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Background: The optimal technique for lesion preparation in heavily calcified coronary lesions (HCCL) prior to drug-eluting stent (DES) implantation has not been described. The aim of this study was to compare the clinical outcomes of lesion preparation with rotational atherectomy (ROTA), plain old balloon angioplasty (POBA), or cutting-balloon angioplasty (CBA) in patients with HCCL who were treated with DES., Methods: The study cohort comprised 737 consecutive patients (874 lesions) who underwent RA (n = 264), POBA (n = 220), or CBA (n = 253) for HCCL at our institution and were treated with DES. Patients with mild or moderate calcified lesions, restenotic lesions, treatment with bare-metal stent (BMS), or history of prior coronary artery bypass graft (CABG) were excluded. The analyzed clinical parameters were the 1-month, 6-month, and 12-month rates of death (all-cause and cardiac), Q-wave myocardial infarction (MI), target-lesion revascularization (TLR), definite stent thrombosis (ST), and major adverse cardiac event (MACE), defined as the composite of death, Q-wave MI, or TLR., Results: The patients were well matched for their baseline characteristics except for age (RA = 71.9 ± 10.4 years; POBA = 68.0 ± 10.8 years; CBA = 68.7 ± 11.8 years; P<.001) and hypertension (RA = 90.9%; POBA = 80.9%; CBA = 84.2%; P=.01), which were different among the three cohorts. The three cohorts had similar clinical outcomes at both short-term and long-term follow-up. The 12-month results were all-cause death (RA = 9.8%; POBA = 8.2%; CBA = 4.5%; P=.18), cardiac death (RA = 3.1%; POBA = 2.5%; CBA = 1.3%; P=.61), Q-wave MI (RA = 0%; POBA = 0%; CBA = 0.7%; P>.99), TLR (RA = 5.2%; POBA = 3.5%; CBA = 3.9%; P=.76), ST (RA = 0%; POBA = 0%; CBA = 0.6%; P=.63) and MACE (RA = 14.6%; POBA = 12.3%; CBA = 8.3%; P=.20). The 1-year MACE-free survival rates were also similar among the three cohorts (log-rank P=.20)., Conclusion: A strategy of lesion preparation with RA, POBA, or CBA in HCCL may be associated with similar clinical outcomes in patients undergoing percutaneous intervention with DES. The RA group had a trend toward greater MACE, death, and TLR.

Objective: This study aimed to assess the long-term safety and clinical effectiveness of the Xience V everolimus-eluting stent (EES) compared to both Taxus paclitaxel-eluting stent (PES) and Cypher sirolimus-eluting stent (SES) in an unselected patient population., Background: There are limited long-term data comparing Xience V EES vs the first-generation Cypher SES., Methods: This retrospective analysis included 6069 patients treated with Cypher SES, Taxus PES, or Xience V EES from 2003-2009 at our institution. Patients were followed by telephone contact or office visit up to 2 years after the index procedure., Results: Baseline characteristics were generally comparable, with the exception of a significantly higher prevalence of diabetes mellitus, systemic hypertension, history of angioplasty, and coronary bypass surgery among Xience V EES patients. At 2 years, the incidence of major adverse cardiovascular events was 13.3% (Xience V EES) vs 17.8% (Cypher SES) vs 22% (Taxus PES) (P<.001). The main drivers for the differences in event rates were lower mortality, the need for target vessel revascularization, and Q-wave myocardial infarction. Stent thrombosis was lowest in Xience V EES patients (0.2% vs 1.2% SES vs 0.7% PES, respectively; P=.01). A landmark analysis after 1 year showed that the benefits of Xience V EES continued in long-term follow-up., Conclusions: In a contemporary clinical United States practice with an unselected patient population, Xience V EES use was associated with improved safety profile and reduction of all-cause mortality and stent thrombosis when compared to both first-generation drug-eluting stents. This superiority continues to widen from 1 to 2 years.

Background: Recent data suggest a clinical benefit with the systematic use of thrombus aspiration (TA) for the treatment of ST-elevation myocardial infarction (STEMI). Nevertheless, the impact of TA as a treatment strategy for stent thrombosis (ST) is unknown. This study aimed to analyze the impact of TA use for the treatment of ST on patient outcomes., Methods: From 2003 to 2008, 91 consecutive patients who presented with a definite ST were included in this analysis. We compared procedural success rates and the incidence of the composite criteria death-recurrent MI-recurrent ST at 30 days in patients who were treated with TA (TA group, n = 36) versus those who were not (No-TA group, n = 55)., Results: Baseline characteristics were similar between the two groups except for the body mass index: 26.2 +/- 5.4 vs. 29.3 +/- 6.2 in the TA and No- TA groups, respectively (p = 0.028). ST presented more likely as STEMI in the TA group: 86.1% vs. 67.3% (p = 0.043). Except for TA use, there was no difference in the treatment therapeutics between groups, including for glycoprotein IIb/IIIa inhibitors. The rate of procedural success was higher in the TA group than in the No-TA group: 88.9% vs. 70.9% (p = 0.043). The incidence of the endpoint of death-recurrent MI-recurrent ST was significantly lower in the TA group: 22.2% vs. 47.2% (p = 0.026). By multivariate analysis, TA use was independently associated with a decrease in the composite criteria (HR = 0.45, p = 0.039)., Conclusion: This study suggests that TA use for ST treatment permits an improvement in patient outcomes at 30 days with a significant decrease in the incidence of the composite criteria death-recurrent MI-recurrent ST. Further prospective studies are needed, however, to definitively address the benefit of TA use in this particular setting.

The long-term outcome of a moderately diseased left main coronary artery (LMCA) remains unknown. One hundred and fourteen patients who underwent angiographic and intravascular ultrasound (IVUS) evaluation for moderate LMCA disease (< 50% diameter stenosis) without intervention were followed for 5 years. There were 11 patients who underwent coronary artery bypass graft surgery (CABG) within 30 days of IVUS analysis based on IVUS findings and 3 patients who died of noncardiac diseases during the follow-up period. These 14 patients were excluded from the cohort, and 100 patients comprised the study group. Six patients (6%) died (1 of cardiac causes and 5 of unknown causes) at a follow up of 31.5 +/- 17.0 months post-IVUS assessment. Two patients (2%) underwent CABG at a follow up of 19.0 +/- 7.1 months. There were no percutaneous LMCA interventions and no myocardial infarctions. Univariate predictors for events were age, mean plaque and media (P&M) area and plaque burden over the entire length of the LMCA lesion, and minimum luminal area (MLA), P&M area, plaque burden, and arc of calcium > 90 degrees at the MLA site. By multiple logistic regression analysis, plaque burden at the MLA (odds ratio = 1.34, 95% confidence interval 1.04-1.73; p = 0.025) was the only independent predictor of events. In conclusion, moderately diseased LMCAs had a 5- year event rate of 8%. The occurrence of future events in moderate diseased LMCAs is dependent on the amount of disease at the MLA site.

Background: Ruptured plaques are associated with elevated C-reactive protein (CRP) that, in turn, are associated with a poor prognosis in acute myocardial infarction (AMI) patients., Objectives: The purpose of this study was to evaluate the impact of plaque rupture and elevated CRP on major adverse cardiac events (MACE) in patients with AMI treated with coronary stenting., Methods: We used pre-intervention intravascular ultrasound (IVUS) to evaluate infarct-related arteries in 72 AMI patients treated with coronary stenting to study the impact of plaque rupture and CRP levels on MACE., Results: Infarct-related artery plaque rupture was observed in 30 patients (42%), and multiple infarct-related artery plaque ruptures were observed in 10 patients (14%). The CRP level was higher in patients with plaque rupture than in those without plaque rupture (31.3 +/- 20.3 vs. 4.2 +/- 5.8 mg/l; p < 0.001). Patients with elevated CRP levels had more plaque rupture and more multiple plaque ruptures than the normal CRP group (26/42 [62%] vs. 4/30 [13%]; p < 0.001, and 10/42 [24%] vs. 0/30 [0%]; p = 0.004, respectively). Plaque rupture and ST-segment elevation MI independently predicted CRP elevation (Hazard ratio [HR] = 5.329; p < 0.001 and HR = 3.790; p = 0.032, respectively). At 1-year follow up, MACE occurred in 9 plaque-rupture patients (30%), in 5 non-plaque rupture patients (12%) and in 29% of elevated CRP patients versus 7% of normal CRP patients. Patients with elevated CRP plus plaque rupture had more MACE than patients with normal CRP and no plaque rupture (31% vs. 4%; p = 0.010). In the multivariate analysis, an elevated CRP was the only independent predictor of MACE (HR = 6.561; p = 0.012)., Conclusions: Plaque rupture and elevated CRP were associated with poor prognosis; however, an elevated CRP was the only independent predictor of 1-year MACE in AMI patients treated with coronary stenting.

Background: The clinical significance of intravascular ultrasound (IVUS) assessed remodeling in left main coronary artery (LMCA) lesions has not been studied. Thus, we evaluated the impact of coronary arterial remodeling on cardiac events in patients with angiographically mild LMCA disease., Methods: Two hundred thirty-six patients who underwent IVUS evaluation to determine the severity of angiographically mild LMCA lesions (diameter stenosis < 50%) were included. Negative remodeling (NR) was defined as a remodeling index (lesion/reference external elastic membrane crosssectional area [CSA]) < 0.95, intermediate remodeling (IR) as between 0.95-1.05, and positive remodeling (PR) as > 1.05., Results: NR was observed in two-thirds of patients (156/236). NR lesions were more proximal in location (45.6% vs. 25.0%; p = 0.003), less frequently associated with soft plaque morphology (23.1% vs. 43.8%; p = 0.001), and had smaller plaque burdens (34.0 +/- 12.0 vs. 40.3 +/- 10.7%; p < 0.001) than IR/PR lesions. At 1-year follow up, LMCA-related cardiac events occurred in 15 patients (6.3%). NR was less frequently associated with LMCA-related cardiac events than IR/PR [6/156 (3.8%) vs. 9/80 (11.3%); p = 0.027]. In lesions associated with LMCA-related events, lumen CSA was smaller, plaque burden was larger, and the remodeling index was greater than in lesions not associated with cardiac events, but only non-NR was an independent predictor of LMCA-related events in patients with mild LMCA disease (hazard ratio 4.095; 95% CI, 1.275-13.149; p = 0.018)., Conclusions: Angiographically mild LMCA disease was more frequently associated with NR, and NR was associated with fewer LMCA-related cardiac events in patients with mild LMCA lesions.

Background: Stents are used to treat the first and even successive episodes of in-stent restenosis (ISR)., Methods: In 18 patients (19 lesions), intravascular ultrasound (IVUS) was performed after placement of a stent for a nonrestenotic lesion after the second stent was used to treat the first episode of ISR and after the third stent was used to treat the second episode of ISR. The duration between the first and second stent was 355 +/- 374 days, and between the second and third stent was 330 +/- 279 days. The duration of follow up after the third stent was 307 +/- 145 days. High-pressure inflation (> 14 atm) was performed for 69% (11/16) of patients when treating the first episode of ISR, and all patients when treating the re-ISR (p = 0.018)., Results: Nevertheless, vessel area and final minimal stent area (MSA) did not increase with successive restenting, and the ratio of minimum stent diameter to nominal stent size suggested that chronic stent underexpansion persisted. MSA > 5 mm2 was noted in 54% after the first stent, 35% after the second stent, and 42% after the third stent (p = 0.6). After the third stent, the rate of target lesion revascularization was 26% (5/19) and target vessel revascularization was 37% (7/19); there was 1 nonfatal myocardial infarction. Thus, the overall rate of major adverse cardiac events was 42%., Conclusion: While serial restenting a recurrent ISR lesion was not associated with progressive decrease in MSA, it was still associated with chronic stent underexpansion and a high rate of adverse events. Attention should be directed to achieving better stent expansion to minimize subsequent recurrences.

Background: Significant aorto-ostial disease is difficult to evaluate with angiography and sometimes even with intravascular ultrasound (IVUS)., Methods: We used IVUS to compare ostial lesions in the left main coronary (LMCA, n = 45) versus the right coronary artery (RCA, n = 50). IVUS measurements were performed each 1 mm beginning within the ostium and continuing to the distal reference segment. Negative remodeling was defined as a remodeling index (lesion/distal reference arterial area) < 0.95., Results: Patient age was 66 +/- 11 years in the LMCA group and 66 +/- 11 years in the RCA group; 56% of the LMCA ostial lesions and 46% of RCA ostial lesions were in males, and 35% of the LMCA ostial lesions and 20% of the RCA ostial lesions were in diabetics. With the exception of a smaller minimum lumen area (p < 0.0001) and distal reference plaque burden (p = 0.002) in ostial RCA lesions and a larger eccentricity index in ostial LMCA lesions (p = 0.001), both sites were remarkably similar. Both ostial LMCA and RCA lesions were short, had modest amounts of calcium, had modest plaque burdens, but had a marked frequency of negative remodeling (84% in LMCA and 86% in RCA; p = 1.0)., Conclusion: IVUS morphometry is similar in ostial LMCA and RCA lesions; negative remodeling is the dominant contributor to lumen compromise in both locations.

Objectives: We aimed to compare the clinical outcomes of dialysis versus nondialysis patients after coronary drug-eluting stent (DES) implantation., Background: The revascularization of ischemic heart disease in dialysis patients has remained controversial due to consistent exclusion of this population from major trials, especially in the context of percutaneous coronary interventions (PCI) with DES., Methods: We analyzed the data on 3,442 consecutive patients who underwent PCI and DES implantation since March 2003. Periprocedural events, 1- and 6-month clinical outcomes were then compared between dialysis (n = 72) and nondialysis patients (n = 3,370)., Results: Baseline characteristics revealed a higher prevalence of female gender (p = 0.03), African Americans (p < 0.001), hypertension (p < 0.001), diabetes mellitus (p < 0.001), number of diseased vessels (p = 0.04), lower ejection fraction (p < 0.001), and a higher prevalence of acute myocardial infarction (MI) (p = 0.04) in dialysis patients. Nondialysis patients showed more history of smoking (p < 0.001) and obesity (p = 0.02). Procedural success was higher (p = 0.05), while there was a trend toward a lower mortality rate, in the nondialysis group during hospitalization. At 6 months, the restenosis rate was low and comparable, but mortality occurred more often (16% vs. 3.8%; p < 0.001) in dialysis patients. Multivariate analysis revealed cardiogenic shock (p = 0.04) to be an independent predictor of mortality., Conclusions: PCI with DES in dialysis patients is safe and feasible, with a similar reduction of repeat revascularization when compared with nondialysis patients. There was, however, a higher incidence of mortality in dialysis patients at 6 months, mostly influenced by contributing comorbidities and more severe conditions at presentation.

Recurrent in-stent restenosis (ISR) following intracoronary radiation therapy (IRT) continues to be a therapeutic challenge. The present study aims to evaluate the clinical outcomes of patients who were treated with drug-eluting stent (DES) implantation versus repeat IRT for recurrent ISR after brachytherapy failure. A cohort of 88 patients who were previously treated with brachytherapy for ISR and presented with angina and recurrence of angiographic restenosis were evaluated for treatment with either DES [sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES); n = 34] or percutaneous coronary intervention (PCI) and repeat radiation (gamma or beta radiation; n = 54). The two groups had similar baseline clinical and angiographic characteristics. The in-hospital outcomes were similar between both groups. At long-term follow-up of 9.7 +/- 4.1 months for the DES group and 10.3 +/- 3.5 months for the repeat IRT group, there were no deaths or myocardial infarctions (MI). There was a trend toward more target vessel revascularization-major adverse cardiac events (TVR-MACE) in the DES group (p = 0.09). In addition, the patients in the DES group had a significantly lower survival rate compared to those in the repeat IRT group (p = 0.018). For patients who had recurrent ISR following IRT, either DES implantation or repeat radiation is safe and is associated with excellent immediate outcomes. Yet, at long-term follow-up, repeat IRT was associated with less recurrences and need for repeat revascularization when compared to DES implantation. Therefore, repeat IRT should be considered as an option for this difficult patient subset.

Pre-treatment of patients with clopidogrel prior to coronary angiography (CAG) and possible percutaneous coronary intervention (PCI) is a standard practice. Candidates for coronary artery bypass surgery (CABG) are discharged or remain in the hospital until CABG after clopidogrel is discontinued. We investigated whether any differences exist in the rates of surgical complications and outcomes between these two groups of patients. We conclude that continued hospitalization of clopidogrel pre-treated patients does not confer any safety benefit with regard to post-operative complications and 30-day mortality. Discharging these patients after CAG may reduce hospitalization costs.

Whether percutaneous coronary intervention (PCI) alone is safe in patients with moderate or severe aortic stenosis (AS) and coexisting coronary artery disease (CAD), and whether aortic valve replacement (AVR) can be deferred in patients with moderate AS by undergoing PCI alone is not known. We conducted a retrospective study of surgically inoperable patients with AS who underwent PCI (moderate AS, n = 28; and severe AS, n = 28) and compared to those with AVR (n = 55). The clinical characteristics, procedural complications, in-hospital and long-term clinical outcomes of PCI were compared. Baseline and procedural characteristics were similar except that lower age, hypertension, and renal impairment were seen in the AVR group. In-hospital complications were comparable among the 3 groups. Six-month and 1-year rates of myocardial infarction (MI), non-Q-wave MI, death and out-of-hospital death were similar between AVR and moderate AS patients (p = NS) and significantly high (p < 0.04) in patients with severe AS. On multivariate analysis, severe AS was the only significant predictor of 6-month and 1-year mortality. Our study suggests that PCI is safe in patients with moderate AS and coexisting CAD but is associated with poor outcomes in patients with severe AS.

Background: Factors leading to subacute vessel closure after percutaneous coronary intervention (PCI) have not been well established in lesions treated with balloon angioplasty or atherectomy., Methods and Results: We used intravascular ultrasound (IVUS) to determine the pre- and post-PCI characteristics involved in subacute vessel closure after PCI. Of 3,403 patients undergoing IVUS imaging during coronary balloon angioplasty or atherectomy, 8 patients (0.2%) developed angiographically documented subacute vessel closure within 1 week post-PCI and were compared to a group matched by procedure date (within 6 months), age, gender, stable or unstable angina, lesion location and treatment (balloon angioplasty or atherectomy). IVUS identified at least one cause for subacute vessel closure in 87% of patients (vs 25% in matched lesions, p < 0.01). Causes were all procedure-related and included inadequate final lumen (60%), dissection (50%) and thrombus (25%). Pre-procedure lesion characteristics were not different from matched lesions., Conclusions: Subacute vessel closure after balloon angioplasty or atherectomy is mostly related to insufficient post-procedure lumen dimension or dissection.

Background: Contrast-induced nephropathy (CIN) is a recognized complication after percutaneous interventions (PCI). We sought to determine the impact of gender on incidence and clinical outcome of CIN., Methods and Results: Of a total 8,628 patients who underwent PCI, there were 1,431 (16.5%) who developed CIN (defined as > 25% rise in creatinine after PCI). Patients were followed clinically for one year. CIN was present in 23.6% of female versus 17.4% of male patients (p < 0.0001). Multivariate analysis showed that female gender (OR = 1.4, 95% CI = 1.25 1.60; p < 0.0001), pre-PCI chronic renal failure (CRF) (OR= 1.8, 95% CI = 1.53 2.10, p < 0.0001), diabetes mellitus (OR = 1.5, 95% CI = 1.34 1.70; p < 0.0001), age (OR = 1.01, 95% CI = 1.01 1.02, p < 0.0001), and hypertension (OR = 1.2, 95% CI = 1.06 1.36, p = 0.0035) were independent predictors of CIN. Clinical outcomes after CIN were examined in patients with or without CRF. Among patients without CRF who developed CIN, females (n = 465) had higher rates of one-year mortality, and MACE comparing to males (n = 710) without CRF (14% vs. 10% mortality, 36% vs. 30% MACE; p = 0.05 and 0.06, respectively). In patients with CRF who developed CIN, we found no significant gender differences in one-year clinical events (37% vs. 36% mortality, 42% vs. 45% MACE; p = 0.8 and 0.6, respectively). By multivariate analysis only baseline CRF, diabetes, age, functional NYHA IV class were identified as independent predictors of one-year mortality in patients with CIN after PCI., Conclusions: Female gender is an independent predictor of CIN development after PCI and a marker of worse 1-year mortality after CIN in patients without baseline CRF. After CIN is developed, pre-PCI CRF, diabetes mellitus, age, severe heart failure (not gender) are independent predictors of one-year mortality.

Because of the extensive use of arterial conduits for coronary surgery and the increased risk of repeat surgery in cases of graft failure, there is a growing interest in percutaneous interventions (PI) for patients with conduit dysfunction. PI on arterial conduits is a challenge for the interventional cardiologist, due to anatomic and functional characteristics of the graft. There are no large-scale multicenter or randomized studies focusing on PI of arterial conduits. Few single-center experiences are available, and all report short-term encouraging results and < 20% restenosis rates. Procedural failures are mainly due to graft tortuosity or length. Spasm is not rarely reported in muscular conduits. Stents are effective for the treatment of ostial disease and in bail-out cases, but should be cautiously used in anastomotic lesions. In patients with patent internal mammary artery, large pectoralis branches are sometimes considered responsible for steal phenomena, but flow diversion is usually trivial and embolization should be accomplished only after careful functional evaluations. PI can safely be performed on arterial grafts, with careful planning and knowledge of conduit pathophysiology.

Pre-intervention administration of abciximab in patients at "high risk" for coronary angioplasty has been shown to reduce acute and long-term cardiac outcomes. The role of intra-procedural ("rescue") administration of abciximab has not been fully elucidated. We assessed the clinical outcomes associated with rescue administration of abciximab during complex percutaneous coronary interventions. We studied in-hospital and long-term (1-year) outcomes (death, myocardial infarction and target lesion revascularization) of 298 consecutive patients (78% male; age, 62 +/- 11 years; 83% with acute coronary syndrome) treated with abciximab for thrombus-containing lesions, sub-optimal angioplasty results, procedural dissections or other complications. Stents were used in 73% of procedures. Procedural success was 97.0% and overall major in-hospital complication rate was 3.0% (death, 1.3%; Q-wave myocardial infarction, 0.7%; and emergent bypass surgery, 1.0%). Most frequent angiographic complications included visible thrombus (17%), dissections (17%), threatened closure (7%), and distal embolization (7%). In-hospital non-Q wave myocardial infarction (defined as CK-MB 5 times normal) occurred in 31.0%. Out-of-hospital to one-year events included death (1.7%), Q-wave myocardial infarction (2.7%), and target lesion revascularization (15.1%); cardiac event-free survival was 82.9%. We conclude that rescue administration of abciximab is associated with relatively low in-hospital complications and favorable long-term outcome in patients with sub-optimal angioplasty results and/or procedure-related complications, although peri-procedural non-Q wave myocardial infarction rate is high. A clinical and cost-effective comparison between provisional and rescue administration of abciximab may be warranted.

Restenosis occurs after 30% to 50% of transcatheter coronary procedures; its mechanisms remain incompletely understood. Intravascular ultrasound (IVUS) studies were analyzed in 360 nonstented native coronary artery lesions in which follow-up quantitative angiographic and/or IVUS data was available. Pre-intervention, post-intervention, and follow-up, the external elastic membrane (EEM) and lumen cross-sectional areas (CSA) were measured; plaque+media (P+M=EEM Ð lumen CSA), and cross-sectional narrowing (CSN=P+M/EEM CSA) were calculated. The anatomic slice selected for serial analysis had an axial location within the lesion at the smallest follow-up lumen CSA. At follow-up, 73% of the decrease in lumen CSA was due to a decrease in EEM CSA; 27% was due to an increase in P+M CSA. The change in lumen CSA correlated more strongly with the change in EEM CSA than with the change in P+M CSA. The change in EEM CSA was bidirectional; 47 lesions (22%) showed an increase in EEM CSA. Despite a greater increase in P+M CSA, lesions exhibiting an increase in EEM CSA had (1) no change in lumen CSA, (2) decreased restenosis, and (3) a 49% frequency of late lumen gain. The independent clinical, angiographic, and IVUS predictors of angiographic restenosis (³ 50% diameter stenosis at follow-up) were the IVUS reference lumen CSA, angiographic pre-intervention diameter stenosis, and post-intervention IVUS CSN. Restenosis appeared to be determined primarily by the direction and magnitude of the change in EEM CSA. An increase in EEM CSA was adaptive while a decrease in EEM CSA contributed to restenosis. The most powerful predictor of restenosis was the IVUS post-procedural CSN. The importance of the post-procedural CSN was related to the change in EEM CSA as a mechanism of restenosis.

Currently, surgical carotid endarterectomy has been the standard therapy for symptomatic and asymptomatic patients with significant carotid artery stenoses. However, there are high surgical risk and other patient subsets, wherein a Òlesser invasiveÓ catheter-based procedure may be worthwhile. Carotid stent-assisted angioplasty (CSSA) is a percutaneous interventional treatment approach for appropriately selected patients with common and internal carotid artery lesions. The present report discusses preliminary technique-related, angiographic, and intravascular ultrasound observations of CSSA. Five symptomatic patients (with six carotid stenoses) with other co-morbid states were treated by a multidisciplinary team under the aegis of an approved protocol using conventional equipment and available Palmaz tubular slotted stents. On-line quantitative angiography and intravascular ultrasound imaging was performed to guide stent insertion and monitor results. There were no procedure-related complications and angiographic results were excellent (final mean diameter stenosis 5%). Intravascular ultrasound imaging was feasible and safe. In two cases, the findings obtained from ultrasound images assisted in subsequent operator decisions. Thus far, there have been no additional clinical sequelae in these patients (@ 30 days). This preliminary experience with CSSA indicates that interventional neurovascular therapies may provide a useful alternative for selected patients requiring endoluminal reconstruction of carotid stenoses. Extensive additional studies are required to establish the appropriate clinical application of this technique.

To investigate the strategy of ÒdebulkingÓ in complex lesions before stent implantation (stent synergy) to improve procedural safety and achieve optimal acute and long-term results, we reviewed our experience in 389 patients with 504 lesions undergoing a combined stent procedure (45% rotational atherectomy, 24% laser angioplasty, 20% directional atherectomy, and 11% transluminal extraction atherectomy before stent implantation). Procedural success was achieved in 94.5%, with 4% major ischemic complications (1.1% death, 1.9% Q-wave myocardial infarction, and 2.3% emergency coronary artery bypass surgery). Overall, subacute stent thrombosis occurred in 1.5% of patients. Target-lesion revascularization during follow-up was required in 9.8% of the patients. We conclude that a strategy of selective pre-stent atheroablation in complex lesion subsets results in excellent procedural outcomes with acceptable complications and favorable long-term results.

The frequency and prognostic importance of subclinical myocardial necrosis after new device coronary intervention is not known. To identify the frequency of CPK-MB release after balloon and single new device angioplasty in native coronary arteries, we reviewed the course of 810 patients who underwent successful single lesion, native vessel angioplasty using balloon angioplasty (N=174), Gianturco-Roubin stent placement for suboptimal angioplasty results (N=31), Palmaz-Schatz stent deployment (N=320), directional coronary atherectomy (N=102), or rotational atherectomy (N=183). All patients had serial measurements of CPK-MB isoenzymes 6 and 18Ð24 hours after coronary intervention; absolute CPK-MB levels were determined by radioimmunoassay (normal assay < 4 ng/ml). CPK-MB isoenzymes were > 2 times normal (> 8 ng/dl) in 15.6% of procedures, > 3 times normal (³ 12 ng/ml) in 11.5% of procedures, > 4 times normal (³ 16 ng/ml) in 8.6% of procedures, and > 5 times normal (³ 20 ng/ml) in 7.7% of procedures. CPK-MB elevation > 2 times normal was more common in those undergoing directional atherectomy (20.8%) and Gianturco-Roubin stent placement (34,4%) than in those undergoing balloon angioplasty (11.7%). No significant differences were noted in patients undergoing rotational atherectomy (13.2%) or Palmaz-Schatz stent placement (15.6%) than in those undergoing balloon angioplasty. CPK-MB > 5 times normal occurred after 7.7% of procedures, but did not vary significantly among the devices used in this study. We conclude that CPK-MB elevations > 2 times normal are highest in patients undergoing directional coronary atherectomy and ÒbailoutÓ use of the Gianturco-Roubin stent. No significant differences in CPK-MB elevation were seen in patients undergoing balloon angioplasty, Palmaz-Schatz stent deployment, or rotational atherectomy. Identification of the prognostic importance of these CPK-MB elevations is currently under study.

Restenosis occurs after 30% to 50% of transcatheter coronary procedures; its mechanisms remain incompletely understood. Intravascular ultrasound (IVUS) studies were analyzed in 360 non-stented native coronary artery lesions in which follow-up quantitative angiographic and/or IVUS data was available. Pre-intervention, post-intervention, and follow-up, the external elastic membrane (EEM) and lumen cross-sectional areas (CSA) were measured; plaque + media (P + M = EEM - lumen CSA), and cross-sectional narrowing (CSN = P + M/EEM CSA) were calculated. The anatomic slice selected for serial analysis had an axial location within the lesion at the smallest follow-up lumen CSA. At follow-up, 73% of the decrease in lumen CSA was due to a decrease in EEM CSA; 27% was due to an increase in P+M CSA. The change in lumen CSA correlated more strongly with the change in EEM CSA than with the change in P + M CSA. The change in EEM CSA was bidirectional; 47 lesions (22%) showed an increase in EEM CSA. Despite a greater increase in P + M CSA, lesions exhibiting an increase in EEM CSA had (1) no change in lumen CSA, (2) decreased restenosis, and (3) a 49% frequency of late lumen gain. The independent clinical, angiographic, and IVUS predictors of angiographic restenosis (³ 50% diameter stenosis at follow-up) were the IVUS reference lumen CSA, angiographic pre-intervention diameter stenosis, and post-intervention IVUS CSN. Restenosis appeared to be determined primarily by the direction and magnitude of the change in EEM CSA. An increase in EEM CSA was adaptive while a decrease in EEM CSA contributed to restenosis. The most powerful predictor of restenosis was the IVUS post-procedural CSN. The importance of the post-procedural CSN was related to the change in EEM CSA as a mechanism of restenosis.