In-stent restenosis after interventional treatment of carotid artery stenoses: a long-term follow-up of a single center cohort.

BACKGROUND: Whereas in-stent restenosis (ISR) is widely discussed after coronary stenting procedures, this phenomenon is a considerable problem after interventional treatment of carotid artery stenosis as well. We sought to quantify ISR rate and to identify important respective risk factors in our cohort. METHODS: We retrospectively analyzed data of our carotid artery stenting database comprising 1165 angiographically successful interventional procedures during the last 19 years. Significant ISR was assessed by Doppler ultrasound and defined as a flow velocity exceeding 300 cm/s representing a lumen narrowing >70%. Examinations were performed the day after intervention, at follow-up visits 1, 6 and 12 months after index hospitalization and once a year afterwards. RESULTS: Thirty-nine patients (3.4%) developed a significant ISR > 70% during the follow-up period (median 19.6 months, IQR 5.1-49.6 months). In 13 of them, restenosis was caused by a mechanical collapse (stent crush) of the implanted stent. All patients with significant ISR were free of neurological events during follow-up and 31 patients underwent a stent-in-stent implantation. We found a shorter stent length, a narrower stent diameter, performance of post-dilatation as well as stent type to significantly influence development of ISR. CONCLUSION: ISR > 70% after carotid artery stenting is a rare finding also during long-term follow-up. Especially in patients treated with balloon-expandable stents, post-dilatation reduced ISR significantly. As ISR was rare and clinically benign, this technique seems to remain a good therapy option in patients with significant carotid artery stenosis.

Low high-density lipoprotein cholesterol predicts cardiovascular events after carotid stenting: a long-term survey.

BACKGROUND: Apart from advanced age, little is known about predictors of the long-term outcome after carotid artery stenting (CAS). OBJECTIVE: We sought to determine whether atherosclerotic risk factors predict the long-term outcome after CAS. PATIENTS AND METHODS: We enrolled 532 patients assigned for CAS. The primary composite end-point, including stroke, myocardial infarction and all-cause mortality, was observed in 100 patients (19%) during the long-term follow-up (median 28 months, interquartile range 14-49 months). RESULTS: Cumulative event rates at 1, 3 and 5 years were 4.4%, 17.1% and 33.4%, respectively. High-density lipoprotein (HDL) cholesterol was an independent predictor of event-free survival. The adjusted hazard ratio for the primary end-point was 0.97 per increase of 1 mg dL(-1) HDL cholesterol [95% confidence interval (CI) 0.95-0.99, P = 0.002) and 2.7 (95% CI 1.6-4.4, P < 0.001) for low HDL cholesterol (< 40 mg dL(-1) in men and < 50 mg dL(-1) in women). Inflammatory activation (leukocyte count > 10,000 mL(-1) or fibrinogen > 450 mg dL(-1) or erythrocyte sedimentation rate > 20 mm h(-1)) was the only other independent atherosclerotic risk factor (P = 0.001). Patients with low HDL cholesterol and elevated inflammatory activation were at very high risk, with a 5-year event rate of 59.4% (95% CI 43.6-75.2%) as compared to 15.1% (95% CI 8.2-22.0%) in those without both risk factors (log rank, P < 0.001). Age, occlusion of the contralateral carotid artery and heart failure were further independent risk predictors (P < 0.01 for all). CONCLUSIONS: Low HDL cholesterol is an independent predictor of the long-term outcome after CAS. The combination of low HDL cholesterol and elevated inflammatory markers identified high-risk patients.

Internal carotid artery stent placement without emboli protection: results and long-term outcome.

Patients with symptomatic > or = 60% (n = 134), asymptomatic > or = 80% (n = 143), and asymptomatic progressive > or = 60% (n = 25) internal carotid artery stenosis underwent stenting and were followed clinically and by Doppler-assisted duplex imaging for 27.1 +/- 15.6 months. Stroke and death from stroke occurred within 30 days after stenting in 4.7% of the symptomatic and in 3.0% of the asymptomatic patients and in the follow-up period in 2.3% of the symptomatic and in 1.2% of the asymptomatic patients.

Coronary angiography in patients undergoing carotid artery stenting shows a high incidence of significant coronary artery disease.

OBJECTIVE: To assess the incidence, morphology, and associated clinical symptoms of coronary artery disease in patients undergoing elective carotid artery stenting. METHODS: In a prospective observational study at a tertiary care centre (university teaching hospital) 444 consecutive patients underwent elective stenting of the carotid artery. Twenty four patients had to be ruled out because of urgent carotid intervention for severe neurological symptoms, lack of compliance, complications from vascular puncture, or renal failure. In 390 patients, the coronary angiography was performed together with carotid artery stenting in a single session; the remaining 30 patients have had a recent coronary angiography. RESULTS: One, two, and three vessel disease and left main stenoses were found in 70 (17%), 64 (15%), 93 (22%), and 31 (7%) patients, respectively. Sixty six (16%) patients had a history of coronary artery disease but no current significant stenosis. Only 39% of the patients with significant stenoses (n = 258) had clinical cardiac symptoms. CONCLUSIONS: For patients undergoing elective stenting of the carotid, routine coronary angiography reliably discloses morphologically significant coronary artery disease and enables consecutive treatment in 61% and 29%. This safe measure is useful because a majority of patients with a significant stenosis are asymptomatic.

[Patellofemoral pain syndrome in young men compared to a normal population exposed to the same physical strain]. / Das patellare Schmerzsyndrom bei jungen männlichen Patienten im Vergleich zu einem symptomlosen Kollektiv bei gleicher körperlicher Beanspruchung.

AIM: The causes of the patellofemoral pain syndrome, especially in young patients, continue to be largely unknown. The purpose of the study was to determine the extent to which weight and activities that impose a strain on the knee influence the occurrence of patellofemoral pain in young, physically active men. METHOD: 248 soldiers on mandatory military service were included in the study. 133 persons had pain in the knee prior to or during military service while 115 persons had no symptoms in the knee. Anthropometric data and patient history were recorded for all individuals. This was followed by clinical examination. RESULTS: Age distribution and body mass index were identical in both groups. However, significantly more subjects in the group with pain prior to military service had been active sportsmen while a significantly larger number of normal individuals had had jobs that strained the knees. The greatest difference, however, was seen in the number of previous injuries. These were much more common in the group that had pain and the injuries most commonly were contusions. CONCLUSION: It is well known that previous injuries and sports favor the emergence of patellar pain. However, persistent strain on the knee at work appears to be less commonly associated with this symptom. The individual's body-mass index was of no importance in this context.

Midterm results after aortic valve replacement with the autologous tissue cardiac valve.

OBJECTIVE: To assess midterm results after aortic valve replacement (AVR) with an autologous tissue cardiac valve (ATCV). This new technique was developed to construct a tissue prosthesis for AVR using the patients pericardium, harvested at the time of operation with negligible effect on operating time. METHODS: Briefly, glutaraldehyde tanned pericardium is mounted on a stent requiring no suturing. Between March 1994 and December 1996, 87 patients, 44/43 M/F and aged 70 +/- 6 years had AVR for aortic stenosis (80%), aortic insufficiency (6%) and combined lesions (14%), one patient suffered from endocarditis. Additional coronary artery bypass was done in 25%, aortic root enlargement in 7%. Aortic cross clamp and cardiopulmonary bypass times were 69 +/- 21 and 93 +/- 29 min. All patients were followed by clinical examination and color flow Doppler echocardiography in 3-12 months interval. Follow up was 99% complete. RESULTS: There were five perioperative deaths (6%), none of them valve related. Eighty-one patients were followed up to a period of 52 months (mean interval 37.5 +/- 1.3 months), one patient was lost for follow up. Overall survival was 86, 81, 79 and 71% at 12, 24, 36 and 48 months, respectively. There were 14 late deaths with eight (10%) valve related (four cerebral deaths, four sudden deaths). Sixteen patients (20%) had to be re-operated due to severe valve incompetence. Freedom from reoperation was 98, 97, 90 and 63% at 12, 24, 36, and 48 months, respectively. Valve incompetence occurred suddenly, without previous signs in the follow-up examinations. Selection and preparation of the pericardium, the way of fixation of the tissue--brief immersion in glutaraldehyde--and engineering problems might be responsible for this disastrous outcome. CONCLUSION: Due to these results we must state, that the ATCV did not fulfill our expectations and presently we can not recommend it as an aortic valve substitute.