Multiple Stents Research Articles

Single-center experience on endovascular reconstruction of traumatic internal carotid artery dissections

Traumatic internal carotid artery dissection (CAD) has a potentially grave outcome. Anticoagulant therapy may be ineffective or contraindicated; surgery impractical. We present our experience with endovascular stenting in CAD patients. From 2004 to 2011, 23 patients with angiographically proven traumatic CAD underwent endovascular stent-assisted arterial reconstruction based on clinical and radiographic criteria: contraindication or failure of anticoagulation, evidence of impending ischemic stroke, or need for urgent intracranial revascularization. Dissections were graded based on degree of stenosis and extent of injury. Seventeen patients (73.9%) presented with stroke or transient ischemic attack. Carotid revascularization was achieved with one (11 patients, 48%) or multiple stents (12 patients, 52%); distal protection was used rarely (three patients, 13%). No complications were directly attributed to stenting. Mean dissection-related stenosis improved from 72% ± 28.87% to 4% ± 8.29%. At a mean clinical follow-up of 28.7 months ± 31.9 months, 16 patients (69.6%) improved, six (26.1%) remained stable, and one (4.3%) had died secondary to multiple traumatic injuries. At long-term follow-up, no patient had a transient ischemic attack or stroke or presented evidence of de novo in-stent stenosis or stent thrombosis. There were no neurologic sequelae after partial or total discontinuation of antiplatelet therapy in seven patients undergoing trauma-related surgeries. Selected cases of traumatic CAD can be safely managed by endovascular stent-assisted angioplasty. Procedural complications are infrequent; the need for postprocedure antiplatelet therapy is a concern. Early detection is essential to avoid stroke. Stenting restores the integrity of the vessel lumen immediately, efficiently prevents the occurrence or recurrence of ischemic events, and avoids the need of long-term anticoagulation.

Long-term Clinical and Angiographic Follow-up of the New Non-Polymeric Paclitaxel-Eluting Stent for the Treatment of De Novo Coronary Lesions: Outcomes of the PAX-B Study

Compared with the Taxus® stent, the non-polymeric paclitaxel-eluting Amazonia® PAX stent shows no differences in the occurrence of coronary restenosis or clinical events after four months of follow-up. However, the performance of the Amazonia® PAX stent in more complex cases and with longer angiographic follow-up has not been demonstrated. The PAX-B study was a prospective, non-randomised, multicentre study assessing the long-term follow-up of patients treated with the Amazonia® PAX stent. The primary outcome was late in-stent lumen loss. The study included 103 patients with a mean age of 61.3 ± 11.4 years; 26.2% were diabetics, 24.3% had acute coronary syndromes, and 71.6% had type B2/C lesions. Multiple stents were implanted in 4.7% of the patients, and angiographic success was achieved in 100% of the cases. During hospitalisation, the periprocedural acute myocardial infarction rate was 3.9%, and one of these events led to target-lesion revascularisation (TLR). At the nine-month angiographic follow-up, the median late in-stent lumen loss was 0.91 [0.50; 1.21] mm. The cumulative rates of major adverse cardiac events at the six-month, nine-month, and 12-month follow-ups were 7.8%, 18.5%, and 21.3%, respectively, mostly due to TLR. There were no deaths or stent thromboses at 12 months. The Amazonia® PAX stent showed excellent immediate results and a good safety profile. However, angiographic recurrence rates were relatively high because of the low efficacy of neointimal hyperplasia inhibition. Seguimento Angiográfico e Clínico Tardio do Novo Stent Farmacológico Não Polimérico Liberador de Paclitaxel para o Tratamento de Lesões Coronárias De Novo : Resultados do Estudo PAX-B O stent farmacológico eluidor de paclitaxel, não polimérico, Amazonia® PAX não mostrou diferença na reestenose coronária ou eventos clínicos aos 4 meses de evolução quando comparado com o stent Taxus®. Entretanto, o desempenho do stent Amazonia® PAX em cenários de maior complexidade e com seguimento angiográfico mais longo ainda não foi demonstrado. O Estudo PAX-B foi um estudo prospectivo, não randomizado, multicêntrico, que avaliou os resultados tardios de pacientes tratados com o stent Amazonia® PAX. O desfecho primário foi a perda tardia do lúmen intrastent. Foram incluídos 103 pacientes com média de idade de 61,3 ± 11,4 anos, 26,2% eram diabéticos, 24,3% apresentaram-se com síndrome coronária aguda e 71,6% tinham lesões tipo B2/C. Implante de múltiplos stents ocorreu em 4,7% dos casos e o sucesso angiográfico foi de 100%. Na fase hospitalar, a taxa de infarto agudo do miocárdio periprocedimento foi de 3,9%, e um desses eventos levou à revascularização da lesão-alvo (RLA). No seguimento angiográfico de 9 meses, a mediana da perda tardia do lúmen intrastent foi de 0,91 [0,50; 1,21] mm. As taxas cumulativas de eventos cardíacos adversos maiores nos seguimentos de 6 meses, 9 meses e 12 meses foram, respectivamente, de 7,8%, 18,5% e 21,3%, principalmente em decorrência de RLA. Não se observou morte ou trombose de stent em 12 meses. O stent Amazonia® PAX demonstrou excelentes resultados imediatos e alto perfil de segurança. Entretanto, as taxas de recorrência angiográfica foram relativamente altas, em razão da pouca eficácia na inibição da formação de hiperplasia neointimal.

Management of chronic pancreatitis: Role of endoscopic therapy

AbstractChronic pancreatitis (CP), a disease of varied etiology can, from the endoscopists perspective present as ductal strictures, stones, ductal leaks and fluid collections, biliary strictures or duodenal narrowing. This article deals with role of ERCP in the management of CP associated strictures and calculi. ERCP has a limited role in the diagnosis CP, though we feel that it is better at identifying small ductal calculi or leaks as compared to MRCP. Major and minor papilla sphincterotomy gives relief from pain in patients with mild or moderate ductal changes. Pancreatic ductal strictures are best managed by stenting. Use of multiple plastic stents (8.5-11Fr diameter) gives relief from pain in 84% and strictures resolution in 95% on follow up of over 3 years. CP associated CBD strictures are also managed by placement of multiple stents. Covered SEMS are increasingly being used in these strictures. Surgery is often the best option for CP associated CBD strictures which recur after adequate endotherapy. ESWL is the standard of therapy for pancreatic ductal calculi which are large, as seen in the tropics and the non alcoholic form of CP. Our experience has shown complete or partial clearance with ESWL in over 90% of patients with large PD calculi. Good pain relief was seen in both on short and long term follow up. In selected patients of CP, ERCP and endotherapy should be offered as first line of treatment, as the results are comparable to surgery. Prior endotherapy also does not interfere with subsequent surgical procedures.

Initial Experience with Neuroform EZ in the Treatment of Wide-neck Cerebral Aneurysms

PurposeStent-assisted coiling allows embolization and parent vessel reconstruction of wide-necked intracranial aneurysms. The Neuroform EZ (Boston Scientific, Fremont, CA, U.S.A.) stent delivery system offers deployment of a Neuroform stent with fewer steps and improved operator control. Initial experience, technical considerations, and treatment outcomes using the Neuroform EZ stent delivery system in combination with coil embolization are reported.Materials and MethodsSeventeen consecutive patients harboring 21 wide-necked saccular cerebral aneurysms were treated with stent reconstruction. Twenty aneurysms were unruptured; one was treated within 24 hours of diagnosis of rupture. Twenty aneurysms were located in the anterior circulation; one was in the posterior circulation. Immediate and six-month post-treatment angiography and clinical assessment were performed.ResultsIn all cases, the stents were delivered and positioned without difficulty in deployment. Technical complications occurred in 4 patients, but none were directly related to the stent delivery system. On immediate post-treatment angiography, 5 of 21 aneurysms showed complete occlusion, 5 of 21 showed residual neck, and 11 of 21 showed residual contrast filling of the aneurysm sac. At six month follow-up, all 17 patients were clinically stable. Angiography of 18 of the aneurysms showed total occlusion in 12, residual neck in 3, and residual aneurysm filling in 3. Retreatment was performed in the three with residual aneurysm.ConclusionThe Neuroform EZ stent system offers improved anchoring and support in stent delivery, which is particularly useful when multiple stents are overlapped to further protect the parent vessel and increase flow diversion away from the aneurysm sac. The only significant problem encountered was coil prolapse, which could be treated with a second stent when necessary. The ease of deployment improves upon the already clinically successful Neuroform design.

Endoscopic ultrasonography-guided gallbladder drainage was effective for the treatment of two patients with acute cholecystitis who had multiple metallic stents deployed due to biliary tract carcinoma

Endoscopic ultrasonography-guided gallbladder drainage was effective for the treatment of two patients with acute cholecystitis who had multiple metallic stents deployed due to biliary tract carcinoma

Bilateral Vertebral Artery Dissecting Aneurysms Presenting with Subarachnoid Hemorrhage Treated by Staged Coil Trapping and Covered Stents Graft

The treatment of bilateral vertebral artery dissecting aneurysms (VADAs) presenting with subarachnoid hemorrhage (SAH) is still challenging. The authors report a rare case of bilateral VADA treated with coil trapping of ruptured VADA and covered stents implantation after multiple unsuccessful stent assisted coiling of the contralateral unruptured VADA. A 44-year-old woman was admitted to our hospital because of severe headache and sudden stuporous consciousness. Brain CT showed thick SAH and intraventricular hemorrhage. Cerebral angiography demonstrated bilateral VADA. Based on the SAH pattern and aneurysm configurations, the right VADA was considered ruptured. This was trapped with endovascular coils without difficulty. One month later, the contralateral unruptured VADA was protected using a stent-within-a-stent technique, but marked enlargement of the left VADA was detected by 8-months follow-up angiography. Subsequently two times coil packing for pseudosacs resulted in near complete occlusion of left VADA. However, it continued to grow. Covered stents graft below the posterior inferior cerebellar artery (PICA) origin and a coronary stent implantation across the origin of the PICA resulted in near complete obliteration of the VADA. Covered stent graft can be used as a last therapeutic option for the management of VADA, which requires absolute preservation of VA flow.

Single Stage Multiple Stenting in Takayasu's Arteritis

A 32-year-old Filipino female presented with Takayasu's arteritis manifesting as an abrupt onset of syncope. Physical examination revealed diminished consciousness, right hemiparesis, and a large discrepancy in blood pressure between the upper and lower extremities. Magnetic resonance imaging revealed cerebral infarcts in the left basal ganglia and the left temporal lobe. Angiography revealed complete occlusion of the left common carotid artery and severe stenosis of the brachiocephalic artery, the right common carotid artery, and the left subclavian artery. Based on the clinical examination and studies, the diagnosis was Takayasu's arteritis, type I. The patient's condition stabilized after 2 months of prednisone and anti-platelet therapy. Single stage multiple stenting in the brachiocephalic artery, the right common carotid artery, and the left subclavian artery was then performed using high pressure inflation to dilate the arteries due to the remarkably rigid lesions that resulted from extensive and diffuse fibrosis throughout the vessel walls. Although a small intimal flap occurred during inflation of the left subclavian artery, re-dilation was possible with the stent. Even with evidence of notable recovery in blood pressure and cerebral blood flow, no further neurological improvement was observed. In view of the favorable short- and intermediate-term results, single stage multiple stenting may be the optimum treatment option for first-line stent-supported angioplasty in patients with Takayasu's arteritis.

Endoscopic management of benign biliary strictures: Possibility or exercise in futility?

AbstractBenign biliary strictures for which endoscopic treatment is proposed are mostly related to liver transplantation or chronic pancreatitis (one third of cases each) and, less frequently, to other causes (e. g., cholecystectomy, sphincterotomy). The question of futility of exercise may therefore be of importance before embarking in these techniques. Endoscopic treatment of iatrogenic (post-operative) benign strictures may be considered as the gold standard since 90% of success is achieved with multiple stent placement. In strictures due to chronic pancreatitis, success rates are lower and surgery may be an appropriate alternative, although it may not be futile to propose an endoscopic try, especially when strictures are related to acute pancreatitis, pseudocyst obstruction or any reversible pancreatic cause of obstruction. In sclerosing cholangitis, endoscopic management is also focused on detection of malignancy. It should therefore not be considered as a futile exercise, but indications and aims of endotherapy should be discussed in a multidisciplinary team involving gastroenterologists, radiologists, and surgical specialists.

WEO NEWSLETTER AND CONTENTS

WEO NEWSLETTER AND CONTENTS

Three-Dimensional Fusion Images of Hepatic Vasculature and Bile Duct used for Preoperative Simulation before Hepatic Surgery

Recent developments in radiological technology allowed acquisition of images with high spatial resolution that facilitate effective 3-dimensional (3D) reconstruction of fusion images. Present study utilized 3D cholangiography and angiography with multi-detector-row computed tomography (MDCT) to acquire information regarding operative simulations. 3D-fusion images were evaluated in 39 patients with hepatobiliary malignancies who underwent surgical resections. An aberrant branch of segment 3 over the umbilical portal vein, a large hepatoma compressed the hilar vessels, an aberrant branch of the caudate lobe vasculature in case of metastatic liver tumor with a right-sided umbilical portal vein and transected biliary leakage were clearly observed by 3D imaging system. Four patients with intrahepatic cholangiocarcinoma underwent multiple biliary stent placements and adequate placement of biliary stents was possible. In 22 patients with extrahepatic biliary carcinomas, visualization of the extent of tumor invasion by 3D-fusion images was equivalent to conventional cholangiography. In 2 patients, adequate placement of multiple stents could be visualized with this system. In 2 patients who underwent hepatectomy, more extended cancer invasion was observed than was visualized by 3D-fusion images. 3D fusion images were very useful for preoperative simulations in order to understand relationships between tumors and adjacent vasculatures.

Reconstructive stent-buttressed coil embolization of a traumatic pseudoaneurysm of the supraclinoid internal carotid artery

It is critical that traumatic intracranial pseudoaneurysms should be removed completely from the parent artery because there is a possibility of significant morbidity and mortality from the high risk of rebleeding from any remnants of the pseudoaneurysm. However, the deconstruction of the parent artery has the risk of ischemic damage to the distal to the trapped artery. We describe a case of a successful reconstructive stent-buttressed coil embolization in a patient with a traumatic pseudoaneurysm of the intracranial internal carotid artery. A 30-year-old man with a stuporous mentality was admitted to our institution after a traffic accident. The initial computed tomography scan showed a diffuse subarachnoid hemorrhage and a pseudoaneurysm of the left supraclinoid internal carotid artery. A reconstructive endovascular treatment using stent-assisted coil embolization with a stent-within-a-stent technique was conducted in order to save carotid blood flow. The pseudoaneurysm was completely obliterated and the patient recovered without any neurological deficit. We suggest that multiple stent placements with coiling may be considered as a treatment option for intracranial traumatic pseudoaneurysms as a reconstructive treatment.

Reply to Dutau et al.

We thank Dr Dutau et al. [1] for their comments regarding our article ‘Novel biodegradable stents in the treatment of bronchial stenosis after lung transplantation’ [2]. In our previous experience, there was a place for both metal and silastic stents in tracheal and bronchial stenosis management, as the authors suggest. Silicone stents were used at our institution in the era before biodegradable stenting. Between January 1997 and January 2005, we performed 98 lung transplants in 67 patients (36 single-lung transplants and 31 bilateral-lung transplants). Four bronchial anastomotic complications requiring stenting (4.1%) occurred in four patients (6.0%). All were successfully treated with silicone–Dumon stents, which were removed at the end of the treatment. Due to our close cooperation with general surgeons, we were confronted with excellent results of biodegradable oesophageal stenting. After the appreciation of laboratory and ongoing animal studies [3], we decided to switch from silicone stents to biodegradable stents. We strongly believe that controlled biodegradation of stents is the future of any stenting, not only in airways. As our study was the very pilot study, we were limited in resources, patient population and of course experience. Currently, more biodegradable stents are available and the period of time for which the stents keeps its sufficient resistive radial forces could be chosen. We do not know if a multiple stent placement for a short period of time is superior to the single stent placement for a longer period of time with all concomitant risks (necrosis, granulation, displacement and complicated removal). This is an issue, which should be addressed in a multicentre trial, which is indeed inevitably needed. Currently, at our institution, we cannot justify the use of silicone stents in benign airway stenosis. Hence, we do not plan to conduct a prospective comparative study. Nevertheless, we feel that more evaluation is needed in designing, manufacturing and in vitro testing of polydioxanone biodegradable stents. Meanwhile, the use of these stents (currently not European Conformity marked) remains highly specifically indicated, although the recent results show high safety, efficacy and biocompatibility. First reports of biodegradable stenting in children (another challenging population with growing airways) were published by our colleagues from Great Ormond Street Hospital in London [4] and one prospective study is conducted in Hannover. To summarize, Dutau et al. are kind in their comments on the place of our work in the development of this field. We agree that future phase III trials of absorbable, and other new stents such as drug-eluting devices, should be compared with both metal and silastic stents, the gold standard comparator carefully chosen depending on the clinical setting. International collaboration in the design and conduct of these trials is essential, and for this reason, we fully welcome this debate and interest.

Stents farmacológicos liberadores de Everolimus XienceTM V no tratamento de pacientes com lesões coronárias complexas na prática diária: resultados iniciais do registro brasileiro BRAVO

INTRODUCAO: A eficacia e a seguranca do stent farmacologico (SF) de segunda geracao liberador de everolimus XienceTM V (Abbott Vascular, Santa Clara, Estados Unidos) ja foram estabelecidas no tratamento de pacientes selecionados com lesoes coronarias. No entanto, o impacto do stent XienceTM V em populacoes da pratica clinica com lesoes complexas ainda nao esta totalmente definido. METODOS: O Registro BRAVO foi um estudo prospectivo, nao-randomizado, multicentrico, que avaliou os resultados clinicos tardios de pacientes minimamente selecionados tratados com o SF XienceTM V na pratica diaria brasileira. No total, foram incluidos 535 pacientes em 25 centros clinicos entre setembro de 2008 e setembro de 2010. Eventos cardiacos adversos maiores (ECAM) foram definidos como morte cardiaca, infarto agudo do miocardio (IAM) e revascularizacao do vaso-alvo (RVA). RESULTADOS: A media de idade dos pacientes era de 62,7 ± 11,1 anos, 40% dos quais tinham diabetes, 24,9% apresentavam IAM previo e 41,9% apresentaram-se com sindrome coronaria aguda. Cerca de dois tercos dos pacientes tinham lesoes tipo B2/C e 46,1% trataram a arteria descendente anterior. Implante de multiplos stents ocorreu em 13,8% dos casos, e o sucesso angiografico foi > 99%. Na fase intra-hospitalar, a taxa de IAM periprocedimento foi de 1,9%. Ja no seguimento de 6 meses, as taxas cumulativas de obito cardiaco, IAM e RVA foram de 1,1%, 2,2% e 1,3%, respectivamente (taxa de ECAM de 4,3%). Com relacao a trombose de stent (definida de acordo com os criterios do Academic Research Consortium ARC), foram reportados 4 casos ate 6 meses, representando taxa de evento de 0,75% (0,4% definitiva/provavel). CONCLUSOES: Neste Registro, que incluiu pacientes e lesoes complexos tratados em multiplos centros nacionais, o SF de segunda geracao XienceTM V demonstrou excelentes resultados imediatos e efetividade clinica e seguranca sustentadas ate o seguimento a medio prazo (6 meses). Os resultados do seguimento a longo prazo sao aguardados.

Successful endovascular treatment of a growing megadolichoectasic vertebrobasilar artery aneurysm by flow diversion using the “diverter-in-stent” technique

Giant dolichoectatic and fusiform aneurysms of the vertebrobasilar artery are among the most difficult and dangerous aneurysms to treat. Conservative management may be reasonable in asymptomatic elderly patients. Nevertheless, due to the frequent presence of mass effect on the brainstem and the risks of thromboembolic events and rupture, these aneurysms often demand treatment rather than observation. With the advancement of endovascular techniques some of these lesions have become treatable without the high morbidity and mortality rates associated with open surgical treatment. When dealing with giant, progressively enlarging symptomatic aneurysms, more limited therapeutic alternatives are available. The authors present a case of a growing megadolichoectatic vertebrobasilar artery aneurysm causing major disability due to increasing mass effect in a 51-year-old man. The aneurysm was treated with flow diversion by placing multiple telescoped stents and diverters (“diverter-in-stent” technique), achieving thrombosis of the aneurysm and reduction of the mass effect on the brainstem, with neurological improvement. The successful clinical and angiographic results observed in our case of giant dolichoectasic vertebrobasilar aneurysm contribute to the literature on giant aneurysms treated by means of flow diversion.

Abstract P283: Operator Variation in Coronary Angioplasty and Stenting

Background: Post COURAGE trial the treatment of coronary artery disease has become a complex decision process, with many physicians advocating initial revascularization only for medical failures and high risk subgroups. The decision of whether to use Drug Eluting or Bare Metal Stents has also drawn wide attention and has changed practice. We examined the extent of variability with its implications for quality, utilization and health care costs on physician driven interventions compared to the UHC and national comparison benchmarks. Methods: The practice patterns of 11 interventional cardiologists in 2009 were reviewed relative to patient treatment and outcomes for determinants of variation in revascularization practice. Associations were evaluated by Chi square for significance and Pearson's correlation coefficients were calculated. Results: There were 1,977 PCI (44.6%) performed on 4,428 patients undergoing cardiac catheterization. PCI as a percentage of total cases varied widely by physician from 22.8% to 58.8%. The use of Bare Metal Stents ranged from 12.7% to 61.4% of cases [25.2% mean; benchmarks 18.4%, 21.8%]; Drug Eluting Stent use varied from 38.6% to 87.3% by operator [74.8% mean]. The number of stents placed/patient was significantly less for Bare Metal Stent cases (1.19-2.0 mean 1.9; benchmarks 1.6, 1.54) than for Drug Eluting Stent cases (1.46-2.92 mean 2.20; benchmarks 1.99,2.18). There was no significant correlation between the number of stents placed and 30 day readmission. There was no significant correlation between cath lab operator volume and conversion rate to angioplasty or to the number of stents placed. Conclusions: There is wide variation in revascularization practice that is physician associated. DES stent use has declined from a high of 90% to about 75% with procedures requiring multiple stents favoring the use of DES. Higher PCI revascularization rates and more extensive revascularization were not associated with a short term increase in adverse outcomes, LOS, or readmissions. The long-term outcomes and cost of more aggressive revascularization with PCI are unknown and will merit further investigation.

Endovascular Management of Symptomatic Cerebral Malperfusion Due to Carotid Dissection After Type A Aortic Dissection Repair

Type A acute aortic dissection is a surgical emergency, and supra-aortic trunk involvement may be complicated by stroke in 6% to 20% of cases. A 66-year-old Caucasian female patient underwent a composite repair of the ascending aorta for type A aortic dissection. Postoperative period was complicated by episodes of "drop attack." Doppler ultrasound of supra-aortic trunks revealed an intimal flap occluding right internal carotid artery. Multiple stenting was performed from carotid bifurcation to internal carotid artery in order to exclude the dissection intimal flap. After endovascular procedure physiatrist considered that motor functional improvement was better than expected, and we support that endovascular resolution of carotid malperfusion led to a better outcome. According to other experience, endovascular procedure resulted as a safe and effective way. Moreover, ultrasound monitoring of supra-aortic trunks in postoperative period is recommended.

Does it pay to be indecisive when considering revascularization during percutaneous coronary intervention?

Angiographic complete revascularization (CR) has been associated with better long-term clini- cal outcomes after percutaneous coronary inter- vention (PCI) or coronary artery bypass graft (CABG) surgery (1,2). In real world practicehow- In real world practicehow- everdiseased segments are often incompletely revascularized in patients undergoing PCIdue to technical complexitylow ejection fraction or safety concerns regarding the implantation of multiple drug-eluting stents. Furthermoreeven in patients undergoing CABGincomplete revas- cularization (IR) has occasionally been adopted to reduce operation-related complicationspar- ticularly when minimally invasive or off-pump surgery is attempted. Although several previous studies have demonstrated the benefit of CR after PCI or CABGthose results had limited applica- tion to current practices due to recent updates in the use of drug-eluting stent (DES) � left internal mammary artery graftingoff-pump surgery and current medications. Thereforea critical review evaluating the clinical impact of angiographic CR is appropriate at this time. Definitions of angiographic CR

Early and long-term results of unprotected left main coronary artery stenosis with paclitaxel-eluting stents: the FRIEND (French multicentre registry for stenting of unprotected LMCA stenosis) registry

To evaluate the angiographic and clinical outcome of patients undergoing paclitaxel-eluting stent (PES) implantation for unprotected left main coronary artery (ULMCA) stenosis in a "real-world" multicentre, prospective registry. Percutaneous coronary intervention (PCI) is an increasingly utilised method of revascularisation in patients with ULMCA. A prospective registry including all patients with a significant (>50%) ULMCA stenosis. Of 151 such patients, the target lesion involved the distal bifurcation in 100 patients (66%), which was treated predominantly by a "provisional T-stenting" strategy. In the distal ULMCA disease group, 72% had only one stent implantation while 28% had multiple (either two or three) stents implanted. At a median follow-up of 1,123±80 days, cardiac death occurred in five patients (3.3%) and major adverse cardiac and cerebrovascular events (MACCE) in 32 patients (21.2%). The three-year survival rate was 93.3%. In the drug-eluting stent era, paclitaxel-eluting stent implantation of ULMCA stenosis provided excellent immediate and long-term results in this selected population, suggesting that this approach may be considered as a safe and effective alternative to CABG for selected patients with ULMCA who are treated in experienced institutions performing large numbers of PCI procedures.

Spot Drug-Eluting Stenting for Long Coronary Stenoses: Long-term Results of a Randomized Clinical Study

Preliminary results of a randomized trial have suggested that total lesion coverage with drug-eluting stents (DES) is not necessary in the presence of diffuse disease of nonuniform severity. In the present study, we report long-term results of this trial. Consecutive, consenting patients with a long (>20 mm) coronary lesion of nonuniform severity and indication for percutaneous coronary intervention were randomized to full stent coverage of the atherosclerotic lesion with multiple, overlapping (full DES group, n = 90) or spot stenting of the hemodynamically significant parts of the lesion only (defined as diameter stenosis > 50%) (spot DES group, n = 89). At a follow-up of 2-7 years, 30 patients with full DES (33.3%) and 12 patients (13.5%) with spot DES had a major adverse cardiac event (MACE) (P = 0.015). Cox proportional hazard model showed that the risk for MACE was almost 65% lower among patients who were subjected to spot DES compared to those who underwent full DES (HR = 0.35, 95% CI = 0.18-0.68, P = 0.002). This association remained significant even after controlling for age, sex, and lesion length, and the type of stent used (HR = 0.41, 95% CI = 0.20-0.81, P = 0.011). In the presence of diffuse disease of nonuniform severity, selective stenting of only the significantly stenosed parts of the lesion confers better long-term results compared to total lesion coverage with DES.

Current Evidence for Genetic Testing in Clopidogrel-Treated Patients Undergoing Coronary Stenting

A combined dual antiplatelet treatment consisting of aspirin and the P2Y12 receptor inhibitor clopidogrel is still considered the standard of care treatment in most of the patients undergoing percutaneous coronary intervention (PCI). Numerous research studies during the last decade, however, have highlighted possible shortcomings of the oral antiplatelet agent clopidogrel, namely its large response variability resulting in an unpredictable response for the individual patient,1,2 the association of both a low3 or enhanced response4,5 with a worse clinical outcome and the dependency of individual responsiveness on nongenetic and genetic variables.6 Response by Pare and Eikelboom on p 513 Clopidogrel is a prodrug that requires bioactivation into its active thiol metabolite before it targets the P2Y12 receptor on blood platelets. In vivo bioactivation of the drug is a 2-step process that is closely linked to the cytochrome P450 (CYP) system. Different isoenzymes are responsible for clopidogrel bioactivation and among them the isoenzyme CYP2C19 was found to play a key role in this setting by contributing to both clopidogrel bioactivation steps.7 In this context, common genetic variants within the CYP2C19 gene have been the subject of considerable attention and have stimulated numerous research projects in recent years.8–14 Beyond CYP2C19, other genes involved in clopidogrel absorption, bioactivation or interplay with the blood platelet and their receptors have been associated with drug responsiveness and clinical outcome as well. Indeed, a growing body of evidence suggests a possible role of genotyping in patients undergoing coronary stenting with a view on optimizing response to P2Y12 receptor inhibitors during and after the procedure. We review available evidence on the need of individualizing antiplatelet treatment regimens in everyday clinical practice. ### Genetic Determinants for Clopidogrel Response and Clinical Outcome In recent years, multiple genetic factors within different candidate genes being involved in clopidogrel absorption, bioactivation, and …