Transluminal extraction catheter atherectomy followed by immediate stenting in treatment of saphenous vein grafts.

OBJECTIVES: The purpose of this study was to evaluate the effectiveness of transluminal extraction catheter (TEC) atherectomy followed by immediate Palmaz-Schatz coronary stenting of coronary bypass vein grafts. BACKGROUND: Degeneration of saphenous vein coronary bypass grafts has become a common problem. Repeat bypass surgery is associated with greater risk and a poorer outcome than the initial operation. Moreover, percutaneous interventional procedures in vein grafts have been associated with high procedural complication rates, including distal embolization, and high restenosis rates. TEC atherectomy may reduce distal embolization, and stenting may reduce restenosis rates. METHODS: We evaluated the procedural, hospital and clinical outcomes of TEC atherectomy followed by immediate Palmaz-Schatz coronary stenting of 53 vein grafts in 49 consecutive patients. The strategy was to limit instrumentation to extraction debulking and to stabilizing the site with stent deployment before using balloon dilation for optimal gain in lumen diameter. RESULTS: Results are shown as mean value (95% confidence interval [CI]). The mean graft age was 9.2 years (95% CI 7.9 to 10.5), and 1.0 (95% CI 1 to 1) TEC cutter (2.2 mm [95% CI 2.1 to 2.3]) and 1.7 (95% CI 1.4 to 2.0) Palmaz-Schatz coronary stents/ vein graft were used. The procedural success rate was 98%, with a minimal lumen diameter at baseline of 1.3 mm (95% CI 1.1 to 1.5), increasing to 3.9 mm (95% CI 3.6 to 4.2) (p < 0.05) after the TEC-stent procedure. Procedural complications occurred infrequently: graft perforation in 1 (2%) of 53 patients and distal embolization in 1 (2%) of 53 (same patient). In-hospital complications included non-Q wave myocardial infarction in two patients and death after a successful procedure in three (6%) (n = 1 each: massive bleeding from the catheter site; sepsis; and acute myocardial infarction with asystole in the distribution of the stented vessel). The event-free survival rate to hospital discharge was 90%. Clinical follow-up (13 months [95% CI 11 to 15]) was available for all patients. There were five (11%) revascularization procedures (three bypass grafts and two percutaneous transluminal coronary interventions), four (9%) nonfatal myocardial infarctions and five (11%) deaths, for a cumulative rate of 28% for any adverse outcome occurring in 13 of 46 patients. CONCLUSIONS: TEC atherectomy followed by immediate Palmaz-Schatz coronary stenting of stenoses in old (> 9 years) saphenous vein grafts can be successfully performed, with a low incidence of procedural and hospital complications. Clinical restenosis rates are low and less than those previously reported; however, late morbid cardiac events are still frequent in this high risk group of patients. These observational findings suggest that this technique may improve percutaneous management of vein graft disease, but optimal long-term management strategies remain to be determined.

Cellular localization of CD4 in the human placenta. Implications for maternal-to-fetal transmission of HIV.

CD4 is a 55-kDa glycoprotein that serves as an important cellular differentiation Ag and cell signaling protein on T lymphocytes, as well as a principal receptor for HIV-1 on a variety of cell types including lymphocytes. CD4 receptor expression in syncytiotrophoblasts, the principal cellular barrier in the human placenta, has not been clearly defined. Knowledge concerning the expression of the CD4 receptor on placental trophoblasts is important to define potential mechanisms of transmission of the virus between maternal blood and fetal tissues. Both mature and immature placenta (n = 10) were examined using an avidin D-based immunohistochemical procedure that permits clear morphologic distinction of cell types in placental sections. Syncytiotrophoblasts were defined using anti-cytokeratin mAb (AE1/3), whereas endothelial cells in placental villi were distinctly identified using a mAb directed to CD31. Placental Hofbauer cells (macrophages) and other leukocytes were identified by mAb staining of leukocyte common Ag (CD45). CD4 expression (identified by staining with three separate anti-CD4 mAb) was exclusively localized using this immunohistochemical method to leukocytes in placental villi (e.g., Hofbauer cells); however, no CD4 staining was evident in syncytiotrophoblasts, cytotrophoblasts, or villus endothelial cells. Furthermore, immunoaffinity-purified trophoblasts were negative for CD4 receptor expression. CD4 RNA was not identified in purified trophoblasts using both Northern blot assay and a sensitive polymerase chain reaction method to identify CD4 RNA. In addition, time course studies of purified trophoblasts immediately after purification and at 24, 48, and 72 h in culture indicated that CD4 RNA was not present as a transient, but labile transcript in trophoblasts. These data indicate that the transmission of HIV-1 across syncytiotrophoblasts may occur by mechanisms other than by binding the CD4 receptor and that tissue leukocytes (in particular Hofbauer cells) are likely the principal CD4+ cellular target of HIV-1 in the placenta.