A predictive index for the diagnosis of cirrhosis in hepatitis C based on clinical, laboratory, and ultrasound findings.

OBJECTIVE: To develop and validate a non-invasive index to predict the presence of cirrhosis in patients with chronic hepatitis C on the basis of clinical, laboratory, and ultrasound findings. MATERIALS AND METHODS: Data from the complete history and physical examination, serologic studies, liver ultrasound, and liver biopsy of patients with chronic hepatitis C were analyzed using multivariate regression to develop a cirrhosis predictive index. This index was then applied prospectively to another group of patients with chronic hepatitis C to determine its accuracy. RESULTS: Three hundred and thirty-two patients were included (mean age, 48.5+/-18.7 years; male-female ratio, 1.27). Sixty-seven patients (20%) had cirrhosis at histology. Logistic regression identified seven variables that predicted cirrhosis: age>or=60 years, platelet countor=1, prothrombin time (Ratio)>or=1.1, caudate hypertrophy, right lobe atrophy and splenomegaly. Patients scoring>or=22 in total had a statistically significant probability of cirrhosis (sensitivity, 80%; specificity, 96%; and diagnostic accuracy, 94%). CONCLUSION: Cirrhosis can be predicted in patients with chronic hepatitis C by the evaluation of seven clinical, laboratory, and sonographic variables. The index will be useful for the management and follow-up of hepatitis C patients drastically reducing the indications for biopsy in this context.

[Neointimal tissue proliferation after coronary stent implantation without predilatation]. / Proliferación neointimal después de la implantación coronaria de stent sin predilatación.

INTRODUCTION AND OBJECTIVES: Intravascular ultrasound (IVUS) studies in conventional stent angioplasty with predilatation have demonstrated that late luminal narrowing is caused by neointimal proliferation. In the present study, we analyzed the degree and distribution of in-stent neointimal proliferation after direct stent implantation and aimed to identify variables that predict a proliferative response. MATERIAL AND METHOD: We studied 45 patients who underwent successful stent implantation without predilatation and 23 patients with similar clinical and angiographic characteristics who underwent conventional stent angioplasty with predilatation. IVUS imaging was performed at 7.85+/-2.81 months. The cross-sectional area was measured at five predetermined points in the stented coronary segment. The inflation pressure used in patients who underwent direct stent implantation was higher than that employed in those who underwent conventional angioplasty with predilatation (13+/-3 atm vs 10+/-2 atm; P=.005). RESULTS: Luminal and stent cross-sectional areas were greater in the group that did not undergo predilatation than in the group that did. Neointimal proliferation in the 5 sections analyzed along the axis of the stent was similar in the 2 groups. There was a weak linear relationship between the amount of plaque outside the stent and neointimal proliferation in both the group that underwent predilatation (r=0.37; P=.005) and the group that did not (r=0.33; P=.005). CONCLUSIONS: As with conventional angioplasty, the neointimal proliferation that occurred after direct stent implantation showed a diffuse homogeneous pattern along the length of the stent. There was a weak correlation between this proliferative response and the amount of plaque outside the stent.

Proliferación neointimal después de la implantación coronaria de stent sin predilatación / Neointimal tissue proliferation after coronary stent implantation without predilatation

Introducción y objetivos. En la implantación de stent con predilatación la ecografía intracoronaria ha demostrado que la reducción luminal tardía se debe a la proliferación neointimal. En la presente serie analizamos el grado y la distribución de la proliferación neointimal intra-stent después de la implantación sin predilatación, así como las variables implicadas en esta respuesta proliferativa. Material y método. Se analizó a 45 pacientes después de la implantación exitosa de un stent sin predilatación y 23 pacientes con lesiones de características clínicas y angiográficas similares después de la implantación de un stent con predilatación. La ecografía intracoronaria en el seguimiento se realizó a los 7,85 ± 2,81 meses. Se midieron las áreas transversales (AT) en 5 segmentos predeterminados del segmento con stent. En el grupo de stent directo se empleó una presión de hinchado mayor que en el grupo con predilatación (13 ± 3 atm frente a 10 ± 2 atm; p = 0,005).Resultados. Los AT luminal y del stent fueron mayores en el grupo sin predilatación que en el grupo con predilatación. La proliferación neointimal en los 5 segmentos a lo largo del eje axial del stent fue similar en los dos grupos. Se observó una ligera relación lineal entre la placa fuera del stent y la proliferación neointimal en el grupo con predilatación (r = 0,37; p = 0,005) y sin predilatación (r = 0,33; p = 0,005). Conclusiones. De forma similar a la angioplastia convencional, en el stent directo la respuesta neointimal presenta un patrón difuso y homogéneo a lo largo del eje longitudinal del stent. Esta respuesta proliferativa se correlacionó ligeramente con la placa excluida por el stent (AU)

Introduction and objectives. Intravascular ultrasound (IVUS) studies in conventional stent angioplasty with predilatation have demonstrated that late luminal narrowing is caused by neointimal proliferation. In the present study, we analyzed the degree and distribution of in-stent neointimal proliferation after direct stent implantation and aimed to identify variables that predict a proliferative response. Material and method. We studied 45 patients who underwent successful stent implantation without predilatation and 23 patients with similar clinical and angiographic characteristics who underwent conventional stent angioplasty with predilatation. IVUS imaging was performed at 7.85±2.81 months. The cross-sectional area was measured at five predetermined points in the stented coronary segment. The inflation pressure used in patients who underwent direct stent implantation was higher than that employed in those who underwent conventional angioplasty with predilatation (13±3 atm vs 10±2 atm; P=.005). Results. Luminal and stent cross-sectional areas were greater in the group that did not undergo predilatation than in the group that did. Neointimal proliferation in the 5 sections analyzed along the axis of the stent was similar in the 2 groups. There was a weak linear relationship between the amount of plaque outside the stent and neointimal proliferation in both the group that underwent predilatation (r=0.37; P=.005) and the group that did not (r=0.33; P=.005). Conclusions. As with conventional angioplasty, the neointimal proliferation that occurred after direct stent implantation showed a diffuse homogeneous pattern along the length of the stent. There was a weak correlation between this proliferative response and the amount of plaque outside the stent (AU)

[Immediate and long-term outcome after angioplasty with stenting of the left main coronary artery]. / Resultados inmediatos y a largo plazo de la angioplastia con stent del tronco común.

INTRODUCTION AND OBJECTIVES: Coronary artery bypass graft surgery is the treatment of choice for severe left main coronary artery stenosis. The results of a number of multicenter trials have suggested angioplasty with stenting as a possible alternative treatment. The aim of the present study was to analyze the immediate and long-term results of angioplasty with stenting of the left main coronary artery, and to identify factors predictive of death. PATIENTS AND METHOD: A total of 38 nonconsecutive patients (mean age 69 [8] years) with a severe lesion in the left main coronary artery were treated with angioplasty and stenting between November 1997 and March 2003. The procedure was elective in 27 patients and urgent in the remaining 11. In 23 patients (60.5%) the left main coronary artery was not protected by aortocoronary bypass. All patients underwent clinical follow-up examination at 25 (20) months. RESULTS: Angiographically documented success was obtained in all patients. However, one patient died from acute occlusion one hour after the operation. Four patients (10%) had a non-Q-wave myocardial infarction. In-hospital mortality was 15.8% (6/38 patients). Five of the 11 patients (45.4%) who underwent emergency angioplasty and stenting died in the hospital from acute myocardial infarction complicated by severe (Killip grade III-IV) heart failure. However, only one of 27 patients (3.7%) in the elective surgery group died (P=.007). Major clinical cardiac events during follow-up occurred in 5 patients (13%); 3 died and the other 2 had recurrent angina. All patients who died had an unprotected left main coronary artery. Cumulative survival rates for the elective group were 92 (0.5)% at 6 months, 88 (0.6)% at 1 year and 86 (0.7)% at 3 years, respectively. For the emergency surgery group cumulative survival rate was 54 (0.2)% at 6 months (P<.05). CONCLUSIONS: Elective angioplasty and stenting of the left main coronary artery in selected patients was associated with a high immediate success rate. In patients who underwent elective angioplasty and stenting, the incidence of major cardiac events during follow-up was relatively low. Emergency angioplasty and signs of left ventricular dysfunction were the main predictors of in-hospital mortality.

[Cardiac perforation complicated by cardiac tamponade and sealed with metallic coils]. / Perforación coronaria complicada con taponamiento cardíaco sellada mediante coils metálicos.

Distal coronary artery perforation with an angioplasty guidewire is a rare complication that may cause cardiac tamponade, myocardial infarction, arrhythmia, and even death. The use of platelet IIb/IIIa glycoprotein receptor inhibitors increases the risk of potentially fatal complications that are difficult to manage. We report a patient on treatment with abciximab who presented coronary perforation in a distal branch of the right coronary artery caused by the coronary guidewire tip, and complicated by acute cardiac tamponade. Blood extravasation to the pericardium was stopped by releasing two metallic coils into the distal vessel, thereby avoiding the need for emergent cardiac surgery.