Physiological effects of percutaneous interventions / Coronary stenting in challenging cases 1244 | Loss of functional recovery In regional wall motion Is predictive for restenosis of the supplying angloplasty vessel - follow-up echocardtographlc study after high-risk angloplasty Adrian C. Borges, Franz Xaver Kleber, Dorothee SchOrger, Qert Baumann, Rosa Sicari', Alessandro Plngitore', Eugenio Rcano 1 . Medical Department I, Humbotdt-Unlverslty BerSn (Charite), Germany;1 Physiologic CSnic, CNR Pisa, Italy, on behalf of the VIDA (Viability Identification with Dobutantine-CHpyiidamote Adrrfnistmtion}Study Group The prediction of functional regional recovery Is possible wtth pharmacological stress echocarcbography and has In patients with severe left ventricular dysfunction and coronary artery disease a great prognostic Impact The aim of the study was to evaluate If the loss of recovery of regional left ventricular function after successful revascuiarization can predict a restenosis of the target vessel. Eighteen patients with resting wall motion dyssynergy, an ejection fraction < 35% and with anglographically proven coronary artery disease underwent stress echocardtography wfth: 1) low dose dobutamine (DOB): 5-10 /ig/kg/mln over 3 min; 2) infratowdose dipyridamoie (DIP): 0.28 mg/kg over 4 mln; 3) combination of Infra low dose DIP followed bytowdose DOB (DIDO). All patients underwent elective assisted percutaneous translumina! coronary revascuiarization under Intraortic baltoon counterputeation (n = 8); extracorporal circulation (n = 4) and hemopump (n = 4) as mechanical support systems. EchocardJography and coronary angiography was performed in each patient within 4-6 weeks and 6 months after angkipiasty. Out of 67 dyssynergic segments, which demonstrate a functional recovery at least one grade within the first 4 weeks, 38 segments (57%) tost their recovery and reached the status before revascuiarization. The positive predictive value of toss of functional recovery for restenosis was 85%. In conclusion the toss of functional recovery of viable and revascularized dyssynergic segments has high predictive value for restenosis in patients with severe systolic dysfunction after angloplasty. G.B. Anguissola2, J. Marco 1 , M. Kozakova 3 , C. Patombo3, J. Fajadet1, M. Bemles 1 , B. Cassagneau 1 , C. Loubeyre 1 , C. Jordan 1 , A. Distante3, L Gregorini 2 . 1 Cllnique Pasteur, Toulouse, France;2 CUnka Medics e Ovrurgica-Ospedale Maggtore, Unlverstta cB KUIano;2~3 Centro <S Fisiotogia CUnka;3 CNR- Unlverslta oV Pisa, Italy During acute myocardJal ischemia, an increase in systolic shortening and in wail thickening has been measured In non ischemlc areas In experimental animals (Theroux Circ Res 74). Being the effects of repeated baitoon Inflations on LV thickening largely unknown In humans, in 10 patients undergoing PTCA for a 76 ± 2% eptoanfioi vessel stenosis we studied dtastolic (DWT) and systolic (SWT) wall thickness by means of transesophageal echocardtogram (TEE, short axis, HP2500-Tomtec) during 2 subsequent 3 mln inflations followed by 2 min reperfusion. TEE was continuously performed during inflations and reperfuslon. DWT and SWT were measured In the region supplied by the balloon occluded vessel and in 3 other normally supplied regions (No-PTCA). DWT and SWT measurements at 1 " , 2 nd and 3"1 min Inflation were compared to the corresponding mln during the 2 nd Inflation. Results: During the 1 " and 2 n d inflation DWT and SWT progressively decreased as shown in graph but no significant differences were found between 1 " , 2 nd and 3"1 mln % reduction in wall thickness nor between 1 " and 2 nd Inflation measurements. Differently from previous findings obtained in animal studies no Increase In LV regional function or in systolic wall thickening was found during balloon inflation in normally supplied regions (No-PTCA). As shown in graph, a significant reduction in D and SWT was observed during the 1 " Inflation. This effect was less evident but still present during the 2 nd Inflation. 2 PTCA » NOJTCA 2nd Inflation Conclusions: In man repeated episodes of myocardJal ischemia eflctted by balloon inflation, followed by reperfusion, Induce a significant reduction in regional wall thickening which occurs not only in acutely anoxic myocardium but also in surrounding normally supplied territories. CORONARY STENTING IN CHALLENGING CASES 1246 | Elective stenting for the treatment of lesions located In small coronary arteries M. Romero, J. Suarez de Lezo, A. Medina, M. Pan, E. Hernandez, J. Segura, F. Mellan, M. Ruiz, R. Zayas, J.R. Ortega. Retna Sofia Hospital; University of Cdfdoba and Pino Hospital, University of Las Palmas, Spain Lesions located in small coronary arteries have not been considered for elective stent implantation due to a higher risk of subacute occlusion. However, new strategies in deployment technique and anttthromtiotic therapy could improve the results of this type of therapy in small coronary arteries. Thus, from a total of 1359 patients (pts) treated wtth stent Implantation, we selected for analysis 127 of 61 ± 10 years of age, with coronary stenosis developed in vessels of an arterial size less than 2.75 mm diameter (moan: 2.55 ± 0.18 mm; range: 2.15-2.75 mm), measured after a bolus (0.3 mg) of intracoronary nitroglycerin. The clinical condition was stable In 26 and unstable In 101 pts. The treated artery was the left anterior descending in 72 pts, the circumflex In 36 and the right coronary artery in 19. In ail Instances a standard 2.5 mm diameter balloon catheter was used for stent deployment; then, an additional overexpanston was performed wtth a short (9-15 mm length) balloon of 3 mm diameter at 14-16 atmospheres. The antJtfirombotic regimen was as follows: tow-molecular weight heparin (Fragmin 10000 ILJ/day) from day one to 3 weeks, Bctopkfine 500 mg/day and aspirin 150 mg/day. The baseilne minimal lumen diameter was 0.5 ± 0.3 mm, and It increased to 2.6 ± 0.4 mm after Implantation. There were no subacute occlusions or major complications. After 7 ± 3 months follow-up, 47 pts out of 127 (37%) underwent angtographlc re-evaluation. Restenosis (stenosis > 50%) developed In 20 (43%); 12 of them were successfully redilated, while 3 underwent elective surgery. Conclusions: New technical and pharmacotogicai strategies altow for elective stenting of lesions In small coronary arteries. This treatment provides a high rate of primary success and atowincidence of complications. However, restenosis rate seems higher than that observed in larger vessels. 1247 Coronary stenting of small coronary arteries. Preliminary results of a pilot study with a 2.5-mm mlcrostent AVE M.C. Morlce 1 , B. Valeix2, P. Dumas, Y. Louvard, T. Lefevre, P. Labrunie. ' ICV Paris Sud, France; * UCV Marseille, France Coronary stenting demonstrates its capacity to Increase acute success of PTCA and to prevent restenosis In arteries of 3 mm and more. However In small arteries coronary stenting Is associated with a high risk of subacute thrombosis, furthermore the prevention of restenosis by stenting has not been proven In small arteries. In order to assess the feasibility and the safety of elective stenting In small arteries, we decided to conduct a pilot study in two institutions with 100 pts etectrvety stented with a 2.5 mm AVE mlcrostent Patients had stable or unstable angina, single or muttivessel disease, single or multiple PTCA sites but at least one lesion on a small vessel stented wtth a 2.5 mm AVE mlcrostent The end points were: In-hospital events and anglographic patency of the stented arteries at 6 months. From March 1995 to February 1996, 30 pts received 36 (1.2 stents/pts) 2.5 mm mlcrostents. Reasons for stenting were: 15 (50%) elective, 10 (36.6%) suboptimal results, 5 (13.8%) non ocdusJve dissection. The patients were treated with 100 mg Aspirin and 250 to 500 mg of Tictopidine for one month; they did not receive post-procedural Heparin. Results: during hospital stay (mean 3.6 days) no patient dted, had surgery or an Ml. Eighteen pts had their 6 month angtogram, no stent was occluded, 5 (28%) pts had restenosis at the stem site and had repeat PTCA. In conclusion: If these preliminary results are confirmed wtth a larger number of patients, coronary stenting of small arteries with 2.5 mm mlcrostent seems to be feasible and safe. This pilot study will be followed by a randomized trial which will compare the restenosis rate of 2.5 mm microstent AVE with GOBA. Downloaded from by guest on November 10, 2014 1245 Effect of Ischaemlc pre-conditioning on left ventricular regional function in man 217 218 1248 Coronary stenling in challenging cases Is endolumlnal coronary reconstruction using overlapped Glanturco-Roubln atents to treat long complex lesions an acceptable procedure? C. Karam, C. Loubeyre, B. Cassagneau, J. Fajadet, C. JojrJan, J.P. Laurent J. Marco. Ctinkjue Pasteur, Toulouse, France PTCA of long complex coronary lesions often requires the use of two of more overlapped sterns in the same artery. From August 1993 to January 1996, we Implanted In 101 patients two or more overlapped Glanturco-Floubin (QR) stems in the same vessel: 82 men and 19 women, mean age 63 ± 10 years (34-83), of whom 74% had muttivesse! disease and 62% unstable angina. All patients received aspirin and tfdopkfine associated wfth subcutaneous low molecular heparln. Indications for stenting were: dissection in 39.6%, bailout In 8.9%, elective Implantation in 51.5% and restenosis in 4% of the procedures. Attempted vessels were: 51.5% LAD, 31.7% RCA, 11.9% LCx, 4.0% left main artery and 1.0% saphenous vein graft. 92.1% of the patients had no inhospltal complications. None required emergency CABQ. Major cardiac events occurring during the first month following stent implantation were compared with those obtained in 489 pts treated with single GR stents during the same period: Femoral compflcaUora Myocardlal Infarction Death Subacut* thrombosis Reconstruction Single GR 3.0% 20% 1 1% 1.1% 2.7% 0 8% 0.5% 0.5% MS NS NS NS 1249 Single centre Initial experience with the new long coronary Wallstent M.R. Thomas, R J . Wainwrlght, J. Metcatfe, D.E. Jewltt. Dept of CanHotogy, King's College Hospital, Denmark HIH, London, UK We report our Initial experience, including procedural success and In-hospital complications of the newty available long coronary Wallstent. Between May and February 1996 we attempted to deploy 103 WalJstente In 89 patients (pts). Indications were saphenous vein graft (SVG) stenoses and long segment disease in native coronary arteries. Stenting was performed electively in 72 (81%) patients, for sub-optimal PTCA result In 15 (17%) and threatened vessel closure In 2 (3%). In 3 pts a Wallstent could not be delivered resulting In a successful deployment rate of 100/103 (97%). Wallstents were deployed in both SVGs (n = 22) and native coronary arteries (RCA = 43, LAD = 14 and Cx = 7). The mean Wallstent diameter was 3.9 mm and mean length 36.9 mm (Implanted stent length range •> 22 to 49 mm). All pts received prolonged heparln, aspirin and warfarin. Stents were sized according to the reference diameter in the first 50 patients but oversized by 0.5-1.0 mm in the final 49 patients. A single Wallstent was placed in 75 patients while multiple Wallstents were used in 11. Alternative stents were used to tidy up' the final angiographlc appearance In 30 pts (33%). Six pts had stent thrombosis. This occurred In 1/22 SVGs (4.5%), 1/43 RCAs (2.3%), 4/14 LADs (28.6%) and 0/7 (0%) Cx vessels. Angiographic factors potentially associated with stent thrombosis could be Identified In 4/5 cases of stem thrombosis In native coronary arteries (failure to overlap multiple stents in 2, proximal non-etented disease In 1 and poor caliber distal vessel in 1). At follow-up 2 pta have had clinical restenosis (1 rpt PTCA, 1 CABG). There have been no late Mis or but 1 late sudden death. In conclusion care to optimise the post-deptoyment angtographic appearances (including overlapping multiple stents and ensuring adequate cflstal runoff) appears important when this stent is used in long segment disease. A policy of oversizlng the stent to the reference diameter may be important In reducing stent thrombosis but the effect of this policy on subsequent restenosis is unclear. Some concern must remain about the use of this stent In the native LAD. We believe the corona/y Wallstent shows potential for the interventional treatment of this difficult group of pts with SVG stenoses and long segment disease of native coronary arteries, particularly the right coronary artery. B. Chevalier, B. Glatt, T. Royer. Centre CanBologJque du Nord, Saint-Denis, France Bifurcation lesions, including stenosis of the side branch, is a complex lesion; its stenting can improve short and midterm results but its complete coverage is a technical challenge. We retrospectively studied the feasibility of a "kissing stenting" procedure using coil stenting of the main branch then a coil Meriting of the side branch crossing the struts of the first stent, according a "reverse Y" design. Eleven pts were treated using Glanturco-Roubin' stem in 2 and Freedom stent in 9, on 7 LAD 3 RCA and one circumflex artery. Procedure was done with a 6F access In 5 pts. Anglographic and procedural data were: Main branch C type lesion Artery diameter (mm) Lesion length (mm) pre-PTCA MLD (mm) De novo Indication Stem length (mm) Stem darneler (mm) Final MLD (mm) Residual stenosis (%) Success SUe branch 1 6 3.1 ± 0 . 7 2.6 ±9 16±9 0.5 ± 0.4 0.8 ± 0.7 7 25±8 3.2 ±0.3 2.8±07 9±12 11 9±6 2 17±4 3 ±0.3 2.45 ±1.1 3±6 11 In two cases, side branch stent crossing through the main branch stent was Initially impossible and needs additional balloon Inflation. After deployment of the two stents, additional balloon Inflation was done: in the main branch in 6 cases, in the two branches simultaneously in 3 cases. The only clinical event was a noo-Q Ml In a ball-out case. Thus, the use of a cdl stent in the main branch of bifurcation lesion allows a complete coverage of the bifurcation using a second coil In the side branch, even In case of suboptimal result. This "reverse Y" stenting seems highly feasible. 11251 | Multivessel stenting without anticoagulaUon: immediate and short-term outcome Issam Moussa, Carlo Dl Mario, Lucia Di Francesco, Bemhard Relmers, Slmonetta Blenglno, Massimo Ferraro, Giovanni Martini, Jonathan Tools, Antonio Colombo. Columbus Hospital, Milan, Italy This study evaluates short term results of multivessel stenting without anfJcoagulatkxi In 100 consecutive pts (mean age 59 ± 10 yr.) wtth 239 lesions. 2 vessel and 3 vessel disease were present In 75%, and 25% of pts respectively. Pts with unprotected left main stenting and with ejection fraction < 0.35 were excluded. Stenting was elective in 62% of lesions. Reference vessel size was 3.15 ± 0.48 mm. Different stents were used (Palmaz-Schatz 54%), wtth 1.4 ± 0.8 stents per lesion, 1.8 ± 1.2 stents per vessel, and 3.3 ± 1 . 6 stents per patient Balloon-to-vessel ratio was 1.1 ± 0.16, maximal balloon Inflation pressure was 16 ± 3 aim, and the final lumen diameter % stenosis achieved was - 2 ± 15%. (VUS guidance was used m 87% of lesions. Antiplatelet regimen consisted of: ticlopldlne+asplrln (69%), aspirin alone (26%), and (5%) of pts received wartarin+aspirin. Angiographic procedural success was achieved In 97% of lesions, procedural complications Included: vascular 2%, non-Q wave Ml 6%, O-wave Ml 1%, CABG 2%, death 0%. Angiographic subacute stent thrombosis occurred In 1 lesion (0.4%). Clinical follow-up was performed In 95% of patients at 7.3 ± 3.3 mo, with a cumulative event rate as follows: target lesion PTCA 17%, Ml 3.2%, CABG 3.2%, death 3.2%. Follow-up angina was present In 23% of patients. Angiographic follow-up was performed in 85% of lesions at 5 ± 1.8 mo, angiographic restenosis (defined as > 50% diameter stenosis) was 22.5% based on a per-leston basis. Conclusions: 1) Multivessel stenting without anticoagulation could be performed with a low rate of procedural complications Including acute and subacute stent thrombosis. 2) Short-term clinical events are relatively high reflecting the occurrence of restenosis. Effective strategies to control the incidence of restsno&s need to be developed to improve the long term benefits of this procedure. Downloaded from by guest on November 10, 2014 Despite differences In terms of type C lesions (58.4% vs 48.5%) and bailout situation (8.9% vs 4.9%), short-term results were not statistically different between the two groups, though myocardlal infarction and death rates were slightly higher in the reconstruction group. We conclude that, with the use of aspirin and ticlopidlne, endoluminal reconstruction with overlapped Glanturco-Roubtn stents In long complex lesions is feasible, safe and allows to expect acceptable short-term results. 11250 | Kissing stenting In bifurcation lesions
© Copyright 2024