Single-vessel Intervention Research Articles

The Effect of Enhanced External Counter Pulsation on Improving Quality of Life in Patient with 3 Vessels Disease Treated Medically Versus Percutaneous Coronary Intervention, 1 Year Follow Up

Background : Refractory angina usually refers to as (equal or more than 3 months in duration) stableischemic heart disease which cannot be regulated by a therapeutic treatment, surgical cardiac intervention,and where reversible cardiac ischemia has been stated to be the reason for the manifestation clinically.Aim:The efficacy of use enhanced external counter pulsation in treating refractory angina pectoris in those do PCIvs. medical alone and short-term outcome. PMethodology: 91 patients with refractory angina pectoris unrespond to treatment and/or intervention or unfit for intervention or surgery have been enrolled in this study,for all ECG, echocardiography study done to assess LV and valvular function, Doppler study for lower limbartery to assess if there is peripheral vascular disease, abdominal ultrasound done to exclude the presenceof aortic abdominal aneurysm, then if patient eligible for EECP inclusion criteria refer for EECP unit .Afterend of all session all patients assess improvement according to change in Canadian cardiovascular societygrading CCS pre and post EECP and on follow up 6 month and 1 year. Result: Over 12 month’s period of thestudy, 91 persons were assessed including 32(35%) women and 59 (65%) men. The age range was 45 yearsto 80 years with the mean age range 61 years (SD ± 8.2). Most patients treated with 30 session with 1 hourper session on average of 26 (SD ± 7) session with response rate at end of sessions 88.7% where responsemean improvement of symptom and according to (CCS) change per and post EECP.Conclusion: No befit from doing single vessel intervention in patient with 3 vessels disease in improvingresponse to EECP or improving echocardiographic parameter. EECP appear as safe effective therapy inselective patient with refractory angina not respond to medical and unfit for intervention or surgery. Responseto EECP in well selected patient persist for 1 year.

Clinical results of single-vessel versus multiple-vessel infrapopliteal intervention

ObjectiveThe effects of concomitant endovascular interventions on multiple infrapopliteal vessels are not well known, and the short-term and long-term sequelae of such procedures have not been reported. MethodsFrom 2004 to 2014, 673 limbs in 528 patients underwent an infrapopliteal endovascular intervention for tissue loss (77%), rest pain (13%), stenosis of a previously treated vessel (5%), acute limb ischemia (3%), or claudication (2%). Outcomes included wound healing, RAS events (reintervention, major amputation, or stenosis [>3.5x step-up by duplex]), and mortality. Patients without an initial indication of critical limb ischemia (CLI) were excluded. Patients were characterized as having undergone either a single-vessel infrapopliteal intervention or a multiple-vessel infrapopliteal intervention. ResultsOf the 673 limbs, 558 underwent a successful infrapopliteal endovascular intervention for CLI (86% for tissue loss, 14% for rest pain). During a single procedure, 503 limbs (90%) underwent a single-vessel intervention and 55 (10%) underwent a multiple-vessel intervention. Patients undergoing a single-vessel intervention more commonly underwent a prior ipsilateral endovascular procedure (17% vs 6%; P = .03) or a prior ipsilateral bypass procedure (20% vs 9%; P = .04). Kaplan-Meier analysis revealed that a RAS event ≤1 year occurred in 229 limbs (49%), with no significant difference in the 1-year rates of reintervention (22% vs 20%; P = .53), major amputation (16% vs 10%; P = .24), or stenosis (29% vs 21%; P = .25). After adjustment for baseline characteristics, multivariable regression illustrated that neither major amputation rates nor RAS events differed between patients undergoing a single-vessel vs a multiple-vessel intervention (P = .26 and P = .61, respectively). ConclusionsOur data suggest that a multiple-vessel intervention does not improve outcomes when compared to a single-vessel intervention following infrapopliteal angioplasty for CLI.

Endovascular Treatment of Chronic Mesenteric Ischemia in the Setting of Occlusive Superior Mesenteric Artery Lesions

Endovascular intervention is considered the first-line treatment for chronic mesenteric ischemia (CMI) when feasible. Two-vessel revascularization is most definitive when celiac (CA) and superior mesenteric arteries (SMA) are diseased, but single-vessel intervention may be performed in patients with 2-vessel disease due to anatomic/technical factors. We evaluated anatomic predictors of clinical outcomes associated with endovascular treatment of CMI among patients with occlusive SMA lesions. Patients with CMI treated with endovascular revascularization over 10years were identified. Patients with SMA occlusions were selected for analysis. Between-group comparisons based on inclusion of an SMA revascularization were evaluated using t-test and chi-squared test. Freedom from symptomatic recurrence or repeat intervention was analyzed using proportional hazards regression. Fifty-four patients with CMI were analyzed. Sixteen (29.6%) patients had CA-only intervention, and 38 (70.4%) patients had SMA revascularization with or without CA intervention. No significant differences in demographics or comorbidity were identified between groups. In the CA-only intervention group, 8 of the 16 (50%) patients developed symptomatic recurrence compared with 8 of the 31 (21.1%) patients whose intervention included the SMA. Patients treated without SMA intervention also had decreased freedom from both symptomatic recurrence (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.2-8.6, P=0.016) and repeat intervention (HR 5.5, 95% CI 1.8-16.3, P=0.001). Among patients with CMI and occlusive SMA lesions, SMA revascularization appears to be the key determinant for symptomatic outcomes and repeat intervention. Patient counseling should include potential future need for surgical revascularization if endovascular SMA treatment cannot be accomplished.

Minimally Invasive Valve Surgery and Single Vessel Coronary Artery Bypass via Limited Anterior Right Thoracotomy.

Coronary artery bypass grafting with aortic valve replacement (AVR) or mitral valve replacement (MVR) is traditionally performed via sternotomy. Minimally invasive coronary surgery (MICS) and minimally invasive valve surgery have been successfully performed independently. Patients with critical right coronary artery (RCA) stenosis not amenable to percutaneous intervention are candidates for valve replacement and single vessel coronary artery bypass. We present our series of six patients who underwent a concomitant valve and single vessel intervention via right thoracotomy. Between January 2011 and June 2013, six patients underwent right thoracotomy with valve replacement and single vessel bypass. Four aortic and two mitral valves were replaced and all received single vessel RCA bypass using reversed saphenous vein graft. Thoracotomy was via right anterior approach for AVR and right lateral for MVR. The patients were assessed postoperatively for overall outcomes. The average age was 74 years (range 69-81); two patients were elective (AVR-1; MVR-1) and four were urgent (AVR-3; MVR-1). For MICS AVR and MICS MVR, the average cardiopulmonary bypass time was 171 ± 30 and 169 ± 7 minutes and the average aortic cross-clamp time was 122 ± 36 and 112 ± 2 minutes, respectively. Three patients were discharged home, one patient to a nursing home, and two to rehab. No patients required conversion to sternotomy; one patient developed atrial fibrillation, and one sepsis. Concomitant valve replacement and single bypass grafting via right anterior mini-thoracotomy is a viable option for select patients, particularly in non-stentable RCA stenosis. In the appropriate patient population, combined coronary artery bypass grafting and valve surgery can be safely performed via right thoracotomy.

Clinical Results of Single Versus Multiple-Vessel Infrapopliteal Intervention

The effects of concomitant endovascular interventions on multiple infrapopliteal vessels are not well known, and the long-term sequelae of such procedures have not been reported. From 2004 to 2014, 673 patients underwent an infrapopliteal endovascular intervention for tissue loss (77%), rest pain (13%), stenosis of a previously treated vessel (5%), acute limb ischemia (3%), or claudication (2%). Data collected included renal artery stenosis (RAS) events (revascularization, major amputation, or stenosis [>3.5× step-up by duplex]) and wound healing. Patients without an initial indication of critical limb ischemia (CLI) were excluded. Patients were characterized by single-vessel infrapopliteal interventions and multiple-vessel infrapopliteal interventions. Worsened Rutherford class between index procedure and failure was also noted. Of the 673 patients, 596 underwent an infrapopliteal endovascular intervention for CLI: 85% for tissue loss and 15% for rest pain. During a single procedure, 533 (89%) patients underwent a single-vessel intervention, and 63 (11%) underwent a multiple-vessel intervention. Patients undergoing a single-vessel intervention had more commonly experienced a prior ipsilateral endovascular procedure (17% vs 10%; P = .04), whereas patients undergoing a multiple-vessel intervention more often suffered from diabetes (78% vs 89%; P = .03) and were more often discharged to a rehabilitation facility (33% vs 41%; P = .04). Survival analysis revealed no difference in the proportion of patients experiencing a restenosis (P = .11). A Cox regression model illustrated that long-term outcomes do not differ between patients undergoing a multiple-vessel intervention vs those undergoing a single-vessel intervention. Among the 596 patients, a RAS event occurred in 284 limbs (48%), and there was no significant difference in the rate of RAS events between single-vessel and multiple-vessel infrapopliteal interventions (48% vs 49%; P = .84; Fig). The amputation rate also did not significantly differ between the two groups (14% vs 16%; P = .71). In both groups, 8% of RAS patients presented with a worse ischemia class compared with their initial symptoms. Our data suggest that multiple-vessel intervention does not improve outcomes compared with single-vessel intervention after any infrapopliteal procedure for CLI.

26 The effects of pre-existing significant coronary artery disease upon outcome after transcatheter aortic valve implantation using the Edwards bioprosthesis

<h3>Introduction</h3> Patients undergoing surgical aortic valve replacement (sAVR) routinely undergo simultaneous coronary artery bypass grafting (CABG) for significant coronary artery disease (CAD) due to adverse prognostic impact. While manufacturers advise percutaneous intervention (PCI) of significant CAD prior to transcatheter aortic valve implantation (TAVI) there is considerable variation among operators. <h3>Methods</h3> We performed a retrospective analysis of 168 patients who underwent TAVI using the Edwards bioprosthesis from March 2008 to October 2010 at St. Thomas Hospital, London. They were divided into two groups according to the results of the pre-TAVI coronary angiogram: (Group 1) patients with ≥1 coronary stenosis of ≥70% severity and those without (Group 2). The end-point was all-cause mortality. <h3>Results</h3> In total, 70 patients (41.7%) had significant CAD prior to TAVI, with 10 (6.0%) undergoing PCI prior to their procedure. There were no significant differences in either the baseline characteristics or access approach between the two groups (Abstract 26 tables 1 and 2). At a mean follow-up of 335±277 days (mean±SD), the overall mortality was 22.6%; Group 1 mortality was 30% and in group 2 was 17.3% (p=0.124) (see Abstract 26 figure 1) There was no difference seen in the length of stay in the intensive care unit (2.7±6.2 vs 4.1±14.9 days, p=0.462) nor in the number of days to discharge (12.6±10.1 vs 12.8±13, p=0.928). Among those patients who underwent PCI in Group 1, 8 had single vessel intervention and 2 had PCI to 2 vessels. The target vessels were left main stem (LMS) (n=2), proximal left anterior descending artery (LAD) (n=5), circumflex (n=1), right coronary artery (RCA) (n=2), saphenous vein graft (SVG) to LAD (n=1) and SVG to circumflex (n=1). Mortality in this sub-group was not significantly different from the CAD patients who did not receive PCI (50% vs 26.7%, p=0.272). <h3>Conclusion</h3> The presence of significant CAD had no significant impact upon the all-cause mortality of patients after TAVI in our study. As yet, the impact of PCI to significant CAD upon outcome after TAVI is not known and will be assessed in a prospective, randomised controlled trial currently underway.

Interventional Cardiology in Switzerland during the Year 2007

Summary Background: Since 1987, a nationwide annual survey of percutaneous cardiac interventions is performed in Switzerland in order to assess trends with respect to type and frequency of endovascular cardiac procedures. Methods: Volume and type of endovascular procedures performed during the year 2007 were collected, by means of a standardised questionnaire, from all adult invasive cardiac intervention centres in Switzerland. Results: A total of 37489 coronary angiographies (CA; 2006: 36817; +1.8%) and 17080 percutaneous coronary interventions (PCI; 2006: 17061; +0.1%) were performed in 28 centres (5 university, 10 public, nonuniversity, and 13 private hospitals). Most PCI (92%) were performed ad hoc, and 80% of them were single vessel interventions. Stents were used in 91% of all PCI (2006: 89%). Drug-eluting stents (DES) were predominantly used although at a lower rate than during the previous year (2007: 71% of all stents; 2006: 82%). Emergency PCI for ST-segment elevation myocardial infarction accounted for 22% of PCIs (2006: 20%). Whereas the numbers of valvuloplasties of the mitral (n = 40), aortic (n = 20), and pulmonary (n = 6) valves did not differ from previous years, transcatheter aortic valve implantation was introduced as a new therapeutic intervention (n = 18). The number of procedures for patent foramen ovale (PFO; n = 624; 2006: 515) and atrial septal defect closure (n = 116; 2006: 88) continued to increase. Conclusions:In 2007, the increase in the number of CA and PCI continued to flatten but did not decrease in Switzerland. The use of DES remained high, although there was a decrease compared to the previous year. In contrast, procedures for percutaneous PFO and atrial septal defect closure were performed with increasing frequency. During that year, transcatheter aortic valve implantation was introduced.

Abstract 5609: In-Stent Restenosis - Benign or Dangerous? Clinical Presentation of Coronary Restenosis in Sweden

Background Restenosis after percutaneous coronary intervention (PCI) was earlier thought to be a benign event clinically manifested as stable exertional angina. The aim of this prospective multicenter registry study was to investigate the incidence of acute coronary syndrome in patients with restenosis in Sweden. Methods Using data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR), we analyzed all registered cases of PCI for restenosis (in-stent, after balloon angioplasty) from 1995 to 2005 in Sweden. Both multivessel and single vessel interventions were included. Restenosis presentations were classified as: stable angina; unstable angina/non-STEMI; STEMI; and other reasons. As routine angiographic screening was not performed, restenosis episodes were defined clinically based on symptoms. Results We identified 6642 cases of restenosis in 2978 patients (4790 in men, 1852 in women). Restenosis presented in 39.7% of cases as stable angina, in 46.0% as unstable angina/non-STEMI, in 11.5% as STEMI and in 2.8% as other reasons. Cardiogenic shock was reported in 48 patients. Women had a higher incidence of unstable angina/non-STEMI compared with men (52.3% v. 43.6%) but a lower incidence of STEMI (9.6% v. 12.2%). The frequency of STEMI was lower with restenosis after balloon angioplasty v. in-stent restenosis (6.9% v. 13.8%), and after drug-eluting stents v. bare metal stents (7.9% v. 18.5%). Mortality rate was 1.7% at 30 days, 3.2% at 6 months and 4.6% at one year in patients with restenosis. These covariates were independent predictors of acute coronary syndrome: gender, age, vessel diameter, smoking, stent type, number of stents, treated vessel, previous stroke and previous infarction. Conclusion The majority of patients with coronary restenosis present either with acute MI or unstable angina requiring hospitalization and new interventions. Women may have a higher risk of developing acute coronary syndrome due to restenosis. Prevention of restenosis may be an important target for improvement of “hard” clinical outcomes in patients undergoing coronary revascularization.

Interventional cardiology in Switzerland 2006

Background: Since 1987, a nationwide survey of percutaneous cardiac interventions is performed annually in Switzerland, which allows recognition of contemporary trends and comparison with other countries. Methods: Volume and type of procedures performed during the year 2006 were collected by means of a standardised questionnaire from all adult percutaneous cardiac intervention centres in Switzerland. Results: During the year 2006, 36817 coronary angiographies (CA; 2005: 36436; +1.0%) and 17061 percutaneous coronary interventions (PCI; 2005: 16624; +2.6%) were performed in 27 centres (5 university hospitals, 9 public, nonuniversity hospitals, and 13 private hospitals) by 193 operators (64 of them performing only diagnostic studies). Ninety-three percent of PCI procedures were performed ad hoc, and 78% of them were single-vessel interventions. Stents were used in 89% of all PCI (2005: 91%) procedures with drug-eluting stents (DES) being responsible for the largest share (82% of all stents) (2005: 78%). Emergency procedures (primary PCI or rescue PCI after failed thrombolysis) accounted for 20% of interventions (2005: 19%). Glycoprotein IIb/IIIa inhibitors were used in 19% of PCI (2005: 23%) procedures. In addition, valvuloplasties of mitral, aortic, and pulmonary valves were performed in 42, 21, and 5 cases, respectively. Finally, percutaneous closure of a patent foramen ovale and an atrial deptal defect were performed in 515 (2005: 510) and in 88 (2005: 94) cases, respectively. Conclusions: The increase in the number of CA and PCI has flattened during 2006. The use of DES remained high, though the previously rapidly growing utilisation of these devices reached a plateau. The number of procedures for the percutaneous closure of patent foramen ovale and atrial septal defect has stabilised.

Interventional cardiology in Switzerland 2004

Summary Background: Since 1987, a nationwide annual survey of percutaneous cardiac interventions is performed in Switzerland, which allows recognition of contemporary trends and comparison with other countries. Methods: Based on a standardised questionnaire, all adult percutaneous cardiac intervention centres in Switzerland were asked to report on the volume and the circumstances of their activities in 2004. The response rate was 100%. Data were compared with those from previous years. Results: In 2004, 35 201 coronary angiographies (CA; 2003: 33 066; + 6.5%) and 15 680 percutaneous coronary interventions (PCI; 2003: 14 235; + 10.2%) were carried out in 5 university hospitals, 9 public, non-university hospitals, and 12 private hospitals by 194 operators (75 of them performing only diagnostic studies). 86% of PCI were performed ad hoc, and 80% were single-vessel interventions. Stents were placed in 91% of PCI (2003: 88%). In 60% of stenting procedures one stent was implanted, whereas in 40% two or more stents were placed. Drug-eluting stents (DES) were used in 66% of procedures (2003: 52%). PCI for ongoing myocardial infarction, ie primary PCI or rescue PCI after failed thrombolysis, accounted for 20% of interventions. Glycoprotein IIb/IIIa inhibitors were used in 23% of PCI, the variability among different centres being high. Myocardial infarction after PCI was reported in 1.4% of PCI, emergency coronary artery bypass grafting was needed in 0.1% of cases, and in-hospital mortality after PCI was 0.5%. In addition to PCI, 40 mitral, 21 aortic, and 7 pulmonary balloon valvuloplasties, and 438 interventions for closure of patent foramen ovale as well as 92 interventions for closure of atrial septal defect were performed. Conclusions: The number of CA and PCI, the frequency of stent placement during PCI, and the utilisation of DES are steadily increasing in Switzerland. There is also a significantly growing number of interventions for closure of patent foramen ovale and atrial septal defect, whereas the number of balloon valvuloplasties has been more or less stable over the last years.

Outcome of Multivessel Coronary Intervention in the Contemporary Percutaneous Revascularization Era

Clinical outcomes after multivessel versus single-vessel percutaneous coronary intervention (PCI) in the era of stents, glycoprotein IIb/IIIa inhibitors, and clopidogrel pretreatment have not been well studied. Thus, we compared outcomes from the Do Tirofiban and ReoPro Give Similar Efficacy Outcome Trial (TARGET) for patients who underwent multivessel versus single-vessel PCI and separately considered the effect of acute coronary syndromes on the results. Composite clinical outcomes (death, myocardial infarction, and target vessel revascularization) were evaluated at 30 days and 6 months and mortality at 1 year. Safety analysis included in-patient major and minor bleeding. Despite similar baseline characteristics, patients who underwent multivessel PCI (n = 775) had significantly higher 30-day and 6-month composite event rates than did those who were treated in a single coronary artery territory (n = 3,969). This association remained significant at 30 days (hazard ratio 1.57, 95% confidence interval 1.06 to 2.33, p = 0.025) after using propensity matching to minimize confounding factors. The higher event rate was primarily due to an increase in periprocedural myocardial infarction. However, there were no significant differences in propensity-matched ischemic outcomes at 6 months and 1 year or in bleeding. In addition, in a propensity-matched analysis that included 810 patients with acute coronary syndrome, multivessel stenting resulted in numerically more ischemic events than did single-vessel stenting, although this did not reach statistical significance (hazard ratio 1.32, 95% confidence interval 0.85 to 2.05, p = 0.221). In conclusion, multivessel PCI was more often associated with periprocedural myocardial infarction than single-vessel intervention, although this did not translate into higher 1-year mortality. A randomized trial comparing multivessel PCI with staged or surgical revascularization is warranted.

Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures

Background Current practice, trends, and early outcomes in patients undergoing surgical and percutaneous coronary interventions (PCI) are changing and subject to speculation. Methods 148,396 consecutive patients in 69 HCA, Inc hospitals who underwent either PCI or coronary artery bypass grafting (CABG) were tracked in the HCA Casemix Database from 1999 through the first quarter of 2002. Comorbid conditions, procedures, complications, and outcome variables were defined through International Classification of Diseases, Ninth Revision coding. Odds ratios (OR) for death and other procedure-related complications were estimated using logistic regression adjusting for age, sex, and 31 other patient clinical and procedural characteristics. Results Now 65.4% of all coronary revascularization is by PCI with a 6.8% annual rate of increase whereas CABG volume is declining by 1.9% per year. However the majority of these changes occurred between 1999 and 2000 with only small changes in the last 3 years. Coronary artery bypass grafting is still utilized primarily for multivessel disease (3.38 bypasses per patient) whereas PCI is predominately (83%) still limited to single-vessel intervention. Unadjusted mortality rates over the full 13-quarter period were 1.25% for PCI and 2.63% for CABG ( p < 0.001), with PCI rates remaining constant and CABG mortality declining. Twenty-three percent of CABG is performed off pump with a lower mortality than conventional on-pump CABG (2.37% versus 2.69%, p < 0.001). Percutaneous coronary intervention patients have lower mortality (OR 0.51), and fewer acute renal failure (OR 0.39), neurologic (OR 0.12), and cardiac (OR 0.16) complications than CABG patients ( p < 0.001). Conclusions Interventions for coronary artery disease continue to rise primarily due to an increase in PCI. The volume of PCI continues to increase relative to CABG. Although adverse outcomes are higher after CABG, the proportion of multivessel disease treated is greater. The difference in adverse outcomes between CABG and PCI remains small and continues to decline.

Procedural results and late clinical outcomes following multivessel coronary stenting

ObjectivesTo evaluate in-hospital and long-term clinical outcomes in a large consecutive series of patients undergoing percutaneous multivessel stent intervention.BackgroundHigh restenosis and recurrent angina rates have limited the clinical outcomes of multivessel coronary angioplasty before stents were available to improve angioplasty results.MethodsWe evaluated in-hospital and long-term clinical outcomes (death, Q-wave myocardial infarction [MI], and repeat revascularization rates at one year) in 398 consecutive patients treated with coronary stents in two (94% of patients) or three native arteries, compared to 1,941 patients undergoing stenting procedure in a single coronary artery between January 1, 1994 and August 29, 1997.ResultsOverall procedural success was obtained in 96% of patients with two- or three-vessel stenting and in 97% of patients with single-vessel stent intervention (p = 0.36). Procedural complications were also similar (3.8% for multivessel versus 2.9% for single vessel, p = 0.14). During follow up, target lesion revascularization was 15% in multivessel and 16% in single-vessel interventions (p = 0.38), and repeat revascularization (calculated per treated patient) was also similar for both groups (20% vs. 21%, p = 0.73). There was no difference in death (1.4% vs. 0.7%, p = 0.26), and Q-wave MI (1.2% vs. 0%, p = 0.02) was lower following multivessel interventions. Overall cardiac event-free survival was similar for both groups (p = 0.52).ConclusionsUnlike previous conventional angioplasty experiences, multivessel stenting has (1) similar in-hospital procedural success and major complication rates and (2) similar long-term (one year) clinical outcomes compared with single-vessel stenting. Thus, stents may be a viable therapeutic strategy in carefully selected patients with multivessel coronary disease.