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Objectives: The aim of our study is to evaluate the safety and efficacy of DES implantation in an unselected, "real world," high-risk population., Background: Several clinical trials showed that drug-eluting stents (DESs) implantation is safe and effective in selected population. In spite of these encouraging results, there are some concerns about "real world" utilization of these stents., Methods: One thousand four hundred and fifty-five off-label patients have been included in our registry. Primary end-points were: long-term clinical incidence of major adverse cardiac and cerebrovascular events (MACCE) and thrombosis (ST). We detected the difference between uniDES vs. multiDES implantation in terms of MACCE, death, nonfatal-MI, the composite of death/nonfatal-MI and target lesion revascularization (TLR) and the difference between DES type in term of MACCE., Results: At 36 months follow-up we found: cardiac death occurred in 20 patients (1.6%); 33 patients (2.6%) had a nonfatal MI and 81 patients (6.3%) had a TLR. We observed one (0.1%) acute, 9 subacute (0.6%), 6 late (0.6%), and 1 (0.5%) very late definite ST. No difference were found in terms of overall MACCE, MI, death and composite of death/nonfatal-MI between uni- and multiDES implantation but multiDES group had a higher incidence of TLR. No difference between DES type in term of MACCE was detected., Conclusions: DES utilization shows their safety and efficacy in off-label patients with complex clinical and angiographic profile in terms of long-term incidence of MACCE. MultiDES implantation is associated with a higher risk of long-term TLR. No difference between DES type was found., (Copyright © 2011 Wiley Periodicals, Inc.)

Unligated side branches of the left internal mammary artery (LIMA) have been indicated as a cause of coronary steal resulting in postoperative angina. Although a number of studies have reported successful embolization of the side branches to relieve angina, this phenomenon is still controversial and it has been either emphasized or rejected in studies that attempted to obtain hemodynamic evidence of the steal using angiographic and intravascular Doppler techniques. In this case study, we tried to reproduce physiological decrease in the muscular and coronary beds as it could occur during activity. Our results, using an intracoronary Doppler wire with adenosine combined with forced ventilation, showed that a trial occlusion of the LIMA side branch with a balloon technique can demonstrate whether the flow through the LIMA would increase after embolization of the side branch., (Copyright 2002 Wiley-Liss, Inc.)

Few data are available on the quantitative assessment of complexity (C), especially in relation to a patient's exposure to radiation. The relationship between several clinical (CFs), anatomic (AFs), and technical factors (TFs) versus fluoroscopy time (FT) was evaluated in 402 random percutaneous transluminal coronary angioplasty (PTCA) procedures. CFs were age, sex, single or multivessel disease, ejection fraction, and previous coronary artery bypass graft. AFs were assessed based on the American Heart Association / American College of Cardiology classification. TFs were multivessel PTCA, use of the double wire or double balloon technique, stenting, ostial stenting, bifurcation stenting, and intravascular ultrasonography. No CFs significantly influenced FT, whereas all AFs and TFs (except multivessel PTCA) did significantly influence FT. A scoring system was developed, and two complexity indexes (CI) were conceived, based on which the procedures were divided into three groups: simple, medium, and complex. The mean FTs were 471+/-289, 805+/-532, and 1,190+/-641 (P <0.0001), respectively. Total cine frame recordings were 1,119+/-572, 1,265+/-644 (P = 0.0355), and 1,418+/-785 (P<0.0001 vs. simple; P = NS vs. medium). The dose/area product measurement was 65.8+/-41.4, 93 +/-58.5 (P<0.0001), and 116.7+/-72.8 (P<0.0001 vs. simple; P = 0.00159 vs. medium), respectively. In our series, CI was directly related to AF and TF, but not to CF. Comparison of PTCA procedures and definition of appropriate FT should consider CIs.

We present a previously unreported complication of the "trousers" stent procedure used for treatment of a bifurcation lesion in the left anterior descending artery and the first diagonal branch. Closure of the main vessel occurred. A balloon, however, could not be advanced across the side-branch stent to open the struts toward the main branch. Therefore, a bailout rotational atherectomy was performed to ablate the stent that then allowed a further dilatation with a PTCA balloon. This procedure resolved a potentially lethal outcome for the patient who subsequently underwent uneventful coronary by-pass grafting.

A detailed monitoring, on the basis of single procedures, was undertaken to assess the patient exposure and the occupational doses received by the operators (cardiologist, technician, and nurse) during diagnostic coronary angiography (CAG) and percutaneous transluminal coronary angioplasty (PTCA). The occupational dose to the staff was measured at the collar level using thermoluminescent dosimeters (TLD) to examine the neck and head exposure. Patient exposure was assessed by the dose-area product (DAP in Gy/cm2) and by the skin dose (mGy) at the level of thyroid. The mean neck dose per procedure for cardiologist was about 0.05 mGy, a reasonable level to comply with the International Commission on Radiological Protection (ICRP) eye lens recommended limit. No significant differences were detected between CAG (39 procedures) and PTCA (19 procedures). Relatively high radiation doses are given to the lung of the patient with a significant ICRP lifetime risk of about 10(-3). The patients' mean DAP was 55.9 Gy/cm2 for CAG (79 procedures) and 91.8 Gy/cm2 for PTCA (31 procedures) (P < 0.01). About 70% in CAG and 48% in PTCA of the total dose resulted from the cine examination; in PTCA the total mean DAP was about 60% higher than in CAG procedures.