Pretreatment with nitroprusside for microcirculatory protection in saphenous vein graft interventions.
ABSTRACT We hypothesized that the prophylactic administration of sodium nitroprusside (NTP) during saphenous vein graft (SVG) PCI would ameliorate the detrimental effects of distal embolization and reduce the frequency and magnitude of post-procedural myonecrosis.
Sixty-four consecutive patients with normal preprocedural cardiac enzymes underwent SVG PCI without embolic protection devices and received prophylactic intragraft NTP before initial device activation. For each case, 2 control patients were selected in reverse chronologic order and were matched for stent use, thromboatherectomy device use, clinical presentation, presence of thrombus and pre-PCI thrombolysis in myocardial infarction (TIMI) flow.
Mean patient age was 66 +/- 10 years, 78% of whom were males. Stent and thromboatherectomy use was 95.3% and 3.1%, respectively in both groups (p = ns). Prior to intervention, TIMI < 3 flow was present in 26.6% of cases and in 24.2% of control patients (p = ns). Thrombus was present in 20.3% of cases and in 19.5% of controls (p = ns). Post-PCI creatinine kinase (CK)-MB elevation > 3 x the upper limit of normal (ULN) occurred in 6.3% of cases vs. 16.4% of controls (p = 0.049) and > 5 x ULN in 1.6% of cases vs.10.9% of controls (p = 0.022). In a multivariate regression model that included stent use, in-stent restenosis, thrombus presence, preprocedural TIMI 3 flow, MI as procedural indication, NTP and glycoprotein IIb/IIIa use, NTP was the only independent and significant predictor of reduced post-procedural CK-MB elevation > 5 x ULN.
Prophylactic administration of intragraft NTP during SVG PCIs results in a lower frequency and magnitude of post-procedural cardiac enzyme elevation.
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ABSTRACT: We sought to evaluate the contemporary use of embolic protection devices (EPDs) in saphenous vein graft (SVG) interventions. We examined EPD use in the stenting of saphenous vein grafts (SOS) trial, in which 80 patients with 112 lesions in 88 SVGs were randomized to a bare metal stent (39 patients, 43 grafts, and 55 lesions) or paclitaxel-eluting stent (41 patients, 45 grafts, and 57 lesions). An EPD was used in 60 of 112 lesions (54%). A Filterwire (Boston Scientific) was used in 70% of EPD-treated lesions, Spider (ev3, Plymouth, Minnesota) in 12%, Proxis (St. Jude, Minneapolis, Minnesota) in 12%, and Guardwire (Medtronic, Santa Rosa, California) in 7%. Of the remaining 52 lesions, an EPD was not utilized in 13 lesions (25%) because the lesion was near the distal anastomosis, in 14 lesions (27%) because of an ostial location, in one lesion (2%) because of small SVG size, in two in-stent restenosis lesions (4%) because of low distal embolization risk, and in 22 lesions (42%) because of operator's preference even though use of an EPD was feasible. Procedural success was achieved in 77 patients (96%); in one patient a Filterwire was entrapped requiring emergency coronary bypass graft surgery and two patients had acute stent thrombosis. In spite of their proven efficacy, EPDs were utilized in approximately half of SVG interventions in the SOS trial. Availability of a proximal protection device could allow protection of approximately 25% of unprotected lesions, yet operator discretion appears to be the major determinant of EPD use.Catheterization and Cardiovascular Interventions 08/2010; 76(2):263-9. DOI:10.1002/ccd.22438 · 2.40 Impact Factor
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ABSTRACT: Stent implantation into atherosclerotic plaques releases, apart from particulate debris, soluble substances that contribute to impaired microvascular perfusion. Objective: To quantify the release of vasoconstrictors and to determine the efficacy of coronary dilators to attenuate their action. Using a distal protection/aspiration device, coronary arterial blood was retrieved before and during stenting in 22 patients with severe saphenous vein aorto-coronary bypass stenoses. The release of catecholamines, endothelin, serotonin, thromboxane B(2), and tumor necrosis factor (TNF)α was measured. The response of rat mesenteric arteries with intact (+E) and denuded (-E) endothelium to aspirate plasma was normalized to that by KCl. Responses to selective receptor blockade, adenosine, nitroprusside, and verapamil against the aspirate-induced constriction were determined. The coronary arterial plasma withdrawn before stenting induced 21±5% and the aspirate plasma after stenting induced 95±8% of maximum KCl-induced vasoconstriction. Serotonin, thromboxane B(2), and TNFα release into aspirate plasma increased by 1.9±0.2 μmol/L, 25.6±3.1 pg/mL, and 19.7±6.1 pg/mL, respectively, during stenting. The aspirate-induced vasoconstriction was largely antagonized by selective serotonin receptor blockade, with little further antagonism by additional thromboxane receptor blockade. TNFα did not induce constriction per se but potentiated the constriction with serotonin and the thromboxane-analog U-46619 in arteries +E. The concentrations to induce half-maximal vasodilation were comparable for nitroprusside (+E, 3.3×10(-8); -E, 1.9×10(-8) mol/L) and verapamil (+E, 8.3×10(-8); -E, 7.8×10(-8) mol/L), and the vasoconstriction was eventually eliminated. The vasodilator response to adenosine was dependent on functional endothelium and weaker. Serotonin is the main coronary vasoconstrictor after stenting, and thromboxane and TNFα somewhat potentiate the serotonin response. Nitroprusside and verapamil are more potent than adenosine to attenuate the aspirate plasma-induced vasoconstriction, and they are not dependent on functional endothelium.Circulation Research 02/2011; 108(3):344-52. DOI:10.1161/CIRCRESAHA.110.235713 · 11.09 Impact Factor
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ABSTRACT: We sought to examine contemporary practice patterns of saphenous vein graft (SVG) interventions. A link to a 10-item online questionnaire was completed in June 2009 by 275 (7%) of 3,771 US interventional cardiologists surveyed. Sixty-five percent of the respondents use an embolic protection device (EPD) in >75% of SVG interventions. The main reason for not using an EPD was "anatomic difficulties" (55%), followed by device complexity (20%). Filter-based EPDs were the most widely available, well known, and commonly used EPDs, whereas the Guardwire (Medtronic Vascular) was the least commonly used EPD. The main factors underlying EPD selection were lesion location (83%), familiarity with devices (72%), and SVG diameter (64%). Factors that could increase EPD use included availability of simpler to use devices (63%), and more studies demonstrating benefit from EPD use (37%). Compared with interventionalists who used EPDs in most cases (>75%), those who utilized EPDs less frequently were less likely to be familiar with each EPD and had less EPDs available for use. Many interventionalists (84%) administer intragraft vasodilators during SVG interventions, prefer drug-eluting stents (63%) and administer >12 months antiplatelet therapy poststent implantation. During SVG interventions (1) "anatomic difficulties" are the most common reason for not utilizing an EPD; (2) filter-based EPDs are most commonly used; (3) lesion location is the most important factor for EPD selection; (4) availability of simpler to use devices could increase EPD use; and (5) intragraft vasodilators, drug-eluting stents and prolonged antiplatelet therapy are commonly utilized.Catheterization and Cardiovascular Interventions 04/2012; 79(5):834-42. DOI:10.1002/ccd.23111 · 2.40 Impact Factor