Comparison of self-expanding and balloon-expandable stents for the reduction of restenosis.

To compare the efficacy of self-expanding (SE) and balloon-expandable (BE) stents in native coronary arteries, we randomly assigned 1,096 patients with new and restenotic lesions to receive either device. Baseline demographics and coronary angiographic characteristics were similar in the 2 groups. The incidence of major adverse cardiac events including death, myocardial infarction, bypass surgery, and repeat intervention was similar for both groups at 1 month (2.9% vs 3.1% for SE vs BE, respectively) and at 9 months (19.3% vs 20.1%, SE vs BE respectively). In a subgroup of patients who underwent follow-up angiography (n = 250), the binary restenosis rates (24.2% vs 18.7%, p = 0.30), late loss (0.98 vs 94 mm, p = 0.60), and loss index (0.55 vs 55, p = 0.95) were not significantly different for both groups. In 62 patients who underwent intravascular ultrasound examination (IVUS), there was a trend toward a lower incidence of edge tears in the SE group (6% vs 23%, p = 0.06). Follow-up IVUS analysis showed that the minimum stent area of the SE stent increased by 33% at 6 months, whereas no change occurred in the BE stents; this was accompanied by a greater degree of intimal proliferation in the SE stents compared with BE stents (3.1 +/- 2.0 vs 1.7 +/- 1.7 mm(2)). Thus, the SE stents had similar clinical and angiographic outcomes in patients with lesions in native coronary arteries.

Low- versus high-dose recombinant urokinase for the treatment of chronic saphenous vein graft occlusion.

Recanalization of a totally occluded saphenous vein graft (SVG) using commercially available urokinase from human kidney cells has been shown to be effective, but the duration of infusion and complications such as allergic reactions, bleeding events, and non-Q-wave myocardial infarction have limited its acceptance. Recently, genetic engineering has allowed the synthesis of recombinant urokinase (r-UK). Patients with an occluded SVG from 37 centers were randomized to receive a 6-hour infusion of either low-dose (125,000 IU/hour) or high-dose (350,000 IU/hour) r-UK followed by up to a maximum of 18 hours of r-UK (125,000 IU/hour) via a subselective catheter directly into the occluded vein graft. The primary study end point was final preintervention achievement of Thrombolysis In Myocardial Infarction (TIMI) flow > or = 2 using core angiographic analysis. One hundred seven patients were randomized and 98 received the study drug (low dose 52 patients, high dose 46 patients). TIMI flow > or = 2 after completion of the study drug was higher in the high-dose group (51% vs 24%, p = 0.019). This difference narrowed, but a trend was still evident on the final angiogram after adjunctive mechanical intervention (72% vs 58%, p = 0.254). Bleeding complications were frequent; severe or life-threatening bleeding occurred in 12% of patients on the low dose and 11% of patients on the high dose (p = NS), including 2 intracerebral bleeds, both of which were fatal with 1 in each group. Thus, in patients with an occluded SVG, a randomized trial of direct low-dose versus high-dose r-UK infusion demonstrated increased recanalization rates (TIMI flow > or = 2) in the high-dose arm. Percutaneous revascularization of SVG with r-UK can be accomplished with acceptable success rates, but complications are frequent.

PTCA using the right radial artery access site.

UNLABELLED: In order to evaluate the right radial artery approach (RRA) in PTCA, our first 50 patients (pts) who had undergone PTCA from this access site were evaluated. Seventy-eight percent of pts were male, 68% had unstable angina or recent MI. Seventy-seven lesions were dilated (31 type A, 32 type B, 13 type C). Access time was 4.3 +/- 2.4 minutes (min). Six French Voda and multipurpose guide catheters were primarily utilized (mean 1.2 guides/case). Several different balloon types were used satisfactorily (mean 1.5 balloons/case). Sheaths were pulled 3.4 +/- 1.2 hours post-procedure when ACT was less than 200 seconds. Compression time was 24.8 +/- 11 and heparin was immediately resumed. No access site complications occurred. Results were compared to a cohort of 100 pts who had undergone PTCA from the right femoral artery approach (RFA). PTCA time, fluoroscopy time, contrast utilized, primary success rate, emergency bypass and cath lab charges were the same in both groups. Access site complications were significantly less in the right radial group (0 RRA vs. 4 RFA, p < .02). Post PTCA length of stay (1.9 +/- 0.3 vs. 3.4 +/- 0.6, p < .05) and total hospital length of stay (3.7 +/- 0.5 vs. 5.2 +/- 0.6, p < .05) were significantly less in the radial group. As a result of the shorter hospital stay, total hospital charge was less in the radial group (14,730 +/- 882 vs. 17,461 +/- 908, p < .05). CONCLUSION: Results of PTCA performed from RRA are similar to those from RFA with a significant reduction in access site complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Infected femoral arteriovenous fistula after percutaneous insertion of an intra-aortic balloon.

We have reported an infected arteriovenous fistula of the femoral artery after percutaneous intra-aortic balloon insertion. This case was successfully managed with extra-anatomic bypass followed by resection and drainage of the infected area.

Evaluating the radiographic assessment of pulmonary venous hypertension in chronic heart disease.

This study evaluated how accurately the chest film could be used to determine pulmonary capillary wedge pressure (PCW) in patients with chronic heart disease. Six experienced readers interpreted the erect posteroanterior chest radiographs of 50 patients whose measured PCWs ranged from 6 to 38 mm Hg. Direct numeric estimates of PCW from the films were closely related to measured levels of PCW (r = 0.675). This linear correlation increased to 0.81 when individual-reader variations were reduced by taking a "consensus" (mean) of the six readers' estimates for each case. A combination of the judged degree of pulmonary blood flow redistribution (PFR) and three particular signs of pulmonary venous hypertension (PVH), basal and perihilar vascular blurring and alveolar edema, adequately summarized the radiographic information about PCW. These combined judgments of PFR/PVH identified films from patients with higher and lower PCW levels as accurately as readers' numeric estimates of PCW. Other radiographic signs (enlargement of the heart and central pulmonary vessels and the presence of Kerley lines or pleural effusion) were also positively related to increases in PCW, but added little to the information provided by the PFR/PVH criteria.