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Percutaneous coronary intervention using smaller-diameter guide catheters may have a favorable impact on groin complications, mobilization time, hospital stay, and contrast use. This prospective registry study assessed the feasibility of routine stent delivery through 5 Fr guide catheters. Of the 100 consecutive patients, 5 Fr guided intervention was attempted in 84 and was successful in all but 2 patients who had chronic complete occlusions. Reasons for not selecting a 5 Fr guide were planned kissing balloons (eight), directional coronary atherectomy (one), and no suitable 5 Fr guide in stock (seven). There was no stent dislodgment, need to change to a larger-caliber guide, or inadequate contrast opacification. When necessary, guide support was achieved by deep-vessel intubation, which was not associated with vascular damage. The only adverse sequelae were non-Q-wave myocardial infarctions in two patients. Coronary artery stenting using 5 Fr guide catheters is feasible and applicable to most patients.

To report coronary angioplasty data collected by the New Zealand Coronary Angioplasty Registry from 1995-1998.Information on all patients undergoing attempted coronary angioplasty in eight New Zealand institutions was recorded on datasheets at the time of, or soon after, the procedure. These were forwarded to the registry at Green Lane Hospital.Over the four-year period, 8395 angioplasty procedures were performed by 26 cardiologists in eight coronary interventional facilities, with a procedural success rate of 94%. Procedural numbers grew steadily, with 55% more coronary angioplasties performed in 1998 than in 1995 (p = 0.02). The New Zealand national angioplasty rate, which rose from 459/million population in 1995 to 684/million in 1998, remains lower than that of Australia and Western European countries. Excluding those that underwent angioplasty for acute myocardial infarction, the number of peri-procedural deaths was similar, with six in 1995 and four in 1998 (p = 0.30), and the requirement for emergency bypass surgery fell from 22 cases in 1995 to three in 1998 (p0.001). The use of stents increased dramatically, with 85% of patients receiving a stent in 1998, compared with 23% in 1995 (370% increase, p0.001). This was associated with a reduction in the number of patients requiring repeat percutaneous interventions for restenosis (10.7% in 1995 to 6.4% in 1998, p0.001).There has been a steady growth in the numbers of patients with coronary artery disease treated by coronary angioplasty, and in the number treated by intracoronary stents from 1995 to 1998. The need for urgent coronary bypass surgery has fallen. Continued submission of complete and accurate data to the coronary angioplasty registry is vital for ongoing audit.

This randomized trial compared a strategy of direct stenting without predilatation (n = 39) with conventional stenting with predilatation (n = 42) in patients with suitable lesions in native vesselsor = 2. 5-mm diameter to be covered by either a 9- or 16-mm-length NIR Primo stent. Equipment cost [mean (median) +/- SD] was less in those with direct stenting [$1,199 (979) +/- 526] than in those with predilatation [$1,455 (1,285) +/- 401, P0.001]. There was no significant difference in contrast use or fluoroscopy time. Procedural time was shorter in the direct stenting group. The clinical outcome at 1 month was satisfactory in both groups. In selected patients, a strategy of direct stenting is feasible, costs less, and is quicker to perform than the conventional strategy of stenting following predilatation.

Longitudinal flexibility is an important property of coronary stents, facilitating delivery and allowing the expanded stent to conform to vessel contour. Subjective descriptions of flexibility abound, but there are few independent quantitative data to aid stent selection. A three-point bend test was employed to measure stiffness, the reciprocal of flexibility, for 13 stent designs in the unexpanded (bare) state, then after expansion with a 3.5-mm balloon. For eight of the designs, stiffness of the proprietary stent/balloon delivery system was also measured. In the unexpanded state, there was a wide spread of stiffness, which ranged from 0.5+/-0.2 to 91.5+/-10.0 g force/mm, depending on design. Stiffness was least for the coil (Wiktor and Crossflex) and hybrid (AVE GFX and Bard XT) designs. The MultiLink was the most flexible and the Crown the stiffest of the slotted tube designs. All stents became stiffer upon expansion. For most manufacturer-mounted stents, the delivery balloon was the main determinant of stent/balloon delivery system stiffness. Manufacturer-mounted stent profile ranged from 1.15+/-0.11 mm for the Jostent to 1.53 +/- 0.05 mm for the MultiLink system. Independent quantitative assessment of characteristics such as flexibility and profile should aid rational comparison of stent designs.

A guidewire-induced distal coronary artery perforation presenting with cardiac tamponade was occluded by distal Gelfoam embolization via an infusion catheter. This extends the treatment options for this rare complication of coronary interventional procedures. Cathet. Cardiovasc. Intervent. 49:214-217, 2000.

This study was performed to assess whether angiography six months after coronary balloon angioplasty or stent implantation has an influence on clinical management and one-year outcome.The Benestent II study randomized 827 patients to balloon angioplasty or stent implantation. A subrandomization was undertaken allocating patients to six-month clinical follow-up (CF) or clinical and angiographic follow-up (AF).Seven hundred and six patients (349 CF and 357 AF) had no intercurrent angiography, so that restenosis and disease progression elsewhere remained unknown until the time of six-month follow-up. These two groups, which were well matched at enrolment, were compared with respect to symptoms, medication and major cardiac events defined as death, myocardial infarction and need for revascularization at six and 12 months.At six-month follow-up, 53 (15%) of the CF and 76 (21%) of the AF patients had stable angina (p = 0.041), while 5 (1%) and 4 (1%) had symptoms of unstable angina. At 12-month follow-up, 44 (13%) patients in both groups had stable angina, and only 1 patient in the CF group had unstable angina. Seventy-seven patients (27 CF and 50 AF; p0.01) had major cardiac events between 6 and 12 months. Of the 349 patients in the CF group, 21 underwent repeat percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery between 6 and 12 months, compared with 44 of the 357 patients in the AF group (relative risk 2.05 [1.24 to 3.37], p = 0.003).Patients who had AF six months after balloon angioplasty or stent implantation experienced more repeat revascularization procedures than those who had CF. They also had significantly more angina at six-month follow-up but this may be due to bias.

Procedural and 1-month outcome data following implantation of the V-Flex Plus stent in our first 54 consecutive patients (35 male; mean age, 62 years) are described. Sixty-four stents were implanted for 60 mainly complex lesions; 48% were left anterior descending; 20%, circumflex; 27%, right coronary artery; and 5%, saphenous vein graft. The Indication for stenting was elective in half of the patients and for a suboptimal result or as a bailout procedure in the other half. The stents were deployed at a mean of 12 atm (range, 6-18) and postdilatated to a mean of 15 atm (range, 8-20). Pre- and postdilatation balloon sizes were 2.96 +/- 0.57 mm and 3.16 +/- 0.34 mm, respectively. The procedural success rate was 98%. There were no deaths or Q-wave myocardial infarctions. One patient suffered a non-Q-wave myocardial infarction and another developed a femoral false aneurysm. At 1-month follow-up, there were no additional events, in particular no revascularization procedures. Eighty-nine percent of patients were free of angina. Implantation of the V-Flex Plus stent is safe and effective with an excellent early success rate comparable to that of published randomized trials and registries of carefully selected patients.

We aimed to determine the effects of simulated stent side-branch dilatation and subsequent redilatation of the central lumen. Following coronary stent implantation it may be necessary to dilate through the side of a stent to maintain branch patency. Branch dilatation through the side of 3.5-mm-diameter stents (AVE GFX, beStent, Crown, MultiLink, and NIR) was simulated in a plexiglass phantom using 2.5-, 3.0-, 3.5-, and 4.0-mm balloons. In further experiments, the main lumen was redilated with a 3.5-mm balloon after 3.0-mm side-branch dilatation. Thereafter, a 3.5-mm central and a 3.0-mm side-branch balloon were simultaneously inflated ("kissing balloons"). The larger the balloon size used for side-branch dilatation, the greater the distortion of the stent immediately distal to the side-branch, which for a 4.0-mm balloon ranged from 36% +/- 2% (Crown) to 65% +/- 6% (NIR). Central lumen redilatation or kissing balloons abolished this stenosis with little reduction of the side-lumen diameter. The main stent lumen compromise caused by side-branch dilatation can be abolished by main-lumen redilatation or by kissing balloons.

Rotational atherectomy is a new interventional technique and can be used as an alternative percutaneous treatment for selected coronary atherosclerotic lesions. We report the initial Green Lane/Mercy hospitals experience with rotational atherectomy and review the published international experience with the device.Patient case notes and prospectively recorded New Zealand national angioplasty data forms were reviewed for basic demographic data and angina symptoms, in-hospital complications and length of the hospital stay. Catheter laboratory worksheets were reviewed to obtain the duration of ablation, burr diameter and adjunctive PTCA balloon diameter.The main indications for rotational atherectomy were heavy lesion calcification, ostial location, or failure of an angioplasty balloon to cross or to dilate the lesion. Procedural success was achieved in 28 of 30 patients (93%). One patient suffered a Q wave myocardial infarction and in another the lesion could not be crossed with the guide wire. Two patients required repeat balloon angioplasty for early reocclusion without other sequelae and one patient had directional atherectomy 2 weeks later for ongoing sumptoms.Rotational atherectomy is a useful adjunct to the percutaneous devices available to treat coronary disease.

Manipulation of thin-walled coronary guiding catheters, especially directional coronary atherectomy guides, may sometimes be difficult. This is particularly so in patients with tortuous or ectatic aorto-iliac arterial systems. To improve torque transmission and eliminate kinking, the introducer catheter or a smaller caliber diagnostic catheter is advanced to within 1.5 cm of the distal guide tip. Connecting the rotating hemostatic valve to the introducer hub or diagnostic catheter proximally allows distal contrast injections and pressure monitoring via this inner catheter. Other methods of enhancing guide catheter manipulation are also discussed.

Percutaneous balloon angioplasty was successful initial treatment for 2 infants who, early after operation, developed obstruction at the proximal anastomotic site of a modified Blalock-Taussig shunt. Two years later the first child had not required reoperation and the dilatation site was patent angiographically. The other baby progressed well after angioplasty but because of surgical concern about the long-term success of angioplasty, shunt surgery was repeated, the baby dying after reoperation. Angioplasty of proximal obstruction in these shunts is feasible and satisfactory long-term palliation can be achieved avoiding repeat shunt surgery before the more definitive Fontan-type procedure.

directional coronary atherectomy is a new percutaneous interventional technique in which coronary arterial stenotic material is shaved off to alleviate stenosis. This study presents the initial outcome of coronary atherectomy at Green Lane and Mercy hospitals where the major indications for atherectomy are lesions with angiographic appearances unfavourable for balloon angioplasty or where balloon angioplasty had been unsuccessful.data on patients undergoing coronary atherectomy between February 1990 and December 1991 were analysed. No patient or procedure was excluded.for the first 28 lesions in 25 patients, procedural success, improvement in lumen diameter to less than 50% diameter loss stenosis, but freedom from myocardial infarction, death or emergency bypass surgery, was achieved in 27 of 28 lesions. In one patient there was acute thrombotic coronary arterial closure treated successfully by balloon angioplasty. Another patient developed an asymptomatic fistulous connection with an adjacent coronary vein which resolved spontaneously.although technically more difficult than balloon angioplasty, directional coronary atherectomy can be carried out in selected patients with a high initial success rate and low complication rate. The technique has allowed percutaneous treatment of a number of selected patients unsuitable for balloon angioplasty, and has turned an unsuccessful angioplasty into an initial procedural success in others.

In proportion to its size, the infirmary at the United States Naval Air Station, Quonset Point, R. I., has a large dependent service. About 90 deliveries are made a month. The nursery has a capacity for 20 full-term infants. Insofar as possible, the standards of the American Academy of Pediatrics are followed in the management of the nursery. In this connection a bacteriological study of the formulas was instituted in March of 1952. At this time the old aseptic technique method was used in formula production. Bottles and utensils were washed, wrapped, and autoclaved prior to use. Nipples were boiled before being used. The ingredients in the formula were boiled water and liquid Similac (liquid form of Similac powder containing 3.35% fat, 6.61% lactose, 1.72% protein, and vitamins and minerals) or Lactum (evaporated milk with maltose and dextrins and added vitamin D). Thus the principal source of contamination would be