Self-expanding stent for complex percutaneous coronary interventions: A real life experience.

AIM: Self-expanding stents represent a re-emerging option for percutaneous coronary interventions. Their application covers a wide spectrum of angiographic situations, i.e., coronary bifurcations, acute coronary syndromes with large thrombotic burden and stenosis of ectatic coronaries. We review our experience with self-expanding stents for different clinical and angiographic indications, with long clinical follow-up. METHODS: From 2011 to 2013 we used self-expanding STENTYS® stents in 40 consecutive patients followed-up for death from any cause and from cardiovascular cause, myocardial infarction, target lesion revascularization (TLR), stent thrombosis (mean 21±13months). We also revised rate of procedural outcomes, acute stent thrombosis and TLR in patients treated with conventional stents for similar clinical/angiographic situations, in the same period at our institution. RESULTS: We identified three anatomical settings of STENTYS® use: coronary bifurcations with proximal/distal main branch diameter discrepancy (55% of cases), massive thrombotic burden in the setting of acute coronary syndrome (35% of cases) and stenosis of ectatic coronaries (15%). We observed one death related to acute heart failure and 1 case (2.5%) of acute stent thrombosis (2.5% in the control group). During follow-up 2 cases of stent restenosis leading to TLR (5%) occurred (6.25% in the control group). CONCLUSIONS: According to our real life experience, self-expanding STENTYS® stents appear to be an effective tool for different angiographic situations in which they may be preferable to balloon-expandable stents, showing a low rate of complications and good results at long term follow-up.

Drug eluting balloon: a multipurpose tool for coronary revascularization with optimal long-term follow-up results.

AIMS: This study aimed to evaluate safety and efficacy of drug-coated balloon (DCB) at long-term follow-up; a large series of real-life patients underwent revascularization with DCB for a wide spectrum of clinical and angiographic situations. METHODS AND RESULTS: One hundred ten patients underwent percutaneous revascularization using paclitaxel eluting balloon (Sequent Please, Braun, Germany). End-points were major adverse cardiac events (MACE; all-cause death, myocardial infarction [MI], target vessel revascularisation [TVR], and vessel thrombosis). DCB were used for stable angina (58%), unstable angina/nonST elevation MI (31%) and ST elevation MI (11%). DCB were used for in-stent restenosis (61%), small vessel disease (25%), with bare metal stent (BMS) to avoid long dual antiplatelet therapy (10%) or for impossibility to place a stent (4%). Cumulative MACE at follow-up (median 23 months, IQR 13-32) was 12.7%, with 8.2% all-cause death (1 fatal MI), 4.5% TVR, 3.6% TLR, and no vessel thrombosis. Three of four TLRs occurred in patients who received DEB for DES restenosis. CONCLUSIONS: DCB are a very effective tool for a variety of clinical and angiographic situations. DCB use seems to be affected by a low rate of complications and adequate results at long-term follow-up.

A coronary pseudoaneurysm within a restenotic stent treated by implantation of a pericardium-covered stent and drug-eluting balloon.

Coronary pseudoaneurysm after bare-metal stent implantation is a rare event. Observation, surgical resection, or implantation of another stent, bare or covered, are alternative and equivalent management options. Since no option prevails over the other, the most appropriate treatment should be evaluated in every single patient. We report the case of a pseudoaneurysm within a stent with diffuse restenosis, treated with implantation of a pericardium-covered stent, followed by postdilation with a paclitaxel-eluting balloon.

[Biomaterials and technologies for vascular grafts: from bench to bedside]. / Biomateriali e graft technology per protesi vascolari: dal laboratorio alla clinica.

Peripheral artery disease and related revascularization procedures are increasing, due to the aging population and growing incidence of diabetes mellitus. Up to now, autologous saphenous vein is the conduit of choice for peripheral by-pass. Synthetic vascular graft in polyethylene terephthalate (Dacron®) and expanded polytetrafluoroethylene (ePTFE) are used if vein access cannot be obtained. These synthetic grafts are successfully used to replace large diameter vessels, but they fail in small diameters (<6 mm) such as for infragenicular by-pass. Reasons for failure are early thrombosis and late intimal hyperplasia. Novel small-diameter vascular grafts with an acceptable clinical outcome are therefore needed. Here, the main materials and technologies for the manufacturing of vascular grafts and the pathway from bench to bedside are discussed .

Impact of early abciximab administration on infarct size in patients with ST-elevation myocardial infarction.

BACKGROUND: Early abciximab administration in patients requiring transportation to undergo primary percutaneous coronary intervention (PPCI) has been reported to improve clinical outcome. We aimed to verify whether early administration leads to reduced infarct size (IS), assessed by delayed-enhancement magnetic resonance imaging (DE-MRI). METHODS: We randomized 110 patients with acute myocardial infarction with symptom-to-diagnosis time <6h to either early (55 patients) or late (55 patients) abciximab administration. DE-MRI was performed at 4 days and 6 months. The primary end point was IS at 6 months. Secondary end points were the rate of ST-segment elevation resolution ≥ 50% (STR) at 60 min after PPCI, the extent of microvascular obstruction at 4 days, and the change in IS and transmurality at 6 months vs. 4 days. RESULTS: DE-MRI was performed in 103 patients after 4 days, and in 87 at 6 months. The mean IS at 6 months was 13.8 ± 9.0% in the early vs. 13.0 ± 9.9% in the Late group (P>0.2). Similarly, microvascular obstruction and the change in IS were not significantly different. The Early group showed a significantly higher STR (94.5% vs. 80.0%, P=0.04) and a larger reduction in infarct transmurality (-9.2 ± 7.0% vs. -5.9 ± 6.4%; P=0.03), while a larger reduction in IS was observed only in patients with ECG-to-Cath Lab time >60 min. CONCLUSIONS: Early abciximab administration did not lead to a smaller IS at 6-month DE-MRI, and was associated with a significant reduction in IS and transmurality only in patients with longer transportation time, warranting further investigation in this patient subset.

[Venous graft in-stent restanosis: diagnostic and treatment evolution]. / Multiple restenosi intrastent di graft venoso: evoluzione diagnostica e terapeutica.

This is the case of a 77 year-old man with previous coronary by-pass grafting. After the occlusion of the saphenous vein graft to marginal branch, corrected by angioplasty and stenting with a bare metal stent (BMS), during the next 4 years he experienced multiple further episodes of in-stent restenosis of the first BMS. Angioplasty was performed each time. After 4 months since the last procedure, he had new episode of unstable angina. An EKG-gated, 64-row multislice CT (MSCT) examination was performed to evaluate the venous graft lumen, showing high-grade in-stent restenosis. Angiography confirmed the MSCT diagnosis, thus he underwent angioplasty and stenting with a drug eluting stent (DES). Thereafter, he remained stable for 4 years, when new anginal episodes led to a further coronary angiogram, showing progression of the atherosclerosic disease at the proximal and distal anastomosis of the venous graft; however, the previous implanted DES was patent. In the complex management of venous grafts restenosis, MSCT can be useful to help in detecting obstructive bypass graft disease. When revascularization is needed, DES have shown to be superior compared to BMS.

Endovascular treatment of acute thoracic aortic syndromes with a proximal landing zone extension strategy: procedural and follow-up results.

PURPOSE: To report the procedural and long-term follow-up data (mean, 43 ± 29 months; range, 12-90 months) of endovascular stent grafting (ESG) of acute thoracic aortic syndromes (ATAS) with a proximal landing zone extension strategy. METHODS: From November 1999 to May 2008, 26 patients (25 males, 1 female; mean age, 57.9 ± 17 years) with ATAS underwent ESG at our institution. Underlying pathologies were: penetrating aortic ulcer (n=7); rupture of a descending aorta aneurysm (n=5), post-traumatic false aneurysm (n=5); acute type B dissection (n=6) and traumatic descending aorta transection (n=3). RESULTS: ESG was performed successfully in all patients. In 5 patients (19%), an extra-anatomic revascularization of the supra-aortic vessels was performed. In 19 patients (73%), overstenting of the left subclavian artery, without preliminary revascularization, was performed. The mean proximal landing zone length was 57 ± 19 mm. No intraprocedural deaths occurred; 3 patients died postoperatively (1 from an unrelated cause, 1 from a myocardial infarction and 1 for the sequelae of an ischemic stroke). One patient underwent cardiac surgery for post-procedural retrograde type-A dissection. Follow up involved a computed tomography (CT) scan at 1, 3, 6 and 12 months, then yearly thereafter. At follow up, no deaths or major complications occurred. The CT scans revealed 1 small type-IB endoleak at 1 year. CONCLUSION: In ATAS patients treated with ESG, the extension of the proximal landing zone, despite the need of subclavian coverage or hybrid procedures, is associated with an immediate procedural outcome and low morbidity at follow-up.

Osteopontin plasma levels and accelerated atherosclerosis in patients with CAD undergoing PCI: a prospective clinical study.

OBJECTIVES: Growing evidence supports the role played by inflammation in atherosclerosis. Identifying sensitive biomarkers is useful in predicting accelerated atherosclerosis. We investigated prospectively the relationship between plasma levels of inflammatory biomarkers [osteopontin, C-reactive protein (CRP), interleukin-6 (IL-6)] and instent restenosis, and rapid coronary plaque progression in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI). METHODS: We studied 77 patients with CAD: 45 affected by unstable angina/non-ST elevation myocardial infarction [acute coronary syndrome (ACS)], and 32 by chronic coronary syndrome (CCS). Plasma osteopontin, IL-6, and CRP levels were measured before intervention in all patients; measurements were carried out on the basis of the following time course at 1,15, 30, 90, and 180 days follow-up in a subgroup of 39 consenting patients. Clinical and biohumoral data were correlated with baseline and 6-month PCI follow-up angiography. RESULTS: Osteopontin, IL-6, and CRP were higher in patients with ACS than in those with CCS (analysis of variance: P<0.001, 0.05, and 0.05, respectively). Baseline osteopontin levels proved to be associated with rapid coronary plaque progression (P=0.005) and instent restenosis (P=0.05). The highest osteopontin levels were found in patients with CAD with both rapid plaque progression and instent restenosis (P=0.003). PCI increased inflammatory markers acutely, and osteopontin remained elevated in patients with ACS. Patients with ACS showed a higher percentage (74%) of rapid plaque progression than those with CCS (26%) (P<0.05). CONCLUSION: The study prospectively shows the link between inflammatory status and accelerated atherosclerosis in patients with CAD undergoing PCI. The baseline and persistent rise of osteopontin is an expression of its contribution to the accelerated plaque progression, and therefore osteopontin may be a useful prognostic biomarker.

[Door-to-balloon time and in-hospital mortality in patients with ST-evaluation myocardial infarction: a network experience in a province in northwest Tuscany, Italy]. / Tempo door-to-balloon e mortalità intraospedaliera nel paziente con infarto miocardico acuto con sopraslivellamento del tratto ST: esperienza di una rete integrata in una provincia dell'area nord-ovest della Toscana.

BACKGROUND: A network system for ST-elevation myocardial infarction (STEMI) patients offers a quick diagnosis and a rapid transfer to a specialized center for primary percutaneous coronary intervention. The aim of our study was to evaluate the relationship between door-to-balloon time and in-hospital mortality in our network of STEMI patients. METHODS: Our Hub & Spoke network in the province of Massa-Carrara in the northwest of Tuscany Region, Italy, began in April 2006. This program involved 5 Spoke and 1 Hub centers, 1 medical helicopter, 3 advanced life support ambulances with direct transmission of the ECG and vital parameters to our cath lab on call 24h a day for primary percutaneous coronary intervention. Data regarding clinical, echocardiographic and hemodynamic parameters, the door-to-balloon (DTB) time and their impact on mortality were analyzed. RESULTS: Up to January 2008, 312 STEMI patients were enrolled (242 male, mean age 66.6 +/- 12.3 years). The DTB time was 93 min (79-117, 25th-75th percentile, respectively). The gold standard of a DTB < or = 90 min was reached in 47.1% of patients. In-hospital mortality was associated with a longer DTB time as compared to alive patients (92 vs 120 min, p < 0.03). Two geographic areas of our territory were considered: the coast and the mountain area. Patients from the coast (n = 238) had a DTB time lower than patients from the mountain area (89.5 vs 122.5 min, p < 0.0001), and the risk of in-hospital mortality was significantly and independently correlated with the increase in DTB time (p = 0.04). CONCLUSIONS; Our data confirm the correlation between DTB time and in-hospital mortality. More efforts are necessary to reduce the time to treatment and mortality rates.

Drug-eluting stents versus bare-metal stents in acute ST-segment elevation myocardial infarction. a single-center experience with long-term follow up.

OBJECTIVES: To compare the efficacy and safety of drugeluting stents (DES) vs. bare-metal stents (BMS) in patients with acute ST-segment-elevation myocardial infarction (STEMI). BACKGROUND: DES effectively reduce restenosis in elective percutaneous coronary intervention. Limited data are available about the use of DES in patients with STEMI. METHODS: 453 consecutive patients who presented with STEMI between July 2003 and May 2006 were studied. The procedural characteristics, 30-day, 12-, 18- and 26-month outcomes of 277 patients treated with DES were compared with 176 patients treated with BMS. RESULTS: At 26-month follow up, DES therapy was associated with a significant decrease in major adverse cardiac events (MACE) (relative risk [RR] -35%; p = 0.01) and target lesion revascularization [TLR], RR -64%; p = 0.009). The DES group included more diabetic patients (20% vs. 9%; p < 0.001), and the stents were longer (22 +/- 0.28 mm vs. 19.4 +/- 0.36 mm; p < 0.001) and smaller (diameter: 2.9 +/- 0.02 mm vs. 3.1 +/- 0.02 mm; p < 0.001). The rate of stent thrombosis was similar and the prolonged combined antiplatelet therapy was an independent factor predicting a protective effect on MACE. CONCLUSIONS: DES reduce the incidence of TLR and MACE in patients with STEMI without evidence of additional risks at 2-year follow up. DES therapy was associated with more complex interventional techniques, which yielded similar procedural results and clinical outcomes that may be influenced by prolonged combined antiplatelet therapy.