Search

Coronary calcification is found in intima as atherosclerotic lesions with cholesterol clefts and thrombi as well as in media (so called Moncheberg type). In coronary intervention, as coronary calcification disturbs dilatation, rotational atherectomy is necessary for calcified lesions. Coronary artery bypass is also difficult to suture at the calcified sites. Thus, surgeons have to find non-calcified area. Severe coronary artery disease complicates coronary calcification. Thus, it is important to improve success rate in coronary intervention as well as bypass surgery.

Objectives: The short-term and long-term predictors of outcome after coronary angioplasty in the unprotected left main coronary artery were investigated., Methods: The procedure was performed in 122 consecutive patients for de novo lesions without myocardial infarction in our hospital between April 1986 and October 1998, including 16 emergency cases. Procedures were directional coronary atherectomy (73 patients), balloon angioplasty (31 patients), and stent implantation (18 patients). There were 101 males and mean age was 68 +/- 10 years. Follow-up angiography was performed in 98% of discharged patients, and all patients were clinically followed up for more than 1 year. Clinical and angiographic predictors of in-hospital and long-term outcome were evaluated., Results: The in-hospital mortality was 5.7% (7 of 122 patients). Multivariate analysis revealed that more patients were admitted as emergency cases (57% vs 10%, p = 0.0088), with left ventricular ejection fraction < or = 35% (57% vs 22%, p = 0.029) and renal failure (43% vs 3%, p = 0.0004) finally died. Mean follow-up period was 3.5 years. Estimated survival rate was 77.1%, and cardiac-death free survival rate was 81.0% at 5 years by the Kaplan-Meier method. Univariate analysis showed that the predictors of cardiac death were emergency angioplasty, renal failure, decreased left ventricular ejection fraction, multivessel disease and unstable angina and/or congestive heart failure. Cox's regression model showed that renal failure (p = 0.0004) and multivessel disease (p = 0.0075) were significant predictors of long-term prognosis., Conclusions: Renal failure was the strongest predictor of outcome after unprotected left main coronary artery angioplasty.

Atherectomy (ATE) is a new catheter-mediated technique for the removal of atheroma in patients with arteriosclerosis obliterans (ASO). ATE was performed using 7-10 Fr. Simpson Peripheral Athero Track catheters at 186 sites in 146 patients, whose lesions involved 49 common iliac arteries, 66 external iliac arteries, 68 femoral arteries and three other arteries. The initial success rate was 94.1%. The mean percent of the diameter stenosis was reduced from 79.0 +/- 1.2% (mean +/- SD) to 22.7 +/- 1.0%. There were two cases of perforation that required surgical treatment (1.1%). The complication rate was 4.4%. The 0.5-, 1-, 2- and 3-year patency rates were 87.6%, 79.6%, 62.5% and 62.5%, respectively. The rate of long-term patency in each segment of arterial lesions revealed that the patency rate in the common iliac artery was significantly higher than the rates in the external iliac artery (p < 0.05) and femoral artery (p < 0.01). The patency rates for long lesions (> or = 2.0 cm) and occluded lesions were significantly (p < 0.01) lower than those for short lesions (< 2.0 cm). Diabetic patients had a higher re-stenosis rate than nondiabetic patients (p < 0.05). In conclusion, ATE is an effective new method for the treatment of patients with ASO.

A case is reported of mycotic aneurysm at the petrous portion of the internal carotid artery (ICA) treated with an endovascular procedure. A sixty-seven-year-old male who had suffered from chronic otitis media bilaterally for the last five years showed a sudden onset of massive left otorrhagia. Cerebral angiogram at the eighth day of otorrhagia disclosed a big aneurysm at the petrous portion of the left ICA. The aneurysm was round in shape but its wall was irregular. The angiogram also showed that a stenotic finding of the left ICA just at the proximal portion of the aneurysm and the neck of the aneurysm was not broad. Bone window computed tomography showed a destroyed petrous bone around the left ICA. The results of the Matas test and the Allcock test told us that left ICA occlusion should not be selected as a treatment. We decided that endovascular surgery could be applied as the treatment of this pathology. An endovascular procedure was performed for this pathology one month after the otorrhagia. The aneurysm was successfully embolized using platinum coils beside a part of the neck without occlusion of the parent artery. The patient's postoperative course was not eventful. We concluded that endovascular surgery might be the first choice for the treatment of an ICA petrous portion mycotic aneurysm.

We studied the preliminary results of atherectomy of atherosclerotic lesions involving the lower extremities in 10 patients. Fifteen arterial stenotic lesions, five iliac, eight superficial femoral, one popliteal, and one anterior tibial, were treated. Five lesions were re-stenoses after balloon angioplasty, while the remaining lesions were previously untreated primary stenoses. For atherectomy, over-the-wire atherectomy catheters ranging in size from 7 to 10-F were used. Balloon angioplasty was also performed in cases 3, 6 and 9. Atherectomy was considered a success in all patients based on angiographic and clinical criteria. Complications occurred in three patients: intimal dissection, distal embolism and arterial spasm. In the patients with distal embolism, a surgical approach was required to remove the embolus. The internal elastic lamina or media was resected in 10 lesions on the histopathologic specimens. Although further assessment of complications and long-term results is required, these results suggest that atherectomy is useful for treating occlusive peripheral vascular disease.

Catheter-based intravascular ultrasound (IVUS) imaging is new, evolving technique in which a high-frequency transducer is attached to the tip of a catheter. In this study, we evaluated the usefulness of catheter-based IVUS in 11 patients with atherosclerotic disease as an adjunct to PTA or atherectomy. A 30-MHz ultrasound catheter was inserted through a 6 F sheath to obtain real-time and cross-sectional images. The IVUS images demonstrated a three-layered appearance of muscular arteries, intimal thickening and calcification. IVUS was performed in 11 patients undergoing percutaneous transluminal angioplasty (7 patients) or atherectomy (4 patients). The presence of dissection between the media and atheroma was observed after balloon angioplasty, while IVUS imaging demonstrated a smooth wall after atherectomy. There was a good correlation between IVUS and angiography in the quantitative assessment of luminal %diameter stenosis before vascular intervention, but a poor correlation was observed after angioplasty, probably due to the dissections from balloon dilatation that resulted in irregular crescentic pathways with unclear borders to the lumen on angiography. The results of our study illustrate the potential utility of IVUS as an adjunct to transluminal vascular intervention.

Arteriosclerosis obliterans (ASO) has become one of major health problems in the elderly people in Japan. This paper reviews the recent progress in the diagnosis and treatment of ASO. Both medical and surgical treatments, such as atherectomy catheters, endovascular metallic stenting, laser angioplasty and LDL-apheresis have recently been greatly developed. As atherosclerosis is a generalised disease, patients with ASO tend to have other atherosclerotic diseases, i.e., cerebrovascular disease, coronary heart disease and renal vascular disease. For the selection of treatments, we have to consider the whole background of the patients, including a quality of life.

The treatment of atherosclerotic vascular diseases has improved greatly. Clinical and epidemiological studies have recently revealed the following data. Changes in lifestyles is extremely effective and should be prevailed widely. Amelioration of atherosclerosis by drugs, including hypolipidemics, antihypertensives and antioxidant agents, is also confirmed. Skills and devices are much improved in PTCA and DCA which face the possibility of restenosis. Control of risk factors is also considered to be important to prevent restenosis.

Various kinds of surgical technique have been utilized for vascular reconstruction for arteriosclerotic arterial occlusive disease (ASO). In general concept, application of thromboendarterectomy is limited to the segmental occlusive aortoiliac atherosclerosis and bypass surgery can be used for almost all types of arterial occlusion. Patency result after bypass surgery are well established and the five year patency rates reveal more than 90% in aortoiliac disease, 75-80% in femoropopliteal disease, and around 70% in crural reconstruction respectively. Despite of these recent advances of reconstructive vascular surgery, there have been augmented several controversies in surgical treatment of ASO. How to treat multisegmental lesion which is characterized by high incidence of ischemic ulcer or gangrene. What is the treatment of choice for high risk patient especially with ischemic heart disease. In Japan, aged patient over 80 have been increasing and they are frequently complicated with limb threatening ischemia and usually grouped into high risk patient. Endovascular intervention, which is developed under the basis of recent technology, is the one of the topics of treatment of peripheral vascular disease. Its long term results, however, are not sufficiently evaluated and how to select the proper reconstructive procedures including the endovascular intervention for high risk patient is remained to be controversy.