bluuebunny/crossref_metadata_2025 huggingface dataset:
Mechanism of Myocardial Infarction in a Case with Acute Reocclusion of a Recanalized Chronic Total Occlusion: A Case Report
Authors: WASER MARCO , KAUFMANN URS , MEIER BERNHARD
Published: June 2007

Catheter recanalization of chronically occluded coronary vessels is considered a low risk intervention although significant complications can occur. Collateral arteries normally prevent ischemia in the myocardial territory distal to the occluded segment even in case of reocclusion after successful recanalization. This case report documents the unexpected event of myocardial infarction in such a setting due to an almost simultaneous procedure related peripheral embolization of thrombotic and/or atherosclerotic material and subsequent reocclusion of the dilated vessel segment.
Intracoronary Irradiation with 186/188Rhenium Following Balloon Overstretch Injury Reduces Neointima But Does Not Impair Vasoreactivity of Porcine Coronary Arteries
Authors: BHARGAVA BALRAM , WAKSMAN RON , VODOVOTZ YORAM , CHAN ROSANNA C. , COLLINS SARA D. , PIERRE ANTHONY , LAVIE EFI
Published: June 2007

Objective: The purpose of this study was to assess the effect of 186/188rhenium (186/188Re) on the neointimal proliferation and on the vasomotion of irradiated porcine coronary arteries following balloon injury. Background: Intracoronary radiation (IR) at doses of 10–25 Gy reduces intimal hyperplasia in animal models and lowers restenosis in clinical trials. The response of coronary arteries to acetylcholine (ACh) has been used to examine endothelial function, but this has not been reported in porcine coronary arteries subjected to overstretch balloon injury (BI) and subsequent IR. Methods: Vasomotor response was studied at baseline and at 2 weeks in 20 swine. Baseline vasomotor study without BI was carried out in six animals (12 arteries; Group I, no injury, no radiation). Subsequently the left anterior descending (LAD) and the left circumflex (LCX) arteries of 11 animals were subjected to BI. Eight of these animals (15 arteries) were subjected to IR with 186/188Re in the LAD and LCX arteries in doses of 15 Gy followed by vasomotor studies at 2 weeks (Group II, BI, radiation). Three animals, (six arteries) of the BI group were not subjected to IR and their vasomotor functions assessed two weeks later (Group HI, BI, no radiation). Endothelium dependent vasomotion was assessed by Doppler flow wire and by quantitative coronary angiography (QCA) following selective infusion of serial doses of ACh proximal to the injured and irradiated segments. Nitroglycerin (200 μg) was injected intracoronary to detect endothelium independent vasodilatation. Histomorphometry and QCA analysis was performed to confirm the effect of IR on intimal area (IA), and IA corrected for fracture length (IA/FL). Results: Responses to ACh infusion and coronary flow reserve were similar at baseline before injury and at 2 weeks following injury with and without radiation. The irradiated vessels demonstrated normal vasodilatation responses to nitroglycerin. The irradiated vessels showed a marked reduction in IA and IA/FL. Conclusion: The vasoreactivity of irradiated coronary arteries is preserved at doses that inhibit neointima formation in the porcine model.
Experimental Results with 90Yttrium Beta‐Particle Emitting Radioactive Stents in a Porcine Model of Restenosis
Authors: CARTER ANDREW J. , SWEET WILLIAM , BAILEY LYNN , JONES RUSS , VIRMANI RENU , FISCHELL TIM A.
Published: June 2007

Background: Radioactive stents have been proposed as a means to prevent restenosis. The ideal radioisotope to deliver endovascular irradiation via a radioactive stent is unknown. Objectives: To evaluate the dose response effects of “high” dose rate irradiation delivered by a high energy, short half‐life, beta‐particle emitting 90yttrium (90Y) radioactive stent on neointimal formation in a porcine coronary model of restenosis. Methods: Fifty‐two 0–16.0 μCi 90y radioactive stents were implanted in the coronary arteries of 19 swine. Stents were oversized 10% to 20% greater than the baseline angiographic lumen diameter. After 28 days, quantitative histological analysis was completed to determine neointimal area and percent in‐stent stenosis. Results: The mean vessel injury scores were similar for the control and each of the 90Y radioactive stent groups. Neointimal area correlated with vessel injury for the control (r =0.54, P < 0.0001) stents. The percent in‐stent stenosis was similar for the nonradioactive control and the 0.25, 0.5, 1.0, 1.25, 2.0, 8.0, and 16.0 μCi 90Y radioactive stents. The neointimal area was greater for the 4.0 μCi (3.95 ± 1.16 mm2) and 8.0 μCi (3.55 ± 1.09 mm2) 90Y stents as compared with the nonradioactive control stents (2.40 ± 7.72 mm2, P ≤ 0.03). The increased neointimal area for the 4.0 μ90Y stents resulted in significantly greater percent in‐stent stenosis (55 ± 12) versus control nonradioactive stents (36 ± 18, P < 0.05). Conclusions: A radioactive stent manufactured with the short half‐life beta‐particle emitting radioisotope 90Y, designed to deliver a higher dose rate at implant than a 32P radioactive stent, is ineffective in reducing neointimal formation in the porcine coronary model of restenosis. Further study is required to define effective cumulative dose and dose rate delivery for radioactive stents.
Noninvasive Assessment of Left Ventricular Viability: Did We Underestimate the Potential of Stress Echocardiography
Authors: NIXDORFF UWE
Published: June 2007

The presence of myocardial viability within a noncontracting infarct zone is an important determinant for left ventricular function recovery after interventional coronary revascularization. However, this holds true only for hibernating myocardium in which a perfusion‐limiting infarct‐associated coronary artery stenosis persists (in contrast to stunning with postischemic reperfusion and spontaneous recovery). Echocardiographic techniques are highly valuable in identifying hibernation, especially in conjunction with dobutamine titration. Low doses may detect the inotropic reserve by significant enhancement of segmental wall‐motion abnormalities while high doses may surpass the ischemic threshold and the wall motion deteriorates (biphasic response). Dobutamine echocardiography should not be performed too early after the infarct, not only because of security reasons (arrhythmogenic potential), but also because of higher diagnostic accuracy (resolution of stunning within the first several days postmyocardial infarction thereby separating viable myocardium attributed to hibernation). According to the Task Forces on Clinical Application of Echocardiography by the American Heart Association in cooperation with the American College of Cardiology, dobutamine echocardiography is officially recommended for the purpose of clinical decision making in respect to revascularization therapies (whether during the subacute infarct period or, especially, in chronic left ventricular dysfunction due to coronary artery disease).
Polytetrafluoroethylene‐Covered Stents: Indications, Advantages, and Limitations
Authors: STÖRGER HANS , HAASE JÜRGEN
Published: June 2007

Stents are the most important advance for percutaneous coronary revascularization. However, restenosis, peripheral embolism following stent implantation in old vein grafts, and conditions in which there is a discontinuity of the coronary lumen (rupture or perforation, aneurysm, and fistula) remain a problem in interventional therapy. Stent grafts with integration of a polytetrafluoroethylene (PTFE) membrane into a coronary stent represent an interesting concept to possibly prevent intraluminal proliferation, to seal degenerated vein grafts, and to cover coronary artery perforations, symptomatic aneurysms, and fistula with high success and acceptable rates of acute complications. Based on a potentially delayed reendothelization of PTFE‐covered stents, possibly leading to late thrombo‐occlusive events, prolonged antiplatelet therapy seems to be necessary. Although the overall information about restenosis in stent grafts is limited, there are some promising long‐term results in degenerated vein grafts that require confirmation by randomized, controlled studies.
Surface Profile of the Internal Elastic Lamina May Modulate Thrombosis Following Intracoronary Radiation in Balloon‐Injured Porcine Arteries
Authors: COTTIN YVES , KOLLUM MARC , KIM HAN‐SOO , CHAN ROSANNA C. , BHARGAVA BALRAM , CATES PAMELA C. , VODOVOTZ YORAM , WAKSMAN RON
Published: June 2007

Background: Intracoronary radiation (IR) can prevent neointima formation (NF) by reducing smooth muscle cell (SMC) proliferation after balloon angioplasty, but is complicated by subacute and late thrombosis. Rupture or abnormalities of the internal elastic lamina (IEL) structure and subsequent exposure of blood to the injured arterial wall can induce thrombosis and inflammation. The purpose of this study was to evaluate the effect of IR on the media and IEL after balloon overstretch injury in porcine coronary arteries. Methods: Seventeen juvenile swine (25 coronary arteries) were injured by overstretch balloon and subsequently given IR at doses of 0 or 18 Gy 90Y prescribed to 1.2 mm from vessel wall inner surface. Two weeks following treatment, tissue sections were perfusion fixed and stained by hematoxylin‐eosin or by Verhoeff‐von Giesson. Smooth muscle cell α‐actin was detected immunocytochemically and quantified by digital image analysis using arbitrary density units. Histomorphometry was carried out to assess intimal area (IA) and IA corrected for medial fracture length (IA/FL). The roughness index (RI) of the IEL was calculated from the surface profile length and the straight‐line length. Results: NF was markedly smaller after IR as compared to control treatment. Mural thrombi were increased significantly in irradiated versus control arteries (11/14 [78%] vs 1/11 [9%]; P < 0.001). A significant decrease in SMC density was observed in the irradiated group (128 ± 13 vs 74 ± 10; P < 0.001) despite a lack of difference in medial area. The surface of the IEL was more irregular in irradiated arteries, particularly at the medial breaks (RI =20.1 ± 3.1 vs 8.7 ± 1.2; P < 0.001). When mural thrombi were present, thrombus area correlated with RI (α= 0.76; P < 0.01). Furthermore, in the irradiated group RI correlated positively with SMC density (α=0.64; P < 0.01). Conclusion: Medial structure and RI may be useful parameters by which to assess arterial healing following IR. These findings may influence the design of future IR studies aimed at reducing thrombosis and enhancing arterial healing.
Excimer Laser Angioplasty with Adjunctive Balloon Dilatation Versus Balloon Dilatation Alone for the Treatment of In‐Stent Restenosis: Results of a Randomized Single‐Center Study
Authors: HAASE JÜRGEN , STÖRGER HANS , HOFMANN MANFRED , SCHWARZ FRANZ
Published: June 2007

Background: Laser ablation of neointimal tissue prior to balloon dilatation has been shown to be a potential treatment modality for restenosis within previously implanted stents. It remains controversial whether this treatment provides superior acute and long‐term results compared to conventional balloon dilatation. Methods and Results: Between November 1995 and November 1996, 96 patients with significant (≥ 50%) in‐stent restenosis were randomized to receive excimer laser angioplasty with adjunctive balloon dilatation (ELCA + PTC A, n = 47) or PTCA alone (n = 49). Both groups did not differ with regard to gender, clinical history, location of the lesion, reference diameter, or lesion length. Angiographic success was achieved in 46 patients with ELCA + PTCA (98%) and in 48 patients with PTCA alone (98%). In‐hospital complications included acute closure in one patient of each group, one CABG, one repeat PTCA, and one non‐Q wave MI with ELCA + PTCA, versus two bleeding and one death with PTCA. Clinical follow‐up was obtained in all patients, while angiographic follow‐up was available in 35 of 47 (ELCA+PTCA) versus 35 of 49 (PTCA) patients with a mean follow‐up time of 163 ± 81 days. With ELCA+PTCA, MLD increased from 0.82 ± 0.38 to 1.99 ± 0.33 mm versus 0.81 ± 0.39 mm to 2.07 ± 0.60 mm with PTCA (P = NS). At follow‐up, MLD was 1.32 ± 0.60 mm with ELCA + PTCA versus 1.45 ± 0.75 mm with PTCA (P = NS). Late adverse events included nine repeat PTCA with ELCA +PTCA (19%) versus 12 with PTCA (24%), three CABG with ELCA +PTCA (6%) versus two with PTCA (4%), and one death (2%) with PTCA (P = NS). Angiographic restenosis rate was 52% with ELCA + PTCA versus 47% with PTCA alone (P = NS). Conclusion: Our data suggest that excimer laser angioplasty with adjunctive balloon dilatation for the treatment of in‐stent restenosis provides similar acute results as plain balloon dilatation and may offer no advantage over PTCA alone with regard to intermediate‐term outcomes.
Directional Coronary Atherectomy of In‐stent Restenosis: A Two‐Center Experience
Authors: HABERBOSCH WERNER , WAAS WOLFGANG , WALDECKER BERND , HEIZMANN HEINRICH , HÖLSCHERMANN HANS , RAU MATTHIAS , TILLMANNS HARALD
Published: June 2007

Background: Tissue proliferation is the major cause of in‐stent restenosis (ISR). Thus, debulking of material should be the most favorable method to treat ISR. The present study was performed to test the clinical and angiographic outcome of directional coronary atherectomy (DCA) in the treatment of restenosis within different stents. Methods and Results: Fifty patients with ISR in single stents (12 Palrnaz‐Schatz stents, 8 Pura stents, 10 Multilink stents, 10 NIR stents, 8 Wallstents, and 2 Microstents) underwent DCA with adjunctive balloon angioplasty in 38 patients. Primary success was achieved in 48 patients (96%). Two patients developed CK‐MB elevations, one with a Q‐wave infarction. Some minor technical problems occurred with respect to the different stent types. The percent diameter stenosis decreased from 76 ± 7% at baseline to 29 ± 6% after atherectomy (P < 0.0001) and 20 ± 4% after adjunctive PTCA, and it increased to 45 ± 19% at 4‐month angiography (P < 0.0001). Angiographic restenosis occurred in 14 (29.2%) of 48 patients who were reevaluated after 4 months. Conclusion: While DCA is able to remove u significant amount of intimal tissue in selected patients with in‐stent restenosis, new atherectomy catheter designs are required to make this a feasible and safe procedure.
Soft X Rays: The Alternative?
Authors: ALTMAN JOHN D. , LUBBE DIETER , STAFFORD SCOTT , HOLMES DAVID R. , SCHWARTZ ROBERT S.
Published: June 2007

Summary

Intravascular radiation therapy to prevent restenosis remains promising and is currently undergoing large randomized clinical trials. Intravascular brachytherapy sources include beta particles, gamma rays, and now, soft X rays. The presented, but unpublished data from the START trial indicate that beta radiation is effective in the treatment of in‐stent restenosis. However, the limited range of beta particles in tissue increase the complexity for treating large arteries, more dose asymmetry with imperfect centering, and the potential for shadowing when treating calcified or stented arteries. These dosing problems are avoided with high energy gamma rays, but at a cost of increased radiation exposure. Soft X rays generated by high voltage, miniaturized x‐ray tubes may be turned off at will, pose little radiation exposure risk to medical personnel, provide a satisfactory dose profile to the artery, and do not require special use licensing. The higher LET and RBE for soft X rays indicates that lower doses may be as effective. Soft x‐ray sources will permit a new therapy to enter the expanding discipline of vascular brachytherapy.
Management of Patients with Acute Coronary Syndrome: Should We Rely on Cardiac Markers?
Authors: HEINTZEN MATTHIAS P. , HEIDLAND ULRICH E. , STRAUER BODO E.
Published: June 2007

Early diagnosis and risk stratification of patients presenting to the emergency room for a suspected acute coronary syndrome is an emerging problem. In general, diagnosis is based on an ECG, clinical presentation, and elevated cardiac markers. In the past decade cardiac troponins and myoglobin have been identified as important markers for the global assessment and treatment of patients with acute coronary syndromes. Recent studies have identified patients with increased troponin I and T levels as a high risk population gaining benefit from the adjunctive treatment with glycoprotein (GP) IIb/IIIa receptor antagonists or low molecular weight heparin. Myoglobin was introduced as a sensitive marker of successful or failed reperfusion following thrombolytic therapy. These studies indicate that cardiac markers are important tools in the risk stratification of patients with acute coronary syndromes allowing adequate treatment decisions. However, certain limitations of cardiac markers have to be considered. These limitations mainly refer to the delay in time from presentation to the emergency room to the availability of the results of the blood sample. Thus, in the individual case, especially if an ECG and clinical presentation are unspecific or there is doubt concerning the success of thrombolytic therapy, early angiography remains the gold standard for diagnosis and establishment of adequate therapy. In this setting, early reperfusion by percutaneous coronary interventions will increase myocardial salvage, and therefore, should be preferred to the delayed confirmation of the diagnosis by repeated determination of cardiac markers.
Transradial Approach for Coronary Intervention: 25 Years for 25 Centimeters
Authors: LEFÉVRE THIERRY , LOUVARD YVES , LOUBEYRE CHRISTOPHE , DUMAS PIERRE , PIECHAUD JEAN‐FRANQOIS , MORICE MARIE‐CLAUDE
Published: June 2007

The first series of transradial coronary angiograms was carried out by Lucien Campeau and published in 1989. The devices available at that time made the technique difficult to perform. Four years later, when stenting started being widely used with a significant rate of local complications induced by Coumadin treatment, F. Kiemeneij proposed the radial approach as a good alternative to the femoral approach to reduce the rate of local complications. Since then, the use of the radial approach has been increasing, though it remains limited. The first reason for this lies in the significant learning period that is all the longer as a low percentage of patients are treated via this approach. This is why we think it is preferable to perform at least 25% of all procedures, and especially coronary angiograms, through this approach before setting up a radial program. Patients with contraindications to the femoral approach (anticoagulation or GP IIb/IIIa inhibitors, obesity, aneurysm of the abdominal aorta, or vessel disease of the lower limbs, etc.) should be selected. The second reason is the small diameter of the radial artery that can generate a number of problems when large diameter guiding catheters are used (7Fr or 8Fr). However, the reduction in guiding‐catheter size, and the increasing use of 6Fr catheters should solve this problem. In our center, the femoral approach is usually selected when 7Fr or 8Fr catheters are used. It is to be noted that the radial approach is now widely used in some interventional cardiology centers where the learning period has been completed. With operator experience, puncture failure is extremely rare and the technical failure rate is around 1%, mainly due to the anatomic variations of the radial artery (antebrachial and humeral loops). Apart from the difficulties associated with the learning curve, the radial approach has few limitations. The procedure and x‐ray exposure times are slightly longer for coronary angiography but not for angioplasty. The risk of radial occlusion ranges from 2% to 5%, however, radial occlusion is asymptomatic in patients with a normal Allen's test. Conversely, the radial approach has many advantages. Patient comfort is significantly improved due to the ease of radial compression, ambulation is almost immediate, and the rate of local complications is almost nil. Same day discharge following coronary angiography and angioplasty can be considered. Finally, with the increasing use of GP IIb/IIIa inhibitors, sometimes in combination with thrombolysis in the treatment of myocardial infarction, the radial approach could become the preferred approach in this setting.
Stenting Versus Surgery of the Thoracic Aorta
Authors: INCE HÜSEYIN , NIENABER CHRISTOPH A.
Published: June 2007

Aneurysms and dissections of the aorta represent a potentially life‐threating situation. Surgical resection and interposition of vascular prostheses (Gortex or Dacron) has long been considered the only treatment option. Although there have been great strides during the past decades in the management of patients with thoracic aortic aneurysms and dissections by new surgical techniques, postoperative morbidity and mortality remain high. The afflicted population is usually of older age and present with a variety of comorbidities and significant impact on postsurgical outcome. Postoperative complications, such as paraplegia and renal insufficiency, contribute to prolonged hospital stays and higher medical costs. Conversely, interventional stent‐graft placement may be a promising nonsurgical strategy for the treatment of thoracic aortic aneurysms and dissections. The endovascular stent‐graft prostheses is based on the concept of a metal grid covered with vessel graft material. The initiation of the natural healing process by exclusion of an aneurysm or sealing of the proximal entry in dissection induces remodeling of the aortic wall and consolidation of the false lumen. Although the initial results of stent‐graft treatment of thoracic aortic aneurysms and dissections are promising, the concept of nonsurgical reconstruction must be subjected to a randomized long‐term study.
Identification of Hemodynamically Significant Restenosis after Percutaneous Transluminal Coronary Angioplasty in Acute Myocardial Infarction by Transesophageal Dobutamine Stress Echocardiography and Comparison with Myocardial Single Photon Emission Computed Tomography
Authors: ROSENKRANZ STEPHAN , VOTH EBERHARD , LAROSÉE KARL , BAER FRANK M. , KETTERING KLAUS , SMOLARZ KAMILLA , MOKA DETLEF , SCHICHA HARALD , ERDMANN ERLAND , DEUTSCH HANS J.
Published: June 2007

Background: Beside thrombolysis, percutaneous transluminal coronary angioplasty (PTCA) has become a well‐established treatment for acute myocardial infarction. However, restenosis occurs in approximately 15%‐40 % of patients. Despite a frequently occurring infarct‐related regional systolic dysfunction at rest, the identification of hemodynamically relevant restenosis seems important in terms of risk stratification, adequate treatment, and possible improvement of prognosis in these patients. This study was designed to assess the role of transesophageal dobutamine stress echocardiography and myocardial scintigraphy for identification of hemodynamically significant restenosis after PTCA for acute myocardial infarction. Methods: Multiplane transesophageal stress echocardiography (dobutamine 5, 10, 20, 30, and 40 μg/kg per min) studies and myocardial single photon emission computed tomography (SPECT) studies were performed in 40 patients, all of whom underwent PTCA in the setting of acute myocardial infarction ≥ 4 months prior to the test. Repeated coronary angiography was performed in all study patients who showed stress‐induced perfusion defects or wall‐motion abnormalities, or both. Results: Significant restenosis (≥ 50%) was angiographically found in 15 (37.5%) of 40 patients. Of these 15 patients, transesophageal dobutamine stress echocardiography identified restenosis in 12 (80%) and myocardial SPECT in 14 (93%), yielding diagnostic agreement in 70% of patients. Echocardiographic detection of restenosis was based mainly on a biphasic response to increasing doses of dobutamine. Sensitivity and specificity for identification of hemodynamically relevant restenosis in individual patients was 80% and 92%, respectively for dobutamine stress echocardiography versus 93% and 68% for myocardial SPECT. Conclusions: Both transesophageal dobutamine stress echocardiography and myocardial SPECT were highly sensitive in identifying significant restenosis after PTCA for acute myocardial infarction. Therefore, either test, as a single diagnostic tool or especially if performed together, are clinically valuable alternatives to coronary angiography for the detection of restenosis after PTCA for acute myocardial infarction.
Interventional Occlusion of Congenital Vascular Malformations with the Detachable Cook Coil System
Authors: SIEVERDING LUDGER , BREUER JOHANNES
Published: June 2007

Introduction: Nonsurgical closure of pathologic vascular communications can be achieved by coil embolization. Different systems used in patients with congenital heart disease (e.g., patent ductus arteriosus) allow controlled release of the devices. However, they are too stiff for coil occlusion of small or tortuous vessels. Methods and Patients: The new detachable Cook coil system combines flexibility with a simple release control mechanism. Five children, age 8 days to 10 years, underwent heart catheterization for interventional occlusion of different vascular malformations (two coronary artery fistulas, two aortopulmonary collaterals, and one hemangioma). The diameter of the vessels varied between 1.8 mm and 3.6 mm and the length between 10 mm and 22 mm. Results: Up to four 0.018” soft spiral coils were placed as distally as possible in the feeding vessels. In addition, in two patients, one to three J‐shaped coils were placed inside and proximal to spiral coils. Positioning of the coils was controlled easily by radio‐opaque markers. Counter‐clockwise rotation of the delivery wire provided fast and safe detachment without movement of the detached coils. Control angiograms showed complete occlusion of the vessels within 10 minutes after delivery of coils. Conclusion: Interventional closure of vascular malformations can be successfully obtained with the detachable Cook coil system. This system offers safe and controlled placement of coils, and it works rapidly in an uncomplicated manner.
Transcatheter Closure of Atrial Septal Defects with the STARFlex Device: Early Results and Follow‐Up
Authors: CARMINATI MARIO , CHESSA MASSIMO , BUTERA GIANFRANCO , BINI ROBERTA M. , GIUSTI SANDRA , FESTA PIERLUIGI , SPADONI ISABELLA , REDAELLI SOFIA , HAUSDORF GERD
Published: June 2007

Background: The STARFlex (SF) device is a CardioSEAL (CS) double‐umbrella device that has been modified by the addition of a self‐centering mechanism comprised of nitinol springs connected between the two umbrellas and a flexible core wire with a pin‐pivoting connection. This paper compares the results of atrial septal defect (ASD) closure with CardioSEAL and STARFlex devices. Patients and Methods: Between December 1996 and March 2000, 117 patients underwent ASD closure with CardioSEAL (n = 79) and STARFlex (n = 38). The mean age (17 years), weight (49 kg), and ASD size (15 mm) were similar in the two groups. The procedures were performed under general anesthesia with both fluoroscopic and transesophageal echocardiographic monitoring. Immediate Results: The devices were successfully implanted in all patients. Ten patients had multiple ASDs. A single device was used in four patients (CardioSEAL in three, STARFlex in one), while a simultaneous placement of two CardioSEAL (one patient) or two STARFlex (five patients) were performed in six patients. The results are summarized as follows:
A Time‐to‐Treatment Analysis in the Medicine Versus Angiography in Thrombolytic Exclusion (MATE) Trial
Authors: MCCULLOUGH PETER A. , O'NEILL WILLIAM W. , GRAHAM MARIANN , STOMEL ROBERT J. , ROGERS FELIX , DAVID SHUKRI , FARHAT ALI , KAZLAUSKAITE RASA , AL‐ZAGOUM MAJID , GRINES CINDY L.
Published: June 2007

Patients with acute coronary syndromes who are considered ineligible for thrombolytic therapy are at high risk of recurrent ischemia and death. This trial randomized 201 patients to triage angiography in the first 24 hours of hospital admission versus conventional medical care. Of the 165 patients who underwent angiography that was either protocol‐driven or on the basis of physician preference, those who underwent angiography within 6 hours of symptom onset had a reduction in early and late adverse events. The rates of in‐hospital recurrent ischemia were 15.4%, 15.4%, 17.5%, 32.4%, and 38.5%, respectively (P = 0.01 for trend), and rates of cumulative recurrent myocardial infarction or death were 0%, 12.8%, 10.0%, 11.8%, and 7.7%, respectively (P = 0.48 for trend) for patients who underwent angiography at 0–6, 6–12, 12–24, 24–48, and over 48 hours, respectively from symptom onset. Future trials of invasive versus conservative therapy should focus on performing angiography within 6 hours of symptom onset.
Initial Experience with a Low Profile, High Energy Excimer Laser Catheter for Heavily Calcified Coronary Lesion Debulking: Parameters and Results of First Seven Human Case Experiences
Authors: FRETZ ERIC B. , SMITH PATTY , HILTON J. DAVID
Published: June 2007

Background: Excimer laser coronary angioplasty (ELCA) has not been used in the setting of highly calcified, tight stenoses because the energies required to use existing catheters would lead to excessive heat damage and dissection. There are, however, cases that frequently benefit from debulking prior to percutaneous intervention. A new, small laser catheter capable of high energies and repetition was previously examined in vitro. This study describes the first in vivo use. Purpose: To determine the safety and feasibility of a new, low profile, high energy laser catheter for creating a pilot hole to facilitate coronary angioplasty and stenting in patients with heavily calcified and occluded coronary arteries where a balloon has either failed to pass or was predicted to perform poorly. These patients represent the first patients treated with this new catheter. Methods: At a high volume center, seven consecutive patients with anatomy as summarized above were treated and studied with QCA and then followed for 30 days postprocedure for complications and Canadian Cardiovascular Society (CCS) angina class. Results: The laser catheter crossed five out of seven lesions and partially penetrated the remaining lesions. The mean maximum luminal diameter (MLD) postlasing was 1.0 mm with Thrombolysis in Myocardial Infarction (TIMI) 3 flow. It was possible to easily balloon and stent after the pilot hole creation in all but one patient. TIMI 3 was achieved for the final result after adjunct therapy in all patients. All patients except one, who died at 3 months postprocedure of stroke, were improved by an average of two angina classes. No late procedural‐related complications developed. Conclusions: The new, low profile laser catheter is easy to use and achieved good results in cases where a balloon either failed to pass or was predicted to give poor results. Further trials are warranted for this niche technology.
Cerebral Protection Systems for Distal Emboli During Carotid Artery Interventions
Authors: TAN WALTER A. , BATES MARK C. , WHOLEY MARK H.
Published: June 2007

Carotid angioplasty and stenting is associated with liberation of cerebral emboli that can cause periprocedural stroke. There are currently three classes of emboli protection devices (EPDs) that are undergoing feasibility studies and one randomized clinical trial. Preliminary data from a small series appear to be promising, and there appears to be attenuation of embolic signals on a cerebral Doppler exam with EPD use. However, rare strokes and patient intolerance due to imposed ischemia have been observed. The advantages and disadvantages of each EPD class and the issues involving clinical trials and surrogate end points in this area of study are discussed.
The Management of Acute Limb Ischemia: Techniques for Dealing with Thrombus
Authors: LAIRD JOHN R.
Published: June 2007

Acute limb ischemia (ALI) has long been a major clinical problem, producing significant risks for limb loss and death. It is most commonly caused by arterial thrombosis in the setting of underlying atherosclerotic peripheral vascular disease or by arterial embolism, usually of cardiac origin. Over the past several decades, preferred treatment options for ALI have alternated between medical and surgical approaches. More recently, direct intra‐arterial thrombolysis became the standard of care after several randomized trials demonstrated the benefit of this approach as compared with acute surgical intervention. Despite all of the experience with direct intra‐arterial thrombolysis for the treatment of ALI, the optimal thrombolytic approach not been clearly established. Current investigation is directed at identifying the ideal thrombolytic agent for this purpose and the appropriate dosing regimen. In addition, there is interest in the newer mechanical thrombectomy devices and the use of platelet glycoprotein IIb/IIIa inhibitors to speed the time to reperfusion of the acutely ischemic Limb.
Intracoronary Beta Radiation: State of the Art
Authors: AJANI ANDREW E. , WAKSMAN RON
Published: June 2007

This state‐of‐the‐art review is intended to explore the development of beta radiation including catheter delivered and permanent implants from its inception to current practice. Specific focus will be given to the isotopes currently available, radiation physics of beta emitters, preclinical studies, clinical trials, beta radiation delivery systems, and implications for future practice. The encouraging results from the clinical trials have established vascular brachytherapy as a standard of care for patients with in‐stent restenosis. Vascular brachytherapy requires additional “fine‐tuning” to achieve full optimization.
Carotid Artery Stenosis: Who Should Undergo Surgery and Who Should Undergo Stenting?
Authors: SIEVERT HORST
Published: June 2007

Carotid angioplasty and stent implantation is a rapidly evolving treatment option currently under evaluation in several randomized trials. Although this technique needs some special technical skills and knowledge, it is technically simpler than many other interventional procedures. Current data indicate that the results regarding success rate and complication rate may be similar to surgery. It will take years to get the results of the randomized trials that are currently planed or have already started. Unfortunately, the results of these studies will not reflect the state‐of‐the‐art because new stents and new protection devices will become available during these studies. Therefore, in clinical practice the decision has to be made depending on individual patient and lesion characteristics. Patients with concomitant diseases considered to be a risk factor for surgical procedures and patients with contralateral occlusion may be better candidates for angioplasty and stenting. However, patients with diffuse disease of the common carotid artery and patients with difficult vascular access may be better candidates for surgery.
Initial and Follow‐Up Results of the Tenax Coronary Stent
Authors: CARRIÉ DIDIER , KHALIFÉ KHALIFÉ , HAMON MARTIAL , CITRON BERNARD , PIERRE JEAN , SABATIER RÉMI , LIPIECKY JANUS , MOURALI SAMI , SARFATY LAURENT , ELBAZ MEYER , FOURCADE JOELLE , PUEL JACQUES
Published: June 2007

The Tenax coronary stent is laser sculpted from high precision 316 L stainless steel using advanced production procedures. An a‐Sic : H (hydrogen‐rich amorphous silicon carbide) coating reduces its thrombogenicity and improves its biocomputibility. From April to July 1998, 266 stents were implanted in 241 patients (aged 62.7 ± 10.8 years) in five centers. The clinical indication for intervention was unstable angina (33.2%) and recent myocardial infarction (29.8%) in many cases. Most lesions (83.8%) had complex characteristics (Class B2 or C). The target vessel was the LAD in 42.8% and the right coronary artery in 36.8% of all cases. Four primary stent deployment failures occurred and implantation was successful in 289 (97.4%) of 266 stents. No death and no Q‐wave myocardial infarction or emergency CABG occurred during hospital stay. Clinical success, defined as successful deployment without procedural or clinical event, was achieved in 230 (98.4%) of 241 patients. One‐year clinical follow‐up shows a low need for target lesion revascularization (17/237 [7.1%] patients) and a 15.8% rate of major adverse cardiac events (36/237 patients). The clinical and angiographic outcomes of our study suggest that the hybrid, amorphous hydrogenated silicon carbide coated design is promising and merits further evaluation in larger clinical trials. (J Interven Cardiol 2001; 14: 1–5)
Percutaneous Transluminal Angioplasty of the Anomalous Circumflex Artery
Authors: BLANCHARD DIDIER , ZTOT SAMIR , BOUGHALEM KAMEL , LEDRU FRANÇOIS , HENRY PATRICK , BATTAGLIA SALVATORE , LOUALI ABDOU , NADER ROLAND , PAGNY JEAN‐YVES , GUERMONPREZ JEAN‐LÉON
Published: June 2007

The technical experience reported in the literature concerning angioplasty in patients with anomalous origin of the left circumflex artery is limited. Balloon angioplasty seems to be a favorable approach for revascularization in these vessels, and major determinants of successful angioplasty are angiographic knowledge of their course and structure, appropriate selection of guiding catheter, and the possibility of advancing the balloon into the anomalous vessel. Five consecutive patients with severe atherosclerotic lesions on the anomalous left circumflex artery who underwent coronary angioplasty of the anomalous vessel are reported. Angiographic and clinical success were achieved in three patients with balloon alone and in one with stent implantation. (J Interven Cardiol 2001;14:11–16)
Early Experience with the Amplatzer Ductal Occluder for Closure of the Persistently Patent Ductus Arteriosus
Authors: MAKRAM R , MASURA JOZEF , HIJAZI ZIYAD M.
Published: June 2007

Using an Amplatzer duct occluder, 106 patients (weight 21 ± 18 kg) underwent an attempt at catheter closure of a persistently patent ductus arteriosus (PDA). Their age ranged from 22 days to 48 years. The PDA measured between 1.2 to 8.1 mm at its narrowest diameter. The device was successfully implanted in 105 patients. The immediate closure rate was 70% and gradually increased to 100% at 1 ‐month follow‐up. There was no clinical evidence of hemolysis and no incidence of device embolization or bacterial arteritis. Doppler evaluation showed no evidence of aortic arch or pulmonary artery obstruction. The device, which is currently undergoing multicenter clinical trial in the United States, is proving to be a safe and effective device for closure of the persistently PDA. (J Interven Cardiol 2001;14:33–36)
The Use of Amplatzer Devices to Occlude Vascular Fistulae
Authors: de GIOVANNI J.V.
Published: June 2007

The Amplatzer occluders are Nitinol‐based devices that are preshaped for specific indications, primarily to close atrial septal defects, patent foramen ovale/fenestrations, or to occlude patent arterial ducts or one designed specifically for closure of ventricular septal defects. The flexible quality of the Nitinol together with the different designs of Amplatzer occluders make it possible for these plug devices to be used for conditions other than what they are designed for. This is particularly the case for fistulae where no specific devices are available and hence improvisation may be required. The established use of the Amplatzer occluder devices primarily for atrial septal defects and for patent arterial ducts provide the confidence to use them for alternative conditions where few or no alternatives are available or if surgery is the only option. This article describes the use of Amplatzer occluder devices for two unusual conditions, namely to occlude a pulmonary arteriovenous malformation and to close an aorto‐left ventricular tunnel. (J Interven Cardiol 2001;14:45–48)
Centering‐on‐Demand Buttoned Device: Its Role in Transcatheter Occlusion of Atrial Septal Defects
Authors: RAO P. SYAMASUNDAR , SIDERIS ELEFTHERIOS B.
Published: June 2007

Since the initial design and description of the buttoned device, it has undergone a number of design changes. Introduction of radiopacity in the knot (button) made it easier to visualize and document that buttoning has indeed occurred. Introduction of two buttons has markedly decreased the unbuttoning rate with potential for eliminating it. A centering mechanism was then incorporated into the device, which allowed closure of larger defects and use of smaller‐sized devices. For some unknown reason, unbuttoning rate no longer occurs since the introduction of this device. The centering‐on‐demand (COD) device also appears to have increased the effective occlusion rates. At the present time, however, no long‐term follow‐up data are available to assess the long‐term efficacy of the new device. Experience in a larger number of patients and evaluation of follow‐up data are necessary to confirm the safety and efficacy observed in the small cohort reported in this review. (J Interven Cardiol 2001;13:81–89)
A Novel Automated Injection System for Angiography
Authors: GOLDSTEIN JAMES A. , KERN MORTON , WILSON ROBERT
Published: June 2007

The present method of performing manual coronary angiography requires repetitive manipulation of a cumbersome stopcock‐manifold system and contrast injection by hand syringe. This study reports a novel mechanical contrast injector with automated manifold that provides finger touch operator‐controlled contrast injections. The ACIST Injection System components include a software‐controlled syringe injector, a disposable automated manifold without stopcocks, a disposable hand controller, and a touch screen control panel. The ACIST system was evaluated in 50 patients undergoing diagnostic coronary angiography (n = 37) or coronary interventions (n = 13). In all cases, the system was easy to use and provided excellent quality images even with four catheters, as well as imaging during stent positioning with 6Fr guides. This mechanical injector facilitates precision operator‐controlled angiographic injections, provides superb high quality coronary images even with very small lumen catheters, and expedites ventriculography during angiographic procedures. (J Interven Cardiol 2001;14:147–152)
Directional Coronary Atherectomy: The Vienna Experience
Authors: KISS KATHARINA , HIRSCHL MICHAEL M. , WEXBERG PAUL , HASSAN ALI , STEURER GÜNTER , GLOGAR DIETMAR
Published: June 2007

Background: Several multicenter trials have shown excellent results for directional coronary atherectomy (DCA) in a selected patient cohort. To prove the applicability of this method in daily clinical routine and a nonselected patient cohort, we analyzed 46 consecutive cases performed at our catheterization lab. Methods: DCA was performed as a routine procedure in 45’suitable patients. Balloon dilatation or stent implantation postprocedure was accomplished only in case of unsatisfactory results. Quantitative coronary angiography was achieved pre‐and postprocedure as well as at 6‐month follow‐up. Results: Optimal atherectomy < 20% residual stenosis was reached in 24 (5′2%) of 46 target lesions and a residual stenosis < 50% in 46 (100%) lesions. Procedure‐related complications occurred in three (6%) patients (one major complication, death, < 24 hours, 2%; two minor complications, pseudoaneurysm, 4%). The 6‐month angiographic follow‐up revealed a binary restenosis rate of 29% (n=11). Ten out of 11 restenotic lesions required revascularization. When patients were stratified in two groups according to their preprocedural minimal lumen diameter (MLD), this parameter proved to be a very strong predictor of outcome. The percentage of restenosis was significantly higher in patients with an MLD > 1.60 mm compared to patients with a smaller MLD (54% vs 19.3%; P < 0.0001). Reference vessel diameter preprocedure did not differ significantly. Conclusions: Our study demonstrated that DCA is a suitable technique for the daily clinical routine, as the rates of complications and restenosis were similar to that in a highly selective patient cohort. Additionally, our study showed that patient selection should include preprocedural analysis of MLD in order to achieve optimal results. Therefore, atherectomy yielded comparable results to other conventional techniques and may be used instead of or in combination with them. (J Interven Cardiol 2001; 14:153–158)
Use of Fenoldopam for Prevention of Radiocontrast Nephropathy in the Cardiac Catheterization Laboratory: A Case Series
Authors: MADYOON HOOMAN , CROUSHORE LINDA
Published: June 2007

Many of the longstanding challenges in interventional cardiology, such as restenosis and thrombosis, have been met. However, radiocontrast‐induced nephropathy (RCN) continues to be problematic, particularly as the population of patients who are diagnosed and treated for vascular occlusions in the cardiac catheterization laboratory have become increasingly older and more complex. Introduction of nonionic contrast media has not eliminated this problem. We present the cases of four high risk patients whom we treated with a newly available renal vasodilator, fenoldopam, as a strategy to prevent RCN and its associated morbidity and mortality. (J Interven Cardiol 2001;14:179–186)
Echocardiographically Guided Closure of a Patent Foramen Ovale During Pregnancy After Recurrent Strokes
Authors: DAEHNERT INGO , EWERT PETER , BERGER FELIX , LANGE PETER E.
Published: June 2007

Background: Stroke during pregnancy and puerperium is a severe complication that causes high morbidity and mortality. A patent foramen ovule (PFO) allowing paradoxical embolism is one identified risk factor. Case: A 25‐year‐old pregnant woman with PFO suffered from recurrent cerebral embolism. To prevent recurrent cerebral embolism during pregnancy, delivery, and puerperium, interventional closure of the PFO was pegormed without fluoroscopy under echocardiographic guidance. The postinterventional course was uneventful. Conclusion: Percutaneous transvenous closure of a PFO during pregnancy is feasible without the use of fluoroscopy. (J Interven Cardiol 2001;14:191–192)
From Disk Devices to Transcatheter Patches: The Evolution of Wireless Heart Defect Occlusion
Authors: SIDERIS ELEFTHERIOS B. , SIDERIS CHRYSOULA E. , TOUMANIDES SAVVAS , MOULOPOULOS SPYRIDON D.
Published: June 2007

Since 1988, we have been using double‐disk devices with several device generations and improving results. Our current disk device, “The ButtonSeal Centering on Demand Device”, is a multipurpose device made of stainless steel and polyurethane. It has shown high occlusion rates and no significant complications in atrial septal defects (ASDs) up to 30 mm in diameter. It can be used according to the ASD anatomy both in large, single defects (centering) and in multiple fenestrations (noncentering). The ButtonSeal shares the same limitations as other disk devices, namely, the possibility of wire‐related problems and the need for significant septal rim. The development of wireless balloon‐delivered devices and patches addresses these problems and limitations. Both detachable balloon devices and patches were used experimentally in animals and in feasibility studies in humans. The results showed good occlusion rates and lack of wire‐related complications. Both methods required a minimal rim and occluded more defects than the disk devices. The transcatheter patch method was safer and had only one disadvantage, which was the need for 48‐hour balloon support. (J Interven Cardiol 2001;14:211–214)