Palmaz-Schatz Coronary Stent Implantation Without Intravascular Ultrasound and Without Subsequent Anticoagulation: Clinical Outcome.

OBJECTIVES: To determine the safety and efficacy of antiplatelet therapy alone in a selected group of patients following coronary stenting. BACKGROUND: Coronary stent implantation is an effective treatment for abrupt closure, and can also reduce the restenosis rate following percutaneous transluminal coronary angioplasty. However, anticoagulation therapy following stent implantation is associated with a significant incidence of vascular complications and subacute stent thrombosis. METHODS: Between February and November 1994 we implanted 62 Palmaz-Schatz stents in 50 patients with an optimal angiographic result following stent deployment. In these patients, intravascular ultrasound was not used, and a regimen of aspirin 100 mg daily indefinitely and ticlopidine 250 mg twice daily for 3 months was started without anticoagulation. RESULTS: Of these 50 patients (10 females : 40 males, mean age 63 +/- 12 years, LVEF 64 +/- 10%), 39 (78%) were stented for a suboptimal angiographic result post angioplasty, 2 (4%) received stents as a bailout procedure, and 9 (18%) were stented electively. Average hospital stay following stent implantation was 3.7 +/- 3.0 days. After a mean follow-up period of 140 +/- 70 days, there were no instances of stent occlusion, death, stroke, need for coronary bypass surgery, Q-wave myocardial infarction or femoral artery pseudoaneurysm. There was 1 case (2%) of significant puncture site hemorrhage. CONCLUSIONS: Immediate angiographic appearance after stent implantation can be used to define patients at low risk of stent thrombosis who do not require anticoagulation and can safely be discharged early from the hospital.

Dissection of the descending thoracic aorta extending into the ascending aorta. A therapeutic challenge.

Proper management of dissections of the descending thoracic aorta with intimal disruption close to the left subclavian artery and retrograde extension of the dissection into the aortic arch or the ascending aorta is controversial, because the standard approach for ascending aortic aneurysms is surgical repair, which is difficult to achieve through a median sternotomy if the predominant aortic lesion is located in its descending part. Sixteen patients with descending thoracic aortic dissection, intimal disruption close to the subclavian artery, and extension of the dissection into the aortic arch or the ascending aorta are described here: Eleven patients underwent surgical repair including 9 emergency (82%) and 2 elective (18%) procedures. Retrograde aortic dissection included the aortic arch in 11 of 11 patients (100%) and the ascending aorta in 7 of 11 (63%). Pericardial effusion was present in 1 of 11 patients (9%) and mild aortic regurgitation was found in 1 of 11 (9%). Repair of the ascending aorta and arch with transaortic closure of the entrance tear in the descending thoracic aorta was performed in 4 of 11 patients (36%) via a median sternotomy. In 6 of 11 patients (55%) a lateral thoracotomy was used for repair of the descending thoracic aorta and closure of the entrance tear. Hospital mortality occurred in 1 of 11 patients (9%) and there was 1 late death. Paraplegia occurred in 1 of 11 patients (9%). Five patients with descending thoracic aortic dissection, intimal disruption close to the subclavian artery, and extension into the ascending aorta but without ascending aortic aneurysm (diameter 4.2 +/- 0.2 cm), pericardial effusion, or aortic incompetence were treated medically without early mortality. These results are compared with those achieved in 120 patients operated on during the same period for type A (89/120) and type B (31/120) aortic dissections. Considering the technical difficulties of simultaneous repair of dissections of the ascending and the descending thoracic aorta, we recommend that descending thoracic aortic dissection extending into the arch or the ascending aorta be managed in accordance with the site of the predominant lesion. Replacement of the arch with a varying portion of ascending aorta via a median sternotomy is recommended in patients with enlarged aortic diameter, pericardial effusion, and/or aortic insufficiency. Predominantly distal dissections with dilated descending thoracic aorta and/or distal complications are best approached via a lateral thoracotomy.

Improved distal circulatory support for repair of descending thoracic aortic aneurysms.

Bleeding is a well-known problem when cardiopulmonary bypass with full systemic heparinization is used for distal support during aortic cross-clamping. The recent advent of heparin-coated cardiopulmonary bypass equipment prompted our review of 91 consecutive patients who underwent repair of descending thoracic and thoracoabdominal aortic aneurysms. Two different surgical techniques were used: 42 of 91 patients had simple aortic cross-clamping and rapid reanastomosis, whereas 49 of 91 had distal support using all heparin-coated perfusion equipment with low systemic heparinization (100 IU/kg body weight; activated coagulation time > 180 seconds). Baseline parameters, location (thoracoabdominal: 28/91; 31%), and type of aneurysm (ruptured: 14/91; 15%) were similar in both groups. Cross-clamp time was 37 +/- 22 minutes for support versus 29 +/- 13 minutes for simple clamping (p < 0.05). There were fewer revisions due to bleeding for support (1/49 patients; 2%) versus simple (4/42; 10%; p < 0.05) and fewer patients with impaired renal function requiring temporary hemofiltration for support (4/49 patients; 8%) versus simple (6/42; 14%). Hospital mortality was lower for support (5/49; 10%) versus simple (8/42; 19%). Transfusion requirements during operation were 3,732 +/- 3,458 mL for simple versus 3,392 +/- 2,058 mL for support (not significant). Chest tube drainage totaled 982 +/- 1,102 mL for simple versus 720 +/- 618 mL for support (not significant). The total volume requirements were 8,156 +/- 4,753 mL for simple versus 7,495 +/- 3,342 mL for support (not significant) during operation and 4,416 +/- 2,422 mL for simple versus 3,380 +/- 1,432 mL for support (p < 0.025) during the 24 hours after operation.(ABSTRACT TRUNCATED AT 250 WORDS)