Implante de Stent guiado por ultrassom intracoronariano melhora desfechos: meta-análise de ensaios randomizados / Intracoronary ultrasound-guided stenting improves outcomes: a meta-analysis of randomized trials / Implante de stents guiado por ultrasonido intracoronario mejora desenlaces: metanálisis de ensayos randomizados

FUNDAMENTO: Ultrassom Intracoronariano (USIC) tem sido usado como um método auxiliar a fim de otimizar o implante de stents. No entanto, o impacto desse método em alguns resultados é controverso. OBJETIVO: Analisar sistematicamente o impacto dos stents coronarianos guiados por USIC, em comparação com os stents guiados angiograficamente, sobre os resultados clínicos e angiográficos. MÉTODOS: Foi realizada uma busca em bases de dados (MEDLINE, Cochrane CENTRAL, EMBASE) e referências de estudos publicados entre 1982 e 2010. Foram incluídos Ensaios Clínicos Randomizados (ECR) que compararam o implante de stents coronarianos guiados por angiografia e USIC versus implante de stents coronarianos guiados apenas por angiografia (ANGIO). O seguimento mínimo foi de seis meses e os resultados avaliados foram eventos cardíacos adversos importantes (MACE), Revascularização da Lesão-alvo (RLA) e reestenose angiográfica. Dois revisores extraíram os dados de forma independente. Razão de risco sumário e intervalos de confiança de 95 por cento (CI) foram calculados com modelos com efeitos aleatórios. A abordagem GRADE foi utilizada para determinar a qualidade geral de evidências para cada resultado. RESULTADOS: Dos 3.631 artigos identificados, oito ECR avaliando um total de 2.341 pacientes foram incluídos. Houve uma redução de 27 por cento na reestenose angiográfica (95 por cento IC: 3 por cento -46 por cento) e uma redução de 38 por cento em RLA (95 por cento IC: 17 por cento -53 por cento) em favor de USIC versus ANGIO. No entanto, os MACE não foram reduzidos por USIC (RR: 0,79; 95 por centoCI: 0,61-1,03). Os dados MACE representam apenas 47 por cento do tamanho ótimo de informações necessárias para detectar com segurança um efeito de tratamento plausível. CONCLUSÕES: Observamos que o implante de stent coronariano guiado por USIC oferece reduções significativas em RLA e reestenose angiográfica em comparação com implante de stent guiado por angiografia, porém não reduz casos de MACE.

BACKGROUND: Intracoronary ultrasound (IVUS) has been used as an adjunctive method in order to optimize implantation of stents. However, the impact of this method in some outcomes is controversial. OBJECTIVE: To systematically review the impact of routine IVUS-guided coronary stent as compared to angiographic-guided, on clinical and angiographic outcomes. METHODS: A search of databases (MEDLINE, Cochrane CENTRAL, EMBASE) and references of published studies, from 1982 to 2010, was conducted. Randomized clinical trials (RCTs) that compared angiography plus IVUS-guided (IVUS) vs. angiography alone guided (ANGIO) coronary stent implantation were included. Minimum follow-up was 6 months and the outcomes assessed were major adverse cardiac events (MACE), target lesion revascularization (TLR) and angiographic restenosis. Two reviewers independently extracted the data. Summary risk ratio and 95 percent confidence intervals (CI) were calculated with random-effects models. The GRADE approach was used to determine the overall quality of evidence for each outcome. RESULTS: Out of 3,631 articles identified, 8 RCTs evaluating a total of 2,341 patients were included. There was a 27 percent reduction in angiographic restenosis (95 percentCI: 3 percent-46 percent) and a 38 percent reduction in TLR (95 percentCI: 17 percent-53 percent) in favor of IVUS vs. ANGIO. However, MACE were not reduced by IVUS (RR: 0.79; 95 percentCI: 0.61-1.03). The MACE data represent only 47 percent of the optimal information size required to reliably detect a plausible treatment effect. CONCLUSIONS: We observed that IVUS-guided coronary stenting provides significant reductions in TLR and angiographic restenosis compared to angiographically-guided stenting, but it does not reduce MACE.

FUNDAMENTO: El ultrasonido intracoronario (USIC) ha sido utilizado como método Complementario para optimización del implante de stents. Entre tanto, el impacto de ese método en algunos desenlaces es controvertido. OBJETIVO: Revisar sistemáticamente el impacto de la adición del USIC a la angiografía para optimización del implante de stents sobre los desenlaces clínicos y angiográficos MÉTODOS: Fue conducida búsqueda en las bases MEDLINE, Cochrane CENTRAL y EMBASE y referencias de estudios publicados, de 1982 a 2010. Fueron incluidos ensayos clínicos randomizados (ECRs) que compararon USIC adicionado a angiografía coronaria (USIC) vs. Angiografía aislada (ANGIO) como guía para implantación de stents. El seguimiento mínimo fue de 6 meses y los desenlaces analizados fueron eventos cardiovasculares mayores (ECVM), revascularización del vaso blanco (RVB) y reestenosis angiográfica. Dos revisores independientes extrajeron los datos. El riesgo relativo y el intervalo de confianza (IC) de 95 por ciento fueron calculados con efectos randómicos. El GRADE fue usado para determinar la calidad global de la evidencia para cada desenlace. RESULTADOS: De los 3.631 artículos identificados, 8 ECRs totalizando 2.341 pacientes fueron incluidos. Hubo una reducción de 27 por ciento en la reestenosis angiográfica (IC95 por ciento: 3 por ciento-46 por ciento) y una reducción de 38 por ciento en la RVB (IC95 por ciento: 17 por ciento-53 por ciento) en favor del USIC vs. ANGIO. Entre tanto, ECVM no fueron reducidos por el USIC (RR: 0,79; IC95 por ciento: 0,61-1,03). Los datos de ECVM representan solamente 47 por ciento del tamaño óptimo de la información necesaria para detectar un efecto plausible de tratamiento. CONCLUSIONES: Fue observado que el implante de stents guiado por USIC promueve reducciones significativas en la RVB y reestenosis angiográfica cuando es comparado a angiografía aislada, sin embargo no reduce ECVM.

Morbimortalidad de la endarterectomía carotídea extracraneana en el Hospital DIPRECA / Carotid endarterectomy at Dipreca Hospital: morbidity and mortality

Introducción: La estenosis grave de la arteria carótida es una causa importante de accidente vascular encefálico(AVE) y evento isquémico transitorio (TIA) (10-20 por ciento). La endarterectomía carotídea extracraneana (ECE) ha demostrado ser efectiva en reducir este riesgo en pacientes seleccionados, sintomáticos y asintomáticos. Objetivo: Presentar los resultados de una serie de pacientes sometidos a ECE. Métodos: Serie de 135 ECE en 121 sujetos (84 hombres y 37 mujeres), con mediana de 72,2 +/- 7,7 años, tratados con ECE en el Servicio de Cirugía Vascular del Hospital Dipreca entre enero de 1998 y diciembre de 2004. La operación consistió en endarterectomía carotídea (común e interna) luego de realizar arteriotomía longitudinal amplia y endarterectomía carotídea externa por eversión. En la mayoría de los casos se utilizó shunt y bloqueo anestésico cervical profundo y superficial; en todos se fijó la placa distal y arteriorráfia con parche. Se utilizó estadística descriptiva y se calculó porcentajes, medianas, promedios, desviaciones estándar y supervivencia. Resultados: El déficit neurológico central homolateral postoperatorio fue de 1,5 por ciento. La morbilidad general fue de 12,6 por ciento. No hubo mortalidad perioperatoria. Se obtuvo un 94 por ciento de seguimiento. La causa de muerte más frecuente fue la de origen cardíaco (74 por ciento) y hubo un 4,7 por ciento de eventos neurológicos tardíos (TIA o AVE). La supervivencia libre de re estenosis fue de 92 por ciento. Conclusión: La ECE sigue siendo una alternativa de tratamiento en nuestro Hospital con baja morbimortalidad en sujetos seleccionados con estenosis carotídea sintomática y asintomática.

Background: Critical carotid artery stenosis is an important cause of stroke (CVA) and transient ischemic attack (TIA). Extra cranial endarterectomy (ECE) has proven effective in reducing the risk of these complications in selected patients, both symptomatic and asymptomatic. Aim: To report the results of ECE at Dipreca Hospital in Santiago, Chile. Methods: From January 1998 to December 2004, 135 ECE procedures were performed in 121 patients (84 males and 37 females). Mean age was 72.2 years (SD 7.7). ECE consisted of common and external carotid artery endarterectomy with eversion. In most cases, superficial and deep anesthetic blockade and shunts were utilized. A patch and fixation of distal plaque were performed in all. Results are presented with standard statistics methods. Results: Homolateral postoperative neurologic deficit was observed in 1.5 percent. All cause morbidity was 12.6 percent. There was no perioperative mortality. Follow up data was obtained for 94 percent of patients. Seventy-four percent of late deaths were due to cardiac events and 4.7 percent of patients developed late neurologic events (CVA or TIA). Restenosis free survival was 92 percent. Conclusion: ECE is a safe procedure for patients with both symptomatic and asymptomatic carotid artery stenosis.

Serum Levels of Advanced Glycation End Products Are Associated with In-Stent Restenosis in Diabetic Patients

The formation of advanced glycation end products (AGEs), in various tissues has been known to enhance immunoinflammatory reactions and local oxidant stresses in long standing diabetes. Recently, AGEs have been reported to play a role in neointimal formation in animal models of arterial injury. We attempted to determine whether the serum levels of AGEs are associated with coronary restenosis in diabetic patients. Blood samples were collected from diabetic patients with coronary artery disease undergoing stent implantation and the serum levels of AGEs were analyzed by the fluorescent intensity method. The development of in-stent restenosis (ISR) was evaluated by a 6-month follow-up coronary angiography. A total of 263 target lesions were evaluated, in 203 patients. The ISR rate in the high-AGE (> 170 U/ml) group (40.1%) was significantly higher than in the low-AGE group (< or =170 U/ml) (19.6%) (p < 0.001). Furthermore, multivariate analysis revealed that a high level of serum AGEs is an independent risk factor for the development of ISR (odds ratio, 2.659; 95% CI, 1.431-4.940; p=0.002). The serum levels of AGEs constitute an excellent predictive factor for ISR, and should be one of the guidelines for medical therapy and interventional strategy to prevent ISR in diabetic patients.

The Long-term Clinical Results of a Platelet Glycoprotein IIb/IIIa Receptor Blocker (Abciximab: ReoPro (R) ) Coated Stent in Patients with Coronary Artery Disease

BACKGROUND: Previously, the inhibition of coronary restenosis with Abciximab (ReoPro (R) ) -coated stent in a porcine model was reported. ReoPro (R) inhibits platelet aggregation, the proliferation of vascular smooth muscle cells and the inflammatory reaction. METHODS: A prospective randomized trial was performed to compare two types of stent for revascularization in the native coronary artery. The primary effective end points were major adverse coronary events (MACE) : cardiac death, acute myocardial infarction, target vessel revascularization (TVR) and restenosis at the 6-month clinical and angiographic follow-ups. RESULTS: One hundred and fifty-five patients were enrolled between August 2001 and June 2003. The mean ages (56.0 +/- 10.0 vs. 56.9 +/- 10.8 years), baseline diameter of stenosis and minimal luminal diameter were no different between the two groups. There was one myocardial infarction and revascularization during the hospital stay in control stent group. During the clinical follow-up there were two myocardial infarctions in control group. Follow-up coronary angiograms were performed in 62.3% (48/77) and 65.4% (51/78) of the coated and control groups, respectively. The diameter of stenosis and late loss were significantly less in the ReoPro (R) -coated stent group compared with the controls (16.4 +/- 5.8% vs. 34.3 +/- 6.1%, p=0.009; and 0.33 +/- 0.28 mm vs. 0.88 +/- 0.41 mm; p=0.002). The restenosis and TVR rates of the ReoPro (R) -coated stent were relatively lower compared with the control stent [14.6% (7/48) vs. 29.4% (15/51), p=0.062; and 9.2% (7/76) vs. 14.7% (11/75) ; p=0.327]. CONCLUSION: A ReoPro (R) -coated stent is safe, and may be effective in the prevention of coronary restenosis.

Angioplasty for chronic total coronary occlusions: safety and efficacy.

OBJECTIVE: To determine the short term results and safety of angioplasty in chronic coronary occlusions. METHODS: Eighty consecutive patients undergoing percutaneous transluminal coronary angioplasty (PTCA) for chronic coronary occlusions were prospectively analyzed for acute success rate and safety of the procedure. RESULTS: The mean age was 46.7 years (range 30-78 years). There were 72 males and eight females. Clinical presentation was recent myocardial infarction (MI) in four cases (5%), unstable angina in 20 (25%), chronic stable angina in 24 (30%) and past history of MI in 32 (40%) cases. Vessel distribution was left anterior descending artery (LAD) in 40 (50%), left circumflex artery (LCx) in 12 (15%) and right coronary artery (RCA) in 28 (35%) cases. Lesion length varied from 8 mm to 37 mm with a mean of 16.7 mm. Acute success rate was 70% (56/80). Twenty four cases (30%) had unsuccessful result due to failure to cross with wire (18 cases) or inability to cross with the balloon (six cases). One major complication in the form of type III coronary perforation was encountered which was successfully managed surgically. CONCLUSION: Percutaneous transluminal coronary angioplasty (PTCA) in chronic total occlusion has a reasonable success rate and very low complication rate.