Temporal changes in the pattern of invasive angiography use and its outcome in suspected coronary artery disease: implications for patient management and healthcare resources utilization.

INTRODUCTION: Invasive coronary angiography (CAG), the 'gold standard' in coronary artery disease (CAD) diagnosis, requires hospitalization, is not risk-free, and engages considerable healthcare resources. AIM: To assess recent (throught out 10 years) evolution of 'significant' (≥ 50% stenosis(es)) CAD prevalence in subjects undergoing CAG for CAD diagnosis in a high-volume tertiary referral center. MATERIAL AND METHODS: Anonymized medical records were compared for the last vs. the first 2-years of the decade (June 2007 to May 2018). Referrals for suspected CAD were 2067 of 4522 hospitalizations (45.7%) and 1755 of 5196 (33.8%) respectively (p < 0.001). RESULTS: The median patient age (64 vs. 68 years) and the prevalence of heart failure (24.1% vs. 42.2%) increased significantly (p < 0.001). The CAG atherosclerotic lesions, for all stenosis categories (< 50%; ≥ 50%; ≥ 70%; occlusion(s)), were significantly more prevalent in men. The proportion of subjects with any atherosclerosis on CAG increased (80.7% vs. 77.6%, p = 0.015). However, in the absence of any gross change in, for instance, the fraction of women (40.4% vs. 41.8%), the proportion of CAGs with significant CAD (lesion(s) ≥ 50%) decreased from 55.2% in 2007/2008 to below 1 in every 2 angiograms (48.9%) in 2017/2018 (p < 0.001). This unexpected finding occurred consistently across nearly all CAG referral categories. CONCLUSIONS: Despite more advanced age and a higher proportion of subjects with 'any' coronary atherosclerosis on CAG, the likelihood of a 'negative' angiogram (lesion(s) < 50%; no further evaluation/intervention) has increased significantly over the last decade. The exact nature of this phenomenon requires further investigation, particularly as a reverse trend would be expected with the growing role (and current high penetration) of contemporary non-invasive diagnostic tools to rule out significant CAD.

Prognostic value of fibrosis-related markers in dilated cardiomyopathy: A link between osteopontin and cardiovascular events.

INTRODUCTION: Serum markers of fibrosis provide an insight into extracellular matrix (ECM) fibrosis in heart failure (HF) and dilated cardiomyopathy (DCM). However, their role as predictors of cardiovascular (CV) events in DCM is poorly understood. METHODS: This is an observational, prospective cohort study. 70 DCM patients (48±12.1years, ejection fraction - EF 24.4±7.4) were recruited. Markers of collagen type I and III synthesis - procollagen type I and III carboxy- and amino-terminal peptides (PICP, PIIICP, PINP, PIIINP), fibrosis controlling factors - ostepontin (OPN), transforming growth factor (TGF1-ß) and connective tissue growth factor (CTGF), and matrix metalloproteinases (MMP-2, MMP-9) and tissue inhibitor (TIMP-1), were measured in serum. All patients underwent endomyocardial biopsy. The end-point was combined with CV death and urgent HF hospitalization. Patients were divided into two groups: those who did (group 1, n=45) and did not reach (group 2, n=25) an end-point. RESULTS: Over a 12-month period of observation, 6 CV deaths and 19 HF hospitalizations occurred. Qualitative and quantitative measures of ECM fibrosis were similar in both groups. The levels of all of the markers of collagen synthesis, TGF1-ß, MMP-9 and TIMP-1 were similar, however, OPN, CTGF and MMP-2 were significantly lower in group 1. CONCLUSIONS: Invasively-determined fibrosis levels were not related with CV outcomes in DCM. Out of the 11 markers of fibrosis under study, only OPN was found to be related to CV outcomes. OPN is not only the pivotal protein controlling fibrosis, but may also serve as a biomarker associated with prognosis.

Left ventricular reverse remodeling is not related to biopsy-detected extracellular matrix fibrosis and serum markers of fibrosis in dilated cardiomyopathy, regardless of the definition used for LVRR.

Left ventricular reverse remodeling (LVRR) is reported in dilated cardiomyopathy (DCM) patients (pts). However, numerous definitions of LVRR exist. Measurements of serum markers of fibrosis provide insight into myocardial fibrosis. The relationship between LVRR and fibrosis is poorly understood. From July 2014 until October 2015, we included 63 consecutive DCM pts (48 ± 12.1 years, EF 24.4 ± 7.4%) with completed baseline and 3-month follow-up echocardiograms. LVRR was assessed on the basis of four differing definitions. Procollagens type I and III carboxy- and amino-terminal peptides (PICP, PINP, PIIICP, and PIIINP), collagen 1, ostepontin, tumor growth factor beta-1, connective tissue growth factor, and matrix metalloproteinases (MMP-2, MMP-9), and their tissue inhibitor (TIMP-1) were measured in serum. In addition, all pts underwent right ventricular endomyocardial biopsy. Depending on the definition chosen, LVRR could be diagnosed in between 14.3 and 50.8% pts. Regardless of the LVRR definition used, the frequency of LVRR was similar in fibrosis negative and positive DCM. Minor differences of markers of fibrosis were detected between pts with and without LVRR. For every LVRR definition, adjusted and unadjusted models were constructed to evaluate the predictive value of serum fibrosis parameters. Only an increase of TIMP-1 by 1 ng/ml was found to independently increase the probability of LVRR by 0.016%. The choice of a particular definition of LVRR determines the final diagnosis, and this has a profound impact on subsequent management. LVRR is unrelated to biopsy-detected ECM fibrosis. Serum markers of fibrosis are only weakly related to LVRR, and are not of use in the prediction of LVRR.

Fibrosis of extracellular matrix is related to the duration of the disease but is unrelated to the dynamics of collagen metabolism in dilated cardiomyopathy.

BACKGROUND: Fibrosis of extracellular matrix (ECM) in dilated cardiomyopathy (DCM) corresponds to the myocardial over-production of various types of collagens. However, mechanism of this process is poorly understood. OBJECTIVE: To investigate whether enhanced metabolism of ECM occur in DCM. METHODS: Seventy consecutive DCM patients (pts) (48 ± 12.1 years, EF 24.4 ± 7.4 %) and 20 healthy volunteers were studied. Based on symptoms duration, pts were divided into new-onset (n = 35, 6 months) and chronic DCM (n = 35, >6 months). Markers of collagen type I and III synthesis-procollagen type I carboxy- and amino-terminal peptides (PICP and PINP) and procollagen type III carboxy- and amino-terminal peptides (PIIICP and PIIINP), collagen 1 (col-1), ECM metabolism controlling factors-tumor growth factor beta-1 (TGF1-ß), connective tissue growth factor (CTGF), and ECM degradation enzymes-matrix metalloproteinases (MMP-2, MMP-9) and their tissue inhibitor (TIMP-1) were measured in serum. All pts underwent right ventricular endomyocardial biopsy to study ECM fibrosis. RESULTS: The presence of fibrosis was detected in 24 (34.3 %) pts and was more prevalent in chronic DCM [17 (48.6 %) vs. 7 (20 %), p < 0.01]. The levels of PIIINP [4.41 (2.17-6.08) vs. 3.32 (1.69-5.02) ng/ml, p < 0.001], CTGF [3.82 (0.48-23.87) vs. 2.37 (0.51-25.32) ng/ml, p < 0.01], MMP-2 [6.06 (2.72-14.8) vs. 4.43 (2.27-7.4) ng/ml, p < 0.001], MMP-9 [1.98 (0.28-9.25) vs. 1.01 (0.29-3.59) ng/ml, p < 0.002)], and TIMP-1 [15.29 (1.8-36.17) vs. 2.61 (1.65-24.09) ng/ml, p < 0.004] were significantly higher in DCM, whereas levels of col-1 [57.7 (23.1-233.4) vs. 159.4 (31.2-512.9) pg/ml, p < 0.001] were significantly lower in DCM compared to controls. There were no differences in all measured serum markers of ECM metabolism between newonset and chronic DCM and as well as fibrosis positive and negative pts. Fibrosis was weakly correlated only with the duration of DCM (r = 0.23, p < 0.05), however, not a single serum marker of fibrosis correlated with fibrosis. Neither unadjusted nor adjusted models, constructed from serum markers of ECM metabolism, predicted the probability of myocardial fibrosis. CONCLUSIONS: Dynamics of ECM turnover in DCM is high, which is reflected by the increased levels CTGF and degradation enzymes. Synthesis of collagen type III prevailed over collagen type I. ECM metabolism was not different in DCM regardless of the duration of the disease and status of myocardial fibrosis. Serum markers of ECM metabolism were found not to be useful for the prediction of myocardial fibrosis in DCM.

Impact of renal artery stenting on cytokine levels, left ventricle mass and diastolic function.

BACKGROUND: Significant renal artery stenosis (RAS) may lead to left ventricle (LV) hypertrophy and diastolic function (DF) impairment through complex mechanisms: activation of cytokines and/or systolic and diastolic blood pressure (SBP, DBP) increase. AIM: To assess interrelations between LV mass (LVM), DF and cytokines in patients undergoing renal artery stenting (PTA, percutaneous angioplasty of renal artery). METHODS: The study group comprised 72 subjects (44.4% men), 64.1 ± 9.9 years with RAS referred to PTA. SBP, DBP, transforming growth factor beta1 (TGF-ß1), aldosterone, B-type natriuretic peptide (BNP) levels and change in LVM and LVM index (LVMI) and DF (E(vel), e'(vel), E/A ratio, E/e' ratio, Ar(time)-A(time)) on echocardiography were assessed preprocedurally, and three and 12 months postprocedurally. RESULTS: TGF-ß1 level decreased from 13.3 ± 14.9 to 8.6 ± 8.0 ng/mL (p = 0.027), while BNP increased from 89.1 ± 86.3 to 131 ± 105 pmol/mL (p < 0.001). A significant reduction in LVMI in women (79.4 ± 16.9 vs. 95.7 ± 18.5 g/m², p < 0.001) and men (77.2 ± 16.8 vs. 100.1 ± 19.7 g/m², p < 0.001) was found at 12 months vs. baseline. Degree of LVM reduction correlated with baseline LVM (p < 0.001; r = -0.612) and e'(vel) (p = 0.05; r = 0.230), but not with BP values. Among DF parameters, only e'(vel) increased significantly at 12 months (5.54 ± 1.57 vs. 5.92 ± 1.65 cm/s; p = 0.039), while A/E and E/e' ratio, Ar(time)-A(time) remained similar (p = 0.457, p = 0.283 and p = 0.258). Factors associated with e'(vel) increase ≥ 0.3 cm/s at 12 months were baseline LVM < 165 g (p = 0.043, RR = 1.39, CI 1.01-1.46), E(vel) (p = 0.015, RR = 1.26, CI 1.15-1.52), e'(vel) (p < 0.001, RR = 1.42, CI 1.18-1.7), DBP decrease > 10 mm Hg (p = 0.055, RR = 1.2, CI 1.0-1.44) and TGF-ß1 > 8 ng/mL (p = 0.024, RR = 1.24, CI 1.03-1.49) at 12 months. CONCLUSIONS: Significant LVMI reduction was observed after PTA of RAS, but it was independent of BP reduction. e'(vel) increase was independently associated with baseline LVM, E(vel), e'(vel), and 12 month decrease in DBP > 10 mm Hg.

Effect of renal artery revascularization on left ventricular hypertrophy, diastolic function, blood pressure, and the one-year outcome.

OBJECTIVE: The study aimed to determine the potential interrelations between left ventricle mass (LVM), LV diastolic function, systolic blood pressure (SBP) and diastolic blood pressure (DBP) and cardiovascular events in patients undergoing renal artery stenting [corrected] (RAS). METHODS: Prior to RAS, 3 and 12 months afterward, the change in LVM, left ventricular mass index (LVMI), diastolic function (E/A ratio, E' wave velocity, isovolumetric relaxation time [IVRT], E/E' ratio) on echocardiography and change in SBP and DBP on 24-hour monitoring were assessed in 84 patients, aged 63.7 ± 10 years, who underwent RAS for renal artery stenosis > 60%. RESULTS: During 12 months, 12 (14.3%) cardiovascular (CV) events (five deaths) occurred. At 1 year, the mean LVM decreased from 179 ± 49 g to 141 ± 31 g (P < .001), LVMI in men decreased from 100 ± 20 g/m(2) to 79 ± 18 g/m(2) (P < .001), and the LVMI in women decreased from 96 ± 18 g/m(2) to 80 ± 17 g/m(2) (P < .001). No improvement in diastolic function parameters was seen. The mean SBP and DBP decreased from 133.5 ± 16.9 mm Hg to 127.9 ± 13.2 mm Hg (P = .007) and from 75.4 ± 10.2 mm Hg to 73.1 ± 8.8 mm Hg (P = .035), respectively. On multivariate logistic regression analysis, coronary artery disease (CAD) severity (relative risk [RR], 1.27; P = .023), smoking (RR, 1.29; P = .016), and baseline LVM (RR, 1.21; P = .07) were found as independent CV event risk factors. The independent factors associated with SBP and DBP improvement were grade of renal stenosis (RR, 1.28; P = .006), bilateral RAS procedure (RR, 1.17; P = .07), and baseline DBP value (RR, 1.74; P < .001). LVM reduction was associated with higher baseline ejection fraction (RR, 1.53; P < .001) and baseline LVM (RR, 1.7; P < 0.001). SBP and DBP value changes were independent of LVM change (r = 0.031; P = .796 and r = 0.098; P = .413, respectively). CONCLUSIONS: RAS induced LVM and LVMI reduction, which is independent of the change in blood pressure. Baseline LVM is associated with higher CV event risk following RAS.

Polyvascular extracoronary atherosclerotic disease in patients with coronary artery disease.

BACKGROUND: Cardiovascular diseases are the number one killer in the developed countries, accounting for approximately half of all deaths, with the leading causes being myocardial infarction and ischaemic stroke. In line with the ageing population, the prevalence of coronary artery disease (CAD), lower extremity peripheral arterial disease (PAD), supra-aortic arterial disease (SAD) and renal stenosis (RAS) is increasing. Polyvascular atherosclerosis (PVA) coexisting in several territories has an adverse effect on cardiovascular morbidity and mortality. AIM: To determine prevalence, coexistence and predictors of significant PAD, SAD and RAS in patients with suspected CAD. METHODS: Based on angiography, the frequency of coexisting CAD, SAD, PAD and RAS (stenosis > or =50%) was determined in 687 (487 male) consecutive patients, aged 63.5 +/- 9.1 years, referred for coronary angiography. RESULTS: Significant CAD was found in 545 (79.3%) patients (1-vessel in 164; 2-vessel in 157; 3-vessel in 224). SAD, RAS and PAD were found in 136 (19.8%), 55 (8%), and 103 (15%) patients, respectively. Of the 545 patients with confirmed CAD, 346 (63.5%) had stenoses limited to coronary arteries. 2-, 3- and 4-level PVA was found in 130 (23.8%), 61 (11.2%) and 8 (1.5%) patients, respectively. Of the 142 patients without CAD, 127 (89.4%) had no significant stenoses elsewhere, 12 (8.5%) had 1 extracoronary territory and 3 (2.1%) had 2-territory involvement. Backward stepwise binary logistic regression analysis showed the following independent predictors of at least 2-level PVA: 2- and 3-vessel CAD (p < 0.001), hyperlipidaemia (p = 0.067), smoking (p < 0.001), creatinine level > or = 1.3 ml/dl (p < 0.001), lower extremities claudication (p < 0.001) and female gender (p = 0.003). The relative risk of having at least 2-territory PVA was 15.7-fold higher in patients with claudication, 2.1-fold in patients with multivessel CAD, 2.8-fold for serum creatinine level > 1.3 mg/dl; and 1.9-fold, 2.4-fold and 2-fold in patients with hyperlipidaemia, smokers and women, respectively. CONCLUSIONS: Significant atherosclerosis in extracoronary arterial territories is present in 36% of patients with documented CAD. With advancing PVA, accumulation of atherosclerosis risk factors, previous atherothrombotic events and more severe CAD is observed.

Supra-aortic extracranial artery atherosclerotic lesions in patients diagnosed for coronary artery disease: prevalence and predictors.

BACKGROUND: In patients with coronary artery disease (CAD), the presence of atherosclerotic lesions in other vascular beds is associated with a markedly worse prognosis. AIM: To determine the prevalence and predictors of extracranial supra-aortic artery atherosclerotic disease (SAD) in patients with suspected CAD. METHODS: Supra-aortic artery angiography was performed in 379 consecutive patients aged 64.2 +/- 8.8 years (231 male) referred for coronary angiography. Clinical and laboratory data (total cholesterol, LDL, HDL cholesterol, hs-CRP, creatinine level) and left ventricular ejection fraction were analysed. RESULTS: Significant stenosis (> or =50% by quantitative angiography) within at least one main branch of the coronary arteries was found in 314 (82.8%) patients, including 87 (27.7%), 96 (30.6%) and 131 (41.7%) with 1-vessel, 2-vessel, and 3-vessel CAD, respectively. Among all 379 patients, stenosis > or =50% of the carotid artery was documented in 9.5%, vertebral in 13.7%, and subclavian in 7.4% of patients. We found 130 stenoses > or =50% within the supra-aortic arteries in 90 patients (23.7% of the whole study group, and 28.7% of CAD patients), including 42 internal carotid artery stenoses in 36 patients, 58 vertebral artery stenoses in 52, and 30 subclavian stenoses in 28 patients. In 24 (6.3%) patients more than one SAD was present. The SAD > or =50% was found in 8 (12.3%) patients without significant CAD, in 22 (25.3%), 17 (17.7%) and 43 (32.8%) with 1-, 2- and 3-vessel CAD, respectively (p = 0.001). Independent predictors of SAD > or =50% identified by multivariate analysis were: previous neurological ischaemic event (p = 0.001), CAD (p = 0.015), creatinine level (p = 0.031), male gender (p = 0.001), claudication (p < 0.001) and low HDL cholesterol (p = 0.033). The following independent predictors of vertebral and/or subclavian artery stenosis > 50% were identified: CAD severity (p = 0.002), creatinine level (p = 0.024), male gender (p = 0.013), claudication (p < 0.001) and low HDL cholesterol level (p = 0.059). CONCLUSIONS: In a large patient sample, we have found that significant supra-aortic atherosclerosis is present in a quater of patients with suspected CAD. Importantly, SAD prevalence increases with CAD severity. Previous neurological ischaemic event, CAD, creatinine level, male gender, claudication and hyperlipidaemia were identified as independent predictors of SAD > or =50%.

Internal carotid artery stenosis in patients with degenerative aortic stenosis.

BACKGROUND: In patients with severe degenerative aortic stenosis (DAS) the operative mortality risk is 3% for isolated aortic valve replacement (AVR), but it significantly increases in patients with concomitant coronary artery disease (CAD) and internal carotid artery stenosis (ICAS). AIM: To assess the frequency of ICAS > or = 50% and factors determining its occurrence in patients with severe calcified DAS referred for AVR. METHODS: The study included 104 patients (67 men), aged 63.4+/-8.4 years, with symptomatic moderate-to-severe DAS (aortic valve area <1.5 cm2) undergoing coronary angiography prior to valve surgery. In all patients Doppler ultrasound of carotid arteries was performed with the assessment of lumen stenosis. RESULTS: Significant CAD, defined as at least one lumen reduction > or = 50% in a main coronary artery, was found in 44 (42.3%) patients and ICAS > or = 50% in 13 (12.5%) patients. Among patients with DAS, 12 (27.3%) out of 44 patients with significant CAD and 1 (1.7%) out of 60 patients without CAD had ICAS > or = 50% (p <0.001). The frequency of ICAS > or = 50% increased with advancing CAD, occurring in 4 (25%) out of 16 patients with 1-vessel CAD, 3 (25%) out of 12 with 2-vessel CAD and (31.3%) out of 16 patients with 3-vessel CAD (p <0.001). The independent ICAS predictors by multivariate regression analysis were identified as: concomitant CAD (p <0.001), diabetes (p=0.054), cigarette smoking (p=0.08) and decreased left ventricular ejection fraction (p=0.039). ICAS > or = 50% was found to be an independent predictor of CAD (p=0.002). CONCLUSIONS: ICAS > or = 50% occurs in 13% of patients with isolated DAS and in 27% of those with DAS and CAD. Independent ICAS risk factors were identified as CAD, diabetes and cigarette smoking. Duplex ultrasound of carotid arteries should be considered in patients with DAS and concomitant CAD prior to AVR.

Renal artery stenosis in patients with coronary artery disease.

BACKGROUND: Renal dysfunction is an important factor of cardiovascular risk. Renal artery stenosis (RAS) is a potential cause of secondary hypertension and by renal ischemia may lead to progressive renal insuficiency. In RAS patients a significant increase in prevalence of coronary artery disease (CAD) as well as revascularisation rate and mortality rate was observed. AIM: To determine the prevalence of RAS in patients with suspected CAD. METHODS: The study group consisted of 1036 consecutive patients (700 men; 67.6% ) in the mean age of 62.1+/-9.7 (25-85) years admitted to coronary angiography. Simultaneously renal angiography was performed in all patients. RESULTS: Stenosis > or = 50% in at least one main branch of coronary artery was found in 633 (66.1%) patients. The proportion of patients with one, two or three vessel CAD was respectively 291 (46%), 169 (26%) and 173 (27.3%). Non-significant coronary lesions <50% were found in 108 (10.4%) patients, whereas in 295 (28.5%) patients no angiographic evidence of CAD was documented. In the whole group of patients RAS was found in 339 (32.7%) of patients - 124 (12%) had bilateral lesions. RAS prevalence in patients with CAD was 38.3% (284/741) and its frequency increased with severity of CAD: from 25% (27/108) in patients with insignificant coronary lesions up to 36.4% (106/291), 40.2% (68/169) and 48% (83/173) in 1, 2, and 3-vessel disease, respectively (p <0.001). RAS prevalence in patients with normal coronary arteries was 18.6% (55/295). RAS <30% was detected in 194 (18,7%) patients; RAS between 30-49% in 81 patients (8.7%); RAS 50-69% in 38 patients (3.7%) and RAS > or = 70% in the remaining 26 patients (2.5%). RAS > or = 50% was noted in 8 (2.7%) patients without coronary lesions; in 5 (4.6%) with insignificant coronary artery atherosclerosis and 51 (8%) with coronary artery stenosis >50% (p=0.0008). Stepwise regression analysis identified 4 independent predictors of RAS > or = 50%: CAD severity (p=0.014), serum creatinine concentration (p <0.001), cigarette smoking (p=0.02) and stenosis of aortic arch branches (p <0.001). CONCLUSIONS: RAS is a frequent finding in patients with suspected CAD. CAD severity, number of involved aortic arch arteries, cigarette smoking and serum creatinine are independent RAS predictors.

Prevalence and prediction of renal artery stenosis in patients with coronary and supraaortic artery atherosclerotic disease.

BACKGROUND: Renal atherosclerosis is associated with increased cardiovascular mortality. This study aimed to determine the prevalence and predictors of renal artery stenosis (RAS) in patients with coronary artery disease (CAD) and supraaortic arteries (SA) stenosis. METHODS: Renal angiography was performed in 1193 (807 men) consecutive patients referred for coronary or SA angiography. Group I included 296 (136 men, 60.1 +/- 9.5 years) patients with no significant (< 50%) lesion in coronary arteries or SA; group II included 706 (526 men, 62.2 +/- 9.7 years) patients with stenosis > or = 50% within single arterial territory (coronary arteries or SA) and group III included 191 (145 men, 64.9 +/- 8.5 years) patients with stenosis > or = 50% in both territories. RESULTS: Some RAS was found in 55 (18.6%) patients in group I, 250 (35.4%) patients in group II and 115 (60.2%) patients in group III (P < 0.001). The proportion of patients with RAS > or = 50% in groups I, II and III was 3.3, 6.2 and 18.3%, respectively (P < 0.001). RAS prevalence increased with the number of stenosed coronary arteries (38.4% in 1-vessel, 42.1% in 2-vessel, 48.5% in 3-vessel CAD, P < 0.001). Independent predictors of RAS > or = 50% identified by logistic regression analysis were SA stenosis [relative risk (RR) = 3.28, P < 0.001], 2-3-vessel-CAD (RR = 2.04, P = 0.002), creatinine level > or = 1.07 mg/dl (RR = 2.95, P < 0.001), hypertension (RR = 2.97, P = 0.012) and body mass index < 25 kg/m(2) (RR = 1.42, P = 0.169). A calculated score for RAS > or = 50% prediction (based on the regression model) was reliable (coefficient of determination, R = 0.978) and showed a sensitivity of 77.5% and a specificity of 63.9%. CONCLUSIONS: RAS prevalence and severity increases with the number of arterial territories involved and CAD severity. The following independent predictors of RAS > or = 50% were identified: SA involvement, 2-3-vessel-CAD, serum creatinine level and hypertension.

Doppler ultrasonography in suspected subclavian artery obstruction and in patient monitoring after subclavian stenting.

PURPOSE: Subclavian or innominate artery (SIA) stenosis affects up to 5% of patients referred to coronary bypass grafting; it is symptomatic in less than half of these. This study aimed to assess the Doppler ultrasonography (DU) findings in SIA obstruction and patients' follow-up after percutaneous angioplasty (PTA). METHODS: The study enrolled 118 patients (68 men, 50 women), aged 61.3 +/- 8.7 years, with suspected SIA obstruction, in whom peak systolic velocity (PSV) in the SIA and subclavian steal grade were assessed on DU and verified by quantitative angiography (QA). Serial follow-up DU was performed in patients treated with PTA. RESULTS: Grade I-III of subclavian steal from the vertebral artery (VA) was found in 89.8% of patients. In the remaining 10.2% only a PSV increase in the SIA was observed. QA confirmed the presence of SIA obstruction in all patients (stenosis grade: 80.9 +/- 17.3%). In patients with one-sided SIA obstruction, the ultrasonographic steal grade correlated with the QA stenosis grade (p < 0.001, r = 0.648). Lack of subclavian steal was noted in the case of distal subclavian stenosis, VA obstruction, VA originating from the aortic arch, and bilateral SIA obstruction. Successful PTA was performed in 77 of 83 patients referred to that procedure. PSV was reduced from 4.4 +/- 1.2 (2.2-6.5) m/sec to 1.34 +/- 0.51 (0.5-2.5) m/sec and flow in the VA was normalized. During the mean follow-up time of 24.7 +/- 15.6 months, there was a gradual increase in the in-stent PSV as well as gradual VA flow alterations, resulting in symptom recurrence. More than a twofold PSV increase, compared with the post-PTA values, was an indicator of restenosis in 11 of 12 patients. CONCLUSIONS: Careful DU evaluation enables the recognition of SIA obstruction in all patients. Ninety percent of them have subclavian steal correlating with the stenosis grade. Restenosis can be reliably detected with DU based on in-stent PSV and VA flow alterations.

Determinants of immediate and long-term results of subclavian and innominate artery angioplasty.

BACKGROUND: Percutaneous angioplasty (PTA) is widely used in the treatment of subclavian/innominate artery obstruction, but factors of long-term PTA outcome are poorly understood. Our aim was to evaluate the efficiency of PTA on symptom resolution and identify determinants of long-term outcome. METHODS AND RESULTS: Seventy-six lesions were treated in 75 patients (58.7% men) aged 60 +/- 8.5 years. PTA was successful in 70 (93.3%) patients, including 58/58 (100%) stenotic lesions and 13/18 (72.2%) occlusions. The mean stenosis grade (QCA) was reduced from 78.9% +/- 16.6% to 13.5% +/- 10.7% (P < 0.01). A great majority of lesions (87.1%) were stented. In 5 (7.1%) high-risk lesions a proximal or distal neuroprotection system was used. There were no strokes or embolic events. Minor complications occurred in 7 (9.3%) cases. Fifty-seven (89%) of 64 symptomatic patients had complete symptom resolution. The mean follow-up was 24.4 +/- 15.5 months (up to 66 months). Ten restenoses (15.6%), including 9 (13.8%) in-stent restenoses and 1 (16.7%) restenosis after balloon angioplasty, were diagnosed in 64 patients and followed up for at least 6 months. Nine symptomatic restenoses were successfully treated with repeated angioplasty. Cox multivariable analysis revealed the following independent predictors of restenosis: implantation of more than one stent (P = 0.005), low stent diameter (P = 0.088), and postprocedural systolic blood pressure difference between upper extremities (P = 0.044). CONCLUSIONS: PTA is a safe and effective method for the treatment of the subclavian/innominate artery obstruction and leads to symptom resolution in majority of patients. Restenosis is not frequent and it can be effectively treated with repeat angioplasty. Low stent diameter, implantation of two stents, and upper limb systolic blood pressure difference are independent predictors of restenosis.

Treatment options for post-catheterisation femoral pseudoaneurysm closure.

BACKGROUND: Femoral artery pseudoaneurysm (FAP) complicates from 1% to 9% of all coronary angiography procedures and contributes to extended hospitalisation as well as patient discomfort. AIM: To compare three main methods of FAP closure which are used nowadays. METHODS: Seventy-five subjects (38 females, 37 males, mean age 60.8+/-10.4 years) with post-catheterisation FAP were studied. The results of three methods of FAP closure--surgical, local compression and thrombin injection--were compared. RESULTS: Between September 2000 and July 2001, fourteen patients developed FAP; in 9 (64%) patients FAP was closed with repeated prolonged compression whereas the remaining 5 (36%) patients required surgical closure of compression-resistant FAP. We observed that FAPs with longer neck (>10 mm) and primary signs of partial spontaneous coagulation were more prone to self-closure as compared to FAPs with short neck and no signs of perimural coagulation (p=0.01). Since July 2001, we introduced ultrasound-guided thrombin injection into FAP sack. The protocol included attempt of closing FAP with probe compression and compression dressing put overnight, and, if unsuccessful, followed by a quick injection of 2 ml of thrombin solution (400-3200 U), guided by ultrasound. During this period, we identified 61 patients with FAP. Out of this group, 5 (8.2%) subjects were referred for surgery without any attempt of thrombin-injection, in 16 (26.2%) patients FAP was closed with probe compression and dressing put overnight, and in the remaining 40 (65.6%) subjects ultrasound-guided thrombin-injection was performed. Thrombin injection into FAP sack caused closure of its cavity and neck in all patients, however, five patients required additional thrombin injection during the same session, and 2 (5.0%) patients--during the next procedure. No peri-procedural complications were observed. The duration of hospital stay shortened from a mean of 26.6+/-14.5 days in surgically treated patients to 7.9+/-6.7 in those in whom FAPs were closed with compression, and to 4.6+/-2.6 days in those treated with thrombin (p<0.001). During a mean follow-up of 11+/-8.1 months, we re-examined 32 (80.0%) patients in whom FAP was closed with thrombin injection. No long-term thrombotic or embolic complications were observed. However, in 2 (6.3%) patients FAP cavity did not undergo complete resorption after 6 and 12 months of follow-up. CONCLUSIONS: Thrombin-induced closure of femoral pseudoaneurysm is a quick, safe and effective method, shortening hospitalisation time. In our Department this procedure replaced the prolonged and painful compression method.

[Evaluation of patency of coronary artery bypass grafts and stents using multislice spiral computed tomography in comparison with angiography]. / Ocena droznosci pomostów aortalnowiencowych i stentów implantowanych do tetnic wiencowych metoda wielorzedowej spiralnej tomografii komputerowej w porównaniu z angiografia.

UNLABELLED: The aim of the study was to assess usefulness of multislice spiral computed tomography--MSCT (Somatom Plus 4 Volume Zoom, Siemens) in non-invasive assessment of the potency of coronary artery bypass grafts both venous and arterial grafts as well as stents. METHODS: The study was performed using the MSCT method with Heart View Software with retrospective electrocardiographic gating. Nonionic, hypo-osmolar contract media was infused into a peripheral vein to highlight the coronary arteries and bypasses. All patients, due to clinical indications, underwent coronary and bypass angiography. MATERIAL: Two group of patients (82 persons) in total were evaluated: after aorto-coronary bypassing (Group I--57 persons, incl. 40 males and 17 females) and after stent implantation (Group II--25 persons, incl. 19 males and 6 females). The patients were referred to invasive diagnostics for recurrence and aggravation of clinical symptoms. RESULTS: In group I, the patency of 187 bypasses was evaluated (21 arterial and 166 venous). In MSCT, was found in 131 of the bypasses patency (114 venous and 4 arterial). 56 bypasses, (52 venous and 4 arterial) were obstructed. In the bypassography performed were obstructed 53 (5 venous and 3 arterial), 134 bypasses were patent (116 venous and 18 arterial). In the bypass patency assessment using MSCT compared to coronarography, specificity of 94.7% and sensitivity of 92.4% were achieved. In group II, patency was evaluated in 26 stents: 21 implanted to native vessels and 5 in venous bypasses. 19 stents in native vessels were found patent, whereas 2 were obstructed. In the coronary bypasses performed, patency was confirmed in 19 stents and 2 were obstructed. In MST obstruction was demonstrated in 4 stents in coronary bypasses, which was confirmed in bypassography. One stent was assessed patient in both methods. CONCLUSION: The MSCT method is useful for assessment of patency of venous and arterial bypasses as well as stents.