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.
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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.
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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