Double-vessel coronary stenting via 5 french diagnostic catheters

The authors report on the use of 5 French diagnostic catheters to deliver a stent‐on‐a‐wire system during a double vessel coronary intervention. © 2011 Wiley Periodicals, Inc.     

Acute and long‐term clinical and angiographic outcomes of coronary stenting using Palmaz‐Schatz stent and ACS Multi‐Link stent

Acute and long‐term (≥ 3 years) outcomes of coronary artery stenting using Palmaz‐Schatz and Multi‐Link stent implantations between November 1995 and October 1999 were analyzed. There were 655 Palmaz‐Schatz stent implantations in 577 lesions on 477 patients (group A) and 428 Multi‐Link stent implantations in 381 lesions on 326 patients (group B). The baseline characteristics were similar in the two groups. Group B had more complex lesions, longer stenotic lesions, and larger reference vessel sizes than group A. However, both groups had a similar in‐hospital cardiac events. Four hundred and two patients with 488 lesions in group A and 260 patients with 307 lesions in group B underwent a 6‐month follow‐up coronary angiography. The restenotic rate per lesion was 16% in both groups (P = 0.872). A 3‐year angiographic follow‐up was performed in 262 patients of group A (301 lesions) and 139 patients of group B (162 lesions), and restenosis was noted in only 3 patients (1.36%) in group A and 5 patients (4%) in group B, in which the lesion was patent at the 6‐month angiographic follow‐up. Significant increase in minimal luminal diameter was noted from 2.23 ± 0.66 mm at 6 months to 2.33 ± 0.64 mm in group A (P < 0.01), and insignificant increase from 2.23 ± 0.77 to 2.28 ± 0.82 mm was noted in group B (P = 0.27). No differences were noted between the two groups in mortality, reinfarction, recurrent angina, target lesion angioplasty, or elective coronary artery bypass surgery during a follow‐up period of 60 ± 3 months. Forty‐five patients (9.4%) in group A and 18 patients (5.5%) in group B received additional stenting procedures for newly developed lesions. The overall cardiac event‐free survival was 66% in group A and 72% in group B (P = 0.844). In conclusion, the procedural success rate, in‐hospital morbidity, 6‐month angiographic results, and long‐term (≥ 3 years) clinical and angiographic outcomes were similar with coronary stenting using either Palmaz‐Schatz or Multi‐Link stent. The stented lesions were stable; however, late regression of minimal luminal diameter was noted in both groups, and progression of atherosclerotic change in the nonstented site was noted during long‐term follow‐up. Catheter Cardiovasc Interv 2004;62:453–460. © 2004 Wiley‐Liss, Inc.     

Coronary intervention with 4‐French catheters

Objectives: We sought to determine whether 4‐Fr percutaneous coronary intervention (PCI) is associated with technical difficulties that might have an unfavorable impact on procedural parameters. Background: Four‐Fr PCI is often associated with difficulties in catheter manipulation, which may lead to greater time consumption and increased dye usage when compared with PCI employing larger guiding catheters. Methods: From July 2007 to March 2009, 62 patients underwent 4‐Fr PCI. Procedural characteristics were compared between patients who underwent 4‐Fr PCI in 2007 (early phase: 31 lesions in 26 patients) and those underwent in 2008 or later (later phase: 40 lesions in 36 patients). Results: Ad‐hoc coronary intervention (3% vs. 23%, P < 0.05) and deep‐vessel intubation (46% vs. 91%, P < 0.05) were observed less frequently in the late phase than the early phase. Fluoroscopy time (8 ± 6 min vs. 17 ± 15 min, P < 0.05) and the amount of contrast dye used (64 ± 33 mL vs. 90 ± 46 mL, P < 0.05) were significantly reduced in the late phase than the early phase. No access site‐related complications were observed in patients in either phase. Conclusions: The performance of 4‐Fr PCI requires a certain learning curve, following which a reduction in fluoroscopy time and use of contrast dye may be achieved. This improvement in procedural parameters and the low incidence of access site‐related complications might allow 4‐Fr PCI to serve as a minimally invasive approach for the treatment of coronary artery diseases. © 2009 Wiley‐Liss, Inc.     

Mini-invasive strategy in acute coronary syndromes: direct coronary stenting using 5 Fr guiding catheters and transradial approach.

The purpose of this study was to assess the feasibility and safety of direct coronary stenting in acute coronary syndromes using 5 Fr guiding catheters by transradial approach. A series of 119 patients with an acute coronary syndrome (unstable angina, n = 55; acute myocardial infarction, n = 45; recent acute myocardial infarction, n = 19) explored by transradial approach and eligible for direct stenting were included. A large proportion of patients (52%) was treated during the procedure by platelet IIb/IIIa receptor blockade. Only Medtronic 5 Fr guiding catheters were used in this study. Direct coronary stenting was attempted in all 119 highly selected patients. Failure of direct stenting was observed in only five cases (3.9%) and the stent successfully retrieved in each case in the 5 Fr guiding catheter. In these five cases, balloon predilation was performed and then the stent implanted successfully. Different stents were used: ACS stent (54%), AVE stent (33%), Velocity stent (10%), Nir stent (3%), with diameter ranging from 2.5 to 4 mm. In four cases, the dilation was finally performed using 6 Fr guiding catheters because the backup of the 5 Fr catheter was considered to be too low (3%). No vascular access site complications occurred in this series of patients. We conclude that direct coronary stenting using transradial approach and 5 Fr guiding catheters yields excellent procedural success rate. In the setting of acute coronary syndromes requiring platelet IIb/IIIa receptor blockade or after failure of thrombolysis, this mini-invasive strategy is very attractive because of the low risk of access site complications.     

Transradial coronary intervention using a novel 5‐Fr sheathless guiding catheter

We have recently developed a 5‐Fr sheathless guiding catheter system (Virtual 3‐Fr, Medikit, Japan), composed of a hydrophilic catheter and a central dilator. This combination of catheter and dilator enables us to introduce the catheter into the artery without the need of an introducer sheath. Because the outer diameter of this 5‐Fr sheathless guiding catheter system is approximately 2‐Fr sizes smaller than a conventional guiding catheter system, this system provides us with less invasive angioplasty and a puncture site injury equivalent to a conventional 3‐Fr introducer sheath. To demonstrate the potential of this 5‐Fr sheathless guiding system, we report two cases of chronic total occlusion successfully treated by the transradial approach. This novel 5‐Fr sheathless system may become a viable alternative to conventional guiding catheters, and provide a favorable impact upon vascular access complications and patient morbidity. © 2009 Wiley‐Liss, Inc.     

Modified “T” stenting: A technique for kissing stents in bifurcational coronary lesion

The kissing stenting using a new technique in two patients is reported. A stent was positioned at the ostium of the side branch. Another stent was advanced into the main vessel until the center of the stent was positioned near the origin of the side branch. The stent at the ostium of the side branch was deployed and the balloon and the guidewire were removed from the side branch. Thereafter, the stent in the main vessel was deployed. The follow-up angiogram of those patients showed no restenosis in both the vessels. Cathet. Cardiovasc. Diagn. 43:323–326, 1998. © 1998 Wiley-Liss, Inc.     

Impact of operator volume on overall major adverse cardiac events following direct coronary stent implantation versus stenting after predilatation

OBJECTIVES: To determine the impact of operator experience on procedural, clinical and angiographic outcome after (direct) coronary stent implantation.

BACKGROUND: Although for other forms of percutaneous coronary interventions an inverse relationship between operator volume and patient outcomes has been shown, the impact of operator volume on outcome after direct stenting has never been investigated.

METHODS: A retrospective analysis was performed on data from a prospective randomized trial comparing direct stenting with that after predilatation. The trial consisted of 400 patients with stable and unstable angina pectoris and/or myocardial ischemia due to a coronary stenosis of a single native vessel eligible in 1999–2001 for direct stenting. For a single‐center high‐volume clinic (>1500 cases/year), the authors compared the most experienced operators (case load: >4000) with well trained practitioners (case load: 175). One hundred and fifteen patients were identified who were treated by high‐volume and 180 who were treated by medium‐volume operators.

RESULTS: Baseline patient characteristics were evenly distributed among groups. High‐volume, compared with medium‐volume operators, were faster (30.8 versus 42.2 minutes, p?<?0.001), needed less frequent postdilatation (15% versus 24%, p?=?0.06) and had lower fluoroscopy times (7.5 versus 11.2 minutes, p?<?0.001), lower contrast usage (180 versus 228?ml, p?<?0.001), lower procedural costs (€1982 versus €2164, p?=?0.05) and reduced rates of major adverse cardiac and cerebral event (MACCE) at six months (12.2 versus 21.1%, p?=?0.03). The medium‐volume operator group experienced higher angiographic binary restenosis rates after direct stenting compared with stenting after predilatation (31.5 versus 14.9%, p?=?0.005).

CONCLUSIONS: Stenting performed by high‐volume operators resulted in a 50% reduction in MACCE as compared with medium‐volume physicians, which also had twice as much restenosis when using direct stenting. Hence, the more demanding technique of direct stenting should not be performed by unsupervised operators who have not yet completed their training. Furthermore, prolonged training periods and even more intensive supervision by experienced operators seems mandatory. (Int J Cardiovasc Intervent 2004; 1:?5–12)     

The “furrowing effect”: Guidewire-induced “directional” lesion ablation in rotational atherectomy of angulated coronary artery lesions

We discuss a guidewire induced asymmetric abiative effect in three cases of rotational atherectomy facilitated angioplasty of angulated coronary artery lesions. © 1996 Wiley-Liss, Inc.     

Stepwise intravascular ultrasound (IVUS) guidance of high-pressure coronary stenting does not result in an improved acute or long-term outcome: A randomized comparison to “final-look” IVUS assessment

The objective of this study was to evaluate the potential benefit of stepwise intravascular ultrasound (IVUS)-guided coronary stent deployment compared to angiographic stent implantation with final IVUS assessment only. Acute procedural success and 6-month angiographic follow-up were compared in both groups. Intravascular ultrasound was performed using a 20- or 30-MHz mechanically rotated catheter in 85 patients who were prospectively randomized to group A (n = 42; IVUS-guided) and group B (n = 43; angiography + final IVUS assessment). There was no difference in the number of stents implanted (1.5 ± 0.9 stents/lesion in group A and 1.3 ± 0.6 stents/lesion in group B), the duration of the procedure, or the amount of contrast medium used. Defined criteria of optimal stent deployment (stent apposition, stent symmetry, complete coverage of dissections, >90% in-stent lumen area/reference lumen area) were achieved in 54.2% in group A and 56.6% in group B (NS). Angiographic follow-up was 87.1% at 6 ± 2 months, and clinical follow-up was 100% at 8 ± 1 months. There was no significant difference in restenosis rate (33.3% vs. 34.9%) applying a binary >50% diameter stenosis criterion for both groups. There was no significant difference in minimal in-stent lumen area at both baseline (7.91 ± 2.64 mm² vs. 7.76 ± 2.21 mm²) and follow-up (5.84 ± 2 mm² vs. 5.52 ± 1.87 mm²). With regard to immediate procedural lumen gain and rate of restenosis, multiple IVUS examinations during the procedure showed no advantage compared to final IVUS assessment only. Cathet. Cardiovasc. Intervent. 46:135–141, 1999. © 1999 Wiley-Liss, Inc.     

Direct stent implantation without predilatation through 5 French guiding catheter following transfemoral coronary angiogram: a feasibility study.

Direct stenting (DS) is accepted as reducing procedural cost and duration and 5 Fr guiding catheters as lowering peripheral vascular complications. We aimed to evaluate the feasibility and safety of both strategies. We retrospectively studied 150 consecutive patients treated with DS strategy using a 5 Fr femoral approach. A need for 6 Fr devices or balloon predilatation defined 5 Fr DS failure. Procedural success was defined as good angiographic result (residual stenosis < 30% and TIMI flow 3) without ischemic complications. A total of 161 out of 174 lesions were elected as suitable for DS. The success rate of 5 Fr DS was 87.6% (141/161 lesions). The procedural success rate was 92% (138/150 patients). The angiographic success rate was 96.3% (155/161 lesions). Other complications were six non-Q-wave MI and one repeat angioplasty for acute in-stent thrombosis. Only one major peripheral vascular complication occurred. Direct stenting through 5 Fr guiding catheters in selected lesions is safe and effective with a low incidence of peripheral arterial complications.     

Five‐year clinical follow‐up after implantation of the endeavor zotarolimus‐eluting stent: ENDEAVOR I,first‐in‐human study

Objective : To evaluate the 5‐year clinical outcomes of patients treated with the Endeavor zotarolimus‐eluting stent (ZES) in the ENDEAVOR I first‐in‐human study. Background : ENDEAVOR I was a prospective, nonrandomized, multicenter study of the Endeavor ZES in 100 consecutive patients with symptomatic coronary artery disease (CAD) due to de novo, stenotic lesions in native coronary arteries. Methods : Patients with single or multivessel CAD were eligible to participate, but only one lesion per patient was treated. The lesion had to have ≥50% stenosis, be ≤15 mm in length, and located in a vessel with a reference diameter of 3.0–3.5 mm. Major adverse cardiac events (MACE), target lesion revascularization (TLR), target vessel failure (TVF), and stent thrombosis were evaluated 5 years after stent implantation. Results : The cumulative incidence of MACE was 2.0% at 1 year, 3.0% at 2 years, 6.1% at 3 years, 7.2% at 4 years, and 7.2% at 5 years. At 5 years, there were seven patients who had eight events; four noncardiac (cancer) deaths, three cases of TLR, of which one presented as a non‐Q‐wave MI because of a stent thrombosis at 10 days after the index procedure. There were no late or very late stent thromboses by any definition. TVF at 5 years was 5.2%. Conclusions : Use of the Endeavor ZES to treat symptomatic CAD due to de novo lesions in native coronary arteries resulted in sustained clinical benefits to 5 years, with low rates of MACE, TLR, TVF, and stent thrombosis. © 2009 Wiley‐Liss, Inc.     

Probe “balloon on a wire” ultra-low-profile coronary catheter: Results of ptca in 107 patients

A new low-profile “balloon-on-a-wire” angioplasty catheter, the Probe? (USCI), was used in 107 patients over a 4-month period. Twenty-nine patients had stable angina, 59 had unstable angina, and 19 had had myocardial infarction (Ml) 3 to 15 days prior to the procedure; 71 patients had single-vessel and 36 had multi-vessel disease. In this series, 57 lesions were defined as complex. Successful dilatation was defined as a residual stenosis of <30%. Of 132 non-total obstructions, 127 (97%) were successfully dilated. Two distal lesions could not be reached, two lesions could not be crossed by the balloon, and a distal lesion dilatation resulted in acute closure in one case. Of 19 total obstructions, 16 (84%) were successfully dilated (mean residual stenosis 23%). The wire tip was unable to cross the lesion in the three unsuccessful procedures. Seven complications occurred in the series, all involving non-total obstructions: closure of a distal vessel and a side branch caused no clinical symptoms or EKG changes; three local dissections were tacked back with repeat dilatation; and two longitudinal dissections caused no apparent reduction in luminal diameter. The Probe's low-profile and exceptional trackability enabled it to cross very tight lesions with minimal trauma to the vessel wall. The high degree of conformability of the PET balloon minimizes vessel straightening or sheer forces and appears to reduce the potential for dissection. The device may therefore extend the indications and ease of PTCA while reducing complications of the procedure.     

Salvage of side branch by provisional “TAP technique” using absorb™ bioresorbable vascular scaffolds for bifurcation lesions: First case reports with technical considerations

Recent technological developments have led to the development of Absorb? bioresorbable vascular scaffold (BVS) [Abbott Vascular, Santa Clara, USA] for percutaneous treatment of coronary artery disease by percutaneous coronary intervention (PCI). The BVS is now approved for use in many countries but experience in bifurcation lesions is limited and largely unreported and concerns still exist about its use across major side branches. We report for the first time, the successful use of the “T and Protrusion” (TAP) technique of deploying BVS into the side branch (SB) through the struts of main branch (MB) BVS to salvage a suboptimal result and threatened closure of a SB in three cases when treating bifurcation lesions with a planned single BVS strategy. The TAP technique was successful in all cases and there were no complications. All patients continue to do well at short‐term follow‐up. This case report provides information regarding the feasibility as well as technical and procedural insights when using BVS for bifurcation lesions. © 2014 Wiley Periodicals, Inc.     

Utilizing state‐of‐the‐art “omics” technology and bioinformatics to identify new biological mechanisms and biomarkers for coronary artery disease

Identification of the four standard modifiable cardiovascular risk factors (SMuRFs)—diabetes mellitus, hyperlipidaemia, hypertension, and cigarette smoking—has allowed the development of risk scores. These have been used in conjunction with primary and secondary prevention strategies targeting SMuRFs to reduce the burden of CAD. Recent studies show that up to 25% of ACS patients do not have any SMuRFs. Thus, SMuRFs do not explain the entire burden of CAD. There appears to be variation at the individual level rendering some individuals relatively susceptible or resilient to developing atherosclerosis. Important disease pathways remain to be discovered, and there is renewed enthusiasm to discover novel biomarkers, biological mechanisms, and therapeutic targets for atherosclerosis. Two broad approaches are being taken: traditional approaches investigating known candidate pathways and unbiased omics approaches. We review recent progress in the field and discuss opportunities made possible by technological and data science advances. Developments in network analytics and machine learning algorithms used in conjunction with large‐scale multi‐omic platforms have the potential to uncover biological networks that may not have been identifiable using traditional approaches. These approaches are useful for both biomedical research and precision medicine strategies.     

Five‐year long‐term clinical follow‐up of the XIENCE V everolimus eluting coronary stent system in the treatment of patients with de novo coronary artery lesions: The SPIRIT FIRST trial

Background : Drug‐eluting stents have shown to be superior over bare metal stents in clinical and angiographic outcomes after percutaneous treatment of coronary artery stenosis. However, long‐term follow‐up data are scarce and only available for sirolimus‐ and paclitaxel‐eluting stents. Aim : To assess the feasibility and performance of the XIENCE V everolimus‐eluting stent (EES) versus an identical bare metal stent after a 5‐year follow‐up period. Methods : SPIRIT FIRST was a First in Man, multicentre, prospective, single‐blind, clinical trial, randomizing 60 patients with a single de novo coronary artery lesion in a ratio of 1:1 to either an everolimus eluting or a bare metal control stent. Results : At 5‐year clinical follow‐up, data were available in 89% and 86% of patients in the everolimus and control arm, respectively. In the everolimus arm, no additional death, myocardial infarction, clinically driven target lesion revascularization (TLR), or clinically driven target vessel revascularization (TVR) events were observed between 1‐ and 5‐year follow‐up. The 5‐year hierarchical major adverse cardiac events (MACE) and target vessel failure (TVF) rates for the everolimus arm were 16.7% (4/24) for both endpoints. In the control group, no additional cardiac death, myocardial infarction, or clinically driven TLR events were observed between 2‐ and 5‐year follow‐up. No additional clinically driven TVR events were observed between 3‐ and 5‐year follow‐up. The 5‐year hierarchical MACE and TVF rates for the control arm were 28.0% (7/25) and 36.0% (9/25), respectively. No stent thromboses were observed in either the everolimus arm or the control arm up to 5 years. Conclusion : The favorable 5‐year long term clinical outcome of the EES is consistent with the results from other studies of the EES with shorter follow‐up. © 2010 Wiley‐Liss, Inc.     

Stenting coronary trifurcation lesions: Is “ménage à trois” the solution?

Percutaneous treatment of coronary stenoses involving important side branches remains a challenge to the interventionist. We describe two cases of stent deployment in coronary trifurcation lesions. Triple kissing balloon inflation appears important for achieving an optimal angiographic and clinical result.     

Myocardial ischemia in patients with fixed occlusive coronary artery disease secondary to vasospasm in the “normal” vessel

Seven patients with significant fixed occlusive coronary artery disease had coronary artery spasm in a “normal” vessel. All patients had one or more episodes of rest angina and six had exertional angina as well. Four sustained previous myocardial infarction. During spontaneous angina, five patients had ST-segment elevation in the inferior electrocardiographic leads. One patient had ST-segment elevation in anterior leads. During angiography, spasm was demonstrated in the right coronary artery in three patients and in the left anterior descending coronary artery in one patient. This study emphasizes the interaction of fixed and vasospastic disease and has strong implications concerning the management of patients with ischemic heart disease.