Complication Of Angioplasty Research Articles

Carotid Angioplasty and Stenting

The relative indications for CAS versus CEA have not been determined. Whereas endarterectomy remains the gold standard for the treatment of significant carotid artery stenosis, early results suggest that angioplasty and stenting may be indicated in selected patients with risk factors for complications from endarterectomy. Despite involving vastly different mechanisms for treatment of atherosclerotic lesions, permanent neurologic morbidity and mortality rates for both techniques are similar. The transient or minor neurologic events seen more often with CAS may be amenable to prevention with distal protection techniques currently undergoing clinical testing. With careful preprocedural evaluation of medical comorbidities, appropriate treatment with antiplatelet agents, and careful evaluation of the target lesion, most potential complications of angioplasty and stenting may be avoided or at least anticipated. Further technical advancements in endovascular therapy and patient-driven preferences for less-invasive procedures are likely to expand the indications and applications of CAS.

Outcome in patients treated with primary angioplasty for acute myocardial infarction due to left main coronary artery occlusion

Primary percutaneous transluminal coronary angioplasty (PTCA) has been shown to be superior to thrombolytic therapy for the treatment of patients with acute myocardial infarction (AMI), in terms of enzymatic infarct size, left ventricular function, and clinical outcome. 1 Zijlstra F. de Boer M.J. Hoorntje J.C. Reiffers S. Reiber J.H. Suryapranata H. A comparison of immediate coronary angioplasty with intravenous streptokinase in acute myocardial infarction. N Engl J Med. 1993; 328: 680-684 Crossref PubMed Scopus (1175) Google Scholar , 2 Grines C.L. Browne K.F. Marco J. Rothbaum D. Stone G.W. O’Keefe J. Overlie P. Donohue B. Chelliah N. Timmis G.C. A comparison of immediate angioplasty with thrombolytic therapy for acute myocardial infarction. The Primary Angioplasty in Myocardial Infarction Study Group. N Engl J Med. 1993; 328: 673-679 Crossref PubMed Scopus (1878) Google Scholar , 3 Zijlstra F. Hoorntje J.C.A. de Boer M.J. Reiffers S. Miedema K. Ottervanger J.P. van’t Hof A.W. Suryapranata H. Long-term benefit of primary angioplasty as compared with thrombolytic therapy for acute myocardial infarction. N Engl J Med. 1999; 341: 1413-1419 Crossref PubMed Scopus (601) Google Scholar The use of stents and glycoprotein IIb/IIIa inhibitors has resulted in a further improvement in clinical outcome. 4 Suryapranata H. van’t Hof A.W.J. Hoorntje J.C. de Boer M.J. Zijlstra F. Randomized comparison of coronary stenting with balloon angioplasty in patients with acute myocardial infarction. Circulation. 1998; 97: 2502-2507 Crossref PubMed Scopus (325) Google Scholar , 5 Stone G.W. Grines C.L. Cox D.A. Garcia E. Tcheng J.E. Griffin J.J. Guagliumi G. Stuckey T. Turco M. Carroll J.D. Rutherford B.D. Lansky A.J. Controlled Abciximab, and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) InvestigatorsComparison of angioplasty with stenting with or without abciximab, in acute myocardial infarction. N Engl J Med. 2002; 346: 957-966 Crossref PubMed Scopus (1193) Google Scholar However, only few and inconsistent data have been reported with regard to primary PTCA for AMI due to left main coronary occlusion (LMCO). 6 Erbel R. Meinertz T. Wessler I. Meyer J. Seybold-Epting W. Recanalization of occluded left main coronary artery in unstable angina pectoris. Am J Cardiol. 1984; 53: 1725-1727 Abstract Full Text PDF PubMed Scopus (37) Google Scholar , 7 Spiecker M. Erbel L. Rupprecht H.J. Meyer J. Emergency angioplasty of totally occluded left main coronary artery in acute myocardial infarction and unstable angina pectoris—institutional experience and literature review. Eur Heart J. 1994; 15: 602-607 Crossref PubMed Google Scholar , 8 Quigley R.L. Milano C.A. Smith L.R. White W.D. Rankin J.S. Glower D.D. Prognosis and management of anterolateral myocardial infarction in patients with severe left main stenosis disease and cardiogenic shock the left main shock syndrome. Circulation. 1993; 88: 65-70 Google Scholar , 9 Chauhan A. Zubaid M. Ricci D.R. Buller C.E. Moschovich M.D. Mercier B. Fox R. Penn I.M. Left main intervention revisited early and late outcome of PTCA and stenting. Cath Cardiovasc Diagn. 1997; 41: 21-29 Crossref PubMed Scopus (66) Google Scholar , 10 Marso S.P. Steg G. Plokker T. Holmes D. Park S.J. Kosuga K. Macaya C. Moses J. White H. Verstraete S.F. Ellis S.G. Catheter-based reperfusion of unprotected left main stenosis during an acute myocardial infarction (the ULTIMA experience). Am J Cardiol. 1999; 83: 1513-1517 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar The aim of this study was to evaluate the efficacy of primary PTCA for LMCO, and to describe the clinical features, outcome, and prognostic determinants.

Role of distal protection during carotid stenting.

The most common complication of carotid angioplasty is distal embolization of debris and/or thrombus. The only way to avoid this complication is with the use of embolic protection devices. Several filters, distal balloon occlusion devices, and proximal balloon occlusion devices are available. These devices make it possible to capture arteriosclerotic debris during angioplasty and stenting. During the majority of procedures at least some particles can be retrieved. Therefore there is no doubt that these devices are important for carotid angioplasty. However, due to the low complication rate of carotid angioplasty even without embolic protection devices, large randomized trials are necessary to statistically prove the clinical efficacy of these devices.

Targeted antiproliferative drug delivery to vascular smooth muscle cells with a magnetic resonance imaging nanoparticle contrast agent: implications for rational therapy of restenosis.

Restenosis is a serious complication of coronary angioplasty that involves the proliferation and migration of vascular smooth muscle cells (VSMCs) from the media to the intima, synthesis of extracellular matrix, and remodeling. We have previously demonstrated that tissue factor-targeted nanoparticles can penetrate and bind stretch-activated vascular smooth muscles in the media after balloon injury. In the present study, the concept of VSMC-targeted nanoparticles as a drug-delivery platform for the prevention of restenosis after angioplasty is studied. Tissue factor-targeted nanoparticles containing doxorubicin or paclitaxel at 0, 0.2, or 2.0 mole% of the outer lipid layer were targeted for 30 minutes to VSMCs and significantly inhibited their proliferation in culture over the next 3 days. Targeting of the nanoparticles to VSMC surface epitopes significantly increased nanoparticle antiproliferative effectiveness, particularly for paclitaxel. In vitro dissolution studies revealed that nanoparticle drug release persisted over one week. Targeted antiproliferative results were dependent on the hydrophobic nature of the drug and noncovalent interactions with other surfactant components. Molecular imaging of nanoparticles adherent to the VSMC was demonstrated with high-resolution T1-weighted MRI at 4.7T. MRI 19F spectroscopy of the nanoparticle core provided a quantifiable approach for noninvasive dosimetry of targeted drug payloads. These data suggest that targeted paramagnetic nanoparticles may provide a novel, MRI-visualizable, and quantifiable drug delivery system for the prevention of restenosis after angioplasty.

Histomorphometric evaluation of (198)Au endovascular brachytherapy in a renal artery restenosis model in rabbits.

The main mid-term complication of percutaneous transluminal angioplasty of the renal artery is restenosis, which occurs in up to 50% of patients. Although no pharmacologic agent to date has been effective in preventing restenosis, both beta-ray emitters and gamma-ray emitters used in endovascular brachytherapy have been shown to reduce coronary restenosis. The objectives of this study were to evaluate the efficacy of (198)Au endovascular brachytherapy in preventing restenosis after percutaneous transluminal renal angioplasty and to determine the radiation dose to the operator. Twenty-one New Zealand white rabbits (10 females and 11 males) weighing an average of 3.5 kg (range, 3.2-3.8 kg) who had been fed a normal diet underwent bilateral 33% overdilatation with deendothelialization of the renal arteries. After 7 weeks, the induced renal artery stenoses were treated by percutaneous transluminal renal angioplasty. The rabbits were randomly assigned to one of three groups before receiving endovascular 25-Gy irradiation at a radial 2.0-mm depth with a 0.5 x 15 mm (198)Au wire (106 MBq). The right renal artery was irradiated in group A; the left, in group B. The rabbits in group C randomly received a right- or left-sided dummy wire. Operator exposure to radiation was measured using thermoluminescent dosimeters and ionization chambers. The rabbits were sacrificed after 3 weeks. The aorta and renal arteries were perfusion-fixed. The renal arteries were removed for histologic and histomorphometric study. Forty-two renal arteries were cut into a series of 4- micro m-thick slices. Five arteries were thrombosed (two in the irradiated group and three in the control group, p > 0.05). In the patent arteries (n = 37), the average neointimal area was 0.068 mm(2) (range, 0.009-0.234 mm(2)) in 15 irradiated segments (315 slices total), whereas the average neointimal area was 0.135 mm(2) (range, 0.016-0.324 mm(2)) in 22 control segments (462 slices total) (analysis of variance, p < 0.009), showing a percentage area of restenosis of 10.4% in irradiated arteries and 43.4% in non-irradiated arteries (p < 0.0003). Radiation dose per procedure to the operator was 0.034 mSv in the index finger, 0.024 mSv in the wrist, and undectable in the body. Endovascular brachytherapy with (198)Au appears to inhibit early renal artery restenosis and exposes the operator to a safe level of radiation.

Does angioplasty (PTRA) benefit older patients with fibromuscular disease (FMD)? Results of PTRA in 97 patients treated 1996-2000

Hypertension associated with FMD is an important cause of treatment resistance. The age of patients detected with FMD is rising, but few current data address the effects of age on outcomes and complications of angioplasty (PTRA) in this disorder. We studied blood pressure outcomes, BP meds, renal function, need for repeat procedures and complications in 97 patients with FMD undergoing PTRA between 1996-2000 whose median age was 58 years (22-86). As expected, the distribution favored female gender (F/M=89/8). Indications for PTRA included accelerated HTN and/or target organ events. ACE inhibitors or ARBs were used commonly (53.1%). Average time to last follow-up (Last F/U) was 570 days. Five had previous failed PTRA and 12 underwent later repeat PTRA (total 17/97=17.5%) which did not differ by age. By current criteria (BP<140/90 with no medicatons during long term F/U), the number “cured” was 6/97 (6.2%) but with clinical benefit in 66/97 68%. Thirty two % had no measurable benefit by these criteria. Complications were limited to occasional groin hematoma, with renal function remaining stable and no patients developing renal failure. Dissections were rare (2/97=2%) and there was no procedure-related mortality. These data indicate that older patients with FMD had higher systolic pressures and associated atherosclerosis. They were more likely to undergo bilateral intervention. Despite widespread use of ACE inhibitors and increasing patient age for FMD, improved BP control was achieved although “cure” rates were low. Recurrent stenosis occurred in FMD (17.5%) and required repeat procedures and/or surgery. Our results indicate that PTRA can be undertaken at all ages at low risk compared to patients with ASO. (See Table) (p<.05 vs age <58; p<.05 vs pre-PTRA) (p<.05 vs age <58; p<.05 vs pre-PTRA)

Intracoronary retrieval of the dehisced radiopaque ring of a guiding catheter: An unusual complication of coronary angioplasty

The guiding catheter used in coronary intervention may be damaged or some parts could be dehisced during the procedure, producing adverse effects in the vascular tree. So much so that immediate surgery is usually indicated. We report a case with a dehisced radiopaque ring of the catheter during the procedure. It was retrieved percutaneously without thoracotomy.

A trial comparing rheolytic thrombectomy with intracoronary urokinase for coronary and vein graft thrombus (the Vein Graft AngioJet Study [VeGAS 2

Percutaneous coronary or vein graft interventions in thrombus-containing lesions carry high risks for complications including abrupt closure, late reocclusion, periprocedural myocardial infarction, emergent coronary bypass surgery, and death. 1 White C.J Ramee S.R Collins T.J Escobar A.E Karsan A Shaw D Jain S.P Bass T.A Heuser R.R Teirstein P.S et al. Coronary thrombi increase PTCA risk. Angioscopy as a clinical tool. Circulation. 1996; 93: 253-258 Crossref PubMed Scopus (188) Google Scholar , 2 Waxman S Sassower M.A Mittleman M.A Zarich S Miyamoto A Manzo K.S Muller J.E Abela G.S Nesto R.W Angioscopic predictors of early adverse outcome after coronary angioplasty in patients with unstable angina and non-Q wave myocardial infarction. Circulation. 1996; 93: 2106-2113 Crossref PubMed Scopus (74) Google Scholar Various strategies for thrombus removal have emerged including pharmacologic thrombolysis, 3 Hartmann J.R McKeever L.S O’Neill W.W White C.J Whitlow P.L Gilmore P.S Doorey A.J Galichia J.P Enger E.L Recanalization of Chronically Occluded Aortocoronary Saphenous Vein Bypass Grafts with Long-Term, Low Dose Direct Infusion of Urokinase (ROBUST) a serial trial. J Am Coll Cardiol. 1996; 27: 60-66 Abstract Full Text PDF PubMed Scopus (58) Google Scholar mechanical compression by balloon angioplasty, mechanical removal using extraction and atherectomy devices, 4 Dooris M Hoffmann M Glazier S Juran N Reddy V Grines C.L Pavlides G.S Schreiber T O’Neill W.W Safian R.D Comparative results of transluminal extraction coronary atherectomy in saphenous vein graft lesions with and without thrombus. J Am Coll Cardiol. 1995; 25: 1700-1705 Abstract Full Text PDF PubMed Scopus (45) Google Scholar , 5 Lefkovits J Holmes D.R Califf R.M Safian R.D Pieper K Keeler G Topol E.J Predictors and sequelae of distal embolization during saphenous vein graft intervention from the CAVEAT-II trial. Coronary Angioplasty Versus Excisional Atherectomy Trial. Circulation. 1995; 92: 734-740 Crossref PubMed Scopus (113) Google Scholar ultrasonic thrombolysis, 6 Rosenschein U Roth A Rassin T Basan S Laniado S Miller H.I Analysis of coronary ultrasound thrombolysis endpoints in acute myocardial infarction (ACUTE Trial). Results of the feasibility study. Circulation. 1997; 95: 1411-1416 Crossref PubMed Scopus (121) Google Scholar and dissolution using glycoprotein IIb/IIIa inhibitors. 7 Muhlestein J.B Karagounis L.A Treehan S Anderson J.L “Rescue” utilization of abciximab for the dissolution of coronary thrombus developing as a complication of coronary angioplasty. J Am Coll Cardiol. 1997; 30: 1729-1734 Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar These strategies, however, have limitations related to efficacy, complication rates, prolonged hospital stay, or patient discomfort. Rheolytic thrombectomy (AngioJet, Possis Medical, Inc., Minneapolis, Minnesota) is a catheter-based system that uses high-velocity water jets to produce a vacuum for thrombus aspiration and extraction, as described previously 8 Whisenant B.K Baim D.S Kuntz R.E Garcia L.A Ramee S.R Carrozza J.P Rheolytic thrombectomy with the Possis AngioJet technical considerations and initial clinical experience. J Invasive Cardiol. 1999; 11: 421-426 PubMed Google Scholar (Figure 1). The Vein Graft AngioJet Study (VeGAS 1) demonstrated safety and feasibility for AngioJet thrombectomy in native coronary arteries and saphenous vein grafts (SVGs). 9 Ramee S.R Schatz R.A Carrozza P Leon M.B Ho K.K Baim D.S Lanoue A.S Senerchia C Kuntz R.E Results of the VeGAS 1 pilot study of the Possis coronary AngioJet thrombectomy catheter. Circulation. 1996; 94 (abstr): 3622 Google Scholar The randomized VeGAS 2 trial was designed to evaluate the clinical efficacy of rheolytic thrombectomy compared with intracoronary urokinase for the treatment of thrombus-containing lesions in SVGs or native coronary arteries.

Upregulation of Nox-based NAD(P)H oxidases in restenosis after carotid injury.

Restenosis, a frequent complication of coronary angioplasty, is associated with increased superoxide (O2*(-)) production. Although the molecular identity of the responsible oxidase is unclear, an NAD(P)H oxidase appears to be involved. In smooth muscle, p22phox and 2 homologues of gp91phox, nox1 and nox4, are expressed, whereas fibroblasts contain gp91phox. To begin investigating the possibility that these oxidase components might contribute to the increased O2*(-) that accompanies neointimal formation, we measured their expression after balloon injury of the rat carotid artery. The increase in O2*(-) production 3 to 15 days after surgery was not due to inflammatory cell infiltration but appeared to be derived from medial and neointimal smooth muscle cells and adventitial fibroblasts. Nox1 and p22phox mRNAs were increased 2.7- and 3.6-fold, respectively, at day 3 after injury and remained elevated for 15 days. gp91Phox was increased 7 to 15 days after injury, and nox4 expression was increased 2-fold, but only at day 15 after surgery. These results confirm and extend our previous in vitro data and suggest that in the vasculature, the nox-based NAD(P)H oxidases serve different functions. This dynamic regulation of oxidase components may be critical to smooth muscle phenotypic modulation in restenosis and atherosclerosis.

Abciximab is rapidly effective in preventing and arresting established platelet aggregation.

Abciximab reduces the thrombotic complications of angioplasty. It is also used, as a 'bail out' treatment when angioplasty is complicated by thrombus but its speed of action is not known. This study sought to establish how quickly abciximab blocks the aggregation of both quiescent and activated platelets to explain this rapid efficacy. Optical aggregometry (OA) and whole blood electrical impedance platelet aggregometry (WBEA) were performed with blood from 10 healthy volunteers. Abciximab 5 microg/ml was added in each case with saline control 5 minutes before agonist, 10 seconds before agonist and during aggregation. (1) Abciximab administered 5 minutes before agonist, completely inhibited aggregation with OA: (medians and ranges) 0% (all 0), control: 71% (50-95%) p < 0.001. and with WBEA: 0 omega (all 0 omega), control: 7.5 omega (4.8-12.5 omega) p = 0.016. (2) When administered 10 s before agonist with OA a small initial degree of aggregation occurred but this was rapidly reversed (time to reversal: 2 mins (1-4.5 mins) to low levels of aggregation 16.5% (0-22%), control 72.5% (55-95%) p = 0.002. With WBEA aggregation was completely inhibited: 0 omega (all 0 omega), control: 7.5 omega (4.8-12.3 omega) p = 0.016. (3) When administered during aggregation, with OA the rise in the aggregometry tracing was rapidly arrested (time to arrest: 1.5 mins (0.1-3 mins)) with no further aggregation occurring: 42% (30-57%), control: 80% (60-100%) p = 0.002. With WBEA the findings were similar: (time to arrest 1.5 mins (1-2 mins)) 6.3 omega (1.5-11.3 omega), control: 10 omega (3-12 omega) p = 0.031. These data suggest that when administered during a procedure in which thrombus has occurred, aggregation may be rapidly arrested. This applies to quiescent platelets but also activated platelets undergoing aggregation.

Optimizing the Use of Abciximab and Intracoronary Stents in Patients with Acute ST Elevation Myocardial Infarction

Acute ST elevation myocardial infarction (STEMI) is a cause of significant morbidity and mortality in patients with coronary artery disease. Reperfusion therapy, either with thrombolytic agents or primary percutaneous coronary intervention (PCI), is the mainstay of therapy. Worldwide, systemic thrombolysis is the more commonly utilized reperfusion strategy, although an increasing number undergo primary PCI. PCI techniques and adjuvant therapies are evolving. Stents appear to be more useful than thrombolytic therapy or PTCA in acute AMI, especially in decreasing the need for subsequent target lesion revascularization. In patients with STEMI, administration of abciximab with stent placement decreased the primary endpoint [composite of major adverse cardiac events (death, reinfarction, urgent TVR)] by over 50% at 30 days in the Abciximab before Direct angioplasty and stenting in acute Myocardial Infarction Regarding Acute and Long-term follow-up (ADMIRAL) trial, and the benefit appeared to be maintained at 6 months. Despite these promising results, administration of abciximab with a stent did not afford greater benefit over stent alone in the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. The apparent lack of benefit with abciximab in the CADILLAC trial may be explained by the fact that this trial was not powered to detect differences in mortality and enrolled patients were selected after angiography, and were thus at lower risk. The adjuvant therapies of intracoronary stents and abciximab are becoming the standard of care, based on multiple studies. Stent placement during STEMI decreases the risk of restenosis and TVR. Treatment with abciximab may reduce the risk of acute adverse events in the short term.

Six of the Best, Vascular 22

Introduction: One of the arguments for a conservative policy in intermittent claudication is the potential risk of significant complications as a result of interventional treatment. The in-hospital complications of an interventional policy have been assessed for a 5-year period. Aims: All admissions for intermittent claudication between January 1997 and December 2001 have been analysed. Data were entered prospectively in a dedicated database by a single observer. Data were collected on indications for admission, operative procedures and complications. Results: A total of 1115 admissions took place in 531 patients. In 35 admissions, no procedures took place. A total of 569 admissions were for diagnostic arteriography, of which three had cardiac complications, one an allergic reaction and one a groin haematoma. A total of 328 admissions were for angioplasty on a total of 352 vessels. Angioplasty complications included one TIA, one damaged vessel, one severe angina and one distal embolization which required operative intervention. A total of 183 admissions involved reconstructive surgery. Procedures included 19 aortic grafts, 73 above knee and 30 below knee femoro-popliteal bypasses, 14 distal grafts, 34 cross-over grafts and 17 assorted other bypasses. Complications of surgery included 12 assorted cardiac, respiratory and renal complications, 15 significant wound complications, two anastamotic bleeds/graft ruptures and seven graft thromboses. Eight patients required further intervention in the same admission. There have been no deaths and only one late amputation. Conclusion: Radiological investigation and intervention in intermittent claudication should be regarded as a safe procedure but surgery carries a higher risk. Potential amputation should not be regarded as reason for nonintervention.

Mechanisms of ventricular fibrillation during coronary angioplasty: increased incidence for the small orifice caliber of the right coronary artery

Background: Ventricular fibrillation (VF) is not an infrequent complication of percutaneous transluminal coronary angioplasty (PTCA). However, it is not clear why there is a marked discrepancy in the higher incidence of VF during right coronary artery (RCA) approach. Methods and results: We analyzed in detail every case of VF occurring in 905 consecutive PTCA procedures to investigate possible mechanisms. Sixteen patients (M/F=15/1, mean age: 71±8 years) with VF during PTCA for the RCA as Group I. Those 51 patients (M/F=48/3, mean age: 70±9 years) without VF during PTCA for the RCA engagement were designated as Group II. Patients were equipped with cardiac event recorder (CardioCall, Reynolds Medical, UK) before the PTCA, and we set the time period 1 min before and after the event. The lead II was selected to check the QRS width, QTc interval, ST segment change and RR interval before and after event. A total of 905 PTCA procedures were included. There were 561 procedures for the left coronary artery and three events (0.5%) with spontaneous VF. However, there were 16 events (4.6%) of VF during 344 PTCA procedures for the right coronary artery. The incidence of VF for the right side PTCA was significantly higher than for the left side. The orifice of RCA in Group I was smaller than Group II (orifice of RCA in Group I vs. Group II — 2.7±0.8 vs. 4.1±1.2 mm, P<0.001). Most cases (68.7%) presented with ST segment depression before the onset of VF. Conclusion: A small caliber of RCA and associated ST segment changes played important roles in the patients with VF during the PTCA.

Complications of balloon coarctation angioplasty

Balloon angioplasty for both native and recurrent coarctation of the aorta has become an established form of therapy in the treatment of this congenital cardiovascular defect in both children and adults. A significant reduction in upper extremity hypertension, a decrease in the transaortic pressure gradient, and angiographic enlargement at the site of narrowing occur in the majority of patients, both acutely and in mid-term follow-up studies. Acute and delayed complications of this modality of treatment have been well described and include vascular access injury, neurologic events (stroke, transient ischemic attack), reactive hypertension, arrhythmias and sudden cardiac arrest, acute aortic dissection or rupture, and the late development of aneurysm at the dilated site. This review will discuss in depth the incidence and risk factors associated with these complications and the treatment and prevention modalities that can be utilized to decrease the risk of these untoward events.

Incidence, management, and outcome of stent loss during intracoronary stenting

Coronary stent embolization is an uncommon but potentially hazardous complication of percutaneous transluminal coronary angioplasty (PTCA). Previous small-sized clinical studies reported incidence rates ranging from 0.9% to 8.4%.1–5 In this study we report the incidence, management, and hospital follow-up of a large, consecutive series of patients with coronary stent embolization.

Intracoronary radiation therapy.

Over the past 15 years, despite a great deal of effort in assessing a variety of approaches, restenosis reduction has remained the most problematic complication of percutaneous transluminal coronary angioplasty (PTCA). Initial attempts focused on assessing systemic drugs including anticoagulant and antiplatelet agents, calcium antagonists and lipid-lowering agents. Subsequently, agents that were shown to significantly reduce neointima formation in animal models, including angiotensin-converting enzyme inhibitors, low molecular weight heparin, HMG-CoA reductase inhibitors, ketanserin and angiopeptin, were tested but were not found to be successful in restenosis reduction in clinical trials. The introduction of interventional techniques such as directional atherectomy rotational atherectomy and laser angioplasty on their own or as part of facilitated angioplasty or transcatheter device synergy have not generally reduced the frequency of restenosis. Stent implantation initially appeared promising with rates of around 20%–30% in so-called ‘ideal’ lesions, but with improvement of stent technology, the indications for stenting have broadened. Meanwhile the restenosis rate has remained significant with the rate ranging from 15%–50% at 6 months depending on the lesion morphology and other factors. In addition, the use of stents has led to the growing problem of in-stent restenosis. More recently, however, the concept and technique of applying ionizing radiation to the arterial wall during the percutaneous coronary intervention procedure has emerged and gained considerable momentum including entry into clinical trials.

A prospective, multicenter, international randomized trial comparing four reperfusion strategies in acute myocardial infarction: Principal report of the controlled abciximab and device investigation to lower late angioplasty complications (CADILLAC) trial Gregg W. Stone, Cindy L. Grines, David A. Cox, Eulogio Garcia, James E. Tcheng, Thomas Stuckey, John Carroll, Giulio Guagliumi, Barry Rutherford, Gary Johnson, Mark Effron, Paolo Esente, Alexandra J.

A prospective, multicenter, international randomized trial comparing four reperfusion strategies in acute myocardial infarction: Principal report of the controlled abciximab and device investigation to lower late angioplasty complications (CADILLAC) trial Gregg W. Stone, Cindy L. Grines, David A. Cox, Eulogio Garcia, James E. Tcheng, Thomas Stuckey, John Carroll, Giulio Guagliumi, Barry Rutherford, Gary Johnson, Mark Effron, Paolo Esente, Alexandra J.

Long-term follow up of angioplasty for cerebral vasospasm.

Cerebral angioplasty has been reported to be useful for the treatment of symptomatic cerebral vasospasm following subarachnoid hemorrhage [3]. Recent data indicates that angioplasty may be effective in preventing the development of vasospasm [7]. However, the long-term effects of cerebral angioplasty on the human cerebral circulation are not known. In the coronary circulation, complications of angioplasty for atherosclerotic disease include restenosis in 30% of vessels, occlusion of the vessel, transient loss of vascular reactivity, and long-term endothelial dysfunction [4]. In atherosclerotic vessels, angioplasty induces vascular injury and initiates intimai hyperplasia, deposition of extracellular matrix, and ultimately results in vessel remodeling. Although no clinical case reports of delayed complications of cerebral angioplasty have been reported, there has also been no assessment of these patients with regard to their intracranial circulation

Clinical trials with glycoprotein IIb/IIIa antagonists - No benefit without bleeding?

As the glycoprotein GPIIb/IIIa receptor is the final common pathway in platelet aggregation, antagonists of this receptor cause a profound inhibition of aggregation induced by any agonist. The short-term efficacy and safety of GPIIb/IIIa antagonists in patients undergoing coronary angioplasty was demonstrated with murine 7E3 Fab, but this antibody was immunogenic. Abciximab is a chimeric human-mouse monoclonal antibody that is less immunogenic. The first major trial with a GPIIb/IIIa antagonist was the EPIC trial with abciximab, which showed that abciximab reduced the ischemic complications of coronary balloon angioplasty and atherectomy in high-risk patients, but increased the risk of bleeding. Subsequent studies showed that using less concurrent heparin reduced bleeding. Abciximab also reduced the rate of revascularization. Further studies have shown that the benefits of abciximab extended to all patients undergoing angioplasty (EPILOG), including patients with unstable angina (CAPTURE) and acute myocardial infarction (RAPPORT). Clinical trials with eptifibatide and tirofiban have failed to demonstrate benefit, at the doses used, in angioplasty. Abciximab and eptifibatide, but not oral xemilofiban, improve the safety of the coronary stenting procedure. Short-term intravenous treatment with lamifiban, eptifibatide or tirofiban is beneficial in acute coronary syndromes (unstable angina, non-Q wave myocardial infarction). Orally active GPIIb/IIIa antagonists are being developed for use in acute coronary syndromes and myocardial infarction. However, no benefit has been shown with lefradafiban in acute coronary syndromes and sibrafiban and orbofiban are harmful. Eptifibatide, lamifiban and abciximab improve coronary patency in myocardial infarction, and long- term trials of GPIIb/IIIa antagonists are being conducted in acute myocardial infarction. Abciximab can cause thrombocytopenia, and all the GPIIb/ IIIa antagonists increase the incidence of bleeding, but there is no excess of intracranial hemorrhage. (c) 2001 Prous Science. All rights reserved.

Tratamiento con stent recubierto de una perforación de injerto de safena durante una angioplastia

Coronary perforation or rupture is an infrequent complication of angioplasty which may have a poor prognosis and influence patient survival. Cardiac tamponade or the presence of ischemia leading to acute myocardial infarction may require emergency cardiac surgery. Surgical treatment of perforation or rupture of the coronary arteries is based on prolonged inflation with angioplasty balloons or autoperfusion. There are few studies on the placement of covered stents to seal the perforation. We present the case of a patient who presented saphenous vein graft rupture following high pressure stent implantation requiring percutaneous placement of a covered stent.