Quality of life after balloon angioplasty versus stent implantation in the superficial femoral artery: findings from a randomized controlled trial.

PURPOSE: To investigate whether primary nitinol stenting in the superficial femoral artery (SFA) is beneficial to patients' quality of life (QoL). METHODS: One hundred four patients (55 men; mean age 66+/-19 years) with chronic limb ischemia and SFA disease were randomly assigned to primary stent implantation (n=51) or balloon angioplasty (n=53) with optional stenting for a suboptimal angioplasty result (17 of 53). QoL was measured by the SF-36 questionnaire at baseline and at 3, 6, and 12 months post intervention. RESULTS: QoL was significantly improved post intervention and up to 12 months in both treatment groups. Significant inverse associations were observed between QoL parameters and restenosis. Comparing primary stenting (n=51) versus balloon angioplasty with optional stenting (n=53) by the intention to treat, no significant differences in QoL were observed. Analyses of stented patients (n=68) versus balloon angioplasty (n=36) patients, however, demonstrated significantly improved measures of QoL after stenting. CONCLUSION: Endovascular revascularization of SFA disease improves QoL, and restenosis negatively affects QoL outcomes. After stent implantation, whether primary or secondary, QoL was significantly ameliorated compared to balloon angioplasty alone. However, it remains to be proven in larger cohorts whether primary stenting yields a QoL benefit compared to balloon angioplasty with optional secondary stenting.     

切割球囊血管成型术对C-反应蛋白白细胞介素-6及细胞间粘附分子的影响

目的 :比较切割球囊预扩张与普通球囊预扩张后支架置入术对C 反应蛋白 (CRP)、白细胞介素 6 (IL 6 )及可溶性细胞间粘附分子 1(sICAM 1)的影响。方法 :将冠状动脉造影显示单纯前降支近端病变的不稳定型心绞痛患者分为 2组 ,一组给予普通球囊预扩张后支架置入 ,另一组给予切割球囊预扩张后支架置入 ,并分别在术前、术后 1、6、2 4、4 8h测定C 反应蛋白、白细胞介素 6及可溶性细胞间粘附分子的浓度。结果 :2组患者一般情况、病变情况无显著统计学差异 ,术后 6hC 反应蛋白、白细胞介素 6较术前升高 ,2 4h达高峰 ;可溶性细胞间粘附分子术后 1h较术前升高 ,术后 6h达高峰。切割球囊组C 反应蛋白、白细胞介素 6水平在术后 6、2 4、4 8h均显著低于普通球囊组 ,可溶性细胞间粘附分子水平在术后 1、6、2 4、4 8h低于普通球囊组。介入治疗中切割球囊组球囊最大充盈压 (MIP)明显低于普通球囊组。结论 :切割球囊血管成型术对C 反应蛋白、白细胞介素 6及可溶性细胞间粘附分子的影响小于普通球囊组 ,可能是切割球囊降低术后再狭窄的机制之一     

Re-angioplasty of in-stent restenosis versus balloon restenoses--a matched pair comparison

BACKGROUND: Despite different biological mechanisms involved in the restenotic process of in-stent restenosis and restenosis after balloon angioplasty alone, the occurrence of a second restenosis has been reported in the same range. There are no data available comparing the outcome after re-angioplasty of such lesions. We analyzed in a matched pair comparison the clinical outcome and angiographic long-term result of patients with balloon angioplasty of a first in-stent restenosis versus patients with balloon re-angioplasty of a first balloon restenosis. METHODS: Both groups consisted of 74 lesions matched by treated vessel, lesion location differentiated in proximal and non-proximal, and angiographic appearance of coronary artery disease differentiated in singular stenosis, diffuse or mixed pattern. Clinical follow-up was 100%. Angiographic follow-up was 78.4% after median 174 days. RESULTS: Angiographic restenosis rate in matched pairs of patients (n=46/74) was significantly higher in the balloon restenosis group (41.3%, n=19/46) compared to the in-stent restenosis group (21.7%, n=10/46, p<0.042). There was no death or myocardial infarction. After clinical follow-up, target lesion revascularization rate was significantly lower in the in-stent restenosis group compared to the balloon restenosis group (12.1%, n=9/74 versus 27.0%, n=20/74; difference between groups 14.9%, 95% confidence interval 2.0-27.3%, p<0.023). Multivariate logistic regression analysis revealed as predictors for a second restenosis unstable angina pectoris, non-proximal lesion, restenosis after balloon angioplasty and the occurrence of the first restenosis within 90 days after initial intervention. CONCLUSION: Clinical and angiographic outcome after balloon angioplasty of a first in-stent restenosis was significantly better compared with balloon re-angioplasty of a first balloon restenosis.     

Outcome after endovascular treatment of deep femoral artery stenosis: results in a consecutive patient series and systematic review of the literature.

PURPOSE: To evaluate immediate and midterm clinical outcomes after percutaneous transluminal angioplasty (PTA) of deep femoral artery stenosis in patients with chronically occluded superficial femoral arteries (SFA) and to report the results of a systematic review of the literature in this field. METHODS: A retrospective analysis was conducted of 55 consecutive patients (42 men; median age 72 years, interquartile range [IQR] 63-79) with severe intermittent claudication (n = 38) or critical limb ischemia (n = 17) who underwent balloon angioplasty of deep femoral artery stenosis. Patients were followed with ankle-brachial index (ABI) measurement, estimation of maximum walking capacity, clinical staging of peripheral artery disease (PAD), and duplex ultrasound imaging for restenosis. A systematic review of the literature using MEDLINE, EMBASE, and a hand search was done. RESULTS: Technical success (residual stenosis < 30%) was achieved in 85% (47/55), with 1 (2%) minor complication. The median ABI marginally increased from 0.48 at baseline to 0.53 post intervention without significant difference in the change of ABI between patients with supra- or infragenicular reconstitution of the femoropopliteal runoff. During a median 13-month (IQR 3-42) follow-up, no significant improvement in ABI or walking distance was maintained, and only 16 (29%) patients reported a sustained clinical improvement by 1 PAD stage. Cumulative patency and reintervention-free survival rates were, respectively, 71% and 61% at 1 year and 49% and 48% at 3 years. In the literature, only case series were found, but no randomized trial evaluating the efficacy of deep femoral artery PTA. CONCLUSION: PTA of the deep femoral artery can be performed with high technical success rates at a low interventional risk. However, in the majority of patients, this technique yields no sustained hemodynamic or clinical benefit. Due to a high rate of late failures, it should be reserved for limb salvage in patients without a surgical alternative.     

Complement component C5a predicts future cardiovascular events in patients with advanced atherosclerosis.

AIMS: Complement activation occurs in atherosclerotic lesions, and particularly complement component C5a exerts potent chemotactic and proinflammatory effects. However, it is yet unknown, whether plasma levels of C5a may predict cardiovascular risk. The aim of this study was to examine whether plasma levels of the complement component C5a may predict cardiovascular risk in patients with advanced atherosclerosis. METHODS AND RESULTS: We studied 173 patients with symptomatic peripheral artery disease (median age 72, 82 male). Cardiovascular risk profile, levels of the complement factor C5a, and other non-specific inflammatory parameters [high sensitivity C-reactive protein, serum amyloid A (SAA), and fibrinogen] were obtained at baseline, and patients were followed for median 22 months [interquartile range (IQR) 13-27] for the occurrence of major adverse cardiovascular events (MACE: myocardial infarction, percutaneous coronary interventions, coronary artery bypass graft, carotid revascularization, stroke, and death). We observed 65 MACE in 49 patients (28%). Cumulative event rates (95% confidence interval (CI)) within quartiles of C5a at 24 months were 16 (5-27), 26 (13-39), 36 (21-51), and 37% (23-51), respectively (P=0.0077). Adjusted hazard ratios for the occurrence of a first MACE according to increasing quartiles of C5a were 1.81, 2.23, and 2.66, respectively, as compared to the lowest quartile (P=0.038), irrespective of the level of other inflammatory parameters. CONCLUSION: Complement activation, indicated by the elevation of C5a, seems to be associated with increased cardiovascular risk in patients with advanced atherosclerosis. Clinically, determination of C5a may add to the predictive value of other non-specific inflammatory parameters.     

Long-term angiographic follow-up after successful repeat balloon angioplasty for in-stent restenosis

BACKGROUND: Coronary stent implantation is associated with improved angiographic short-term and mid-term clinical outcome. However, restenosis rate still remains between 20 and 30%. HYPOTHESIS: The purpose of the study, performed as a prospective angiographic follow-up to detect restenosis, was to evaluate the immediate and the 6-month angiographic results of repeat balloon angioplasty for in-stent restenosis. METHODS: From April 1996 to September 1997, 335 stenting procedures performed in 327 patients underwent prospectively 6-month control angiography. Of the 96 lesions that showed in-stent restenosis (> 50% diameter stenosis) (29%), 72 underwent balloon angioplasty. RESULTS: The primary success rate was 100%. Follow-up angiogram at a mean of 6.9 +/- 2.4 months was obtained in 54 patients. Recurrent restenosis was observed in 24 of the 55 stents (44%). Repeat intervention for diffuse and body location in-stent restenosis before repeat intervention was associated with significantly higher rates of recurrent restenosis (p < 0.001 and p < 0.05, respectively). Of the 19 patients who underwent further balloon angioplasty (100% success rate), coronary angiography was performed in 18 (95%) at a mean of 8.2 +/- 2.0 months and showed recurrent restenosis in 12 patients (67%). Further repeat intervention for diffuse and severe in-stent restenosis before the second repeat intervention was associated with significantly higher rates of further recurrent restenosis (p < 0.05 and p < 0.005, respectively). CONCLUSIONS: Although balloon angioplasty can be safely, successfully, and repeatedly performed after stent restenosis, it carries a progressively high recurrence of angiographic restenosis rate during repeat 6-month follow-ups. The subgroup of patients with diffuse, severe, and/or body location in-stent restenosis proved to be at higher risk of recurrent restenosis.     

Autoperfusion balloon catheter for complicated coronary angioplasty: a prospective study with retrospective controls.

Prolonged angioplasty balloon inflation with an autoperfusion balloon for failed conventional coronary angioplasty, was compared with emergency surgery for this condition. Restenosis was assessed 6 weeks after successful intervention with the autoperfusion balloon. Forty consecutive patients with persistent acute occlusion and/or severe intimal dissection during conventional angioplasty, were treated with the autoperfusion balloon. They were candidates for emergency surgery if it failed. Total inflation time was significantly longer (p < 0.001) with the autoperfusion balloon (27.5; 10-180 min) than with the standard balloon (10; 1-20 min) (median; range). The number of inflations was significantly lower (p < 0.001) with the autoperfusion balloon (2; 1-5 times) than with the standard balloon (5; 2-14 times) (median; range). Two patients died, one before surgery could be performed. The autoperfusion balloon was successful in 26 patients (65%). After 6 weeks, 16 (62%) were asymptomatic without anti-anginal medication, 24 underwent repeat angiography, 10 (42%) had restenosis, 7 (27%) underwent elective bypass surgery. Emergency surgery remained necessary in 13 patients (33%), 9 received arterial grafts. In 31 retrospective controls, who had undergone immediate surgery for the same indication, only venous grafts could be used. Thus, prolonged autoperfusion balloon inflation was successful in 65% of the cases of failed, conventional angioplasty. The angiographic restenosis rate after 6 weeks was 42%. If emergency surgery remained necessary, the autoperfusion balloon facilitated the use of arterial bypass grafts.     

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 > or =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.     

Update on Lower Extremity Endovascular Interventions

In the past decade there have been major strides in the development of devices and techniques for nonsurgical lower extremity revascularization. These advances have broadened indications for endovascular therapies and expanded the treatment options for patients with peripheral vascular disease. A variety of new laser-etched steel and nitinol stent designs now complement balloon angioplasty. In the iliac segment, stenting has replaced balloon angioplasty as the first-line therapy for treatment of symptomatic occlusive disease. Stenting results in superior acute procedural success and long-term clinical efficacy compared to balloon angioplasty and is a "less invasive" alternative to surgical reconstruction. Endoluminal stent grafts offer promise in the treatment of high-risk patients with abdominal aortic aneurysms. New strategies are being developed to address the diverse nature of the superficial femoral artery (SFA) and infrapopliteal disease where balloon angioplasty, stenting, and stent graft strategies have proven unsatisfactory for treatment of diffuse disease and long occlusions. The next millennium will see the use of "therapeutic angiogenesis," the intravascular and intramuscular administration of DNA fragments or proteins, to stimulate new vessel growth in patients not amenable to conventional surgical or endovascular therapies. Brachytherapy, the intravascular delivery of a retrievable ionizing radiation source, represents an exciting development that offers the potential of reducing restenosis in the SFA.     

Randomized comparison of coronary stent implantation and balloon angioplasty in the treatment of de novo coronary artery lesions (START): a four-year follow-up.

OBJECTIVE: The purpose of this study was to test the hypothesis that stent implantation in de novo coronary artery lesions would result in lower restenosis rates and better long-term clinical outcomes than balloon angioplasty. BACKGROUND: Placement of an intracoronary stent, as compared with balloon angioplasty, has proven to reduce the rate of restenosis. However, the long-term clinical benefit of stenting over angioplasty has not been assessed in large randomized trials. METHODS: We randomly assigned 452 patients with either stable (129 patients) or unstable (323 patients) angina pectoris to elective stent implantation (229 patients) or standard balloon angioplasty (223 patients). Coronary angiography was performed at baseline, immediately after the procedure and six months later. End points were the rate of restenosis at six months and a composite of death, myocardial infarction (MI) and target vessel revascularization over four years of follow-up. RESULTS: Procedural success rate was achieved in 84% and 95% (balloon angioplasty vs. stent, respectively). The increase in the minimal luminal diameter was greater in the stent group both after the intervention (2.02 +/- 0.6 mm vs. 1.43 +/- 0.6 mm in the angioplasty group; p < 0.0001), and at six-month follow-up (1.98 +/- 0.7 mm vs. 1.63 +/- 0.7 mm; p < 0.001). The corresponding restenosis rates were 22% and 37%, respectively (p < 0.002). After four years, no differences in mortality (2.7% vs. 2.4%) and nonfatal MI (2.2% vs. 2.8%) were found between the stent and the angioplasty groups, respectively. However, the requirement for further revascularization procedures of the target lesions was significantly reduced in the stent group (12% vs. 25% in the angioplasty group; relative risk 0.49, 95% confidence interval 0.32 to 0.75, p = 0.0006); most of the repeat procedures (84%) were carried out within six months of entry into the study. CONCLUSIONS: Patients who received an intracoronary stent showed a lower rate of restenosis than those treated with conventional balloon angioplasty. The benefit of stenting was maintained four years after implantation, as manifested by a significant reduction in the need for repeat revascularization.     

Lipid peroxidation may predict restenosis after coronary balloon angioplasty.

The present study assessed whether lipid peroxidation in plasma might predict restenosis after coronary balloon angioplasty. A total of 87 patients, who had undergone successful coronary balloon angioplasty using standard techniques, were enrolled. Fasting blood samples before the intervention were measured for plasma levels of thiobarbituric acid reactive substances (TBARS, an indicator of lipid peroxidation). Angiography was carried out before and 15 min after angioplasty, and at follow-up (4 months after angioplasty), and evaluated using a quantitative approach. There were 23 patients with restenosis (group R) and 64 patients without restenosis (group N) after coronary balloon angioplasty. The plasma TBARS level (mean+/-SEM) of 4.3+/-0.1 micromol/L in group R was significantly higher than that of 3.2+/-0.1 micromol/L in group N (p<0.01). There were no significant differences in other parameters, including plasma lipid levels, between the 2 groups. The plasma level of TBARS positively correlated with lumen loss of the coronary artery at the time of follow-up angiography (r=0.57, p<0.01). Our results suggest that oxidative stress contributes to restenosis and indicate that an elevated plasma level of TBARS may be a reliable predictor of restenosis.     

Early lumen loss after repeat coronary intervention for in-stent restenosis.

The purpose of this study was to compare the effects of balloon angioplasty versus repeat stenting on the early angiographic outcome in patients with in-stent restenosis. The treatment of in-stent restenosis using balloon angioplasty alone often yields excellent early results, but is associated with a high rate of late recurrence. In the SCRIPPS trial, patients with restenosis were treated either with balloon angioplasty alone or placement of additional stents to optimize angiographic results before randomization and exposure of the restenotic segment to gamma radiation or placebo. In patients undergoing repeat catheter based intervention for the treatment of in-stent restenosis, quantitative coronary angiography was used to compare the results of balloon angioplasty alone versus repeat stenting on early lumen loss. After a mean delay time interval of 71 min, the early loss was 0.35 +/- 0.34 mm in the balloon angioplasty alone group compared to 0.01 +/- 0.34 mm in the repeat-stenting group (P = 0.004). The early loss index in the balloon angioplasty alone group (12.8 +/- 12.9%) was significantly greater than in the repeat stenting group (0.7 +/- 12.1%; P = 0.003). Although balloon angioplasty for in-stent restenosis often provides excellent immediate angiographic results, luminal diameters are significantly reduced in the early time period after balloon dilatation. Repeat stenting nearly abolishes this early luminal loss.     

Primary patency of long-segment self-expanding nitinol stents in the femoropopliteal arteries.

PURPOSE: To report a retrospective cohort study of nitinol stent implantation in patients at high risk for restenosis owing to long-segment (> or =10 cm) femoropopliteal disease. METHODS: Sixty-five consecutive patients with peripheral artery disease underwent long-segment (> or =10 cm) femoropopliteal stent implantation using self-expanding nitinol stents after initial failure of plain balloon angioplasty (i.e., residual stenosis >30% or a flow-limiting dissection). Patients were followed for first occurrence of in-stent restenosis, defined as a >50% lumen diameter reduction by color-coded duplex sonography, with angiographic confirmation. RESULTS: Cumulative median length of the stented segments was 16 cm (interquartile range [IQR] 12-25, absolute range 10-40) using up to 5 overlapping stents. During the median 8-month follow-up (IQR 6-11), no early thrombotic reocclusions occurred within 30 days, but 26 (40%) patients developed an in-stent restenosis. Cumulative freedom from restenosis at 6 and 12 months was 79% and 54% overall, respectively; at the same time periods, the rates were 84% and 71% in nondiabetic patients (n=41) versus 68% and 22% in diabetics (n=24) (adjusted hazard ratio 3.8, p=0.01). Cumulative stent length and number of implanted stents were not associated with restenosis. CONCLUSION: Midterm restenosis after long-segment femoropopliteal stenting using self-expanding nitinol stents remains a major problem, particularly in patients with diabetes mellitus. The midterm results in nondiabetics are encouraging.     

Reduction of early elastic recoil by cutting balloon angioplasty as compared to conventional balloon angioplasty

BACKGROUND: Restenosis after successful balloon angioplasty remains problematic. Early elastic response after angioplasty is significant when considering the possible development of restenosis. The purpose of this study was to compare early elastic recoil within 10 minutes after successful percutaneous transluminal coronary angioplasty and early lumen loss at 24 hours after angioplasty in a cutting balloon group and a conventional balloon group. METHODS: Extent of early elastic recoil was quantitatively measured as the difference of mean balloon diameter at maximal inflation pressure and minimal luminal diameter after angioplasty in 82 cutting balloon-treated lesions and 51 conventional balloon-treated lesions. RESULTS: Reference diameter and balloon/artery ratio were similar between the cutting balloon and conventional balloon groups (2.89 0.47 mm vs. 2.88 0.60 mm; 1.19 0.11 vs. 1.19 0.13, respectively). Early elastic recoil after angioplasty was significantly smaller in the cutting balloon than the conventional balloon group (0.96 0.40 mm vs. 1.12 0.37 mm, respectively; p = 0.04). Also, the mean amount of lumen loss from 10 minutes after angioplasty to 24 hours after was significantly smaller in the cutting balloon than the conventional balloon group (0.08 0.28 mm vs. 0.20 0.33 mm, respectively; p = 0.02). CONCLUSION: There is significantly less early elastic recoil in the cutting balloon angioplasty than in the conventional balloon angioplasty group. The efficacy of cutting balloon continues 24 hours after angioplasty.     

Serum levels of soluble urokinase plasminogen activator receptor is associated with parasitemia in children with acute Plasmodium falciparum malaria infection

Serum levels of soluble urokinase plasminogen activator receptor (suPAR) are significantly elevated and of prognostic value in patients suffering from serious infectious diseases such as HIV and tuberculosis. Our objective was to investigate suPAR levels during symptomatic malaria infection and 7 days after treatment. Children younger than 6 years who presented with fever or other symptoms compatible with malaria were enrolled. Blood films and samples were collected on day 0 and day 7. Twenty-five children were allocated to each of three groups according to the amount of Plasmodium falciparum detected in their initial blood film. Children in group 1 had parasite densities in excess of 20 parasites per 200 leucocytes. The median plasma suPAR level was 6.49 ng/mL (interquartile range [IQR]: 4.90-7.61) and correlated to parasitemia (Spearman 0.43, P < 0.0001). Blood was obtained from 20 children in group 1 after 7 days of treatment. All became malaria negative in their blood slides and all decreased in suPAR level to median 3.48 ng/mL (IQR: 3.08-3.91) (P < 0.0001). Group 2 consisted of 25 children with 1-20 parasites in their blood slide. The suPAR level was median 2.91 ng/mL (IQR: 2.27-4.40) and decreased with median 0.5 ng/mL following treatment (P = 0.0002). Group 3 showed to be negative in their blood slides and most received antibiotic treatment. suPAR decreased from median 3.26 ng/mL (IQR: 2.77-4.46) to median 2.47 ng/mL (IQR: 2.01-3.75), on day 7 (P = 0.006). This study demonstrates an important association between suPAR and acute malaria infection in humans.     

Hemostatic and fibrinolytic activation is less following cutting balloon angioplasty of the coronary arteries

Recent studies have shown that percutaneous coronary intervention (PCI) activates systemic hemostatic activity, reflecting platelet activation and thrombin formation in the coronary arteries. The present study compared systemic levels of hemostatic markers induced by plain old balloon angioplasty (POBA), coronary stenting (STENT), and cutting balloon (CB) angioplasty. Sixty-one patients with stable angina pectoris, who underwent elective PCI or diagnostic coronary angiography (CAG) alone, were investigated. Patients who underwent PCI were divided into the POBA group (n = 11), the STENT group (n = 27), and the CB group (n = 11). Patients who underwent CAG alone were assigned to the CAG group (n = 12). Blood samples were collected before, 24 hours after, and 3 days after PCI or CAG. Plasma concentrations of prothrombin fragment 1+2 (F1+2), fibrinopeptide A (FPA), thrombin-antithrombin III complex (TAT), and plasminogen activator inhibitor-1 (PAI-1) were measured. In the CB group, the F1+2 (1.23 +/- 0.4 nmol/L) level 3 days after PCI was significantly smaller than that of the POBA group (2.37 +/- 0.5 nmol/L) (P < 0.05). The FPA (1.81 +/- 0.9 ng/mL), TAT (3.36 +/- 1.2 ng/mL) and PAI-1 (23.0 +/- 4.1 ng/mL) levels in the CB group 3 days after PCI were significantly smaller than those of the POBA group (P < 0.05, respectively) and STENT group (P < 0.05, respectively), but similar to the CAG group. Systemic hemostasis is activated to a greater extent after POBA and stenting than it is after CB angioplasty of the coronary arteries. This may contribute to the favorable long-term outcome of CB angioplasty.     

Percutaneous transluminal coronary angioplasty utilizing prolonged balloon inflations: initial results and six-month follow-up

Coronary angioplasty (PTCA) using prolonged balloon inflation has obviated emergency coronary bypass surgery in some patients with acute occlusions at the time of PTCA. However, the use of prolonged balloon inflations has not been shown to improve long-term restenosis rates. As an alternative to the passive autoperfusion catheter, we evaluated a hemoperfusion system in which blood was obtained from the side arm of an arterial sheath and infused through the central lumen of standard balloon catheters via a modified Medrad IV pump during balloon inflation. PTCA was performed in 71 male patients (median age 57 yr). The median balloon inflation time was 4.8 minutes and the median rate of blood perfusion was 30 ml/min. PTCA was successful (lumen increase by 20 percentage points) in 83% of patients (59/71) with diameter stenosis decreasing from a median 82% to 30%. Emergency coronary bypass was required in four patients (5%). Angiographic data for six-month followup was available on 37 patients. The restenosis rate (loss of 50% of gain) was 46% (17/37). The conclusion is that prolonged balloon inflation angioplasty has a role in complicated PTCA but offers no advantage in improving long-term restenosis rates in elective PTCA.     

Stenting of Nonacute Total Coronary Occlusions: Predictors of Late Angiographic Outcome

Objectives. This study was designed to determine and assess factors predictive of the intermediate-term outcome of stenting of nonacute total coronary occlusions.Background. Balloon angioplasty of recanalized coronary occlusions is associated with a combined restenosis/reocclusion rate of up to 65%. Adjunctive stenting holds the potential to reduce this rate significantly. However, variables affecting the late angiographic outcome of coronary stenting in the setting of a total occlusion have not been elucidated sufficiently.Methods. Coronary stenting was performed in 143 consecutive patients with a nonacute total occlusion; 120 of these patients (84%), with a total of 121 occlusions, underwent repeat angiography within 6 months and comprised the study group. High pressure stent implantation aimed to cover the site of the occlusion as well as adjacent diameter stenoses ≥70% and all possibly induced dissections. Pertinent angiographic and procedural variables obtained at the time of the intervention were entered into a multivariate logistic regression analysis model to assess their influence on the angiographic outcome at follow-up.Results. Mean preinterventional reference lumen diameter for the 121 vessels was 2.99 ± 0.53 mm (mean ± SD); occlusion length ranged from 4 to 44 mm (median of 7.7). After balloon angioplasty, dissections were found in 80% of patients. Lesions were covered with stents a median of 16 mm in length (range 8 to 53). The minimal lumen diameter (MLD) achieved after stenting was 2.89 ± 0.48 mm. After a median follow-up period of 4.5 months, mean MLD was assessed at 1.91 ± 0.90 mm, corresponding to a loss index of 0.34 ± 0.31. There were 27 vessels with a nonocclusive restenosis ≥50% and 8 with a reocclusion, for a combined restenosis/reocclusion rate of 29%. Factors found to adversely influence angiographic outcome were a post-stenting MLD ≤2.54 mm, a stented vessel segment length >16 mm, a balloon/vessel diameter ratio for final stent expansion ≤1.00 and the presence of a dissection after balloon angioplasty.Conclusions. Compared with previous reports on stand-alone balloon angioplasty, stenting of nonacute total coronary occlusions lowers the 6-month restenosis/reocclusion rate to ∼30%. The late procedural outcome is independently and statistically significantly influenced by the MLD after stenting, the length of the stented vessel segment, the balloon/vessel diameter ratio for final stent expansion and the incidence of dissections after balloon angioplasty.     

Novel approach to the analysis of restenosis after the use of three new coronary devices.

Restenosis after coronary intervention has remained a vexing problem despite the introduction of nearly 24 newer coronary interventional devices. To more clearly evaluate the potential impact of three such new devices on restenosis, coronary lumen diameters were measured before, immediately after and at 6 months after intervention, and restenosis was analyzed using continuous geometric techniques. Lumen diameters were measured before and immediately after intervention in 223 coronary vessels treated with one of three new devices: a single Palmaz-Schatz stent (n = 87), directional atherectomy (n = 125) and laser balloon angioplasty (n = 11); 184 (83%) of the patients underwent follow-up angiography 6 months after treatment. The immediate increase in lumen diameter produced by the intervention (acute gain) and the subsequent reduction in lumen diameter between the time of intervention to 6 month follow-up study (late loss) were examined. For each of the three interventions, the restenosis rate at follow-up study was analyzed using a traditional dichotomous definition (greater than or equal to 50% diameter stenosis), as well as a novel graphic technique. Although the apparent restenosis rates differed significantly among the three interventions (19% for stents, 31% for atherectomy and 50% for laser balloon angioplasty; p = 0.02), late loss among the three interventions was equivalent (average 1 mm; p = 0.91). There were, however, marked differences in the acute gain achieved by the three interventions: 2.6 mm for stents, 2.2 mm for atherectomy and 2 mm for laser balloon angioplasty; p less than 0.001). It was these differences in acute gain rather than late loss that explained the observed differences in restenosis rate.(ABSTRACT TRUNCATED AT 250 WORDS)