Is Stent Underexpansion the Main Cause of In-Stent Restenosis after Sirolimus-Eluting Stent Implantation?: An Intravascular Ultrasound Study

BACKGROUND AND OBJECTIVES: Intravascular ultrasound (IVUS) can be useful for assessing the causes of in-stent restenosis (ISR) after sirolimus-eluting stent (SES) implantation. We used IVUS to evaluate the causes of ISR after SES implantation. SUBJECTS AND METHODS: SES implantation was performed in 502 patients with 670 coronary lesions. Of these patients, 27 patients had angiographic ISR in 28 lesions. We evaluated the patterns of ISR and we wanted to elucidate the possible mechanism of ISR after SES implantation with using IVUS analysis. RESULTS: The ISR pattern was focal in 26 lesions, and diffuse in 2 lesions, including 1 total occlusion. When analyzing the 21 IVUS-applicable lesions, stent underexpansion [the minimal stent cross-sectional area (CSA) was < 5 mm2 and it was < 4.5 mm2 in the cases of small coronary arteries (reference vessel diameter < 2.8 mm)] was observed in 10 lesions (48%). Stent fracture (defined as non-visualization of the struts on IVUS at the restenotic segments) and edge restenosis was identified in the 3 (14%) and 3 lesions (14%), respectively. Except for edge stenosis, stent underexpansion was observed in 55% of the intra-stent restenotic lesions and it was more prominent in the small coronary arteries (7/8 small coronary artery lesions). Stent underexpansion, stent fracture or edge restenosis were not related to the 7 ISR lesions (33%) in which profound intimal hyperplasia within the stent occurred. CONCLUSION: Our observation of ISR after SES implantation with using IVUS showed that most ISR lesions have mechanical problems, especially stent underexpansion. However, one third of the ISR lesions were associated with profound intimal hyperplasia within the stent.

Clinical Outcomes Following Sirolimus-Eluting Stent Implantation in Patients with End-Stage Renal Disease: Korean Multicenter Angioplasty Team (KOMATE) Registry

BACKGROUND AND OBJECTIVES: Sirolimus-eluting stents (SES), as opposed to bare metal stents (BMS), have been shown to markedly reduce restenosis. However, many clinical trials have excluded the subset of patients (pts) with end-stage renal disease (ESRD). The aim of this study was to evaluate the clinical outcomes following SES implantation in ESRD pts. SUBJECTS AND METHODS: We analyzed the clinical outcomes in 50 pts from our registry following SES implantation, and compared the outcomes between those with ESRD receiving SES (SES-ESRD) and BMS (BMS-ESRD), and with non-ESRD pts following SES implantation (SES-non ESRD). RESULTS: A comparison of the SES-ESRD (50 pts, 72 lesions) with BMS-ESRD groups (42 pts, 45 lesions); those in the SES-ESRD group included; diabetes 78%, hypertension 94% and age 62+/-10 years. Those in the SES-ESRD group were more likely to have diabetes (diabetes of BMS-ESRD, 57%; p=0.04). The reference vessel diameters (RVD) of the SES-ESRD group were smaller (2.76+/-0.50 mm vs. 3.05+/-0.46 mm, p<0.001), but the lesion length was longer (25.6+/-7.0 mm vs. 19.1+/-8.8 mm, p<0.001) than those of the BMS-ESRD group. The SES-ESRD group had a lower 1-year major adverse cardiac events (MACE) rate than the BMS-ESRD group (6.0% vs. 33.3%; p<0.001). There were no differences in mortality and incidence of myocardial infarction between the two groups. The incidence of target vessel revascularization decreased significantly in the SES-ESRD group (2.0% vs. 19.0%, p=0.01). From a multivariate regression analysis, the use of SES was the only significant independent predictor of MACE (OR=0.054, 95% confidence interval 0.01 to 0.26, p<0.001). A comparison with SES-non ESRD group in our total registry (644 pts, 758 lesions); MACE in the SES-ESRD group (6.0%) was higher than in the SES-non ESRD group (3.1%), but there was no statistical significance (p=0.23). CONCLUSION: Compared with BMS, SES caused an improvement in the clinical outcomes in pts with ESRD.

Delayed Stent Fracture after Successful Sirolimus-Eluting Stent(Cypher(R)) Implantation

BACKGROUND AND OBJECTIVES: Sirolimus-eluting stent (SES) is very effective for preventing in-stent restenosis through the suppression of neointimal proliferation. Treatment failure cases related to stent fracture have recently been reported on, but any studies concerning the pattern or mechanism of SES fracture are very rare. SUBJECTS AND METHODS: Between December 2003 to January 2005, 457 patients underwent follow-up coronary angiography after SES implantation at three referral center. We reviewed the angiographic and procedural data for eleven of theses patients [6 males (55%), mean age: 60 year-old age, range: 43-74 years] who were proven to have experience complete SES fracture. RESULTS: The left anterior descending artery (LAD) and right coronary artery (RCA) stent fracture were 7 cases (63%) and 4 cases (37%), respectively. Myocardial bridge was shown in 6 cases with LAD fracture (86%). Overlapping stent implantation was performed in 5 cases (45%). The mean value of the maximal angulations at the fracture site before intervention was 50 degrees (range; 39-70 degrees) and the mean change between the maximal and minimal angulations was 13.2 degrees (range; 2-28 degrees). The mean stent diameter and length were 3.0 mm (range; 2.75-3.50 mm) and 40 mm (range; 23-52 mm). Stent inflation with high pressure was performed on 6 cases (54%) and it's frequency was higher in the RCA than the LAD (3 cases, 75%, mean inflation pressure: 13.1 mmHg). The mean follow-up duration was 7.2 month and only 2 cases were admitted due to the recurrent chest pain. The binary restenosis rate was 55% (6 cases) and the restenotic lesions were treated by balloon angioplasty in 2 cases and additional stenting was done in 2 cases. CONCLUSION: Our results demonstrated that SES fracture occurred in 7 cases with LAD lesion and in 4 cases with RCA lesion. Long stenting including overlapping implantation and more than 40 degrees angulated long stent implantation may be the factors for SES fracture. Our results also showed high pressure stent inflation was performed more frequently at the RCA lesion, and myocardial bridge and kinking motion was detected more frequently at the LAD lesions.

Immediate and Mid-Term Outcomes of the Endovascular Stent-Graft Treatment of Abdominal Aortic Aneurysm

BACKGROUND AND OBJECTIVES: Although the standard management of an abdominal aortic aneurysm (AAA) is surgery, endovascular stent-graft treatment is more attractive for patients with significant co-morbid conditions. We evaluated the immediate and mid-term outcomes for the endovascular treatment of AAA. SUBJECTS AND METHODS: Between November 1996 and August 2004, 59 patients with an AAA (53 males, mean age 68.0+/-9.6 years, 3 cases with ruptured AAA) underwent an endovascular stent-graft repair at our institute. All patients were evaluated by an angiography, taken just after the completion of the procedure and at followed up with computed tomography (CT) at 1, 3, 6 and 12 months, and yearly thereafter. RESULTS: Technical success was achieved in 54 of the 59 patients (91.5%). The periprocedural mortality rate was 3.4% (2 of the 59 patients). A primary endoleak was found in 12 patients (20.3%)(type I; 9 patients, type II; 2 patients, type III; 1 patient), 2 of which required subsequent surgical conversion. Spontaneous resolution of an endoleak was seen in 4 patients (33.3%). The average follow-up period of 57 patients was 27.5 months (range from 72 days to 2581 days). In 8 patients (14.0%), a newly developed secondary endoleak was documented. A total 14 patients (23.7%) died during the follow-up period (rupture; 3, operation-related sepsis; 3, unrelated causes; 3, cardiac arrest; 1, unknown causes; 4). The cumulative survival rates at 30 days and at 1 and 2 years were found to be 93.0, and 85.7 and 76.3%, respectively, using Kaplan-Meier methods. Secondary intervention was required in 12 patients (21.8%), and surgical conversion in 4 (6.8%), with 2 (3.4%) requiring conversion to open surgery immediately after the intervention. In those with technical success, without endoleaks and graft failure, the survival rate during follow-up was higher (97.1%; rate with the exception of unrelated cause of death) than that of all the patients. CONCLUSION: The immediate and mid-term results suggest that the endovascular treatment of an AAA is technically feasible and effective. There was higher mortality and morbidity in primary and newly developed endoleak cases; therefore, proper selection of cases, according to the anatomical and clinical criteria, is essential, with meticulous regular follow-ups being critical for the optimal endovascular treatment of an AAA.

Clinical outcome in elderly patients older than 70 years with acute myocardial infarction after use of platelet glycoprotein IIb/IIIa receptor blocker during percutaneous coronary intervention: Comparison with those younger than 70 years / 대한내과학회지

No abstract available.

The risk factors in patients with candiduria associated with candidemia / 대한내과학회지

BACKGROUND: The early diagnosis of candidemia is critical for the management. The candidemia is known to be associated with 10% of candiduria. But the risk factors in patients with candiduria who are associated with candidemia are not known. We analyzed the risk factors in patients with candiduria who are associated with candidemia. METHODS: We retrospectively reviewed 164 patients with candiduria in Yonsei Medical Center from January 1998 to December 1998. Candiduria patients were divided into two groups. Candiduria patients without candidemia (Group I, 147 patients) and candiduria patients with candidemia (Group II, 17 patients). RESULTS: 1) The mean age of the patients were 57.5 years in group I and 62.5 years in group II. There were no significant differences in the sex ratio between the two groups. 2) Central venous catheter insertion (53%, 100% in group I, II), hypotension (14%, 59% in group I, II), other associated infections (64%, 100% in group I, II), intensive care (41, 76% in group I, II) and fever (46%, 82% in group I, II) were the very significant risk factors in patients with candiduria who were associated with candidemia. 3) Urinary tract procedure (11%, 88% in group I, II), urinary catheter insertion (63%, 94% in group I, II), thrombocytopenia (17%, 41% in group I, II) and DM (8%, 24% in group I, II) were the significant risk factors of candidemia. 4) Candida colony count (cfu/mL) of urine culture was not a significant risk factor. 5) Mortality rate (27%, 59% in group I, II) was significantly high in patients with candidemia. CONCLUSION: Central venous catheter insertion, hypotension, other associated infections, intensive care and fever were the very significant risk factors of candidemia in patients with candiduria.

The risk factors in patients with candiduria associated with candidemia / 대한내과학회지

BACKGROUND: The early diagnosis of candidemia is critical for the management. The candidemia is known to be associated with 10% of candiduria. But the risk factors in patients with candiduria who are associated with candidemia are not known. We analyzed the risk factors in patients with candiduria who are associated with candidemia. METHODS: We retrospectively reviewed 164 patients with candiduria in Yonsei Medical Center from January 1998 to December 1998. Candiduria patients were divided into two groups. Candiduria patients without candidemia (Group I, 147 patients) and candiduria patients with candidemia (Group II, 17 patients). RESULTS: 1) The mean age of the patients were 57.5 years in group I and 62.5 years in group II. There were no significant differences in the sex ratio between the two groups. 2) Central venous catheter insertion (53%, 100% in group I, II), hypotension (14%, 59% in group I, II), other associated infections (64%, 100% in group I, II), intensive care (41, 76% in group I, II) and fever (46%, 82% in group I, II) were the very significant risk factors in patients with candiduria who were associated with candidemia. 3) Urinary tract procedure (11%, 88% in group I, II), urinary catheter insertion (63%, 94% in group I, II), thrombocytopenia (17%, 41% in group I, II) and DM (8%, 24% in group I, II) were the significant risk factors of candidemia. 4) Candida colony count (cfu/mL) of urine culture was not a significant risk factor. 5) Mortality rate (27%, 59% in group I, II) was significantly high in patients with candidemia. CONCLUSION: Central venous catheter insertion, hypotension, other associated infections, intensive care and fever were the very significant risk factors of candidemia in patients with candiduria.

A Comparison of Clinical Outcomes and Risks for Major Adverse Cardiac Events between the Pre- and Post-Stent Period

BACKGROUND AND OBJECTIVES: everal studies have demonstrated improved outcomes achieved with stents vice balloon angioplasty. The purpose of this study was to compare the clinical outcomes and risk factors for major adverse cardiac events (MACE) between the pre- and post-stent period. SUBJECTS AND METHODS: linical outcomes for 294 patients who had undergone balloon angioplasty alone in 1991 and 1992, were compared with those for of 320 patients who underwent stent implantation in 1998. The duration of follow-up was 12 months. RESULTS: here were more patients with diabetes and hyperlipidemia in the stent group (p<0.05). The stent group had significantly more 3-vessel diseases and complex lesion morphology (p<0.05). Cardiac event-free survival rates in the stent group at 1, 6, and 12 months were significantly higher than those in the balloon group (1, 6, 12 month:7.0 vs 93.9%, 89.6 vs 82.3%, 83.7 vs 77.2%, p=0.03). MACE rates were highly associated with lesion morphology (OR=2.6, 95% CI 1.4-4.9) and angiotensin converting enzyme (ACE) inhibitors (OR=2.4, 95% CI 1.3-5.4) in the balloon group, and hypertension in the stent group (OR=2.7, 95% CI 1.3-5.6). Excluding acute myocardial infarction in the stent group, risk factors included diabetes (OR=4.8, 95% CI 1.6-14.2) and hypertension (OR=4.4, 95% CI 1.2-15.7). The stent group had significantly higher event-free survival rates in the complex lesions (p=0.002), but showed no difference in simple lesions. CONCLUSION: ompared with balloon angioplasty in the early 1990s, stent implantation in 1998 was associated with higher early and late cardiac event-free survival rates. Risk factors included complex lesion morphology and the use of ACE inhibitors in balloon angioplasty, and hypertension and diabetes in the stent group.

Phase IV Study on the Antihypertensive Effect and Safety of Irbesartan in Patients with Mild to Moderate Hypertension and Renal Disease / 대한신장학회잡지

Irbesartan is a new selective angiotensin II subtype 1 receptor antagonist. We evaluated the efficacy and tolerability of irbesartan in patients with mild to moderate hypertension and renal disease. On 24 hypertensive patients, oral irbesartan 150mg a day was administered. In cases whose seated diastolic blood pressure did not decrease to 85mmHg after treatment for 4 weeks, the dose of irbesartan was increased to 300mg per day. Every 4 weeks, blood pressure, heart rates, and adverse effects were monitored. And we assessed WBC counts, hemoglobin, hematocrits, platelets, creatinine, BUN, total protein, albumin, fasting blood sugar, total cholesterol, AST, ALT, alkaline phosphatase, total bilirubin, sodium, potassium, calcium, uric acid and urine protein/creatinine ratio to evaluate the change of renal and hepatic function and other adverse effects. Seated systolic blood pressure was decreased from 157.1+/-3.1mmHg to 135.5+/-3.7mmHg, and seated diastolic blood pressure was also decreased from 99.2+/-1.7mmHg to 84.3+/-2.5mmHg. Irbesartan was effective in lowering blood pressure in 20 among 24 patients, and the effective rate of this drug was 83.3%. After treatment, a non clinically significant increase of heart rates and statistically significant decrease of total cholesterol level were noted. There was no dose-related adverse effect. We conclude that irbesartan is a safe and effective angiotensin II subtype 1 receptor antagonist for lowering blood pressure in patients with mild to moderate hypertension and renal disease.

Coronary Stenting in 15year-old boy with Coronary Artery Stenosis Secondary to Kawasaki Disease

Kawasaki disease is an acute febrile illness frequently developed in infants and children. This disease may involve coronary arteries in 15- 25% of the patients and may progress to coronary aneurysms, ischemic cardiac diseases, and sudden cardiac death. Recently we experienced successful balloon angioplasty followed by coronary stenting in a 15-year old boy with unstable angina and severe coronary arterial occlusive disease secondary to Kawasaki disease. He was diagnosed as unstable angina by 24 hours Holter monitoring, treadmill exercise stress test, echocardiography, and Dipyridamole 99mTc-sestamibi scan. And coronary angiogram revealed severe multiple stenosis and aneurysmal changes due to Kawasaki disease. We successfully performed a percutaneous transluminal coronary angioplasty with stent implantation at left circumflex arterial occlusive lesion.

Polyarteritis Nodosa Presenting as Acute Myocardial Infarction

Coronary involvement of polyarteritis nodosa (PAN) is rarely identified at premortem. Herein, we report a case of PAN presenting as acute myocardial infarction (MI). A 66-year-old man without previous history of heart disease presented with excruciating substernal chest pain of 3 hours duration. On admission, cardiac enzyme and ECG changes were compatible with acute MI of inferior wall. Emergency coronary angiography showed multiple aneurysmal dilatations of both left and right coronary arteries (RCA) and total occlusion with large thrombi at mid-RCA. After balloon angioplasty and intracoronary urokinase, huge coronary aneurysm was defined at mid-RCA and coronary flow partially improved. The patient was transferred to coronary care unit and continous intravenous heparin infusion was started. On the 7th hospitalization day, the patient was discharged in good condition. Two months later, follow-up coronary angiography showed no significant luminal narrowings in RCA with multiple aneurysmal dilatation, but abdominal angiography revealed multiple aneurysms in right renal and superior mesenteric arteries. These findings were compatible with the diagnosis of PAN. The patient was started on prednisone 60mg once daily and cytoxan 125mg bid. At follow-up 8 month later, there was no recurrence of symptoms.