Successful stent delivery through 5 French guiding catheter.

BACKGROUND AND OBJECTIVE: In vessels with moderate-severe tortuosity, rigidity or calcium, 6 French guiding catheters may be of help in stent delivering, allowing a deep coronary intubation and, hence, an easier coronary stent advancement. In this study, we describe our experience in coronary stenting using 5 French guiding catheters. METHODS AND RESULTS: The study population is constituted by 46 patients in whom coronary stenting was attempted through a 5 French guiding catheter. Sixty-six stents were delivered in 56 vessels; the 5 French Zuma guiding catheter (MedtronicAVE, Minneapolis, Minnesota) was used. In 74% of cases, a moderate-severe tortuosity was present, and calcium was visible by fluoroscopy in 27%. The stented lesions were de novo in 95%, and 42% of stents were placed in the right coronary artery. The stent was successfully delivered and implanted in all but one case (98.5%). In one patient with severe vessel tortuosity, a successful balloon dilation was performed, but the stent could not be successfully advanced through the coronary artery to the left anterior descending, and could be retrieved without any complication. Changing to a larger size guiding catheter was not required in any patient. Balloon predilation was performed before coronary placement in 41 of the 66 stents (62.1%), whereas stents were directly implanted without balloon predilation in the remaining 25 cases (37.9%). CONCLUSION: Coronary stenting through 5 French guiding catheters is feasible. This strategy may be especially indicated in patients with moderate-severe vessel tortuosity.

Heparin-coated Wiktor stents in human coronary arteries (MENTOR trial). MENTOR Trial Investigators.

The purpose of this study was to determine the feasibility, safety, and efficacy of elective stenting with heparin-coated Wiktor stents in patients with coronary artery disease. In experimental studies, heparin coating has been shown to prevent subacute thrombosis and restenosis. Recently, a new method of heparin coating was developed, resulting in a more stable and predictable heparin layer on stent devices. This trial constitutes the first in-human use of this coating procedure, applied on the well-known Wiktor stent device. Heparin-coated Wiktor stent implantation was performed in 132 consecutive patients (132 lesions) in a multicenter international trial from September 1996 to February 1997. Forty-three percent of patients had unstable angina, 33% had previous myocardial infarction, and 10% had diabetes mellitus. Patients were followed for 12 months for occurrence of major adverse cardiovascular events, and 96% of the eligible patients underwent quantitative angiographic control at 6 months. Stent deployment was successful in 95.5% of lesions. Minimal lumen diameter increased by 1.67 +/- 0.48 mm (from 1.02 +/- 0.38 mm before to 2.69 +/- 0.37 mm after the stent implantation). Mean percent diameter stenosis decreased from 67.4 +/- 11.3% before to 18.9 +/- 7.7% after the intervention. A successful intervention (<50% diameter stenosis and no major adverse cardiac events within 30 days) occurred in 97% of the patients. The subacute thrombosis rate was 0.8%, which compares favorably with historical controls of this stent, and a low incidence of postprocedural increase in creatine kinase-MB was noted. At 6 months, event-free survival was 85% and angiographic restenosis rate was 22% with late loss of 0.78 +/- 0.69 mm and a loss index of 0.48 +/- 0.44. Heparin-coated Wiktor stents appeared to be an efficacious device to treat Benestent-like lesions, yielding angiographic and clinical results comparable to a heparin-coated Palmaz-Schatz stent. Despite its use in more complex lesions, the incidence of subacute thrombosis appeared to be lower than historical controls with a similar noncoated stent.

[A comparison of clinical and angiographic outcome after implantation of a Wiktor stent in large and small coronary arteries]. / Una comparación de los resultados clínicos y angiográficos del implante del stent Wiktor en arterias grandes y pequeñas.

UNLABELLED: The objective of this study was to investigate the mid term influence of vessel size in clinical and angiographic outcome, after Wiktor stent implantation in arteries larger and smaller than 3 mm. METHOD: A total of 188 stents were implanted in 167 patients divided in two groups. Group 1: stents implanted in arteries smaller than 3 mm, 40 stents in 38 patients. Group 2: in arteries larger than 3 mm. 148 stents in 129 patients. Clinical follow up and a repeated coronary angiographic study were carried out after six months. RESULTS: Angiographic success was achieved in 97% and 98% cases, with clinical success in 92% and 95% respectively. Acute occlusion occurred in 2 patients of group 1 (5%), and in four patients in group 2 (2.7%); one patient died and four patients suffered a non-fatal myocardial infarction. During clinical follow up, nine patients presented a major complication, two in group 1 and seven in group 2 (5.5% vs. 5.6%). Asymptomatic survival was 86% and 84% respectively. In angiographic follow up we observed a restenosis rate of 41% of the patients in group 1 and 25% of those in group 2. Immediate gain was similar in both groups, but late loss (1.06 +/- 0.85 vs 0.97 +/- 0.86) and loss rate (0.60 vs 0.46) were greater in group 1. CONCLUSION: The frequency of stent thrombosis as well as the incidence of restenosis were higher in arteries smaller than 3 mm. No differences were observed in the incidence of major ischemic events.

[The placement of a Wiktor stent for the treatment of vasospastic angina: a case report]. / Colocación de stent de Wiktor para el tratamiento de angina vasoespástica: presentación de un caso.

A 46-year-old male with a fixed stenosis in the mid-segment of the left anterior descending artery underwent balloon angioplasty. The procedure included the placement of two Wiktor stents because of severe dissection. Five months later he complained of Prinzmetal angina with ST elevation in the anterior wall. A metilergobasine test during the coronary arteriogram showed a discrete, severe spasm on the proximal segment of the left anterior descending artery. Because of a lack of symptomatic improvement with high-dose nitrates and calcium blockers, a Wiktor coronary stent was successfully implanted in the proximal left anterior descending artery, resulting in complete relief of the angina.

[Registry of activities of the Hemodynamics and Interventional Cardiology Section in 1993]. / Registro de actividad de la Sección de Hemodinámica y Cardiología Intervencionista del año 1993.

Results of the Spanish Registry for Interventional Cardiology 1993 are presented, as previous years, by the Section of Haemodinamics and Interventional Cardiology of Sociedad Española de Cardiología. There are 72 participating cardiac catheterization laboratories. That represents 100% of those laboratories who had activity in 1993, Public medicine (51 centers) and Private practice (21 centers). From those, 8 laboratories exclusively performed pediatric cases. There have been performed 47353 diagnostic procedures and 2647 endomiocardial biopsies. In diagnostic cases greater proportion corresponds to coronariography (37591, 75.2%). Therapeutic interventionalism is also accomplished in 61 laboratories, on which 7807 balloon PTCA, 535 coronary atherectomies, 825 mitral valvotomies were performed, and 503 endocoronary prostheses were implanted. Mean rate of coronary interventionalism was 222 procedures by a million of inhabitants. This activity represents approximately a 17% increase from 1992, in diagnostic as well interventional procedures. Results of therapeutic cases did not show any significant changes, balloon PTCA primary success rate is 91.5%, with an incidence of 4.2% of complications that includes 0.7% mortality rate.

[Influence of prolonged inflation on coronary restenosis after balloon angioplasty]. / Influencia del inflado prolongado sobre la restenosis postangioplastia coronaria con balón.

BACKGROUND AND OBJECTIVES: Previous noncontrolled studies yield conflicting data about the influence of long inflation times on restenosis rate after PTCA. To clear these differences, we designed an open, prospective and randomized study to assess the effect of long versus standard balloon inflations in the incidence of restenosis. METHODS: 153 consecutive patients selected for one-vessel PTCA (62 LAD, 43 LCx, 48 RCA), were randomized to prolonged inflation (13.5 +/- 3.3 min) at 6 atmospheres using an autoperfusion catheter (72 patients) or to standard inflations (3.1 +/- 1.6 min) using conventional catheters (81 patients). Vessel diameter < 2.5 mm, lesions located at distal segments, complete occlusions, tortuous, long, bifurcated or thrombotic lesions were excluded. RESULTS: No significant differences in age, gender, coronary risk factors, ejection fraction, incidence of unstable angina or previous myocardial infarction existed between the two groups. There were no differences either between the dilated vessel, type of lesion (A, B, C) or the segment (proximal, mid) attempted. Successful dilation was obtained in 77/81 (95.0%) cases with standard inflation and in 58/72 (80.5%) with prolonged inflations (p = 0.01), leading to a decrease in the percentage of stenosis from 79.1 +/- 10.6% to 20.2 +/- 15.8% and from 81.4% +/- 9.9% to 21.0 +/- 13.0%, respectively (p = NS). A follow-up coronary arteriogram was obtained in 72/77 patients (93.5%) with standard inflation (mean: 18 +/- 6 weeks) and in 54/58 patients (93.1%) with prolonged inflation (mean: 17 +/- 3 weeks). Restenosis (arterial diameter reduction > 50%) was present in 23/72 (31.9%) of the standard inflation and in 22/54 (40.7%) of the prolonged inflation group (p = 0.4). CONCLUSIONS: These results suggest that longer balloon inflation periods do not reduce the restenosis rate after balloon coronary angioplasty.

Transesophageal echocardiographic monitoring of percutaneous mitral balloon valvulotomy.

This study was designed to evaluate the usefulness of performing transesophageal echocardiography (TEE) during percutaneous mitral balloon valvulotomy (PMBV). TEE was performed in 35 consecutive patients with symptomatic severe mitral stenosis during PMBV (group A). Another group of 27 patients with mitral stenosis who underwent PMBV without TEE was used for comparison (group B). TEE was most helpful in guiding transseptal puncture, aiding in proper positioning of the balloon during the dilatation procedure and enabling early detection of complications. The results show that PMBV when aided by TEE has a tendency to decrease the frequency of significant mitral regurgitation without compromising the final mitral valve area. TEE decreased the x-ray exposure time and was well-tolerated. Thus, TEE provides information that makes this interventional catheterization procedure safer and easier to perform.

[Mitral valve aneurysm. Its diagnosis by transesophageal echocardiography]. / Aneurisma de la válvula mitral. Diagnóstico por ecocardiografía transesofágica.

Aneurysm of the mitral valve is a rare complication of infectious endocarditis. We report a 65-years-old woman with left heart failure and mitral regurgitation secondary to a mitral valve aneurysm. The diagnosis was made by transesophageal echocardiography.

Prevention of early aortocoronary bypass occlusion by low-dose aspirin and dipyridamole. Grupo Español para el Seguimiento del Injerto Coronario (GESIC)

To analyze the efficacy of low-dose aspirin in preventing early aortocoronary vein graft occlusion, 1,112 consecutive patients were enrolled in a multicenter, randomized, double-blind, placebo-controlled trial comparing 50 mg t.i.d. aspirin, 50 mg aspirin plus 75 mg t.i.d. dipyridamole, and placebo. All patients received 100 mg q.i.d. dipyridamole for 48 hours before surgery, and assigned treatment was started 7 hours after surgery. Vein graft angiography was performed in 927 patients (83%) within 28 days of surgery (mean, 10 days). Aspirin plus dipyridamole significantly (p = 0.017) reduced the occlusion rate of distal anastomoses from 18% (placebo) to 12.9%. Occlusion rate in the aspirin group was 14%, which approached statistical significance (p = 0.058). Furthermore, only aspirin plus dipyridamole reduced (p = 0.01) the number of patients with occluded grafts (placebo, 33%; aspirin, 27.1%; aspirin plus dipyridamole, 24.3%). Mediastinal drainage was slightly higher (p = 0.04) in the aspirin plus dipyridamole group (713 +/- 456 ml) than in the other two groups (placebo, 670 +/- 437 ml; aspirin, 629 +/- 337 ml), but hospital mortality (average, 4.6%) and early reoperation (average, 3.9%) rates were similar among the three groups. Thus, low-dose aspirin plus dipyridamole safely improves early saphenous vein aortocoronary graft patency; this effect is an added benefit to a preoperative regimen of dipyridamole.

[Coronary angioplasty in acute coronary syndrome]. / Angioplastia coronaria en los síndromes coronarios agudos.

PTCA is a widely used technique in patients post-acute myocardial infarction (AMI) as well as in unstable angina (UA). The precise timing of its application and some aspects of the indication nowadays remains a matter of controversy. Primary PTCA is not generally considered to be the initial treatment of AMI. In contrast, immediate PTCA after thrombolysis has been proposed attempting to decrease the incidence of early reocclusion, improve myocardial salvage, decrease the incidence of postinfarction angina and improve survival. Nevertheless, three recent controlled studies (TAMI, TIMI II and ECSG) have demonstrated that an "aggressive" strategy with obligatory, invasive intervention following thrombolysis does not provide any advantage in terms of survival, rate of reocclusion or improved ventricular function and is, in fact, likely to be harmful. Emergent coronary arteriography after AMI should be reserved for unstable patients with continued or recurrent ischemia in the CCU. In elective basis it should be indicated in all patients with spontaneous or provocable ischemia prior to hospital discharge. If high grade coronary stenoses are identified, the patient should be considered for PTCA or surgical revascularization. In our own experience with coronary arteriography 24 hours to 15 days after intravenous thrombolysis with SK, PTCA is anatomically feasible in 44% of all the patients and in 60% of those showing a patent vessel. However, when indicated because of postinfarction angina or a positive stress test, PTCA was performed only in 22%, some of them presenting with a totally occluded vessel. In case of stenosis lesser than 100% the dilation success rate is slightly lower than that of out entire series (84% vs 88%), but the incidence of acute occlusion is significantly higher (10% vs 6%), particularly in patients with angiographic evidence of intracoronary thrombi. The incidence of "non-significant" (less than 70%) stenosis spontaneously increases when the coronary arteriography is performed late during hospitalization (34% vs 17% when the patient is studied in the first 24-48 hours).(ABSTRACT TRUNCATED AT 250 WORDS)

[Immediate results of coronary angioplasty in elderly patients. Experience at the Gregorio Marañón General Hospital]. / Resultados inmediatos de la angioplastia coronaria en pacientes geriátricos. Experiencia del Hospital General Gregorio Maranón.

In order to assess the results of PTCA in geriatric patients we retrospectively analysed the coronary angiographic findings and the indication, results and major complications (non-fatal myocardial infarction, emergent surgery and death) in 105 consecutive patients aged 65 or more who had PTCA as a part of a whole group of 600 patients. Among the older patients there were more female gender (p less than 0.001), severe angina (Canadian functional class III or IV) (p less than 0.05), unstable angina (p less than 0.05) and multivessel disease (p less than 0.05) in comparison with the younger group (495 patients). There was no significant difference between the two groups in the success rate (78.7% in patients aged 65 or more versus 84.1% in younger patients) or in the complication rate (8.6% versus 7.9%). A tendency was observed toward a higher complication rate (14%) and a lower success rate (72%) in patients aged 70 or more, but without reaching statistical significance. There were two deaths (1.9%). All the patients with a successful PTCA were improved at hospital discharge, including 21 with multivessel disease that underwent "incomplete vascularization" (single vessel PTCA). Thus, PTCA is feasible in selected old patients with severe angina with an incidence of success and of major complications similar to that obtained in younger patients. On the other hand, the complication rate and the in-hospital mortality of PTCA advantageously compares with those reported for coronary bypass surgery. PTCA could be considered as the first therapeutic option in old patients with an adequate coronary anatomy in whom a myocardial revascularization procedure is required.