Adjunctive stent implantation following directional coronary atherectomy in patients with coronary artery disease

Objectives. This prospective case control study evaluated the acute and long-term results of stent implantation preceded by debulking of the plaque by means of directional coronary atherectomy. Background. In comparison with balloon angioplasty, intracoronary stenting produces a larger luminal diameter, maintains artery patency and reduces the incidence of restenosis. Optimal stent deployment is a pivotal factor for achieving the best results, but the bulk of the atherosclerotic plaque opposes stent expansion and may limit the success of the procedure. Debulking of the plaque may provide a better milieu for optimal stent deployment. Methods. Directional coronary atherectomy followed by a single Palmaz-Schatz stent implantation was attempted in 100 patients. The successes, complications and angiographic results of the combined procedure were evaluated both acutely and during follow up. Matched patients undergoing successful Palmaz-Schatz stent implantation alone during the same period served as controls. Results. Atherectomy followed by stent implantation was performed in 94 patients with 98 lesions; periprocedural complications were observed in four cases. The stenosis diameter decreased from 76 +/- 9% at baseline to 30 +/- 13% after atherectomy (p < 0.0001), and 5 +/- 9% after stent implantation (p < 0.0001); it increased to 27 +/- 15% at 6 month angiography (p < 0.0001). During the 14 +/- 10 months of follow-up, none of the patients died or experienced myocardial infarction, but three patients under went target lesion revascularization. The patients undergoing stent implantation alone achieved smaller acute gains, tended to have a higher late lumen loss, had a higher restenosis rate (30.5% vs. 6.8%, p < 0.0001) and showed a greater incidence of clinical events during follow up (p < 0.0001). Conclusions. Debulking atherosclerotic lesions by means of directional coronary atherectomy before stent implantation is a safe procedure with a high success rate and a low incidence of restenosis at follow-up. (J Am Coll Cardiol 1998;32:1855-60) (C) 1998 by the American College of Cardiology

Right subclavian approach as a feasible alternative for transcatheter aortic valve implantation with the CoreValve ReValving System.

Aims: Arterial access selection is crucial during transcatheter aortic valve implantation. When traditional femoral access has been deemed unfeasible the left subclavian artery has been used successfully. In cases where even the latter was ineligible, we opted, despite the lack of any data, for the right subclavian approach. We hereby present the results of the first series available. Our aim was to evaluate the feasibility and performance of the CoreValve ReValving System (CRS) implantation via the right subclavian artery in patients with contraindication to femoral and left subclavian accesses. Methods and results: Among 300 patients who have undergone CRS implantation, 70 (23%) have been treated via the subclavian approach, 10 via the right subclavian artery and 60 via the left. Demographic features were quite similar except for the presence of significant left subclavian disease in all patients treated via the right subclavian artery. The success rate was 100% for both groups. At 30-day follow-up, there was no significant difference in terms of all-cause mortality and cardiac mortality between right vs. left subclavian approach (0% vs. 6.6% and 0% vs. 6.6%, respectively). Consistent results were observed at a mean follow-up of 12±7.9 months (all-cause mortality: 10% vs. 15%). Incidences of new AV block requiring PM implantation were also statistically equivalent. Conclusions: CRS implantation via the right subclavian artery was as feasible and safe as the left subclavian approach. It poses very particular technical issues but should be considered when more conventional approaches are inadequate in order to provide patients with a further chance to be treated effectivel

Insertion/deletion polymorphism of the Angiotensin I-Converting Enzyme gene and risk of restenosis after directional coronary atherectomy followed by stent implantation

Background: The renin-angiotensin system is involved in neointimal hyperplasia in response to arterial injury. The insertion/deletion (I/D) polymorfism of the Angiotensin Converting Enzyme (ACE)gene largely controls plasma levels. It has been reported that D allele is associated with increased risk of restenosis after coronary stenting. However, plaque remodelling may also be an important determinant of restenosis after stent implantation. Debulking the lesion before stent implantation by means of directional coronary atherectomy (DCA) reduce the influence of plaque remodelling leaving neointimal hyperplasia as the major mechanism of restenosis. Therefore, DCA followed by stent implantation represents an ideal model to investigate the relationship between ACE I/D polymorphism and restenosis. Methods: We prospectively evaluated 113 consecutive patients (102 male, 90%; mean age 57±9 yrs) who underwent seccessful (residual stenosis 75% and <100% of coronary stenosis with a lesion length <15 mm. Genomic DNA was prepared from peripheral blood leukocytes and analysed by means of PCR amplification. Baseline, post-DCA, post-stent and follow-up angiograms, performed after 6-12 months, were quantitatively analysed. Subjects were divided into three groups, according to the genotype (DD, ID, II). Results: The observed genotype distribution was in agreement with the expected Hardy-Weinberg proportion. No significant differences were observed among the three groups in terms of acute gain (DD=2.27±0.49 mm;ID=2.16±0.57 mm; 11=2.24±0.38 mm; p=ns), late loss (DD=0.73±0.73 mm; ID=0.9±0.72 mm; 11=0.63±0.65 mm; p=ns), net gain (DD=1.54±0.72 mm; ID=1.25±0.78 mm; 11=1.62±0.78 mm; p=ns) or percent of patients developing angiographic restenosis (DD=8.8%; ID=7.2%; 11=9.8%). Conclusion: Our data indicate that ACE I/D gene polymorphism is not associated with the risk of developing restenosis in a model of plaque debulking plus stent implantation

Insertion/deletion polymorphism of the Angiotensin I-Converting Enzyme gene and risk of restenosis after directional coronary atherectomy followed by stent implantation

Background: The renin-angiotensin system is involved in neointlmal hyperplasia in response to arterial injury. The insertion/deletion (l/D) polymorphism of the enzyme gene largely controls angiotensin converting enzyme (ACE) plasma level, and it has been observed that D allele is associated with restenosis after coronary stenting. However, plaque remodelling, vessel tearing at the edge of the stent and longitudinal redistributing of plaque could remain important determinants of restenosis after PTCA and stent implantation; debulking prior stenting eliminates these factors, leaving neointimal hyperplasia as the major mechanism of restenosis. Directional coronary atherectomy (DCA) followed by stent implantation therefore represent an ideal model to investigate the relationship between ACE l/D polymorphism and restenosis. Methods: We prospectively evaluated 113 consecutive patients (102 male, 90%; mean age 57+/- 9 years) who underwent successful (residual stenosis ~50%) DCA followed by stent implantation for de nova coronary lesion. Angiographic criteria for enrolment include significant stenosis (>75%, ~100%) of a tnon-tortuous native vessel with a reference diameter >2.5 mm and a lesion length <15mm. Genomic DNA was prepared from peripheral blood leukocytes and analysed by means of PCR amplification. Baseline, post-DCA, post-stent and follow-up angiograms, performed after 6-12 months, were quantitatively analysed. Subject were divided into three groups according to the genotype (DD, ID, II). Results: No significant differences were observed among the three groups in terms of acute, late loss, net gain or percent of patients developing angiographic restenosis. Conclusions: Our data indicate that ACE I/D gene polymorphism is not assiciated with the risk of developing restenosis in a model of plaque debulking plus stent deployment

What is the risk of intensifying platelet inhibition beyond clopidogrel? A systematic review and a critical appraisal of the role of prasugrel.

Thienopyridines are a class of drug targeting the platelet adenosine diphosphate 2 receptor. They have been shown to significantly reduce platelet activity exerting an important role in those clinical settings in which such an effect is beneficial. Ticlopidine was first to be introduced several years ago but it was quickly replaced by clopidogrel as it had a better risk/benefit profile. Recently, prasugrel has been developed and tested in several ex vivo studies and clinical trials showing able to provide a more powerful antiplatelet effect at the expense of a higher risk of bleeding complications. Great debate rose around its recent approval in the US as well as in Europe. This review aims at exploring the development and available clinical data of this third-generation thienopyridine while discussing its practical implementation in routine practice

Drug eluting stents versus bare metal stents in the treatment of saphenous vein graft disease: a systematic review and meta-analysis.

AIMS: Treatment of saphenous vein graft (SVG) disease is still a matter of debate given the uncertainty of the available conflicting data. Our aim was to assess, by means of a meta-analytic approach, the risk/benefit profile of drug eluting stents (DES) versus bare metal stents (BMS) in the treatment of SVG disease. METHODS AND RESULTS: A search of relevant studies in several databases was performed. The endpoints of interest such as: major adverse events (MAE) (the combination of overall death and non-fatal myocardial infarction [AMI]), target vessel revascularisation (TVR), and target lesion revascularisation (TLR) have been calculated in-hospital and at the longest follow-up. Single endpoints and the rate of stent thrombosis (ST) were also assessed. Three randomised controlled trials and 15 registry studies were appraised, totalling 3,294 patients. During hospitalisation, there was no difference in the risk of MAE, overall death, AMI and TVR. No data were available to calculate the TLR rate. At a mean follow-up of 19.8 months, no significant differences were found in the risk of MAE and AMI. BMS were associated with a trend towards a higher risk of overall death (OR 1.32 [1,00-1.74], p=0.05, number needed to treat [NNT]=55). DES showed superiority in terms of TVR (OR 1.86 [1.33-2.61], p=0.0003, NNT=16), and TLR (OR 1.77 [1.27-2.48], p&lt;0.0001, NNT=25). According to pre-specified subgroup analyses, these effects seem less evident at the long-term follow-up. DES were not associated with an increased risk of ST. CONCLUSIONS: Use of DES in SVG substantially reduces both TVR and TLR. These data also demonstrate that using DES in SVG is safe and contradict previous reports of potential risks

Transcatheter Valve-in-Valve Implantation Using CoreValve Revalving System for Failed Surgical Aortic Bioprostheses.

OBJECTIVES: The purpose of this study was to evaluate the performance of CoreValve Revalving System (CRS) (Medtronic, Minneapolis, Minnesota) implantation in patients with failed aortic bioprostheses. BACKGROUND: Transcatheter aortic valve implantation with the CRS is an effective option in high-risk patients with severe aortic stenosis. It may be an option for patients with a failed aortic bioprosthesis, especially when the risk of a surgical redo is deemed prohibitive. METHODS: CRS "valve-in-valve" implantation was performed in 25 high-risk patients with a failed bioprosthesis. Their mean age was 82.4 ± 3.2 years. New York Heart Association functional classes III and IV were present in 21 and 4 patients, respectively. The logistic EuroSCORE was 31.5 ± 14.8%, whereas the Society of Thoracic Surgeons score was 8.2 ± 4.2. Patients/prostheses were divided in type A (mainly stenotic, n = 9) and type B (mainly regurgitant, n = 16). RESULTS: The implantation success rate was 100%. In group A, the peak aortic gradient significantly decreased from 77.6 ± 21.6 mm Hg to 34.6 ± 19.4 mm Hg (p = 0.001). In all but 2 patients in group B, no significant regurgitation was observed post-implantation. No patients died during the procedure. At 30 days, there were 3 deaths (12%), 2 myocardial infarctions (8%), and 3 atrioventricular blocks requiring pacemaker implantation (12%). At a mean follow-up of 6 months, there were another death (survival rate of 84%) and a pacemaker implantation (cumulative incidence of 16%). New York Heart Association functional class improved in all patients to I and II. CONCLUSIONS: CRS implantation was feasible and effective regardless of the prevalent mode of failure. This finding may significantly affect the treatment of patients with a failed bioprosthesis deemed at a prohibitive risk for surgical redo