Stenting of venous bypass grafts: A new treatment modality for patients who are poor candidates for reintervention

Abstract During a 2-year period, 136 self-expanding Wall-stents were implanted in saphenous vein bypass grafts in 69 patients with end-stage coronary artery disease. All patients had severe symptoms and the majority were poor candidates for either repeat surgery or conventional bypass coronary angioplasty because of unfavorable native anatomy, impaired left ventricular function, or a high-risk bypass lesion anatomy for coronary angioplasty. All procedures were technically successful without major complications and a need for emergency bypass surgery. However, during the hospital stay acute thrombotic complications occurred in seven patients (10%) resulting in one death and acute myocardial infarction in five patients and necessitating emergency repeat PTCA in two patients and repeat CABG in four. Twenty-three patients had serious hemorrhagic complications directly related to the rigorous anticoagulation schedule. Two patients died of fatal cerebral bleeding. During follow-up, another five patients died accounting for a total mortality rate of 12%. At late angiographic follow-up (4.9 ± 3.4 months, n = 53), 25 patients (47%) had a restenosis (≥50% DS) within or immediately adjacent to the stent, necessitating reintervention in 19 patients (PTCA, n = 12; repeat CABG, n = 7). In the group without stent-related restenosis (n = 28), 15 patients had progression of disease in either the native or bypass vessels leading to recurrence of major anginal symptoms within 1 to 24 months. Ten of these patients required further intervention (stent, n = 6; PTCA, n = 3; repeat CABG, n = 1). Stenting in saphenous coronary bypass grafts can be performed safely with excellent immediate angiographic and clinical results. Early occlusion, late restenosis, and bleeding complications associated with the aggressive anticoagulant treatment remain significant limitations. Reintervention as a result of restenosis or progression of disease in other lesions is common. Stenting of diseased bypass grafts in symptomatic patients with end-stage coronary artery disease (who are at high risk for conventional angioplasty or surgical reintervention) may be useful as palliative therapy

Coronary stenting : a quantitative angiographic and clinical evaluation

Following implantation of the first coronary stent in 1986 by Jacques Puel in Toulouse, coronary stenting has, from a sequence of pioneering registries in the late 1980's to an era of randomized trials in the 1990's, come to adopt a prominent role in today's practice of interventional cardiology. In its conventional naked metallic form, coronary stenting represents a mechanical approach to a biological problem. When appropriately deployed, the coronary stent can tack back dissections and restore normal flow in vessels with threatened or acute closure and provides a means to optimize elective angioplasty of primary and recurrent stenoses in both native coronary arteries and aorto

Fate of stent-related side branches after coronary intervention in patients with in-stent restenosis

AbstractOBJECTIVESWe sought to assess the fate of stent (ST)-related side branches (SB) after coronary intervention in patients with in-ST restenosis.BACKGROUNDIn-ST restenosis constitutes a therapeutic challenge. Although the fate of lesion-related SB after conventional angioplasty or initial coronary stenting is well established, the outcome of ST-related SB in patients with in-ST restenosis undergoing repeat intervention is unknown.METHODSOne hundred consecutive patients (age 61 ± 11 years, 22 women) undergoing repeat intervention for in-ST restenosis (101 ST) were prospectively studied. Two hundred and twenty-six SB spanned by the ST were identified. The SB size, type, ostium involvement, location within the ST and take-off angle were evaluated. The SB TIMI (Thrombolysis in Myocardial Infarction trial) flow grade was studied in detail before, during, immediately after the procedure, and at late angiography.RESULTSOcclusion (TIMI flow grade = 0) was produced in 24 (10%) SB, whereas some degree of flow deterioration (≥1 TIMI flow grade) was observed in 57 SB (25%). The SB occlusion was associated with non–Q wave myocardial infarction in two patients (both had large and diseased SB). Side-branch occlusion at the time of initial stenting (RR [relative risk] 11.1, 95% CI [confidence interval] 3.5–35.5, p < 0.001), diabetes (RR 3.5, 95% CI 1.1–10.5, p = 0.02), SB ostium involvement (RR 5.0, 95% CI 1.4–17.2, p = 0.004), baseline SB TIMI flow grade <3 (RR 5.5, 95% CI 1.7–18.1, p = 0.005), and restenosis length (RR 1.05 95% CI 1.01–1.11, p = 0.03) were identified as independent predictors of SB occlusion. Late angiography in 19 initially occluded SB revealed that 17 (89%) were patent again. The long-term clinical event-free survival (81% vs. 82% at two years) in patients with and without initial SB occlusion was similar.CONCLUSIONSOcclusion or flow deterioration of SB spanned by the ST is relatively common during repeat intervention for in-ST restenosis. Several factors (mainly anatomic features) are useful predictors of this event. However, most SB occlusions are clinically silent and frequently reappear at follow-up

Stent thrombosis following bare-metal stent implantation: success of emergency percutaneous coronary intervention and predictors of adverse outcome

Aims To investigate the efficacy and outcome of emergency percutaneous coronary interventions (PCI) in patients with stent thrombosis. Methods and results Between 1995 and 2003, 6058 patients underwent bare-metal stent implantation, of which 95 (1.6%) patients suffered from stent thrombosis. The timing of stent thrombosis was acute in 10 (11%), subacute in 61 (64%), and late in 24 (25%) patients. Procedural and clinical outcomes of emergency PCI for treatment of stent thrombosis were investigated. Emergency PCI was successful in 86 (91%), complicated by death in 2 (2%), and coronary artery bypass grafting in 2 (2%) patients. Myocardial infarction occurred in 77 (81%) patients with a peak creatine kinase level of 1466±1570 U/L. Left ventricular ejection fraction declined from 0.54±0.19 prior to 0.48±0.16 (P<0.05) at the time of stent thrombosis after emergency PCI. A 6 month major adverse clinical events comprised death (11%), reinfarction (16%), and recurrent stent thrombosis (12%) after emergency PCI. Multivariable logistic regression analysis identified the achievement of TIMI 3 flow (OR=0.1, CI 95% 0.01-0.54, P<0.001) and diameter stenosis <50% (OR=0.06, CI 95% 0.01-0.32, P<0.001) during emergency PCI to be independently associated with a reduced risk of cardiac death. Recurrent stent thrombosis was independently predicted by the omission of abciximab (OR=4.3, CI 95% 1.1-17.5). Conclusion Emergency PCI for treatment of stent thrombosis effectively restores vessel patency and flow. Patients presenting with stent thrombosis are at risk for recurrent myocardial infarction and recurrent stent thrombosi

The SSTARS (STeroids and stents Against Re-Stenosis) Trial: Different stent alloys and the use of peri-procedural oral corticosteroids to prevent in-segment restenosis.

Stent design and technological modifications to allow for anti-proliferative drug elution influence restenosis rates following percutaneous coronary intervention (PCI). The main aim of this study was to investigate whether peri-procedural administration of corticosteroids or the use of thinner strut cobalt alloy stents would reduce rates of binary angiographic restenosis (BAR) after PCI. In addition, the role of the acute phase highly sensitive C-Reactive protein (hs-CRP) in restenosis in bare metal stents (BMS) was also investigated. This was a two centre, mixed single and double blinded, randomised controlled trial using a factorial design. The use of prednisolone was compared against placebo, starting at least six hours pre-PCI and continued for 28 days post-PCI. Additionally, cobalt chromium (CoCr) stents were compared to stainless steel (SS) alloy stents, in patients admitted for PCI. The primary end-point was BAR at six months. Three hundred and fifteen (359 lesions) were randomly assigned to either placebo (n=145) or prednisolone (n=170) and SS (n=160) or CoCr (n=160). The majority (58%) presented with an acute coronary syndrome (ACS), 11% had diabetes and 287 (91%) completed angiographic follow up. The primary endpoint, binary angiographic restenosis, occurred in 26 cases in the placebo group (19.7%) versus 31 cases in the prednisolone group (20.0%) respectively, p=1.00. For the comparison between SS and CoCr stents, BAR occurred in 32 patients (21.6%) versus 25 patients (18.0%) respectively, p=0.46. Hs-CRP was monitored at 5 points during the trial. The pre-PCI hs-CRP measurement was ≤5mg/l in 213 patients (71%) of whom only 28 (13%) had a raised CRP at day 7. There was some evidence of prednisolone suppressing hs-CRP response at day 7 (-5.98 mg/L, 95%CI: -8.35 to -3.61, p<0.001). There was no correlation between lowering hs-CRP and stenosis diameter at follow-up. This study showed that treating patients with a moderately high dose of prednisolone to cover most of the period of inflammation associated with restenosis in BMS did not reduce the incidence of BAR. There was also no significant reduction in six month BMS restenosis rates with stents composed of CoCr alloy compared to SS alloy and no observed relationship to hs-CRP