Prior Angioplasty Research Articles

Beta Blockers are Associated with Increased Mortality Without a Decrease in Reinterventions After Endovascular Abdominal Aortic Repair (EVAR)

ObjectivePredictors of sac behavior after EVAR and the impact of sac behavior on long-term survival are not well known. There are limited multicenter trials studying the impact of beta-blockers (BB) on sac behavior. Beta-blockers have consistently failed to show a benefit on AAA sac regression in patients with connective tissue disorders and the general population. This study aims to assess the association between BBs and sac behavior after endovascular aortic aneurysm repair (EVAR). MethodsPatients undergoing EVAR registered in Vascular Quality Initiative (VQI) (2003-2021) stratified by BB and no BB on discharged after an index procedure were assessed at follow-up of 30-days and 1-year. The primary outcomes included mortality and reintervention at 30-days and 1-year. The causes of reintervention were also studied at the defined time endpoints. Categorical and continuous variables were analyzed separately for association between the two groups. A p-value of <0.05 was considered statistically significant. ResultsA total of 50,411 patients, stratified by BB (28,866; 57.3%), and No BB (21,545; 42.7%) were studied. Patients with hypertension, diabetes, COPD, coronary artery disease, prior history of coronary artery bypass graft or percutaneous coronary intervention, prior angioplasty or stent, lower extremity bypass, carotid surgery, major amputation, and smokers were more likely to be on a BB at the time of discharge (p<0.05). There was no significant difference in reinterventions when comparing patients with and without BB (p=0.061). At 30-day follow up, there was no significant difference between the two groups for any cause of reintervention. At 1-year follow up, patients on BB were less likely to need reintervention for graft occlusion (no BB 18.70%, BB 11.77%, p=0.002). There was no significant difference in reintervention for all other causes at 1-year follow up. There was an increase in 30-day (no BB 0.20%, BB 0.33%, p=0.007) and 1-year mortality (no BB 2.35%, BB 3.19%, p<0.001) in patients on beta-blockers. A time to event adjusted analysis based on Cox proportional hazard model revealed a 26% higher risk of 1-year mortality for patients on BB (HR:1.26 [1.10-1.41] p<0.001) ConclusionDespite theoretical benefits of beta-blockers on aneurysm behavior, review of the largest national vascular surgery database shows that patients on beta-blockers do not have lower incidence of endovascular reinterventions after EVAR while additionally showing a higher mortality in this patient population.

Forewarned Is Forearmed: Machine Learning Algorithms for the Prediction of Catheter-Induced Coronary and Aortic Injuries

Catheter-induced dissections (CID) of coronary arteries and/or the aorta are among the most dangerous complications of percutaneous coronary procedures, yet the data on their risk factors are anecdotal. Logistic regression and five more advanced machine learning techniques were applied to determine the most significant predictors of dissection. Model performance comparison and feature importance ranking were evaluated. We identified 124 cases of CID in electronic databases containing 84,223 records of diagnostic and interventional coronary procedures from the years 2000-2022. Based on the f1-score, Extreme Gradient Boosting (XGBoost) was found to have the optimal balance between positive predictive value (precision) and sensitivity (recall). As by the XGBoost, the strongest predictors were the use of a guiding catheter (angioplasty), small/stenotic ostium, radial access, hypertension, acute myocardial infarction, prior angioplasty, female gender, chronic renal failure, atypical coronary origin, and chronic obstructive pulmonary disease. Risk prediction can be bolstered with machine learning algorithms and provide valuable clinical decision support. Based on the proposed model, a profile of 'a perfect dissection candidate' can be defined. In patients with 'a clustering' of dissection predictors, a less aggressive catheter and/or modification of the access site should be considered.

Peculiarities and Consequences of Different Angiographic Patterns of STEMI Patients Receiving Coronary Angiography Only: Data from a Large Primary PCI Registry.

Background. Inappropriate cardiac catheterization lab activation together with false-positive angiographies and no-culprit found coronary interventions are now reported as costly to the medical system, influencing STEMI process efficiency. We aimed to analyze data from a high-volume interventional centre (>1000 primary PCIs/year) exploring etiologies and reporting characteristics from all “blank” coronary angiographies in STEMI. Methods. In this retrospective observational single-centre cohort study, we reported two-year data from a primary PCI registry (2035 patients). “Angio-only” cases were assigned to one of these categories: (a) Takotsubo syndrome; (b) coronary embolisation; (c) myocardial infarction with nonobstructive coronary arteries; (d) myocarditis; (e) CABG-referred; (f) normal coronary arteries (mostly diagnostic errors); and (g)others (refusals and death prior angioplasty). Univariate analysis assessed correlations between each category and cardiovascular risk factors. Results. 412 STEMI patients received coronary angiography “only,” accounting for 20.2% of cath lab activations. Barely 77 patients had diagnostic errors (3.8% from all patients) implying false-activations. 40% of “angio-only” patients (n = 165) were referred to surgery due to severe atherosclerosis or mechanical complications. Patients with diagnostic errors and normal arteries displayed strong correlations with all cardiovascular risk factors. Probably, numerous risk factors “convinced” emergency department staff to call for an angio. Conclusions. STEMI network professionals often confront with coronary angiography “only” situations. We propose a classification according to etiologies. Next, STEMI guidelines should include audit recommendations and specific thresholds regarding “angio-only” patients, with specific focus on MINOCA, CABG referrals, and diagnostic errors. These measures will have a double impact: a better management of the patient, and a clearer perception about the usefulness of the investments.

Performance of acute coronary syndrome approaches in Brazil: a report from the BRACE (Brazilian Registry in Acute Coronary SyndromEs).

Diagnostic and therapeutic tools have a significant impact on morbidity and mortality associated with acute coronary syndromes (ACS). Data about ACS performance measures are scarce in Brazil, and improving its collection is an objective of the Brazilian Registry in Acute Coronary syndromEs (BRACE). The BRACE is a cross-sectional, observational epidemiological registry of ACS patients. Stratified 'cluster sampling' methodology was adopted to obtain a representative picture of ACS. A performance score (PS) varying from 0 to 100 was developed to compare studied parameters. Performance measures alone and the PS were compared between institutions, and the relationship between the PS and outcomes was evaluated. A total of 1150 patients, median age 63 years, 64% male, from 72 hospitals were included in the registry. The mean PS for the overall population was 65.9% ± 20.1%. Teaching institutions had a significantly higher PS (71.4% ± 16.9%) compared with non-teaching hospitals (63.4% ± 21%; P < 0.001). Overall in-hospital mortality was 5.2%, and the variables that correlated independently with in-hospital mortality included: PS-per point increase (OR = 0.97, 95% CI 0.95-0.98, P < 0.001), age-per year (OR = 1.06, 95% CI 1.03-1.09, P < 0.001), chronic kidney disease (OR = 3.12, 95% CI 1.08-9.00, P = 0.036), and prior angioplasty (OR = 0.25, 95% CI 0.07-0.84, P = 0.025). In BRACE, the adoption of evidence-based therapies for ACS, as measured by the performance score, was independently associated with lower in-hospital mortality. The use of diagnostic tools and therapeutic approaches for the management of ACS is less than ideal in Brazil, with high variability especially among different regions of the country.

Stent-Graft Length Is Associated with Decreased Patency in Treatment of Central Venous Stenosis in Hemodialysis Patients

Central venous occlusion may occur in hemodialysis patients, resulting in arm or facial swelling and failure of dialysis access. Endovascular management with balloon angioplasty or stenting has been described, but there are minimal data on the use of covered stents in this pathology. We sought to review a single institution's experience with the use of covered stents for central venous occlusive disease in hemodialysis patients. A retrospective review of all patients undergoing placement of covered stents between April 2014 and December 2016 for central venous occlusive disease to preserve a failing dialysis access was performed. Patients' records were reviewed to identify demographics, medical comorbidities, operative variables, primary patency rates, and secondary interventions. A total of 29 patients were included in the analysis. Viabahn (W.L. Gore and Associates, Flagstaff, AZ) stent grafts were exclusively used in all patients. Technical success rate was 100%. The patients were predominantly female (65.5%), with a mean age of 67.9±12.1 and medical comorbidities of hypertension (86%), diabetes (76%), and tobacco use (7%). The majority (86%) had prior angioplasty and 17 of 29 (59%) patients had previous central venous catheters. The right brachiocephalic vein was the most commonly stented vessel (28%). The median stent length and diameter used were 50millimeters (range 25-100millimeters) and 13millimeters (range: 9-13millimeters), respectively. The majority of patients (83%) received a single stent, with only 2 patients requiring more than one. Median follow-up was 24months (range: 6-41months). Four of 29 (13.8%) patients developed symptomatic stent restenosis requiring secondary intervention, all of which occurred in patients with primary stenosis between 50% and 75%. When compared to the patients without restenosis, longer stents were found to be significantly associated with restenosis (62.5centimeters, interquartile range [IQR]: 0] vs. 50centimeter, IQR: 0, P=0.002). Primary patency rates were 92.9%, 91.7%, and 80.0% at 6, 12, and 24months respectively. Secondary patency rates were 96.4%, 95.8%, and 93.3% at 6months, 12months, and 24months, respectively. The overall primary patency rate was estimated at 86.2% using Kaplan-Meier analysis at 30.5months (95% confidence interval: 26.5-34.5months). Covered stent grafts have reasonable primary patency and excellent secondary patency when used for central venous stenosis in dialysis patients. Stent-graft length is associated with poorer long-term patency rates.

Abstract 115: Gender Based Disparity in Transcatheter Aortic Valve Replacement Utilization: Insights from Nationwide Inpatient Sample 2012-2016

Background: Transcatheter aortic valve replacement (TAVR) has increasingly become the treatment of choice for symptomatic, severe aortic stenosis in patients at high surgical risk. While women have better morbidity &amp; mortality outcomes following TAVR, it is unclear if there is gender disparity in utilization. We investigated gender-based utilization trends of TAVR and assessed associations with income quartiles &amp; comorbidities. Methods: The Nationwide Inpatient Sample (NIS) data was queried from January 2012 to December 2016 to identify patients undergoing TAVR using International Classification of Diseases (ICD) procedural codes. Statistical analyses included baseline comparisons by gender, analyzing associations between gender, TAVR utilization, income &amp; co-morbidities, with use of Chi-square test for categorical variables and Wilcoxon rank sum test for age. The associations were also analyzed using a propensity score matched subset &amp; a logistic regression model. Results: We identified 21,859 TAVR patients (46.9% women, n=10,259). Women were older than men (median, IQR: 83, 77-87 vs 82, 76-87) and had higher prevalence of hypertension, diastolic heart failure, and pulmonary hypertension (p&lt;0.001). Conversely diabetes, renal disease, atrial fibrillation, prior coronary angioplasty, and systolic heart failure were more prevalent in men (Table 1). TAVR utilization trend from 2012 to 2016 demonstrated a widening gap between the genders (p= 0.006) (Figure A). Median household income was associated with TAVR utilization in women in the entire cohort (p=0.028). However, in the propensity score matched subset, though heterogeniety was noted, the association was not significant per income quartile per year (Figure B). Combining data from all years, a multivariable logistic regression model confirmed that gender-based utilization did not associate with socio-economic factors such as income after adjustment for comorbidities. Conclusion: These findings showed widening utilization gap of TAVR between men and women, despite knowledge of better long-term outcomes in women. Economic factors were not associated with the gender disparity in TAVR utilization. Therefore, further research into TAVR registries is needed to analyze factors impacting this disparity and measures to correct it.

Endovascular Treatment of Intracranial Atherosclerotic Stenosis: Current Debates and Future Prospects.

Intracranial atherosclerotic stenosis (ICAS) is a common cause of transient ischemic attack (TIA) and ischemic stroke. Endovascular treatment, including balloon angioplasty alone, balloon-mounted stents, and self-expandable stent placement with or without prior angioplasty, is an alternative to medical treatment for the prevention of recurrent TIA or ischemic stroke in patients with ICAS. Although the SAMMPRIS and VISSIT trials supported medical management alone against endovascular treatments, both randomized controlled trials (RCT) were criticized due to flaws relating to patient-, intervention-, and operator-related factors. In this review, we discuss the current debate regarding these aspects and suggest approaches to solve current controversies in the future. In our opinion, endovascular treatment in carefully selected patients, individualized choice of endovascular treatment subtypes, and an experienced multidisciplinary team managing the patient in the pre-, peri- and post-procedural period have the potential to provide safe and efficious treatment of patients with symptomatic ICAS.

Safety and effectiveness of combined scoring balloon and paclitaxel-coated balloon angioplasty for stenosis in the hemodialysis access circuit.

To evaluate the safety and effectiveness of combined scoring balloon (SB) and paclitaxel-coated balloon (PCB) angioplasty for stenosis in the dysfunctional hemodialysis access circuit. Patients were referred from outpatient dialysis centers by their nephrologists because of dysfunctional dialysis access circuit. Fistulogram/graftogram was performed by experienced interventional radiologists. Those with in-stent stenosis, stent edge stenosis or vessel diameter at the culprit segment larger than 6mm were excluded. Angioplasty of the stenotic segment was performed with SB and followed by PCB. All study outcomes were defined according to the Society of Interventional Radiology technology assessment committee reporting standards for percutaneous interventional procedures in dialysis access circuit. A total of 23 patients received combined SB/PCB angioplasty for stenosis of hemodialysis access circuit which included 15 fistulas and 8 grafts. There were 10 men and 13 women with a mean age of 63.3±2.7 (SD) years (range: 37-85years). The technical success and clinical success rates were both 100%. There were no complications during or after the procedures. The target lesion primary patency rates at 3, 6 and 12months were 91.3%, 69.6%, and 45.2%, respectively and the estimated median target lesion restenosis (TLR) free duration was 11.0months (95% confidence interval [CI]: 5.1-16.9months). In patients with a recurrent stenosis, the median TLR-free duration of combined angioplasty was significantly higher than that of prior angioplasty with plain balloon (10.2months [95% CI: 6.4-14.0months] vs. 4.2months [95%CI: 2.1-6.4months]) (P=0.047). The mean TLR-free duration was significantly higher in patients with a juxta-anastomotic stenosis than those with non-juxta-anastomotic lesion (21.3months [95% CI: 14.7-28.0months] vs. 8.2months [95% CI: 5.1-11.4months]) (P=0.004). Combined SB/PCB angioplasty is safe and effective for the hemodialysis access stenosis.

Results of bypass graft surgery after prior angioplasty in critical limb ischaemia treatment.

The aim of this study was to determine the outcomes of primary bypass graft surgery (BGS) compared to BGS after failed angioplasty (PTA). Between January 2007 and January 2014, we performed 136 BGSs exclusively for the treatment of critical limb ischaemia. Two cohorts were identified: 1) primary BGS (n = 102; group I), and 2) BGS after prior PTA (n = 34; group II). Data were analysed retrospectively and the primary endpoints were the rates of secondary patency, amputation-free survival, freedom from major adverse outcomes (graft occlusion, amputation, or death), and overall survival, which were assessed with the Kaplan-Meier method. Both groups were comparable with a predominance of Rutherford's category 5 ischaemic lesions (73.3 %). Most patients had extensive TASC D athe-rosclerotic disease (83.6 %), and the main conduit was the greater saphenous vein (58.1 %). The mean follow-up time was 36.2 months. The 3-year secondary patency rates were better for group I (64.3 % vs 49.6 %; P = 0.04). During the same period, the amputation-free survival rates were similar between the groups (77.4 % vs 74.5 %; P = 0.59). For multivariate Cox regression analysis, BGS after prior PTA was the only factor associated with re-intervention for limb salvage (hazard ratio = 2.39; CI 95 % = 1.19 - 4.80; P = 0.02). At the 3-year point, there were no differences in the overall survival rates (72.6 % vs 70 %; P = 0.97), but the proportion of patients without adverse outcomes was higher in group I (37.3 % vs 13.4 %; P = 0.007). Although secondary patency was better after primary BGS, the amputation-free and overall survival rates support the use of BGS after prior PTA.

Bioprosthetic versus mechanical prostheses for valve replacement in end-stage renal disease patients: systematic review and meta-analysis.

Patients with end-stage renal disease (ESRD) indicated for dialysis are increasingly requiring cardiac valve surgery. The choice of bioprosthetic or mechanic valve prosthesis for such patients requires careful risk assessment. A systematic review and meta-analysis was performed to assess current evidence available. A comprehensive search from six electronic databases was performed from their inception to February 2015. Results from patients with ESRD undergoing cardiac surgery for bioprosthetic or mechanical valve replacement were identified. Sixteen studies with 8,483 patients with ESRD undergoing cardiac valve replacement surgery were included. No evidence of publication bias was detected. Prior angioplasty by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery was significantly higher in the bioprosthetic group compared to the mechanical group (16.0% vs. 12.0%, P=0.04); all other preoperative baseline patient characteristics were similar. There was no significant difference in 30-day mortality or all-cause mortality between the two comparisons. Compared with the mechanical group, the frequency of bleeding (5.2% vs. 6.4%, P=0.04) and risk of thromboembolism (2.7% vs. 12.8%, P=0.02) were significantly lower in the bioprosthetic group. There were similar rates of reoperation and valve endocarditis. The present study demonstrated that patients with ESRD undergoing bioprosthetic or mechanical valve replacement had similar mid-long term survival. The bioprosthetic group had lower rates of bleeding and thromboembolism. Further studies are required to differentiate the impact of valve location. The presented results may be applicable for ESRD patients requiring prosthetic valve replacement.

MP79-08 SURGICAL MANAGEMENT OF RENAL ARTERY STENOSIS DUE TO TAKAYASU'S AORTOARTERITIS:RESULTS FROM A TERTIARY CARE CENTER IN SOUTH INDIA

You have accessJournal of UrologyTransplantation & Vascular Surgery: Renal Transplantation & Vascular Surgery I1 Apr 2015MP79-08 SURGICAL MANAGEMENT OF RENAL ARTERY STENOSIS DUE TO TAKAYASU'S AORTOARTERITIS:RESULTS FROM A TERTIARY CARE CENTER IN SOUTH INDIA John S. Banerji, Antony Devasia, Nitin S. Kekre, Ninan K. Chacko, and Ganesh Gopalakrishnan John S. BanerjiJohn S. Banerji More articles by this author , Antony DevasiaAntony Devasia More articles by this author , Nitin S. KekreNitin S. Kekre More articles by this author , Ninan K. ChackoNinan K. Chacko More articles by this author , and Ganesh GopalakrishnanGanesh Gopalakrishnan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.2865AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Takayasu's arteritis is a rare disease with significant morbidity amongst young patients, with a predilection to involve renal vasculature. As literature regarding long term outcome is sparse, we decided to elucidate our experience with treatment for renal artery stenosis in this group. METHODS After institutional review board clearance, electronic records were reviewed retrospectively. Patients with renal artery stenosis, secondary to Takayasu's arteritis, as diagnosed by American College of Rheumatology criteria (1990) were included, over a 10 year period (2000- 2010). Data on presentation, antihypertensive usage, renal function and intra and post operative complications were described. RESULTS There were 48 patients with renal artery stenosis, during the 10 year period, with a female preponderance (F: M =7:1). Mean ages were 27 years in female patients and 33.7 years in males. Unilateral renal artery stenosis was present in 8 subjects; the rest had bilateral disease. All had hypertension, and 72% (35/48) presented with headache as the predominant symptom. More than half (54%; 26/48) had fever. Clinically audible renal bruit was present in less than 10% (4/48). At presentation, 6 patients had creatinine levels more than 2 mg % (Range 2-4.5 mg %). Inflammatory markers viz. Erythrocyte sedimentation rate (ESR) and C- reactive protein (CRP) were elevated in 79% (38/48) and 91% (32/35) respectively. Angiogram revealed aortic arch involvement in 88% (37/42), with aorta and renal vessels involved in isolation in 5. Prior angioplasty with stenting was performed in 8 patients, with 2 failures. 10 patients underwent nephrectomy. 38 underwent renal auto transplantation, with bench surgery in 4 who had multiple vessels and technically demanding renal vasculature. The mean renal size was 8.8 cm. Perioperative complications included post op haemorrhage (5/48), and thrombosis of graft in 1 patient, leading to graft loss. One patient developed abdominal compartment syndrome leading to small bowel gangrene and death. Follow up was available for 38 of the 48 patients. The average follow up was 48 months. In the group with elevated creatinine (>2 mg %), all but one had a significant fall in creatinine. Inflammatory markers returned to normal in a majority of the patients. There was a decreased need for antihypertensive in 78% (30/38). CONCLUSIONS Renal revascularization helps in preserving renal function in patients with Aortoarteritis. There is an appreciable decrease in the use of antihypertensives with revascularization. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e1013 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information John S. Banerji More articles by this author Antony Devasia More articles by this author Nitin S. Kekre More articles by this author Ninan K. Chacko More articles by this author Ganesh Gopalakrishnan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Construção e validação de um Sistema Integrado de Dados de Intervenção Coronária Percutânea no Brasil (Registro ICP-BR): perfil clínico dos primeiros 1.249 pacientes incluídos

INTRODUÇÃO: A intervenção coronária percutânea cresceu de modo expressivo nas últimas décadas. Entretanto, relatos de resultados imediatos e a longo prazo desse procedimento em instituições brasileiras são esporádicos e restritos a alguns centros. A presente proposta objetiva descrever um sistema nacional para a avaliação dos indivíduos tratados por intervenção coronária percutânea no Brasil. MÉTODOS: O Registro ICP-BR foi constituído por meio de rede informatizada para a captação de dados, via web, sobre angioplastias coronárias realizadas no dia a dia da cardiologia intervencionista, sem critérios de exclusão. Em sua fase piloto, 8 centros nacionais foram selecionados para a coleta inicial de dados. Relatamos o perfil clínico e a evolução intra-hospitalar dos primeiros pacientes incluídos. RESULTADOS: De março de 2009 a dezembro de 2009, foram incluídos 1.249 pacientes na base de dados. No total, 60% foram tratados pelo Sistema Único de Saúde, 38% por planos de saúde e 2% eram pagantes. A média de idade era de 63,7 ± 11,3 anos, 36% eram diabéticos, 12% tinham cirurgia prévia e 27% tinham angioplastia prévia. À admissão, 39% eram estáveis e 18% tinham infarto com supradesnivelamento do segmento ST. Ultrassom intracoronário ou reserva fracionada de fluxo foram utilizados em 2,8% dos casos. Stents foram utilizados em 93% dos procedimentos, sendo farmacológicos em 16,2% dos pacientes. A mortalidade foi de 0,2% nos pacientes estáveis, de 2,4% nos casos de coronariopatia aguda sem supradesnivelamento do segmento ST, de 6,1% nos pacientes com infarto com supradesnivelamento do segmento ST e de 3,6% naqueles com "equivalente anginoso". CONCLUSÕES: Descrevemos a construção e a efetiva implementação de sistema informatizado para a coleta detalhada de dados sobre procedimentos de intervenção percutânea coronária no Brasil. Em decorrência do caráter inclusivo sem restrições (all-comers) e do seguimento prospectivamente desenhado dos pacientes, esse sistema de captação e registro poderá contribuir de forma decisiva para que se trace o perfil das intervenções percutâneas coronárias em nosso País.

The additive prognostic value of end-systolic pressure-volume relation in patients with diabetes mellitus having negative dobutamine stress echocardiography by wall motion criteria

Background/objective:The end-systolic pressure-volume relation (ESPVR) is a useful method to assess left ventricular contractility during stress providing prognostic information above and beyond regional wall motion. The aim of the study...

Characterization of primary and restenotic atherosclerotic plaque from the superficial femoral artery: Potential role of Smad3 in regulation of SMC proliferation

To characterize and compare primary and restenotic lesions of the superficial femoral artery and analyze the contribution of TGF-beta/Smad3 signaling to the pathophysiology of peripheral artery occlusive disease. Immunohistochemical studies were performed on specimens retrieved from the superficial femoral artery of patients undergoing either atherectomy for primary atherosclerotic or recurrent disease after stenting and/or prior angioplasty. Immunohistochemical analysis revealed a significantly higher smooth muscle cell (SMC) content (alpha-actin+) and expression of Smad3 in restenotic lesions while primary lesions contained significantly more leukocytes (CD45+) and macrophages (CD68+). Further studies demonstrated colocalization of Smad3 with alpha-actin and PCNA, suggesting a role for Smad3 in the proliferation observed in restenotic lesions. To confirm a role for Smad3 in SMC proliferation, we both upregulated Smad3 via adenoviral mediated gene transfer (AdSmad3) and inhibited Smad3 through transfection with siRNA in human aortic SMCs, then assessed cell proliferation with tritiated thymidine. Overexpression of Smad3 enhanced whereas inhibition of Smad3 decreased cell proliferation. Differences in cellular composition and cell proliferation in conjunction with the finding that Smad3 is expressed exclusively in restenotic disease suggest that TGF-beta, through Smad3 signaling, may play an essential role in SMC proliferation and the pathophysiology of restenosis in humans.

Changing Operative Characteristics of Patients Undergoing Operations for Coronary Artery Disease: Impact on Early Outcomes

Aggressive nonsurgical revascularization results in high-risk patients presenting for operation at a later stage of coronary artery disease (CAD). This study investigated the effect of temporal changes in operative characteristics on outcomes of surgical revascularization. We compared preoperative, intraoperative, and postoperative variables of 5633 patients who underwent surgical revascularization for CAD between April 1998 and January 2007, divided into early (1998 to 2002, n = 2746) and late (2004 to 2007, n = 2887) eras. End points were major adverse outcomes (postoperative myocardial infarction, stroke, new dialysis) and operative mortality. Median age (66 vs 68 years, p < 0.0001), prevalence of left ventricular systolic dysfunction, left main stem disease, prior angioplasty, diabetes mellitus, concomitant valve operation, and aprotinin use increased steadily over time. Severe symptoms, nonelective operations, mean number of grafts, postoperative bleeding, reopening for bleeding, and blood transfusion declined. Major complications were evenly distributed between the eras. Operative mortality for isolated coronary artery bypass grafting did not change (2.0% vs 1.8% p = 0.62) despite increasing operative risk (p < 0.0001); there was a 100% reduction in the absolute risk (110% to 210%) over time. The markers for operative difficulties, such as longer bypass times, were determinants of operative mortality and, in addition to other predictors like age and left ventricular systolic dysfunction, were more prevalent in the late era. Coronary operations are increasingly performed in higher-risk patients; however, surgical revascularization is nearly twice as safe in current practice compared with a decade ago.

Endovascular brachytherapy prevents restenosis after femoropopliteal angioplasty: results of the Vienna-3 randomised multicenter study

Background and purpose The aim of the trial was to investigate the effect of Iridium-192 gamma endovascular brachytherapy on reduction of restenosis after femoropopliteal angioplasty. Patients and methods Between Oct, 1998 and Jul, 2001 a total of 134 patients have been randomized after successful angioplasty to brachytherapy or sham irradiation in a prospective, randomized, multicenter, double blind controlled trial. Patients with de novo lesion of at least 5 cm or recurrent lesion of any length after prior angioplasty have been enrolled. Brachytherapy was performed with 7 F centering catheter. Mean lesion length was 9.1 cm (1.5–25 cm) and mean intervention length 13.6 cm (4–27.5 cm) in brachytherapy cohort. Results In placebo cohort mean lesion length was 10.3 cm (2–25 cm) and mean intervention length 14.1 cm (2–29 cm). A dose of 18 Gy was prescribed 2 mm from the surface of centering balloons. Analyzed (based on angiography) on intention to treat basis the binary restenosis rate at 12 months was 41.7% (28/67) in brachytherapy cohort and 67.1% (45/67) in placebo cohort ( χ 2 test, P<0.05). Corresponding data for as treated analysis (A total of 38 patients was excluded from analysis due to lack of follow-up, early recurrence within 30 days and >30% residual stenosis after angioplasty) have been 23.4% in the brachytherapy and 53.3% in the placebo group ( P<0.05), respectively. The cumulative patency rates after 24 months on intention to treat analysis were 54% in the brachytherapy and 27% in the placebo group ( P<0.005). Corresponding data for as treated analysis were 77% in the brachytherapy and 39% in the placebo group ( P<0.001). Late thrombosis was not seen. Conclusions Significant reduction of restenosis rate was obtained with endovascular gamma brachytherapy after femoropopliteal angioplasty.

2493 Flu vaccination in acute coronary syndromes and planned percutaneous coronary interventions (FLUVACS) study: 1-year follow-up

Aims We have previously reported a significant benefit of vaccination against flu on the incidence of a single and composite end-point of death, myocardial infarction or recurrent ischaemia in patients with myocardial necrosis and planned percutaneous coronary interventions. To determine whether the observed benefits of vaccination against flu were maintained beyond the winter season a 1-year follow-up was conducted. Methods and results During the winter season, we enrolled prospectively 200 myocardial infarction patients admitted in the first 72 h, and 101 planned angioplasty/ stent patients (PCI) without unstable coronary artery disease, prior by-pass surgery, angioplasty or tissue necrosis. Only four patients failed to meet the inclusion criteria. Participants were randomly allocated to receive flu vaccination or remain unvaccinated on top of standard medication (control group). The study was conducted in hospitalized patients with the aim to test the potential beneficial effect of flu vaccination in a secondary prevention scenario. Under intention to treat analysis the incidence of the primary end-point cardiovascular death at 1 year was significantly lower among patients receiving vaccination, 6% as compared with controls, 17% (relative risk with vaccine as compared with controls, 0.34; 95% confidence interval (Cl), 0.17 to 0.71; P=0.002). The triple composite end-point occurred in 22% of the patients in the vaccine group vs 37% in controls, hazard ratio 0.59, 95% Cl 0.4 to 0.86) P=0.004. The beneficial effect was mainly detected in acute myocardial infarction patients (four events in the active arm vs 21 in the control group, P=0.0002 [95% Cl 0.19, 0.07-0.53]), and Cox regression analyses revealed that there was a greater benefit with flu vaccination in patients at high risk according with the TIMI score, and those with non-ST-segment deviation myocardial infarction (95% CI: 0.13 [0.030.52]) Conclusions Influenza vaccination may reduce the risk of death and ischaemic events in patients suffering from infarction and post-angioplasty during flu season. This effect was significantly evident at 1-year follow-up. Larger confirmatory studies are needed to evaluate the real impact on flu vaccination on outcome after acute coronary syndromes.

Time to presentation with acute myocardial infarction in the elderly: associations with race, sex, and socioeconomic characteristics.

Although prompt treatment is a cornerstone of the management of acute myocardial infarction (AMI), prior studies have shown that one fourth of AMI patients arrive at the hospital >6 hours after symptom onset. It would be valuable to identify individuals at highest risk for late arrival, but predisposing factors have yet to be fully characterized. Data from the Cooperative Cardiovascular Project, involving Medicare beneficiaries aged >65 years hospitalized between January 1994 and February 1996 with confirmed AMI, were used to identify patients who presented "late" (>/=6 hours after symptom onset). Patient characteristics were tested for associations with late presentation by use of backward stepwise logistic regression. Among 102 339 subjects, 29.4% arrived late. Significant predictors of late arrival (odds ratio, 95% CI) included diabetes (1.11, 1.07 to 1.14) and a history of angina (1.32, 1.28 to 1.35), whereas prior MI (0.82, 0.79 to 0.85), prior angioplasty (0.80, 0.75 to 0.85), prior bypass surgery (0.93, 0.89 to 0.98), and cardiac arrest (0.52, 0.46 to 0. 58) predicted early presentation. Additionally, initial evaluation at an outpatient clinic (2.63, 2.51 to 2.75) and daytime presentation (1.67, 1.59 to 1.72) predicted late arrival. Finally, female sex, black race, and poverty, which were evaluated with an 8-level race-sex-socioeconomic status interaction term, were also risk factors for delay. Delayed hospital presentation is a common problem among Medicare beneficiaries with AMI. Factors associated with delay include not only clinical and logistical issues but also race, sex, and socioeconomic characteristics. Education efforts designed to hasten AMI treatment should be directed at individuals with risk factors for late arrival.

Adverse Cardiac Outcomes After Noncardiac Surgery in Patients with Prior Percutaneous Transluminal Angioplasty

Adverse Cardiac Outcomes After Noncardiac Surgery in Patients with Prior Percutaneous Transluminal Angioplasty

Long-term (three-year) prognosis of patients treated with reperfusion or conservatively after acute myocardial infarction

OBJECTIVESThis survey sought to assess the frequency of the use of thrombolytic therapy, invasive coronary procedures (ICP) (angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting [CABG]), variables associated with their use, and their impact on early (30-day) and long-term (3-year) mortality after acute myocardial infarction (AMI).BACKGROUNDFew data are available regarding the implementation in daily practice of the results of clinical trials of treatments for AMI and their impact on early and long-term prognosis in unselected patients after AMI.METHODSA prospective community-based national survey was conducted during January–February 1994 in all 25 coronary care units operating in Israel.RESULTSAmong 999 consecutive patients with an AMI (72% men; mean age 63 ± 12 years) acute reperfusion therapy (ART) was used in 455 patients (46%; thrombolysis in 435 patients [44%] and primary angioplasty in 20 [2%]). Its use was independently associated with anterior AMI location and hospitals with on-site angioplasty facilities, whereas advancing age, prior myocardial infarction (MI) and prior angioplasty or CABG were independently associated with its lower use. The three-year mortality of patients treated with ART was lower than in counterpart patients (22.0% vs. 31.4%, p = 0.0008), mainly as the result of 30-day to 3-year outcome (12.4% vs. 21.1%; hazard ratio = 0.73, 95% confidence interval [CI] 0.52 to 1.03). Independent predictors of long-term mortality were: age, heart failure on admission or during the hospitalization, ventricular tachycardia or fibrillation and diabetes. The outcome of patients not treated with ART differed according to the reason for the exclusion, where patients with contraindications experienced the highest three-year (50%) mortality rate. After ART, coronary angiography, angioplasty and CABG were performed in-hospital in 28%, 12% and 5% of patients, respectively. Their use was independently associated with recurrent infarction or ischemia, on-site catheterization or CABG facilities, non–Q-wave AMI and anterior infarct location. In the entire study population, and in patients with a non–Q-wave AMI, performance of ICP was associated with lower 30-day mortality (odds ratio [OR] = 0.53, 95% CI 0.25 to 0.98, and OR = 0.21, 0.03 to 0.84, respectively), but not thereafter.CONCLUSIONSThis survey demonstrates the extent of implementation in daily practice of ART and ICP and their impact on early and long-term prognosis in an unselected population after AMI.