[Long-term clinical benefits of using active stents in diabetic patients: two year follow-up of a consecutive series of 122 patients]. / Bénéfice clinique à long terme de l'utilisation des stents actifs chez les patients diabétiques: suivi à deux ans d'une série consécutive de 122 patients.

The objective of our study is to evaluate the long-term results of coronary angioplasty using active stents in a population of diabetic patients. This is a single-centre study on a consecutive series of 122 diabetic patients (40% of them insulin dependent) who between January 2003 and June 2004 underwent angioplasty with implantation of an active stent (sirolimus Cypher(R) or paclitaxel Taxus(R)) for one or more de novo coronary lesions. The mean age was 66 +/- 10 years and a total of 171 coronary segments were treated. The lesions treated were complex (type B2 + C) in 69% of the cases, with a mean stent length of 21 +/- 15 mm and a mean stent diameter of 2.7 +/- 0.3 mm. Follow-up at two years for 119 patients (3 lost to follow-up) revealed a mortality rate of 4.2%, and a myocardial infarction rate of 7.5%. The rates for revascularisation of the target lesion and the target vessel were 11.4% and 17.8% respectively, with a rate of major cardiac events of 22.5%. During this period, 25.2% of the patients underwent revascularisation of at least one vessel. This study confirms the benefits of using active stents for revascularisation of the target lesion in diabetic patients. However, it serves as a reminder that the progression of coronary atheroma is global, and that the prognosis for these patients depends essentially upon managing risk factors, and particularly on controlling their diabetes.

[Mycotic coronary aneurysm with Escherichia coli sepsis: a case report]. / Anévrisme coronaire mycotique consécutif à une septicémie à Escherichia coli: à propos d'un cas.

We report the case of a patient who was admitted for acute coronary syndrom associated with fever originating from urinary tract. Coronary arteriography revealed a huge coronary aneurysm which ruptured a short time after diagnosis. After surgery, it was proven to be mycotic aneurysm related to Escherichia Coli sepsis.

[Mortality prognostic factors of cardiogenic shock complicating an acute myocardial infarction and treated by percutaneous coronary intervention]. / Facteurs pronostiques de mortalité chez les patients en etat de choc cardiogénique primaire traités par angioplastie en phase aiguë d'infarctus.

OBJECTIVE: To determine the in-hospital prognosis and late outcome of cardiogenic shock complicating acute myocardial infarction treated by early (< 24 hours) percutaneous coronary intervention (PCI). METHODS: Retrospective monocentric study of a consecutive cohort of patients undergoing early PCI (< 24 heures) for cardiogenic shock complicating acute myocardial infarction from 1994 to 2004. RESULTS: The cohort included 175 patients (mean age = 65 +/- 14 years, 68% male). A successful PCI was obtained in 69% of patients. The in-hospital mortality was 43%. Independent risk factors associated with an increased mortality were: absence of TIMI three flow (P < 0.0001), absence of smoking (P < 0.009) and the need for mechanical ventilation (P < 0.002). Nor stent use or anti GP IIb/IIa infusions were predictors of a better outcome. At hospital discharge, mean left ventricular ejection fraction (LVEF) was 38 +/- 12%. Kaplan-Meier estimate of survival was 63% for in-hospital survivors (maximum follow-up = 9 years). Independent predictors of an impaired long-term outcome were: a LVEF < 0.3 (P < 0.028) and 3-vessel disease on coronary angiography (P < 0.004). CONCLUSION: In-hospital mortality of patients suffering cardiogenic shock complicating acute myocardial infarction and treated by PCI remains high despite PCI improvement. The long-term survival appears, however, to be better than that of patients with coronary artery disease and low LVEF.

[Acute or sub-acute thrombosis of steel stents]. / Thrombose aiguë ou subaiguë des stents en acier. A propos d'une série consécutive de 2 997 patients.

The use of coronary endoprostheses has greatly contributed to the improvement in the results of coronary angioplasty. Nevertheless, the risk of stent thrombosis remains a major preoccupation. We studied a retrospective series of 2997 patients who had undergone coronary angioplasty between 1999 and 2003. 36 patients (1.2%) had an acute or sub-acute stent thrombosis, occurring in two thirds of cases in the first 4 days with particularly serious clinical consequences: 5 deaths (13.8%) and 27 myocardial infarctions (75%). A comparison between the 2 groups of patients with thrombosis (n = 36) and without thrombosis (n = 2961) using multivariate analysis determined predictive factors for thrombosis: systolic LV dysfunction < 40% (p < 0.0001 OR 3.8 [2-7.3]), angioplasty for lesions on the anterior interventricular artery (p < 0.0001 OR 2.7 [1.4-5]), angioplasty performed in the acute phase of MI (p < 0.05 OR 13.9 [6.7-29.2]), B2-type complex lesions (p < 0.01 OR 2.5 [1.3-5]), residual dissection at the dilated site (p < 0.02 OR 5.1 [1.4-18.2]). More than ever, acute thrombosis remains a topical subject. This study emphasises the incidence of steel stent thrombosis; the clinical consequences and the predictive factors for early occlusion.

[Imaging of the coronary arteries with multi-channel CT: a pictorial assay]. / Illustration de l'anatomie coronaire en Scanner Volumique.

Advances in cardiac imaging with multidetector row CT allow new applications in the diagnosis of cardiac pathology. The purpose of this article is to illustrate the normal anatomy and main anatomical variants of the coronary arteries that can be detected with multi-channel CT. The images presented here were obtained using 4-channel and 16-channel multi-detector row CT units. Post-processing of CT imaging data was performed using: VRT, MPVR, and 2D curved MPR. Because of continuing technical advances, the use of CT imaging in the evaluation of cardiac disorders is likely to increase.

Emergency coronary artery bypass surgery following coronary angioplasty and stenting: results of a French multicenter registry.

This study investigates the influence of coronary stenting on the risk of emergency bypass surgery performed within 24 hr of percutaneous transluminal coronary angioplasty (PTCA) with particular concern for incidence and indication. Since 1995, coronary stenting has been increasingly performed in France during angioplasty procedures, altering significantly the role of emergency bypass surgery. The outcome of elective stenting and widespread use of coronary stenting and its influence on emergency surgery have not been evaluated so far. Through a retrospective (1995) and prospective (1996) registry, we analyzed the incidence, indication and results of emergency bypass surgery performed within 24 hr of PTCA in 68 and 57 centers, respectively, accounting for nearly half of all angioplasty procedures in France. Data were collected through questionnaires consisting of separate forms for every case report that were sent to every center. Over the two years, 26,885 and 27,497 procedures were investigated with a stenting rate of 46% and 64%, respectively. The observed need for emergency surgery was constantly low throughout this period (0.38% and 0.32%, respectively). Indications for surgery included complications directly due to stent in 37% of cases in the 2-year period. Outcome remained poor, with in-hospital mortality in 10% and 17% and myocardial infarction in 27% and 25% of cases, respectively. A comparison of the results in centers with and without surgical facilities showed no differences in outcome, despite a longer time to surgery (359 min +/- 406 min vs. 170 min +/- 205 min, P = 0.0001) and a lower incidence of emergency surgery (0.25% vs. 0.44%, P = 0.0001) in centers without on-site surgery backup. The French multicenter registry reveals an increase in the use of stents together with a dramatic decrease in the incidence of emergency bypass surgery (below 0.5%) following PTCA. There has been a significant evolution in the indication, and stent implantation now accounts for a third of the indications for emergency bypass surgery.

Percutaneous transluminal angioplasty of the subclavian arteries.

PURPOSE: To review the feasibility, risks, and long-term results of subclavian artery angioplasty with and without Palmaz stent placement. METHODS: Over a 9-year period, 113 patients (67 males; mean age 63 +/- 13 years) underwent percutaneous balloon angioplasty of subclavian occlusive lesions for a variety of indications: vertebrobasilar insufficiency (n = 70), upper limb ischemia (n = 50), coronary steal syndrome (n = 6), or anticipated coronary artery bypass grafting using the internal mammary artery in 12 asymptomatic patients. There were 94 (83%) stenoses and 19 (17%) occlusions with a mean percent stenosis of 80.1% +/- 7.4% (range 70 to 100). Mean lesion length was 24 +/- 8 mm (range 10 to 50). Beginning in 1989, stents were implanted for suboptimal dilation; in 1995, stenting became routine. RESULTS: Overall, 103 (91%) of 113 lesions were successfully treated; 10 (53%) occlusions could not be recanalized. Fifty-one stents were implanted in 46 patients. There were 3 (2.6%) procedural complications: a transient ischemic attack, one major (fatal) stroke, and an arterial thrombosis 24 hours after the procedure (treated medically) (0.9% major stroke and death rate). During a mean 4.3-year follow-up (range to 10), 16 (15.5%) restenoses were treated with angioplasty (n = 4), stenting (n = 7), or surgery (n = 5). Primary and secondary patencies for all treated lesions (n = 113) at 8 years were 75% and 81%, respectively; in patients without initial stent placement, the rates were 69% and 76%, while in those with stents, the rates rose slightly to 87% and 94% at 2.5 years (NS). Patency rates for all 103 recanalized lesions were 83% and 90% at 8 years (81% and 90% without stent and 87% and 94% with stent at 2.5 years, respectively [NS]). CONCLUSIONS: Balloon angioplasty with or without stenting is safe and effective for treating subclavian artery occlusive diseases with good long-term patency. Recanalization of occlusions is more difficult to achieve. Stents (implanted only for suboptimal dilation) do not seem to improve long-term patency.

Stents in the treatment of renal artery stenosis: long-term follow-up.

PURPOSE: To evaluate the role of percutaneous stenting in the treatment of renal arterial lesions after failure of balloon angioplasty. METHODS: Two hundred ten patients (139 males; mean age 67.7 +/- 9.9 years, range 27 to 87) had 259 balloon-expandable stents (165 Palmaz and 94 Renal Bridge stents) implanted in 244 renal artery stenoses (171 ostial and 73 nonostial lesions). The patients were suffering from intractable hypertension (n = 210) and/or renal dysfunction (n = 48). The majority of the lesions (n = 234) were atheromatous in origin. Stents were implanted for suboptimal balloon dilation (n = 182, 75%), restenotic lesions (n = 27, 11%), or dissection (n = 9, 4%); 26 (11%) ostial lesions were stented primarily. Mean lesion length was 11.9 +/- 4.4 mm (range 5 to 30) and mean percent stenosis was 81.9% +/- 8.25% (range 70 to 100). RESULTS: Immediate technical success was 99% (241 of 244). Three (1.2%) major complications included one intraprocedural stent thrombosis, one arterial perforation manifesting as a perirenal hematoma 24 hours after the procedure, and one renal arterial rupture. Follow-up over a mean 25.4 +/- 22.8 months (range 1 to 96) in 185 eligible patients (209 arteries) found 24 cases of restenosis (11.4%). Primary and secondary patencies for all lesions at 60 months were 79% and 98%, respectively, with no significant differences between ostial and nonostial lesions or stent types. Hypertension was reversed in 35 (19%), improved in 112 (61%), and remained unchanged in 37 (20%). Renal function was improved in 29% (14 of 48), unchanged in 67% (32 of 48), and worse in 4% (2 of 48). CONCLUSIONS: Renal artery stenting is safe, effective, and may be an alternative to surgery, particularly in ostial lesions. Our experience shows reduction in the restenosis rate compared to conventional angioplasty. All ostial stenoses should be stented.

Percutaneous endoluminal treatment of iliac occlusions: long-term follow-up in 105 patients.

PURPOSE: To evaluate the long-term results of percutaneous recanalization techniques in occluded iliac arteries. METHODS: Percutaneous recanalization was attempted in 105 patients (97 men; mean age 56 years, range 34 to 80) with iliac occlusions using thrombolysis (n = 15), excimer laser (n = 4), mechanical thrombectomy (n = 16), balloon angioplasty alone (n = 23), and angioplasty plus stenting (n = 69). The majority of lesions (n = 72) were in the common iliac artery (CIA); 33 were in the external iliac artery (EIA). RESULTS: The primary recanalization rate was 88% (92/105) independent of location (EIA: 90%, CIA: 86%) and lesion length, but dependent on age of thrombus (< 3 months: 100%, > 3 months: 79%, p < 0.02). Complications included 5 (4.8%) cases of distal embolism treated by thromboaspiration or Fogarty balloon embolectomy. Seven (6.7%) early thromboses were treated surgically. Primary and secondary patency rates were calculated at 6 years for all 105 cases and for the 92 recanalized lesions using life-table analysis. Overall, primary patency was 52% (CIA: 58%, EIA: 34%) and secondary 66% (CIA: 74%, EIA: 40%). Lesions < 6 cm had a primary patency of 70%, while those > 6 cm had a 31% rate (p < 0.01). Secondary patencies were 86% and 42%, respectively (p < 0.01). Among recanalized lesions, the primary patency was 61% (CIA: 69%, EIA: 38%) and secondary 77% (CIA: 88%, EIA: 45%; p < 0.05). Lesions < 6 cm had a primary patency rate of 72%, while longer lesions had a primary rate of 44% (p < 0.04); secondary patencies were 89% and 59%, respectively (NS). Primary patency without stent was 57% and with stent 65% (NS); secondary patency without stent was 71% and with stent 82% (NS). CONCLUSIONS: Percutaneous recanalization of iliac occlusions represents a true alternative to vascular surgery and a first-line treatment option. Stents have a tendency to improve long-term results and are recommended for routine use in chronic iliac occlusions.

[Hospital results of angioplasty in multiple coronary vessel disease in 1990-1991 and 1994-1995. What conclusions should be drawn about the improvement of results with respect to the relevance of data of randomized trials comparing angioplasty and surgery]. / Résultats hospitaliers de l'angioplastie chez les multitronculaires en 1990-1991 et en 1994-1995. Quelles conséquences tirer de l'amélioration des résultats quant à l'applicabilité des données des études randomisées comparant angioplastie et chirurgie?

The aim of this study was to determine whether advances in angioplasty techniques have improved results in multiple vessel coronary disease and to compare present results with those reported in randomised trials comparing angioplasty and surgery. The hospital results of two cohorts of multivessel coronary patients treated by angioplasty during two different periods were compared (group 1: 1990-1991. group 2: 1994-1995). The first period corresponded to the inclusion period of randomised trials comparing surgery and angioplasty. The patients in group 2 (n = 449) were older than those in group 1 (n = 424), had more triple vessel disease, more severe angina and more previous angioplasty attempts. Moreover, there were more cases of unfavourable lesions. Nevertheless, the clinical success rate was high in group 2 (92% vs 84%; p < 0.001) and the major complication rate (death, myocardial infarction or emergency bypass surgery) was lower (2.9% vs 6.1%; p = 0.02). The main technical difference between the two periods concerned the use of coronary stents (12% vs 8%; p < 0.001). The fact of being in group 2 was identified by multivariate analysis as an independent predictor for clinical success and a lower major complication rate. The authors conclude that, since the publication of randomised trials comparing angioplasty with coronary surgery, the hospital results of angioplasty have significantly improved. This should be taken into account in considering the clinical applications of the results of these trials.

Abnormal transoesophageal Doppler coronary flow reserve in patients with dilated cardiomyopathy: relationship to exercise capacity.

1. In patients with dilated cardiomyopathy, abnormal myocardial blood flow may contribute to poor myocardial function. 2. The aim of this study was to investigate the possible contribution of abnormal myocardial blood flow to the limitation of exercise capacity in patients with dilated cardiomyopathy. 3. Coronary flow reserve was assessed in 16 patients with dilated cardiomyopathy and 9 matched normal control individuals. All participants had angiographically normal coronary arteries. At rest and after dipyridamole infusion (0.56 mg/kg intravenously), peak systolic and diastolic coronary flow velocities were measured in the proximal left anterior descending coronary artery using transoesophageal pulsed Doppler echocardiography, guided by colour flow imaging. Coronary flow reserve was calculated as the ratio of hyperaemic to basal diastolic and systolic peak coronary flow reserve. 4. Baseline diastolic and systolic coronary flow velocities were significantly higher in patients (50 +/- 6 and 30 +/- 4 cm/s respectively) compared with control individuals (37 +/- 3 and 20 +/- 1 cm/s respectively) (mean +/- S.E.M.) (P < 0.05). Diastolic and systolic peak coronary flow reserve were significantly lower in patients (1.60 +/- 0.14 and 1.40 +/- 0.09 respectively) compared with control individuals (2.89 +/- 0.15 and 2.17 +/- 0.17 respectively) (P < 0.001). Although peak VO2 and exercise time were significantly lower in patients compared with control individuals, coronary flow reserve did not correlate to exercise capacity in patients with dilated cardiomyopathy. 5. These results confirm the abnormalities of coronary flow reserve previously observed in patients with dilated cardiomyopathy, but suggest that such abnormalities do not contribute to the limitation of exercise capacity in these patients.

[Normal coronary angiography. Have the indications changed during the 1980's?]. / La coronarographie normale. Les indications ont-elles varié au cours des années 1980?

If the indications of coronary angiography are well chosen, the percentage of normal coronary angiographies should decrease. The authors analysed 7858 primary coronary angiographies performed between 1981 and 1990 in patients without valvular or congenital heart disease. The second 5 years were compared to the first. The percentage of primary coronary angiographies decreased (63% vs 75%; p < 0.01), the percentage of women increased (21.7% vs 18.4%; p < 0.001), and the mean age increased (58.5 +/- 0.3 vs 53.9 +/- 0.3; p < 10(-9)). The lesions were less extensive: 16.3% triple vessel disease versus 24.2% (p < 0.001); 31.3% double vessel disease versus 28.1% (p < 0.02); 49.1% single vessel disease versus 44.2% (p < 0.001). The percentage of normal coronary angiographies remained constant: 20.2% in the second five years versus 19.9% in the first. Over the 10 year period, there was no significant difference one year from another. The percentage of normal investigations remained the same in men (15.7%), decreased in women (34.7 vs 40.1%, p < 0.04), remained constant in patients under 60 years of age (24.5 vs 23.8%), but increased in the more elderly (14.9 vs 10.2%; p < 0.001). The percentage remained unchanged in stable angina (19.6 vs 19.8%) and in unstable angina (12.3 vs 11.2%): it increased in cases of atypical chest pain (72.2 vs 54.3%; p < 0.01). Although, globally, the number of normal coronary angiographies was unchanged at 20%, the indications of this investigation were more selective in the younger patients, especially women, in the second five years, but coronary angiography was more commonly performed in elderly patients because of the possibility of benefiting from coronary angioplasty.

Changes in immediate outcome of percutaneous transluminal coronary angioplasty in multivessel coronary artery disease in 1990 to 1991 versus 1994 to 1995.

Coronary angioplasty has undergone major technical changes since the period of inclusion in the randomized trials, comparing it with surgery, particularly with the increased use of coronary stents. This study shows improved in-hospital outcome in terms of primary success and complication rates in patients treated with coronary angioplasty for multivessel disease from 1994 to 1995, compared with the 1990 to 1991 period.

Clinical experience with a new nitinol self-expanding stent in peripheral arteries.

PURPOSE: To evaluate a new self-expanding nitinol coil stent in stenotic or occluded peripheral arteries. METHODS: Seventy-three symptomatic patients (58 men; mean age 67 years) were treated with nitinol stents for lesions in the iliac artery (9 stenoses); superficial femoral artery (SFA) (39 stenoses, 6 occlusions); popliteal artery and tibioperoneal trunk (9 stenoses, 7 occlusions); and 3 bypass grafts. Mean diameter stenosis was 84.4% +/- 9.9% (range 75% to 100%), and mean lesion length was 45 +/- 23 mm (range 20 to 120 mm). RESULTS: Eighty-eight 40-mm-long stents with diameters between 5 and 8 mm were implanted percutaneously for suboptimal dilation (n = 45); dissection (n = 21); and restenosis (n = 7). All stents but one were implanted successfully; the malpositioned stent was removed, and another stent was successfully deployed. There were 3 (4.1%) failures due to thrombosis at 24 hours. During the mean 16-month follow-up (range to 44 months), 4 restenoses (3 femoral, 1 popliteal) have occurred; 2 were treated with repeat dilation and 2 underwent bypass. Primary and secondary patency rates at 18 months were 87% and 90%, respectively, for all lesions (iliac: 100% for both; femoral: 85% and 88%; popliteal: 87% and 100%). CONCLUSIONS: This new nitinol stent seems to be safe and effective with favorable long-term results, even in distal SFA lesions and popliteal arteries. Its flexibility and resistance to external compression allow its placement in tortuous arteries and near joints.

Influence of cigarette smoking on rate of reopening of the infarct-related coronary artery after myocardial infarction: a multivariate analysis.

OBJECTIVES: This study sought to determine whether the reopening of the infarct-related vessel is related to clinical characteristics or cardiovascular risk factors, or both. BACKGROUND: In acute myocardial infarction, thrombolytic therapy reduces mortality by restoring the patency of the infarct-related vessel. However, despite the use of thrombolytic agents, the infarct-related vessel remains occluded in up to 40% of patients. METHODS: We studied 295 consecutive patients with an acute myocardial infarction who underwent coronary angiography within 15 days (mean [+/- SD] 6.7 +/- 3.2 days) of the onset of symptoms. Infarct-related artery patency was defined by Thrombolysis in Myocardial Infarction trial flow grade > or = 2. Four cardiovascular risk factors--smoking, hypertension, hypercholesterolemia and diabetes mellitus--and eight different variables-age, gender, in-hospital death, history of previous myocardial infarction, location of current myocardial infarction, use of thrombolytic agents, time interval between onset of symptoms, thrombolytic therapy and coronary angiography--were recorded in all patients. RESULTS: Thrombolysis in current smokers and anterior infard location on admission were the three independent factors highly correlated with the patency of the infarct-related vessel (odds ratios 3.2, 3.0 and 1.9, respectively). In smokers, thrombolytic therapy was associated with a higher reopening rate of the infard vessel, from 35% to 77% (p < 0.001). Nonsmokers did not benefit from thrombolytic therapy, regardless of infarct location. CONCLUSIONS: These observational data, if replicated, suggest that in patients with acute myocardial infarction, thrombolytic therapy may be most effective in current smokers, whereas nonsmokers and ex-smokers may require other management strategies, such as emergency percutaneous transluminal coronary angioplasty.

Stent placement in the renal artery: three-year experience with the Palmaz stent.

PURPOSE: To evaluate the long-term results of stent placement in the renal arteries. PATIENTS AND METHODS: From January 1990 to August 1994, 59 hypertensive patients underwent 64 stent placement procedures. Indications were residual stenosis after percutaneous transluminal renal angioplasty in 42 patients, restenosis in 20 patients, and acute dissection in two patients. Follow-up (mean, 14 months) was obtained in 54 patients. Six-month restenosis rates were based on results of arteriography, and even more long-term patency rates were based on duplex ultrasound. RESULTS: Technical success was achieved in all patients. Major complications occurred in two patients. No minor or puncture-site complications were observed. The overall 6-month restenosis rate was 1.6% (2.9% for ostial lesions). Survival analysis with the Kaplan-Meier method showed primary and secondary patency rates of 92% +/- 3.6 and 98% +/- 1.9, respectively, at 1 year and 79% +/- 8.8 and 92% +/- 6.1, respectively, at 2 years. Seventy-six percent of hypertensive patients benefited from the procedure. However, renal function was not improved by stent placement. CONCLUSION: Stent placement in renal arteries is a useful adjunct to percutaneous transluminal angioplasty for atherosclerotic renal-artery stenoses.

Palmaz stent placement in iliac and femoropopliteal arteries: primary and secondary patency in 310 patients with 2-4-year follow-up.

PURPOSE: To define the long-term outcome of stent placement in iliac and femoropopliteal arteries. MATERIALS AND METHODS: Three hundred ten patients received 418 balloon-expandable Palmaz stents. Two hundred thirty stents were implanted in iliac arteries of 184 patients, and 188 stents were implanted in femoropopliteal arteries in 126 patients. Restenosis rates were based on results of angiography performed 4-6 months after stent placement. Long-term patency rates were determined with duplex ultrasound. RESULTS: Immediate procedural success was achieved in 309 patients. Acute thrombosis ( < 24 hours) occurred in five patients, and immediate clinical success in 288. The 30-day mortality and morbidity rates were 0% and 8%, respectively. Angiography performed at 6 months in 299 patients revealed restenosis rates of 0.5% in iliac lesions, 11% in superficial femoral artery (SFA) lesions, and 20% in popliteal lesions. Survival analysis revealed 4-year primary patency rates of 86% +/- 4.1 for iliac artery lesions, 65% +/- 7.5 for SFA lesions, and 50% +/- 17.7 for popliteal artery lesions. Most restenotic lesions were successfully treated with repeat angioplasty. CONCLUSION: Implantation of Palmaz stents in iliac arteries allows long-term primary patency to be maintained in most patients.

Percutaneous peripheral atherectomy using the rotablator: a single-center experience.

PURPOSE: In order to assess the role of percutaneous peripheral rotational ablation using Rotablator, 150 symptomatic patients (94 males, 56 females; mean age 73 +/- 1 years, range 42 to 90) having 212 complex peripheral vascular lesions were treated. METHODS: Fifty percent of lesions were below the knee; 65% of patients had severe claudication, 11% moderate (24% were in stage III or IV Fontaine classification). The femoral lesions were significantly longer than those at other sites (5.7 +/- 0.4 versus 2.9 +/- 0.3 cm, p < 0.001). The mean length was 4.0 +/- 0.2 cm (range 1 to 20). All the lesions were considered complex; 93% of the lesions were clacified, and 63% were located at a bifurcation. Complementary balloon dilation (percutaneous transluminal angioplasty [PTA]) was significantly (p < 0.001) more frequent in femoropopliteal lesions (70 PTAs in 86 femoral arteries, 10 PTAs in 19 popliteal arteries) than in distal leg lesions (14 in 106 arteries). RESULTS: After Rotablator therapy alone, the percent stenosis decreased from 81.0% +/- 0.8% to 18.0% +/- 1.1%. The residual stenosis was greater at the femoral (44%) than at the distal level (19%) (p < 0.01). Adjunctive PTA (47 lesions) lowered residual stenosis to 10% at the femoral level and 3% at the distal level. Thirty-seven intraprocedural complications occurred (spasm, thrombosis, dissection, perforation, distal emboli, no reflow); seven procedures subsequently failed for an overall technical success of 97%. The mean follow-up period was 14.4 +/- 1.0 months (range 1 to 51). Among 125 patients having a follow-up period > or = 4 months, 114 patients representing 163 lesions underwent angiography. One hundred twenty-three lesions (76%) were patent, and 40 lesions (24%) showed restenosis (> or = 50% luminal narrowing) of 82.0% +/- 21%. The restenosis rate was higher in femoral (36%) than in distal (21%) or popliteal arteries (7%). Restenosis was more frequent for all lesions > or = 7 cm (p < 0.001) and for both above- and below-knee locations: 55% versus 19% for < 7 cm at the femoropopliteal level (p < 0.03), and 80% versus 18% at the distal level (p < 0.01). CONCLUSIONS: In our experience, percutaneous peripheral rotational ablation has taken a pre-eminent position in the treatment of distal leg arteries, especially in complex lesions. Our results have led us to broaden its indications to complex vascular lesions < or = 6 cm. In particular, the use of this technique for treatment of runoff vessels should improve the long-term patency of proximal PTA and bypass grafts. This device has become indispensable in our laboratory, where Rotablator therapy comprises 15% of all PTA procedures.

Abnormal coronary flow velocity pattern in patients with left ventricular hypertrophy, angina pectoris, and normal coronary arteries: a transesophageal Doppler echocardiographic study.

Previous invasive studies have suggested that coronary flow reserve is impaired in patients with left ventricular hypertrophy (LVH) and symptoms of ischemia. We tested whether transesophageal Doppler, a semiinvasive technique, can detect altered characteristics of baseline coronary blood flow velocity in such patients. Thirty patients with LVH (hypertrophic cardiomyopathy in 4, aortic stenosis in 17, hypertension in 9) were studied. Fourteen patients had asymptomatic LVH. Sixteen patients had clinical symptoms of ischemia with angiographically normal epicardial coronary arteries. Ten subjects with no cardiovascular disease were studied as a control group. Peak diastolic and systolic coronary flow velocities were recorded in the proximal part of the left anterior descending artery (LAD) with the use of pulsed Doppler guided by color flow imaging. Patients with symptomatic LVH had higher diastolic peak coronary flow velocity (81 +/- 10 cm/sec, p = 0.0001) compared with normal subjects (41 +/- 8 cm/sec) and patients with asymptomatic LVH (44 +/- 8 cm/sec). In patients with asymptomatic LVH the diastolic coronary flow velocity/indexed ventricular mass ratio was lower (0.28 +/- 0.09 cm/gm/m2, p = 0.0001) compared with symptomatic patients (0.52 +/- 0.12 cm/gm/m2) and compared with controls (0.47 +/- 0.16 cm/gm/m2). Patients with symptomatic LVH but no aortic stenosis also had higher peak systolic coronary flow velocity (38 +/- 9 cm/sec) compared with the other groups (p = 0.0001). In the group of patients with aortic stenosis a significant inverse linear relation was found between peak systolic coronary flow velocity and peak pressure gradient (r = -0.60, p 0.01). In conclusion, patients with symptomatic LVH have abnormally high baseline coronary flow velocities resulting in magnified intimal shear stress. Because flow velocity equals flow/vessel cross-sectional area, it is suggested that high coronary flow velocities in patients with symptomatic LVH result from both augmented coronary flow and failure of the vessel to enlarge commensurately with the increase in LV mass (relative functional stenosis). In patients with aortic stenosis, peak systolic coronary flow velocity appears to be influenced by transvalvular pressure drop.

Initial experience with the Cragg Endopro System 1 for intraluminal treatment of peripheral vascular disease.

PURPOSE: To evaluate the safety and efficacy of a new covered stent, the Cragg Endopro System 1, for intraluminal treatment of peripheral vascular disease in the iliac and femoropopliteal arteries. METHODS: Forty symptomatic patients with predominantly lengthy stenotic (24) or occlusive (13) lesions or aneurysms (3) in the iliac (19), femoral (19), or popliteal (2) arteries were treated percutaneously with balloon angioplasty followed by implantation of the self-expanding nitinol Cragg stent covered by a woven polyester fabric coated with low-molecular-weight heparin. The mean length of femoropopliteal lesions was 13.0 +/- 1.8 cm, as compared to 6.7 +/- 0.8 cm (p < 0.01) for iliac lesions. Mean percent stenosis was 89% +/- 2% with no significant difference between the arterial segments. RESULTS: With a total of 52 covered stents implanted, technical success was achieved in 98% (39/40 patients). One tortuous femoral artery aneurysm was not satisfactorily excluded to prevent leakage. Clinical success was seen in all patients with demonstrable improvements in the claudication stage and the ankle-brachial index from a mean 0.54 to 0.92. Three local complications (one hematoma, two false aneurysms) required surgical repair. One distal embolism, one acute thrombosis, and three subacute thromboses were encountered and successfully treated by thrombolysis and/or surgery. One patient with two iliac stents developed contralateral common iliac artery occlusion from a stent partially obstructing the aorta; placement of a covered stent in the blocked artery re-established normal flow. Over an 8-month follow-up with arteriographic re-examination, all iliac stents remained patent. At the femoropopliteal level, two stents were occluded at 4 months; one was successfully dilated, but the other required surgical bypass grafting. A third patient developed a stenotic lesion proximal to the stent; dilation restored adequate inflow to the stent. CONCLUSIONS: The Cragg Endopro System 1 appears to be effective as an "internal bypass" for iliac and femoropopliteal occlusive disease. More complications and restenosis were seen in femoropopliteal implantations; however, a change in postoperative medication may improve these results. Long-term results will determine if the Cragg Endopro System 1 can achieve a patency equal to conventional bypass grafting.