA combined with intracoronary stenting in a complex patient cohort, is associated with a high frequency of procedural success and good long-term clinical outcomes.

Percutaneous Lower-extremity Arterial Interventions with Primary Balloon Angioplasty Versus SilverHawk Atherectomy and Adjunctive Balloon Angioplasty: Randomized Trial

Purpose Target lesion revascularization (TLR) with primary percutaneous transluminal angioplasty (PTA) versus SilverHawk atherectomy and adjunctive PTA of de novo infrainguinal disease has not been well defined. This study was conducted to compare the two approaches. Materials and Methods In this prospective, two-center randomized trial of PTA versus atherectomy of infrainguinal vessels, the primary endpoint of TLR was evaluated at 1 year. Secondary endpoints included the rate of “bailout” stent placement for suboptimal acute angiographic results and the rate of target vessel revascularization (TVR). Results Fifty-eight patients were included in the study. Of these, 29 (36 vessels) were randomized to the atherectomy arm and 29 (48 vessels) to the PTA arm. Final acute angiographic success rates were 100% in the PTA arm and 97.2% in the atherectomy arm ( P value not significant). There was no statistical difference in TLR (16.7% vs 11.1%) or TVR (21.4% vs 11.1%) between the PTA and atherectomy groups, respectively. Bailout stent placement was performed in 18 of 29 patients (62.1%) in the PTA arm and eight of 29 patients (27.6%) in the atherectomy arm ( P = .017). Major adverse events were similar between the PTA and atherectomy arms. Finally, when embolic filter protection was used, distal macroembolization occurred in 11 of 17 patients (64.7%) treated with atherectomy versus none of 10 in the PTA group ( P < .001). Conclusions TLR and TVR at 1 year were statistically similar in atherectomy and primary PTA. Atherectomy reduced the need for bailout stent placement compared with primary PTA.

Impact of bifurcation lesions on angiographic characteristics and procedural success in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Bifurcation lesions (BFLs) remain a challenging lesion subset, often associated with lower success rates than less complex lesions. There are few data regarding the impact of BFLs in the setting of ST-segment elevation myocardial infarction (STEMI). To assess the impact of BFLs on angiographic characteristics and procedural success in primary percutaneous coronary interventions (PCIs). Out of 1070 primary PCIs performed between November 2006 and December 2008, 114 patients (10.7%) with a BFL (side branch ≥2.0mm) were identified and matched with 114 patients without a BFL, according to age, sex and infarct-related artery. Baseline characteristics were similar in both groups. Using the Medina classification, true BFLs ([1,1,1]; [1,0,1]; [0,1,1]) were found in 46.5% of cases. Mean contrast volume (265±91 and 207±68mL), procedural time (51.0±26.6 vs 35.3±11.5min) and fluoroscopy time (16.2±11.2 vs 9.8±5.1min) were significantly higher in the BFL group than the non-BFL group (p<0.0001). However, time to reperfusion and angiographic success rates (residual stenosis ≤ 30% and Thrombolysis in Myocardial Infarction flow grade 3 in main branch) were similar in BFL and non-BFL patients (13.7±7.9 vs 12.1±5.7min, respectively, p=0.087; 96.5 vs 99.1%, respectively, p=0.18), with no periprocedural events (in-hospital death, emergent coronary artery bypass graft or repeat PCI<24h). Despite being challenging lesions, BFLs in STEMI were associated with similar time to reperfusion and procedural success but led to significantly greater contrast use and prolonged procedural time compared with non-BFLs.

Use of the Impella 2.5 for prophylactic circulatory support during elective high-risk percutaneous coronary intervention

Patients undergoing percutaneous coronary intervention (PCI) who are at high risk for cardiovascular collapse during the procedure may benefit from prophylactic circulatory support. The objective was to evaluate the safety and feasibility of prophylactic use of the Impella 2.5 during high-risk PCI. We used the Impella 2.5 for partial circulatory support during 60 consecutive elective high-risk PCI cases over 20 months. All patients either were deemed inoperable by the cardiac surgeons or were offered bypass surgery but declined. The patients had multiple risk factors including hypertension (95%), diabetes (52%), chronic pulmonary disease (23%), prior myocardial infarction (62%) and prior bypass surgery (18%). Forty-five percent presented with acute coronary syndrome. The mean left ventricular ejection fraction was 23%±15%. Nearly all patients had multivessel disease (93%), and 60% had left main disease. The average SYNTAX score was 30±9. Despite lesion complexity and high-risk factors, we achieved an angiographic success rate of 96%. Left main lesions were treated in 55% of the patients, and 83% of patients had multiple lesions treated. There was one procedural death. At 30 days postintervention, mortality was 5%, and rates of myocardial infarction, stroke, target vessel revascularization and urgent bypass surgery were 0%. The single-center experience reported here demonstrates that use of the Impella 2.5 during high-risk PCI in the "real world" - outside the controlled environment of a clinical trial - is safe and feasible.

Application of penetration device (Tornus) for percutaneous coronary intervention in balloon uncrossable chronic total occlusion—procedure outcomes, complications, and predictors of device success

To evaluate procedure outcomes, complications, and the predictors of device success while using the Tornus in CTO revascularization. The success of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) may be limited by the presence of severe calcified CTO lesions, especially in the smallest balloon uncrossable arteries. A penetrating device (Tornus) could improve the success rate. Device and angiographic success rates as well as procedural complications were assessed in 56 patients, who were consecutively and retrospectively enrolled into this study. Device success was defined as successful passage of the Tornus catheter through a CTO lesion. Procedure success was defined by a final TIMI 3 flow and <30% residual stenosis. The device success rate was 71.4% in 40 patients and failure rate was 28.6% in 16 patients. The final procedure success was significantly higher in the Tornus success group compared with the Tornus failure group (87.5% vs. 37.5%, P < 0.001). One patient in the Tornus success group (1.8%) had wire perforation resulting in cardiac tamponade and cardiac death. Another patient (1.8%) in the Tornus success group had acute in-stent thrombosis and non-Q MI in 24 hr and was resuscitated by emergent PCI. The only independent predictor of device success was a calcium score < 2 (odds ratio (OR): 3.86 (95% CI: 1.14-13.1, P = 0.03). The Tornus catheter can be used in severe calcified CTO PCI when the calcium score <2 and not be used in patients with a calcium score ≥2.

Six‐month clinical follow‐up of the tryton side branch stent for the treatment of bifurcation lesions

Treatment of bifurcation lesions with the Tryton Sidebranch stent has been shown to be feasible with an acceptable clinical outcome and low side branch late loss in the first in man trial. To report acute procedural and six month clinical follow-up after the use of the Tryton Sidebranch stent in an "all comer" registry. The first 100 coronary bifurcation lesions assigned for treatment with the Tryton stent were included in a prospective registry. Procedural and angiographic success rates were determined from patient charts and pre- and postprocedural quantitative coronary angiography. Totally, 96 patients with 100 lesions were included in the study. Seventy-two percent presented with stable angina, 25% with unstable angina/NSTEMI, and 3% STEMI. The bifurcation was located in the left main in 8%. Two lesions were chronic total occlusions. Sixty-nine percent were true bifurcation lesions. One failure of stent delivery occurred. Acute gain in SB was 0.76 ± 0.64 mm and three patients had residual stenosis of >30%. Angiographic success rate was 95%; procedural success rate reached 94%. Peri-procedural MI occurred in two and there was one cardiac death during hospitalization. At a median six months follow-up, TLR rate was 4%, MI 3%, and cardiac death 1%. The percentage MACE-free survival at six months was 94%. No cases of definite stent thrombosis occurred. In a real world the use of the Tryton Sidebranch stent is associated with good procedural safety and angiographic success rate and acceptable outcome at six months of follow-up.

Magnetic navigation system assisted stenting of coronary bifurcation lesions

Magnetic guidewire assisted percutaneous coronary interventions (MPCI) could have certain advantages in coronary bifurcation lesions. We aimed to report the angiographic characteristics of the bifurcation lesions, as well as the procedural and clinical outcomes of the MPCI patients. The lesion characteristics and the treatment effect were assessed by performing diagnostic and quantitative coronary angiography with dedicated bifurcation software. A total of 76 patients (age 65 years, 78% male) were assigned to undergo MPCI, in which two-thirds of the lesions were located in LAD/D1. Fifty-seven out of 78 lesions (73%) had a diseased side branch and complex stenting techniques were used in the majority of the lesions (64%). All 59/78 (76%) fenestration attempts were successfully performed and only 13 dedicated bifurcation stents were implanted. The average acute gain in minimal luminal diameter was 1.08±0.81 mm, 0.80±0.70 mm and 0.59±0.56 mm for the proximal, distal and side branch, respectively. The procedural success was 69% with a procedure time of 107±43 minutes, fluoroscopy time of 34±24 minutes and contrast use of 338±136 ml. At a mean of 1.8-years follow-up, 15 patients (20%) had a cardiac event. MPCI is associated with good angiographic, fenestration and procedural success rates in the treatment of coronary bifurcation lesions.

074 Risk factors for procedural failure of percutaneous coronary intervention for chronic total occlusion. Impact of novel guide wire “Fielder XT”

Chronic total occlusion (CTO) remains one of the last frontiers of percutaneous coronary intervention (PCI). Recently, a novel “soft” guidewire (GW) developed for tracking invisible micro-channels (Fielder XT) became available in France. The purpose of this study was to clarify the risk factors contributing to PCI success for CTO lesions and evaluate the efficacy and safety of this GW. The study included 166 consecutive Pts with CTO's (European CTO Club definition) who underwent primary PCI at our institution between June 2008 and Feb 2010 by 2 experienced operators. The cohort was divided into 2 groups: group 1 (n = 83), treated before availability of “Fielder XT” GW in France and group 2 (n = 83), treated since availability. Clinical and angiographic characteristics were similar in both groups (age 63.9 ± 11.3 years, lesion length 23.0 ± 18.1 mm, bridging collateral 37.%, tortuosity score 0.16 ± 0.37/1 and calcification score 0.94 ± 1.08/3). Fielder XT was used in 1 case (1.2%) in group 1 and 67 (80.7%) in group 2. Micro catheters were used more frequently in group 2 (73.2% vs 56.6%; p = 0.013) and parallel wire technique was less required (16.2% vs 31.3%; p = 0.011). Angiographic success rate was significantly higher in group 2 (84.3% vs 67.5%; p = 0.005) with a lower rate of dissection (12.2% vs 24.7%; p = 0.02) and a trend for a lower rate of perforation (4.9% vs 1.2%; p = ns). Predictors of failure in the total cohort were by multivariate logistic regression analysis: proximal tortuosity (p = 0.048, OR = 3.15), absence of bifurcation (p = 0.024, OR = 3.39), no visible stump (p<0.0001, OR = 6.25), calcification (p = 0.029, OR = 1.56) and patient in group 1 (p = 0.015, OR = 3.37). Introduction of a dedicated “soft” wire in the CTO treatment strategy improves the angiographic success rate of PCI with a more simple and “soft” technique. Multivariate analysis confirmed classical independent predictors of failure but also demonstrated that a new device may influence success rate.

070 A comparison of the success rates of transradial and transfemoral approaches for percutaneous coronary intervention of chronic total occlusions

Chronic total occlusions (CTOs) are found in approximately 30% of Pts with coronary artery disease and represent the most difficult group for treatment by percutaneous coronary intervention (PCI) with a lower angiographic success rate. Transradial PCI is safe and effective, though the efficacy of this approach in CTOs has not been well studied. All Pts treated with PCI for CTOs between Jan 2004 and Dec 2009 were retrospectively identified from a dedicated database. We compared the success rates via the transradial (TRA) and transfemoral approach (TFA) with attention to the lesion characteristics and techniques applied. 979 Pts (63.2 ± 11.6 years, 87.3% male) were studied. Baseline demographics and angiographic characteristics were similar between groups with no difference in lesion length, calcification or proximal vessel tortuosity. There was a significant difference in the rate of bifurcations performed via the TRA and TFA (29.1% vs. 14.6%, p<0.0001). Parallel wire technique and retrograde recanalisation were used more frequently from the TFA. TRA was associated with an increased use of anchoring balloons. Sheath sizes > 6 French were used in 20/979(2%). Larger sheath size was associated with a higher rate of parallel wire technique (p = 0.0004), retrograde recanalisation (p<0.0001) and tornus use (p = 0.027). TRA has equivalent success rates to TFA in Pts with similar lesion characteristics, requires less invasive sheath sizes and allows complex techniques such as retrograde recanalisation. TFA (233 patients) TRA (646 patients) P value Sheath size – 6F 218 (93.6%) 642 (99.4%) <0.0001 Sheath size – 8F 11 (4.7%) 0 (0) <0.0001 Parallel wire 54 (23.2%) 106 (16.4%) 0.029 Side branch technique 7 (3.0%) 41 (6.3%) 0.06 Anchoring balloon 7 (3.0%) 48 (7.4%) 0.017 Retrograde recanalisation 16 (6.9%) 18 (2.8%) 0.009 Procedural time 73.4 +/–41.2min 80.7+/–40.7min 0.03 Contrast use 238.7mls +/–180.2mls 286.2 +/–157.3mls 0.001 Angiographic Success 139 (67.8%) 441 (70.7%) 0.44

Percutaneous Coronary Intervention in Very Elderly Patients. In-hospital Mortality and Clinical Outcome

There are very few data about percutaneous coronary intervention (PCI) in very elderly patients. This study was aimed at assessing the demographic, clinical and angiographic features, procedural characteristics and in-hospital results of very elderly patients (VEP), aged ≥85 years undergoing PCI and comparing their results with those of a control group (CG) of patients younger than 85 years undergoing PCI throughout the same period of time. Between November 2004 and January 2007, 1699 consecutive PCI procedures were evaluated, 102 (6%) PCI procedures were performed in VEP and 1597 (94%) in patients <85 years. The mean age in the VEP group was 87.4 ± 2.4 years vs. 66.7 ± 11.2 years in the CG (p<0.0001). There were more females in the VEP group 49% vs. 22% than in the CG p<0.0001. Acute coronary syndromes (ACS) were a more frequent indication for PCI in VEP than in the CG: ST segment elevation myocardial infarction (STEMI) 14.7% vs. 8.3%, p = 0.025 and non-ST segment elevation acute coronary syndromes 54.9% vs. 43.5%, p = 0.024. The proportion of drug-eluting stents used, although high in both groups, was lower in VEP than in the CG (86.5% vs. 92.9%, p = 0.005). Angiographic lesion success rates were similar in both groups (95.9%). Global unadjusted in-hospital mortality was higher in the VEP group in comparison with the CG 3.9% vs. 0.68%, p = 0.01. The difference in mortality was due only to PCI in patients presenting with STEMI (26.6% in VEP group vs. 3.7% in the CG p = 0.007). There were no in-hospital deaths in VEP presenting with stable coronary syndromes or other ACS. There were no differences in unadjusted in-hospital myocardial infarction, new revascularisation or stroke between both groups. In patients ≥85 years old, PCI seems effective and carries an acceptable in-hospital mortality rate. The presence of STEMI substantially increases the risk of in-hospital death.

TCT-31: An Assessment of the Presence of Collateralisation as a Predictor of Angiographic Success Rates of Percutaneous Coronary Intervention in Chronic Total Occlusions

TCT-31: An Assessment of the Presence of Collateralisation as a Predictor of Angiographic Success Rates of Percutaneous Coronary Intervention in Chronic Total Occlusions

Treatment of a large thrombus containing lesion with the MGuard™ protective net coronary stent system: optical coherence tomographic evidence of complete plaque sealing

Avoidance of distal embolization is the key of success in the percutaneous treatment of patients with ST elevation myocardial infarction. Embolization may lead to microvascular obstruction, and consequently impairment of myocardial perfusion with increased infarct size and mortality [1, 2]. Different types of devices have been proposed to avoid this issue. Prospective randomized clinical trials have shown the beneficial effect of thrombus aspiration devices in the setting of primary percutaneous coronary intervention (PCI) [3, 4]. Recently, the use of MGuard net coronary stent system (MGS, Inspire-MD, Tel Aviv, Israel) in the setting of primary PCI has shown high rate of myocardial reperfusion and angiographic procedural success [5]. MGS is a new stainless-steel closed-cell design stent concept. Other than conventional available bare-metal stents (BMS), it has an ultrathin flexible polyethylene terephthalate mesh sleeve that is anchored to the external surface of the struts. This biocompatible microfiber net (string diameter 10–22 lm) has minimal effects on stent crossing profile and deliverability (Fig. 1). During stent deployment, the net stretches and slides over the expanding stent struts, creating custom designed pores of &200 lm in diameter. The idea of this design is to entrap the thrombus burden between stent mesh and the wall of the artery, isolating the high-thrombogenic intima components and preventing the ‘‘snow plug effect’’. This is the first time, at our knowledge, that the optical coherence tomography (OCT) assessment of MGS implantation for the treatment of a large thrombus burden right coronary artery (RCA) lesion is being reported. A 78-year-old female with mild hypertension and dislipidemia, previously treated with dual chamber pacemaker implant, was admitted at our hospital for coronary angiography following an inferior ST elevation myocardial infarction treated with a partial effective systemic thrombolytic therapy with reteplase. At the time of coronary angiography, the patient was already on double antiplatelet therapy (600 mg loading dose of clopidogrel and 300 mg loading dose of acetylsalicylic acid). The angiography showed a significant mid-RCA lesion with large thrombus burden (Fig. 2a), while there were no lesions on the left coronary system. PCI was then performed using the standard approach. A bolus of 80 UI/kg of unfractioned heparin was given at the start of procedure. No glycoprotein IIb/IIIa inhibitors were given during the procedure to avoid bleeding complications related to the already administered anti-platelet therapy and patient’s age. After cannulation of the RCA with a 7 French side holes Judking right 4 guiding catheter, a BMW guide wire (Abbott Vascular, Redwood City, CA, USA) was advanced until the distal postero-lateral branch and an OCT scan using the C7XR OCT image system (LightLab Imaging Inc., Westford, MA, USA) was then performed using the nonocclusive flushing technique [6]. The OCT pullback showed a tight stenosis of RCA with a very large intraluminal stratified red thrombus (Fig. 2b). Subsequently, it was decided to perform a direct stenting with 4.0/24 mm MGS implantation, which was deployed at 16 atm. The OCT was repeated thereafter showing a malapposition at the mid part of the stent. Therefore, post-dilatation was A. La Manna S. D. Tomasello C. Tamburino Clinical Division of Cardiology, Department of Internal Medicine and Systemic Disease, Ferrarotto Hospital, University of Catania, Catania, Italy

A Routine Invasive Strategy for Out-of-Hospital Cardiac Arrest Survivors

Out-of-hospital cardiac arrest (OHCA) is estimated to afflict approximately 236 000 to 325 000 people in the United States annually,1 with wide regional1 and interhospital2 variation in the survival to discharge rates. The prospective, multicenter registry of OHCA in 8 US and 3 Canadian emergency medical service (EMS) agencies and receiving institutions (ROC Epistry–Cardiac Arrest) serving an area of 21.4 million people reported a survival to discharge rate of a mere 1.1% to 8.1% for all EMS-assessed OHCAs, 3.0% to 16.3% for EMS-treated, and 7.7% to 39.9% for patients who presented with ventricular fibrillation.1 Of note, these reported rates are for all EMS-assessed or EMS-treated OHCA regardless of whether there was return of spontaneous circulation (ROSC) before hospital entry. In patients with ROSC at hospital entry, the survival to discharge rate ranges from 10% to 42%.2,–,7 With the initiation of a community-wide early defibrillation program, White et al8 reported that in patients with ventricular fibrillation and sustained ROSC after defibrillation (only in the field), the survival to discharge rate was a remarkable 87%. Thus, there is wide variation in reported rates of survival depending on the cohort reported and the regional systems of care. There are great opportunities to further improve outcomes in OHCA. In this setting, the role of urgent cardiac catheterization and percutaneous coronary intervention (PCI) is of great interest. Article see p 200 In patients with cardiac arrest (predominantly due to ventricular fibrillation) up to 71% have coronary artery disease and 50% have acute coronary artery occlusion.9,10 Prior studies have shown that in postcardiac arrest patients with ST elevation on ECG, PCI was associated with angiographic success rates of 78% to 95% and overall survival to discharge rates of 44% to 75%.11, …

Percutaneous closure of patent ductus arteriosus: A multiinstitutional registry comparing multiple devices

There are no guidelines and multiple devices available now for closure of PDA. We sought to determine which devices are used and their outcomes. Prospectively collected data on closure of PDA at 12 US catheterization labs was entered into the MAGIC data registry between November 2005 and September 2008. PDA closure was accomplished in 357 of 359 attempted closures during the study period. Mean age, weight, and minimum ductal diameter were 4.3 ± 6.8 years, 18.7 ± 18.4 kg, and 2.1 ± 1.4 mm, respectively. Devices used were Gianturco coils (161/359), Amplatzer Duct Occluder (ADO, 174/359), Flipper coils (18/359), and other devices (6/359). Gianturco coils had the least fluoroscopy and contrast exposure (8.7 ± 7.5 min, P = 0.00001, 2.6 ± 1.4 cm(3) kg(-1), P = 0.00001). Immediate angiographic success rates were 96.9% (156/161) for Gianturco coils, 89.7% (156/174) for the ADO, 100% (18/18) for Flipper coils, and 66.7% (4/6) for other devices. Major complication rates were 0.6% for Gianturco coils (1/161), 1.7% for ADO (3/174), and 83.3% for other devices (4/6). Minor complication rates by device were 1.9% for Gianturco coils (3/161), 2.3% for ADO (4/174), and 16.7% (1/6) for other devices. Gianturco coils, the ADO and Flipper coils were immediately successful with low complication profiles. The ADO and Gianturco coils were the predominate devices. The ADO was the device of choice for PDA > 3 mm with good success. In PDA < 3 mm, the Gianturco coil is as effective and safe as the ADO with less cost, less radiation, and less contrast exposure. © 2010 Wiley-Liss, Inc.

Can a Penetration Catheter (Tornus) Substitute Traditional Rotational Atherectomy for Recanalizing Chronic Total Occlusions?

The efficacy of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) has improved dramatically due to the development of new devices. Severe calcification of coronary lesions may be encountered even when the guidewire crosses the CTO, preventing the balloon from penetrating the lesion. A new "Tornus" penetration catheter has been developed for CTO recanalization. The purpose of this study was to evaluate the feasibility and safety of the Tornus catheter compared with traditional rotational atherectomy for CTO lesions. From August 2002 to July 2009, 77 patients with CTO of the coronary artery were selected to undergo PCI. Forty-one patients were treated with rotational atherectomy before the availability of the Tornus catheter when the smallest balloon failed to pass the CTO lesion. Later, 36 patients were treated with a Tornus catheter. Device and angiographic success rates as well as procedural complications were assessed. Device success was defined when the Tornus or Rota burr passed through the lesion. Major complications included death, Q-myocardial infarction, or emergency bypass surgery. Minor complications included perforation, cardiac tamponade, no reflow phenomenon, or long spiral dissection.The mean procedural time was significantly longer in the Tornus group (144 minutes versus 115 minutes, P = 0.01), while the device success rate was significantly lower (77% versus 95%, P = 0.024). Rotational atherectomy was subsequently performed in 3 of 8 Tornus failure cases. There were no between group differences in major complication rate (6% Tornus versus 5% rotational atherectomy). There was an insignificant trend for lower minor complication rates in the Tornus group (17% versus 20%).Use of the Tornus catheter was associated with significantly longer procedural duration and lower device success rates compared to rotational atherectomy. Major and minor complications were not different between the groups. Our findings suggest that Tornus catheter penetration is not superior to conventional rotational atherectomy for CTO recanalization.

Thrombus aspiration for the treatment of definite stent thrombosis

Thrombus aspiration (TA) has been associated with high rates of thrombotic material retrieval, which results in improved myocardial reperfusion. In addition, a recent study has shown that systematic TA for treatment of ST-segment elevation myocardial infarction (STEMI) related to de novo lesions improves patient outcomes. Evaluation of a single-centre experience of TA before percutaneous coronary intervention (PCI) for stent thrombosis (ST) treatment. Between 2004 and 2006, we indexed 24 patients presenting with definite ST. All patients underwent TA (Export Medtronic 6F catheter) followed by PCI for ST treatment. Baseline clinical and angiographic characteristics, and complications related to the TA device were indexed. The median time of ST occurrence was 7 days. All patients except one presented with STEMI. Bare-metal and drug-eluting ST represented 70.8% and 29.2% of cases, respectively. Mean stent length was 18.8 + or - 5.6mm; mean stent diameter was 2.8 + or - 0.4mm; mean number of implanted stents was 1.58 + or - 0.7. There was no failure to cross the catheter and no TA device-related complications were reported. The numbers of patients with initial thrombolysis in myocardial infarction (TIMI) flow grades 0, 1 and 2 were 15 (62.5%), 3 (12.5%) and 6 (25.0%), respectively. No patient had TIMI flow grade 3 before TA. After TA, 16 (66.7%) patients had TIMI flow grade 3; final procedural success was obtained in 23 (95.8%) patients. The 1-year death rate was 12.5%. In our experience, TA before PCI for ST treatment shows promising results, providing high rates of immediate reperfusion and final angiographic success, and low death rates, compared with the literature.

Resultados hospitalares da intervenção coronária percutânea primária no infarto agudo do miocárdio em pacientes com mais de 80 anos

INTRODUÇÃO: O aumento da expectativa de vida da população e o risco de sangramento com o uso de trombolíticos têm permitido que pacientes cada vez mais idosos com infarto agudo do miocárdio sejam tratados pela intervenção coronária percutânea (ICP) primária. Analisamos os resultados hospitalares da ICP primária em pacientes com idade > 80 anos. MÉTODO: No período de janeiro de 2002 a outubro de 2008, foram realizadas 4.788 ICPs, sendo 428 ICPs primárias. Destas, 34 foram em pacientes com idade > 80 anos e 394 em pacientes < 80 anos. RESULTADOS: O sexo feminino (47,1% vs. 27,7%; P = 0,017), a classe funcional Killip IV (11,8% vs. 4,1%; P = 0,002) e o fluxo coronário TIMI 2/3 pré-ICP (60% vs. 44,4%; P = 0,032) foram mais frequentes nos idosos. Tabagismo (44,9% vs. 8%; P < 0,001) e uso de inibidores da glicoproteína IIb/IIIa (32,5% vs. 11,7%; P = 0,04) prevaleceram no grupo < 80 anos. Não ocorreram diferenças significativas quanto ao tempo portabalão (117,4 ± 125,7 minutos vs. 179,3 ± 169,8 minutos; P = 0,095), à taxa de utilização de stents (91,2% vs. 98,2%; P = 0,78), e ao uso de stents farmacológicos (0 vs. 2,8%; P = 0,067) ou de dispositivos de aspiração de trombos (11,7% vs. 12,2; P = 0,65). Não houve diferença quanto à taxa de sucesso angiográfico (97,1% vs. 96,5%; P > 0,99), porém o grupo > 80 anos apresentou mortalidade hospitalar mais elevada (11,8% vs. 2,3%; P = 0,014). Reinfarto, acidente vascular cerebral, complicações vasculares maiores e insuficiência renal aguda foram semelhantes entre os grupos. CONCLUSÃO: A ICP apresenta, em geral, altas taxas de sucesso angiográfico e baixo índice de complicações, reforçando seu papel como método preferencial de reperfusão na fase aguda do infarto do miocárdio. Os pacientes muitos idosos, com mais de 80 anos, apresentam maior mortalidade, possivelmente reflexo da maior comorbidade desse grupo.

Study on 100 cases of coronary artery disease underwent percutaneous coronary interventions

This prospective study was done in National Institute of Cardiovascular Diseases, Dhaka, Bangladesh during the period of January 2004 to January2005 to see the effectiveness and safety profile of percutaneous coronary interventions in patients with coronary artery disease. 100 patients with male 90 percent and female 10 percent undergo percutaneous coronary intervention in our unit during this period. Indication of percutaneous coronary interventions were chronic stable angina with stress test positive in 20 percent cases, unstable angina with prior myocardial infarction in 30 percent cases, unstable angina without prior myocardial infarction in 20percent cases, acute inferior myocardial infarction with post myocardial infarction angina in 20 percent cases and acute anterior myocardial infarction with post myocardial infarction angina in 10 percent cases. Angiographic diagnosis of the patients were single vessel disease in 70 percent cases , double vessel disease in 24 percent cases and triple vessel disease in 11 percent cases. Total number of disease coronary arteries was 146 and 125 lesions were treated. Out of 125, 120 lesions were treated with percuteneous transluminal coronary angioplasty with stenting and 5 lesions with plain percuteneous transluminal coronary angioplasty .Total occlusion was treated in 7 cases. Mean diameter of stent used was 3.02 ± 0.42 mm. Patients were discharged by three to four days of the procedure with improved clinical conditions. Residual stenosis after deploying of stent was less than l 0 percent. Our angiographic success rate was 98 percent, procedural success 96 percent and clinical success 95 percent. Failed percuteneous transluminal coronary angioplasty in 2 cases all of them were chronic total occlusion. One patient died on third day of the procedure due to ventricular asystole, he was a patient of triple vessel disease. Following procedure, course of the patients were uneventful. In the field of maagement of coronary artery disease percutaneous coronary intervention is the internationally recognized standard treatment worldwide for more than last 2 decades. From our result it is found that in most of the indicated cases of PCI can be done efficiently with very minimum rate of failure &amp; complication. Key word: Percutaneous coronary interventions, coronary artery disease. doi: 10.3329/uhj.v5i1.3434 University Heart Journal Vol. 5, No. 1, January 2009 13-16

Tibial Angioplasty for Limb Salvage in High-Risk Patients and Cost Analysis

We examined the efficacy and cost of tibial angioplasty in patients with critical limb ischemia (CLI) at high operative risk. A retrospective analysis of all consecutive patients who underwent tibial angioplasty with critical ischemia Rutherford class 4 and 5 from January 2001 to April 2007 was performed. Demographic information, presentation, and angiographic characteristics of the lesions were analyzed. The primary end point was freedom from major amputation. Secondary end points were overall survival and recurrence. Cost comparison was performed between the endovascular group and a matched group of high-risk patients submitted to femoral tibial bypass in the same period. Forty-five patients, with mean age of 69.6 years and a 2.5:1 (male:female) ratio, had 49 limbs treated. The mean follow-up was 7.7 months (range 1-61.5). Eighty percent of the patients were Rutherford class 5. Incidence rates were as follows: diabetes 90%, chronic renal failure 73%, end-stage renal disease (ESRD) on hemodialysis 45%, and coronary disease 69%. Single vessel run-off to the foot was present in 57% of patients and complete occlusion of all tibial vessels in 12%. Only the tibial vessels were angioplastied in 55% of patients. Angiographic success rate was 84%. Thirty-day mortality was 2% and major complications occurred in 6.1%. A poor angiographic result was a statistically significant predictor (p = 0.009) of symptomatic recurrence (43%) (worsening of preexisting symptoms and/or signs or new ones). Cardiac disease was the major cause of mortality beyond 30 days (12.5%). Freedom from major amputation in the entire group was 75.5%, with no difference between tibial and diffuse infrainguinal angioplasty (p = 0.61). Recurrence, especially early recurrence, was a significant predictor of amputation (p = 0.04 and p = 0.0008, respectively). There was a trend toward presence of ESRD and recurrence (p = 0.06). Both average hospital cost ($2,910.60 vs. $17,703.50) and length-of-stay (LOS) (<1 vs. 9 days) were significantly reduced in the angioplasty group (p < 0.0001). Tibial angioplasty has acceptable rates of limb salvage in patients with CLI considered to be at high risk for surgery, despite high recurrence rates. The presence of diabetes or ESRD did not reduce the rate of success in this series, although ESRD seemed to predict recurrence. The procedure has low morbidity and mortality with lower cost and LOS compared with open revascularization. Aggressive angioplasty should be an option to patients who otherwise would face primary amputation.

Two‐Year Outcomes of the Sirolimus‐Eluting Stent According to Unprotected Left Main Lesion

The data of long-term outcomes of sirolimus-eluting stent (SES) according to lesion location of unprotected left main coronary artery (LMCA) is scarce. The purpose of this study was to evaluate the long-term outcomes after implantation of the SES in LMCA. A total of 84 patients (51 males) who had undergone SES implantation for the treatment of native LMCA stenosis were enrolled. The patients were divided into 2 groups based on angiographic lesion location: those with significant stenosis in the ostium and/or body (group 1; n = 39) and those involving bifurcation (group 2; n = 45). All of the group 1 patients were treated with simple lesion coverage while different stenting techniques were used in group 2 (cross-over: 44.8%, T: 6.7%, kissing: 37.8%, and crush techniques: 11.1%). The 8-month quantitative angiographic findings and in-hospital and 2 year rates of major adverse cardiac events (MACE) were compared between the 2 groups. Although angiographic success and in-hospital MACE rates were similar in both groups with 1 cardiac death due to acute stent thrombosis in group 2, at 2-year follow-up, the MACE rate was significantly higher in group 2 than in group 1 at 2 years (22.2% vs 2.6%, respectively, P = 0.008). Coronary angiography revealed a significantly higher binary restenosis rate in group 2 compared with group 1 (20% vs 0%, respectively, P = 0.003). Interventional treatment using SES in left main lesions showed favorable short-term and long-term outcomes in selected patients with lesion location being an important determinant of clinical and angiographic outcomes.