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In order to study the safety of ‘rescue’ strategies in the treatment of patients with failed thrombolysis, all 548 patients admitted with evolving myocardial infarction to the Thoraxcenter, Rotterdam, from January 1997 until April 1999 were reviewed. Of these patients, 49% had received thrombolysis. Of patients treated with thrombolysis and not referred from other hospitals (n=154) 36% received rescue therapy for failed thrombolysis. Three rescue therapies were used after failed thrombolysis: percutaneous coronary intervention (74%), retreatment with thrombolysis (39%) and platelet glycoprotein (GP) IIb/IIIa receptor blockers (53%), often in combination. Platelet GP IIb/IIIa receptor blockers were administered in 64% of patients treated with rescue percutaneous coronary intervention. Major bleeding occurred in 14% of all thrombolysis treated patients, and in 30% of patients who received multiple rescue therapies. Bleeding was related to heparin usage and platelet GP IIb/IIIa receptor blockers, as was the insertion of catheters for percutaneous coronary intervention or intra-aortic balloon pumps. Major bleeding resulted in one death due to a ruptured ventricle, one haemorrhagic stroke, and three cases of tamponade for which surgery was needed. Four of these patients had received combination rescue therapy. Rescue therapy is a widely used strategy for failed thrombolysis, but is associated with a high bleeding rate. Alternative reperfusion strategies to avoid failed thrombolysis should be considered in high risk patients. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

Aims Intracoronary radiation is a promising therapy potentially reducing restenosis following catheter-based interventions. Currently, only limited data on this treatment are available. The feasibility and outcome in daily routine practice, however, is unknown.Methods and Results In 100 consecutive patients, intracoronary beta-radiation was performed with a 90Strontium system (Novoste Beta-Cath™) following angioplasty. Predominantly complex (73% type B2 and C) and long lesions (length 24·3±15·3mm) were included (37% de novo, 19% restenotic and 44% in-stent restenotic lesions). Radiation success was 100%. Mean prescribed dose was 19·8±2·5Gy. A pullback procedure was performed in 19% lesions. Geographic miss occurred in 8% lesions. Periprocedural thrombus formation occurred in four lesions, dissection in nine lesions. During hospital stay, no death, acute myocardial infarction, or repeat revascularization was observed. Major adverse cardiac events occurred predominantly between 6 and 12 months after the index procedure with major adverse cardiac event-free survival of 66% at 12 months (one death, 10 Q-wave myocardial infarctions, 23 target vessel revascularizations; ranked for worst event).Conclusion Routine catheter-based intracoronary beta-radiation therapy after angioplasty is safe and feasible with a high acute procedural success. The clinical 1-year follow-up showed delayed occurrence of major adverse cardiac events between 6 and 12 months after the index procedure. Copyright 2001 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved. [ABSTRACT FROM PUBLISHER]

Aims We sought to compare the effect of intracoronary β-radiation on the vessel dimensions in de novo lesions using three-dimensional intravascular ultrasound quantification after balloon angioplasty and stenting.Methods and Results Forty patients (44 vessels; 28 balloon angioplasty and 16 stenting) treated with catheter-based β-radiation and 18 non-irradiated control patients (18 vessels; 10 balloon angioplasty and 8 stenting) were investigated by means of three-dimensional volumetric intravascular ultrasound analysis post-procedure and at 6–8 months follow-up. Total vessel (EEM) volume enlarged after both balloon angioplasty and stenting (+37mm3 vs +42mm3, P=ns), but vessel wall volume (plaque plus media) also increased similarly (+33mm3 vs +49mm3, P=ns) in the irradiated patients. Lumen volume remained unchanged in both groups (+3mm3 vs −7mm3, P=ns). In the stent-covered segments, neointima at follow-up was significantly smaller in the irradiated group than the control group (8mm3 vs 27mm3,P =0.001, respectively), but the total amount of tissue growth was similar in both groups (33mm3 vs 29mm3, P=ns).Conclusions Intracoronary β-radiation induces vessel enlargement after balloon angioplasty and/or stenting, accommodating tissue growth. Additional stenting may not play an important role in the prevention of constrictive remodelling in the setting of catheter-based intracoronary β-radiotherapy. [ABSTRACT FROM PUBLISHER]

Aims Coronary stenting is limited by a 10%–60% restenosis rate due to neointimal hyperplasia. Sirolimus is a macrocyclic lactone agent that interacts with cell-cycle regulating proteins and inhibits cell division between phases G1 and S1. The hypothesis tested in this study is that local delivery of sirolimus with an eluting stent can prevent restenosis.Methods and Results Fifteen patients were treated with 18mm sirolimus eluting BX VELOCITY™ stents. Quantitative angiography and three-dimensional quantitative intravascular ultrasound were performed at implantation and at the 6 months follow-up. All stent implantations were successful. One patient died on day 2, of cerebral haemorrhage and one patient suffered a subacute stent occlusion due to edge dissection (re-PTCA, CKMB 42). At 9 months no further adverse events had occurred and all patients were angina free. Quantitative coronary angiography revealed no change in minimal lumen diameter and percent diameter stenosis and hence no in-lesion or in-stent restenosis. Quantitative intravascular ultrasound showed that intimal hyperplasia volume and percent obstruction volume at follow-up were negligible at 5·3mm3and 1·8%, respectively. No edge effect was observed in the segments proximal and distal to the stents.Conclusion Implantation of a sirolimus-eluting stent seems to effectively prevent intimal hyperplasia. [ABSTRACT FROM PUBLISHER]

Aims This study is the contribution by the Thoraxcenter, Rotterdam, to the European32P Dose Response Trial, a non-randomized multicentre trial to evaluate the safety and efficacy of the radioactive Isostent™ in patients with single coronary artery disease.Methods and Results The radioactivity of the stent at implantation was 6–12μCi. All patients received aspirin indefinitely and either ticlopidine or clopidogrel for 3 months. Quantitative coronary angiography measurements of both the stent area and the target lesion (stent area and up to 5mm proximal and distal to the stent edges) were performed pre- and post-procedure and at the 5-month follow-up. Forty-two radioactive stents were implanted in 40 patients. Treated vessels were the left anterior descending coronary artery (n=20), right coronary artery (n=10) or left circumflex artery (n=10). Eight patients received additional non-radioactive stents. Lesion length measured 10±3mm with a reference diameter of 3·07±0·69mm. Minimal lumen diameter increased from 0·98±0·53mm pre-procedure to 2·29±0·52mm (target lesion) and 2·57±0·44mm (stent area) post-procedure. There was one procedural non-Q wave myocardial infarction, due to transient thrombotic closure. Thirty-six patients returned for angiographical follow-up. Two patients had a total occlusion proximal to the radioactive stent. Of the patent vessels, none had in-stent restenosis. Edge restenosis was observed in 44%, occurring predominantly at the proximal edge. Target lesion revascularization was performed in 10 patients and target vessel revascularization in one patient. No additional clinical end-points occurred during follow-up. The minimal lumen diameter at follow-up averaged 1·66±0·71mm (target lesion) and 2·12±0·72 (stent area); therefore late loss was 0·63±0·69 (target lesion) and 0·46±0·76 (stent area), resulting in a late loss index of 0·65±1·15 (target lesion) and 0·30±0·53 (stent area).Conclusion These results indicate that the use of radioactive stents is safe and feasible, however, the high incidence of edge restenosis makes this technique currently clinically non-applicable. [ABSTRACT FROM PUBLISHER]

AimsThere is increased late loss in luminal diameter following long-term coronary stenting, compared with balloon angioplasty. We evaluated short- and long-term vessel wall injury after experimental implantation of two stent designs as well as balloon angioplasty and their relationship to neointimal hyperplasia.Methods and ResultsWiktor stents and Palmaz-Schatz stents were implanted in normal coronary arteries of pigs (balloon/artery ratio: 0·9–1·1). In control coronary arteries, balloon angioplasty was performed. At 1, 4 and 12 weeks, the vessel injury score, neointimal thickness and inflammatory response were assessed by histology.The vessel injury score increased over time in both Wiktor and Palmaz-Schatz stents: 0·9±0·1, 1·5±0·5 and 1·7±0·6 (mean±SD) for Wiktor stents and 0·7±0·2, 1·0±0·1 and 1·2±0·3 for Palmaz-Schatz stents at 1, 4 and 12 weeks follow-up, respectively. No increase in injury was seen in balloon angioplasty controls. Inflammation was seen in both stented groups but was absent 12 weeks after balloon angioplasty. No strong correlation between injury and neointimal thickness was apparent.ConclusionStents induce chronic injury in contrast to balloon angioplasty. Stent design (coil vs slotted tube) as well as inflammation may influence vessel response. [ABSTRACT FROM PUBLISHER]