115 results on '"Graft Occlusion, Vascular"'
Search Results
2. Everolimus-Eluting Bioresorbable Scaffolds Versus Everolimus-Eluting Metallic Stents
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Gennaro Giustino, Birgit Vogel, Ciro Indolfi, Samin K. Sharma, George Dangas, Serdar Farhan, Roxana Mehran, Sabato Sorrentino, Michela Faggioni, and A. Kini
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Target lesion ,medicine.medical_specialty ,medicine.medical_treatment ,Coronary Artery Disease ,030204 cardiovascular system & hematology ,Coronary Angiography ,Prosthesis Design ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,Percutaneous Coronary Intervention ,Randomized controlled trial ,law ,Absorbable Implants ,Medicine ,Humans ,030212 general & internal medicine ,Everolimus ,Tissue Scaffolds ,business.industry ,Absolute risk reduction ,Graft Occlusion, Vascular ,Percutaneous coronary intervention ,Drug-Eluting Stents ,Number needed to harm ,Confidence interval ,Surgery ,Relative risk ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Background Recent evidence suggests that bioresorbable vascular scaffolds (BVS) are associated with an excess of thrombotic complications compared with metallic everolimus-eluting stents (EES). Objectives This study sought to investigate the comparative effectiveness of the Food and Drug Administration–approved BVS versus metallic EES in patients undergoing percutaneous coronary intervention at longest available follow-up. Methods The authors searched MEDLINE, Scopus, and web sources for randomized trials comparing BVS and EES. The primary efficacy and safety endpoints were target lesion failure and definite or probable stent thrombosis, respectively. Results Seven trials were included: in sum, 5,583 patients were randomized to receive either the study BVS (n = 3,261) or the EES (n = 2,322). Median time of follow-up was 2 years (range 2 to 3 years). Compared with metallic EES, risk of target lesion failure (9.6% vs. 7.2%; absolute risk difference: +2.4%; risk ratio: 1.32; 95% confidence interval: 1.10 to 1.59; number needed to harm: 41; p = 0.003; I2 = 0%) and stent thrombosis (2.4% vs. 0.7%; absolute risk difference: +1.7%; risk ratio: 3.15; 95% confidence interval: 1.87 to 5.30; number needed to harm: 60; p 1 year) periods (pinteraction = 0.49). Conclusions Compared with metallic EES, the BVS appears to be associated with both lower efficacy and higher thrombotic risk over time. (Bioresorbable vascular scaffold compare to everolimus stents in long term follow up; CRD42017059993).
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- 2017
3. Bioresorbable Vascular Scaffold Technology Benefits From Healthy Skepticism
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Salvatore Cassese and Adnan Kastrati
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Male ,medicine.medical_specialty ,Scaffold ,Percutaneous ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Coronary artery disease ,Coronary Restenosis ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,Absorbable Implants ,medicine ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,Acute Coronary Syndrome ,Bioresorbable vascular scaffold ,Tissue Scaffolds ,business.industry ,Graft Occlusion, Vascular ,Stent ,medicine.disease ,Thrombosis ,Surgery ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Current high-performance metallic drug-eluting stents (DES) represent the gold standard for the percutaneous treatment of obstructive coronary artery disease (CAD) [(1)][1]. Notwithstanding this, the permanent nature of the metallic implants may elicit pathophysiological processes at the level of
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- 2015
4. Intensive Lipid-Lowering With Atorvastatin for Secondary Prevention in Patients After Coronary Artery Bypass Surgery
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Sanjiv J. Shah, John J.P. Kastelein, David A. DeMicco, Andrei Breazna, David D. Waters, Nanette K. Wenger, John C. LaRosa, James Shepherd, Philip J. Barter, ACS - Amsterdam Cardiovascular Sciences, and Vascular Medicine
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Adult ,Male ,medicine.medical_specialty ,Atorvastatin ,Coronary Artery Disease ,law.invention ,Coronary Restenosis ,chemistry.chemical_compound ,Coronary artery bypass surgery ,Randomized controlled trial ,law ,Internal medicine ,medicine ,Clinical endpoint ,Humans ,Pyrroles ,cardiovascular diseases ,Myocardial infarction ,Coronary Artery Bypass ,Stroke ,Triglycerides ,Aged ,Cholesterol ,business.industry ,Anticholesteremic Agents ,Graft Occlusion, Vascular ,Cholesterol, LDL ,Middle Aged ,medicine.disease ,medicine.anatomical_structure ,Treatment Outcome ,chemistry ,Heptanoic Acids ,Cardiology ,lipids (amino acids, peptides, and proteins) ,Female ,business ,Cardiology and Cardiovascular Medicine ,medicine.drug ,Artery - Abstract
OBJECTIVES: The aim of this post hoc analysis from the TNT (Treating to New Targets) trial is to determine whether patients with previous coronary artery bypass grafting (CABG) surgery achieved clinical benefit from intensive low-density lipoprotein (LDL)-cholesterol lowering. BACKGROUND: The development and progression of atherosclerosis is accelerated in coronary venous bypass grafts. METHODS: A total of 10,001 patients with documented coronary disease, including 4,654 with previous CABG, were randomized to atorvastatin 80 or 10 mg/day and were followed for a median of 4.9 years. The primary end point was the occurrence of a first major cardiovascular event (cardiac death, nonfatal myocardial infarction, resuscitated cardiac arrest, or stroke). RESULTS: A first major cardiovascular event occurred in 11.4% of the patients with prior CABG and 8.5% of those without prior CABG (p < 0.001). In CABG patients, mean LDL-cholesterol levels at study end were 79 mg/dl in the 80-mg arm and 101 mg/dl in the 10-mg arm, and the primary event rate was 9.7% in the 80-mg arm and 13.0% in the 10-mg arm (hazard ratio 0.73, 95% confidence interval 0.62 to 0.87, p = 0.0004). Repeat revascularization during follow-up, either CABG or percutaneous coronary intervention, was performed in 11.3% of the CABG patients in the 80-mg arm and 15.9% in the 10-mg arm (hazard ratio 0.70, 95% confidence interval 0.60 to 0.82, p < 0.0001). CONCLUSIONS: Intensive LDL-cholesterol lowering to a mean of 79 mg/dl with atorvastatin 80 mg/day in patients with previous CABG reduces major cardiovascular events by 27% and the need for repeat coronary revascularization by 30%, compared with less intensive cholesterol-lowering to a mean of 101 mg/dl with atorvastatin 10 mg/day. (A Study to Determine the Degree of Additional Reduction in CV Risk in Lowering LDL Below Minimum Target Levels [TNT]; NCT00327691)
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- 2008
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5. Extracellular Superoxide Dismutase Accelerates Endothelial Recovery and Inhibits In-Stent Restenosis in Stented Atherosclerotic Watanabe Heritable Hyperlipidemic Rabbit Aorta
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Matias Inkala, Samar Basu, Juha Rutanen, Mikko O. Laukkanen, Max Levin, Jan Hinrich Bräsen, Tommi Heikura, Anna-Liisa Levonen, David Bergqvist, Seppo Ylä-Herttuala, Günter Klöppel, Olli Leppänen, Thomas Zeller, Fabian Ahrens, and Hubertus Pietsch
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Pathology ,medicine.medical_specialty ,Endothelium ,Genetic Vectors ,Aortic Diseases ,Pharmacology ,medicine.disease_cause ,Adenoviridae ,Superoxide dismutase ,chemistry.chemical_compound ,Restenosis ,medicine.artery ,medicine ,Animals ,Aorta ,biology ,business.industry ,Vascular disease ,Superoxide ,Superoxide Dismutase ,Graft Occlusion, Vascular ,Free Radical Scavengers ,medicine.disease ,Atherosclerosis ,Disease Models, Animal ,Oxidative Stress ,medicine.anatomical_structure ,chemistry ,Circulatory system ,biology.protein ,Stents ,Endothelium, Vascular ,Rabbits ,business ,Cardiology and Cardiovascular Medicine ,Oxidative stress - Abstract
ObjectivesThis study examined whether local gene therapy with extracellular superoxide dismutase (EC-SOD) could inhibit in-stent restenosis in atherosclerotic Watanabe heritable hyperlipidemic rabbits.BackgroundStenting causes an acute increase in superoxide anion production and oxidative stress; EC-SOD is a major component of antioxidative defense in blood vessels and has powerful cardioprotective effects in ischemic myocardium.MethodsEndothelial denudation and stenting were done in 36 adult (15 to 18 months old) rabbits. Catheter-mediated intramural delivery of clinical good manufacturing practice-grade adenoviruses encoding rabbit EC-SOD were done simultaneously with stenting. Control animals received adenovirus-encoding nuclear-targeted β-galactosidase (AdLacZ). Circulating markers for oxidative stress (nonesterified 8-iso-prostaglandin F2alpha) were measured. Analysis of 6-day, 28-day, and 90-day vessel histology, radical production, oxidation-specific epitopes, and expression studies were performed.ResultsThe EC-SOD treatment reduced oxidant production in stented vessels compared with control vessels. Early systemic recovery of total SOD activity was observed in the treated rabbits. The EC-SOD significantly accelerated endothelial recovery (67.4% ± 10.8% vs. 24.2.1% ± 4.6% at 6 days, p < 0.05; 89.3% ± 3.7% vs. 45.1% ± 9.6% at 28 days, p < 0.05), and the beneficial effect involved increased proliferation of regenerating endothelium. The EC-SOD group showed a 61.3% lower (p < 0.05) neointimal formation at 28 days, with a similar, albeit nonsignificant trend at 90 days (1.20 ± 0.32 mm2vs. 1.88 ± 0.24 mm2, p = 0.06).ConclusionsThe results suggest a central pathogenetic role of oxidation sensitive signaling processes in endothelial recovery and developing in-stent restenosis in atherosclerotic vessels. Local therapy against oxidative stress represents a promising therapeutic strategy in stent-induced vascular injury.
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- 2007
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6. Bioresorbable Coronary Scaffold Thrombosis: Multicenter Comprehensive Analysis of Clinical Presentation, Mechanisms, and Predictors
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Serban, Puricel, Florim, Cuculi, Melissa, Weissner, Axel, Schmermund, Peiman, Jamshidi, Tobias, Nyffenegger, Harald, Binder, Holger, Eggebrecht, Thomas, Münzel, Stephane, Cook, and Tommaso, Gori
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Male ,Time Factors ,Tissue Scaffolds ,Incidence ,Graft Occlusion, Vascular ,Middle Aged ,Coronary Angiography ,Prognosis ,Prosthesis Design ,Coronary Restenosis ,Survival Rate ,Germany ,Absorbable Implants ,Humans ,Female ,Acute Coronary Syndrome ,Switzerland ,Aged ,Follow-Up Studies ,Retrospective Studies - Abstract
Recent reports suggest an elevated incidence of bioresorbable vascular scaffold (BVS) thrombosis (scaffold thrombosis [ScT]).This study investigated occurrence rates, clinical and angiographic characteristics, and possible mechanisms of ScT in all-comer patients undergoing BVS implantation at 2 German and 2 Swiss hospitals.A total of 1,305 consecutive patients (mean age 64 years, 78% male) who received 1,870 BVS (mean 1.4 ± 0.8 BVS/patient) were enrolled. Clinical/procedural characteristics, mortality, and ScT data at 485 days (range 312 to 652 days) were examined.ScT occurred in 42 patients. The incidence of probable and definite ScT was 1.8% at 30 days and 3.0% at 12 months, without differences among centers (p = 0.60). A total of 22 (52%) ScTs presented as ST-segment elevation myocardial infarction and 6 (17%) as sudden cardiac death. In multivariable analysis, ostial lesions (p = 0.049) and impaired left ventricular ejection fraction (p = 0.019) were independently associated with ScT. Nine (21%) of the ScTs occurred in patients who had suspended dual antiplatelet therapy, in 6 cases prematurely. Lower post-procedural minimum lumen and reference vessel diameters were hallmarks of ScT (all p0.0001). The risk of ScT appeared to rapidly increase for post-procedural minimum lumen diameters below 2.4 mm (for the 2.5- to 3.0-mm BVS) and 2.8 mm (for the 3.5-mm BVS). When a BVS-specific implantation strategy was implemented, 12-month ScT rates fell from 3.3% to 1.0%, an effect that remained significant when adjusted for multivariable propensity score (p = 0.012; hazard ratio: 0.19; 95% confidence interval: 0.05 to 0.70).The 12-month incidence of ScT reached 3% and could be significantly reduced when an optimized implantation strategy was employed. (retrospective multicentric registry and Mainz Intracoronary Database. The Coronary Slow-flow and Microvascular Diseases Registry [MICAT]; NCT02180178).
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- 2015
7. Meta-Analyses of Dual Antiplatelet Therapy Following Drug-Eluting Stent Implantation: Do Bleeding and Stent Thrombosis Weigh Similar on Mortality?
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Davide, Capodanno, Giuseppe, Gargiulo, Sergio, Buccheri, Daniele, Giacoppo, Piera, Capranzano, and Corrado, Tamburino
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Percutaneous Coronary Intervention ,Graft Occlusion, Vascular ,Myocardial Infarction ,Humans ,Drug-Eluting Stents ,Platelet Aggregation Inhibitors - Published
- 2015
8. Short- versus long-term dual antiplatelet therapy after drug-eluting stent implantation: an individual patient data pairwise and network meta-analysis
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Tullio, Palmerini, Diego, Sangiorgi, Marco, Valgimigli, Giuseppe, Biondi-Zoccai, Fausto, Feres, Alexandre, Abizaid, Ricardo A, Costa, Myeong-Ki, Hong, Byeong-Keuk, Kim, Yangsoo, Jang, Hyo-Soo, Kim, Kyung Woo, Park, Andrea, Mariani, Diego, Della Riva, Philippe, Genereux, Martin B, Leon, Deepak L, Bhatt, Umberto, Bendetto, Claudio, Rapezzi, and Gregg W, Stone
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Percutaneous Coronary Intervention ,Graft Occlusion, Vascular ,Myocardial Infarction ,Humans ,Drug-Eluting Stents ,Drug Administration Schedule ,Platelet Aggregation Inhibitors ,Randomized Controlled Trials as Topic - Abstract
Randomized controlled trials comparing short- (≤6 months) with long-term (≥1 year) dual antiplatelet therapy (DAPT) after drug-eluting stent(s) (DES) placement have been insufficiently powered to detect significant differences in the risk of major adverse cardiac events (MACE).This study sought to compare clinical outcomes between short- (≤6 months) and long-term (1 year) DAPT and among 3 months, 6 months, and 1 year of DAPT post-DES placement by performing an individual patient data pairwise and network meta-analysis.Randomized controlled trials comparing DAPT durations after DES placement were searched through the MEDLINE, EMBASE, and Cochrane databases and in international meeting proceedings. The primary study outcome was 1-year risk of MACE (cardiac death, myocardial infarction, or definite/probable stent thrombosis).Four trials including 8,180 randomized patients were identified. At 1-year follow-up, short-term DAPT was associated with similar rates of MACE (hazard ratio [HR]: 1.11; 95% confidence interval [CI]: 0.86 to 1.43; p = 0.44), but significantly lower rates of bleeding (HR: 0.66; 95% CI: 0.46 to 0.94; p = 0.03) versus prolonged DAPT. Comparable results were apparent in the landmark period between DAPT discontinuation and 1-year follow-up (for MACE: HR: 1.20; 95% CI: 0.77 to 1.89; p = 0.42) (for bleeding: HR: 0.44; 95% CI: 0.21 to 0.91; p = 0.03). There were no significant differences in 1-year rates of MACE among 3-month versus 1-year DAPT, 6-month versus 1-year DAPT, or 3-month versus 6-month DAPT.Compared with prolonged DAPT, short-term DAPT is associated with similar rates of MACE but lower rates of bleeding after DES placement.
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- 2014
9. Prevalence and clinical impact of stent fractures after femoropopliteal stenting
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Andrej Schmidt, Matthias Ulrich, Susanne Scheinert, Giancarlo Biamino, Dierk Scheinert, Jacqueline Sax, Sven Bräunlich, and Christopher Piorkowski
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medicine.medical_specialty ,medicine.medical_treatment ,Radiography ,Arterial Occlusive Diseases ,Femoral artery ,Long segment ,Severity of Illness Index ,% diameter reduction ,Restenosis ,medicine.artery ,Alloys ,Medicine ,Vascular Patency ,Humans ,Clinical significance ,Popliteal Artery ,cardiovascular diseases ,business.industry ,Graft Occlusion, Vascular ,Stent ,medicine.disease ,equipment and supplies ,Surgery ,Femoral Artery ,surgical procedures, operative ,Equipment Failure ,Stents ,Radiology ,business ,Cardiology and Cardiovascular Medicine ,Follow-Up Studies - Abstract
Objectives The aim of this study was to investigate the occurrence and the clinical impact of stent fractures after femoropopliteal stenting. Background The development of femoral stent fractures has recently been described; however, there are no data about the frequency and the clinical relevance. Methods A systematic X-ray screening for stent fractures was performed in 93 patients. In total, 121 legs treated by implantation of self-expanding nitinol stents were investigated after a mean follow-up time of 10.7 months. The mean length of the stented segment was 15.7 cm. Results Overall, stent fractures were detected in 45 of 121 treated legs (37.2%). In a stent-based analysis, 64 of 261 stents (24.5%) showed fractures, which were classified as minor (single strut fracture) in 31 cases (48.4%), moderate (fracture of >1 strut) in 17 cases (26.6%), and severe (complete separation of stent segments) in 16 cases (25.0%). Fracture rates were 13.2% for stented length ≤8 cm, 42.4% for stented length >8 to 16 cm, and 52.0% for stented length >16 cm. In 21 cases (32.8%) there was a restenosis of >50% diameter reduction at the site of stent fracture. In 22 cases (34.4%) with stent fracture there was a total stent reocclusion. According to Kaplan-Meier estimates, the primary patency rate at 12 months was significantly lower for patients with stent fractures (41.1% vs. 84.3%, p Conclusions There is a considerable risk of stent fractures after long segment femoral artery stenting, which is associated with a higher in-stent restenosis and reocclusion rate.
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- 2005
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10. A randomized trial of polytetrafluoroethylene-membrane-covered stents compared with conventional stents in aortocoronary saphenous vein grafts
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Christian W. Hamm, Stephan Baldus, Roman Arnold, Ludger Thiele, Benno Hennen, Peter Probst, Eberhard Grube, Volker Schächinger, Jürgen vom Dahl, Thomas Konorza, Franz-Josef Neumann, Tassilo Bonzel, Ralf Köster, Stents (STents In Grafts) Investigators, Andreas M. Zeiher, Jürgen Haase, Thomas Münzel, Michael Haude, and Harald Mudra
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Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Vein graft ,Coronary Angiography ,law.invention ,Coronary Restenosis ,chemistry.chemical_compound ,Coated Materials, Biocompatible ,Randomized controlled trial ,Blood vessel prosthesis ,law ,medicine ,Humans ,Saphenous Vein ,In patient ,Prospective Studies ,Coronary Artery Bypass ,Polytetrafluoroethylene ,Covered stent ,Aged ,business.industry ,Graft Occlusion, Vascular ,Follow up studies ,Stent ,Membranes, Artificial ,Blood Vessel Prosthesis ,Surgery ,chemistry ,Female ,Stents ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
ObjectivesWe compared a conventional stent (Jostent Flex, Jomed GmbH, Rangendingen, Germany) with a polytetrafluoroethylene (PTFE)-membrane-covered stent (Jostent Stentgraft) in patients undergoing intervention of a stenosis in an obstructed vein graft.BackgroundThe use of stents improved results of percutaneous revascularization of obstructed vein grafts, but did not demonstrate the reduced elevated restenosis rate. In addition, long-term clinical event rate is still high compared with intervention in native vessels. Observational studies suggested that stents covered with a PTFE membrane might be associated with a low complication and restenosis rate in venous bypass grafts.MethodsThis prospective multicenter study included a total of 211 patients who were randomly assigned to receive either a Flex stent or Stentgraft. The primary end point was binary restenosis rate at six months by core lab quantitative coronary angiography.ResultsAcute success and procedural events were comparable between the two groups. Restenosis rate was not significantly different between the Flex (20%) and the Stentgraft (29%) groups (p = 0.15), although there was a nonsignificant trend toward a higher late occlusion rate in the Stentgraft group (7% vs. 16%, p = 0.069) at follow-up. Likewise, after a mean observation period of 14 months, cumulative event rates (death, myocardial infarction, or target lesion revascularization) were comparable in the two groups (31% vs. 31%, p = 0.93).ConclusionsThis controlled trial does not indicate a superiority of the PTFE-membrane-covered Stentgraft compared with a conventional stent with respect to acute results, restenosis, or clinical event rates.
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- 2003
11. Effect of percutaneous coronary interventions for in-stent restenosis in degenerated saphenous vein grafts without distal embolic protection
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Frank Kuepper, Ioannis Iakovou, Dale T. Ashby, George Dangas, Jeffery W. Moses, Roxana Mehran, Gregg W. Stone, Martin B. Leon, and Eve A Aymong
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Embolism ,Coronary Angiography ,Risk Assessment ,Severity of Illness Index ,Cohort Studies ,Coronary Restenosis ,Restenosis ,Coronary Circulation ,Angioplasty ,Internal medicine ,medicine ,Humans ,Saphenous Vein ,Prospective Studies ,cardiovascular diseases ,Myocardial infarction ,Angioplasty, Balloon, Coronary ,Coronary Artery Bypass ,Aged ,Aged, 80 and over ,business.industry ,Coronary Stenosis ,Graft Occlusion, Vascular ,Stent ,Length of Stay ,Embolic Protection Devices ,medicine.disease ,Surgery ,Survival Rate ,Treatment Outcome ,Conventional PCI ,Cardiology ,Female ,Stents ,Cutting balloon ,Cardiology and Cardiovascular Medicine ,business ,TIMI ,Follow-Up Studies - Abstract
Objectives This study was designed to investigate the impact of percutaneous coronary interventions (PCIs) in degenerated saphenous vein grafts (SVGs) without distal embolic protection. Background Distal embolic protection devices have been shown to reduce the incidence of no reflow/slow flow during PCI of de novo lesions in degenerated SVGs. It is unclear whether PCI of in-stent restenosis (ISR) lesions in degenerated SVGs is associated with no reflow/slow flow and whether distal embolic protection is beneficial in these cases as well. Methods We studied 54 consecutive patients with treated ISR lesions in degenerated SVGs who underwent PCI without distal embolic protection in a single center. Procedural and in-hospital outcomes were examined. Results The average age was 71 ± 8 years; 32% of the patients had diabetes. The mean lesion length was 13 ± 6 mm and the procedural success rate was 98% (53/54). Cutting balloon angioplasty was used in 46% (25/54) of cases, and a new stent was inserted in 46% (25/54) of patients. Gamma brachytherapy was performed in 19% (10/54) of patients. During the procedure there were no episodes of no reflow/slow flow, and there were no patients with in-hospital Q-wave or non–Q-wave myocardial infarction. There was one in-hospital noncardiac death. Conclusions In this consecutive series of patients with ISR of degenerated SVGs undergoing PCI without distal protection, there were no episodes of slow flow/no reflow and no procedure-related myocardial infarctions. It appears that distal embolic protection may not be necessary during PCI of ISR lesions in degenerated SVGs.
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- 2003
12. The outcome of percutaneous coronary intervention in patients with In-Stentrestenosis who failed intracoronary radiation therapy
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Rosanna C. Chan, Dong-Hun Cha, Joe Lindsay, Edouard Cheneau, Marco T. Castagna, Ellen Pinnow, Ron Waksman, Andrew E. Ajani, Augusto D. Pichard, Lowell F. Satler, Kenneth M. Kent, and Scott McGlynn
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Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Revascularization ,Balloon ,Coronary Angiography ,Cohort Studies ,Restenosis ,Angioplasty ,Outcome Assessment, Health Care ,medicine ,Humans ,Angioplasty, Balloon, Coronary ,Coronary Artery Bypass ,Aged ,Retrospective Studies ,business.industry ,Graft Occlusion, Vascular ,Percutaneous coronary intervention ,Middle Aged ,medicine.disease ,Surgery ,Conventional PCI ,Retreatment ,Female ,Cutting balloon ,business ,Cardiology and Cardiovascular Medicine ,Mace - Abstract
Objectives This study reports the outcome of patients who failed intracoronary radiation therapy (IRT) for the treatment of in-stent restenosis (ISR). Background Intracoronary radiation therapy has demonstrated a reduction in the recurrence rate of restenosis for patients with ISR. However, 10% to 30% of these patients require repeat intervention to the irradiated site. Methods Of 961 patients who were assigned to gamma or beta radiation for the treatment of diffuse ISR, we evaluated the outcome of 282 (29%) consecutive patients who failed IRT and compared them with the 679 (71%) patients who had successful IRT. For patients who failed radiation, the mean time to the first target vessel revascularization (TVR) was 173 ± 127 days after the index procedure and the total duration of follow-up was 494 ± 304 days. Results Patients who failed IRT were younger (60 ± 10 vs. 63 ± 11 years, p = 0.002) and had a higher incidence of restenting (51% vs. 41%, p = 0.003). The majority (55%) of the restenotic lesions after IRT failure were focal (≤10 mm), with a mean lesion length of 11.9 ± 1.9 mm. Of the 257 patients who had subsequent TVR after failed IRT, 68 (26%) underwent coronary artery bypass grafting and 189 (74%) underwent percutaneous coronary intervention using balloon in 61%, restenting in 26%, atheroablation in 11%, and the cutting balloon in 2% of cases. At six months, 6% of patients died, 1% had Q-wave MI, 17% had repeat TVR, and the overall rate of major adverse cardiac events was 21%. Conclusions The predominant angiographic pattern of lesions in patients who failed IRT is focal restenosis, with these lesions responding well to conventional revascularization methods.
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- 2003
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13. Statin therapy, inflammation and recurrent coronary events in patients following coronary stent implantation
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Wolfgang Auch-Schwelk, Patrick Rosin, Andreas M. Zeiher, Stephan Fichtlscherer, Volker Schächinger, Dirk Walter, and Martina B. Britten
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,MIRACL ,Coronary Angiography ,Coronary Restenosis ,Internal medicine ,Angioplasty ,Coronary stent ,medicine ,Combined Modality Therapy ,Humans ,cardiovascular diseases ,Angioplasty, Balloon, Coronary ,Coronary Artery Bypass ,Aged ,Chemotherapy ,biology ,business.industry ,Anticholesteremic Agents ,C-reactive protein ,Coronary Stenosis ,Graft Occlusion, Vascular ,Stent ,Middle Aged ,Surgery ,C-Reactive Protein ,Relative risk ,Retreatment ,biology.protein ,Cardiology ,Female ,Stents ,Hydroxymethylglutaryl-CoA Reductase Inhibitors ,business ,Cardiology and Cardiovascular Medicine ,Follow-Up Studies - Abstract
OBJECTIVES We sought to investigate whether statin therapy affects the association between preprocedural C-reactive protein (CRP) levels and the risk for recurrent coronary events in patients undergoing coronary stent implantation. BACKGROUND Low-grade inflammation as detected by elevated CRP levels predicts the risk of recurrent coronary events. The effect of inflammation on coronary risk may be attenuated by statin therapy. METHODS We investigated a potential interrelation among statin therapy, serum evidence of inflammation, and the risk for recurrent coronary events in 388 consecutive patients undergoing coronary stent implantation. Patients were grouped according to the median CRP level (0.6 mg/dl) and to the presence of statin therapy. RESULTS A primary combined end point event occurred significantly more frequently in patients with elevated CRP levels without statin therapy (RR [relative risk] 2.37, 95% CI [confidence interval] [1.3 to 4.2]). Importantly, in the presence of statin therapy, the RR for recurrent events was significantly reduced in the patients with elevated CRP levels (RR 1.27 [0.7 to 2.1]) to about the same degree as in patients with CRP levels below 0.6 mg/dl and who did not receive statin therapy (RR 1.1 [0.8 to 1.3]). CONCLUSIONS Statin therapy significantly attenuates the increased risk for major adverse cardiac events in patients with elevated CRP levels undergoing coronary stent implantation, suggesting that statin therapy interferes with the detrimental effects of inflammation on accelerated atherosclerotic disease progression following coronary stenting.
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- 2001
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14. Provisional stenting strategies: systematic overview and implications for clinical decision-making
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Warren J. Cantor, James P. Zidar, Michael H. Sketch, Jeffrey J. Popma, E. Magnus Ohman, James E. Tcheng, and Eric D. Peterson
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medicine.medical_specialty ,medicine.medical_treatment ,Decision Making ,Coronary Disease ,Fractional flow reserve ,Coronary Angiography ,Prosthesis Design ,Blood Vessel Prosthesis Implantation ,Restenosis ,Angioplasty ,Internal medicine ,Intravascular ultrasound ,medicine ,Humans ,Myocardial infarction ,cardiovascular diseases ,Risk factor ,Ultrasonography, Interventional ,medicine.diagnostic_test ,business.industry ,Patient Selection ,Graft Occlusion, Vascular ,Stent ,Health Care Costs ,medicine.disease ,equipment and supplies ,surgical procedures, operative ,Angiography ,Cardiology ,Stents ,business ,Cardiology and Cardiovascular Medicine - Abstract
Coronary stents reduce the rates of abrupt closure, emergency coronary artery bypass graft surgery and restenosis, but do not prevent myocardial infarction or death at six months. The financial burden of increased stent use and the difficulty in managing in-stent restenosis have provided the impetus to develop provisional stenting strategies. Patients at low risk for restenosis after balloon angioplasty may not derive additional benefit from stent implantation and may be successfully managed with percutaneous transluminal coronary angioplasty (PTCA) alone. Numerous patient, lesion and procedural predictors of restenosis have been identified. Postprocedural assessment using quantitative coronary angiography, intravascular ultrasound (IVUS), coronary flow velocity reserve (CVR) or fractional flow reserve (FFR) may further enhance the ability to predict adverse outcomes after PTCA. Several studies have been performed to investigate the feasibility of provisional stenting strategies using various modalities to identify low risk patients who could be managed with PTCA alone. An optimal or “stent-like” angiographic result after PTCA is associated with favorable clinical outcomes. Preliminary results of studies using IVUS or CVR to guide provisional stenting appear promising. Angiography alone may be inadequate to identify truly low risk patients and may need to be combined with clinical factors, assessment of recoil, IVUS or physiologic indexes. Strategies that avoid unnecessary stenting in even a small proportion of patients may have large impacts on health care costs. Provisional stenting may potentially reduce costs and rates of in-stent restenosis without compromising the quality of health care delivery.
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- 2000
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15. Application of a continuous regression model of restenosis to saphenous vein grafts after successful percutaneous transluminal coronary angioplasty or directional coronary atherectomy
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Richard E. Kuntz, Eric J. Topol, Jeffrey J. Popma, Charles J. Bruce, David R. Holmes, and Karen S. Pieper
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Atherectomy, Coronary ,Male ,Reoperation ,medicine.medical_specialty ,Percutaneous transluminal coronary angioplasty ,Lumen (anatomy) ,Vein graft ,Coronary Artery Disease ,Coronary Angiography ,Lesion ,Restenosis ,Internal medicine ,medicine ,Humans ,Saphenous Vein ,Angioplasty, Balloon, Coronary ,Coronary Artery Bypass ,Aged ,Models, Statistical ,business.industry ,Graft Occlusion, Vascular ,Middle Aged ,medicine.disease ,Surgery ,Coronary arteries ,medicine.anatomical_structure ,Treatment Outcome ,Cardiology ,Female ,medicine.symptom ,Vein graft disease ,business ,Cardiology and Cardiovascular Medicine ,Artery - Abstract
OBJECTIVES To evaluate a quantitative model of restenosis in patients with vein graft disease undergoing percutaneous transluminal coronary angioplasty (PTCA) or directional coronary atherectomy (DCA). BACKGROUND A quantitative relationship between acute gain and late loss has been developed to describe the late changes in lumen dimension after native vessel coronary intervention. This same relationship may also be seen after treatment of saphenous vein graft disease. METHODS Patients with native coronary artery stenoses (CAVEAT-I) or saphenous vein graft lesions (CAVEAT-II) were randomized to either DCA or PTCA, and data from these trials were analyzed retrospectively. Angiographic results of the target lesions were reviewed, and each lesion was assessed for vessel caliber and reference diameter, absolute minimal lumen diameter, percent diameter stenosis, percent stenosis of the cross-sectional area, acute gain and late loss. Linear regression models were used to determine late loss and to detect differences in angiographic outcomes. RESULTS Vein grafts had significantly larger reference vessel diameters than native coronary arteries; they also had significantly more acute gain and more late loss. Directional coronary atherectomy was associated with a larger acute gain in both studies. Patients undergoing DCA also experienced greater late loss although the effect was statistically significant only in the CAVEAT-I study. After adjusting for the acute gain, the treatment effect on late loss became nonsignificant in both studies. CONCLUSIONS In patients undergoing DCA or PTCA of saphenous vein graft narrowings, the relationship between late loss and acute gain is also demonstrated, similar to the device-independent relationships seen in native coronary lesions. In CAVEAT-II, larger degrees of acute gain were also associated with higher degrees of late lumen loss.
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- 2000
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16. Percutaneous revascularization of the internal mammary artery graft: short- and long-term outcomes
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Lowell F. Satler, George Dangas, Alexandra Lansky, Mun K. Hong, Augusto D. Pichard, Kenneth M. Kent, Roxana Mehran, Martin B. Leon, Gary S. Mintz, Ron Waksman, Luis Gruberg, and Gregg W. Stone
- Subjects
Adult ,Male ,Reoperation ,medicine.medical_specialty ,Percutaneous ,medicine.medical_treatment ,Myocardial Infarction ,Coronary Disease ,Coronary Angiography ,Balloon ,Revascularization ,Recurrence ,Cause of Death ,Angioplasty ,Myocardial Revascularization ,medicine ,Humans ,Myocardial infarction ,Angioplasty, Balloon, Coronary ,Survival rate ,Aged ,Aged, 80 and over ,business.industry ,Graft Occlusion, Vascular ,Middle Aged ,medicine.disease ,Surgery ,Survival Rate ,Ostium ,Treatment Outcome ,Bypass surgery ,Female ,Stents ,Cardiology and Cardiovascular Medicine ,business - Abstract
OBJECTIVES We evaluated the short- and long-term clinical outcomes after percutaneous revascularization of the internal mammary artery (IMA) graft. BACKGROUND Previous reports in a relatively small number of patients have indicated the safety of balloon angioplasty for the treatment of stenoses in the IMA graft. However, the use of alternative interventional techniques and their long-term results have not yet been evaluated. METHODS We analyzed the in-hospital and one-year clinical outcomes of 174 consecutive patients who underwent percutaneous revascularization of 202 lesions located in the IMA graft, by either balloon angioplasty or stenting. RESULTS Anastomotic lesions were evident in 128 cases (63%), and they were more commonly treated with balloon angioplasty (116/128, 91%), whereas lesions located at the ostium (n = 16, 8%) were more frequently treated with stents (11/16, 69%). Procedural success was 97% with excellent in-hospital outcome: 0.6% mortality rate, no Q-wave myocardial infarction (MI) and 0.6% rate of urgent bypass surgery. Cumulative one-year rates were: mortality 4.4%, MI 2.9% and target lesion revascularization (TLR) 7.4%. CONCLUSIONS Revascularization of the IMA graft can be performed safely, with high procedural success and a low rate of in-hospital complications. Long-term follow-up showed very low TLR rate.
- Published
- 2000
17. Acute and chronic tissue response to coronary stent implantation: pathologic findings in human specimen
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A. Machraoui, Thomas Deneke, Peter H Grewe, Klaus-Michael Müller, and Jürgen Barmeyer
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Male ,Pathology ,medicine.medical_specialty ,Endothelium ,medicine.medical_treatment ,Lumen (anatomy) ,Coronary Disease ,Muscle, Smooth, Vascular ,Extracellular matrix ,Restenosis ,Coronary stent ,Medicine ,Humans ,cardiovascular diseases ,Thrombus ,Aged ,Aged, 80 and over ,business.industry ,Graft Occlusion, Vascular ,Stent ,Hyperplasia ,Middle Aged ,medicine.disease ,Actins ,Extracellular Matrix ,medicine.anatomical_structure ,cardiovascular system ,Female ,Stents ,Endothelium, Vascular ,business ,Tunica Intima ,Cardiology and Cardiovascular Medicine ,Cell Division ,Follow-Up Studies - Abstract
OBJECTIVES The aim of our study was to analyze the cellular components of neointimal tissue regeneration after coronary stenting. BACKGROUND High restenosis rates are a major limiting factor of coronary stenting. To reduce the occurrence of restenoses, more insights into the mechanisms leading to proliferation and expression of extracellular matrix are necessary. METHODS Twenty-one autopsy cases with coronary stents implanted 25 h to 340 days before death were studied. The stented vessel segments were analyzed postmortem by light microscopy and immunohistochemical staining. RESULTS In the initial phase stents are covered by a thin multilayered thrombus. Alpha-actin-positive smooth muscle cells (SMCs) are found as the main cellular component of the neointimal tissue. Later (>6 weeks) extracellular matrix increases and fewer SMCs can be found. In every phase the SMC layers are loosely infiltrated by inflammatory cells (T lymphocytes). In the early postinterventional phase all endothelial cells are destroyed. The borderline between the vessel lumen and the vascular wall is constituted by a thin, membranous thrombus. Six weeks after stenting, SMCs form the vessel surface. Complete reendothelialization is first found 12 weeks after stenting. CONCLUSIONS Stent integration is a multifactorally triggered process with proliferating SMCs generating regenerative tissue. In the early phase predominantly thrombotic material can be observed at the site of stenting, followed by the invasion of SMCs, T lymphocytes and macrophages. The incidence of delayed reendothelializations and the occurrence of deep dissections may be associated with excessive SMC hyperplasia.
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- 2000
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18. Arterialization of human vein grafts is associated with tenascin-C expression
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Michael C. Fishbein, Chen Li, Kurt Wallner, Behrooz G. Sharifi, and Prediman K. Shah
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Neointima ,Pathology ,medicine.medical_specialty ,Tenascin ,In situ hybridization ,Adventitia ,medicine ,Humans ,Saphenous Vein ,Coronary Artery Bypass ,Vein ,In Situ Hybridization ,Chi-Square Distribution ,biology ,business.industry ,Tenascin C ,Graft Occlusion, Vascular ,Arteries ,medicine.disease ,Pulmonary hypertension ,Immunohistochemistry ,medicine.anatomical_structure ,biology.protein ,cardiovascular system ,business ,Cardiology and Cardiovascular Medicine ,Immunostaining - Abstract
OBJECTIVES This study was performed to test the hypothesis that tenascin-C (TN-C), an extracellular matrix (ECM) protein with counteradhesive chemotactic and vascular growth-promoting effects, is expressed in “arterialized” human saphenous vein grafts (SVGs). BACKGROUND Tenascin-C is expressed in the vessel wall after vascular injury in the experimental model, where it has been implicated in the formation of neointima. Overexpression of TN-C has also been implicated in the development and progression of pulmonary hypertension. Saphenous vein grafts are exposed to hemodynamic stress when interposed in the arterial circulation and mechanical stress upregulates expression of TN-C, whereas stress-relaxation suppresses its synthesis. We hypothesized that the hemodynamic stress of increased arterial pressure could also induce TN-C expression in SVG. METHODS We examined the expression of TN-C protein and mRNA in normal vein and “arterialized” human SVG using immunohistochemistry and in situ hybridization, respectively. RESULTS TN-C protein was not detected in control human saphenous veins; however, it was uniformly and strongly expressed in the adventitia and media of patent human vein grafts, with minimal or no expression in the neointima (n = 27, 100%). In situ hybridization showed that TN-C mRNA was not detected in the neointima, but was strongly upregulated in the adventitia and media, corroborating immunostaining data (n = 10, 100%). Unlike patent SVG, TN-C was not expressed in the adventitia of occluded grafts, except for a low level of expression around the newly formed vessels in neointima (n = 5, 100%). Smooth muscle cell-specific staining demonstrated that the lack of expression of TN-C in occluded vein grafts is not due to the lack of presence of smooth muscle cells in the graft. CONCLUSIONS These findings suggest that placement of a venous graft in the arterial system leads to expression of TN-C, which may in turn facilitate graft remodeling. Conversely, loss of flow and intravascular pressure, associated with vein graft occlusion, is accompanied by disappearance of TN-C expression.
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- 1999
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19. Lipoprotein(a) and coronary thrombosis and restenosis after stent placement
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Adnan Kastrati, Albert Schömig, Hannsjörg Baum, Shpend Elezi, Siegmund Braun, Anne Wehinger, and Franz-Josef Neumann
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Sensitivity and Specificity ,Coronary thrombosis ,Restenosis ,Recurrence ,Angioplasty ,Internal medicine ,Coronary stent ,medicine ,Humans ,Prospective Studies ,Angioplasty, Balloon, Coronary ,Prospective cohort study ,Aged ,biology ,business.industry ,Coronary Thrombosis ,Graft Occlusion, Vascular ,Stent ,Lipoprotein(a) ,Middle Aged ,medicine.disease ,Surgery ,Treatment Outcome ,biology.protein ,Cardiology ,Female ,Stents ,business ,Cardiology and Cardiovascular Medicine ,Follow-Up Studies ,Lipoprotein - Abstract
OBJECTIVES The objective of this prospective study was to evaluate the relation between high lipoprotein(a) levels and thrombotic and restenotic events after coronary stent implantation. BACKGROUND Lipoprotein(a) may promote atherogenesis, coronary thrombosis and restenosis after balloon angioplasty, but the clinical significance remains unclear. METHODS The study included 2,223 consecutive patients with successful coronary stent placement. According to the serum level of lipoprotein(a), patients were divided in two groups: 457 patients of the highest quintile formed the high lipoprotein(a) group, and 1,766 patients of the lower four quintiles formed the low lipoprotein(a) group. Primary end points were the incidence of angiographic restenosis at six months and the event-free survival at one year. Secondary end point was the incidence of angiographic stent occlusion. RESULTS Early stent occlusion occurred in four of the 457 patients (0.9%) with high and 37 of the 1,766 patients (2.1%) with low lipoprotein(a) levels, odds ratio of 0.41 (95% confidence interval, 0.15 to 1.16). Angiographic restenosis occurred in 173 of the 523 lesions (33.2%) in the high lipoprotein(a) group and 636 of the 1,943 lesions (32.7%) in the low lipoprotein(a) group, odds ratio of 1.02 (0.83 to 1.25). The probability of event-free survival was 73.0% in the high lipoprotein(a) group and 74.8% in the low lipoprotein(a) group (p = 0.45). On the basis of the findings in the low lipoprotein(a) group, the power of this study to detect a 25% increase in the incidence of restenosis and adverse events in the group with elevated lipoprotein(a) was 90% and 75%, respectively. CONCLUSIONS Elevated lipoprotein(a) levels did not influence the one-year clinical and angiographic outcome after stent placement. Thrombotic events and measures of restenosis were not adversely affected by the presence of high lipoprotein(a) levels.
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- 1999
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20. Antithrombotic Therapy Following CABG: For the Patient, Not the Bypass Graft.
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Alexander JH
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- Coronary Artery Bypass, Fibrinolytic Agents, Graft Occlusion, Vascular, Humans, Aspirin, Rivaroxaban
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- 2019
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21. Rotational atherectomy for in-stent restenosis: acute and long-term results of the first 100 cases
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John A. Ambrose, Srinivas Duvvuri, Samin K. Sharma, George Dangas, Jonathan D. Marmur, Raghuraman Vidhun, Kakarala Venu, and Annapoorna Kini
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Atherectomy, Coronary ,Male ,Reoperation ,medicine.medical_specialty ,medicine.medical_treatment ,Coronary Disease ,Coronary Angiography ,Balloon ,Atherectomy ,Restenosis ,Recurrence ,Angioplasty ,Internal medicine ,Intravascular ultrasound ,medicine ,Humans ,Angioplasty, Balloon, Coronary ,Ultrasonography, Interventional ,Retrospective Studies ,Neointimal hyperplasia ,medicine.diagnostic_test ,business.industry ,Graft Occlusion, Vascular ,Stent ,Middle Aged ,Prognosis ,medicine.disease ,Balloon dilation ,Cardiology ,Female ,Stents ,Safety ,business ,Cardiology and Cardiovascular Medicine ,Follow-Up Studies - Abstract
Objectives. This study evaluated the clinical safety and long-term results of rotational atherectomy (RA) followed by low-pressure balloon dilatation (percutaneous transluminal coronary angioplasty [PTCA]) for the treatment of in-stent restenosis (ISR).Background. In-stent restenosis is associated with a high incidence of recurrence after interventional treatment. Because ISR is due to neointimal hyperplasia, rotational ablation may be a more effective treatment than PTCA.Methods. Between November 1995 and November 1996, 100 consecutive patients with first-time ISR were treated by RA. Quantitative coronary angiography and intravascular ultrasound (IVUS) were used to analyze the acute procedural results. The incidence of repeat in-stent restenosis and target vessel revascularization (TVR) at follow-up was determined.Results. Procedural success without any major in-hospital complications was achieved in 100% of cases. Slow flow was observed in 3% and creatine kinase-MB enzyme elevation >3× normal occurred in 2%. The mean burr-to-artery ratio was 0.68 ± 0.18 and adjuvant balloon dilatation was performed at 4.2 ± 2.1 atm. Minimum luminal diameter increased from 0.86 ± 0.28 mm to 1.89 ± 0.21 mm after RA and to 2.56 ± 0.29 mm after adjunct PTCA. Quantitative IVUS analysis showed that 77% of the luminal gain occurred due to rotational ablation of the restenotic tissue and only 23% occurred after adjunct balloon dilation, and further stent expansion did not contribute to the luminal enlargement. At a mean follow-up of 13 ± 5 months, repeat in-stent restenosis occurred in 28% of patients with TVR of 26%. Univariate predictors of repeat restenosis were burr-to-artery ratio
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- 1998
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22. A case of inferior vena cava obstruction: restenosis with pseudoaneurysm
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Budanur Chikkaswamy, Srinivas, Vikram B, Kolhari, Babu, Reddy, Chamarajnagara Mahadevappa, Nagesh, Sunil, Srinivas, and Cholenahalli Nanjappa, Manjunath
- Subjects
Male ,Recurrence ,Graft Occlusion, Vascular ,Humans ,Vena Cava, Inferior ,Constriction, Pathologic ,Vascular Diseases ,Middle Aged ,Tomography, X-Ray Computed ,Aneurysm, False ,Blood Vessel Prosthesis - Published
- 2013
23. Short-term and long-term clinical impact of stent thrombosis and graft occlusion in the SYNTAX trial at 5 years: Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery trial
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Vasim, Farooq, Patrick W, Serruys, Yaojun, Zhang, Michael, Mack, Elisabeth, Ståhle, David R, Holmes, Ted, Feldman, Marie-Claude, Morice, Antonio, Colombo, Christos V, Bourantas, Ton, de Vries, Marie-Angèle, Morel, Keith D, Dawkins, Arie Pieter, Kappetein, and Friedrich W, Mohr
- Subjects
Percutaneous Coronary Intervention ,Time Factors ,Treatment Outcome ,Graft Occlusion, Vascular ,Humans ,Drug-Eluting Stents ,Thrombosis ,Prospective Studies ,Coronary Artery Bypass ,Taxus ,Follow-Up Studies - Abstract
The aim of this study was to report the short-term and long-term clinical impact of stent thrombosis (ST) and graft occlusion (GO) in the final 5-year outcomes of the SYNTAX (SYNergy Between PCI With TAXUS and Cardiac Surgery) trial.The clinical effect of newer-generation drug-eluting stents and operative factors in complex coronary artery disease is uncertain.The incidence of 5-year ST and GO, and their association with clinical outcomes, were analyzed in the randomized percutaneous coronary intervention and coronary artery bypass graft cohorts. ST and GO were defined by the SYNTAX protocol definitions (clinical presentation with acute coronary syndrome and angiographic/pathological evidence), the Academic Research Consortium (ARC) definition for ST, and the newly devised "ARC-like" definition of GO (i.e., definite, probable, or possible GO).At 5 years, 871 of 903 patients (96.5%) in the percutaneous coronary intervention cohort and 805 of 897 patients (89.7%) in the coronary artery bypass graft cohort completed follow-up. As compared with other vessel locations, protocol ST (72 lesions) occurred more frequently in the left main (14 of 72; 19%) and proximal coronary vasculature (37 of 72; 51%) and protocol GO (41 lesions) with grafts anastomosed to the distal right coronary artery (17 of 41; 42%). The incidence of 5-year ARC definite ST and ARC-like definite GO did not significantly differ (7% [n = 48] vs. 6% [n = 32], log rank p = 0.34); landmark analyses indicated significantly increased ARC definite ST within 30 days (3% [n = 19] vs. 1% [n = 6], log rank p = 0.033) but not30 days to 5 years (4.2% [n = 29] vs. 4.5% [n = 26], log rank p = 0.78). At presentation, ARC definite ST (n = 48) and ARC-like definite GO (n = 32) were adjudicated to be linked to 4 (8%) and 0 deaths, respectively. At 5 years, ARC definite ST (n = 48) and ARC definite/probable ST (n = 75) were associated with 17 (17 of 48, 35.4%; median days to death: 0 days; interquartile range: 0 to 16 days; maximum: 321 days) and 31 (31 of 75, 41.3%; median: 0 days; interquartile range: 0 to 9 days; maximum: 721 days) cardiac deaths, respectively. At 5 years, ARC-like definite GO (n = 32) and ARC-like definite/probable GO (n = 53) were associated with 0 and 12 (12 of 52, 23.1%; median: 0 days; interquartile range: 0 to 14 days; maximum: 257 days) cardiac deaths, respectively.Although the incidence of ST and GO was similar at 5 years, the clinical impact of ST appeared greater, with a negative impact on short-term to long-term mortality.
- Published
- 2013
24. Recanalization of chronically occluded aortocoronary saphenous vein bypass grafts with long-term, low dose direct infusion of urokinase (ROBUST): A serial trial
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Andrew J. Doorey, Christopher J. White, Louis S. McKeever, Patrick L. Whitlow, William W. O'Neill, Elaine L. Enger, Joseph P. Galichia, Joseph R. Hartmann, and Paul Gilmore
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Male ,medicine.medical_specialty ,medicine.medical_treatment ,Myocardial Ischemia ,Coronary Angiography ,Angina ,Plasminogen Activators ,Recurrence ,Cause of Death ,Angioplasty ,medicine ,Humans ,Saphenous Vein ,Derivation ,Myocardial infarction ,Angioplasty, Balloon, Coronary ,Coronary Artery Bypass ,Infusions, Intravenous ,Stroke ,Vascular Patency ,Urokinase ,medicine.diagnostic_test ,business.industry ,Graft Occlusion, Vascular ,Thrombolysis ,Middle Aged ,medicine.disease ,Urokinase-Type Plasminogen Activator ,Surgery ,Survival Rate ,Cerebrovascular Disorders ,Treatment Outcome ,Angiography ,Patient Compliance ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies ,medicine.drug - Abstract
Objectives. This multicenter study sought to evaluate the shortterm efficacy and safety of prolonged, low dose, direct urokinase infusion in recanalization of chronically occluded saphenous vein bypass grafts in a large sample of patients, as well as to determine the 6-month patency rates for this procedure. Background. Patients with chronically occluded aortocoronary vein grafts and uncontrolled angina pectoris have limited options for therapy. Previous work has shown that chronically occluded vein grafts can be recanalized by thrombolysis. Methods. A coaxial infusion of urokinase (100,000 U/h) was given directly into occluded vein grafts in 107 patients. Balloon angioplasty was performed after lysis was achieved. Patients were discharged with warfarin and aspirin therapy. Six-month clinical follow-up data were obtained, and repeat angiography was encouraged. Results. Initial patency was achieved in 74 patients (69%). Mean duration of infusion was 25.4 h, and mean urokinase dosage was 3.70 million U. Acute adverse events included acute myocardial infarction in 5 patients (5%), enzyme level elevation in 18 (17%), emergency coronary artery bypass graft surgery in 4 (4%), stroke in 3 (3%) and death in 7 (6.5%). Recanalization was unsuccessful in all seven patients who died. Six-month follow-up angiograms were obtained for 40 patients (54%), 16 of whom maintained a patent graft (40%). Angina was present in 13 patients with successful (22%) and 12 with unsuccessful (71%) recanalization at 6-month follow-up. Conclusions. Chronically occluded aortocoronary vein grafts can be recanalized in ∼70% of appropriately selected patients. Complications are similar to those observed with repeat operations. Clinical follow-up shows an improvement in angina. This procedure is intended for patients with only one occluded vein graft. Strict adherence to the protocol will improve patency and reduce complications.
- Published
- 1996
25. Comparative results of transluminal extraction coronary atherectomy in saphenous vein graft lesions with and without thrombus
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Melissa Hoffmann, Theodore Schreiber, Mark Dooris, Cindy L. Grines, William W. O'Neill, Gregory Pavlides, Nadine Juran, Venu M. Reddy, Robert D. Safian, and Sue Glazier
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Atherectomy, Coronary ,Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Coronary Angiography ,Revascularization ,Atherectomy ,Postoperative Complications ,Coronary thrombosis ,Risk Factors ,Internal medicine ,medicine ,Humans ,Saphenous Vein ,Myocardial infarction ,cardiovascular diseases ,Coronary Artery Bypass ,Thrombus ,Aged ,Retrospective Studies ,Interventional cardiology ,medicine.diagnostic_test ,business.industry ,Coronary Thrombosis ,Incidence ,Graft Occlusion, Vascular ,medicine.disease ,Surgery ,Case-Control Studies ,Angiography ,Cardiology ,cardiovascular system ,Female ,business ,Cardiology and Cardiovascular Medicine ,TIMI ,Follow-Up Studies - Abstract
Objectives. The purpose of this retrospective study was to compare the results of transluminal extraction coronary atherectomy in saphenous vein graft lesions with and without angiographic thrombus.Background. Percutaneous interventions in lesions with thrombus are associated with reduced procedural success and increased risk of complications. Use of the transluminal extraction catheter, which cuts and aspirates atheroma and thrombus, has been advocated as a potential revascularization strategy for lesions with thrombus.Methods. Baseline patient characteristics, lesion morphology, immediate angiographic results, in-hospital complications and follow-up were prospectively entered into an interventional cardiology data base. The results of transluminal extraction coronary atherectomy in saphenous vein bypass grafts with angiographic thrombus were compared with results in similar grafts without angiographic thrombus.Results. Transluminal extraction coronary atherectomy was performed in 175 patients with 183 vein graft lesions, including 59 lesions (32%) with thrombus (Group 1) and 124 (68%) without thrombus (Group 2). Compared with lesions in Group 2, lesions in Group 1 were associated with a higher incidence of baseline total occlusion, diffuse disease and abnormal Thrombolysis in Myocardial Infarction (TIMI) grade flow (p < 0.05); more severe diameter stenosis at baseline, after atherectomy and after final angiography (p < 0.05); a lower rate of clinical success (69% vs, 88%, p < 0.01); and more angiographic and clinical complications, including no reflow (p < 0.05), vascular repair (p < 0.05) and Q wave myocardial infarction (p = 0.09).Conclusions. In transluminal extraction coronary atherectomy of saphenous vein bypass grafts, the presence of thrombus is associated with more baseline lesion complexity, reduced clinical success and increased risk of no reflow, Q wave myocardial infarction and vascular repair.
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- 1995
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26. Relation of saphenous vein graft obstruction to serum cholesterol levels
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Hiroshi Yamaguchi, Hisashi Yokoi, Yasuyuki Hosoda, Thomas E. Kottke, Hiroshi Mokuno, Hiroshi Miyano, Hiroyuki Satoh, and Hiroyuki Daida
- Subjects
Male ,medicine.medical_specialty ,Saphenous vein graft ,Coronary Angiography ,Coronary artery bypass surgery ,Japan ,Risk Factors ,Internal medicine ,Medicine ,Humans ,Saphenous Vein ,Derivation ,Coronary Artery Bypass ,Serum cholesterol ,Aged ,Retrospective Studies ,business.industry ,Vascular disease ,Graft Survival ,Graft Occlusion, Vascular ,Middle Aged ,medicine.disease ,Surgery ,Coronary arteries ,medicine.anatomical_structure ,Cholesterol ,surgical procedures, operative ,Multivariate Analysis ,Cardiology ,Female ,business ,Complication ,Cardiology and Cardiovascular Medicine ,Artery ,Follow-Up Studies - Abstract
Objectives. To determine the potential of lipid-lowering therapy to reduce saphenous vein graft obstruction, we retrospectively studied the association between graft obstruction and serum cholesterol levels.Background. Atherosclerosis is the major cause of vein graft obstruction. Approximately 50% of grafts are occluded by 10 years after operation. It remains to be established whether lipid control affects long-term graft survival.Methods. We carried out a retrospective review of all 284 patients who had undergone coronary artery bypass graft surgery at Juntendo University Hospital between 1976 and 1991 and met the following additional criteria: at least one saphenous vein graft, repeat coronary arteriography at some point after coronary artery bypass graft surgery and a serum cholesterol level ≥200 mg/dl before operation. Saphenous vein graft obstruction rates were compared among three groups classified by serum cholesterol levels at follow-up arteriography: group I
- Published
- 1995
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27. Radial artery and saphenous vein patency more than 5 years after coronary artery bypass surgery: results from RAPS (Radial Artery Patency Study)
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Saswata, Deb, Eric A, Cohen, Steve K, Singh, Dai, Une, Andreas, Laupacis, Stephen E, Fremes, and K, Tsang
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Adult ,Male ,Canada ,Time Factors ,Graft Occlusion, Vascular ,Middle Aged ,Coronary Angiography ,Coronary Vessels ,Treatment Outcome ,Radial Artery ,Humans ,Female ,Saphenous Vein ,Coronary Artery Bypass ,Vascular Patency ,Aged - Abstract
The purpose of this study was to present radial and saphenous vein graft (SVG) occlusion results more than 5 years following coronary artery bypass surgery.In the RAPS (Radial Artery Patency Study) study, complete graft occlusion was less frequent in radial artery compared with SVG 1 year post-operatively while functional occlusion (Thrombolysis In Myocardial Infarction flow grade 0, 1, 2) was similar.A total of 510 patients80 years of age undergoing primary isolated nonemergent coronary artery bypass grafting with 3-vessel disease were initially enrolled in 9 Canadian centers. Target vessels for the radial artery and study SVG were the right and circumflex coronary arteries, which had70% proximal stenosis. Within-patient randomization was performed; the radial artery was randomized to either the right or circumflex territory and the study SVG was used for the other territory. The primary endpoint was functional graft occlusion by invasive angiography at least 5 years following surgery. Complete graft occlusion by invasive angiography or computed tomography angiography was a secondary endpoint.A total of 269 patients underwent late angiography (234 invasive angiography, 35 computed tomography angiography) at a mean of 7.7 ± 1.5 years after surgery. The frequency of functional graft occlusion was lower in radial arteries compared with SVGs (28 of 234 [12.0%] vs. 46 of 234 [19.7%]; p = 0.03 by McNemar's test). The frequency of complete graft occlusion was also significantly lower in radial compared with SVGs (24 of 269 [8.9%] vs. 50 of 269 [18.6%]; p = 0.002).Radial arteries are associated with reduced rates of functional and complete graft occlusion compared with SVGs more than 5 years following surgery. (Multicentre Radial Artery Patency Study: 5 Year Results; NCT00187356).
- Published
- 2011
28. Long-term angiographic follow-up of normal and minimally diseased saphenous vein grafts
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Eli R. Farhi, Joseph A. Cinderella, and Enrique E. Campos
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Male ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Severe disease ,Vein graft ,Coronary Angiography ,Internal medicine ,medicine ,Humans ,Saphenous Vein ,Derivation ,Coronary Artery Bypass ,Veterans Affairs ,Vascular Patency ,Cardiac catheterization ,medicine.diagnostic_test ,business.industry ,Graft Occlusion, Vascular ,medicine.disease ,Surgery ,Stenosis ,Bypass operation ,Angiography ,Cardiology ,business ,Cardiology and Cardiovascular Medicine ,Follow-Up Studies - Abstract
Objectives. We sought to ascertain the long-term fate of saphenous vein grafts known to be angiographically normal or minimally diseased 5 years after operation. This information may prove helpful in the management of such grafts at reoperation. Background. Patients undergoing a second coronary bypass operation frequently have one or more saphenous vein grafts that remain widely patent. It is common practice during such reoperations to replace all vein grafts that are older than 5 years, including those with little or no angiographic stenosis, because of the risk of late vein graft closure. However, the long-term behavior of these angiographical normal or minimally diseased vein grafts has not been well elucidated. Methods. Sixty-two patients with a total of 131 angiographically normal or minimally diseased (
- Published
- 1993
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29. Intravascular stent prosthesis for right ventricular outflow obstruction
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Toshio Nakanishi, William G. Williams, Robert M. Freedom, Patricia E. Burrows, Martin C.K. Hosking, and Lee N. Benson
- Subjects
Heart Defects, Congenital ,Male ,medicine.medical_specialty ,Time Factors ,Heart disease ,Heart Ventricles ,medicine.medical_treatment ,Ventricular Outflow Obstruction ,Pulmonary Artery ,Balloon ,Inferior vena cava ,Internal medicine ,medicine.artery ,Angioplasty ,medicine ,Humans ,cardiovascular diseases ,Child ,Pulmonary artery stenosis ,business.industry ,Graft Occlusion, Vascular ,Stent ,Equipment Design ,medicine.disease ,Surgery ,Radiography ,medicine.vein ,Pulmonary artery ,cardiovascular system ,Cardiology ,Feasibility Studies ,Female ,Stents ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Objectives. This study was designed to assess the impact of implantation of balloon-expandable stents on right ventricular outflow obstruction in children with congenital heart disease. Background. Intravascular stenting has been established as a useful treatment in adults with coronary and peripheral vascular disease. Its application in the treatment of infants and children with pulmonary, systemic and right ventricular conduit obstruction resistant to balloon angioplasty is limited. Methods. A total of 24 stainless steel stents were implanted in 17 patients. Five stents were placed within right ventricular to pulmonary artery conduits, 17 in branch pulmonary arteries and 1 in an aortopulmonary collateral vessel. Follow-up time has ranged from 1 to 14 months, with 6 patients having hemodynamic and angiographic studies >1 year after stent placement. The mean age at implantation was 7.4 ± 5.6 years and the mean weight 33 ± 16 kg. Results. Optimal stent position was obtained in 22 of 24 implantations. In one patient the stent slipped from the delivery balloon and was left positioned in the inferior vena cava. No embolization or thrombotic event has been documented. Among patients with right ventricular to pulmonary artery conduit obstruction, the gradient was immediately reduced from 85 ± 30 mm Hg to 35 ± 20 mm Hg after stent implantation; however, three patients required conduit replacement because of persistent obstruction with elevated right ventricular pressures (82 ± 16 mm Hg). In 10 of 11 patients with pulmonary artery stenosis, clinical improvement was noted in association with enlargement of vessel diameter by 92% ± 90% (range 17% to 355%) and the gradient reduction of 22 ± 24 mm Hg to 3 ± 4 mm Hg. Conclusions. These data support the view that intravascular stenting will become an important adjunct in the management of children with congenital heart disease.
- Published
- 1992
30. Aspirin plus clopidogrel therapy increases early venous graft patency after coronary artery bypass surgery a single-center, randomized, controlled trial
- Author
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Ge, Gao, Zhe, Zheng, Yi, Pi, Bin, Lu, Jinguo, Lu, and Shengshou, Hu
- Subjects
Male ,Ticlopidine ,Time Factors ,Aspirin ,Graft Occlusion, Vascular ,Administration, Oral ,Coronary Artery Disease ,Middle Aged ,Coronary Angiography ,Clopidogrel ,Electrocardiography ,Treatment Outcome ,Humans ,Drug Therapy, Combination ,Female ,Saphenous Vein ,Prospective Studies ,Coronary Artery Bypass ,Tomography, X-Ray Computed ,Platelet Aggregation Inhibitors ,Vascular Patency ,Follow-Up Studies - Abstract
We sought to evaluate the effect of aspirin plus clopidogrel versus aspirin alone on saphenous vein graft occlusion at 3 months after coronary artery bypass grafting (CABG).Prevalence of graft occlusion is high after CABG. Aggressive antiplatelet therapy is expected to improve early post-operative graft patency.From December 2007 through December 2008, 249 consecutive patients undergoing elective CABG at Fuwai Hospital were randomly assigned to 2 groups: 124 received aspirin (100 mg) plus clopidogrel (75 mg) daily (AC group), and 125 received aspirin (100 mg) alone daily (A group). Antiplatelet therapies were initiated when post-operative chest tube drainage was ≤ 30 cc/h for 2 h. All participants were invited for clinical follow-up and 64-slice multislice computed tomography angiography (MSCTA) analysis at 3 months post-operatively. Generalized estimating equations analysis was used to determine predictors of graft patency.One participant, from group A, died before 3-month follow-up. Of the remaining 248 patients, 224 (90.3%) underwent MSCTA. Participants had similar pre-operative and intraoperative characteristics at baseline. No significant differences were observed in intraoperative transit-time flow measurement findings or major adverse cardiac-related events. Three-month MSCTA follow-up revealed that saphenous vein graft patency was 91.6% (219 of 239) in the AC group versus 85.7% (198 of 231) in the A group (p = 0.043). In multivariate analysis, combined antiplatelet therapy independently increased venous graft patency (p = 0.045).Aspirin plus clopidogrel is more effective in venous graft patency than aspirin alone in the short term after CABG, but further, long-term study is needed. (The Clopidogrel and Aspirin After Surgery for Coronary Artery Disease; NCT00776477).
- Published
- 2009
31. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures
- Author
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Frances Chan, Frederick A. Spencer, Harold L. Dauerman, David A. Johnson, Sunil V. Rao, Eamonn Martin Quigley, Marc S. Sabatine, Richard C. Becker, Neena S. Abraham, and James M. Scheiman
- Subjects
medicine.medical_specialty ,Heart disease ,medicine.medical_treatment ,Hemorrhage ,Coronary Artery Disease ,Risk Assessment ,Endoscopy, Gastrointestinal ,Coronary artery disease ,Pharmacotherapy ,platelet antagonists ,Risk Factors ,Angioplasty ,medicine ,Animals ,Humans ,Drug Interactions ,Thrombolytic Therapy ,Angioplasty, Balloon, Coronary ,coronary heart disease ,Clinical Trials as Topic ,Risk Management ,Hepatology ,medicine.diagnostic_test ,business.industry ,Vascular disease ,Graft Occlusion, Vascular ,Gastroenterology ,Percutaneous coronary intervention ,Thrombosis ,medicine.disease ,Endoscopy ,Surgery ,periprocedural risk assessment ,Conventional PCI ,Practice Guidelines as Topic ,Platelet aggregation inhibitor ,Drug Therapy, Combination ,Stents ,Cardiology and Cardiovascular Medicine ,business ,TIMI ,Platelet Aggregation Inhibitors - Abstract
The periprocedural management of patients with atherosclerotic coronary heart disease, including those who have heart disease and those who are undergoing percutaneous coronary intervention and stent placement who might require temporary interruption of platelet-directed pharmacotherapy for the purpose of an elective endoscopic gastrointestinal procedure, is a common clinical scenario in daily practice. Herein, we summarize the available information that can be employed for making management decisions and provide general guidance for risk assessment.
- Published
- 2009
32. Coronary stent fracture and in-stent restenosis at coronary computed tomography
- Author
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Vincent Dor, Filippo Civaia, Fabiola B. Sozzi, Stephane Rusek, and Philippe Rossi
- Subjects
Adult ,Male ,medicine.medical_specialty ,medicine.medical_treatment ,education ,Myocardial Infarction ,Anterior Descending Coronary Artery ,Coronary Restenosis ,Diagnosis, Differential ,Restenosis ,Internal medicine ,Coronary stent ,Medicine ,Humans ,Angioplasty, Balloon, Coronary ,business.industry ,Coronary artery lesion ,Graft Occlusion, Vascular ,Stent ,Acute anterior myocardial infarction ,Coronary computed tomography ,medicine.disease ,Prosthesis Failure ,behavior and behavior mechanisms ,Cardiology ,Stents ,In stent restenosis ,business ,Cardiology and Cardiovascular Medicine ,Tomography, X-Ray Computed ,psychological phenomena and processes ,Follow-Up Studies - Abstract
[Figure][1] [![Graphic][3] ][3][![Graphic][4] ][4][![Graphic][5] ][5] A 43-year-old man presented with acute anterior myocardial infarction. A critical ostial stenosis of the left anterior descending coronary artery and moderate distal left main lesion were visualized at
- Published
- 2009
33. Stent gap by 64-detector computed tomographic angiography relationship to in-stent restenosis, fracture, and overlap failure
- Author
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Harvey S, Hecht, Sotir, Polena, Vladimir, Jelnin, Marcelo, Jimenez, Tandeep, Bhatti, Manish, Parikh, Georgia, Panagopoulos, and Gary, Roubin
- Subjects
Adult ,Male ,Graft Occlusion, Vascular ,Reproducibility of Results ,Middle Aged ,Coronary Angiography ,Prosthesis Failure ,Coronary Restenosis ,Humans ,Female ,Stents ,Tomography, X-Ray Computed ,Aged ,Follow-Up Studies ,Retrospective Studies - Abstract
The goal of this study was to define the frequency of stent gaps by 64-detector computed tomographic angiography (CTA) and their relation to in-stent restenosis (ISR), stent fracture (SF), and overlap failure (OF).SF defined by catheter angiography or intravascular ultrasound has been implicated in ISR.A total of 292 consecutive patients, with 613 stents, who underwent CTA were evaluated for stent gaps associated with decreased Hounsfield units. Correlations with catheter coronary angiography (CCA) were available in 143 patients with 384 stents.Stent gaps were noted in 16.9% by CTA and 1.0% by CCA. ISR by CCA was noted in 46.1% of the stent gaps (p0.001) as determined by CCA, and stent gaps by CTA accounted for 27.8% of the total ISR (p0.001). In univariate analysis, stent diameteror =3 mm was the only CCA characteristic significantly associated with stent gaps (p = 0.002), but was not a significant predictor by multivariate analysis. Bifurcation stents, underlying calcification, stent type, location, post-dilation, and overlapping stents were not observed to be predisposing factors. Excessive tortuosity and lack of conformability were not associated with stent gaps; however, their frequency was insufficient to permit meaningful analysis.Stent gap by CTA: 1) is associated with 28% of ISR, and ISR is found in 46% of stent gaps; 2) is associated withor =3-mm stents by univariate (p = 0.002) but not by multivariate analysis; 3) is infrequently noted on catheter angiography; and 4) most likely represents SF in the setting of a single stent, and may represent SF or OF in overlapping stents.
- Published
- 2009
34. Recanalization of chronically occluded aortocoronary saphenous vein bypass grafts by extended infusion of urokinase: Initial results and short-term clinical follow-up
- Author
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Joseph C. Marek, Louis S. McKeever, Joseph R. Hartmann, John M. Cahill, Nicholas J. Stamato, Vincent J. Bufalino, Alan S. Brown, Mark J. Goodwin, and Elaine L. Enger
- Subjects
Male ,medicine.medical_specialty ,Time Factors ,Percutaneous ,medicine.medical_treatment ,Coronary Disease ,Coronary Angiography ,Angioplasty ,Internal medicine ,Occlusion ,medicine ,Humans ,Saphenous Vein ,Thrombolytic Therapy ,Derivation ,Coronary Artery Bypass ,Infusions, Intravenous ,Vein ,Vascular Patency ,Aged ,Aged, 80 and over ,Urokinase ,medicine.diagnostic_test ,business.industry ,Graft Occlusion, Vascular ,Middle Aged ,Urokinase-Type Plasminogen Activator ,Surgery ,Treatment Outcome ,medicine.anatomical_structure ,Bypass surgery ,Chronic Disease ,Angiography ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies ,medicine.drug - Abstract
Chronic occlusion of saphenous vein aortocoronary bypass grafts is a common problem. Although percutaneous transluminal angioplasty of a saphenous vein with a stenotic lesion is feasible, angioplasty alone of a totally occluded vein graft yields uniformly poor results. Patients with such occlusion are often subjected to repeat aortocoronary bypass surgery. Experience with a new technique that allows angioplasty to be performed in a totally occluded saphenous vein bypass graft is reported. This technique utilizes infusion of prolonged low dose urokinase directly into the proximal portion of the occluded graft. Forty-six consecutive patients with 47 totally occluded grafts were studied. Patients had undergone end to side saphenous vein bypass grafting 1 to 13 (mean 7) years previously. All patients presented with new or worsening angina pectoris with ST-T changes or non-Q wave acute myocardial infarction and all had a totally occluded saphenous vein bypass graft. The new technique entailed the positioning of an angiographic catheter into the stub of the occluded graft and the advancement of an infusion wire into the graft. Patients were returned to the coronary care unit, where urokinase was delivered at a dose of 100,000 to 250,000 U/h. The total dose of urokinase ranged from 0.7 to 9.8 million U over 7.5 to 77 h (mean 31). After therapy, recanalization was seen in 37 (79%) of the 47 grafts. In 20 successfully treated patients, angiography was performed 1 to 24 (mean 11) months after treatment; 13 (65%) of these grafts were patent. It is concluded that direct, extended, low dose infusion of urokinase in a totally occluded saphenous vein bypass graft offers a promising alternative to repeat bypass surgery.
- Published
- 1991
35. Differential histopathology of primary atherosclerotic and restenotic lesions in coronary arteries and saphenous vein bypass grafts: Analysis of tissue obtained from 73 patients by directional atherectomy
- Author
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David R. Holmes, Ronald E. Vlietstra, William D. Edwards, Kirk N. Garratt, and Urs P. Kaufmann
- Subjects
Male ,Pathology ,medicine.medical_specialty ,medicine.medical_treatment ,Constriction, Pathologic ,Coronary Artery Disease ,Endarterectomy ,Muscle, Smooth, Vascular ,Atherectomy ,Restenosis ,Recurrence ,Fibrosis ,Angioplasty ,medicine ,Humans ,Saphenous Vein ,Coronary Artery Bypass ,Thrombus ,business.industry ,Graft Occlusion, Vascular ,Middle Aged ,Hyperplasia ,medicine.disease ,Coronary Vessels ,Coronary arteries ,medicine.anatomical_structure ,Female ,Radiology ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Vascular tissue obtained using a directional percutaneous atherectomy device was examined microscopically. Tissue was obtained from coronary arteries without prior instrumentation (primary lesions, n = 31), aortocoronary saphenous vein bypass grafts with primary lesions (n = 8), coronary arteries with lesions developing after prior balloon angioplasty or mechanical atherectomy (reste-notic lesions, n = 30) and vein bypass grafts with restenotic lesions (n = 4). Primary lesions were characterized by dense intimai fibrosis with necrotic debris (83% of intimai tissue) and foam cells typical of atherosclerosis. These lesions frequently contained cholesterol crystals (45% of coronary arteries, 50% of vein grafts) and calcium deposits (65% of coronary arteries, 38% of vein grafts). Restenotic lesions were characterized by an increased proportion of loose fibroproliferative tissue (45% of coronary artery intima, 35% of vein graft intima). Immunohistochemical stains confirmed this proliferative tissue to be primarily smooth muscle cells. Thrombus was rarely observed. Comparison of resected tissues indicated that dense fibrosis and necrosis are significantly more common in primary than in restenotic lesions (83% versus 56% of intimai tissue, p = 0.0005), whereas smooth muscle cell hyperplasia is more common in restenotic than in primary lesions (44% versus 17% of intimai tissue, p Partial-thickness resection of medial tissue or full-thickness resection of media with associated adventitial tissue occurred in 22 (56%) of 39 primary atheromatous lesions and 16 (47%) of 34 restenotic lesions; subintimal tissue obtained from primary lesions appeared identical to that obtained from restenotic lesions. These data indicate that the histopathologic characteristics of the neointimal layer of restenotic lesions differ from those of the intimai layer of primary atherosclerotic lesions. The ability to examine vascular tissue from living patients with restenotic lesions may provide new insight into the pathophysiology of restenosis and could have important implications pertaining to adjuvant therapies, such as platelet or mitogenic inhibitors.
- Published
- 1991
36. Percutaneous coronary excimer laser-assisted balloon angioplasty: Initial clinical and quantitative angiographic results in 50 patients
- Author
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John A. Ambrose, Ronnie A. Hershman, Warren Sherman, Sabino Torre, Timothy A. Sanborn, Marc Cohen, and Samin K. Sharma
- Subjects
Male ,medicine.medical_specialty ,Percutaneous ,medicine.medical_treatment ,Coronary Disease ,Balloon ,Excimer ,Coronary Angiography ,Angioplasty, Laser ,Restenosis ,Angioplasty ,medicine ,Humans ,Saphenous Vein ,Embolization ,Coronary Artery Bypass ,Excimer laser ,business.industry ,Graft Occlusion, Vascular ,Middle Aged ,medicine.disease ,Surgery ,Bypass surgery ,Feasibility Studies ,Female ,business ,Cardiology and Cardiovascular Medicine - Abstract
The initial clinical experience and quantitative angiographic results of percutaneous coronary excimer laser-assisted balloon angioplasty are described for 55 lesions in 50 patients. With use of a xenon chloride (308 nm) excimer laser generator and 1.5 to 1.75 mm catheters, excimer laser angioplasty was attempted at 135 ns pulse width, 25 to 40 Hz repetition rate, 2 to 5 s laser delivery lime and 30 to 60 mj/mm2energy fluence. Laser success (>20% reduction in absolute percent diameter stenosis) was achieved in 41 (75%) of 55 lesions, with 100% subsequent balloon angioplasty success (
- Published
- 1991
- Full Text
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37. New stent implantation for recurrences after stenting for in-stent restenosis: implications of a third metal layer in human coronary arteries
- Author
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Fernando, Alfonso, Javier, García, Maria-José, Pérez-Vizcayno, Lorenzo, Hernando, Rosana, Hernandez, Javier, Escaned, Pilar, Jiménez-Quevedo, Camino, Bañuelos, and Carlos, Macaya
- Subjects
Male ,Reoperation ,Graft Occlusion, Vascular ,Drug-Eluting Stents ,Equipment Design ,Middle Aged ,Cohort Studies ,Coronary Restenosis ,Treatment Outcome ,Humans ,Female ,Angioplasty, Balloon, Coronary ,Ultrasonography, Interventional ,Aged - Published
- 2008
38. Aspirin resistance an underestimated risk in patients with drug-eluting stents?
- Author
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Dietmar, Trenk and Franz-Josef, Neumann
- Subjects
Ticlopidine ,Aspirin ,Risk Factors ,Drug Resistance ,Graft Occlusion, Vascular ,Humans ,Drug-Eluting Stents ,Coronary Artery Disease ,Platelet Activation ,Platelet Aggregation Inhibitors ,Clopidogrel - Published
- 2008
39. Small vessel replacement by human umbilical arteries with polyelectrolyte film-treated arteries: in vivo behavior
- Author
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Halima, Kerdjoudj, Nicolas, Berthelemy, Simon, Rinckenbach, Anna, Kearney-Schwartz, Karine, Montagne, Pierre, Schaaf, Patrick, Lacolley, Jean-François, Stoltz, Jean-Claude, Voegel, and Patrick, Menu
- Subjects
Cryopreservation ,Graft Rejection ,Tissue Engineering ,Graft Survival ,Transplantation, Heterologous ,Graft Occlusion, Vascular ,Ultrasonography, Doppler ,Immunohistochemistry ,Sensitivity and Specificity ,Umbilical Arteries ,Blood Vessel Prosthesis ,Blood Vessel Prosthesis Implantation ,Disease Models, Animal ,Random Allocation ,Carotid Arteries ,Reference Values ,Animals ,Humans ,Endothelium, Vascular ,Rabbits ,Polytetrafluoroethylene ,Vascular Patency ,Probability - Abstract
The aim of this study was to evaluate the patency of human umbilical arteries treated with polyelectrolyte multilayers (PEMs) after rabbit implantation.The development of small-caliber vascular substitutes with high patency after implantation remains a real challenge for vascular tissue engineering.Cryopreserved human umbilical arteries were enzymatically de-endothelialized and the luminal surfaces were coated with poly(styrene sulfonate)/poly(allylamine hydrochloride) (PSS/PAH) multilayers. The PEM-untreated arteries and PEM-treated rabbit carotids were used as graft control. The native rabbit carotids were bypassed by grafts.The Doppler ultrasound evaluation, performed in vivo, showed that all PEM-treated grafts remained patent during the full experimental period, whereas after only 1 week, no blood circulation was detected in untreated arteries. Scanning electron microscopy and histological graft examination showed pervasive thrombus formation on the luminal surface of untreated arteries after 1 week and clean luminal surface for treated arteries for at least up to 12 weeks. The arterial wall cells were identified through alpha-smooth muscle actin alphaupsilondelta platelet endothelial cell adhesion molecule-1 expression. The smooth muscle cells positive to alpha-smooth muscle actin were identified in adventitia and media and the endothelial cells positive to platelet endothelial cell adhesion molecule in intima. Von Kossa reaction didn't reveal any calcium salt deposits on the wall arteries, suggesting a good wall remodelling with no sign of graft rejection.The in vivo evaluation of human umbilical arteries treated with PSS/PAH multilayers demonstrated a high graft patency after 3 months of implantation. Such modified arteries could constitute a useful option for small vascular replacement.
- Published
- 2008
40. Incidence and clinical impact of dual nonresponsiveness to aspirin and clopidogrel in patients with drug-eluting stents
- Author
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Anna Maria Gori, Rita Paniccia, Rosanna Abbate, Renato Valenti, David Antoniucci, Angela Migliorini, Piergiovanni Buonamici, Guia Moschi, Ruben Vergara, Rossella Marcucci, and Gian Franco Gensini
- Subjects
Male ,medicine.medical_specialty ,Ticlopidine ,medicine.medical_treatment ,Coronary Artery Disease ,Loading dose ,Cohort Studies ,Risk Factors ,Internal medicine ,drug-eluting stent ,nonresponsiveness ,medicine ,Clinical endpoint ,Humans ,Platelet ,cardiovascular diseases ,Aged ,stent thrombosis ,Aged, 80 and over ,Aspirin ,business.industry ,Incidence ,Graft Occlusion, Vascular ,Stent ,Drug-Eluting Stents ,Middle Aged ,Clopidogrel ,medicine.disease ,Platelet Activation ,Thrombosis ,Drug Resistance, Multiple ,Radiography ,Drug-eluting stent ,Anesthesia ,Cardiology ,Female ,Cardiology and Cardiovascular Medicine ,business ,Platelet Aggregation Inhibitors ,circulatory and respiratory physiology ,medicine.drug - Abstract
ObjectivesThis study sought to determine the incidence of aspirin nonresponsiveness in addition to clopidogrel nonresponsiveness and whether this association identifies patients at an increased risk of drug-eluting stent (DES) thrombosis.BackgroundNonresponsiveness to clopidogrel is a predictor of DES thrombosis. No prospective data exist about the possible association of dual nonresponsiveness to clopidogrel and aspirin with DES thrombosis.MethodsPlatelet function was assessed after a loading dose of 600 mg clopidogrel in 746 patients who had successful DES implantation followed by 6-month dual-antiplatelet therapy. Platelet reactivity was assessed by light transmittance aggregometry using adenosine 5′-diphosphate, arachidonic acid, and collagen. The primary end point was definite/probable DES thrombosis at 6 months. The secondary end point was the composite of cardiac mortality and DES thrombosis.ResultsThe incidence of dual nonresponsiveness to aspirin and clopidogrel was 6%. Definite/probable DES thrombosis was significantly higher in dual aspirin and clopidogrel nonresponders (11.1%) than in clopidogrel and aspirin responders (2.1%, p < 0.001), isolated clopidogrel nonresponders (2.2%, p < 0.05), or aspirin nonresponders (2.3%, p < 0.05). The incidence of the secondary end point was 4.4% in isolated clopidogrel nonresponders, 2.3% in isolated aspirin nonresponders, and 13.3% in dual aspirin and clopidogrel nonresponders. Dual clopidogrel and aspirin nonresponsiveness was an independent predictor of DES thrombosis (hazard ratio: 3.18, 95% confidence interval: 1.14 to 8.83, p = 0.027) and the composite of cardiac mortality and DES thrombosis (hazard ratio: 2.94, 95% confidence interval: 1.16 to 7.41, p = 0.022).ConclusionsDual nonresponsiveness to aspirin and clopidogrel is a relatively infrequent condition that identifies patients at a very high risk of DES thrombosis or death.
- Published
- 2008
41. Restenosis after directional coronary atherectomy: Differences between primary atheromatoes and restenosls lesions and influence of subintimal tissue resection
- Author
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Ronald E. Vlietstra, John F. Bresnahan, William D. Edwards, Kirk N. Garratt, Malcolm R. Bell, Urs P. Kaufmann, and David R. Holmes
- Subjects
Male ,Reoperation ,medicine.medical_specialty ,medicine.medical_treatment ,Constriction, Pathologic ,Coronary Artery Disease ,Balloon ,Atherectomy ,Restenosis ,Recurrence ,Internal medicine ,Angioplasty ,medicine ,Humans ,Angioplasty, Balloon, Coronary ,Coronary Artery Bypass ,Neointimal hyperplasia ,business.industry ,Graft Occlusion, Vascular ,Middle Aged ,medicine.disease ,Coronary Vessels ,Coronary arteries ,Stenosis ,medicine.anatomical_structure ,Cardiology ,Female ,Radiology ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Rates of restenosis were evaluated in 70 patients (74 lesions) after successful directional coronary atherectomy. The extent of vascular tissue resection was correlated with restenosis rates for coronary (n = 59) and vein bypass graft (n = 15) lesions.After 6 months, the overall restenosis rate was 50% (37 of 74 lesions); it was 42% (15 of 36 lesions) when intima alone was resected, 50% (7 of 14 lesions) when media was resected and 63% (15 of 24 lesions) when adventitia was resected. Subintimal tissue resection increased the restenosis rate for vein grafts (43% with intimal resection versus 100% with subintimal resection, p = 0.01) but not for coronary arteries (50% versus 48%). There was no overall difference in restenosis rates after atherectomy between primary lesions and restenosis lesions that occurred after balloon angioplasty (46% versus 54%). Among postballoon angioplasty restenosis lesions, a higher rate of restenosis after atherectomy was found with subintimal than with intimal resection (78% versus 32%, p = 0.01).Tissues from patients undergoing a second atherectomy for restenosis after initial atherectomy (n = 8) demonstrated neointimal hyperplasia that appeared histotogically identical to restenotic tissue developing after balloon angioplasty (n = 37).These data suggest that the cellular response to directional coronary atherectomy is characterized by neointimal proliferation similar to that which may develop after balloon angioplasty. The extent of fibrous hyperplasia appears to be related to the depth of tissue resection in vein graft lesions and coronary artery restenosis lesions that occur after balloon angioplasty but not in primary atheromatous coronary artery lesions.
- Published
- 1990
42. Balloon expandable stent implantation in stenotic right heart valved conduits
- Author
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Michael Jones, Antonio L. Bartorelli, Louis G. Prevosti, Martin B. Leon, Victor J. Ferrans, Yaron Almagor, and Gad Keren
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Heart Ventricles ,Femoral vein ,Constriction, Pathologic ,Pulmonary Artery ,Balloon ,Catheterization ,Blood vessel prosthesis ,medicine.artery ,Internal medicine ,medicine ,Animals ,cardiovascular diseases ,business.industry ,Balloon catheter ,Graft Occlusion, Vascular ,Stent ,medicine.disease ,Surgery ,Blood Vessel Prosthesis ,Stenosis ,medicine.anatomical_structure ,surgical procedures, operative ,Pulmonary artery ,Cardiology ,cardiovascular system ,Stents ,business ,Cardiology and Cardiovascular Medicine ,Artery ,Papio - Abstract
Although valved conduits have been used successfully in severe forms of right ventricular-pulmonary artery discontinuity, progressive valved conduit stenosis is an important clinical problem. To determine the feasibility of reducing right heart valved conduit stenosis with a balloon expandable stent, a baboon model was used, in which the pulmonary artery was ligated and a right ventricular to pulmonary artery 14 mm bioprosthetic Dacron valved conduit implanted.In five baboons, at an average of 40 months after valved conduit implantation, fibrointimal stenosis at the valve site resulted in narrowing and a mean transconduit pressure gradient of 49 mm Hg (range 33 to 65). A tubular slotted steel stent (1.2 cm long) was deployed within the valved conduit after inflation of an 8 to 15 mm diameter balloon catheter that was introduced through the femoral vein. A stent was delivered to all valved conduits; however, in two baboons, balloon undersizing resulted in stent dislodgment. In the remaining three baboons, the transconduit gradient was reduced by 59% (49 to 20 mm Hg) and right ventricular systolic pressure decreased acutely by 35% (77 to 50 mm Hg).It is concluded that stent deployment is feasible in right ventricular to pulmonary artery stenotic valved conduits and may result in significant hemodynamic improvement. However, successful stent delivery is critically dependent on the proper selection of stent length and balloon diameter.
- Published
- 1990
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43. A randomized comparison of sirolimus- versus Paclitaxel-eluting stent implantation in patients with diabetes mellitus
- Author
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Si Wan Choi, Kyoung Suk Rhee, Seung-Whan Lee, Myeong Ki Hong, Jae-Hwan Lee, Cheol Whan Lee, In Whan Seong, Jei Keon Chae, Seung-Jung Park, Seong Wook Park, June Hong Kim, Jae Hyeong Park, Kook Jin Chun, Young-Hak Kim, Jin Ok Jeong, Hyun-Sook Kim, Jae Ki Ko, Duk-Woo Park, Yoon Haeng Cho, Nae Hee Lee, and Sung Cheol Yun
- Subjects
Male ,medicine.medical_treatment ,law.invention ,Coronary artery disease ,Cohort Studies ,chemistry.chemical_compound ,Restenosis ,Randomized controlled trial ,law ,Intravascular ultrasound ,paclitaxel-eluting stent ,Myocardial infarction ,Prospective cohort study ,Antibacterial agent ,medicine.diagnostic_test ,Graft Occlusion, Vascular ,Drug-Eluting Stents ,Middle Aged ,Tubulin Modulators ,surgical procedures, operative ,Treatment Outcome ,Paclitaxel ,Drug-eluting stent ,diabetes mellitus ,sirolimus-eluting stent ,Female ,Cardiology and Cardiovascular Medicine ,coronary artery disease ,Immunosuppressive Agents ,medicine.drug ,medicine.medical_specialty ,Randomization ,Diabetes Complications ,Blood Vessel Prosthesis Implantation ,Internal medicine ,Diabetes mellitus ,medicine ,Stent implantation ,Humans ,In patient ,cardiovascular diseases ,Aged ,Sirolimus ,business.industry ,Coronary Stenosis ,equipment and supplies ,medicine.disease ,Surgery ,Clinical trial ,Radiography ,chemistry ,business ,human activities ,Mace - Abstract
ObjectivesThe aim of this study was to compare the effectiveness of sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) in patients with diabetes mellitus (DM).BackgroundDrug-eluting stent implantation significantly improved the angiographic and clinical outcomes compared with bare-metal stent implantation in diabetic patients. However, comparison of SES with PES in diabetic patients has not been sufficiently evaluated.MethodsThis prospective, multicenter, randomized study compared SES (n = 200) and PES implantation (n = 200) for diabetic patients (n = 400). The primary end point was in-segment restenosis at 6 months according to intention-to-treat principle.ResultsThe 2 groups had similar baseline clinical and angiographic characteristics. Six-month in-stent (3.4% vs. 18.2%, p < 0.001) and in-segment restenosis (4.0% vs. 20.8%, p < 0.001) and 9-month target lesion revascularization (2.0% vs. 7.5%, p = 0.017) were significantly lower in the SES versus the PES group. The incidence of death (0% in SES vs. 0.5% in PES, p = 0.999) or myocardial infarction (0.5% in SES vs. 0.5% in PES, p =0.999) at 9-month follow-up was not statistically different between the 2 groups. Major adverse cardiac events including death, myocardial infarction, and target lesion revascularization at 9 months (2.0% vs. 8.0%, p = 0.010) were lower in the SES versus the PES group.ConclusionsSirolimus-eluting stent implantation is superior in reducing angiographic restenosis and improving 9-month clinical outcomes in patients with DM and coronary artery disease compared with PES implantation.
- Published
- 2007
44. The PROXIMAL trial: proximal protection during saphenous vein graft intervention using the Proxis Embolic Protection System: a randomized, prospective, multicenter clinical trial
- Author
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Laura, Mauri, David, Cox, James, Hermiller, Joseph, Massaro, Joyce, Wahr, Sew Wah, Tay, Michael, Jonas, Jeffrey J, Popma, Jim, Pavliska, Dennis, Wahr, and Campbell, Rogers
- Subjects
Male ,Coronary Thrombosis ,Coronary Stenosis ,Graft Occlusion, Vascular ,Prostheses and Implants ,Middle Aged ,Coronary Angiography ,Epoprostenol ,Thromboembolism ,Multivariate Analysis ,Creatine Kinase, MB Form ,Humans ,Female ,Saphenous Vein ,Stents ,Prospective Studies ,Angioplasty, Balloon, Coronary ,Coronary Artery Bypass ,Filtration ,Aged - Abstract
To determine if outcomes could be further improved, we investigated an embolic protection device placed proximal to the target lesion that could provide protection before lesion instrumentation, allow the use of conventional guidewires, and permit embolic protection in anatomy unfavorable for distal devices.Embolic complications during stenting of degenerated saphenous vein coronary bypass grafts are reduced, but not eliminated, by distal protection.A total of 594 patients undergoing stenting of 639 saphenous vein grafts were prospectively randomized, using a noninferiority design, to compare 2 treatment strategies: control (distal protection whenever possible) or test (proximal protection when possible, distal when not).The primary composite end point of death, myocardial infarction, or target vessel revascularization at 30 days by intention to treat analysis occurred in 10.0% of control and 9.2% of test patients; difference = -0.8% (95% confidence interval [CI] -5.5% to 4.0%); p for noninferiority = 0.0061. In device specific analysis, this composite end point occurred in 11.7% of distal protection patients and 7.1% of proximal protection patients (difference = -4.6% [95% CI -9.6% to 0.3%]; p for superiority = 0.10, p for noninferiority = 0.001). Finally, in the subset of patients with lesions amenable to treatment with either proximal or distal protection devices (n = 410), the primary composite end point occurred in 12.2% of distal protection patients and 7.4% of proximal protection patients; difference = -4.7% (95% CI -10.4% to 1.0%), p for superiority = 0.14, p for noninferiority = 0.001.Using proximal embolic protection whenever possible during treatment of diseased saphenous vein grafts produced outcomes similar to those with distal embolic protection.
- Published
- 2007
45. Angiographic stent thrombosis after routine use of drug-eluting stents in ST-segment elevation myocardial infarction: the importance of thrombus burden
- Author
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Georgios, Sianos, Michail I, Papafaklis, Joost, Daemen, Sofia, Vaina, Carlos A, van Mieghem, Ron T, van Domburg, Lampros K, Michalis, and Patrick W, Serruys
- Subjects
Male ,Coronary Thrombosis ,Graft Occlusion, Vascular ,Myocardial Infarction ,Middle Aged ,Coronary Angiography ,Severity of Illness Index ,Cohort Studies ,Treatment Outcome ,Predictive Value of Tests ,Humans ,Female ,Stents ,Angioplasty, Balloon, Coronary ,Immunosuppressive Agents ,Aged ,Retrospective Studies - Abstract
This study sought to investigate the impact of thrombus burden on the clinical outcome and angiographic infarct-related artery stent thrombosis (IRA-ST) in patients routinely treated with drug-eluting stent (DES) implantation for ST-segment elevation myocardial infarction (STEMI).There are limited data for the safety and effectiveness of DES in STEMI.We retrospectively analyzed 812 consecutive patients treated with DES implantation for STEMI. Intracoronary thrombus burden was angiographically estimated and categorized as large thrombus burden (LTB), defined as thrombus burdenor =2 vessel diameters, and small thrombus burden (STB) to predict clinical outcomes. Major adverse cardiac events (MACE) were defined as death, repeat myocardial infarction, and IRA reintervention.Mean duration of follow-up was 18.2 +/- 7.8 months. Large thrombus burden was an independent predictor of mortality (hazard ratio [HR] 1.76, p = 0.023) and MACE (HR 1.88, p = 0.001). The cumulative angiographic IRA-ST was 1.1% at 30 days and 3.2% at 2 years, and continued to augment beyond 2 years. It was significantly higher in the LTB compared with the STB group (8.2% vs. 1.3% at 2 years, respectively, p0.001). Significant independent predictors for IRA-ST were LTB (HR 8.73, p0.001), stent thrombosis at presentation (HR 6.24, p = 0.001), bifurcation stenting (HR 4.06, p = 0.002), age (HR 0.55, p = 0.003), and rheolytic thrombectomy (HR 0.11, p = 0.03).Large thrombus burden is an independent predictor of MACE and IRA-ST in patients treated with DES for STEMI.
- Published
- 2006
46. Effectiveness of drug-eluting stents in patients with bare-metal in-stent restenosis: meta-analysis of randomized trials
- Author
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Alban, Dibra, Adnan, Kastrati, Fernando, Alfonso, Melchior, Seyfarth, Maria-José, Pérez-Vizcayno, Julinda, Mehilli, and Albert, Schömig
- Subjects
Male ,Sirolimus ,Treatment Outcome ,Paclitaxel ,Graft Occlusion, Vascular ,Humans ,Female ,Stents ,Middle Aged ,Immunosuppressive Agents ,Tubulin Modulators ,Aged ,Randomized Controlled Trials as Topic - Abstract
We sought to synthesize the available evidence on the effectiveness of drug-eluting stents for bare-metal in-stent restenosis.Although there is clinical evidence that drug-eluting stents are associated with better results than other treatments for in-stent restenosis, they are not yet approved for this indication. Meta-analysis of randomized trials may yield more precise estimates of treatment effects and enable a rapid adoption of effective treatments in clinical practice.Data sources included PubMed and conference proceedings. Prespecified criteria were met by 4 randomized studies comparing sirolimus- or paclitaxel-eluting stents versus balloon angioplasty or vascular brachytherapy in 1,230 patients with bare-metal in-stent restenosis. Studies reported the clinical outcomes of efficacy and safety during a minimum of 9 months. The primary outcome was target lesion revascularization.No significant heterogeneity was found across trials, thus showing a similar effect size regardless of the use of balloon angioplasty or vascular brachytherapy as comparators. The risk of target lesion revascularization (odds ratio 0.35, 95% confidence interval [CI] 0.25 to 0.49; p0.001) and that of angiographic restenosis (odds ratio 0.36, 95% CI 0.27 to 0.49; p = 0.001) were markedly lower in patients treated with drug-eluting stents. There were no differences between patients treated with drug-eluting stents and those treated with other techniques with respect to the composite of death or myocardial infarction (odds ratio 1.04, 95% CI 0.54 to 2.03; p = 0.55).Drug-eluting stents are markedly superior to conventional techniques (balloon angioplasty and vascular brachytherapy) and should be considered as first-line treatment for patients with bare-metal in-stent restenosis.
- Published
- 2006
47. Incidence and clinical correlates of ruptured plaques in saphenous vein grafts: an intravascular ultrasound study
- Author
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Jerzy, Pregowski, Pawel, Tyczynski, Gary S, Mintz, Sang-Wook, Kim, Adam, Witkowski, Ron, Waksman, Augusto, Pichard, Lowell, Satler, Kenneth, Kent, Mariusz, Kruk, Szymon, Bieganski, Patrick, Ohlmann, and Neil J, Weissman
- Subjects
Male ,Rupture, Spontaneous ,Incidence ,Graft Occlusion, Vascular ,Coronary Artery Disease ,Middle Aged ,Radiography ,Risk Factors ,Humans ,Female ,Saphenous Vein ,Coronary Artery Bypass ,Ultrasonography, Interventional ,Aged - Abstract
The goal of this study was to assess the incidence, clinical correlates, and angiographic appearance of ruptured atherosclerotic plaques detected in saphenous vein grafts (SVGs).Ruptured atherosclerotic plaques in native coronary arteries but not in SVGs have been well described with intravascular ultrasound (IVUS).We reviewed 791 pre-intervention IVUS SVG studies and identified 95 ruptured plaques in 76 SVGs in 73 patients. Standard clinical, angiographic, and IVUS measurements were collected and/or measured. Ruptured plaques were compared with nonruptured plaques in 276 randomly selected patients.The IVUS-detected ruptured plaques had angiographically complex morphology (95%) with ulceration (79%), intimal flap (71%), and sometimes aneurysm formation (14%). Compared with control SVG lesions, ruptured plaques occurred more often in patients with acute coronary syndromes, in older SVGs (12.3 +/- 5.0 years vs. 8.6 +/- 5.2 years, p0.001), and in patients with hypercholesterolemia (92% vs. 81%, p = 0.021) and hypertension (78% vs. 63%, p = 0.015). Multiple ruptured plaques were identified in 22 patients in 19 grafts, more often in diabetic patients (55% vs. 29%, p = 0.054). A tear in the fibrous cap could be identified in 59% of plaques; in 70% it occurred at the shoulder of the plaque and in 30% at the center of the plaque. The IVUS features of ruptured plaques included positive remodeling in 71%, which was more common than in control plaques (40%, p0.001).Ruptured atherosclerotic plaques occur in old SVGs with an incidence of 9.7%. These lesions have a complex angiographic appearance and positive remodeling characteristics. This is similar to ruptured plaques in native arteries.
- Published
- 2005
48. Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis
- Author
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Emile, Ferrari, Mustapha, Benhamou, Pierre, Cerboni, and Baudouy, Marcel
- Subjects
Male ,Aspirin ,Graft Occlusion, Vascular ,Myocardial Infarction ,Thrombosis ,Coronary Artery Disease ,Syndrome ,Middle Aged ,Angina Pectoris ,Treatment Refusal ,Fibrinolytic Agents ,Withholding Treatment ,Risk Factors ,Humans ,Female ,Stents ,Aged - Abstract
We sought to determine whether aspirin withdrawal is an encountered situation in coronary disease patients who relapsed.Despite the recognized benefits of aspirin in coronary disease, and because of the threat of bleeding or poor compliance, aspirin intake is sometimes stopped. It is not known whether withdrawal of aspirin can be harmful in coronary-disease patients.Between September 1999 and April 2002, a total of 1,236 patients hospitalized for acute coronary syndrome (ACS) were questioned in order to determine whether aspirin intake had been interrupted.Fifty-one of these ACSs occurred within 1 month after aspirin withdrawal. This represents 4.1% of all coronary events but 13.3% of recurrences. Among those patients who relapsed, the incidence of ST-segment elevation ACS was higher in those who stopped aspirin when compared to the 332 patients who did not stop aspirin (39% vs. 18%; p = 0.001). Ten (20%) cases involved a thrombosis of an uncoated stent implanted on average 15.5 +/- 6.5 months previously. Mean delay between aspirin withdrawal and the acute coronary event was 10 +/- 1.9 days. Reasons for aspirin withdrawal included minor surgery in 7 cases, fibroscopy in 8 cases, dental treatment in 13 cases, bleeding in 3 cases, and patient non-compliance in 20 cases.Our results support the hypothesis that aspirin withdrawal in coronary patients may represent a real risk for the occurrence of a new coronary event. Many cases involved late uncoated-stent thrombosis. Assessment of the exact incidence of coronary recurrences after aspirin withdrawal will need prospective studies.
- Published
- 2004
49. Treatment of saphenous vein graft lesions with drug-eluting stents: immediate and midterm outcome
- Author
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Lei, Ge, Ioannis, Iakovou, Giuseppe M, Sangiorgi, Alaide, Chieffo, Gloria, Melzi, John, Cosgrave, Matteo, Montorfano, Iassen, Michev, Flavio, Airoldi, Mauro, Carlino, Nicola, Corvaja, and Antonio, Colombo
- Subjects
Male ,Sirolimus ,China ,Paclitaxel ,Graft Occlusion, Vascular ,Coronary Angiography ,Survival Analysis ,Coronary Restenosis ,Hospitalization ,Postoperative Complications ,Treatment Outcome ,Italy ,Case-Control Studies ,Humans ,Female ,Saphenous Vein ,Stents ,Registries ,Angioplasty, Balloon, Coronary ,Immunosuppressive Agents ,Aged ,Follow-Up Studies ,Proportional Hazards Models ,Retrospective Studies - Abstract
The purpose of the present report was to evaluate clinical and angiographic outcomes of drug-eluting stent (DES) implantation in saphenous vein graft (SVG) lesions.The safety and efficacy of DES implantation for the treatment SVG lesions remains uncertain.We evaluated in-hospital and six-month outcomes in 61 consecutive patients treated with DES in SVG lesions from March 2002 to March 2004 (DES group), as compared to 89 consecutive patients treated with bare-metal stents (BMS) in the 24 months immediately before the introduction of DES (BMS group). Major adverse cardiac events (MACE) including death, myocardial infarction, target lesion revascularization (TLR), and target vessel revascularization (TVR) were recorded in-hospital and at six-month follow-up.The rate of in-hospital MACE was similar between the two groups (6.6% vs. 5.6%, p = 1.0). Cumulative MACE at six months was 11.5% in the DES group and 28.1% in the BMS group (p = 0.02). The DES group had a significantly lower incidence of in-segment restenosis (10.0% vs. 26.7%, p = 0.03), TLR (3.3% vs. 19.8%, p = 0.003), and TVR (4.9% vs. 23.1%, p = 0.003). By Cox regression analysis, diabetes (hazard ratio [HR]: 3.03; 95% confidence interval [CI]: 1.33 to 6.90; p = 0.008), usage of BMS (HR: 2.53; 95% CI: 1.07 to 5.97; p = 0.03), and age of SVG (HR: 1.10; 95% CI: 1.02 to 1.19; p = 0.02) were identified as predictors of MACE at six-month follow-up.Compared to BMS implantation, DES implantation in SVG lesions appears safe with favorable and improved mid-term outcomes.
- Published
- 2004
50. Sirolimus-eluting stent implantation for unprotected left main coronary artery stenosis: comparison with bare metal stent implantation
- Author
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Seung-Jung, Park, Young-Hak, Kim, Bong-Ki, Lee, Seung-Whan, Lee, Cheol Whan, Lee, Myeong-Ki, Hong, Jae-Joong, Kim, Gary S, Mintz, and Seong-Wook, Park
- Subjects
Male ,Sirolimus ,Graft Occlusion, Vascular ,Middle Aged ,Coronary Restenosis ,Radiography ,Treatment Outcome ,Humans ,Female ,Stents ,Immunosuppressive Agents ,Aged ,Follow-Up Studies ,Retrospective Studies ,Ultrasonography - Abstract
This study was designed to compare the clinical and angiographic outcomes of sirolimus-eluting stent (SES) and bare metal stent (BMS) implantation for unprotected left main coronary artery (LMCA) stenosis.The safety and effectiveness of SES implantation for unprotected LMCA stenosis have not been ascertained.Elective SES implantation for de novo unprotected LMCA stenosis was performed in 102 consecutive patients with preserved left ventricular function from March 2003 to March 2004. Data from this group were compared to those from 121 patients treated with BMS during the preceding two years.Compared to the BMS group, the SES group received more direct stenting, had fewer debulking atherectomies, had a greater number of stents, had more segments stented, and underwent more bifurcation stenting. The procedural success rate was 100% for both groups. There were no incidents of death, stent thrombosis, Q-wave myocardial infarction (MI), or emergent bypass surgery during hospitalization in either group. Despite less acute gain (2.06 +/- 0.56 mm vs. 2.73 +/- 0.73 mm, p0.001) in the SES group, SES patients showed a lower late lumen loss (0.05 +/- 0.57 mm vs. 1.27 +/- 0.90 mm, p0.001) and a lower six-month angiographic restenosis rate (7.0% vs. 30.3%, p0.001) versus the BMS group. At 12 months, the rate of freedom from death, MI, and target lesion revascularization was 98.0 +/- 1.4% in the SES group and 81.4 +/- 3.7% in the BMS group (p = 0.0003).Sirolimus-eluting stent implantation for unprotected LMCA stenosis appears safe with regard to acute and midterm complications and is more effective in preventing restenosis compared to BMS implantation.
- Published
- 2004
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