Control Coronary Angiography Research Articles

Results of coronary bypass surgery of the arteries with extended atherosclerotic abnormalities

Background: In multi-vessel atherosclerotic coronary artery disease, coronary artery bypass grafting remains the method of choice and allows for the best possible revascularization and maximal continuity of the results. Conduit functioning to a large extent depends on the coronary artery (CA) diameter and on the severity of atheromatous involvement and anatomic abnormalities of its walls. However, there is no consensus on what minimal diameter and extent of CA lesions could provide robust long-term results of bypass surgery. Consequently, surgical strategy for bypass grafting in diffuse coronary involvement and small vessel diameters has not been clearly defned. Aim: To perform a comparative analysis of the bypass grafts functioning depending on CA anatomy and methods of revascularization. Materials and methods: The study included 98 patients, who, irrespective of their clinical condition, had a control coronary angiography (CAG) with shuntography (SHG) between 6 months to 5 years after they had undergone direct myocardial revascularization by coronary artery bypass grafting. In total, 215 anastomoses were assessed. The bypassed CAs were divided into two groups according to their diameters and into two subgroups depending on the severity of the coronary vasculature involvement. When bypassing an artery with diffuse involvement, angioplastic anastomoses were done in 52.5% of the cases. Long-term graft functioning was assessed by shuntography. Results: Conduit functioning after bypassing of CA >1.5 mm in diameter and with local CA narrowing did not depend on the graft type and was 95.1% for the internal thoracic artery (ITA) grafts and 90.1% for the great saphenous vein (GSV) grafts. With diffuse lesions, these values decreased to 68.4% for ITA and 69.1% for GSV (р 1.5 mm in diameter, the graft type has not signifcant impact on its long-term functioning. In diffuse CA involvement, angioplastic anastomoses should be used.

PP-441 - Unseen Part of the Iceberg Before Obesity Surgery: Multivessel Coronary Artery Disease

Case report: 47 years old man evaluated for class II exertional dsypnea before obesity surgery as an outpatient. He had a history of hyperlipidemia and smoking with 30 packs a year. Physical examination revealed obesity (body mass index 36.2 kg/m2, 120 kg, 1.82 cm). Electrocardiography demonstrated sinus rhythm, and left anterior hemiblock. Echocardiography demonstrated normal systolic function, and mild mitral regurgitation. Due to the exertional dyspnea, he underwent myocardial perfusion scintigraphy which is showed myocardial ischemia of inferior and anterior myocardial wall. The coronary angiography showed severe stenosis of proximal left anterior descending and circumflex coronary artery. The retrograd collaterals from left coronary system to right coronary artery and total occlusion and antegrad bridge collaterals at proximal right coronary artery were also demonstrated in left and right coronary angiography. Coronary bypass surgery recommended for the complete revascularization but the patient didn't accept the surgery. First, the opening of the chronic total occlusion of right coronary artery, and then left coronary system were planned. 7F JR4 guiding, and 6F JL4 diagnostic catheters used for dual injection. The conus branch was use to anchor with 1,5 × 15 mm semi-compliant balloon. Gaia-3 guidewire was used to advance proximal cap under back-up with Corsair microcatheter and using drilling technique. By using Gaia 3 guidewire we weren't able to enter from distal cap to true lumen. Therefore, microcatheter changed to Twinpass microcatheter and the Fielder FC was used to enter acute margine branch or distal right coronary artery. Fielder FC was penetrated into the acute margine branch, and distal cap was punctured with the Conquest Pro through the side hole of the Twinpass microcatheter by advancing wire into the distal right coronary artery. By using TRAP technique, Twinpass microcatheter was removed and Corsair microcatheter was advanced into distal right coronary artery to protect coronary perforation by Conquest Pro manipulation. Grand Slam guidewire was advanced through Corsair microcatheter. After removing Corsair microcatheter by TRAP technique, multiple balloon dilatations were performed. 3.0 × 48 mm Xience Pro and 3.0 × 38 mm Cre8 DES were implanted mid-distal right coronary artery while 3.5 × 23 mm Xience Pro was implanted proximally. Multiple post-dilatations were performed with 3.5 × 18 mm non-compliant balloon and TIMI III flow was achieved. The revascularization of left coronary system was planned for two weeks later. Firstful, 4.0 × 26 mm Resolute stent was succesfully implanted to circumflex coronary artery. At the same procedure, 4.0 × 38 mm Resolute stent was succesfully implanted to the left anterior descending coronary artery. Control coronary angiography of the right coronary artery also showed that TIMI III flow with no evidence of thrombosis or stenosis. He discharged with the advice of the lifestyle changes, quit smoking, and weight lost. The obesity surgery was postponed until the 6 months from the procedure for reducing stent thrombosis risk.

Impact of free thyroxine levels and other clinical factors on bare metal stent restenosis.

Thyroid hormones have both direct and indirect effects on thermogenesis such as modulating vascular smooth muscle cell proliferation. However, the influence of more subtle changes in thyroid hormones on coronary atherosclerosis remains a matter of speculation. Smooth muscle cells play a crucial role in the pathogenesis of in-stent restenosis (ISR). However, the relationship between free thyroxine (fT4) and ISR has not been studied. In the present study, we aimed to assess the role of preprocedural serum fT4 level on the development of ISR in patients undergoing coronary bare metal stent (BMS) implantation. We enrolled and analyzed clinical, biochemical, and angiographic data from 705 consecutive patients without a history of primary thyroid disease [mean age 60.3 ± 9.3 years, 505 (72%) male]; all patients had undergone BMS implantation and further control coronary angiography owing to stable or unstable angina pectoris. Patients were divided into 3 tertiles based on preprocedural serum fT4 levels. ISR was observed in 53 (23%) patients in the lowest tertile, 82 (35%) patients in the second tertile, and 107 (46%) patients in the highest fT4 tertile (p < 0.001). Using multiple logistic regression analysis, five characteristics emerged as independent predictors of ISR: diabetes mellitus, smoking, HDL-cholesterol, stent length, and preprocedural serum fT4 level. In receiver operating characteristics curve analysis, fT4 level > 1.23 mg/dL had 70% sensitivity and 73% specificity (AUC: 0.75, p < 0.001) in predicting ISR. Higher preprocedural serum fT4 is a powerful and independent predictor of BMS restenosis in patients with stable and unstable angina pectoris.

Usefulness of the monocyte-to-high-density lipoprotein cholesterol ratio to predict bare metal stent restenosis.

The aim of the present study was to investigate the predictive value of preprocedural monocyte count-to-high-density lipoprotein cholesterol ratio (MHR) on development of in-stent restenosis in patients undergoing coronary bare-metal stent (BMS) implantation. Data from 705 patients who had undergone BMS implantation and additional control coronary angiography were analyzed. Patients were divided into three tertiles based on preprocedural MHR. Restenosis occurred in 59 patients (25%) in the lowest tertile, 84 (35%) in the middle tertile and 117 (50%) in the highest MHR tertile (p < 0.001). Using multiple logistic regression analysis, smoking, diabetes mellitus, stent length, preprocedural MHR and C-reactive protein levels emerged as independent predictors of in-stent restenosis. High preprocedural MHR is related to BMS restenosis.

The assessment of non culprit coronary artery lesions in patients with ST segment elevated myocardial infarction and multivessel disease by control angiography with quantitative coronary angiography.

Conflicting data is present in the literature about patients who are treated with percutaneous coronary intervention (PCI) due to the exaggeration of the non culprit artery. The precise understanding of the non culprit artery in the setting of ST segment elevated myocardial infarct (STEMI) is important since the time and modality of the treatment is planned accordingly. The aim of this study is to evaluate the lesions in the non culprit coronary artery during primary PCI and control coronary angiography (CAG) using quantitative coronary angiography (QCA) in multivessel STEMI patients. In this study, multivessel disease STEMI patients whom underwent primary PCI between January 2010 and March 2011 were included. Critical stenosis degree was accepted as ≥70 % in the non culprit artery. All patients were evaluated with control CAG 1month after primary PCI. Assessment with CAG was performed by two blinded cardiologists. QCA program was used to evaluate reference artery diameter (RAD), minimum luminal diameter (MLD) and degree of stenosis. With regard to the degree of stenosis, significant reduction was accepted as ≥15 % while % 5-15 decrease was accepted as moderate. Of the 81 patients, 61 were males and 20 were females (mean age 58.1 ± 10). In the control CAG, the degree of non culprit artery stenosis was found to be decreased (p < 0.001) while RAD and MLD were increased (p < 0.001 and p < 0.001 respectively). Significant decrease in critical non culprit artery lesions was detected in 22 patients (20.9 %) meanwhile moderate reduction was observed in 26 patients (24.7 %). In 14 patients (13.3 %), non culprit artery lesions accepted as critical during primary PCI were found to be non critical during the control CAG. Planned intervention was cancelled and medical treatment was initiated in those 14 patients. Our data indicated using QCA, approximately the half of non culprit lesions were found less critical during control CAG when compared to primary PCI. Therefore, it is concluded that complete revascularization during primary PCI should be avoided in multivessel STEMI patients and critical non culprit artery lesions should be re-evaluated with later control CAG.

The Relationship Between Lymphocyte-to-Monocyte Ratio and Bare-Metal Stent In-Stent Restenosis in Patients With Stable Coronary Artery Disease.

In-stent restenosis (ISR) is a common clinical problem in patients with coronary artery disease treated with percutaneous coronary intervention. Inflammatory process plays a pivotal role in the development of ISR. Both lymphocytes and monocytes are associated with inflammatory status. Recently, it has been shown that the lymphocyte-to-monocyte ratio (LMR) is a novel inflammatory marker. We aimed to investigate the association of serum LMR levels and ISR in patients undergoing bare-metal stent (BMS) implantation. The study included 273 patients (aged 61 ± 11 years, 66.5% men) with a history of BMS implantation and a further control coronary angiography due to stable angina pectoris. Patients were divided into 2 groups: patients with and without ISR. The LMR levels were significantly lower in patients with ISR than in those without ISR (2.50 ± 0.95 vs 3.87 ± 1.51, respectively, P < .001). On multivariate logistic regression analysis, the LMR was independently associated with ISR (odds ratio [OR]: 0.310, 95% confidence interval: 0.166-0.579, P < .001) together with high-sensitivity C-reactive protein (OR: 1.244, P = .008), reason for stent implantation (OR: 6.566, P = .003), stent diameter (OR: 0.015, P < .001), and stent length (OR: 1.137, P = .007). In conclusion, LMR levels are inversely related to ISR in patients treated with BMS implantation.

The Same Angiographic Factors Predict Venous and Arterial Graft Patency: A Retrospective Study.

To evaluate the value of angiographic factors in predicting failure of both venous and arterial coronary artery bypass graft.We retrieved from our angiographic database 148 patients who underwent venous and/or arterial CABG and for whom a control coronary angiography at more than 1 month after surgery was available. Pre-CABG and follow-up angiographies were analyzed in order to evaluate diameter stenosis (DS,%), stenosis length (mm), Bogaty score (extent index), Sullivan score, and Gensini score for the extent of coronary artery disease, and Jeopardy Duke score for the extent of myocardial area supplied by an artery.Thirty-nine patients (26%) experienced graft failure at follow-up (mean follow-up 11.3 ± 4.6 months). Patients with venous graft failure [26 (20%)] had significantly smaller DS (P = 0.013), shorter stenosis length (P = 0.01), and lower extent index (P = 0.015), Sullivan score (P = 0.013), Gensini score (P = 0.04) as compared with those without venous graft failure. Patients with arterial graft failure [13 (11%)] had significantly lower DS (P = 0.008), shorter stenosis length (P = 0.001), and lower extent index (P = 0.03) and Sullivan score (P = 0.023) as compared with those without arterial graft failure.Venous and arterial graft failure are associated with less severe stenosis and less extensive atherosclerosis of the grafted vessel.

Do pre-procedural laboratory parameters predict drug-eluting stent restenosis?

Drug-eluting stents (DES) have considerably reduced the rates of in-stent restenosis (ISR). Several studies reported pre-procedural C-reactive protein (CRP), neutrophil to lymphocyte (N/L) ratio, red cell distribution width (RDW), serum uric acid (UA), and mean platelet volume (MPV) as independent predictors of ISR using bare metal stents. This study investigates whether any laboratory parameter obtained before the coronary stenting procedure is associated with ISR using DES in stable coronary artery disease. Three hundred fifteen stents were retrospectively analysed in 285 patients who had undergone coronary stenting and a control coronary angiography within one year of stenting, between January 2012 and April 2014. Pre-procedural complete blood count, biochemistry, and CRP were recorded. Off-line quantitative coronary angiography analysis was performed. Overall restenosis rate was 10.2%. When the stents were analysed with respect to the presence of ISR, the number of diabetics and smokers was higher in the ISR group. CRP levels were significantly higher in the ISR group, but there were no differences in N/L, monocytes, eosinophils, RDW, MPV, UA, and total bilirubin levels. In the univariate regression analysis, DM, CRP, stent length, stent diameter, pre-procedural diameter stenosis, pre-procedural minimal lumen diameter (MLD), post-procedural residual diameter stenosis, post-procedural reference vessel diameter, and post-procedural MLD were predictors of ISR. However, multivariate regression analysis identified only DM and post-procedural residual stenosis as independent predictors of ISR. Pre-procedural blood parameters do not independently predict ISR in DES, which is mainly determined by the presence of diabetes and post-procedural residual stenosis.

Improvement of Image Quality and Diagnostic Performance by an Innovative Motion-Correction Algorithm for Prospectively ECG Triggered Coronary CT Angiography.

ObjectiveTo investigate the effect of a novel motion-correction algorithm (Snap-short Freeze, SSF) on image quality and diagnostic accuracy in patients undergoing prospectively ECG-triggered CCTA without administering rate-lowering medications.Materials and MethodsForty-six consecutive patients suspected of CAD prospectively underwent CCTA using prospective ECG-triggering without rate control and invasive coronary angiography (ICA). Image quality, interpretability, and diagnostic performance of SSF were compared with conventional multisegment reconstruction without SSF, using ICA as the reference standard.ResultsAll subjects (35 men, 57.6 ± 8.9 years) successfully underwent ICA and CCTA. Mean heart rate was 68.8±8.4 (range: 50–88 beats/min) beats/min without rate controlling medications during CT scanning. Overall median image quality score (graded 1–4) was significantly increased from 3.0 to 4.0 by the new algorithm in comparison to conventional reconstruction. Overall interpretability was significantly improved, with a significant reduction in the number of non-diagnostic segments (690 of 694, 99.4% vs 659 of 694, 94.9%; P<0.001). However, only the right coronary artery (RCA) showed a statistically significant difference (45 of 46, 97.8% vs 35 of 46, 76.1%; P = 0.004) on a per-vessel basis in this regard. Diagnostic accuracy for detecting ≥50% stenosis was improved using the motion-correction algorithm on per-vessel [96.2% (177/184) vs 87.0% (160/184); P = 0.002] and per-segment [96.1% (667/694) vs 86.6% (601/694); P <0.001] levels, but there was not a statistically significant improvement on a per-patient level [97.8 (45/46) vs 89.1 (41/46); P = 0.203]. By artery analysis, diagnostic accuracy was improved only for the RCA [97.8% (45/46) vs 78.3% (36/46); P = 0.007].ConclusionThe intracycle motion correction algorithm significantly improved image quality and diagnostic interpretability in patients undergoing CCTA with prospective ECG triggering and no rate control.

Medical Therapy in Acute Myocardial Infarction: A Case Report

Acute ST elevation myocardial infarction is among the most important causes of cardiac mortality and morbidity. An 80-year-old female patient was referred to our emergency department with chest pain. The patient, who had been diagnosed with ST elevation inferior and right myocardial infarction, received coronary angiography under primary conditions. There was an intense and long thrombus in the right coronary artery. Therefore, the patient was not considered for percutaneous coronary intervention. Glycoprotein IIb/IIIa receptor blockers and tirofiban were added to antiaggregant and anticoagulant therapy. 2 days later, control coronary angiography did not show any signs of residual thrombus and lesions. Coronary reperfusion was achieved successfully with pharmacological treatment without the requirement of mechanical reperfusion. The patient was discharged without complications with further instructions to regulate the medical treatment. In this paper, we aim to present a case which we successfully treated through pharmacological treatment without the need for an invasive intervention. Key Words: Acute Myocardial Infarction; Thrombus; Tirofiban.

SPECT Myocardial Perfusion Reserve in Patients with Multivessel Coronary Disease: Correlation with Angiographic Findings and Invasive Fractional Flow Reserve Measurements.

Quantification of myocardial perfusion reserve (MPR) is an emerging topic in nuclear cardiology with an expected diagnostic and prognostic incremental value, especially for patients with severe coronary artery disease. The advent of new dedicated solid-state cameras has opened new perspectives for perfusion quantitation in SPECT. We appraised the feasibility of perfusion reserve estimation using a cadmium zinc telluride camera in a cohort of multivessel patients and its pertinence with respect to angiographic data. Twenty-three patients with known multivessel coronary artery disease were prospectively enrolled. Dynamic SPECT acquisitions using (99m)Tc-tetrofosmin at rest and after vasodilator stress were performed using a dedicated cadmium zinc telluride camera. Reconstructed frames were automatically segmented to extract the vascular input function and the myocardial uptake curve. One-compartment kinetic modeling was used to estimate global and regional uptake values, and then myocardial blood flow was derived using the Renkin-Crone equation. Global and regional MPR was assessed using flow difference (stress - rest) and flow ratio (stress/rest). All patients underwent control coronary angiography within 4 wk, which served as the reference for MPR index assessment. Relevant angiographic findings included maximal stenosis and (for a subgroup of 26 vessels) invasive measurement of fractional flow reserve (FFR). A stenosis was considered obstructive if greater than 50% and an FFR abnormal if lower than 0.8. Global MPR correlated well with number of obstructed vessels (P < 0.001). After multivariate analysis, both regional flow ratio and flow difference were significantly associated with maximal stenosis (P < 0.001) and FFR (P < 0.001). Regional MPR indices were significantly different in obstructed and nonobstructed vessels (P < 0.001) and in vessels with normal and abnormal FFR (P < 0.001). With a cutoff of 2, the sensitivity, specificity, and accuracy of regional flow ratio were, respectively, 80%, 85%, and 81% for the detection of obstructed vessels and 89%, 82%, and 85% for the detection of abnormal FFR. Scintigraphic estimations of global and regional MPR in multivessel patients using a cadmium zinc telluride camera appear to correlate well with invasive angiographic findings, including maximal stenosis and FFR measurements.

Preprocedural Albumin Levels and Risk of In-Stent Restenosis After Coronary Stenting With Bare-Metal Stent.

In-stent restenosis (ISR) remains a significant clinical problem in patients with coronary artery disease treated with percutaneous coronary intervention. Decreased serum albumin (SA) level is related to an increased risk of cardiovascular events. The aim of the present study was to assess whether SA levels at admission are an independent predictor of ISR in patients undergoing bare-metal stent (BMS) implantation. A total of 341 patients (aged 61 ± 11, 65.4% men) with a history of BMS implantation and a further control coronary angiography due to stable angina pectoris (SAP) were included. The study population was classified into 2 groups: patients with and without ISR. The ISR was observed in 140 (41.1%) patients. We found significantly lower SA levels in patients who developed ISR than in those who did not (3.69 ± 0.41 vs 4.07 ± 0.35 mg/dL,P< .001). Multivariate analysis revealed that SA level (odds ratio 0.109, 95% confidence interval 0.017-0.700,P= .020), stent diameter, reason for stent implantation, and body mass index were independent risk factors for the development of ISR. The SA level at admission is inversely associated with ISR in patients with SAP.

Long-term results of surgical angioplasty for left main coronary artery stenosis: 18-year follow-up.

BackgroundThe aim of this study was to determine the long-term outcomes of surgical angioplasty for left main coronary artery (SA-LMCA) stenosis.MethodsWe retrospectively analyzed data from 24 consecutive patients (mean age, 55 years; male/female, 12/12) who underwent a surgical angioplasty for the left main coronary artery (LMCA) stenosis at our institution between 1995 and 2002. We used autologous pericardium in 7 patients and bovine pericardium in 17 patients as a patch. We evaluated the late mortality and major adverse cardiac events (MACE) rate.ResultsThere was no operative mortality. Control coronary angiography exhibited wide open and funnel-shaped LMCA in all patients. One patient was lost to follow-up. During the mean follow-up of 167 months, there were 3 sudden cardiac deaths, 4 non-cardiac related deaths, and 9 MACE with one death at reoperation. The Kaplan-Meier method identified freedom from cardiac death in 95.7, 87.0, and 82.4% of the patients, and freedom from MACE in 91.3, 69.6, and 57.7% of the patients at 5, 10, and 15 years, respectively.ConclusionsThis study demonstrated that the long-term outcomes of SA-LMCA with a pericardial patch are acceptable compared to those of coronary artery bypass grafting, despite the controversy over the indications and the patch material used.

RAndomized Comparison of raDIal vs. femorAL Access for Routine Catheterization of Heart Transplant Patients (RADIAL – Heart Transplant Study)

Although a transradial approach (TRA) is considered feasible in many clinical situations, no data are available in patients undergoing orthotopic heart transplantation (OHT). Our goal was to randomly compare TRA versus a transfemoral approach (TFA) in this clinical setting. This single-center, prospective, randomized trial was conducted from January to November 2006, and all OHT patients scheduled for a control coronary angiography were randomized to receive TRA or TFA. The primary endpoint was the amount of contrast used during the procedure. The participating interventional cardiologists were intermediate-volume radial operators, and this was their initial experience of TRA in OHT patients. The analysis was performed according to the intention-to-treat principle. Overall, 49 patients (mean age, 55 ± 13 years; 74% male) were included in the trial: 26 patients were assigned to TRA, and 23 were assigned to TFA. A higher amount of contrast (147 mL [range, 113–175 mL] vs 105 mL [range, 86–127 mL]; P = .009), a longer fluoroscopy time (9.2 minutes [range, 6–12 minutes] vs 3.5 minutes [range, 3–5 minutes]; P < .001), a trend toward increased number of catheters used for left ostium cannulation, and a higher crossover rate (19% vs 0%; P = .03) were associated with TRA compared with TFA. Furthermore, patients treated with TRA exhibit a shorter hospital stay (6 [range 4–8]) compared with the other group (26 [range 24–28]) (P < .001). There were no significant differences between the 2 groups regarding total procedural time, and no vascular complications were reported in either group. For these operators with their first experience of TRA in OHT patients, TFA seemed to be more efficient.

The association of red cell distribution width with in-stent restenosis in patients with stable coronary artery disease

Increased red cell distribution width (RDW) is closely related to the poor prognosis and adverse events of cardiovascular diseases. We aimed to investigate the association of serum RDW levels and in-stent restenosis (ISR) after coronary stenting with bare-metal stent in patients with stable coronary artery disease. A total of 251 patients (age 62 ± 11 years, 69% male) with a history of coronary stenting who underwent control coronary angiography (128 with ISR and 123 without ISR) were enrolled into the study. Laboratory parameters were measured before angiography. ISR was defined as luminal stenosis ≥50% within the stent or within 5 mm of its edges by the quantitative coronary analysis. The patients were divided into the two groups: ISR group and no-ISR group. Baseline characteristics of the patients were similar. The ISR group had significantly higher RDW levels compared with patients in no-ISR group (14.47 ± 1.37 vs. 13.59 ± 0.88, p < 0.001). Furthermore, the ISR group had significantly longer stent length and lower stent diameter when compared to no-ISR group (p = 0.001 and p = 0.004, respectively). In a multivariate analysis, RDW levels >13.75%, high-sensitivity C-reactive protein levels, stent diameter and stent length were independently associated with ISR [odds ratio (OR) = 2.12, 95% confidence interval (CI) = 1.71–3.15, OR = 2.80, 95% CI = (1.34–4.61), OR = −2.60, 95% CI = −(1.19–4.51), OR = 2.02, 95% CI = 1.99–3.76, p = 0.001, respectively]. We concluded that increased serum RDW levels were independently associated with bare-metal ISR in patients with stable coronary artery disease.

O203 Awareness of Harms of Second-hand Smoke among Employees at Hospitality Venues

Introduction: Due to the high rate of restenosis, interventional therapy of bifurcation lesions (BIF – PCI) remains still a challenge. Many different strategies were used with unsatisfactory results in recent years. Objectives: Since very promising studies with drug eluting balloons (DEB) were reported in respect of restenosis, we studied the outcome of patients (PTS) who had been treated by deployment of a drug eluting stent (DES) in the main branch (MB) in combination with a DEB in the side branch (SB). Methods: We analyzed prospectively the outcome of our first 53 consecutive PTS with BIF – PCI, except left main – BIF-PCI, (40 men and 13 women, mean age 74 years) treated in our institution from Nov. 2009 till Dec. 2012 with the DES (Xience V , Abbot Vascular, USA) in MB and DEB (Sequent Please , B. Braun Melsungen, Germany) in SB (n 1⁄4 42 (79%) LAD-, n 1⁄4 6 (11%) CXand n 1⁄4 5 (10%) RCA– BIF – PCI). After 6 – 9 months either control coronary angiography was performed (40 PTS, 76%) or clinical outcome was completed (13 PTS, 24%). Results: In the control angiography we found restenosis of 50% with a need of clinically driven target lesion revascularization in only 1 PTS in SB (TLR rate 1,8%) and in 2 PTS in MB (TLR rate 3,7%). All restenoses we found in LAD – BIF. Since 1 PTS died 6 months after BIF-PCI (cause of death unknown), MACE rate was 5,7%. Conclusion: The BIF PCI strategy “DES in MB and DEB in SB” is safe and highly effective in real life conditions. Randomized studies with larger groups of PTS are mandatory to confirm these preliminary results. Disclosure of Interest: None Declared

O200 Bifurcation Lesion PCI Strategy with a Drug-Eluting-Stent in a Main Branch and a Drug-Eluting-Balloon in a Side Branch is Safe and Effective in Real Life Conditions

Introduction: Due to the high rate of restenosis, interventional therapy of bifurcation lesions (BIF – PCI) remains still a challenge. Many different strategies were used with unsatisfactory results in recent years. Objectives: Since very promising studies with drug eluting balloons (DEB) were reported in respect of restenosis, we studied the outcome of patients (PTS) who had been treated by deployment of a drug eluting stent (DES) in the main branch (MB) in combination with a DEB in the side branch (SB). Methods: We analyzed prospectively the outcome of our first 53 consecutive PTS with BIF – PCI, except left main – BIF-PCI, (40 men and 13 women, mean age 74 years) treated in our institution from Nov. 2009 till Dec. 2012 with the DES (Xience V , Abbot Vascular, USA) in MB and DEB (Sequent Please , B. Braun Melsungen, Germany) in SB (n 1⁄4 42 (79%) LAD-, n 1⁄4 6 (11%) CXand n 1⁄4 5 (10%) RCA– BIF – PCI). After 6 – 9 months either control coronary angiography was performed (40 PTS, 76%) or clinical outcome was completed (13 PTS, 24%). Results: In the control angiography we found restenosis of 50% with a need of clinically driven target lesion revascularization in only 1 PTS in SB (TLR rate 1,8%) and in 2 PTS in MB (TLR rate 3,7%). All restenoses we found in LAD – BIF. Since 1 PTS died 6 months after BIF-PCI (cause of death unknown), MACE rate was 5,7%. Conclusion: The BIF PCI strategy “DES in MB and DEB in SB” is safe and highly effective in real life conditions. Randomized studies with larger groups of PTS are mandatory to confirm these preliminary results. Disclosure of Interest: None Declared

Catheter-Induced in-Stent Coronary Dissection

A 57-year-old male patient presented with exercise-induced angina for the last 10 days. The patient had undergone stent implantation in the right coronary artery (RCA) leading to acute myocardial infarction six months ago. The patient was on aspirin, klopidogrel, perindopril, and metaprolol succinate. Electrocardiogram showed sinus rhythm with Q waves in D2-3, aVF leads and ST-segment depression in V4-6 leads. Echocardiography depicted mild mitral regurgitation, and hypokinesis of the inferobasal segment with ejection fraction of 58%. Coronary angiography revealed 80% restenosis in the previously stented segment of RCA and 40% stenosis in the mid-segment of LAD. When the balloon dilatation of the restenotic segment was performed (Figure 1), instent dissection occurred (Figure 2). We decided to initiate tirofiban and heparin infusion during 24 hours. The patient was stable and cardiac enzymes remained normal. Control angiography showed that the dissection was disappeared (Figure 3). Two days later, he was discharged with same medications. The patient was totally asymptomatic at 6-month follow-up. Coronary dissection is a well-known complication of percutaneous coronary intervention; however, in-stent dissection has been rarely reported. The clinical presentation ranges from asymptomatic to angina, acute myocardial infarction, and sudden cardiac death. Therapy options include conservative medical treatment and interventional treatment with PCI or surgery. Consequently, in-stent coronary artery dissection is an unusual thinking but may occur either spontaneously or catheter-induced. All clinicians should keep in mind this complication and it’s treatment should be tailored individually. Figure 1. Coronary angiography showing the balloon dilatation of the restenotic segment Figure 2. Coronary angiography showing in-stent coronary dissection (arrows), Figure 3. Control coronary angiography showing the same segment without dissection.

Bioresorbable Vascular Scaffold (ABSORB BVS); first report in Egyptian patients with 6month angiographic/IVUS follow up

To evaluate the feasibility, efficacy, and safety of the ABSORB BVS (Bioresorbable Vascular Scaffold) for the treatment of de novo native coronary artery stenosis. Thirty patients with ischemic heart disease were selected between September 2012 and December 2012 and received ABSORB BVS for the treatment of de novo native significant coronary artery stenosis. Patients were followed up for six months after the procedure. In each patient, the treated segment and the periscaffold segments (5 mm proximal and distal to the scaffold edge) were analyzed by Quantitative coronary angiography (QCA) and phased-array intravascular ultrasound (IVUS) catheters in paired matched angiographic views after the procedure and at follow-up. The major clinical end point was ischemia-driven major adverse cardiac events (ID-MACE) defined as a composite of cardiac death, myocardial infarction or ischemia-driven target lesion revascularization. Overall the scaffold area remained unchanged. The angiographic late lumen loss amounted to 0.27 ± 0.32 mm with an IVUS relative decrease in minimal lumen area of 1.94% ( p = 0.12), without significant changes in the mean lumen area. After 2 weeks, 1 patient presented with STEMI, control coronary angiography revealed a patent stent with thrombus distal to it that was treated with a metallic drug-eluting stent (Xience V). There were no cardiac deaths or ischemia-driven target lesion revascularizations. At six months the hierarchical ID-MACE was 3.3%. ABSORB BVS seems an attractive option for the treatment of significant de novo native coronary artery stenosis with low risk of serious adverse events.

Usefulness of Preprocedural Serum Uric Acid Level to Predict Restenosis of Bare Metal Stents

Serum uric acid (SUA) level is known as a significant predictor for cardiovascular diseases, partly through increased inflammatory response and smooth muscle cell proliferation. Inflammation and smooth muscle cells play a crucial role in the pathogenesis of in-stent restenosis (ISR). However, the relation between SUA and ISR has not been studied. The aim of the present study was to investigate the predictive value of preprocedural SUA on the development of ISR in patients who undergo coronary bare-metal stent implantation. Clinical, biochemical, and angiographic data from 708 consecutive patients (mean age 60.3 ± 9.3 years, 71% men) who had undergone bare-metal stent implantation and additional control coronary angiography for stable or unstable angina pectoris were analyzed. Patients were divided into tertiles on the basis of preprocedural SUA levels. Stent restenosis was observed in 54 patients (23%) in the lowest tertile, in 79 (34%) in the middle tertile, and in 109 (46%) in the highest tertile (p <0.001). Using multiple logistic regression analysis, diabetes mellitus, smoking, high-density lipoprotein cholesterol, stent length, C-reactive protein level, and preprocedural SUA level emerged as independent predictors of ISR. On receiver-operating characteristics curve analysis, SUA level >5.5 mg/dl had 75% sensitivity and 71% specificity (area under the curve 0.784, p <0.001) in predicting ISR. In conclusion, higher preprocedural SUA is a powerful and independent predictor of bare-metal stent restenosis in patients with stable and unstable angina pectoris.