Angiographic Success Rate Research Articles

Clinical Manifestation and Prognosis of Early versus Late Stent Thrombosis of Drug‐Eluting Stents

Stent thrombosis (ST) is a serious complication of drug-eluting stents (DES), leading to catastrophic events. ST can occur early or late following the percutaneous coronary intervention (PCI) with different possible consequences. The records of 91 consecutive patients who presented with a definite ST (as defined by the Academic Research Consortium) from 2003 to 2007 were reviewed. Clinical presentation and outcome were compared based on the time of the event. Fifty-one patients presented with an early ST versus 40 with a late ST. The primary end-point was a composite of death-recurrent myocardial infarction (MI)-recurrent ST at 1 year. Baseline characteristics were similar. Patients with early ST had more initial stent implantation for an acute MI indication and presented more with cardiogenic shock when compared to patients with late ST: 43.1% versus 17.5% (P = 0.007) and 39.2% versus 20% (P = 0.042), respectively. There was no difference in the ST treatment except for more intraaortic balloon pump (IABP) use in the early ST group (28% vs. 10%, P = 0.034). Angiographic success rates were similar. The incidence of the composite primary end-point was 52.9% in the early ST group versus 30% in the late ST group (P = 0.034). Early definite ST is associated with more dramatic presentation and worse long-term prognosis when compared with definite late ST. This could be explained at least in part by the occurrence of two successive MIs within 30 days in almost 45% of the patients with early ST, leading to a higher rate of cardiogenic shock.

Endovascular Interventions of Juxtaanastomotic Stenoses and Thromboses of Hemodialysis Arteriovenous Fistulas

To assess the primary and secondary patency rates for juxtaanastomotic stenoses, with or without superimposed thromboses, of arteriovenous hemodialysis fistulas treated with angioplasty and to compare it with National Kidney Foundation Dialysis Outcomes Quality Initiative treatment guidelines for stenosed and occluded arteriovenous fistulas (50% primary patency rate at 12 months). This study was a retrospective analysis, covering a period of 5(1/2) years. Forty-three hemodialysis patients were referred due to secondary fistula dysfunction, and angiography was diagnostic of a juxtaanastomotic lesion. Interventions consisted of standard angioplasty techniques along with thrombolysis and/or thrombectomy and intravascular stent placement as needed. Follow-up was performed at the attending dialysis center, and repeat angiography was performed as clinically required. Immediate postprocedural angiography demonstrated an angiographic success rate of 98%. Clinical success, with at least one session of normal dialysis, occurred in 95% of interventions. Primary patency rates at 12 months for the stenosed and stenosed/thrombosed fistulas were 56% and 64%, respectively. Secondary patency rates at 12 months were 64% and 63%, respectively. Half of the stenosed fistulas were patent at 1.5 years, 28% were patent at 4 years, and 13% remained patent at 6 years. No major complications were documented. Four minor complications, which did not require therapy, were noted. The results achieved are comparable to those reported for interventions at nonjuxtaanastomotic sites and exceed those quoted by the National Kidney Foundation Dialysis Outcomes Quality Initiative guidelines. Angioplastic interventions in a juxtaanastomatic area of arteriovenous fistulas are safe, promote prolonged patency, and postpone the need for surgical intervention or creation of a new fistula.

Lesion Complexity and Angiographic Outcomes in Radial Access Percutaneous Coronary Intervention

Percutaneous coronary intervention (PCI) is increasingly performed from the radial arterial (RA) access site. Few studies have examined the interaction between a default radial approach, lesion complexity, and angiographic outcome. This study investigates lesion complexity, arterial access route, and angiographic outcome in routine clinical practice by default radial operators. All cases of PCI over a 12-month period (Jan 2005 to Jan 2006) at our regional cardiac center were prospectively entered into a database detailing arterial access route, target vessel and lesion characteristics, and lesion-specific angiographic outcome. Angiographic success was defined as residual stenosis <50% for balloon angioplasty alone or <20% for a stented lesion in the presence of TIMI 3 flow in the target vessel. All procedures carried out by default radial operators were selected for further retrospective analysis. Reasons for not completing a case via the radial route were recorded. Radial and femoral cases by default radial operators were evaluated on grounds of lesion complexity and angiographic outcome for each treated lesion. RA was the intended route in 91.5% of 1,324 procedures (91.5% of 2,239 lesions), and the final route in 90.1% of procedures (90.2% of lesions). There were 19 crossover procedures (30 lesions), all from radial to femoral access (FA). Crossovers were due to failed radial artery cannulation or sheath placement (9 procedures), inability to advance the guide catheter into the aortic root (7 procedures), and other guide catheter handling or support issues (3 procedures). Counting crossovers as failures, angiographic success rate was 96% among lesions for which RA was the primary intention. Complexity of cases was high (80.1% of RA lesions ACC/AHA type B2 or C). A default radial approach is compatible with successful treatment of a wide range of coronary lesions, with a low incidence of crossover to femoral access. When the radial approach fails, it is usually due to access problems rather than issues of guide catheter handling and support.

Subintimal tracking and re‐entry technique with contrast guidanc: A safer approach

To assess the procedural and clinical outcomes from a modified subintimal tracking and re-entry (STAR) procedure performed using contrast guidance. Previous data showed that recanalizing a chronic total occlusion (CTO) with the STAR technique was possible. However, this technique was considered difficult and therefore has only been adopted by a limited number of experienced operators. Patients (n = 68) with a CTO of a native coronary artery treated by a single operator with this technique were included. The right coronary artery was involved in 79.4%, the morphology was blunt in 77.9%, and CTO length was longer than 20 mm in 67.6%. Angiographic success rate was 80.9% with a 70.6% rate of complete recanalization. Stent implantation was performed in 82.3% of cases, with drug-eluting stents (DES) implanted in the majority (92.7%). Procedural complications occurred in 10.3% of cases. There were no episodes of myocardial infarction during follow-up, with 1 case (1.5%) of cardiac death. There were no cases of definite or probable stent thrombosis, and there was 1 (1.5%) possible stent thrombosis. The overall rate of in-segment binary restenosis was 44.7%, and target lesion revascularization (TLR) was performed in 25% of lesions. The rate of TLR in lesions treated with DES was 29.4% and in those treated with bare-metal stents was 50%. The contrast-guided STAR technique appears to be feasible and relatively safe. However, this procedure is limited by a high rate of restenosis even with DES, and a second procedure may be necessary to obtain a definitive result.

Wire trapping technique combined with retrograde approach for recanalization of chronic total occlusion

Wire trapping technique combined with retrograde approach for recanalization of chronic total occlusion

Improvement in Survival Following Successful Percutaneous Coronary Intervention of Coronary Chronic Total Occlusions: Variability by Target Vessel

This study compared the survival benefit of opening a chronic total occlusion (CTO) of the left anterior descending (LAD), left circumflex (LCX), or right coronary artery (RCA). Previous analyses demonstrate improved survival following successful percutaneous coronary intervention (PCI) for CTO. Eligible patients underwent attempted CTO PCI in a single vessel. Procedural success rates were calculated for each vessel. The primary end point was survival at 5 years, compared across target vessel groups stratified by procedural success. There were 2,608 patients included. The LAD was the target vessel in 936 (36%), the LCX in 682 (26%), and the RCA in 990 (38%) patients. Angiographic success rates for LAD were 77%, LCX 76%, and RCA 72%. Baseline demographics and comorbidities were well matched, though there were significantly more males in the LCX compared with LAD or RCA groups (80% vs. 75% and 73%, respectively, p = 0.005). Procedural success compared with failure was associated with improved 5-year survival in the LAD (88.9% vs. 80.2%, p < 0.001) group, but not in the LCX (86.1% vs. 82.1%, p = 0.21) and RCA groups (87.7% vs. 84.9%, p = 0.23). In multivariable analysis, CTO PCI success in the LAD group remained associated with decreased mortality risk (HR: 0.61, 95% CI: 0.42 to 0.89). The data suggest that PCI for CTO of the LAD, but not LCX or RCA, is associated with improved long-term survival. This information may assist in selecting patients for attempted CTO PCI.

Feasibility of primary clot extraction prior to percutaneous coronary intervention in acute myocardial infarction

To test the feasibility, safety, and in-hospital outcomes of utilizing the FilterWire EZ to extract clot prior to percutaneous coronary intervention (PCI) in patients presenting with acute myocardial infarction (MI). PCI in patients with acute MI is associated with a higher incidence of distal embolization, no-reflow, or slow flow partly due to the presence of clot burden. The authors describe the feasibility, safety, and outcomes of using a FilterWire EZ distal protection device as a clot extraction device in patients who presented with acute MI and documented clot on coronary angiography. Fifteen consecutive male patients with a mean age of 54 +/- 8 years presented with acute MI (60% ST elevation MI). MI involved left anterior descending artery (n = 4), circumflex artery (n = 3), and right coronary artery (n = 8). Clot extraction followed by PCI reduced the percent diameter stenosis from 94 +/- 12 to 65 +/- 11 (P < 0.001) and restored TIMI 3 flow in all patients without distal embolization. The angiographic, procedural, and clinical success rates were 100%. The mean left ventricular ejection fraction (LVEF) was 52 +/- 8% (range 30-62%) with only three patients (15%) who had an LVEF <50% and five patients (33%) without apparent wall motion abnormalities on echocardiography. Clot extraction before PCI during acute MI in native coronaries is feasible, safe, and effective in restoring TIMI 3 flow without distal embolization. Whether this approach results in better outcomes and improved LV function compared with standard therapy alone requires further investigation.

Outcomes of nonagenarians who undergo percutaneous coronary intervention with drug‐eluting stents

Age is an important predictor of mortality after percutaneous coronary intervention (PCI). The safety and efficacy of PCI with drug-eluting stents (DES) in nonagenarians have not been extensively studied. A retrospective analysis of 889 consecutive patients identified 28 (3.1%) nonagenarians who underwent PCI with DES from May 2003 to December 2005 at our institution. The mean age was 92 +/- 2 years, 39% were male, and 4% were diabetic. Sirolimus-eluting stents were used in 79%. A mean of 1.5 +/- 0.9 stents/patient were implanted with a total stent length of 31 +/- 20 mm. Twenty-nine percent presented with unstable angina and 39% with myocardial infarction. The angiographic success rate obtained was 100%. The 30-day mortality rate was 21%. The 6 patients who died within 30 days included 3 patients who had cardiogenic shock and one patient with critical aortic stenosis who died due to complications during percutaneous aortic valvuloplasty. The cumulative survival rate for all nonagenarians at 1 year and 3 years was (68 +/- 9)% and (61 +/- 9)%. When the four patients who were in extremis on presentation were excluded, there were no in-hospital deaths, the 30-day mortality was 8%, and the 1 year and 3 year survival rate was (79 +/- 8)% and (71 +/- 9)% for the nonagenarians. No patient had definite stent thrombosis. The majority of the nonagenarians who underwent PCI with DES presented with acute coronary syndrome. Percutaneous coronary intervention with DES was safe in nonagenarians as there were no in-hospital deaths and acceptable 3-year survival rates when patients who were in extremis on presentation were excluded. The high-risk profile of these patients and the expected attrition of nonagenarians may contribute to their mortality rates.

Percutaneous Coronary Intervention in Women: In-Hospital Clinical Outcome: Experience from a Single Private Institution in Melbourne

Differences in outcome between women and men treated with percutaneous coronary intervention (PCI) have decreased. This study was aimed at assessing the demographic, clinical, and angiographic features, procedural characteristics and in-hospital results of women undergoing PCI and comparing their results with those of a group of men undergoing PCI throughout the same period of time. All consecutive PCI procedures performed at Epworth Hospital from November 2004 to January 2007 were analysed. Women and men were compared according to baseline clinical, angiographic and procedural characteristics, angiographic success rates and in-hospital outcomes. A total of 1699 consecutive PCI procedures were performed; of these, 405 PCI (23.8%) were performed in women. Women were older (73.9+/-10 years versus 66.1+/-11.9 years, p<0.0001), had a higher prevalence of hypertension (78% versus 63%, p<0.0001), had lower prevalence of prior myocardial infarction (21% versus 27%, p=0.026), and had less history of prior coronary artery by-pass surgery (13% versus 18%, p=0.023) than men. A greater proportion of women presented with acute coronary syndromes (ACS) to PCI than men (63.7% versus 52.9%, p<0.0001). Women had more complex lesions B2/C (78% versus 74%, p=0.049), a higher proportion of ostial lesions (10.5% versus 5.5%, p<0.0001) and less multivessel disease (48% versus 54% p=0.028) than men. Angiographic lesion success rates were similar in both groups. Total unadjusted in-hospital mortality was higher in women than in men (1.97% versus 0.54%, respectively, p=0.013). This difference in mortality was only at the expense of a higher unadjusted mortality in women presenting with ST segment elevation myocardial infarction (STEMI) than men (17.5% versus 1.87%, p=0.002). No women with a stable coronary syndrome or non-ST-segment elevation acute coronary syndrome (NSTE-ACS) died in hospital. There were no differences in in-hospital myocardial infarction, new revascularisation or stroke between both groups. PCI in women has good results but carries an increased unadjusted mortality than in men. This mortality difference between genders in our study, however, was solely at the expense of a higher unadjusted mortality in women than in men undergoing PCI for STEMI.

Segurança e eficácia da reutilização de materiais para angioplastia transluminal coronária percutânea: estudo REMCLI-ATC

INTRODUÇÃO: Apresentamos nossa experiência no estudo REMCLI-ATC (REutilización de Materiales no hospital das CLInicas-ATC), que foi desenvolvido no Setor de Hemodinâmica do Departamento de Cardiologia do Hospital de Clínicas da Faculdade de Medicina de Montevidéu, Uruguai, entre setembro de 2001 e agosto de 2002 e entre janeiro de 2003 e dezembro de 2004. MÉTODO: Foram incluídos, prospectivamente, 100 pacientes submetidos a angioplastia transluminal coronária (ATC), nos quais se utilizou aleatoriamente material novo (grupo 1, n = 49) ou reesterilizado (grupo 2, n = 51), analisando-se uma série de variáveis que avaliaram a eficácia e a segurança de cada um dos grupos. RESULTADOS: O sucesso clínico e angiográfico no grupo 1 foi de 100% e no grupo 2, de 96% (p = 0,54). Não foram observadas diferenças em relação ao número de cateteres-guia, guias e balões utilizados na ATC entre os grupos. O volume de contraste e os tempos de radioscopia e do procedimento também não apresentaram diferenças. As complicações maiores ocorreram somente no grupo 2 (0% vs. 3,9%; p = 0,17) e as menores ocorreram em ambos os grupos (6,1% e 9,8%, respectivamente; p = 0,48). CONCLUSÃO: Concluímos, portanto, que é tecnicamente factível e seguro utilizar material reesterilizado nas ATCs, o que permitiria, uma economia considerável para países como o Uruguai, com recursos econômicos limitados.

Percutaneous Coronary Intervention in the Very Elderly: In Hospital Clinical Outcomes: Experience from a Single Private Institution

Objective: To assess the in-hospital clinical outcome following percutaneous coronary intervention (PCI) in very elderly patients (VEP), aged≥85 years, compared to a control group (CG) of patients <85 years. 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. Results: 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% in the CG p< 0.0001. Acute coronary syndromes (ACS) were a more frequent indication for PCI in VEP than in the CG: ST elevation myocardial infarction (STEMI) 14.7% vs. 8.3% p= 0.025 and non-STEMI ACS 54.9% vs. 43.5% p= 0.024. The proportion of drug-eluting stents used was lower in VEP than in the CG (86.5% vs. 92.9% p= 0.005). Angiographic success rates were similar in both groups (95.9%). Global in-hospital mortality was higher in the V p d b t g V A C a o d

Impacto dos stents de nova geração no tratamento de enxertos venosos aortocoronários - comparação angiográfica e ultra-sonográfica de duas séries first-in-human: MGuard® vs. SESAME®

FUNDAMENTO: As intervencoes percutâneas em pontes de safena (PS) apresentam menores taxas de sucesso angiografico e maior risco de complicacoes, pelo risco aumentado de embolizacao dos fragmentos da placa aterosclerotica friavel. Com o advento dos dispositivos de protecao distal, observou-se maior eficacia e seguranca do procedimento. Nosso objetivo foi comparar os stents MGuard® e SESAME®, dedicados ao tratamento de PS, nos primeiros 30 dias de evolucao. METODO: Estudo retrospectivo, comparando as variaveis angiograficas e ultra-sonograficas e a evolucao clinica aos 30 dias de pacientes portadores de lesoes em PS tratados com stent balao-expansivel MGuard® (n = 11) vs. stent auto-expansivel SESAME® (n = 14). RESULTADOS: Os pacientes tratados com stents MGuard® e SESAME® demonstraram perfis clinicos superponiveis (media de idade, 69 anos; sexo masculino, 72%; diabeticos, 28%; tratados na vigencia de sindrome coronaria aguda, 44%), idade dos enxertos venosos aortocoronarios equivalentes (9,7 ± 6,2 anos vs. 10,1 ± 3,2 anos; p = 0,80) e PS com o mesmo grau de acometimento aterosclerotico. O sucesso angiografico pos-procedimento foi alcancado em todos os casos, porem com tendencia a melhor expansao do stent no grupo MGuard® (87% vs. 68%; p = 0,08). No seguimento clinico de 30 dias, os pacientes tratados com stent SESAME® apresentaram maior frequencia de eventos cardiacos maiores (dois casos de infarto do miocardio nao-Q e um caso de revascularizacao do vaso-alvo), comparativamente a nenhum evento no grupo MGuard®. CONCLUSOES: Nessa analise retrospectiva de pequena serie de pacientes pre-selecionados de duas series first-in-human, o stent balao-expansivel MGuard® mostrou-se superior ao stent auto-expansivel SESAME® nos primeiros 30 dias de acompanhamento clinico.

A novel drug-eluting stent using bioabsorbable polymer technology: Two-year follow-up of the CURAMI registry

Background There are safety concerns on drug-eluting stents (DESs) using durable polymer. The long-term outcome of next generation DESs using bioabsorbable polymer technology remains unknown. Methods From March to June, 2005, a novel sirolimus-eluting (170 μg/cm2), bioabsorbable polymer (PLA and PLGA, eroded over 45 days) coated stent was implanted for treatment of acute myocardial infarction (AMI) in 49 patients (male 86%, age 55 + 10 years, diabetes 31%). All culprits were de novo lesions in the native coronary artery. On discharge, aspirin and clopidogrel for 3 months followed by life-long aspirin were prescribed. Angiographic follow-up was performed at 8 months. Clinical follow-up was performed at 4, 9 and 24 months. Results Angiographic success rate was 100%. In-hospital adverse events consisted of 1 death (2%). All except one patient (due to aspirin allergy) were compliant to the 3 months dual antiplatelet therapy, and there was no adverse event during this period. One patient developed re-infarction in another coronary territory at 6 months. Twenty-seven patients (56%) underwent 8-month angiographic follow-up (Table 3). At 24 months, 6 patients had 7 major adverse cardiac events (12.2%, 1 death, 2 re-infarctions and 4 target lesion revascularizations). There were no incidences of subacute or late stent thrombosis. Conclusions The Cura stent, using bioabsorbable polymer technology, appears to be safe at 2 years follow-up. Although the angiographic follow-up parameters were unfavorable, this report paves the way for further studies on DES using bioabsorbable polymer technology.

Long‐term outcome of simultaneous kissing stenting technique with sirolimus‐eluting stent for large bifurcation coronary lesions

This study was conducted to evaluate the outcomes of simultaneous kissing stenting with sirolimus-eluting stent (SES). Percutaneous intervention for bifurcation coronary lesions is still challenging. This study was designed to evaluate the long-term outcomes of 36 consecutive patients with large bifurcation coronary lesions who underwent simultaneous kissing stenting with SES. Lesion location was unprotected left main in 29 patients (81%) and anterior descending artery in 7 (19%). The patients received a combination of aspirin and clopidogrel for 6 months and cilostazol for 1 month. Mean proximal reference diameter was 4.05 +/- 0.68 mm. Compared with the side branch (SB), the main vessel (MV) involved longer lesions (25.8 +/- 17.0 mm vs. 10.2 +/- 10.8 mm, P < 0.001) and smaller preprocedural minimal lumen diameters (1.02 +/- 0.53 mm vs. 1.46 +/- 0.78 mm, P = 0.006) and was treated with larger stents (3.1 +/- 0.3 mm vs. 3.0 +/- 0.3 mm, P = 0.006). Angiographic success rate was 100%. Over the follow-up of 26.7 +/- 8.6 months, no deaths, myocardial infarctions or stent thromboses occurred. Target lesion revascularization was performed in five patients (14%). Overall angiographic restenosis occurred in 5/30 patients (17%), consisting of 4 (13%) at MV and 3 (10%) at SB. At follow-up angiography, a membranous diaphragm at the carina was identified in 14 patients (47%), but only one of whom was associated with angiographic restenosis. Simultaneous kissing stenting with SES appears a feasible stenting technique in large bifurcation coronary lesions. However, a new angiographic structure of carinal membrane developed in a half of patients at follow-up and its influence needs to be further investigated.

Multivessel Percutaneous Coronary Intervention in Chinese Patients with Acute Myocardial Infarction and Simple Nonculprit Arteries

Multivessel percutaneous coronary intervention (PCI) for patients during acute myocardial infarction (AMI) is currently controversial. In this study, we investigated the significance of multivessel PCI in Chinese patients with ST-segment elevation AMI and relatively simple lesions in nonculprit arteries. We reviewed all consecutive primary PCI of ST-segment elevation AMI in our hospital between 2002 and 2005. The patients with multivessel disease and ACC/AHA type A/B1 lesions in nonculprit arteries who underwent multivessel PCI were identified (n = 105, multivessel PCI group), and 120 patients with single-vessel disease and treatment with primary PCI were enrolled as control subjects (single-vessel PCI group). The primary end points were the occurrences of 6-month major adverse cardiac events (cardiogenic death, nonfatal reinfarction, and target vessel revascularization). The secondary end points included procedure time, angiographic success rate, TIMI grade, reperfusion arrhythmia, ST-segment resolution, and left ventricular ejection fraction. All patients with multivessel PCI tolerated the operations well and had similar TIMI 3 and angiographic success rates but longer procedure times than those patients with single-vessel PCI. There were no significant differences in reperfusion arrhythmia, ST-segment resolution, left ventricular ejection fraction, or 6-month MACEs between both groups. This study suggests that multivessel PCI is effective and safe for Chinese patients with ST-segment elevation AMI and simple lesions in nonculprit arteries.

MIDDLE CEREBRAL ARTERY STENTING FOR ACUTE ISCHEMIC STROKE AFTER UNSUCCESSFUL MERCI RETRIEVAL

Intracranial stenting has been used in the treatment of ischemic stroke caused by acute intracranial vessel occlusion after unsuccessful recanalization with the Merci retriever. We describe our early experience with this technique. Patients who had intra-arterial therapy for acute ischemic stroke with concomitant use of the retriever between February 1, 2005 and May 2, 2006 were identified from our endovascular database. Cases in which recanalization was not achieved with the retriever and in which stenting was attempted as a secondary means of mechanical recanalization were retrospectively reviewed. Ten patients with unsuccessful Merci retrieval underwent intracranial stenting. The average admission National Institutes of Health Stroke Scale score was 16.4. Occlusions were located in the middle cerebral artery (six extended into M2 branches). Four patients received intra-arterial reteplase (two prestent, one preretriever and poststent, and one poststent). Eptifibatide was administered immediately before stenting in every patient. Successful recanalization (thrombolysis in myocardial infarction 2 or 3) was achieved in nine out of 10 patients. Complications included an extradural perforation with arteriovenous fistula. Six patients had intracranial hematoma and/or subarachnoid hemorrhage; there were four deaths. The six surviving patients experienced at least a 6-point National Institutes of Health Stroke Scale improvement at discharge, although only one had a modified Rankin Scale score of 2 or less. Angiographic recanalization has been associated with improvement in clinical outcome after acute cerebral ischemia. Recanalization is not always achieved using the Merci retriever. We found that stenting after unsuccessful Merci retrieval resulted in a high rate of angiographic success. Further research into refining indications and optimizing outcome is warranted.

Impact of Baseline Platelet Count in Patients Undergoing Primary Percutaneous Coronary Intervention in Acute Myocardial Infarction (from the CADILLAC Trial)

Despite the well-recognized role of platelets in the pathogenesis of acute myocardial infarction (AMI) and in the vascular responses to angioplasty, the relation between platelet count and outcomes after primary percutaneous coronary intervention (PCI) in AMI is unknown. We therefore determined the effect of baseline platelet count on clinical and angiographic outcomes of patients with AMI undergoing primary PCI. In the prospective, randomized CADILLAC trial, platelet count on admission was available in 2,021 of 2,082 patients (97.0%). Angiographic results and outcomes at 30 days and 1 year were stratified by quartiles of platelet count. Median platelet count was 231 x 10(9)/L (range 38 to 709). Primary PCI angiographic success rates were independent of platelet count. The 30-day incidence of target vessel thrombosis or reocclusion increased steadily across the higher quartiles of baseline platelet count (0.2%, 0.6%, 1.0%, and 2.0%, p = 0.027). At 1 year, patients with a baseline platelet count >or=234 versus <234 x 10(9)/L had higher rates of death or reinfarction (8.9% vs 4.5%, p <0.0001), death (5.8% vs 3.1%, p = 0.002), and reinfarction (3.4% vs 1.6%, p = 0.008). By multivariable analysis, a higher baseline platelet count was the strongest predictor of 1-year death or reinfarction (hazard ratio [HR] per 10,000 increase in platelet count 1.02, 95% confidence interval [CI] 1.02 to 1.07, p <0.0001) and independently predicted reinfarction (HR 1.06, 95% CI 1.02 to 1.09, p = 0.002) and cardiac mortality (HR 1.03, 95% CI 1.00 to 1.06, p = 0.055) at 1 year. In conclusion, a higher baseline platelet count in patients with AMI is a powerful independent predictor of death and reinfarction within the first year after primary PCI.

Comparison of outcomes of percutaneous coronary intervention on proximal versus non-proximal left anterior descending coronary artery, proximal left circumflex, and proximal right coronary artery: A cross-sectional study

BackgroundPrevious studies have shown that lesions in proximal left anterior descending coronary artery (LAD) may develop more restenosis after balloon angioplasty than lesions in other coronary segments. However, stenting seems to have reduced this gap. In this study, we compared outcomes of percutaneous coronary intervention (PCI) on proximal LAD versus proximal left circumflex (LCX) or right coronary artery (RCA) and proximal versus non-proximal LAD.MethodsFrom 1737 patients undergoing PCI between March 2004 and 2005, those with cardiogenic shock, primary PCI, total occlusions, and multivessel or multi-lesion PCI were excluded. Baseline characteristics and in-hospital outcomes were compared in 408 patients with PCI on proximal LAD versus 133 patients with PCI on proximal LCX/RCA (study I) and 244 patients with PCI on non-proximal LAD (study II). From our study populations, 449 patients in study I and 549 patients in study II participated in complete follow-up programs, and long-term PCI outcomes were compared within these groups. The statistical methods included Chi-square or Fisher's exact test, student's t-test, stratification methods, multivariate logistic regression and Cox proportional hazards model.ResultsIn the proximal LAD vs. proximal LCX/RCA groups, smoking and multivessel disease were less frequent and drug-eluting stents were used more often (p = 0.01, p < 0.001, and p < 0.001, respectively). Patients had longer and smaller-diameter stents (p = 0.009, p < 0.001, respectively). In the proximal vs. non-proximal LAD groups, multivessel disease was less frequent (p = 0.05). Patients had larger reference vessel diameters (p < 0.001) and were more frequently treated with stents, especially direct stenting technique (p < 0.001). Angiographic success rate was higher in the proximal LAD versus proximal LCX/RCA and non-proximal LAD groups (p = 0.004 and p = 0.05, respectively). In long-term follow-up, major adverse cardiac events showed no difference. After statistical adjustment for significant demographic, angiographic or procedural characteristics, long-term PCI outcomes were still similar in the proximal LAD versus proximal LCX/RCA and non-proximal LAD groups.ConclusionDespite the known worse prognosis of proximal LAD lesions, in the era of stenting, our long-term outcomes were similar in patients with PCI on proximal LAD versus proximal LCX/RCA and non-proximal LAD. Furthermore, we had better angiographic success rates in patients with PCI on proximal LAD.

Transcatheter Arterial Embolization of Nonvariceal Upper Gastrointestinal Bleeding with N-Butyl Cyanoacrylate

ObjectiveTo evaluate the clinical efficacy and safety of transcatheter arterial embolization (TAE) with N-Butyl Cyanoacrylate (NBCA) for nonvariceal upper gastrointestinal bleeding.Materials and MethodsBetween March 1999 and December 2002, TAE for nonvariceal upper gastrointestinal bleeding was performed in 93 patients. The endoscopic approach had failed or was discarded as an approach for control of bleeding in all study patients. Among the 93 patients NBCA was used as the primary embolic material for TAE in 32 patients (28 men, four women; mean age, 59.1 years). The indications for choosing NBCA as the embolic material were: inability to advance the microcatheter to the bleeding site and effective wedging of the microcatheter into the bleeding artery. TAE was performed using 1:1-1:3 mixtures of NBCA and iodized oil. The angiographic and clinical success rate, recurrent bleeding rate, procedure related complications and clinical outcomes were evaluated.ResultsThe angiographic and clinical success rates were 100% and 91% (29/32), respectively. There were no serious ischemic complications. Recurrent bleeding occurred in three patients (9%) and they were managed with emergency surgery (n = 1) and with a successful second TAE (n = 2). Eighteen patients (56%) had a coagulopathy at the time of TAE and the clinical success rate in this group of patients was 83% (15/18).ConclusionTAE with NBCA is a highly effective and safe treatment modality for nonvariceal upper gastrointestinal bleeding, especially when it is not possible to advance the microcatheter to the bleeding site and when the patient has a coagulopathy.

Nonemergent coronary angioplasty without on-site surgical backup: A randomized study evaluating outcomes in low-risk patients

Background Percutaneous coronary intervention (PCI) in nonemergent patients with coronary artery disease in hospitals without on-site cardiac surgery backup is still controversial. To prospectively evaluate a set of low procedural risk criteria for PCI, patients with stable or unstable angina were randomized to treatment in either a community hospital, which had all supportive services except for on-site cardiac surgery, or a regional surgical hospital 213 km away. Methods and results During a 4-year period, 609 (57%) of 1064 consecutive patients with stable or unstable angina who underwent coronary angiography at a teaching community hospital in Norway fulfilled the predefined low-risk criteria for PCI. The patients were randomized to treatment at either the community hospital (n = 305) or at the regional hospital (n = 304). The angiographic success rate (96% at both hospitals) and number of major periprocedural complications (overall 0.3%) were equal at the 2 hospitals. In particular, there were no deaths or need for urgent transfer to cardiac surgery. At 6 months of clinical follow-up, there was a significant higher major adverse cardiac event rate rate at the community hospital, compared with the regional hospital (6.9% vs 2.3%, respectively, P = .03) because of more repeat target vessel revascularizations. Improvement in angina functional class and exercise capacity was similar in both groups. The excluded high-risk PCI patients had higher 6-month major adverse cardiac event compared with all low-risk patients (8.4% vs 4.3%, respectively, P = .01). Conclusion Selected nonemergent patients can, based on angiography, safely undergo PCI at hospitals without cardiac surgery backup. The angiographic selection criteria identified high-risk patients, which had worsened outcome at 6 months of follow-up.