Very late thrombosis of a paclitaxel-eluting stent after 72 months in a patient on dual anti-platelet therapy.

Very late thrombosis continues to be a major cause of concern in the era of drug-eluting stents. The duration of vulnerability to this complication remains undefined. A 62-year-old diabetic male underwent primary percutaneous coronary intervention with a Taxus Express stent (Boston Scientific, Natick, Mass) implantation in 2003 for anterior wall myocardial infarction (AWMI). The patient was on dual anti-platelet treatment. He was asymptomatic and his stress test was negative in 2008. After 72 months, the patient was admitted with acute AWMI resulting from stent thrombosis, which was treated successfully. This case underscores the importance of realising that very late stent thrombosis may occur when patients present with angina symptoms.

Elective implantation of intracoronary stents without intravascular ultrasound guidance or subsequent warfarin.

Two hundred forty-three stents (203 Palmaz-Schatz, 40 Glanturco-Roubin) were electively Implanted in 188 lesions in 168 patients (mean age 58 +/- 10 years, 77% males) using angiographic but not ultrasound guidance. Patients were treated subsequently with aspirin and observed in hospital for up to 7 days. Those with acute myocardial infarction, radiolucent defects in coronary arteries suggestive of thrombus, and results that were not optimal after stent implantation were anticoagulated with warfarin and not Included in the study. Two had subacute stent thrombosis and two patients non-Q-wave myocardial infarction in-hospital. At follow-up (median 149 days) none had had subacute stent thrombosis, one suffered non-Q-wave myocardial infarction, none had died, and none had developed major complications at the vascular access site. Fourteen (8%) had undergone further revascularisation procedures. This initial experience suggests that aspirin is sufficient to prevent subacute stent thrombosis after elective high pressure assisted coronary stent implantation without intravascular ultrasound guidance if the angiographic appearance after stent deployment is optimal.

Directional coronary atherectomy for lesions of the proximal left anterior descending artery: initial clinical results, complications and histopathological findings.

BACKGROUND: Directional coronary atherectomy is a percutaneous technique which extends the role of balloon angioplasty to bulky eccentric coronary lesions. AIMS: To report the early experience, clinical results, complications and histopathological findings of directional coronary atherectomy (DCA) in proximal left anterior descending artery (LAD) stenosis. METHODS: Study of 25 lesions in 24 patients on whom directional atherectomy was performed on the proximal LAD artery with the Simpson coronary atherectomy device. RESULTS: Twenty-five procedures were performed on 24 patients with stenosis in the proximal LAD artery. There were 21 males and three females with a mean age of 56.5 years. Sixteen patients presented with stable angina and eight with unstable angina. Eight patients had previous myocardial infarction (MI). Angiographic success was obtained in 24 of 25 lesions (96%). The mean lesion length was 13.1 +/- 3.7 mm and the mean LAD artery diameter was 3.6 +/- 0.5 mm. Minimal luminal diameter improved from 0.9 +/- 0.4 mm to 3.0 +/- 0.5 mm and the percentage diameter stenosis reduced from 75 +/- 12% to 16 +/- 9%. Complications included acute occlusion in one patient, non-Q MI in three patients, local vascular complications in one patient and side-branch loss in one patient. Histology demonstrated fibrous cap of atherosclerotic plaque in 100%, media and internal elastic lamina in 28% and intimal hyperplasia in 100% of restenotic lesions and 27% of native lesions. Restenosis rates in angiographically restudied patients was 27%. The mean minimal luminal diameter at follow-up was 2.3 +/- 0.9 mm and the mean percentage diameter stenosis was 35 +/- 21%. CONCLUSION: From this initial study, we conclude that DCA is an effective and safe procedure for the treatment of large proximal LAD lesions. DCA provides a large luminal diameter and "smoother' angiographic appearance compared to coronary angioplasty. Acute complication rates are low and restenosis rates were comparable with percutaneous transluminal coronary balloon angioplasty.

Sequential implantation of dissimilar tandem stents for long dissections complicating percutaneous transluminal coronary angioplasty.

Acute closure remains a significant complication of percutaneous angioplasty, and coronary artery stenting serves as a useful bail-out device. We describe two cases of sequential implantation of dissimilar tandem stents, a Gianturco-Roubin (4 x 20mm) stent and a Palmaz-Schatz (4 x 15mm) stent, for long dissection complicating percutaneous transluminal coronary angioplasty.