Baseline inflammatory status and long-term changes in renal function after percutaneous renal artery stenting: a prospective study.

OBJECTIVES: To investigate a possible independent predictive role of systemic inflammation markers on renal function after renal artery stenting. BACKGROUND: An elevated baseline serum creatinine has previously been shown to be the strongest predictor of improved renal function after percutaneous renal artery stenting. The inflammatory system is implicated in every stage of chronic kidney disease, and we hypothesized an additional value of markers of systemic inflammation in predicting response after renal artery stenting. METHODS: This single center, prospective study includes 62 consecutive patients with chronic kidney disease at stage ≥ 3 or resistant hypertension who underwent stent placement for 74 angiographically significant atherosclerotic renal lesions. Inflammatory markers, including serum C-reactive protein (CRP), erythrocyte sedimentation rate, and white blood cell count were determined prior to renal angioplasty and related to changes in renal function at follow-up. RESULTS: Six-month clinical follow up was completed in 57 patients. Overall, median serum creatinine concentration exhibited a non significant reduction from 1.40 mg/dl (quartiles: 1.20, 1.75 mg/dl) at baseline to 1.30 mg/dl (quartiles: 1.1, 1.55 mg/dl) at 6 months (p=0.17). Significant multivariate independent predictors of decreased creatinine included higher baseline serum creatinine levels (adjusted OR per quartile increment, 2.5 [1.3 to 4.7], p=0.004) and lower C-reactive protein levels (adjusted OR per quartile increment 0.39 [0.19 to 0.82], p=0.013). CONCLUSIONS: Patients with higher serum creatinine and lower CRP derive the most benefit from renal artery stenting.

Angiographic and clinical outcome of percutaneous coronary intervention for in-stent restenosis of bifurcated lesions.

AIMS: Restenosis and bifurcated lesions represent technically challenging lesions for percutaneous coronary interventions (PCI). Data regarding procedural and clinical outcome of re-PCI for restenosis of stented bifurcated lesions are lacking. Our aims were to evaluate angiographic and procedural results and one-year clinical outcome of PCI for restenosis of stented bifurcated lesions. METHODS AND RESULTS: Consecutive patients undergoing PCI for restenosis of one bifurcated lesion previously treated by stent implantation at our centre entered the study. The primary endpoint was angiographic and procedural success, defined as final residual stenosis ≤30% in the main vessel with TIMI 3 flow in both MV and side branch, and stenosis ≤50% in the SB without death, myocardial infarction or target vessel revascularisation during hospitalisation. The secondary endpoint was the incidence of major adverse cardiac events at one-year clinical follow-up. The study population included 64 patients treated by PCI on a single restenotic bifurcated lesion. Angiographic and procedural success was achieved in 61 cases (95.3%) whereas the three cases of failure were due to SB residual stenosis >50%. At one year, MACE rate was 18.7% (12/64) with rates of cardiac death, MI and TVR of 1.6% (1/64), 6.2% (4/64) and 18.7% (12/64), respectively. No cases of stent thrombosis occurred. Patients treated by a single drug-eluting stent (DES) on main vessel (MV) had a significant lower rate of MACE at one year as compared to patients treated with balloon only PCI or by double-stenting technique or with a BMS, irrespective of the strategy adopted: 4/37 (10.8%) vs. 8/27 (29.6%); p=0.04. CONCLUSIONS: PCI in restenotic bifurcated lesions can be a good treatment option with high rates of angiographic and procedural success and an acceptable rate of long-term MACE. The use of a single DES implantation may be a promising strategy as it is associated with lower rates of MACE in the long term.

Outcome of non-cardiac surgery after stent implantation in the DES era: results of the Surgery After Stent (SAS) registry.

BACKGROUND: Optimal management of patients needing non-cardiac surgery after coronary stenting has not been established. Objective. To assess the perioperative outcome of patients undergoing non-cardiac surgery after coronary bare-metal stent (BMS) or drug-eluting stent (DES) implantation. METHODS: We enrolled consecutive patients undergoing non-cardiac surgery (up to 2008) after coronary stenting in a single-center registry, prospectively registering clinical and procedural data about revascularization and retrospectively recording surgical details, perioperative therapy and in-hospital outcome after surgery. At our institution, we implant BMS for planned surgery at time of revascularization, and use antiplatelet therapy for surgery required within 1 month of BMS or within 12 months of DES implantation. The primary endpoint was defined as perioperative occurrence of major adverse events, both cardiovascular (death, myocardial infarction, stent thrombosis and repeated revascularization) and hemorrhagic (bleeding requiring transfusions or surgical hemostasis). RESULTS: We enrolled 101 patients: 70 treated with BMS (group 1) and 31 with DES (group 2). The mean interval between stenting and surgery was 288 days. The average number of antiplatelet drugs used during the operative period was higher in group 2 than group 1 (p = 0.02). Fifteen patients (15%) experienced major adverse events (5.9% had non-ST elevation myocardial infarction, 12% received blood transfusions), without a significant difference between the two groups (p = 0.72). At multivariate analysis, the predictor of primary endpoint was time interval between stenting and surgery (p = 0.022). CONCLUSION: We found similar outcomes for non-cardiac surgery after coronary stenting when BMS were selected for planned surgery and dual antiplatelet therapy was used, if indicated, during the operative period.

Renal artery stenting in patients with chronic ischemic heart disease.

OBJECTIVES: To investigate the role of renal stenting in selected patients with chronic ischemic heart disease and renal artery stenosis. METHODS: Consecutive patients, with chronic ischemic heart disease and severe hypertension and/or impaired renal function undergoing renal stenting, were prospectively enrolled. Mid-term (at least 2 years) follow-up was performed to assess both changes in renal function [serum creatinine and estimated glomerular filtrate rate (eGFR)] and blood pressure (BP) control (number of required drugs) and to record the incidence of clinical major adverse events. Moreover, in the first consecutive 24 patients, out-of-range pressure values at 24-hr BP monitoring and GFR at renal scintigraphy were measured at baseline and 1 month after stenting. RESULTS: Seventy patients treated by stenting on 86 renal arteries entered the study. Procedural success rate was 99% and no major complication occurred. At 2-year follow-up, both mean serum creatinine (-0.1 +/- 0.7 mg/dl at follow-up compared to baseline, P = 0.6) and eGFR (+3.7 +/- 23.5 ml/min/1.73m(2) at follow-up compared to baseline, P = 0.2) did not significantly change while the number of drugs required to control BP significantly decreased (2.7 +/- 0.8 to 2.2 +/- 0.7, P < 0.0001). In the subset of 24 patients evaluated at 1 month, GFR significantly increased (62 +/- 20 ml/min to 67 +/- 21 ml/min; P = 0.008) and the rate of the out-of-range systolic pressure values at 24-hr monitoring significantly decreased (51-33%, P = 0.005). Elevated baseline creatinine values and the presence of global renal ischemia were identified as predictors of poor outcome at the multivariate analysis. CONCLUSIONS: In selected patients with chronic ischemic heart disease and hypertension and/or renal insufficiency, renal stenting may be performed with very low periprocedural complications and results in unchanged renal function and improved BP control.

Provisional TAP-stenting strategy to treat bifurcated lesions with drug-eluting stents: one-year clinical results of a prospective registry.

OBJECTIVE: To assess the clinical outcome of unselected patients undergoing drug-eluting stent (DES) implantation on bifurcated lesions using a "provisional T And small Protrusion (TAP)" stenting strategy. METHODS: Consecutive patients undergoing DES implantation on one major bifurcation lesion were treated by main-vessel (MV) stenting, followed (if needed) by side-branch (SB) rewiring (with a "pullback" technique) and kissing balloon. SB stenting was performed according to the TAP-technique in selected cases. The endpoint of the study was a 12-month incidence of major adverse cardiac events (MACE) defined as cardiac death, myocardial infarction (MI), stent thrombosis and target vessel revascularization (TVR). RESULTS: The study population included 266 patients (9% unprotected left main). Only 19 patients (7.1%) (with more complex angiographic features) received stents in both the MV and SB using the TAP-technique. Overall, 22 (8.2%) patients had MACE at 1 year. Observed, non-hierarchical MACE were: 1 (0.4%) cardiac death, 11 (4.1%) MI, 2 probable stent thromboses and 12 (4.5%) TVRs. Postprocedural troponin T increase and adverse events up to 12 months were similar between patients treated by MV stenting only or double stenting. CONCLUSIONS: In unselected patients undergoing DES implantation on bifurcated lesions, a provisional TAP-stenting strategy (with a low rate of SB stenting) appears to be safe and effective.

Transradial carotid artery stenting with proximal embolic protection.

Proximal embolic protection devices (PPDs) are increasingly used during carotid artery stenting (CAS) due to the theoretical advantage of cerebral protection during the entire procedure. Transradial approach reduces access site vascular complications and can be useful for CAS in patients at high bleeding risk, with contraindications for prolonged bed rest and when a bovine aortic arch is present. Due to the large size of the available equipment, PPDs have only been employed by transfemoral approach. Recently, one PPD (MoMa, Invatec, Roncadelle, Italy) has become available in 8 Fr configuration. Such improved design may theoretically permit its introduction in the radial artery. Here we report three cases of severe internal carotid artery stenosis successfully treated by CAS with 8 Fr MoMa using transradial approach, showing the technical feasibility of such procedure.

Outcome of patients treated by a novel thin-strut cobalt-chromium stent in the drug-eluting stent era: Results of the SKICE (Skylor in real world practice) registry.

OBJECTIVES: To investigate the outcome of patients undergoing percutaneous coronary interventions (PCI) with implantation of a new thin-strut cobalt-chromium bare-metal-stent (BMS) in the drug-eluting-stent (DES) era. BACKGROUND: Despite the contemporary penetration of DES in the clinical practice, a relevant percentage of patients are still treated by BMS. Data on clinical outcome of novel BMSs are lacking. METHODS: This is a single-centre-registry enrolling patients treated by Skylor stent implantation. During the study, the criteria for BMS selection adopted at our institution ("internal" criteria) were as follows: (1) limited compliance to prolonged double antiplatelet therapy, (2) ST-elevation myocardial infarction (STEMI) or saphenous vein grafts (SVG) interventions, and (3) in the absence of these conditions, noncomplex (no bifurcations, no chronic total occlusions) lesions considered at low restenosis risk on the basis of arbitrary angiographic criteria (short lesions, large vessels). Primary and secondary end-points were respectively major adverse cardiovascular events (MACE) and target vessel failure (TVF) up to 9-month. RESULTS: A total of 150 patients were treated with Skylor stent on 169 lesions. At 9-month follow-up, MACE occurred in 12 patients (8.0%) and TVF in 21 lesions (12.4%). By multivariable analysis, the predictors of MACE were Euroscore>or=9 and ejection fraction < 30% while the predictors of TVF were the absence of the angiographic criteria of low restenosis risk and ejection fraction < 30%. CONCLUSIONS: In the DES era, the use of a last-generation BMS in patients with limited compliance to double antiplatelet therapy, STEMI or SVG interventions, and noncomplex angiographic lesions may be associated with acceptable clinical outcome.