Percutaneous Transluminal Coronary Angioplasty Group Research Articles

The role of inflammation markers in triggering acute coronary events

Studies have shown disparate results in relation to the role of plasma concentrations of inflammation markers such as fibrinogen, cytokines, and cell adhesion molecules in acute coronary syndromes. The differentiation of primary versus secondary alterations of these markers in response to acute coronary syndromes is not clear. The aim of this study was to investigate the effect of soluble cell adhesion molecules and some inflammatory markers on coronary plaque instability. The prospective study consisted of 15 patients with stable angina pectoris (SAP), 16 with unstable angina pectoris (UAP), and 16 who had undergone percutaneous transluminal coronary angioplasty (PTCA). Blood samples were obtained from the SAP group on admission, from the UAP group at the early stage of pain onset within 6 h of pain, and again after 12 h of pain. Samples from the PTCA group were collected before, 2, 14 h after the procedure. Soluble vascular cell adhesion molecule-1 (VCAM-1), endothelial selectin, interleukin-1 beta (IL-1 beta) and interleukin-2 (IL-2), and C-reactive protein (CRP) were analyzed by enzyme-linked immunosorbent assay. CRP serum levels gradually increased although IL-2 gradually decreased in patients with UAP and PTCA. In addition, VCAM-1 levels were sharply decreased after the PTCA procedure. However, this value returned back to the preprocedure levels 14 h after PTCA. Both CRP and IL-2 are directly involved in the triggering mechanisms of acute coronary events.

Long-Term Resource Use and Cost of Percutaneous Transluminal Coronary Angioplasty versus Stenting in the Elderly: A Retrospective Claims Data Analysis

Objective Although the benefits of coronary stenting have been demonstrated in several large clinical trials, controversy remains as to whether stenting results in long-term cost savings compared to percutaneous transluminal coronary angioplasty (PTCA). The objective of this study was to evaluate the resource use and cost (Medicare payment) of PTCA versus bare stent in actual practice over a 2-year period. Methods The data for this study came from the 1996 through 1998 Standard Analytic Files that contain 5% of Medicare claims. The rates of repeat revascularization procedures and hospitalizations were reported at 1 and 2 years. Costs associated with inpatient admission, outpatient procedures, physician services, skilled nursing facility admissions, and home health-care services were included to perform a comprehensive assessment. Regression analysis was performed to test for cost differences controlling for case-mix variation between the patient groups. Results The selection process yielded 3782 PTCA patients and 2690 stent patients for analysis. The rate of revascularization was 26.7% for the PTCA group and 22.2% for the stent group at 2 years. The mean total cost for the initial procedure was $13,724 for PTCA and $15,021 for stenting. At 2 years, the total cumulative cost was $32,654 for the PTCA group and $32,102 for the stent group, a difference that was not statistically significant. Conclusion Although the difference in the rate of repeat revascularization procedures between PTCA and stenting is not as large as those reported in clinical trials, bare stents are cost-neutral when compared to PTCA for the Medicare population.

Local infusion of the nitric oxide donor Sin-1 after angioplasty. Effects on intimal hyperplasia in porcine coronary arteries.

To investigate the development of intimal hyperplasia in response to percutaneous transluminal coronary angioplasty (PTCA) followed by local delivery of the nitric oxide (NO) donor 3-morpholino-sydnonimine (SIN-1). Overdilation PTCA was performed in coronary arteries in 20 healthy pigs. One of the dilated segments was additionally treated with local delivery of SIN-1 for 10 min. Segments distal to the treated part of the arteries served as controls. Arteries were radiographically depicted and analyzed after 1 and 8 weeks for actin, myosin and intermediate filaments (IF), nitric oxide synthetase (NOS) and histological evaluation. Segments treated with PTCA+SIN-1 showed a significantly (p=0.03) larger luminal diameter compared with PTCA only treated segments. The luminal loss after SIN-1 was not significant compared with the diameter prior to treatment. Endothelial NOS content was significantly lower in the PTCA+SIN-1 group compared with the PTCA group after 1 (p=0.03) and 8 weeks (p=0.013). IF/actin ratio after 1 week was significantly increased in PTCA-treated segments compared with untreated controls (p=0.004), and compared with PTCA+SIN-1-treated segments (p=0.004). PTCA-induced intimal hyperplasia was potently inhibited by local delivery of the NO donor SIN-1. Momentary events at the time of injury play a significant role in the development of intimal hyperplasia and long-lasting down-regulation of the endothelial NOS expression after SIN-1 exposure is suggested. The IF/actin ratio can be useful as an early marker of intimal hyperplasia.

Local Infusion of the Nitric oxide Donor Sin-1 After Angioplasty . Effects on intimal hyperplasia in porcine coronary arteries

To investigate the development of intimal hyperplasia in response to percutaneous transluminal coronary angioplasty (PTCA) followed by local delivery of the nitric oxide (NO) donor 3-morpholino-sydnonimine (SIN-1). Overdilation PTCA was performed in coronary arteries in 20 healthy pigs. One of the dilated segments was additionally treated with local delivery of SIN-1 for 10 min. Segments distal to the treated part of the arteries served as controls. Arteries were radiographically depicted and analyzed after 1 and 8 weeks for actin, myosin and intermediate filaments (IF), nitric oxide synthetase (NOS) and histological evaluation. Segments treated with PTCA+SIN-1 showed a significantly (p=0.03) larger luminal diameter compared with PTCA only treated segments. The luminal loss after SIN-1 was not significant compared with the diameter prior to treatment. Endothelial NOS content was significantly lower in the PTCA+SIN-1 group compared with the PTCA group after 1 (p=0.03) and 8 weeks (p=0.013). IF/actin ratio after 1 week was significantly increased in PTCA-treated segments compared with untreated controls (p=0.004), and compared with PTCA+SIN-1-treated segments (p=0.004). PTCA-induced intimal hyperplasia was potently inhibited by local delivery of the NO donor SIN-1. Momentary events at the time of injury play a significant role in the development of intimal hyperplasia and long-lasting down-regulation of the endothelial NOS expression after SIN-1 exposure is suggested. The IF/actin ratio can be useful as an early marker of intimal hyperplasia.

Coronary stent implantation is superior to balloon angioplasty for chronic coronary occlusions: Six-year clinical follow-up of the GISSOC trial

ObjectivesWe investigated whether the benefits of stent implantation over balloon percutaneous transluminal coronary angioplasty (PTCA) for treatment of chronic total coronary occlusions (CTO) are maintained in the long term. BackgroundSeveral randomized trials have shown that in CTO, stent implantation confers clinical and angiographic mid-term outcomes superior to those observed after PTCA. However, limited information on the long-term results of either technique is available. MethodsSix-year clinical follow-up of patients enrolled in the Gruppo Italiano di Studio sullo Stent nelle Occlusioni Coronariche (GISSOC) trial was performed by direct visit or telephone interview. Major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction, target lesion revascularization (TLR), and anginal status, were recorded. ResultsFreedom from MACE at six years was 76.1% in the stent group, compared with 60.4% in the PTCA group (p = 0.0555). This difference was due mainly to TLR-free survival rates (85.1% vs. 65.5% for the stent and PTCA groups, respectively; p = 0.0165). Eleven patients underwent TLR after the nine-month follow-up visit (stent group: n = 5; PTCA group: n = 6); however, in most cases, restenosis of the study occlusion was evident at nine-month angiography. ConclusionsThis study represents the longest reported clinical follow-up of patients after percutaneous recanalization of CTO and demonstrates that the superiority of stent implantation over balloon PTCA is maintained in the long term. Stent and PTCA results appear to remain stable after nine-month angiographic follow-up. Stent implantation in CTO that can be recanalized percutaneously is therefore a valuable long-term therapeutic option.

Deoxyribonucleic acid damage in human lymphocytes after percutaneous transluminal coronary angioplasty

ObjectivesWe investigated the presence of oxidative deoxyribonucleic acid (DNA) damage in the peripheral lymphocytes of patients undergoing percutaneous transluminal coronary angioplasty (PTCA) by using the micronucleus test and comet assay, which are sensitive biomarkers of DNA damage. BackgroundAlthough it has recognized that ischemia-reperfusion can induce oxidative DNA damage, its occurrence in patients undergoing PTCA has not yet been demonstrated. MethodsThree groups of patients were enrolled: 30 patients with documented coronary heart disease who underwent elective PTCA (group I); 25 patients who underwent elective coronary angiography for diagnostic purpose (group II); and 27 healthy, age- and gender-matched subjects (group III). For each subject, the frequency of micronucleated binucleated (MNBN) cells, DNA single-strand breaks (SSBs), endonuclease III-sensitive sites, and sites sensitive to formamidopyrimidine glycosylase (FPG) were analyzed before and after diagnostic procedures. ResultsThe mean basal values of MNBN cells (p = 0.04), DNA-SSBs (p = 0.001), endonuclease III-sensitive sites (p = 0.002), and FPG sites (p < 0.0001) were significantly higher in groups I and II than in group III. A high significant increase of MNBN cell frequency was observed in group I after the PTCA procedure (11.0 ± 1.3 vs. 19.8 ± 1.6, p < 0.0001), whereas no significant difference was observed in group II (10.2 ± 1.3 vs. 12.9 ± 1.4, p = 0.18). A significant positive correlation was observed between the increase in the MNBN cell rate and total inflation time during PTCA (R = 0.549, p = 0.0017). The levels of DNA-SSBs (11.7 ± 1.4 vs. 26.5 ± 3.0, p = 0.0003) and FPG sites (13.8 ± 1.8 vs. 22.5 ± 2.4, p = 0.01) were also higher after PTCA. ConclusionsOur results provide evidence for oxidative DNA damage after PTCA, likely related to ischemia-reperfusion injury.

Long-term outcome of primary percutaneous transluminal coronary angioplasty for low-risk acute myocardial infarction in patients older than 80 years: A single-center, open, randomized trial

Background Although coronary reperfusion therapy with thrombolytic agents or percutaneous transluminal coronary angioplasty (PTCA) immediately after acute myocardial infarction (AMI) has survival benefits for younger patients, the effect of coronary reperfusion therapy for very elderly (aged 80 years and older) patients with AMI remains controversial. Methods and Results We studied 120 patients aged 80 years and older at relatively low risk with AMI. The patients were randomized into a primary PTCA group (n = 61) or a “conservative” no-PTCA group (n = 59). Long-term follow-up examination was conducted with regard to endpoints, which included all causes of death, cardiac death, nonfatal re-MI, the development of congestive heart failure, and cerebral vascular accident. End-diastolic volume index and end-systolic volume index were significantly increased in both groups at follow-up examination 6 months after AMI. However, left ventricular ejection fraction, end-diastolic volume index, and end-systolic volume index were similar between both groups. With endpoints of all causes of death, cardiac death, reinfarction, congestive heart failure, and cerebral vascular accident, a 3-year Kaplan-Meier event-free survival rate analysis revealed no significant benefits in the PTCA group. Anteroseptal MI, multivessel disease, and left ventricular ejection fraction were significantly associated with the combined events with multivariate Cox proportional hazards analysis results. Conclusion First, primary PTCA for very elderly patients with AMI appears to have few beneficial effects on combined events during a 3-year period. Second, early PTCA did not prevent left ventricle remodeling after AMI in patients with AMI at relatively low risk. (Am Heart J 2002;143:497-505.)

The impact of body mass index onshort- and long-term outcomes inpatients undergoing coronary revascularization: insights from the bypass angioplasty revascularization investigation (BARI)

ObjectivesWe sought to investigate the impact of body mass index (BMI) on short- and long-term outcomes after initial revascularization with percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG). BackgroundEquivocal results exist on the impact of BMI on the risk of in-hospital complications after PTCA or CABG, and no long-term mortality data exist from a large series of revascularized patients. MethodsFrom the randomized series and observational registry of the Bypass Angioplasty Revascularization Investigation (BARI), 2,108 patients who had PTCA and 1,526 patients who had CABG were evaluated by taking their BMI at study entry. They were classified as follows: low (<20 kg/m2), normal (20 to 24.9 kg/m2), overweight (25 to 29.9 kg/m2), class I obese (30 to 34.9 kg/m2) and class II/III obese (≥35 kg/m2). In-hospital complications and short- and long-term mortalities were compared between levels of BMI within each mode of initial revascularization. ResultsAmong patients who had PTCA, each unit increase in BMI was associated with a 5.5% lower adjusted risk of a major in-hospital event (death, myocardial infarction, stroke, coma); among patients who had CABG, no difference in the in-hospital outcome was observed according to BMI. In contrast, BMI was not associated with five-year mortality in the PTCA group; among the CABG group, adjusted relative risks of five-year cardiac mortality according to levels of BMI were 0.0 (low), 1.0 (normal), 2.02 (overweight), 3.16 (class I obese) and 4.85 (class II/III obese) (linear p < 0.001). ConclusionsBody mass index appears to have a differential impact on short- and long-term outcomes after coronary revascularization. These results underscore the need for further research to identify factors responsible for the apparent short-term protective effect of a higher BMI in patients undergoing PTCA and to study the impact of weight reduction on the long-term survival of obese patients undergoing CABG.

Clinical Benefit of Small Vessel Stenting: One-year Follow-up of the SISCA Trial

Objective : To assess the long-term clinical benefit of elective stenting as compared with percutaneous transluminal coronary angioplasty (PTCA) in small coronary arteries. Design : The Stenting in Small Coronary Arteries (SISCA) trial was a randomized trial comparing elective stenting with PTCA in coronary arteries with a reference diameter of 2.1-3.0 mm. The heparin-coated beStent was used. Control angiography was performed after 6 months, and the patients were followed clinically for 12 months. Results : At 6 months the clinical outcome was significantly better in the stent group as compared with the PTCA group, with an event-free survival in 90.5 and 76.1% ( p = 0.016), respectively. From 6 to 12 months, event-free survival was unchanged in both groups, demonstrating a sustained long-term clinical benefit of elective stenting. Conclusion : Angioplasty in small coronary arteries is associated with a favorable clinical outcome after 1 year. The clinical benefit of elective stenting using the Hepamed ® -coated beStent is maintained beyond 6 months, without any tendency towards late events. Thus, elective stenting should be considered as an option when treating small coronary arteries.

Neuropsychological and psychiatric outcomes following coronary surgery or angioplasty: A comparative study

Background: Medical outcomes following coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) are similar, but few studies have compared neuropsychological outcomes after these procedures. Methods: A retrospective study compared detailed neurocognitive and psychosocial functioning in 32 patients (CABG, n = 16; PTCA, n = 16) aged 61 ± 6 years, 9–15 months after coronary revascularisation. Subjects were tested for executive functioning, speed of processing/attention and learning/memory, significant psychopathology (General Health Questionnaire, GHQ) and psychosocial functioning (Short Form (SF)-36 health survey). In the prospective study, 55 patients completed GHQ and SF-36 surveys, the day prior to and 6 months following PTCA. Results: There were no significant differences between the CABG and PTCA groups for neuropsychological or psychosocial end-points ( P > 0.20). Executive functioning in both groups, however, was worse than for healthy population controls ( P < 0.01). The PTCA patients were significantly more likely than CABG patients to have psychiatric abnormality (GHQ Score >4; P < 0.01). After PTCA, however, there was a significant improvement in the GHQ and SF-36 scores ( P < 0.05). Conclusions: Although executive function is often impaired after coronary revascularisation, neuropsychological status appears equivalent after CABG or PTCA. Psychiatric pathology is common in patients undergoing PTCA, but improves after this intervention.

Stenting in small coronary arteries (SISCA) trial: A randomized comparison between balloon angioplasty and the heparin-coated beStent

OBJECTIVESThe purpose of this study was to assess the clinical and angiographic benefits of elective stenting in coronary arteries with a reference diameter of 2.1 to 3.0 mm, as compared with traditional percutaneous transluminal coronary angioplasty (PTCA).BACKGROUNDThe problems related to small-vessel stenting might be overcome using modern stents designed for small vessels, combined with effective antiplatelet therapy.METHODSIn five centers, 145 patients with stable or unstable angina were randomly assigned to elective stenting treatment with the heparin (Hepamed)-coated beStent or PTCA. Control angiography was performed after six months. The primary end point was the minimal lumen diameter (MLD) at follow-up. Secondary end points were the restenosis rate, event-free survival and angina status.RESULTSAt follow-up, there was a trend toward a larger MLD in the stent group (1.69 ± 0.52 mm vs. 1.57 ± 0.44 mm, p = 0.096). Event-free survival at follow-up was significantly higher in the stent group: 90.5% vs. 76.1% (p = 0.016). The restenosis rate was low in both groups (9.7% and 18.8% in the stent and PTCA groups, respectively; p = 0.15). Analyzed as treated, both the MLD and restenosis rate were significantly improved in patients who had stents as compared with PTCA.CONCLUSIONSIn small coronary arteries, both PTCA and elective stenting are associated with good clinical and angiographic outcomes after six months. Compared with PTCA, elective treatment with the heparin-coated beStent improves the clinical outcome; however, there was only a nonsignificant trend toward angiographic improvement.

Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: Two-year follow-up of a new hybrid procedure compared with “on-pump” double bypass grafting

Objective Percutaneous transluminal coronary angioplasty (PTCA) or surgery can be chosen as first-line therapies in multiple-vessel coronary disease. A mammary–to–left anterior descending (LAD) graft is the most important statistical determinant of a favorable outcome after coronary artery bypass grafting (CABG) and can be performed with lower morbidity off pump through a minithoracotomy. PTCA and stenting of the “non-LAD” vessels compete with CABG in terms of patency rates. Our purpose was to compare a combination of minimally invasive direct coronary artery bypass (MIDCAB) and PTCA with double CABG as a treatment for double-vessel coronary artery disease involving the proximal LAD. Methods Two matched groups of 20 patients with double-vessel coronary disease undergoing either sequential MIDCAB and PTCA (group 1) or double CABG on cardiopulmonary bypass (group 2) were compared. Angiographic control, complications, hospital costs, quality of life, and 2-year follow-up of ischemia are reported. Results All bypasses were patent at early control. Three adverse events were noted in group 1 and 17 in group 2. The hybrid-procedure group exhibited a shorter intensive care unit stay, fewer blood products transfused, less pain, better early quality of life, faster return to work, and similar cost. Three patients required a second PTCA in group 1, one of which for restenosis. At 2 years all the patients are asymptomatic with no residual ischemia. Conclusions We conclude from this pilot study that the hybrid procedure is feasible and appears to be a safe therapy for double-vessel coronary artery disease and that it appears to generate less perioperative morbidity than classic double CABG does. Therefore we believe that there is room to undertake prospective randomized studies on a larger-scale basis. (Am Heart J 2001;142:563-70.)

Predictors of improvement in left ventricular function after percutaneous revascularization of occluded coronary arteries: A report from the Total Occlusion Study of Canada (TOSCA)

Background The Total Occlusion Study of Canada (TOSCA) is a multicenter, randomized trial evaluating the effect of stenting with ≥1 heparin-coated stent on long-term patency after percutaneous coronary intervention by balloon angioplasty of occluded coronary arteries. The purpose of the current study was to compare the effect of stenting and balloon angioplasty on global left ventricular ejection fraction (LVEF) and regional wall motion and to examine what clinical and angiographic factors may have an effect on left ventricular function in this setting. Methods and Results Analysis at the core angiographic laboratory of paired baseline and follow-up left ventricular angiograms, as well as target vessel patency, was possible in 244 of 410 cases. An improvement in LVEF was observed in the entire group (59.4% ± 11% to 61.0% ± 11%, P =.003). The LVEF change was +1.84 ± 7.54 in the stent group (P =.009) and 1.28 ± 8.16 in the percutaneous transluminal coronary angioplasty group (P =.085). There was no significant intergroup difference. Patients with duration of occlusion ≤6 weeks had an improvement in LVEF (+2.98 ± 8.68, P =.0006), whereas those with an occlusion duration of >6 weeks had no improvement (+0.48 ± 7.01, P not significant). Multivariate analysis revealed baseline LVEF <60%, duration of occlusion ≤6 weeks, and Canadian Cardiology Society angina class I or II to be independent predictors of improvement in LVEF. Conclusions The restoration of coronary patency of nonacute occluded coronary arteries is associated with a small but significant improvement in regional and global left ventricular function, especially in patients with recent occlusions and depressed left ventricular function. In spite of significant effect on long-term patency, stenting of nonacute coronary occlusions does not result in significantly better left ventricular function compared with balloon angioplasty in this setting. (Am Heart J 2001;142:301-8.)

Angiographic analysis of immediate and long‐term results of PTCR vs. PTCA in complex lesions (COBRA study)

We conducted a prospective, randomized trial to compare immediate and long-term effects of percutaneous transluminal coronary angioplasty (PTCA) and high-frequency rotational atherectomy (PTCR) in patients with angiographically predefined complex coronary artery lesions (AHA type B2 and C). The relation of lesion characteristics to procedural results is reported in this angiographic analysis. Patients were randomly assigned to balloon angioplasty (n = 250 patients) or rotational atherectomy (n = 252 patients). Quantitative coronary angiography could be performed in 447 patients to evaluate immediate results and in 293 patients with a 6-month angiographic follow-up. Procedural success was comparable in the PTCR and in the PTCA group (80% vs. 76%, P = 0.260). The need for stent implantation due to a residual stenosis >50% or a bail-out situation was significantly higher in the PTCA group (9.7% vs. 2.0%, P = 0.001). In both treatment groups, diameter stenosis was effectively reduced and MLD increased. The acute gain did not differ between the two groups. At 6-month control, the restenosis rate was comparable in the PTCR and in the PTCA group (37% vs. 35%, P = 0.658), whereas diameter stenosis was significantly more severe in the PTCR group than in the PTCA group (52% vs. 46%, P = 0.039) and, correspondingly, the MLD was significantly smaller in the PTCR group (1.29 mm vs. 1.44 mm, P = 0.031). Late loss was about the same in both groups, however, net gain and net gain index were significantly higher in the PTCA group (0.82 mm vs. 0.64 mm, P = 0.008; and 31% vs. 24%, P = 0.009). Analysis of procedural results for various lesion characteristics revealed no significant difference between treatment groups. In this randomized trial, complex coronary artery lesions were treated with comparable results for angiographic and procedural success and the restenosis rate by both, PTCA and PTCR. Late loss, however, was significantly higher and net gain significantly smaller after PTCR. Stents, although infrequently used, had a relevant impact on immediate PTCA results but not on late results. Cathet Cardiovasc Intervent 2001;53:359-367.

Continued benefit of coronary stenting versus balloon angioplasty: five-year clinical follow-up of Benestent-I trial

OBJECTIVESThis study sought to establish whether the early favorable results in the Benestent-I randomized trial comparing elective Palmaz-Schatz stent implantation with balloon angioplasty in 516 patients with stable angina pectoris are maintained at 5 years.BACKGROUNDThe size of the required sample was based on a 40% reduction in clinical events in the stent group. Seven months and one-year follow-up in this trial showed a decreased incidence of restenosis and clinical events in patients randomized to stent implantation.METHODSData at five years were collected by outpatient visit, via telephone and via the referring cardiologist. Three patients in the stent group and one in the percutaneous transluminal coronary angioplasty (PTCA) group were lost to follow-up at five years. Major clinical events, anginal status and use of cardiac medication were recorded according to the intention to treat principle.RESULTSNo significant differences were found in anginal status and use of cardiac medication between the two groups. In the PTCA group, 27.3% of patients underwent target lesion revascularization (TLR) versus 17.2% of patients in the stent group (p = 0.008). No significant differences in mortality (5.9% vs. 3.1%), cerebrovascular accident (0.8% vs. 1.2%), myocardial infarction (9.4% vs. 6.3%) or coronary bypass surgery (11.7% vs. 9.8%) were found between the stent and PTCA groups, respectively. At five years, the event-free survival rate (59.8% vs. 65.6%; p = 0.20) between the stent and PTCA groups no longer achieved statistical significance.CONCLUSIONSThe original 10% absolute difference in TLR in favor of the stent group has remained unchanged at five years, emphasizing the long-term stability of the stented target site.

Treatment of focal in-stent restenosis with balloon angioplasty alone versus stenting: Short- and long-term results

Background Although both percutaneous transluminal coronary angioplasty (PTCA) and additional stenting can be used for the treatment for focal in-stent restenosis (ISR), no large-scale comparative data on the clinical outcomes after these interventional procedures have been reported. Methods In the current study we compared the in-hospital and long-term clinical results of PTCA alone (n = 266 patients, n = 364 lesions) versus stenting (n = 135 patients, n = 161 lesions) for the treatment of focal ISR, defined as a lesion length ≤10 mm. Results There were significantly more diabetic patients in the PTCA group than in the stent group (36% vs 26%, P =.04), but other baseline characteristics were similar. Lesion length and preprocedure minimal lumen diameter (MLD) were also similar in the two groups, but the stent group had a larger reference vessel diameter (3.40 ± 0.73 mm vs 2.99 ± 0.68 mm, P <.001). Stenting achieved a larger postprocedure MLD than PTCA did (2.95 ± 0.95 mm vs 2.23 ± 0.60 mm, P <.001) and a smaller residual diameter stenosis (11% ± 15% vs 23% ± 16%, P =.04). Angiographic success was achieved in all cases. The rate of death/Q-wave infarction of urgent revascularization was higher with PTCA than with stent (5.6% vs 0.7%, P =.02). Postprocedure creatine kinase myocardial band enzyme elevation >5 times normal was more frequent with stent (18.5% vs 9.7%, P =.05). At 1 year the two interventional strategies had similar cumulative mortality (4.6% PTCA vs 5.1% stent, P not significant) and target lesion revascularization rate (24.6% PTCA vs 26.5% stent, P not significant). By multivariate analysis, the sole predictor of target lesion revascularization was diabetes (odds ratio 2.4, 95% confidence intervals 1.2-4.7, P =.01). Conclusion Repeat stenting for the treatment of focal ISR had a higher postprocedure creatine kinase myocardial band elevation rate and similar long-term clinical results compared with PTCA alone. (Am Heart J 2001;141:610-4.)

Is there any effect of chronobiological changes on coronary angioplasty?

We hypothesized that If there is a chronobiologic variation in the development of acute ischaemic events which is mainly attributed to the tendency for thrombus formation in the morning hours, same time dependent variations must also be seen in the development of ischaemic events after percutaneous transluminal coronary angioplasty (PTCA) and PTCA with stent implantation. Enrolled in this study were 349 consecutive patients with single vessel disease and undergoing elective single vessel angioplasty. Patients had been observed for the development of immediate postprocedural ischaemic events. Working hours of our laboratory were divided into 2-hourly intervals in order to define the ending time of procedure. Analysis of acute complications was carried out according to the ending time of procedure. There was no difference with regard to clinical presentation, but patients who had complications had higher blood cholesterol level (P < 0.05). Patients with stent implantation had more adverse events than the PTCA group, but this difference did not reach the statistical significance (P = 0.07). The time interval between 10:30 a.m.-12:30 p.m. was found to be an independent risk factor for the negative outcomes (P = 0.043, Relative Risk 4838). The results of our study have demonstrated that postprocedural complications after angioplasty is related to the procedure time These patients may be observed more closely for the development of immediate postprocedural ischaemic events.

Intravascular-ultrasound-guided percutaneous transluminal coronary angioplasty/provisional stent implantation strategy: impact on long-term clinical follow-up.

Two hundred and eighty-four consecutive patients with 438 native coronary artery stenoses were enrolled prospectively in a study of intravascular ultrasound (IVUS)-guided percutaneous transluminal coronary angioplasty (PTCA) with provisional stenting: (1) aggressive lesion-site media-to-media balloon-sizing; (2) IVUS-assessment of residual lumen dimensions to identify optimal PTCA results (minimum lumen area = 65% of the average of the proximal and distal reference lumen areas or = 6.0 mm(2) and no major dissection); and (3) liberal stent crossover. Overall, 206 stenoses in 134 patients (47%) were treated with PTCA alone. Reasons for crossover were flow-limiting or lumen-compromising dissections in 28% of patients and suboptimal IVUS minimum lumen area in 72% of patients. At one year, 8% of stenoses in the PTCA group and 16% in the stent crossover group required revascularization. In approximately half of the patients treated using an IVUS-guided aggressive PTCA strategy, stent implantation could be avoided without sacrificing an increase in acute complications or worse clinical outcome.

Improvement of myocardial perfusion reserve early after coronary intervention: assessment with cardiac magnetic resonance imaging

OBJECTIVESThe purpose of this study was to determine the potential value of magnetic resonance myocardial perfusion in the follow-up of patients after coronary intervention.BACKGROUNDIn some patients a residual impairment of myocardial perfusion reserve (MPR) early after successful coronary intervention has been observed. In this study we evaluated an MPR index before and after intervention with magnetic resonance.METHODSThirty-five patients with single- and multivessel coronary artery disease were studied before and 24 h after intervention. The signal intensity time curves of the first pass of a gadolinium-diethylene triamine pentacetic acid bolus injected via a central vein catheter were evaluated before and after dipyridamole infusion. The upslope was determined using a linear fit. Myocardial perfusion reserve index was estimated from the alterations of the upslope.RESULTSThe MPR index in segments perfused by the stenotic artery was significantly lower than in the control segments (1.07 ± 0.24 vs. 2.18 ± 0.35, p < 0.001) and improved significantly after intervention (1.89 ± 0.39, p < 0.001) but did not normalize completely (p < 0.01). After intervention the MPR index remained significantly lower in the balloon percutaneous transluminal coronary angioplasty group (1.72 ± 0.38; n = 13) in comparison with the stent group (1.99 ± 0.36, n = 18, p < 0.05). In the stent group a complete normalization of the MPR index was found 24 h after stenting.CONCLUSIONSMagnetic resonance perfusion measurements allow a reliable assessment of MPR index. An improvement of MPR index can be observed after coronary intervention, which is more pronounced after stenting. Magnetic resonance perfusion measurements allow the assessment and may be useful for the follow-up of patients with coronary artery disease after coronary intervention.

Outcome of coronary revascularization in patients on renal dialysis

Previous retrospective studies showed high periprocedure mortality rate and poor outcome after percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) among renal dialysis patients. The purpose of this study was to compare mortality and clinical event rates in renal dialysis patients after PTCA or CABG. We identified 252 patients from the Emory Cardiovascular Database who were on dialysis and who received PTCA (122 patients) or CABG (130 patients) at Emory University Hospital and Crawford W. Long Hospital between March 1987 and December 1997. Baseline and angiographic characteristics, in-hospital, and 1-year outcome were compared between the 2 groups. Left main disease and 3-vessel coronary artery disease were significantly more common in the CABG group. There was a higher periprocedure and in-hospital mortality in the CABG group (6.9% vs 1.6%, p = 0.04). Patients in the PTCA group underwent repeat revascularization 11 times more frequently within 1 year (22% vs 2%). At 1 year, mortality was 23% in the PTCA group and 27% in the CABG group, with no statistical difference between the 2 groups. This nonrandomized comparison reveals that PTCA and CABG can be performed in selected renal dialysis patients with an acceptable in-hospital major complication rate; however, 1-year mortality remains high in dialysis patients after coronary revascularization. Therefore, attempts at improving outcome in dialysis patients should focus on the prevention and treatment of coronary artery disease before they require coronary revascularization.