Two-year Freedom Research Articles

Effect of Endoscopic Bronchial Ultrasound on Outcomes for Stage I Non–Small-Cell Lung Cancer Patients Receiving Hypofractionated Radiotherapy

BackgroundIn this study we sought to determine if staging endoscopic bronchial ultrasound (EBUS) improves outcomes in stage I non–small-cell lung cancer (NSCLC) patients who received hypofractionated radiation therapy (HFRT). Patients and MethodsPatients with stage I NSCLC treated with HFRT from 2008 to 2015 were retrospectively identified from 3 affiliated institutions. All patients underwent positron emission tomography/computed tomography staging and a subset of patients received pretreatment EBUS. Patients with and without pre-radiation therapy EBUS were compared for baseline characteristics. The log rank test was used to compare Kaplan–Meier estimates. Univariate analysis (UVA) and multivariable analysis (MVA) were used to analyze the effect of factors on disease-free survival (DFS) and overall survival (OS). ResultsNinety-two patients met study criteria. Median follow-up for the entire cohort was 21 months. Two-year DFS and OS were 63% and 81%, respectively. Two-year freedom from local, regional, and distant failure were 93%, 87%, and 87%, respectively. Thirty-seven of 92 patients (40%) received pretreatment EBUS. There were no statistically significant differences in 2-year freedom from regional failure rates, DFS, or OS for EBUS-staged versus non–EBUS-staged patients. On UVA, smaller tumor size (P = .03) and higher performance status (P = .05) were associated with improved OS. On MVA, tumor size retained significance for improved OS (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.19-0.97; P = .04) and higher performance status showed a trend toward improved OS (HR, 0.51; 95% CI, 0.23-1.11; P = .09). ConclusionIn this retrospective series, we did not detect a difference in regional failure or survival outcomes among stage I NSCLC patients who received invasive staging with EBUS before HFRT.

Fetuses with right aortic arch: a multicenter cohort study and meta-analysis.

Use of recent antenatal screening guidelines for cardiac abnormalities has increased fetal diagnoses of right aortic arch (RAA). We aimed to establish the outcome of fetal RAA without intracardiac abnormalities (ICA) to guide postnatal management. In the retrospective cohort part of our study, outcome measures were rates of chromosomal abnormalities, 22q11.2 deletion, fetal extracardiac abnormalities (ECA), postnatal ICA and ECA, and symptoms of and surgery for vascular ring. A systematic review and meta-analysis was also performed; results are reported as proportions. Kaplan-Meier analysis of vascular ring cases with surgery as endpoint was performed. Our cohort included 86 cases; 41 had a vascular ring. Rates of chromosomal abnormalities, 22q11.2 deletion and fetal ECA were 14.1%, 6.4% and 17.4%, respectively. Sixteen studies including our cohort (312 fetuses) were included in the systematic review. Overall rates of chromosomal abnormalities and 22q11.2 deletion were 9.0% (95% CI, 6.0-12.5%) and 6.1% (95% CI, 3.6-9.3%), whilst the respective rates for cases with no ECA were 4.6% (95% CI, 2.3-7.8%) and 5.1% (95% CI, 2.4-8.6%). ECA were seen in 14.6% (95% CI, 10.6-19.0%) prenatally and in 4.0% (95% CI, 1.5-7.6%) after birth. Postnatal ICA were identified in 5.0% (95% CI, 2.7-7.9%). Rate of symptoms of vascular rings (follow-up ≥ 24 months postpartum) was 25.2% (95% CI, 16.6-35.0%), and 17.1% (95% CI, 9.9-25.7%) had surgery. Two-year freedom from surgery was 83.0% (95% CI, 74.3-90.1%). Fetal RAA without ICA is more frequently associated with ECA than with chromosomal abnormalities. Most cases, however, are isolated. Vascular-ring symptoms occur in about 25% of cases. Postnatal surveillance is required mainly in the first 2 years after delivery.

Abstract 17001: Is There Cytomegalovirus Disease After Prophylaxis?

Purpose: Cytomegalovirus (CMV) disease (specific organ involvement) is a significant cause of morbidity and mortality in orthotopic heart transplantation (OHT). CMV disease is reported to increase the development of cardiac allograft vasculopathy (CAV). The duration of CMV prophylaxis in recipients is dependent on their CMV serostatus in relation to the donors. However, the effective duration of CMV prophylaxis post-transplant remains unclear. Methods: Between 2007 and 2012, 267 OHT patients were divided into four groups based on the CMV serostatus of the donors (D) and recipients (R): D+/R-, D+/R+, D-/R+, D-/R-. CMV prophylaxis was given for up to one year in D+/R- patients, up to six months in D+/R+ and D-/R+ patients, and three months in D-/R-. Endpoints included two-year overall survival and freedom from development of CMV disease, CAV, and NF-MACE (defined as myocardial infarction¼..) after the end of CMV prophylaxis in the four study groups, respectively. Results: After the end of respective CMV prophylaxis in the four study groups, there was no significant difference in two-year overall survival and freedom from development of CMV disease, CAV, and NF-MACE among the four groups. Of the D+/R- group, one patient developed CMV gastritis, one patient CMV pneumonia, and one patient CMV colitis. Two patients developed CMV colitis in the D+/R+ group. Conclusions: The current recommendations for the duration of CMV prophylaxis appear to be satisfactory in preventing CMV disease and complications after the end of prophylaxis.

Outcomes after redo aortobifemoral bypass for aortoiliac occlusive disease

Patients presenting with occluded aortobifemoral (ABF) bypass grafts are managed with a variety of techniques. Redo ABF (rABF) bypass procedures are infrequently performed because of concerns about procedural complexity and morbidity. The purpose of this analysis was to compare midterm results of rABF bypass with those of primary ABF (pABF) bypass for aortoiliac occlusive disease to determine if there are significant differences in outcomes. A retrospective review was performed of all patients undergoing ABF bypass for occlusive disease between January 2002 and March 2012. A total of 19 patients underwent rABF bypass and 194 received pABF bypass during that period. Data for an indication- and comorbidity-matched case-control cohort of 19 elective pABF bypass patients were collected for comparison to the rABF bypass group. Primary end points included rate of major complications as well as 30-day and all-cause mortality. Secondary end points were amputation-free survival and freedom from major adverse limb events. The rABF bypass patients more frequently underwent prior extra-anatomic or lower extremity bypass operations compared with pABF bypass patients (P = .02); however, no difference was found in the incidence of prior failed endovascular iliac intervention (P = .4). By design, indications for the rABF and pABF bypass groups were the same (claudication, n = 6/6 [31.6%]; P = 1; critical limb ischemia, n = 13/13 [78.4%]; P = 1). Aortic access was more frequently by retroperitoneal exposure in the rABF bypass group (n = 13 vs n = 1; P < .0001), and a significantly higher proportion of the rABF bypass patients required concomitant infrainguinal bypass or intraprocedural adjuncts such as profundaplasty (n = 14 vs n = 5; P = .01). The rABF bypass patients experienced greater blood loss (1097 ± 983 mL vs 580 ± 457 mL; P = .02), received more intraoperative fluids (3400 ± 1422 mL vs 2279 ± 993 mL; P = .01), and had longer overall procedure times (408 ± 102 minutes vs 270 ± 48 minutes; P < .0001). Length of stay (days ± standard deviation) was similar (pABF bypass, 11.2 ± 10.4; rABF bypass, 9.1 ± 4.5; P = .7), and no 30-day or in-hospital deaths occurred in either group. Similar rates of major complications occurred in the two groups (pABF bypass, n = 6 [31.6%]; rABF bypass, n = 4 [21.1%]; observed difference, 9.5%; 95% confidence interval, -17.6% to 36.7%; P = .7). Two-year freedom from major adverse limb events (±standard error mean) was 82% ± 9% vs 78% ± 10% for pABF and rABF bypass patients (log-rank, P = .6). Two-year amputation-free survival was 90 ± 9% vs 89 ± 8% between pABF and rABF bypass patients (P = .5). Two-year survival was 91% ± 9% and 90% ± 9% for pABF and rABF bypass patients (P = .8). Patients undergoing rABF bypass have higher procedural complexity compared with pABF bypass as evidenced by greater operative time, blood loss, and need for adjunctive procedures. However, similar perioperative morbidity, mortality, and midterm survival occurred in comparison to pABF bypass patients. These results support a role for rABF bypass in selected patients.

Imaging Features Associated With Disease Progression After Stereotactic Ablative Radiotherapy for Stage I Non–Small-Cell Lung Cancer

Introduction/BackgroundThe aim of this study was to identify imaging-based predictors of progression in patients treated with SABR for stage I NSCLC. Patients and MethodsBetween March 2003 and December 2012, 117 patients with stage I NSCLC meeting our study criteria were treated with SABR at Stanford University. Median follow-up was 17 months (range, 3-74 months) for all patients and 19 months for living patients (range, 3-74 months). Tumors were classified according to whether or not they contacted the pleura adjacent to the chest wall or mediastinum (MP), according to their maximum dimension based on computed tomography scans, and, for 102 patients who had archived pretreatment fluorine-18 fluorodeoxyglucose positron-emission tomography scans, according to SUVmax. ResultsTen patients (9%) developed local progression, 17 (15%) developed regional progression, and 19 (16%) developed distant metastasis. Two-year freedom from local progression, freedom from regional progression, and freedom from distant metastasis (FFDM) were 88%, 83%, and 83%, respectively. Overall survival was 70% at 2 years. FFDM was significantly associated with MP contact, maximum tumor dimension, and SUVmax, and these variables could be combined into an exploratory prognostic index that identified patients at highest risk for developing metastases. ConclusionIn our cohort, noninvasive, imaging-based features were associated with distant progression after SABR for early stage NSCLC. If validated, our prognostic index could allow identification of patients who might benefit from systemic therapy after SABR.

Sustained Safety and Effectiveness of Paclitaxel-Eluting Stents for Femoropopliteal Lesions: 2-Year Follow-Up From the Zilver PTX Randomized and Single-Arm Clinical Studies

A prospective, multinational randomized controlled trial (RCT) and a complementary single-arm study evaluated the 2-year safety and effectiveness of a paclitaxel-coated drug-eluting stent (DES) in patients with superficial femoral artery lesions. The RCT compared the DES with percutaneous transluminal angioplasty (PTA) and provisional bare-metal stent (BMS) placement. Local drug delivery for superficial femoral artery lesions has been investigated with the intent of limiting restenosis similarly to DES for the coronary arteries. One-year outcomes of DES in the superficial femoral artery are promising, but longer-term benefits have not been established. In the RCT, patients were randomly assigned to primary DES implantation (n= 236) or PTA (n= 238). Acute PTA failure occurred in 120 patients, who underwent secondary randomization to DES (n= 61) or BMS (n= 59) placement. The single-arm study enrolled 787 patients with DES treatment. Compared with the control group, the primary DES group demonstrated significantly superior 2-year event-free survival (86.6% vs. 77.9%, p= 0.02) and primary patency (74.8% vs. 26.5%, p< 0.01). In addition, the provisional DES group exhibited superior 2-year primary patency compared with the provisional BMS group (83.4% vs. 64.1%, p< 0.01) and achieved higher sustained clinical benefit (83.9% vs. 68.4%, p= 0.05). Two-year freedom from target lesion revascularization with primary DES placement was 80.5% in the single-arm study and 86.6% in the RCT. Two-year outcomes with the paclitaxel-eluting stent support its sustained safety and effectiveness in patients with femoropopliteal artery disease, including the long-term superiority of the DES to PTA and to provisional BMS placement. (Evaluation of the Zilver PTX Drug-Eluting Stent in the Above-the-Knee Femoropopliteal Artery; NCT00120406; Zilver(®) PTX™ Global Registry; NCT01094678).

Initial SYNTAX Score Predicts Major Adverse Cardiac Events After Primary Percutaneous Coronary Intervention

We assessed whether interventional complexity in patients presenting with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) predicted long-term outcome. Consecutive patients undergoing PPCI for STEMI underwent SYNTAX scoring, based on angiographic images obtained at coronary intervention. Patients were classified as SYNTAX score (SS) ≤22 (low, L), 23 to 32 [intermediate (IM)], and ≥33 (high, H). The median SS for the cohort was 19 [Interquartile range (IQR), 11.0-25.5] with median tertile scores of L 14 (IQR 9.0-18.5, n = 437), IM 26 (IQR 24.0-28.5, n = 170), and H 36 (IQR 34.5-40.5, n = 67). Two-year freedom from major adverse cardiac events (MACE) was L 88.1%, IM 78.8%, and H 68.7% (P < .001). Multivariate analysis confirmed that increasing SS tertile was an independent predictor of MACE [IM hazard ratio (HR) 1.61, confidence interval (CI) 1.05-2.47; P = .03, H HR 1.99, CI 1.16-3.41; P = .01]. The SS, when applied to patients undergoing PPCI for STEMI, provides prognostic information.

Midterm Outcomes and Risk Stratification after Endovascular Therapy for Patients with Critical Limb Ischaemia due to Isolated Below-the-knee Lesions

ObjectivesTo assess and risk stratify midterm clinical outcomes after endovascular therapy (EVT) by angioplasty only of patients with critical limb ischaemia (CLI) due to isolated below-the-knee (BTK) lesions. DesignRetrospective multicenter study. Materials and methodsBetween March 2004 and October 2010, 465 limbs (Rutherford 5 and 6: 79%) from 406 patients were studied. Overall survival, limb salvage, and re-intervention were examined out to 3 years by the Kaplan–Meier method and the log-rank test. Their independent predictors and risk stratification were analysed. ResultsPatient age was 71 ± 11 yrs, with 69% diabetics and 60% on dialysis. Mean follow-up was 18 ± 15 months. Overall survival was 76 ± 2 and 57 ± 4% at 1 and 3, years, respectively. Survival predictors were body mass index <18, non-ambulatory status and ejection fraction <45%. Two-year limb salvage rate was 80 ± 2%. Factors associated with major amputation were ulcers (Rutherford 6), diabetes mellitus, C-reactive protein>5 mg/dL, and age < 60 years. Two-year freedom from re-intervention was 66 ± 3%; age and below-the-ankle runoff number after angioplasty was negatively associated with re-intervention. ConclusionsDespite relatively high mortality and re-intervention rates, limb salvage rate was acceptable after EVT for CLI patients with isolated BTK lesions. Risk stratification allows occurrence estimation for each end point.

Early and late failure of tissue-engineered pulmonary valve conduits used for right ventricular outflow tract reconstruction in patients with congenital heart disease

To identify factors associated with the surgical outcome in patients undergoing right ventricular outflow tract reconstruction (RVOTR) using decellularized tissue-engineered pulmonary valve conduits (TEPVc) and to study their safety and longevity. From April 2006 to April 2010, 93 patients underwent either palliative or corrective RVOTR using Matrix P (37) and Matrix P Plus (56) xenogenic decellularized TEPVc (size range 11-27 mm). Median age and weight at operation were 20 (0.16-290) months and 10.15 (2.65-86) kg respectively. Primary and redo surgery occurred in 40 and 60% of cases, respectively. Eighty-eight patients (94.6%) received conduit implantation in the framework of corrective surgery, whereas in 5 (5.4%) a palliative procedure was undertaken. Follow-up was complete in 91% of patients, with a median duration of 12 months (range: 2 days-51 months). Data analysis included diagnosis, type of surgery (palliative vs. corrective) and age at surgery. Predetermined primary outcomes were represented by conduit failure or dysfunction. Two patients with Matrix P and two with Matrix P Plus died in the early post-operatively phase (4.3%). None of the deaths were conduit-related. One patient died at conduit replacement. Thirty-three patients (35.5%) experienced conduit failure whereas conduit dysfunction occurred in 27 patients (29%). Two-year freedom from conduit failure and dysfunction was 60.2% (95% CI: 50.1-69.6) and 77.4% (95% CI: 67.9-84.7), respectively. Reasons for failure were conduit stenosis in 20 cases (61%), pseudoaneurysm in 3 (9%), conduit dilatation (>50% of original diameter) in 2 (6%), stenosis of distal anastomosis involving pulmonary bifurcation in 6 (18%) and allograft dissection in 2 (6%). Histological examination showed inflammatory giant-type cells in the presence of a poor autologous cell seeding in all explanted specimens. Univariate and multivariate analyses showed an association between age at surgery ≤1 year and conduit dysfunction (adjusted HR: 2.29; 95% CI: 1.01-5.20, P = 0.04). Compared with the other conduit for RVOTR Matrix conduits showed a high incidence of failure. Our results suggest that the use of Matrix conduits for RVOTR should be considered with caution.

Randomized comparison between mild and moderate hypothermic cardiopulmonary bypass for neonatal arterial switch operation

To compare neonates receiving arterial switch operation (ASO) either with mild or moderate hypothermic cardiopulmonary bypass. Forty neonates undergoing ASO were randomized to receive either mild (Mi > 32 °C, n = 20) or moderate (Mo > 26 °C, n = 20) hypothermic cardiopulmonary bypass (CPB) between April 2007 and June 2010. All patients were diagnosed with simple transposition of the great arteries. Mean age (Mi: 8.32 ± 4.5 days, Mo: 7.54 ± 5.0 days, P = 0.21) and body weight were similar in both groups (Mi: 3.64 ± 0.91 kg, Mo: 3.73 ± 0.84 kg, P = 0.14). Follow-up was 3.1 ± 2.5 years for all patients. Lowest perioperative rectal temperature was 33.5 ± 1.4 °C (Mi) versus 28.2 ± 2.1 °C (Mo) (P < 0.001). All patients safely weaned from CPB required lower doses of dopamine (Mi: 5.1 ± 2.4 µg/kg min, Mo: 6.5 ± 2.1 µ/kg min, P = 0.04), dobutamine (Mi: 7.2 ± 2.5 µg/kg min, Mo: 8.6 ± 2.4 µ/kg min, P = 0.04) and adrenalin (Mi: 0.02 ± 0.02 µg/kg min, Mo: 0.05 ± 0.03 µ/kg min, P = 0.03) in mild hypothermia group. Intraoperative blood transfusion (Mi: 190 ± 58 ml, Mo: 230 ± 24 ml, P = 0.03) and postoperative lactate levels (Mi: 2.7 ± 0.9 mmol/l, Mo: 3.1 ± 2.2 mmol/l, P = 0.02) were lower under mild hypothermia. Secondary chest closure was performed in 30% (Mi) versus 35% (Mo) (P = 0.65). Duration of inotropic support (Mi: 7 (4-11) days, Mo: 11 (7-15) days, P = 0.03), time to extubation (Mi: 108 (88-128) h, Mo: 128 (102-210) h, P = 0.04), lengths of intensive care unit (ICU) stay (Mi: 9 (5-14) days, Mo: 12 (10-18) days, P = 0.04) and hospital stay (Mi: 19 (10-29) days, Mo: 23 (15-37) days, P = 0.04) were significantly shorter under mild hypothermia. Two-year freedom from reoperation was 100% for both the groups. The ASO under mild hypothermia seemed to be beneficial for pulmonary recovery, need for inotropic support and length of ICU and hospital stay. No worse early- or intermediate-term effects of mild hypothermia were found.

CD28 Down-Regulation on CD4 T Cells Is a Marker for Graft Dysfunction in Lung Transplant Recipients

Repeated antigen-driven proliferations cause CD28 on T cells to down-regulate. We hypothesized that alloantigen-induced proliferations could cause CD28 down-regulation in lung transplant recipients. To ascertain if CD28 down-regulation on CD4 T cells associated with manifestations of allograft dysfunction in lung transplant recipients. Peripheral blood CD4 T cells from 65 recipients were analyzed by flow cytometry, cytokine multiplex and proliferative assays, and correlated with clinical events. Findings that CD28 was present on less than 90% of total CD4 T cells were predominantly seen among the recipients with bronchiolitis obliterans syndrome (specificity = 88%). Perforin and granzyme B were produced by >50% of the CD4(+)CD28(null) cells, but less than 6% of autologous CD4(+)CD28(+) cells (P < 0.006). CD4(+)CD28(null) cells also had increased productions of proinflammatory cytokines, but less frequently expressed regulatory T-cell marker FoxP3 (2.1 +/- 1.3%), compared with autologous CD4(+)CD28(+) (9.5 +/- 1.4; P = 0.01). Cyclosporine A (100 ng/ml) inhibited proliferation of CD4(+)CD28(null) cells by 33 +/- 11% versus 68 +/- 12% inhibition of CD4(+)CD28(+) (P = 0.025). FEV(1) fell 6 months later (0.35 +/- 0.04 L) in recipients with CD4(+)CD28(+)/CD4(total) less than 90% (CD28% Low) compared with 0.08 +/- 0.08 L among CD4(+)CD28(+)/CD4(total) (CD28% High) greater than 90% (CD28% High) recipients (P = 0.013). Two-year freedom from death or retransplantation in CD28% Low recipients was 32 +/- 10% versus 78 +/- 6% among the CD28% High subjects (P < 0.0001). CD28 down-regulation on CD4 cells is associated with bronchiolitis obliterans syndrome and poor outcomes in lung transplantation recipients. CD4(+)CD28(null) cells have unusual, potentially pathogenic characteristics, and could be important in the progression of allograft dysfunction. These findings may illuminate a novel paradigm of transplantation immunopathogenesis, and suggest that CD28 measurements could identify recipients at risk for clinical deteriorations.

Mitral Valve Repair for Ischemic Mitral Regurgitation

Our aim was to evaluate midterm results in patients who underwent mitral valve repair (MVR) for ischemic mitral regurgitation (IMR) in our most recent experience. From March 2006 to March 2008, 105 patients underwent MVR for IMR. Mean IMR grade was 2.6 +/- 1.1, with 46 patients having <or=2/4 and 59 >or=3/4. Five patients (4.8%) died within first month; Two-year freedom from death any cause was 85.5% +/- 3.8, freedom from cardiac death was 88.7% +/- 3.4. NYHA Class of the survivors was 1.3 +/- 0.6, with 3 patients in NYHA Class III. Freedom from death any cause and NYHA Class III-IV was 78.6% +/- 4.6. IMR grade decreased from 2.6 +/- 1.1 to 0.1 +/- 0.3 at the discharge and to 0.5 +/- 0.3 after a mean of 7 +/- 4 months, with no patient with IMR grade 3/4 or 4/4. MVR for IMR should be performed in patients with moderate-or-more IMR grade or when the MV is excessively dilated, to achieve good midterm results.

Factors Affecting Outcome of Patients with Refractory/Relapsed Hodgkin's Disease (HD) Treated with IGEV Chemotherapy (CT) and High Dose Consolidation Therapy (HDT) with Stem Cell Rescue.

Purpose: to identify prognostic factors in pts with relapsing/refractory HD treated with IGEV CT and HDTMethods: From 01/98 to 01/05 104 patients (pts) from our institutions with relapsed/refractory HD received 4 induction cycles of IGEV (ifosfamide 2000 mg/mq d 1–4; gemcitabine 800 mg/mq d 1& 4; vinorelbine 20 mg/mq d 1; prednisolone 100 mg/mq d 1–4, and G-CSF) and HDT consolidation. Prognostic factors for freedom for progression (FFP) were analyzed by means of the chi-square and Fisher's exact tests. Multivariate regression logistic analysis was then applied for variable associated with outcome.Results: Main pt characteristics at accrual: M/F 56/48, median age 31 (range 17–65), refractory/relapsed following last CT course 40/64, median previous CT regimens: 1 (range 1–2), simptoms A/B 32/71, Hasenclever (IPS) score <3/≥ 4: 72/24 (8 pts not evaluable), LDH ratio ≤ 1/> 1: 68/35, previous radiotherapy (RT) yes/no: 62/42. After induction, 45 pts (43%) obtained complete remission (CR), 41(40%) partial remission (PR) and18 (17)% di not response (NR). Overall 89 pts received HDT and at the end of the treatment program 76 out of 104 pts were in CR. On an intent-to treat analysis, two-year freedom from progression (FFP) and overall survival (OS) for the whole series were 47% and 74,6%, respectively.In univariate analysis FFP was negatively influenced by B symptoms, IPS score ≥ 4, LDH ratio > 1, refractory disease, and by response to IGEV (see table).Multivariate analysis revealed that factors retaining statistical significance were refractory disease, B symptoms, high IPS score and chemoresistance (see table).Conclusions: based on this analysis, a prognostic model for IGEV-treated patients with refractory/relapsed HD can be constructed.Factors influencing FFPFactor ≥FFPp (univariate)p(multivariate)Symptoms B/A16/57%0.0030.007IPS > 4/< 332/51%0.00350.051LDH >1/<1−19/61%0.003n.s.refrac/relaps22.5/62%< 0.0010.012< CR/CR to IGEV32/68%0.002n.s.NR/CR + PR23.5/52%0.0010.005

Palliation of allograft vasculopathy with transluminal angioplasty: A decade of experience

ObjectivesThe goal of this study was to examine the outcomes of percutaneous coronary interventions (PCI) and the predictors for restenosis after cardiac transplantation. BackgroundThe role of PCI as definitive therapy for allograft coronary disease (ACD) remains contentious. MethodsBetween January 1, 1990 and December 31, 2000, 62 patients (1.5 to 15.5 years after transplant) underwent 151 procedures resulting in PCIs of 219 lesions. Follow-up after PCI angiography was usually obtained at three and six months, then yearly. Repeat PCI was routinely done to lesions with >60% restenosis. ResultsThe primary procedural success was 97%. Repeat PCI occurred in 74 of 219 lesions (34%); PCI-related mortality was 2.6% (4 of 151). The freedom from re-PCI (of same vessel site) was 75% at six months, 65% at one year, and 57% at four years. The freedom from restenosis was 95% at one month, 81% at three months, and 57% at six months. Multivariate predictors of freedom from restenosis were the use of stents, higher anti-proliferative immunosuppressant dose, and an era effect. In the setting of one-vessel disease at first PCI, the two-year freedom for ACD death or graft loss was 74%, compared with 75% for two-vessel and 27% for three-vessel disease (p = 0.009). ConclusionsDespite the increasing effectiveness of PCI for localized ACD, the survival after development of advanced ACD remains poor. Stents appear to increase effectiveness of PCI for ACD, but other factors in the current era contribute to improved outcomes.

Three year single centre experience with the AneuRx aortic stent graft.

To report the mid-term single-centre experience with the AneuRx self-expandable nitinol stentgraft for endovascular aneurysm repair. Between December 1996 and January 2000 a total of 128 patients were treated with an AneuRx bifurcated stentgraft. Of these, 77 patients had a minimum follow-up of 12 months. Patient operative and follow-up data were prospectively gathered. Two (3%) conversions were necessary. Median hospital stay was 3 days. One superficial wound infection occurred. Periprocedural (30 days) mortality was 5% (four patients). Three graft occlusions were noted of which two required treatment. Fifteen patients developed 18 endoleaks (six type 1, eight type 2 and four type 3). Type 1 and type 3 endoleaks were treated by extension cuffs. Four type 2 endoleaks were treated with embolisation or direct lumbar puncture. Two-year freedom from endoleak was 76%. Graft migration occurred in six cases, resulting in a 2-year freedom from migration of 90%, kinking only once. endovascular AAA treatment is feasible and so far mid-term results are without major problems. Extensive follow-up is essential as secondary problems may occur later. Long-term results are to be awaited.