Medical Resource Consumption and Quality of Life in Peripheral Arterial Disease in Korea: PAD Outcomes (PADO) Research

BACKGROUND AND OBJECTIVES: We aimed to investigate the history of medical resource consumption and quality of life (QoL) in peripheral arterial disease (PAD) patients in Korea. METHODS: This was a prospective, multi-center (23 tertiary-hospitals, division of cardiology), non-interventional study. Adult patients (age ≥20 years) suffering from PAD for the last 12-month were enrolled in the study if they met with any of following; 1) ankle-brachial index (ABI) ≤0.9, 2) lower-extremity artery stenosis on computed tomography angiography ≥50%, or 3) peak-systolic-velocity-ratio (PSVR) on ultrasound ≥2.0. Medical chart review was used to assess patient characteristics/treatment patterns while the history of medical resource consumption and QoL data were collected using a patient survey. QoL was measured using EuroQoL-5-dimensions-3-level (EQ-5D-3L) score system, and the factors associated with QoL were analyzed using multiple linear regression analysis. RESULTS: This study included 1,260 patients (age: 69.8 years, male: 77.0%). The most prevalent comorbidities were hypertension (74.8%), hyperlipidemia (51.0%) and diabetes-mellitus (50.2%). The 94.1% of the patients took pharmacotherapy including aspirin (76.2%), clopidogrel (53.3%), and cilostazol (33.6%). The 12.6% of the patients were receiving smoking cessation education/pharmacotherapy. A considerable number of patients (500 patients, 40.0%) had visit history to another hospital before diagnosis/treatment at the current hospital, with visits to orthopedic units (50.4%) being the most common. At the time, 29% (or higher) of the patients were already experiencing symptoms of critical limb ischemia. Baseline EQ-5D index and EQ VAS were 0.64±0.24 and 67.49±18.29. Factors significantly associated with QoL were pharmacotherapy (B=0.05053; p=0.044) compared to no pharmacotherapy, and Fontaine stage improvement/maintain stage I (B=0.04448; p<0.001) compared to deterioration/maintain stage II-IV. CONCLUSIONS: Increase in disease awareness for earlier diagnosis and provision of adequate pharmacotherapy is essential to reduce disease burden and improve QoL of Korean PAD patients.ope

A Case of Transseptal Approach to Carotid Artery Stenting in Right Internal Carotid Stenosis

Although the carotid endarterectomy presently represents the standard therapeutic approach for most patients with significant carotid artery stenosis, a percutaneous transluminal angioplasty (PTA) with stenting has become an alternative method for treating patients with comobid conditions, particulary coronary artery disease. A PTA with stenting has the potential for being safer, less traumatic, more cost-effective, and useful in patients at high surgical risk. As well, they are not limited to the cervical carotid artery. But it is reported that carotid angioplasty by femoral approach is difficult to do in 1-2% of patients with carotid stenosis due to abnormal origin of carotid artery or occlusion of femoral arteries. We succeeded in PTA with stenting of tight stenosis of right internal carotid artery through the transseptal approach in case of a sharply angled right brachiocephalic artery take-off from the aorta. The transseptal approach can be used for PTA with stenting in case of problems with femoral approach.ope

Therapeutic effects of a mesenchymal stem cell‑based insulin‑like growth factor‑1/enhanced green fluorescent protein dual gene sorting system in a myocardial infarction rat model

The present study was conducted in order to improve gene expression efficiency of insulin‑like growth factor‑1 (IGF‑1)‑transfected mesenchymal stem cells (MSCs) using a non‑viral carrier and a simplified method of dual gene selection. The therapeutic efficacy of this MSC‑based IGF‑1/enhanced green fluorescent protein (EGFP) dual gene sorting system was evaluated in a rat myocardial infarction (MI) model. IGF‑1 and EGFP genes were expressed in MSCs in vitro. The purity of dual gene‑expressing MSCs was 95.1% by fluorescence‑activated cell sorting. Transfected MSCs injected into rats were identified based on green fluorescence, with an increased signal intensity observed in rats injected with sorted cells, compared with unsorted cells. IGF‑1 expression levels were additionally increased in the sorted group, and decreases in infarct size, fibrotic area and fraction of apoptotic cells were observed. These results demonstrated that IGF‑1 overexpression protects against fibrosis and apoptosis in the myocardium and reduces infarct size following MI. Additionally, the present vector sorting system may potentially be applied to other types of stem cell‑based gene therapy.ope

Timing of high intensity statin for acute coronary syndrome: how earlier initiation makes better?

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Spontaneous Pulmonary Hemorrhage and Adult Respiratory Distress Syndrome after Thrombolytic Therapy for Acute Myocardial Infarction

We report a cace of 69-year-old man who developed massive pulmonary hemorrhage and subsuquent adult respiratory distress syndrome following intravenous urokinase for acute myocardial infarction. Pulmonary hemorrhage is a rare but a potentially life-threatening complication after thrombolytic therapy and should be considered in the differential diagnosis of pulmonary infiltrates of falling hemoglobin after thrombolytic therapy for acute myocardial infarction with no obvious site of bleeding.ope

Coronary Arterial Remodeling in Athersclerotic Disease

Background : Adaptive remodeling of the wall of diseased arterial segments occurs to compensate for the accumulation of atherosclerotic plaque. Histopathologic studies and intraoperative high-frequency epicardial coronary ultrasound imaging as well as intracoronary ultrasound imaging have shown that human coronary arteries enlarge in parallel with the formation of atherosclerotic plaque. Therefore, the lumen area is preserved until the progressive accumulation of plaque exceeds the compensatory mechanisms of the vessel. In 1995, however, Pastercamp et al. reported that arterial wall constriction (shrinkage) or inadequate enlargement may be a different mechanism associated with the development of severe arterial lumen narrowing in addition to plaque proliferation. The aim of this study is to examine what extent of de novo native coronary arterial stenosis is accompanied by compensatory enlargement and to find the predictors of inadequate remodeling with intravascualr ultrasound. Methods : Fifty eight patients were enrolled from February 1997 through October 1997. Patients who had the lesion of more than 50% stenosis of minimal luminal diameter in coronary angiography were indicated. The lesion which was located in the ostium or was very tortuous or angulated was excluded. The lesion which had the history of balloon angioplasty or stent insertion was also excluded. We used 20 MHz endosonic intravascular ultrasound catheter. We measured EEM area (External Elastic Membrane area), lumen area and plaque plus media area and analysed plaque characteristics. Results : 1) Fifty-eight consecutive patients (43 men, 15 women ; mean age 55.4 years, range 33 to 78) who had not undergone previous catheter intervention were studied, with a single intravascular ultrasound system. 2) Among 58 patients, 20 patients (35%) had acute myocardial infarction, 30 patients (52%) unstable angina, 6 patients (10%) stable angina and 2 patients (3%) old myocardial infarction. Lesions were located at the left anterior descending arteries in 29 patients (50%), right coronary arteries in 21 patients (36%) and left circumflex coronary artery in 8 patients (14%). 3) Compensatory enlargement was observed in 19 (32%) of 58 lesions and inadequate compensatory enlargement in 39 (68%). 4) EEM and plaque areas at lesion site of compensatory enlargement group were significantly larger than those of inadequate enlargement group (p 240 mg/dl), smokings and plaque characteristics were not statistically related with inadequate enlargement. Although there was no statistical significance, there was a tendency of inadequate enlargement in patients with diabetes mellitus and calcified plaque. 6) The only predictor of inadequate remodeling was the postmenopausal female (p <0,05). Conclusion Adaptive compensatory coronary arterial remodeling was occured less frequently in patients with acute coronary syndromes than in patients with stable angina. The only statistically significant predictor of adaptive compensatory coronary arterial remodeling was postmenopausal women. Inadequate compensatory coronary arterial remodeling was occured more frequently in patients with diabetes mellitus or calcified plaque but without statistical significance.ope

Coronary Stenting for Long Lesions : Comparison of Three Different Types of Stent

Background : Coronary stenting is known to reduce the rates of restenosis in focal lesions, but the efficacy of stents for long lesions have not been thoroughly defined. To evaluate the immediate and follow-up results of three different types of stents in lesions longer than 20mm, consecutive series of patients (pts) were reviewed. Methods : Between February 1996 and January 1997, 123 patients (male 68.3%, mean age 57±10 years) with a total of 130 lesions underwent long stent : stenting. Excluding multiple stents and unplanned use for acute closure fifty-three pts (56 lesions) were treated with the Microstent II (M-II) ; 30 pts (31 lesions) received the Less Shortening Wallstent (WA) ; and 40 pts (43 lesions) were treated by the Gianturco-Roubin II stent (GRII ). Results : With the clinical success defined as 50% diameter stenosis at FU was 26% in M- II, 32% in WA and 38% in GR- II ; there was no significant difference between the three stents. Target lesion revascularization (TLR) defined as CABG or target lesion PTCA at FU was 17.6% in M- II , 12% in WA and 23.1% in GR- II . Restenosis rate correlated closely with lesion length (p-value=0.03, Odds ratio=1.096) and small post-stent luminal diameter (p-value=0.002, Odds ratio=0.063) in a multivariable analysis. Conclusion : Coronary stenting for long lesions can be safely performed with acceptable complication rates using any of the three types of stents. Restenosis and late outcome was not related to type of stent.ope

A Case of Transluminal Stent-Graft for Thoracic Aortic Aneurysm with Behcet´s Syndrome

Behc¸et´s syndrome is a multisystem disorder presenting with recurrent oral and genital ulcerations as well as ocular involvement. Vascular complications consist of venous thromboembolism, arterial aneurysms and occlusions, and they develop in about 25% of patients. Weakening of the aortic wall may lead to aneurysms that may rupture and cause life-threatening hemorrhage, but nothing in the surgical and nonsurgical techniques proposed for the treatment for aneurysms in Behcet s syndrome has proved to be satisfactory. The traditional treatment for thoracic aotic aneurysms is the surgical replacement of a prosthetic graft. Although advances in the operative care of patients with thoracic aortic aneurysms have been achieved, the associated morbidity and mortality are considerable, especially in those with coexisting conditions such as advanced age, coronary artery disease and heart failure. Currently, transluminally placed endovascular stent-grafts offer an alternative approach to treatment that is potentially less invasive with a lower risk. We report a 37-year-old male patient with thoracic aortic aneurysm associated with Behget´s syndrome. Transluminal endovascular stent-graft placement was attempted : the stent-graft was introduced through a 22-Fr sheath using a common femoral artery cut down and expanded to 25 - 30 mm in diamter. There was increased thrombosis of the aneurysm on a follow-up imaging study, and the patient was discharged without complications.ope

Immediate Results of AVE GFX® Stent

Background: The AVE GFX(R) coronary stent, a corrugated ring-type premounted stainless-steel stent, is designed for improved flexibility and trackability with increased vessel support when compared to the current Micro-II stent. We report the immediate results of our experience with the GFX stent. The purpose of this study was to assess the feasibility, safety and efficacy of deployment of the premounted GFX stent in patients with complex coronary anatomy as well as their clinical outcomes within the first month. Method: Between April 1997 and August 1997, fifty-two GFX stents were deployed in the coronary arteries of forrty-nine patients (male 71.4%, mean age 60+/-8 years) with 52 lesions. Thirty-two patients had unstable angina pectoris, five had stable angina, and twelve had acute myocardial infarctions. Results: Results: The frequency of the used stents diameter was 3.0 mm in 23 (44.2%) patients, 3.5 mm in 22 (42.3%) patients, and 4.0 mm in 7 (13.5%) patients. The lengths of used stents were 18 mm (33 cases, 63.6%), 24 mm (17 cases, 32.7%) and 30 mm (2 cases, 3.8%). 2) Single stent implantation was achieved in 47 (92.1%) lesions; multiple stents were deployed in 4 (7.9%) lesions (a case with 2nd GFX stent and 3 lesions overlapped with other kinds of stents). 3) Successful deployment was achieved in 51/52 stents (98.1%) with one case of stent passing failure. Adjuvant high pressure balloon dilatations (over 12 atm) were needed in 14 cases (26.9%) to achieve optimal result. 4) No major adverse cardiac events (MI, repeat PTCA, CABG, death) occurred in this series of 49 consecutive patients within 4 weeks after procedure. Stents were deployed successfully in complex lesions including calcified and angulated (>45degrees) lesions or in lesions with proximal tortuosity; B2 (57.7%), C (28.8%) (procedural success rates and angiographic success rates were both 100%). 5) No subacute stent thrombosis occurred during hospital stay. Peristent dissections were performed in 2 cases distal-to-stent without significant compromise of blood flow. Of the 8 lesions with side branches, 1 side branch was occluded after stent deployment. 6) Mean lumen diameter of target lesion was increased from 0.79+/-0.41 mm to 3.19+/-0.41 mm (P<0.001) after stent implantation. Percent of diameter stenosis was decreased from 75.6+/-12.0% to??.6+/-12.9% (P<0.001) after stent implantation. Mean diameter of reference artery was 3.20+/-0.54 mm. Conclusion: GFX stent implantation can be achieved with high procedural success rate. With several favorable characteristics, good trackability, flexibility, and good vessel support, this new stent was deployed successfully in complex lesions for percutaneous coronary intervention. Follow-up data is needed to assess long term patency of this stent.ope

Electrophysiologic and Clinical Characteristics of Antidromic Reentrant Tachycardia in Ventricular Preexcitation Syndrome

Background：Antidromic reentrant tachycardia(ART), in which an accessory atrioventricular pathway is used as the anterograde limb of an atrioventricular reentrant tachycardia, has been documented clinically in less than 10% of patients with the Wolff-Parkinson-White(WPW) syndrome. The wide QRS complex makes the distinction between antidromic AV reentrant tachycardia and ventricular tachycardia somewhat difficult. The purpose of this study is to evaluate the clinical and electrophysiologic characteristics of the antidromic reentrant tachycardia. Methods and Results：During the electrophysiologic study of 355 patients, from December 1986 to April 1995, referred for evaluation of Wolff-Parkinson-White syndrome, 18(5.1%) patients had preexcited reciprocating tachycardia. 1) The age of the antidromic reentrant tachycardia patients ranged from 15 to 53 years(28±12), and the mean age was younger than that of orthodromic reentrant tachycardia(ORT) patients(p<0.05). 2) Thirteen were male patients, five were females. 3) There were associated heart diseases in 3 cases. Two patients had Ebstein’s anomaly and one had valvular heart disease. 4) The locations of accessory pathways(APs) documented on surface ECG were 7 left side(39%), 9 right side(50%), 1 posteroseptal side(5.5%) and 1 anteroseptal side. 5) Multiple bypass tracts were documented by electrophysiologic study in 7/18(38.9%) cases with ART, more common than cases with ORT(20/337(5.9%))(p<0.05). 6) 25 accessory pathways were documented by EPS in 18 patients(10 left side, 11 right side, 2 posteroseptal side and 2 anteroseptal side). ART patients had more right sided AP(11/25, 44%) than those with ORT(98/357, 27.5%), but ART patients had less posteroseptal AP(2/25, 8%) than those with ORT(63/357, 17.6%).ope