978-118 Exercise Capacity and Coronary Flow Reserve in Patients with Intermediate Coronary Stenoses

In patients with coronary disease, exercise time is a predictor of disease severity. More severe disease is associated with shorter exercise time due to greater ischemia. In patients with intermediate coronary stenoses, however, it is unclear whether stenosis severity predicts functional effects. Thus, we examined the relationship between exercise time and the angiographic and physiologic significance of 25 intermediate coronary stenoses (40–70%). Using an intracororary Doppler flow wire we measured coronary flow reserve (CFR) as the ratio of adenosine-induced hyperemic coronary flow velocity to resting velocity. Stenosis severity was determined by quantitative angiography. Patients subsequently underwent maximal exercise testing on a Bruce protocol. No patient had left ventricular dysfunction, ischemia in other vascular distributions or other diseases known to limit exercise capacity. Exercise time was normalized for age and gender according to the method of Bruce. Total exercise time ranged from 3.9 to 12.8min while normalized time ranged from 37 to 152% of predicted. CFR ranged from 1.0 to 3.5 (normal≥2.0) and was directly related to exercise time (r=0.7, p<0.0001, SEE=2.1) and normalized exercise time (r=0.7 p<0.0001, SEE=25), Normalized exercise time was 72±21% of predicted in patients with an abnormal CFR vs 125±23% of predicted in those with normal CFR (p<0.0001). There was no relationship between angiographic percent stenosis and exercise time (r=-0.01) or normalized exercise time (r=-0.01). Normalized exercise time was ≥100% of predicted in 9 of 11 patients with a normal CFR, and <100% in 13 of 14 patients with abnormal CFR. The sensitivity, specificity and predictive accuracy of normalized exercise time for CFR were 93%, 82% and 88%, respectively. Thus, in patients with intermediate coronary stenoses and no other exercise limitations, treadmill exercise time is a useful marker of the physiologic severity of disease

Results of the ANCHOR prospective, multicenter registry of EndoAnchors for type Ia endoleaks and endograft migration in patients with challenging anatomy

ObjectiveProximal attachment site complications continue to occur after endovascular repair of abdominal aortic aneurysms (EVAR), specifically type Ia endoleak and endograft migration. EndoAnchors (Aptus Endosystems, Sunnyvale, Calif) were designed to enhance endograft proximal fixation and sealing, and the current study was undertaken to evaluate the potential benefit of this treatment.MethodsDuring the 23-month period ending in December 2013, 319 subjects were enrolled at 43 sites in the United States and Europe. EndoAnchors were implanted in 242 patients (75.9%) at the time of an initial EVAR procedure (primary arm) and in 77 patients with an existing endograft and proximal aortic neck complications (revision arm). Technical success was defined as deployment of the desired number of EndoAnchors, adequate penetration of the vessel wall, and absence of EndoAnchor fracture. Procedural success was defined as technical success without a type Ia endoleak at completion angiography. Values are expressed as mean ± standard deviation and interquartile range.ResultsThe 238 male (74.6%) and 81 female (25.4%) subjects had a mean age of 74.1 ± 8.2 years. Aneurysms averaged 58 ± 13 (51-63) mm in diameter at the time of EndoAnchor implantation (core laboratory measurements). The proximal aortic neck averaged 16 ± 13 (7-23) mm in length (42.7% <10 mm and 42.7% conical) and 27 ± 4 mm (25-30 mm) in diameter; infrarenal neck angulation was 24 ± 15 (13-34) degrees. The number of EndoAnchors deployed was 5.8 ± 2.1 (4-7). Technical success was achieved in 303 patients (95.0%) and procedural success in 279 patients (87.5%), 217 of 240 (89.7%) and 62 of 77 (80.5%) in the primary and revision arms, respectively. There were 29 residual type Ia endoleaks (9.1%) at the end of the procedure. During mean follow-up of 9.3 ± 4.7 months, 301 patients (94.4%) were free from secondary procedures. Among the 18 secondary procedures, eight were performed for residual type Ia endoleaks and the others were unrelated to EndoAnchors. There were no open surgical conversions, there were no aneurysm-related deaths, and no aneurysm ruptured during follow-up.ConclusionsUse of EndoAnchors to treat existing and acute type Ia endoleaks and endograft migration was successful in most cases. Prophylactic use of EndoAnchors in patients with hostile aortic neck anatomy appears promising, but definitive conclusions must await longer term follow-up data

Intracoronary Doppler assessment of moderate coronary artery disease: comparison with 201Tl imaging and coronary angiography. FACTS Study Group

BACKGROUND: Coronary angiography may not reliably predict whether a stenosis causes exercise-induced ischemia. Intracoronary Doppler ultrasound may enhance diagnostic accuracy by providing a physiological assessment of stenosis severity. The goal of this study was to compare intracoronary Doppler ultrasound with both 201Tl imaging and coronary angiography. METHODS AND RESULTS: Fifty-five patients with 67 stenotic coronary arteries underwent coronary angiography with intracoronary Doppler ultrasound and had exercise 201Tl testing within a 1-week period. Coronary flow reserve was measured, and analyses were performed by independent core laboratories. The mean stenosis was 59+/-12%; 51 of 67 stenoses were intermediate in severity (40% to 70%). A coronary flow reserve \u3c 1.7 predicted the presence of a stress 201Tl defect in 56 of 67 stenoses (agreement=84%; kappa=0.67; 95% CI=0.48 to 0.86). In the patients who achieved 75% of their predicted maximum heart rate, the Doppler and 201Tl imaging data agreed in 46 of 52 stenoses (agreement=88%; kappa=0.77; 95%CI=0.57 to 0.97). Scatter was evident when angiography was compared with coronary flow reserve (r=.43), and the angiogram did not reliably predict the results of the 201Tl stress test (kappa=0.21; agreement=57% to 63%). CONCLUSIONS: Doppler-derived coronary flow reserve accurately predicts the presence of exercise-induced ischemia on stress 201Tl imaging, and coronary angiography does not reliably assess the physiological significance of an intermediate coronary stenosis