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Central venous catheters (CVC) are used in many clinical settings for a variety of indications. We performed a systematic literature review concerning case reports of retained calcified fibrin sheaths after dialysis CVC removal. The aim of our study was to systematize the knowledge regarding clinical management of this phenomenon, placing special emphasis on diagnostic radiological features in different imaging modalities, including chest radiography, echocardiography, computed tomography, and magnetic resonance imaging. We discuss the most common risk factors associated with this CVC complication. In our review, we found eight cases of hemodialysis patients. The most common risk factors associated with calcified fibrin sheath formation in the analyzed cases were pro-thrombotic and pro-calcification factors related to patient comorbidities, and prolonged catheter dwell time. Differentiating between a calcified fibrin sheath (present in about 6% of patients with long-term indwelling CVC as diagnosed by computed tomography) and a retained catheter tip can be challenging. The initial diagnosis based on imaging methods was incorrect in most of the analyzed cases. This suggests that some cases of retained fibrin sheaths may remain undetected or misinterpreted. This is important in patients with known pro-thrombotic and pro-calcification risk factors and prolonged catheter dwell time. Therefore, implementation of preventive strategies, familiarity with radiological findings of this phenomenon, comparison with previous imaging studies, and an overall comprehensive assessment with clinical data is imperative.

Aims: Evaluation of safety and efficacy of ProNOVA XR, a new generation of polymer-free sirolimus eluting stents (SES), utilizing a pharmaceutical excipient for timed release of sirolimus from the XR platform. Methods and results: Safety and efficacy of ProNOVA XR coronary stent system was examined in EURONOVA prospective, single arm, multi-center registry of 50 patients with de novo native coronary lesions up to 28 mm in length in arteries between 2.25 and 4 mm. At 6-month, in-stent late lumen loss by QCA was 0.45 ± 0.41 mm and in-stent neointimal volume obstruction in the IVUS sub-study was 14 ± 11%. One-year clinical follow-up revealed a favorable safety profile, with 2% of in-hospital MACE and 6.4% of MACE from hospital discharge up to 12 months (including 1 cardiac death >30 days after stent implantation and 2 TLRs). According to the ARC definition, there was no definite or probable stent thrombosis and 1 possible stent thrombosis (2%) up to 12 months of clinical follow-up. Conclusions: In this preliminary evaluation, ProNOVA XR polymer-free sirolimus eluting stent system appeared safe with an early promise of adequate effectiveness in the treatment of de novo coronary lesions in up to 12 months of clinical, angiographic and IVUS follow-up.

Intarcoronary brachytherapy with radioactive source is the method of choice to treat in stent restenosis. Currently, we have data available from randomized clinical trials, yet every day practice and routine results of barchytherapy are not completely defined.We studied 50 patients treated due to in stent restenosis. Procedures were performed by means of beta radiation, and the delivered dose was equal to 2000 cGy.All patient were observed during hospitalization and long term follow-up (from 4 to 21 months). Diffuse and proliferative in stent restenosis (22.02 +/- 21.41 mm) was the most common type of lesions which were treated. Procedure success was 100%, and barchytherapy success was 98%. Median time of hospitalization was one day. Frequency of geographical miss was 7.8%. During in hospital period there were no cases of death, myocardial infarction nor need for revascularization. In long term follow-up 2 myocardial infarctions (4%), 1 bypass grafting (2%) and 9 target vessel revascularizations took place. The cumulative survival without event was 76%. Long term follow-up showed that adverse events occurred in the later period of observation, i.e., up to 6 months after brachytherpy. Median event free survival was 246.5 days.Routine intracoronary brachytherapy due to in stent restenosis is safe and characterized by a high percentage of procedure success in long term follow-up.

Available data indicate that stenting of the left main coronary artery (LMN) is safe and effective. Restenosis remains the main factor limiting the effectiveness of percutaneous coronary intervention (PCI).To evaluate immediate and long-term results of treatment of patients with LMN disease and low preoperative risk of coronary artery bypass grafting.Coronary stents were implanted into LMN in 64 patients. The following strategy was applied: drug eluting stent (DES) for LMN diameteror =3.5 mm (28 subjects) and bare metal stent (BMS) for LMN diameter3.5 mm (36 subjects). Patients enrolled in the study underwent clinical evaluation and coronary angiography. Immediate effect of the procedure and main adverse cardiac events were assessed: death, myocardial infarction and additional target lesion or non-target lesion revascularization.Angiographic and clinical effectiveness of the interventions was 100%. Full revascularisation of ischaemic regions of the myocardium was performed. Mean clinical follow-up period was 9.4+/-4.0 months. Neither death nor myocardial infarction occurred. Additional PCIs were performed in 11 (17.2%) patients; however, target vessel revascularisation (TVR) rate within LMN was 9.4% (i.e. 6 subjects with BMS), and non-TVR rate was 7.8% (5 subjects).LMN stenting is associated with high effectiveness of PCI in patients with low operative risk. Long-term follow-up revealed low incidence of major adverse cardiac events. Strategy of selective use of DESs in the study group produced good clinical outcome. Multivessel disease with LMN stenosis was associated with high rate of additional revascularisation of other vessels. Further improvement of treatment results may be obtained by more common use of DES for multivessel disease and LMN diameters larger than 4.0 mm.

Objective— Safety and feasibility evaluation of intracoronary temperature measurements in patients with acute coronary syndromes (ACS) using a catheter based thermography system. Methods and Results— Thermography was performed in 40 patients with ACS. A 3.5-F thermography catheter containing 5 thermocouples measuring vessel wall temperature, and 1 thermocouple measuring blood temperature (accuracy 0.05°C) was used. Gradient (ΔTmax) between blood temperature (T bl ) and the maximum wall temperature during pullback was measured. The device showed satisfactory safety in ACS. Only in 16 patients (40%) ΔTmax was ≥0.1°C. In 23 patients (57.5%) the highest ΔTmax was found in the culprit segment. ΔTmax between culprit and adjacent non-culprit segments was observed in patients with transient blood flow interruption during thermography (0.11±0.03 versus 0.08±0.01; P =0.04), in contrast to patients with preserved flow (0.07±0.03 versus 0.06±0.02; P =0.058). Conclusions— The novel, technically sophisticated intracoronary thermography proved its safety and feasibility. However, we were not able to convincingly and consistently differentiate between different lesions at risk, despite a selection of lesions that should appear most distinct to differentiate. A systematic interruption of flow may be necessary to achieve diagnostic results consistently, although such requirement may unfavorably change the risk-to-benefit ratio of this developing technology.

A case of a 70-year-old female who underwent CABG (four grafts) 12 years earlier, is presented. Following surgery, the patient suffered from two reinfarctions. Coronary angiography revealed total occlusion of the graft implanted to the right coronary artery which was treated by coronary angioplasty. Because of restenosis, the patient underwent successful intracoronary brachytherapy.

Clopidogrel, especially when combined with aspirin, reduces the rate of ischaemic events in patients with coronary artery disease (CAD). There are scare data in literature on the inter-individual variability in response to clopidogrel.To assess the incidence of clopidogrel resistance using rapid whole blood platelet function assessment, and to examine the possibility of early identification of non-responders.In 31 consecutive patients with stable angina treated with aspirin, the degree of platelet aggregation inhibition (DPAI) in the whole blood was assessed at baseline and 3, 6, 12 as well as 24 hours after administration of loading dose of clopidogrel (300 mg). Response to clopidogrel was measured by calculating the absolute difference between the baseline DPAI and DPAI obtained at the investigated time-points (DPAI).After 24 hours from clopidogrel administration, seven (22.6%) patients were identified as non-responders (DPAIor =10%). Demographic and clinical variables as well as baseline DPAI were similar in responders and non-responders (DPAI: 5.8+/-3.7% vs 7.1+/-5.3%, p=NS). Out of the patients who were found to be resistant to clopidogrel at the six-hour time-point, 87.5% remained resistant to this agent 24 hours after drug administration. DPAI calculated at the 24-hour time-point highly correlated with the six-hour DPAI (r=0.74). No differences in the rate of ischaemic or bleeding complications between responders and non-responders were noted.The assessment of the degree of platelet aggregation inhibition allows early (six hours from the initiation of treatment) identification of patients who are resistant to clopidogrel. The method of the rapid whole blood platelet function assessment is feasible in every-day clinical practice.

Elevated levels of C-reactive protein (CRP) are associated with an increased risk of coronary events. The levels of CRP and other inflammatory markers are significantly elevated in patients with unstable angina. We hypothesised that a high-dose statin therapy alone or with cyclooxygenase-2 (COX-2) inhibitors, administered before coronary diagnostic or invasive procedures, can attenuate CRP elevation after the procedure and, consequently, more effectively reduce the rate of coronary events.All patients with unstable angina in class III and IIB according to Braunwald classification were considered for inclusion in the present study. Finally, 60 patients with elevated CRP level (3 mg/l) were randomised to three groups of pharmacological treatment before coronary angiography and subsequent angioplasty. Patients from group A received placebo, patients from group B - 80 mg of atorvastatin, and patients from group C - 80 mg of atorvastatin and 25 mg of rofecoxib. The levels of CRP were measured at baseline, after 3 days of therapy and 48 hours after invasive coronary procedure.The mean baseline CRP level in group A was 5.67+/-2.82 mg/l, in group B - 4.7+/-1.32 mg/l, and in group C - 6.78+/-2.56 mg/l (NS). After three days of pharmacological treatment, the mean CRP level was 5.82+/-2.69 mg/l in group A (NS compared with baseline) and was significantly reduced in group B to 2.5+/-1.37 mg/l and in group C to 3.01+/-1.57 mg/l (p0.0013 compared with group A). Measurements performed 48 hours after the procedure revealed a marked CRP level increase in group A (up to 24.54+/-5.48 mg/l) and a much lower increase in groups B and C (up to 3.02+/-2.0 mg/l and 7.31+/-2.96 mg/l, respectively).High-dose statin therapy alone or in combination with COX-2 inhibitor, administered before invasive coronary procedure in patients with unstable angina, rapidly lowers CRP levels. This therapy also reduces a marked CRP elevation typically occurring after invasive coronary intervention. Attenuation of inflammatory reaction may be crucial for the reduction of coronary events following invasive coronary interventions.

Aims: To test the feasibility and accuracy of transthoracic, harmonic mode, contrast enhanced Doppler echocardiographic assessment of lesion severity after PCI treatment in native coronary arteries—the LAD, Cx and RCA. Methods and results: Prospective evaluation of 59 patients (66 arteries). Restenosis was diagnosed whenever maximal flow velocity at least doubled in comparison to the segment immediately proximal to the PCI site or when local velocity was at least 2 m/s. At 9 months of follow-up final comparison of Doppler echocardiography and coronary angiography was performed with regard to 44 arteries in 40 patients. Of LAD segments assessed, 15 were proximal and 15 middle. The figures for Cx segments were: 4 proximal and 2 mid, and for RCA 2 proximal, 5 middle and 1 distal (i.e. the posterior descending coronary artery). On final coronary angiography there were 8 restenoses—all correctly diagnosed by echocardiography. There were 2 false-positive diagnoses of restenosis. Specificity for restenosis detection was 94% and sensitivity 100%. Conclusion: Transthoracic echocardiography allowed for accurate stenosis assessment of principal coronary arteries after successful PTCA. Feasibility of lesion site visualization was 100% for the LAD, 75% for the Cx and 43% for the RCA. Ultrasound contrast agent improved the quality of the RCA images.

In-stent restenosis after percutaneous coronary intervention (PCI) is due to the proliferation of intima. Supplementation with L-arginine has been shown to improve endothelial function and decrease neointima proliferation in experimental animal model of restenosis.To assess the effects of L-arginine supplementation on neointima proliferation and endothelial markers as well as growth factor levels in patients after stent implantation.In this prospective, randomised, double-blind, placebo-controlled study 60 patients undergoing stent implantation received placebo or L-arginine (200 mg/kg infused intravenously over 4 hours, 12 and 3 hours before PCI, and 500 mg over 10 minutes prior to stent implantation, followed by oral supplementation of 6 g/day for 14 days after PCI). Quantitative coronary angiography (QCA) and intracoronary ultrasonography (ICUS) were performed at baseline and after a seven-month follow-up period. Serum concentration of L-arginine was measured at baseline, before PCI, 24 hours after PCI, and 7 as well as 14 days after PCI. The transforming growth factor-beta (TGF-beta), vascular endothelial growth factor (VEGF) and endothelin levels were assessed before PCI, and 24 hours as well as 14 days after the procedure.No significant differences in the QCA or ICUS parameters were found between patients receiving L-arginine or placebo. 24 hours after stent implantation patients who received placebo had significantly a higher increase in the endothelin serum concentration and a lower rise in the VEGF level than the patients who received L-arginine (92.6+/-49 pg/ml vs 76.1+/-27 pg/ml, p0.05, and 10 pg/ml vs 17.6+/-12 pg/ml, p0.05, respectively). The TGF-beta level, assessed 14 days after PCI, was significantly higher in the placebo group than in the L-arginine group (14.8+/-10 ng/ml vs 11.2+/-6.1 ng/ml, p0.05).In spite of favourable changes in the vascular endothelial biochemical marker profile, supplementation with L-arginine did not decrease the in-stent reocclusion rate.