Evolution in the practice of primary angioplasty: effect of adjunctive coronary stenting and glycoprotein IIb/IIIa inhibitors on long-term outcomes.

Primary angioplasty strategies have evolved dramatically, including increasing adjunctive use of stents and glycoprotein (GP) IIb/IIIa inhibitors. The purpose of this study was to examine the specific effects of these adjunctive therapies on long-term outcomes after primary angioplasty. From 1996 to 1998, 257 unselected, consecutive patients underwent primary PTCI at our institution. In-hospital mortality was 5.4% (2.9% for patients without cardiogenic shock). The remaining 243 patients were followed for 2.0 +/- 0.7 years. Adjunctive stenting was associated with increased late mortality (8.7% vs. 2.3%, P = 0.02). GP IIb/IIIa inhibitors were associated with reduced late mortality among patients receiving stents (6.9% vs. 21.4%, P = 0.07), but not in those patients treated with balloon angioplasty alone (2.9% vs. 0%, P > 0.20). Coronary stenting remained a significant predictor of late mortality (hazard ratio 5.6, 95% CI 1.5-21.2) after adjustment for other established risk factors. In this unselected series, adjunctive coronary stenting was associated with higher late mortality among hospital discharge survivors. Concomitant GP IIb/IIIa inhibitors partially corrected for this increase. These results are limited by the small sample size and retrospective design of this study. Additional long-term studies are required to test these findings and evaluate for possible mechanisms.

Inadvertent stent extraction six months after implantation by an entrapped cutting balloon.

We report a case of extraction of a restenosed aorto-ostial stent by an entrapped cutting balloon that had inadvertently been passed through a protruding stent cell. Cathet Cardiovasc Intervent 2001;53:415-419.

Late stent thrombosis without antecedent brachytherapy: confirmation and treatment with rheolytic thrombectomy.

We describe two cases of late stent thrombosis (> 30 days postprocedure) following stenting without brachytherapy. Stent thrombosis was confirmed after successful treatment by catheter-based rheolytic thrombectomy. Predictors of stent thrombosis are reviewed and issues concerning the duration of combination antiplatelet therapy after stenting are discussed.

Double-chambered right ventricle in an adult patient.

A 65-year-old male was referred for to our facility for right and left heart catheterization and coronary angiography for evaluation of a ventricular septal defect and to rule out significant coronary artery disease. During the procedure, the patient was diagnosed with a double-chambered right ventricle (DCRV). Most DCRV cases are diagnosed at a young age; presentation in an adult is extremely rare.

Transumbilical balloon angioplasty of subclavian artery thrombosis in a neonate.

We present a case of arterial thrombosis of the upper extremity in a 1-day-old neonate. The initial response to thrombolytic and anticoagulant therapy alone was unsuccessful. Distal flow to the extremity was reestablished by combined percutaneous transluminal angioplasty of the subclavian artery using transumbilical access followed by resumption of the thrombolytic and anticoagulant regimen. Cathet. Cardiovasc. Intervent. 49:56-60, 2000.

Reasons for use of hormone replacement therapy in women undergoing coronary angiography.

The recommendation has been made that all women be counseled about the risks and benefits of hormone replacement therapy (HRT). Use of HRT among women undergoing coronary angiography was explored to assess whether patterns of use were similar to data drawn from community samples. Using a descriptive design, a convenience sample of 414 postmenopausal women was interviewed. Fifty-eight percent had never used HRT, 18.3% were past users, and 23.7% were currently using HRT. The primary reason given for ever using HRT was for symptoms of menopause. Less than 14% of women cited coronary heart disease (CHD) or osteoporosis as their primary reason for using HRT. The most common reasons for stopping HRT were side effects and fear of cancer. The most common reasons given for never having used HRT were that their healthcare provider had never talked about it and that they had never thought about it. Use of HRT among women undergoing coronary angiography is similar to that found in community samples. The challenge is to promote patient-provider interactions that include information about HRT based on the scientific model as well as attention to women's individual concerns.

Transcatheter closure of a patent foramen ovale following mitral valve replacement.

We report the successful closure of a postoperative patent foramen ovale in a patient who underwent coronary artery bypass grafting and mitral valve replacement for severe mitral insufficiency. The postoperative course was complicated by severe hypoxemia due to a large patent foramen ovale. The patient underwent transcatheter closure with the Das Angel Wings transcatheter occluder (Microvena Corporation, White Bear Lake, MN) with immediate improvement.

Successful management of Palmaz-Schatz stents deformed by inadvertent angioplasty outside the stents.

We describe a case in which balloon angioplasty of thrombosed saphenous vein graft stents resulted in compression and deformation of the stents because of inadvertent passage of the guidewire outside the stents. This condition was diagnosed by intravascular ultrasonography, which was then ultimately utilized to direct and optimize placement of additional stents to exclude the deformed stents from the vessel lumen.

Distortion of Palmaz-Schatz stent geometry following side-branch balloon dilation through the stent in a rabbit model.

The compromise of side-branches following coronary angioplasty of the parent vessel remains a limitation of the procedure. Reports of dilation through a Palmaz-Schatz stent to salvage a compromised side-branch covered by the stent have been made. We examined the distortion of stent geometry which occurs following this procedure in a rabbit model. Palmaz-Schatz stents were placed at the aortoiliac bifurcation in 7 rabbits and the contralateral iliac artery was dilated through the stent. Despite good angiographic results, varied degrees of stent distortion were noted on gross pathologic analysis. Most distortion occurred when the arteries were dilated through the ends of the struts or through the "diamonds," and least distortion occurred during dilation through the mid-artriculation site. While good stent depolyment is thought to be necessary for improved outcomes, the distortion of stents after balloon dilation through the stent, despite good angiographic results, may have negative implications for both short- and long-term outcomes.

Transcatheter aspiration of atheroma prolapsing through saphenous vein graft stents.

Endoluminal stenting has often become the percutaneous treatment of choice for older vein grafts. We report a case of successful stenting of a degenerated vein graft that was complicated by prolapse of atheroma through the stents leading to ischemia that was successfully reversed by catheter aspiration of the prolapsed atheroma.

Preparation, characterization, and evaluation of a monoclonal antibody against the rabbit platelet glycoprotein IIb/IIIa in an experimental angioplasty model.

The deposition of platelets at the site of balloon angioplasty is thought to play a major role in the pathogenesis of restenosis. The antibody AZ-1, which binds to the rabbit platelet glycoprotein IIb/IIIa receptor and inhibits platelet function both in vitro and in vivo, was produced and tested in an experimental model of angioplasty. Atherosclerosis was induced by desiccation injury of the femoral artery, followed by a 28-day diet with 2% cholesterol and 6% peanut oil. Rabbits were randomized to receive an infusion of saline, a single infusion of 0.5 mg/kg of AZ-1, or an infusion of 0.6 mg/kg AZ-1 before angioplasty. The latter group received a second infusion of 0.6 mg/kg 72 hours later. Functional platelet inhibition was demonstrated by prolongation of the bleeding time in all treated animals. Angiography was performed at baseline, immediately after a standardized angioplasty, and again 28 days after angioplasty on a total of 42 vessels. There were no significant differences between the antibody-treated group and the control group in the mean angiographic minimum luminal diameter at any of the time points. There was also no difference in the initial improvement after angioplasty (acute gain), in the decrease in luminal diameter from immediately after angioplasty to 28 days after angioplasty (late loss), or in the overall improvement from before angioplasty to 28 days after angioplasty. Quantitative histological analysis confirmed the lack of a beneficial effect of AZ-1. There were no significant differences in the area of the intima, the media, or the combined intima and media between the antibody-treated groups and the control group. Thus, potent platelet inhibition for up to 6 days after balloon angioplasty using a monoclonal antibody that inhibits platelet aggregation did not reduce the response to vascular injury after balloon angioplasty in this rabbit model of experimental atherosclerosis.

Physiologic assessment of ostial left circumflex coronary artery disease using a Doppler guidewire before and after rotational atherectomy facilitated angioplasty.

Intravascular Doppler assessment of coronary flow velocity has demonstrated the physiologic significance of intermediate stenoses and the success of coronary interventions. We describe a patient where Doppler evaluation confirmed the significance of an intermediate left circumflex ostial stenosis. We also describe the Doppler flow velocity characteristics after successful rotational atherectomy facilitated angioplasty.

Potentiation of the vasospastic response to angioplasty by pretreatment with fluoxetine. A study in the atherosclerotic rabbit.

There is evidence that angioplasty-induced vasospasm is mediated by serotonin (5-hydroxytryptamine [5-HT]) release from platelets. We tested the hypothesis that pretreatment of the atherosclerotic rabbit with fluoxetine, a platelet-uptake inhibitor of 5-HT, would reduce vasospasm after balloon angioplasty. Short-term administration of fluoxetine reduced platelet 5-HT uptake to 4% of baseline. Daily administration of fluoxetine for 7 days reduced whole-blood 5-HT levels to 28% of baseline. Thus, fluoxetine inhibited platelet 5-HT uptake in this model as predicted. Contrary to our expectations and despite the substantial reduction in whole-blood 5-HT levels, pretreatment with fluoxetine for 1 week resulted in augmentation of angioplasty-induced vasospasm in atherosclerotic rabbits. Intraperitoneal administration of fluoxetine produced vasoconstriction in normal rabbits that was augmented by 5-HT and not reversed with LY53857, a specific serotonin receptor antagonist. We postulate that this new observation is probably a result of the inhibition of the clearance mechanism for serotonin, with resultant enhancement of the effect of serotonin released by the activated platelets that are deposited on the vessel wall surface at the time of angioplasty. A direct effect of fluoxetine on serotonergic receptors is a second possible mechanism for the observed effect.