PTCA Group Research Articles

CORONARY IN-STENT RESTENOSIS AND CORONARY ARTERY BYPASS GRAFT STENOSIS IN POST MYOCARDIAL REVASCULARISED PATIENTS- SINGLE CENTRE EXPERIENCE FROM NORTH INDIA

Aims and Objective : To calculate the incidence of coronary artery In-stent restenosis and coronary artery bypass graft stenosis in post myocardial re-vascularised patients in Indian context. ThisMethods : is an observational study , coronary artery disease patients earlier re-vascularized either by coronary stent implantation or by coronary artery bypass graft presented with exertional angina , anginal equivalents , symptoms of heart failure or acute coronary event were enrolled in the study, patient with contraindications to coronary angiogram were excluded. The data collected from CAG was analysed by using quantitative coronary angiography and statistical analysis was performed using SPSS version. Study included total 201 patients, 117 in PTCA group , 84 in CABG group. Out of 184 stents, 34 stentsResults : showed >50% restenosis with incident rate 14.3% for DES and 47.80% for BMS respectively The incidence rate of restenosis was higher in BMS than DES in PTCA group ,where as the stenosis rate of LIMA graft(8.7%) was minimal in comparison to SVG graft(43.81%). Statistically no difference in restenosis rate between diabetic and non diabetic population in both PTCA and CABG group. Our observational study reected the rate of In-stent restenosis and coronary artery bypassConclusion:- graft stenosis both in PTCA and CABG groups in concordance with previous studies. In PTCA group BMS have higher incidence of In-stent restenosis in comparison with DES where as in CABG group venous graft have higher stenosis than arterial graft. There is no difference in restenosis rate among diabetic and non diabetic population in our study.

MO180CHRONIC KIDNEY DISEASE IN PATIENT WITH CHRONIC CORONARY DISEASE AFTER CORONARY REVASCULARIZATION

Abstract Background and Aims to study of renal function in patients with coronary artery disease, depending on the method of revascularization and the initial state of the kidneys. Method There were 160 patients with coronary artery disease under observation who underwent re-endovascular procedures (RE). The average age of the patients was 56.6 ± 1.27 years. Coronary artery bypass grafting (CABG group) was performed in 21 patients with coronary artery disease and percutaneous coronary intervention (PCI group) - in 139 patients. The study included patients with an eGFR of at least 60 ml / min, determined by the serum creatinine concentration. Patients received standard therapy: antiplatelet therapy (double therapy), bisoprolol, valsartan, atorvastatin. All patients underwent dynamic determination of serum creatinine concentration in terms of 3 months - 1 year -2 years. Results The CABG groups (21 patients) and the PTCA group (139 patients) who received standard therapy for coronary artery disease (group B). In the CABG and PCI groups, the eGFR was 105.66 ± 3.74 ml / min and 102.71 ± 1.59 ml / min, respectively. By the 3rd month of follow-up, the dynamics of eGFR in the groups, did not differ (-16.36 ± 3.30% and -17.55 ± 1.25%, respectively), by the 3rd month eGFR observation in the CABG and PTCA groups was also comparable, although it also differed in the baseline data (90.14 ± 6.05 ml / min and 86.46 ± 2.37 ml / min, respectively, the differences with the baseline data in both groups - p < 0.001. By the end the 1st year the following pattern emerged: in patients who underwent surgical revascularization, the decrease in eGFR was more pronounced than in patients who underwent stenting of the coronary arteries (-51.80 ± 3.51% versus -42, 39 ± 1.35%, p <0.05), and the differences increased even more during the second year of observation (-57.99 ± 4.75% versus -44.76 ± 1.89%, p <0.05). The second year of observation, eGFR in the CABG group was lower than in the PTCA group (44.63 ± 5.37 ml / min versus 56.54 ± 2.01 ml / min, p <0.05). This pattern can be explained that fact in the CABG group were more patients with diabetes - 80.95% (17 patients out of 21) compared with PTCA patients - 12.23% (17 patients out of 139, chi square 49.83, p < 0.001). All patients divided into 2 subgroups depending on the degree of eGFR by the 3rd month of observation: patients with eGFR by the 3rd month of observation more than 20% (31 patients, group 1) and less than 20% (group 2 - 129 sick). Initially, eGFR in group 1 was lower than in group 2. The relative dynamics of eGFR during the entire observation period was greater in patients of group 1 compared with group 2 (-43.58 ± 1.72% versus -11.10 ± 0.58% by the end 3rd month of observation, -61.30 ± 1.44% versus -39.38 ± 1.29% by the end of the first year and -68.78 ± 2.56% versus -41.14 ± 1.85% by the end of the second year of observation, the reliability of the difference in the relative dynamics between the groups at all three observation points is p <0.001). Conclusion. In patients with coronary artery disease who underwent coronary revascularization, there is a decrease in renal function after revascularization. The most significant decrease was observed in patients undergoing coronary artery bypass grafting, as well as in patients with initially low filtration function of the kidneys.

0144: Depression and anxiety in coronary artery bypass grafting patients: comparisons with percutaneous intervention

Anxiety and depression are two common psychic entities among coronary patients. They are often sub-diagnosed. Several studies demonstrated that they aggravated the morbi-mortality of the coronary patient. The objective of this study was to quantify the anxiety and the depression in coronary artery bypass grafting patients (CABG), to determine the effect of the revascularisation and to find a relation between depression and morbimortality. 64 patients were admitted for a coronary event and divided in two groups. PTCA (N = 34) and CABG (N = 30). The anxiety and the depression were measured by two scales of psychological self-assessment (HAD, BDI) in three time; T1 (To the announcement of the disease), T2 (3 weeks after the revascularisation) and T3 (3 months later). A comparative study between 2 groups was realized. Two groups were comparable on the sociodemographic plan and the risk factors. The cardiovascular histories of myocardial infarction and coronary angioplasty were frequent in the PTCA groups and CABG. The average of the day number of hospitalization was of 7.5 ± 3.9 days for the PTCA group and 10.3 ± 7.4 days for the CABG group. The psychological evaluation in the admission showed scores of anxiety raised in two groups and depression raised only in the group CABG. The myocardial revascularisation had a positive effect on the psychological state of the patients of the groups PTCA and CABG. The evolution of the psychological scores showed that the patients of the group surgery were more depressed and that the patients of the group angioplasty were more anxious. For the group PTCA, the average duration of survival without revascularisation was of 26 months in the absence of depression, against 21 months in its presence. For the group CABG, the average duration of survival without revascularisation was of 27 months in the absence of major depressive episode, against 16 months in its presence. The depression and the anxiety are two frequent symptoms in the ischemic heart disorder. The depression is a factor of bad forecast at CABG patients. The early screening is important for setting up appropriate therapeutic.

Short-term outcomes of balloon angioplasty versus stent placement for patients undergoing primary percutaneous coronary intervention: Implications for patients requiring early coronary artery bypass surgery

In patients with acute ST-elevation myocardial infarction (STEMI) needing early coronary artery bypass graft (CABG) surgery, it is unknown whether primary percutaneous balloon angioplasty (PTCA)-without stent implantation-allows safe transition to subsequent CABG. We examined acute STEMI patients enrolled in the Stent-PAMI and CADILLAC trials to study the differences in the early clinical events between those treated with primary PTCA (n = 1494) or primary stenting (n = 1488). Baseline clinical and pre- and post-procedural angiographic features including post-intervention TIMI 3 flow rates were similar in the 2 groups with the exception of higher median infarct-artery residual stenosis in the PTCA group (26% [IQR 19%-34%] vs. 18% [IQR 11-25%], P < .001]. Provisional stenting was required in 16% of patients in PTCA group, while stents could not be implanted in 2% of the stent group. Sixty-percent of PTCA patients had stent-like balloon result. The rate of 30-day ischemia-driven target vessel revascularization was higher in the PTCA group (4.3% vs. 2.0%, P < .001 [4.6% vs 2.3%, P < .001 among patients with multivessel disease and 3.4% vs. 2.0%, P = .044 in patients with stent-like balloon results]) while 30-day major adverse cardiac events (6.2% vs 4.9%), death (1.8% versus 2.8%), and reinfarction (0.9% vs. 0.7%) were similar in the 2 groups. Compared with primary stenting, primary PTCA of infarct artery in STEMI patients was associated with significant increase in ischemia-driven target vessel revascularization (ITVR) rate, yet with no increased risk of major adverse cardiac events, reinfarction or death. Thus, provided close surveillance is maintained and prompt treatment initiated for early ischemic events, PTCA (particularly in those with stent-like balloon result) may be a reasonable and safe option in STEMI patients needing early CABG.

Clinical Outcome in Patients with Intermediate Stenosis of Left Anterior Descending Coronary Artery after Deferral of Revascularization on the Basis of Noninvasive Coronary Flow Reserve Measurement

Several reports suggest that noninvasive measurements of coronary flow reserve (CFR) by use of echocardiography may support decision making in intermediate stenosis of the left anterior descending coronary artery (LAD). The aim of the present study was therefore to analyze the clinical outcome in patients with intermediate stenosis of LAD after deferral of coronary revascularization on the basis of noninvasive CFR measurement. the study population included 280 patients with intermediate LAD stenosis (50-70% by angiography) (62.2 +/- 9.6 years). All the patients underwent transthoracic CFR assessment of LAD (after dipyridamole infusion) within 2 weeks from coronary angiography. If CFR of LAD was < or = 2, PTCA was recommended; if CFR was > 2, medical treatment was chosen. Primary end points were cardiac death, myocardial infarction, coronary revascularization procedure, and unstable angina. mean follow-up was 43 +/- 11 months (range 12-52 months). In 150 patients (53.6%) (CFR < or = 2), coronary artery revascularization was performed (PTCA group); the remaining 130 patients (46.4%) (CFR > 2) were medically treated (medical group). Survival from cardiac death was 94% in the PTCA group and 92.4% in the medical group (P = 0.56). As for all cardiac events, the Kaplan-Meier percentage survival from cardiac events was 88.3% in the PTCA group and 86.4% in the medical group (P = 0.36). even if CFR as a "stand-alone" diagnostic criterion suffers from several structural limitations, a combined strategy including also other clinical and instrumental measurements before undergoing interventional procedures could improve the cost-benefit practice, in particular, for the management of patients with intermediate LAD stenosis.

Cutting Balloon Angioplasty for the Treatment of In-Stent Restenosis in Diabetics: A Matched Comparison of 6 Months' Outcome With Conventional Balloon Angioplasty

Ranging from 24% to 55%, angiographic in-stent restenosis (ISR) rates in diabetics are higher than the 17% to 28% rates observed in nondiabetics. There are controversies regarding optimal treatment for ISR. Recently, cutting balloon angioplasty (CBA) emerged as a tool in management. The authors assessed the hypothesis that CBA has advantages over conventional percutaneous transluminal balloon angioplasty (PTCA) in treatment of ISR in diabetics. CBA or PTCA was applied to 165 diabetics (267 ISR lesions) in their institution. With a computer algorithm, an attempt was made to match each lesion in the CBA group with a corresponding lesion in the PTCA group. The lesion pairs should match with respect to the patients' age and gender, type of target vessel and stent, reference vessel diameter, and baseline minimal lumen diameter (MLD). Following the matching process, 55 ISR lesion pairs were identified. Baseline patient characteristics were similar among the groups (p = NS). There was no difference in the in-hospital major adverse cardiac events (MACE) between the groups, whereas MACE at follow up was significantly lower in the CBA group compared to the PTCA group (CBA, 20.0% vs PTCA, 43.6%, p<0.05). The recurrent ISR rate was significantly lower in the CBA group compared to the PTCA group (CBA, 27.3% vs PTCA, 49.1%; p < 0.05). Also, a diffuse pattern of recurrence was more common in lesions treated with PTCA, whereas a focal pattern of recurrence was more common in the CBA group. The minimal luminal diameter at follow-up, the acute gain, and net gain were significantly higher in the group of lesions treated with CBA than in the PTCA group. In addition, a significantly higher late loss and loss index at follow-up were observed in the PTCA group compared to the CBA group. CBA has advantages over PTCA in treatment of diabetic patients with ISR, with better immediate and follow-up angiographic outcomes, and better follow-up clinical outcome.

DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction: DECOPI or NOT DECOPI: more smoke on the horizon

The article of Steg et al. 1 has intended ‘to determine whether late recanalization of an occluded infarct artery after acute MI is beneficial’. Of the ‘212 patients, the majority had single vessel disease, less than 1/3 had LAD stenosis, and pharmacological therapy was high in both groups’. The ‘PTCA success was defined as TIMI flow grade 3’ and ‘the follow-up at 6 months included an angiography’ but the ‘subsequent follow-up comprised clinical evaluation’. The conclusion was that ‘At a mean of 34 months of follow-up the occurrence of the primary end point and secondary end point were similar in the medical and the PTCA groups’. We would like to point out several clinical and methodological limitations and the absence of data for accurate evaluation. These limitations have been acknowledged partially by the authors. 1. The type II beta error and inadequate power to demonstrate a clinical benefit because of the small sample size of the groups.2 2. The selection bias due to the low risk of the population …

Revascularização miocárdica em multiarteriais

led us to believe that such objectives were better achieved with surgery, especially when indicated to patients with a lesion in the left main coronary artery, three-vessel disease or ventricular dysfunction. Great advances in clinical (statins, potent antiplatelet agents) and surgical (greater use of arterial grafts, better myocardial protection, procedures without extracorporeal circulation) therapy have occurred, resulting in an undeniable improvement in the prognosis of those patients. In recent years, percutaneous transluminal coronary angioplasty has become the most common form of myocardial revascularization used for the treatment of coronary artery disease. The improvement in the techniques and instruments allowed such less invasive form of revascularization to be offered to patients with multivessel disease with safety and efficacy similar to those of surgical revascularization reported in several studies. Silva et al 4 have reported the results of a randomized study carried out in a single center in our country, assessing the long-term advantages of both strategies of revascularization regarding the clinical evolution of patients with multivessel coronary disease. The first case series, published in the 1990s, compared coronary artery bypass surgery with balloon-catheter coronary angioplasty 5-12 . Those studies showed in a uniform way that the mortality and infarction rates did not statistically differ between the 2 forms of treatment (fig.1); patients undergoing the percutaneous coronary intervention, however, more often required a new revascularization in the long run, due to the occurrence of restenosis. Although those studies had limitations regarding the selection of patients (inclusion of patients with one-vessel disease, clinical and angiographic differences between the populations), they confirmed the safety of coronary angioplasty and its indication to patients with one- or two-vessel disease and less complex lesions. Initially used for managing complications of angioplasty (acute occlusions, vessel dissections), the implantation of coronary stents has become frequent and has been recommended due to their mechanical properties of preventing elastic recoil and negative remodeling of the vascular wall, which are determinant factors in the process of coronary restenosis after balloon angioplasty. By reducing the occurrence of restenosis and acute complications, stent implantation produced results even closer to those obtained with surgery. A meta-analysis 13 comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty involving 2,643 patients and comprising the ARTS 14 , ERACI II 15 , and SOS 16 studies showed no difference in the mortality and non-fatal infarction rates between the 2 groups at the end of one year. The need for a new revascularization in the group undergoing percutaneous transluminal coronary angioplasty with stents was 15%, half of the incidence reported for balloon angioplasty in patients with multivessel disease. The indices of new revascularization, however, continued significantly greater than those of coronary artery bypass graft, mainly due to intra-stent restenosis. The article by Silva et al 4 corroborated those results: the combined-event-free survival in 5 years reported in the study in question (82% for the surgical group, and 55% for the PTCA group, P < 0.001) was similar to that reported in the ARTS I study for the same follow-up period (tab. I) 17 . We face a new era in the percutaneous treatment of coronary artery disease. The use of stents coated with antiproliferative drugs, carried and released in a controlled way in the vascular wall from biocompatible polymers proved effective in reducing neointimal hyperplasia, which is the major determinant of the occurrence of intra-stent restenosis. Since the first clinical use of sirolimus-eluting stents here in Brazil 18

Effect of Reperfusion on P‐Wave Duration and P‐Wave Dispersion in Acute Myocardial Infarction: Primary Angioplasty versus Thrombolytic Therapy

Atrial fibrillation (AF) is a common arrhythmia occurring in about 10-20% of patients with acute myocardial infarction (AMI). P-wave dispersion (PWd) and P-wave duration (PWD) have been used to evaluate the discontinuous propagation of sinus impulse and the prolongation of atrial conduction time, respectively. This study was conducted to compare the effects of reperfusion either by thrombolytic therapy or primary angioplasty on P-wave duration and dispersion in patients with acute anterior wall myocardial infarction. We have evaluated 72 consecutive patients retrospectively (24 women, 48 men; aged 58 +/- 12 years) experiencing acute anterior wall myocardial infarction (AMI) for the first time. Patients were grouped according to the reperfusion therapy received (primary angioplasty (PTCA) versus thrombolytic therapy). Left atrial diameter and left ventricular ejection fraction (LVEF) were determined by echocardiography in all patients. Electrocardiography was recorded from all patients on admission and every day during hospitalization. Maximum (P max) and minimum (P min) P-wave durations and P-wave dispersions were calculated before and after the treatment. There were not any significant differences between the groups regarding age, gender, left ventricular ejection fraction, left atrial diameter and volume, cardiovascular risk factors, and duration from symptom onset to treatment. P-wave dispersions and P-wave durations were significantly decreased after PTCA [Mean P max was 113 +/- 11 ms before and 95 +/- 17 ms after the treatment (P = 0.007)]. Mean PWd was 46 +/- 12 ms before and 29 +/- 10 ms after the treatment (P = 0.001). Also, P max and PWd were significantly lower in PTCA group (for P max 97 +/- 22 ms vs 114 +/- 16 ms and for PWd 31 +/- 13 ms vs 55 +/- 5 ms, respectively). Primary angioplasty reduces the incidence of AF by decreasing P max and P-wave dispersion.

Sirolimus- and paclitaxel-eluting stents in comparison with balloon angioplasty for treatment of in-stent restenosis

This study evaluated the acute and follow-up effectiveness of sirolimus-eluting stents (SESs) and nonpolymer-based paclitaxel-eluting stents (PESs) in comparison will balloon angioplasty for treatment of complex in-stent restenosis (ISR) lesions. Drug-eluting stents have been demonstrated to be highly effective for treatment of de novo lesions. The use of drug-eluting stents for treatment of complex ISR is less well defined. Eighty one lesions with in-stent restenosis (lesion length < 30 mm in a native coronary artery) were treated with either PTCA alone (n = 26 lesions in 25 patients), PES (n = 27 lesions in 24 patients; Achieve, Cook; 3,1 mug paclitaxel/mm(2) nonpolymer-based coating), SES (n = 28 lesions in 28 patients; Cypher, Cordis; 140 mug sirolimus/cm(2) metal surface area). Nine-month MACE rates were 32%, 8%, and 14% (all due to repeated revascularization procedures, except one death in the SES group) in the PTCA, PES, and SES group, respectively. Postintervention minimal lumen diameter in stent was significantly greater in the SES and the PES group in comparison with the PTCA group (2.37 +/- 0.26, 2.54 +/- 0.42, 1.78 +/- 0.23 mm; P < 0.001). At 6-month angiographic follow-up, late loss in stent was 0.77 +/- 0.45, 0.43 +/- 0.53, and 0.29 +/- 0.52 mm for the PTCA, PES, and SES group, respectively (P = 0.005). In-lesion restenosis rate was 61% for the PTCA group, 20% for the PES group, and 13% for the SES group (P = 0.042). The implantation of SES as well as nonpolymer PES proved to be effective for treatment of ISR. The combination of improved acute gain and reduced late loss results in a significantly improved angiographic follow-up result in comparison with PTCA.

DECOPI (DEsobstruction COronaire en Post-Infarctus): a randomized multi-centre trial of occluded artery angioplasty after acute myocardial infarction

To determine whether late recanalization of an occluded infarct artery after acute myocardial infarction is beneficial. Two hundred and twelve patients with a first Q-wave myocardial infarction (MI) and an occluded infarct vessel were enrolled. After coronary and left ventricular contrast angiography, patients were randomized to percutaneous revascularization (PTCA, n=109), carried out 2-15 days after symptom onset or medical therapy (n=103). The primary endpoint was a composite of cardiac death, non-fatal MI, or ventricular tachyarrhythmia. The majority had single-vessel disease and less than one-third had involvement of the left anterior descending artery. The use of pharmacological therapy was high in both groups. At six months, left ventricular ejection fraction was 5% higher in the invasive compared with the medical group (P=0.013) and more patients had a patent artery (82.8% vs 34.2%, P<0.0001). Restenosis was seen in 49.4% of patients in the PTCA group. At a mean of 34 months of follow-up, the occurrence of the primary endpoint was similar in the medical and PTCA groups (8.7% vs 7.3% respectively, P=0.68), but the overall costs were higher for PTCA. The secondary endpoint combining the primary endpoint with admission for heart failure was also similar between groups (12.6% vs 10.1% in the medical and PTCA groups, respectively, P=0.56). Systematic late PTCA of the infarct vessel was associated with a higher left ventricular ejection fraction at six months, no difference in clinical outcomes, and higher costs than medical therapy. These results must be interpreted with caution given the small size and low risk of the population.

Clinical and Angiographic Results of Percutaneous Excimer Laser Versus Balloon Angioplasty for Coronary Intra-Stent Restenosis

Treatment of in-stent restenosis (ISR) with conventional PTCA causes significant recurrent neointimal tissue growth in 30-85% of the cases. Therefore, laser ablation of intra-stent neointimal hyperplasia prior to balloon dilatation can be an attractive alternative. However, the long-term outcomes of such treatment have not been studied thoroughly enough. This prospective case-control study evaluated angiographic and clinical outcomes of PTCA alone and a combination of excimer laser coronary angioplasty (ELCA) and adjunct PTCA in 125 patients with ISR. ELCA was performed prior to balloon dilatation in 67 patients, PTCA alone was performed in 58 patients. Basic demographic and clinical data were comparable in both groups. Lesions included in ELCA group were longer (17.1±9.9 mm versus 13.6±9.1 mm; p=0.034), more complex (36.5% type-C stenoses versus 14.3%; p=0.006) and more frequently had reduced distal blood flow (TIMI < 3: 18.9% versus 4.8%; p=0.025) compared to lesions in PTCA group. Immediate angiographic results of PTCA and ELCA+PTCA appeared to be comparable. PTCA alone was successful in 57 patients (98.3%), ELCA+PTCA - in 66 patients (98.5%). The rates of hospital complications were comparable (3.0% in ELCA group versus 8.6% in PTCA group). The 1 year-follow-up showed that the rates of MACE were comparable in the two groups (37.3% in ELCA group versus 46.6% in PTCA group). The rates of TVR within 1 year after the intervention were also similar in ELCA and PTCA groups (32.8% versus 34.5%). The data mean that ELCA in patients with complex ISR is efficient and safe. Despite a higher complexity of lesions in ELCA group, no increase in the rate of complications was registered.

Immediate and 3‐Month Follow‐Up Outcome After Cutting Balloon Angioplasty for Bifurcation Lesions

Balloon angioplasty of a bifurcation lesion is associated with lower rates of success and higher rates of complications than such treatment of lesions of most other morphologies. To date, the best device or procedure for bifurcation lesions has not been determined. The aim of this study was to compare the immediate and 3-month follow-up outcome of cutting balloon angioplasty (CBA) versus conventional balloon angioplasty (PTCA) for the treatment of bifurcation lesions. We treated 87 consecutive bifurcation lesions with CBA (n = 50) or PTCA (n = 37). Paired angiograms were analyzed by quantitative angiography, and angiographic follow-up was achieved for 93% of the lesions. The procedural success was 92% in the CBA group and 76% in the PTCA group (P < 0.05). Major in-hospital complications occurred in two lesions in the CBA group and six in the PTCA group (P = 0.05). The incidence of bail-out stenting in the CBA group was lower than in the conventional PTCA (8% vs 24%, P < 0.05). At the 3-month follow-up, the restenosis rate was 40% in the CBA group versus 67% in the PTCA group (P < 0.05). Clinical events during follow-up did not differ between the two groups. In conclusion, in comparison with PTCA, procedural success was greater and the restenosis rate lower with CBA. The results of this study support the use of the cutting balloon as optimal treatment for bifurcation lesions.

Randomized trial of Rotational Atherectomy Versus Balloon Angioplasty for Diffuse In-stent Restenosis (ROSTER)

BackgroundVarious autopsy and intravascular ultrasound (IVUS) studies have shown neointimal proliferation as the main mechanism of in-stent restenosis (ISR) responsible for >95% of luminal narrowing while stent struts are not compressed. ISR of diffuse type has a high incidence of recurrence (up to 70%) after balloon angioplasty (PTCA). Tissue ablation with percutaneous rotational coronary atherectomy (PRCA) may be more efficacious compared to tissue compression or extrusion after PTCA for the interventional treatment of diffuse ISR. MethodsThe Rotational Atherectomy Versus Balloon Angioplasty for Diffuse In-Stent Restenosis (ROSTER) trial is a single-center, randomized trial comparing PRCA to PTCA (both with IVUS guidance) in the treatment of diffuse ISR in 200 patients. In the PRCA group (n = 100), rotablation was performed using a burr-to-artery ratio >0.7 followed by adjunctive balloon dilatation at low pressure (4–6 atm). In the PTCA group (n = 100), high-pressure (>12 atm) balloon dilatation was performed using an optimal size balloon. The study's primary end point was target lesion revascularization (TLR) at 9 months and secondary end points included clinical events at 1 year and angiographic restenosis in a substudy of the last 75 patients enrolled. ResultsBaseline clinical and angiographic variables were comparable between the 2 groups with similar procedural and angiographic success, but a higher rate of repeat stenting occurred in the PTCA group (31% vs 10%; P <.001). Although the angiographic acute luminal gain was similar between the 2 groups, IVUS analysis revealed lower residual intimal hyperplasia area after PRCA versus PTCA (2.1 ± 0.9 mm2 vs. 3.3 ± 1.8 mm2; P = .005). At a mean follow-up of 12 ± 2 months, there were 2 deaths, 3 myocardial infarctions, and 3 coronary artery bypass graft procedures in each group. TLR incidence was 32% in the PRCA group and 45% in the PTCA group (P = .042), with a similar trend noted in the angiographic substudy. ConclusionThe ROSTER trial for diffuse ISR revealed both PRCA and PTCA to be safe and effective, but PRCA resulted in less residual intimal hyperplasia, lower repeat stent use, and decreased TLR.

Pre-Hospital Fibrinolysis Followed by Angioplasty or Primary Angioplasty in Acute Myocardial Infarction: The Long-Term Clinical Outcome

Randomized trials comparing primary angioplasty and in-hospital fibrinolysis in acute myocardial infarction (AMI) have shown an advantage for primary angioplasty. The long-term follow-up of pre-hospital fibrinolysis followed by elective or rescue coronary angioplasty versus primary angioplasty is not well established after acute myocardial infarction. This study sought to assess the long-term clinical outcome of patients with AMI having either received pre-hospital fibrinolysis optimized by coronary angioplasty or primary angioplasty. We conducted a retrospective analysis involving 318 patients who either underwent primary angioplasty ( n = 157) or received pre-hospital fibrinolysis followed by an angioplasty (rescue or elective) ( n = 161) within 6 hours of the onset of chest pain. The groups were similar regarding their baseline characteristics except for the ages. No difference was noted for in-hospital mortality (primary PTCA group: 2.48%, combined group: 2.54%; p = ns) with no increased risk of hemorrhage. The 3-year mortality was not significantly different in the two groups (9.7% vs. 4.9%; p = 0.15). Regarding major adverse cardiac events (29.5% vs. 37.5%; p = 0.23), reintervention (22.5% vs. 23.2%; p = 0.99) or target lesion revascularization (16.1% vs. 14.7%; p = 0.68), the groups were statistically similar. These data from real-life practice emphasize the safety and similar benefits on the long-term clinical outcome of AMI patients having undergone either pre-hospital fibrinolysis followed by angioplasty or primary angioplasty.

Increase in soluble E-selectin level after PTCA and stent implantation: a potential marker of restenosis

Background: E-Selectin is expressed only on activated endothelial cells, and may be used as a marker of endothelial activation. The relationship between soluble form of E-selectin (sE-selectin) and development of restenosis after balloon angioplasty (PTCA) is controversial, and there are no data for after stent implantation. We evaluated the role of serially measured sE-selectin levels in predicting the development of restenosis after PTCA and stent implantation. Methods: In sixty-one patients with stable angina pectoris who underwent PTCA ( n=20) or stent implantation ( n=41), peripheral blood samples were taken just before (baseline), at 3 and at 24 h after the intervention. sE-Selectin levels were measured by ELISA. Coronary angiography was repeated at 4–6 months after the intervention, and ≥50% stenosis at the site of the intervention was regarded as restenosis. Levels and time course of sE-selectin after the intervention were compared in patients with and those without restenosis. Results: sE-Selectin levels of the patients with and those without restenosis were similar at each of the three measurements, and significantly increased after the intervention both in the PTCA and stent groups ( P<0.001 for both groups). Posthoc analysis showed that sE-selectin levels increased significantly at 3 h after PTCA ( P=0.024) and stent implantation ( P=0.018), and did not change thereafter in patients with restenosis. In the nonrestenotic group, sE-selectin did not change significantly in the 24 h following PTCA, however, a significant difference was observed only by comparing the values at baseline with those at 24 h after stent implantation ( P=0.021). Conclusions: A substantial increase in sE-selectin levels early (at 3 h) after PTCA and stent implantation may predict development of restenosis.

Outcomes of primary coronary angioplasty and angioplasty after initial thrombolysis in the treatment of 374 consecutive patients with acute myocardial infarction

BackgroundIn patients with acute myocardial infarction (MI), the efficacy of thrombolysis is low. Angioplasty after failed thrombolysis (rescue percutaneous coronary angioplasty [PTCA]) has been associated with an increase in the incidence of inhospital complications. It has been proposed that these complications result from the procedure itself. Thus, the aim of this study was to compare the efficacy, inhospital complications, and mortality rate of patients with MI who are treated with primary PTCA and PTCA after initial thrombolysis (rescue or immediate rescue) in an experienced clinical center specializing in percutaneous coronary interventions. Methods and resultsThe study group consisted of consecutive patients with MI treated with primary PTCA (n = 195) or PTCA after initial thrombolysis (n = 179). The study was performed in a referral center with a 24-hour catheter-laboratory service. The success rate of the procedure was 90.5% and 88.2% in the PTCA after initial thrombolysis group and primary PTCA group, respectively. The groups did not differ in the frequency of reocclusion, emergency surgical revascularization (coronary artery bypass grafting), or stroke. In patients without cardiogenic shock, the inhospital mortality rates were 3.2% and 0.6% in the rescue and immediate rescue group and primary PTCA group, respectively (not significant). In a subgroup of patients with cardiogenic shock, the mortality rate was 36.0% in the initial thrombolysis PTCA group and 30.8% in the primary PTCA group. However, after successful PTCA in this subgroup, the mortality rate dropped to 18% and 10%, respectively. ConclusionsAfter initial thrombolysis, PTCA is safe, effective, and likely to restore grade 3 Thrombolysis In Myocardial Infarction flow in about 90% of patients. When available, immediate rescue PTCA should be performed in all patients, including patients with cardiogenic shock.

Coronariografía y angioplastia coronaria por vía radial: experiencia inicial y curva de aprendizaje

The transradial approach has emerged as an attractive alternative to the femoral approach for coronary angiography and interventions. We describe our experience with the transradial approach and analyze the influence of the learning curve. The transradial approach was attempted in patients with a good radial pulse and normal Allen test. When feasible and clinically indicated, we attempted ad hoc intervention. We divided the study population into two groups: Group A (the first 200 cases) and B (all other patients). We compared the radial group with a matched femoral control group. We attempted the transradial approach in 526 patients (77.6% male; age 63.5 +/- 11.51), and obtained a success rate of 93.7%. We found differences between group A and B in the success rate (91.0 vs 95.4%, p = 0,04), duration of procedure [23 (16-29) vs. 19 (15-24) minutes; p < 0.001], and fluoroscopy time [6.4 (4.2-10) vs. 5.0 (3.0-7.7) minutes; p < 0,001]. At 24 h of follow-up, we found small hematomas in 9.4%, bleeding in 4.9%, and radial artery obstruction in 2.8%, with no cases of arteriovenous fistula, pseudoaneurysm, or need for vascular surgery. We attempted intervention in 169 patients with 258 lesions, achieving angiographic success in 96.1%. We found no differences in the characteristics of the lesions and patients, or in the angiographic success rate of the radial and femoral PTCA groups. The transradial approach is a safe and effective alternative to femoral catheterization. There is a significant learning curve associated with the successful performance of transradial procedures.

Angiographic analysis of the angioplasty versus rotational atherectomy for the treatment of diffuse in-stent restenosis trial (ARTIST)

Patients with diffuse in-stent restenoses (ISRs) are at high risk for recurrent restenosis after percutaneous transluminal balloon angioplasty (PTCA). Percutaneous transluminal rotational ablation (PTCR) has proved effective in removing neointimal burden in ISRs. This study compares the acute and long-term results of PTCA and PTCR for the treatment of diffuse ISR in a randomized, multicenter investigation. The primary end point was the comparison of the minimum luminal diameter (MLD) between both groups at 6-month follow-up. Patients with symptomatic, diffuse, or high-grade ISRs were included; 146 patients were randomized to PTCA and 152 patients to PTCR. Diameter stenosis was reduced from 80 ± 12% to 29 ± 10% and from 80 ± 11% to 28 ± 12%, respectively, and MLD increased from 0.55 ± 0.3 to 1.9 ± 0.3 mm in the PTCA group and from 0.54 ± 0.3 mm to 1.9 ± 0.4 mm in the PTCR group. Spasm in the treated vessel and an intermittent slow flow phenomenon occurred more often after rotational ablation (17.7% vs 8.6%, p = 0.001; 5.3% vs 0%, p = 0.007). Minimum stenosis diameter at 6-month follow-up was smaller in the PTCR group than in the PTCA group (1.0 ± 0.6 vs 1.2 ± 0.6 mm, p = 0.008) and the restenosis rate was higher (64.9% vs 51.2%, p = 0.027). Procedural factors did not influence long-term outcome. In the PTCR group, the restenosis rate increased with decreasing vessel size, whereas this was not seen in the PTCA group. The lesion length and the baseline diameter stenosis were found to be predictive of restenosis with both treatment strategies; however, a residual diameter stenosis of <30% predicted absence of a restenosis only in the PTCR group. Thus, PTCA and PTCR of diffuse ISRs yield comparable acute angiographic results. The recurrence of a restenosis is higher after PTCR than after PTCA.

Basic fibroblast growth factor changes in response to coronary angioplasty in patients with stable angina

Basic fibroblast growth factor (bFGF) has been implicated in the pathogenesis of coronary atherosclerosis and in angiogenesis. We assessed the changes in serum bFGF before, immediately after, and 6 months after coronary angioplasty (PTCA). Using the ELISA methods we measured plasma bFGF in 28 patients who underwent PTCA, in 20 patients with coronary artery disease who underwent elective coronary angiography and in 28 healthy subjects. Before PTCA and coronary angiography, bFGF plasma levels were similar in both patient groups (4.4±1.0 vs. 3.3±0.5 pg/ml), but were significantly higher compared with those of the control group (0.8±0.1 pg/ml, P<0.05). By 24 h, 3 months and 6 months after PTCA, bFGF levels had decreased significantly in the PTCA group (3.2±0.6, 1.7±0.3 and 2.7±0.6 pg/ml, respectively, P<0.05). In conclusion, these findings show that bFGF levels are elevated in patients with coronary artery disease. Following PTCA, bFGF levels decreased significantly and remained stable for 6 months after the procedure. Thus, bFGF level may change in response to PTCA in patients with coronary artery disease and stable angina.