Worse six-month outcome for patients with multiple stents in a single coronary artery.

BACKGROUND: Before the "era" of optimal stent deployment, very few data concerning multiple stents in a single coronary artery showed restenosis rates up to 60%. OBJECTIVE: To evaluate the 6-month outcome of patients receiving multiple Palmaz-Schatz stents (> or =2 stents) in a single coronary artery compared to those receiving single stents. METHODS: Three hundred and forty-eight patients having multiple stents were compared to 174 patients receiving single stents during a 6-month follow-up. RESULTS: Repeat target lesion revascularization (RTLR), either repeat PTCA or CABG, was 10.4% in the single-stent group, 22.6% in the two-stent group, and 23.1% in the > or =2 stent group (p = 0.001, single versus 2 or > or =2 stents). There was not a significant difference between single stent and multiple stent groups in myocardial infarction and death during 6-month follow-up. Multivariate analysis showed multiple stents, diabetes mellitus, and type C lesion to be predictors of RTLR. CONCLUSIONS: Placement of two or more stents was associated with a significantly higher RTLR compared with single stent placement. The optimal approach to diffuse coronary artery disease remains to be defined.

Initial experience with reuse of coronary angioplasty catheters in the United States.

OBJECTIVES: We sought to evaluate the performance of angioplasty catheters, restored under a strict manufacturing process, in patients with coronary artery disease. BACKGROUND: Most countries outside the United States routinely reuse disposable medical equipment, resulting in significant cost savings. Because of quality and legal concerns, reuse in the United States has been limited. We investigated the reuse of percutaneous transluminal coronary angioplasty (PTCA) balloon catheters, restored by a process strictly controlled for bioburden and sterility, in patients undergoing PTCA. METHODS: Used PTCA balloon catheters were shipped to a central facility and were decontaminated, cleaned and tested for endotoxin using the limulus amebocyte lystate (LAL) gel clot method. Physical testing and quality assurance were performed. The products were packaged and sterilized with ethylene oxide. Catheter performance was assessed in a pilot study powered to detect a 5% difference in the angiographic failure rates of new and reused balloons (beta 0.8). RESULTS: The study enrolled 107 patients. The indication for PTCA was stable angina pectoris in 69 patients, unstable angina in 22 and acute myocardial infarction in 16. Of the 107 patients enrolled, 106 had a successful laboratory outcome, and 1 required coronary artery bypass graft surgery after failed rescue stenting. There were 122 lesions attempted (American College of Cardiology/American Heart Association classification A, n = 32; B1, n = 43; > or = B2, n = 35; C, n = 12). Of the 110 lesions initially approached with restored PTCA catheters, 108 were crossed and dilated. Sixty-four required no further procedures. Stenting was performed in 37 patients (29 planned, 8 rescue). Thus, the angiographic failure rate was 7% (10 of 108, 95% confidence interval 2% to 12%), comparable to the 10% rate seen with new balloons in other studies. CONCLUSIONS: Restoration of disposable coronary angioplasty catheters using a highly controlled process appears to be safe and effective, with success rates similar to those of new products and no detectable sacrifice in performance. Cost analysis suggests that implementation of reuse technology for expensive disposable equipment may offer cost savings for U.S. hospitals, without sacrifice of quality.

Progressive preoperative pneumoperitoneum in the repair of large abdominal hernias.

OBJECTIVE: To present our experience of progressive preoperative pneumoperitoneum in the preparation of patients for repair of large hernias of the abdominal wall. DESIGN: Prospective selected series. SETTING: A university hospital and a district hospital. SUBJECTS: 36 Patients of the 252 who presented for abdominal hernia repair between January 1977 and April 1992. INTERVENTIONS: Air was insufflated into the peritoneal cavity through a 19 gauge spinal needle, and between 500 and 2000 ml was usually injected at the first session. Amounts were gradually increased daily or every other day for a period of 6-15 days; the total amount insufflated ranged from 4500-18,500 (mean 7700) ml. MAIN OUTCOME MEASURES: Whether the hernia could be repaired directly without recourse to polypropylene mesh, complications of pneumoperitoneum, and recurrence rate. RESULTS: In one patient air was insufflated into the colon, one developed temporary but severe respiratory distress, and 4 developed moderate subcutaneous emphysema. 30 hernias were repaired directly, and 6 required polypropylene mesh. There were three wound infections (two after direct repair), and two recurrences (both after direct repair). Mean length of follow up was 10 months (range 1-48). CONCLUSION: Progressive preoperative pneumoperitoneum allows direct repair of some large abdominal hernias with a low recurrence rate, and few complications.

Sitting up post angioplasty: a new sheath technology.

A new angioplasty sheath has been developed which permits a patient to sit up to a 60 degree Semi-Fowler position post angioplasty with the sheath in place. To determine the safety of this device, we studied eleven (11) patients undergoing Percutaneous Transluminal Coronary Angioplasty (PTCA) compared with 11 PTCA patients treated in a standard fashion. The patients were evaluated for the length of time the sheath remained in place (study 17 +/- 6 hours versus control 19 +/- 5 hours), the time required to achieve hemostasis upon sheath removal (66 +/- 52 minutes versus 81 +/- 89 minutes), and the need for analgesics (frequency of 1.9 times versus frequency of 6.4 times per patient). Complications in the study group were 0 episodes of severe bleeding at the insertion site versus 1 episode in the control group, slight oozing in 8 study patients versus 7 control patients, small hematoma in 2 study patients versus 1 control patient, and large hematoma formation in 1 study patient versus 0 control patients. In summary, the use of a soft, flexible sheath allows the patient to safely site up in the Semi-Fowler position post PTCA with significant improvement of discomfort.

Interventional cardiology techniques for coronary artery disease.

This review updates and extends observations made in this journal in March 1988. The focus then was on percutaneous transluminal coronary angioplasty and the clinical results of its practical application. A concern was expressed that science lagged in solving the major problems of rethrombosis and restenosis. The NHLBI Bypass Angioplasty Revascularization Investigation (BARI) study was still in the planning phase. In 1991, the scene has changed. Interventional cardiology now embraces a multitude of different catheter devices--angioplasty, atherectomy, laser, stents. Basic scientists are increasingly involved in addressing the restenosis issue. Our national heart meetings are increasingly oriented towards molecular biology approaches to solving the remaining problems. The BARI trial has nearly completed patient entry, and we eagerly await its results. The cardiologist and surgeon are faced with increasingly complex decisions with respect to interventional technologies, involving not only whether to use them, but which ones.

Five-hour balloon inflation to resolve recurrent reocclusion during coronary angioplasty.

A 63-year-old male presented with an acute inferior myocardial infarction with initial clinical reperfusion following thrombolysis. Due to recurrent reocclusion, emergency catheterization was performed, demonstrating a 90% stenosis in the mid right coronary artery. Angioplasty was complicated by multiple reocclusions, ultimately requiring 5-h autoperfusion balloon inflation to maintain patency.

Surgical management of common bile duct stones

A remocao dos calculos coledocianos permanece um problema importante na cirurgia biliar. A alta incidencia de calculos residuais ressalta a importancia da remocao cuidadosa dos calculos coledocianos durante a primeira operacao biliar. Hoje existem disponiveis varios metodos cirurgicos e nao-cirurgicos de tratar tais pacientes. O objetivo do presente estudo e rever nossa experiencia com esses metodos. Foram revisados os prontuarios de 85 pacientes, tratados pelo mesmo cirurgiao, por litiase da via biliar principal, num periodo de 26 anos. Apenas 9,4 por cento dos pacientes nao tinham historia previa de ictericia e 69 por cento estavam ictericos no momento da cirurgia. Colecistectomia havia sido realizada previamente em 16 pacientes, e em dois desses o coledoco havia sido explorado. Oito pacientes foram operados durante um episodio de colangite aguda supurativa. Em tres casos havia calculos coledocianos sem a presenca concomitante de colelitiase. Colecistectomia, exploracao do coledoco, remocao dos calculos e drenagem a Kehr foi realizada em 48 pacientes. Foi associado um procedimento de drenagem em 21 pacientes: em 18 casos anastomose coledocoduodenal latero-lateral, hepaticojejunostomia em um caso e esfincteroplastia em dois. Os 16 pacientes restantes haviam sido submetidos previamente a colecistectomia...

Acute reocclusion during percutaneous transluminal coronary angioplasty: immediate and long-term outcome.

Acute total occlusion of a coronary artery during percutaneous transluminal coronary angioplasty (PTCA) has previously resulted in emergency surgical intervention (CABG). We retrospectively surveyed 211 elective procedures and 65 procedures for acute myocardial infarction (AMI). There were 42 patients (pts) [29 elective (14%) and 13 AMI (20%)] in whom total occlusion occurred after initial dilation had been achieved. In 30 of 42 pts reangioplasty successfully reperfused the vessel. Ten patients (24%) required CABG and two (5%) were treated medically for AMI. Death occurred in 2 pts due to irreversible cardiogenic shock despite successful angioplasty. After 6 months follow-up 22 pts remained asymptomatic. It is concluded that aggressive redilation of total occlusions which develop during PTCA will frequently result in a successful angioplasty with a long-term restenosis rate comparable to uncomplicated angioplasty.

Pentobarbital antagonizes the A1 adenosine receptor-mediated inhibition of hippocampal neurotransmitter release.

Barbiturates have been shown to be competitive antagonists at A1 adenosine receptors in radioligand binding studies. The present study investigates the effects of pentobarbital on the A1 receptor-mediated inhibition of neurotransmitter release from rabbit hippocampal slices. The inhibition of the electrically evoked release of [3H]noradrenaline by the A1 receptor agonist (R)-N6-phenylisopropyladenosine (R-PIA) was antagonized by pentobarbital with an apparent pA2 value of 3.5. Low concentrations of pentobarbital alone altered neither basal nor evoked release of [3H]noradrenaline, whereas 1,000 microM pentobarbital enhanced the basal and reduced the evoked release. In the presence of 8-phenyltheophylline, pentobarbital (200 microM and 1,000 microM) reduced the evoked noradrenaline release. Pentobarbital also antagonized the inhibition of [3H]acetylcholine release by R-PIA. In contrast to the noradrenaline release model, the evoked release of acetylcholine was enhanced by the presence of pentobarbital (50-500 microM), an effect that was lost in the presence of 8-phenyltheophylline. These results indicate that pentobarbital, in addition to a direct inhibitory action at higher concentrations, has a facilitatory effect on neurotransmitter release by blocking presynaptic A1 adenosine receptors. The possible relevance of these findings for the excitatory effects of barbiturates is discussed.

Presynaptic opioid receptors modulating acetylcholine release in the hippocampus of the rabbit.

Slices of the rabbit hippocampus were preincubated with 3H-choline, rinsed and superfused continuously. The release of 3H-acetylcholine in these slices, evoked by electrical field stimulation, was strongly reduced by the preferential kappa-agonists ethylketocyclazocine, dynorphin A (1-13) and dynorphin A (1-17). Dynorphin A (1-9) and (-)MR 2034 [(-)5,9-dimethyl-2'-OH-2-tetrahydrofurfuryl-6, 7-benzomorphan] were less potent, the (+)enantiomer of (-)MR 2034 was ineffective. Whereas the mu-agonist DAGO (D-Ala2-Gly-ol5-enkephalin) showed significant depressant effects, two other mu-agonists morphine and morphiceptine, as well as the delta-agonists DADLE (D-Ala2-D-Leu5-enkephalin) and Leu-enkephalin were much less inhibitory. The preferential mu-antagonist (-)naloxone as well as (-)MR 2266 [(-)N-(3-furylmethyl)-alpha-noretazocine], a preferential kappa-antagonist, did not increase acetylcholine release when given alone, but antagonized the effect of ethylketocyclazocine; (-)MR 2266 (Ke: 1.6 nmol/l) was about 4 times more potent than (-)naloxone (Ke: 6.3 nmol/l). The inhibitory effects of DAGO and DADLE were abolished by (-)MR 2266 (0.1 mumol/l) but not by the delta-antagonist ICI 174864 (N,N-diallyl-Tyr-Aib-Phe-Leu-OH, 0.3 mumol/l). It is concluded that the release of acetylcholine in the hippocampus of the rabbit is inhibited at the level of the axon terminals via kappa-receptors; in addition, mu-receptors may be present. An inhibitory tone of endogenous opioid peptides on hippocampal acetylcholine release could not be demonstrated. Experiments on rat hippocampal slices showed that in this species mu- rather than kappa-receptors may modulate acetylcholine release.