Outcomes following percutaneous coronary intervention in patients previously considered "without option": a subgroup analysis of the PACIFIC Trial.

OBJECTIVES: The present study assesses clinical outcomes in patients from the Potential Angina Class Improvement From Intramyocardial Channels (PACIFIC) trial of percutaneous transmyocardial revascularization (PTMR) who had previously been considered "no-option," but who subsequently underwent percutaneous coronary intervention (PCI) for continuing symptoms. BACKGROUND: Patients with advanced symptomatic coronary artery disease who are not candidates for coronary artery bypass grafting (CABG) or PCI comprise an important group, for which no established treatment is currently available. These patients have been described as having "no option," and are currently targeted for various experimental therapies. One such proposed therapy, PTMR, was recently examined in the PACIFIC trial. A subgroup of patients in this trial subsequently underwent PCI, although to initially qualify for the study they had previously been considered as unsuitable for PCI and as having "no option." The therapeutic benefit of PCI for patients of this type is unknown. METHODS: A retrospective analysis was performed on data obtained from all subjects of the PACIFIC study who underwent PCI within the 12-month follow-up period. RESULTS: Ten subjects originally randomized to PTMR and 11 subjects from the medical treatment group underwent PCI. Most had undergone at least one prior PCI and at least one CABG, and there was a high prevalence of cardiovascular risk factors. Despite excellent immediate procedural success, PCI resulted in only modest, statistically nonsignificant increases in mean exercise duration, small improvements in angina status, and no significant improvements in quality of life. CONCLUSIONS: These data suggest that PCI provides only marginal-if any-symptomatic benefit in these patients.

Evaluation of intracoronary stenting by intravascular optical coherence tomography.

BACKGROUND: Conventional contrast cineangiography and intravascular ultrasound (IVUS) provide a limited definition of vessel microstructure and are unable to evaluate dissection, tissue prolapse, and stent apposition on a size scale less than 100 micro m. OBJECTIVE: To evaluate the use of intravascular optical coherence tomography (OCT) to assess the coronary arteries in patients undergoing coronary stenting. METHODS: OCT was employed in patients having percutaneous coronary interventions. Images were obtained before initial balloon dilatation and following stent deployment, and were evaluated for vessel dissection, tissue prolapse, stent apposition, and stent asymmetry. IVUS images were obtained before OCT, using an automatic pull back device. RESULTS: 42 stents were imaged in 39 patients without complications. Dissection, prolapse, and incomplete stent apposition were observed more often with OCT than with IVUS. Vessel dissection was identified in eight stents by OCT and two by IVUS. Tissue prolapse was identified in 29 stents by OCT and 12 by IVUS; the extent of the prolapse (mean (SD)) was 242 (156) microm by OCT and 400 (100) microm by IVUS. Incomplete stent apposition was observed in seven stents by OCT and three by IVUS. Irregular strut separation was identified in 18 stents by both OCT and IVUS. CONCLUSIONS: Intracoronary OCT for monitoring stent deployment is feasible and provides superior contrast and resolution of arterial pathology than IVUS.

Beyond angioplasty: novel developments in interventional cardiology.

Two specific areas in interventional cardiology have, until recently, remained problematic. First is the emerging issue of the so-called 'no option' patient, considered untreatable by conventional percutaneous coronary intervention (PCI) or surgery. Second is the long-standing dilemma of restenosis following PCI. Strategies addressing these two critical areas have been the subject of intense research efforts recently. Several important breakthroughs are being made in the important areas of novel revascularization techniques, antirestenotic agents and stent-based delivery methods. It is conceivable that these novel developments will soon mean that a broader range of patients can be treated, and that the issue of restenosis will now be seriously challenged.

Significant atheromatous debris following uncomplicated vein graft direct stenting: evidence supporting routine use of distal protection devices.

We present the case of an angiographically uncomplicated direct stent vein graft intervention in which the Percusurge embolization containment device was used. We performed histological examination of the resulting debris and observed massive particulate atheromatous material. This case illustrates the severity of distal embolization that can go clinically unnoticed after direct stenting and also supports the routine use of distal protection devices for vein graft intervention.