Angiographic resteno-sis after successful Wallstent implantation: An analysis of risk predictors
Royal Brompton National Heart and Lung Hospital, Department of Invasive Cardiology, London, U.K.American Heart Journal (Impact Factor: 4.46). 01/1993; 124(6):1473-7. DOI: 10.1016/0002-8703(92)90059-5
Follow-up angiographic study was performed in 86 patients after initially successful Wallstent stent (Medinvent, Lausanne, Switzerland) implantation between April 1986 and October 1990. The stent angiographic restenosis rate was 16% at a mean of 8 months after stenting despite the inclusion of a substantial number of patients at high risk of restenosis after percutaneous transluminal coronary angioplasty (PTCA). Of a total 15 variables analyzed, only suboptimal stent placement was found to be a significant predictor of stent restenosis. Age; gender; baseline New York Heart Association functional class; previous PTCA; indication for stenting; left ventricular ejection fraction; preangioplasty and immediate postangioplasty diameter stenosis severity; stented vessel site, lesional morphology; number, diameter, and length of stents implanted; and the interval between stenting and follow-up angiographic restudy were not significant risk factors of stent restenosis. Our study suggests that intracoronary stent implantation with the Wallstent may be a useful and promising adjunctive option after PTCA, particularly in patients at high risk of restenosis after PTCA. However, because of the significantly enhanced risk of restenosis after suboptimal stent implantation, we strongly recommend the selection and placement of Wallstent stents that adequately cover the entire length of the dilated coronary segment.
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ABSTRACT: Emergency stent implantation for the treatment of failed balloon angioplasty has been limited by a 3-33% incidence of early stent thrombosis and a paucity of information on restenosis. Accordingly, the objective of this study is to determine both the acute and midterm results following single bailout stenting for threatened closure after failed balloon angioplasty. Single stent placement with either a Gianturco-Roubin or Palmaz-Schatz stent for the treatment of threatened closure complicating conventional single-vessel balloon angioplasty of de novo native coronary lesions was carried out in 16 and 24 patients, respectively. Successful stent implantation was achieved in 39 patients (97.5%), reducing the diameter stenosis from 90 +/- 7% before 6 +/- 8% after the procedure. No early stent closure, myocardial infarction, or need for emergency coronary bypass surgery was observed. Furthermore, except for one death due to massive intracranial hemorrhage 1 1/2 weeks after a successful stent implantation, there was no mortality directly related to the procedure. Repeat angiographic study performed at a mean of 5 +/- 3 months after stenting in 30 (86 %) eligible patients revealed in-stent restenosis (> 50% diameter stenosis) in six patients (20%). Five had successful repeat balloon angioplasty. Restenosis rate was significantly higher in patients with diabetes mellitus (83 versus 21% in nondiabetics, P = 0.0047), who had small (< 3 mm diameter) stent (reflecting small vessel diameters) implanted (40 versus 10% for > or = 3 mm stents, P = 0.0528) and those who had received stents to rectify vessel recoil (60 versus 12% for dissection, P = 0.0264). During a follow-up period of 12 +/- 8 months, clinical benefits were maintained in most patients, with none requiring bypass surgery, and no myocardial infarction or death encountered. Our study suggests that single bailout stenting for threatened closure in selected patients is associated with a favorable short and mid-term outcome, with minimal risk of early stent closure and a low restenosis rate. Restenosis rate, however, remains high in diabetic patients, stent placement for vessel recoil indication and those receiving < 3 mm diameter stents.
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ABSTRACT: Percutaneous cardiopulmonary assist devices (PCPS) have become available in interventional cardiology within recent years. These tools offer the opportunity of performing percutaneous transluminal coronary angioplasty (PTCA) in high-risk patients characterized by significant stenoses of several coronary arteries and a poor left ventricular function. It is unclear for which patients PCPS are necessary and which patients will profit by PTCA as compared to coronary artery bypass grafting (CABG). Therefore, the anticipated risk of CABG and of PTCA without assist devices was calculated according to risk scores and compared with our results of assisted PTCA. In addition the long-term survival rate was investigated. In 35 patients (mean 65.5 years of age, 12 females, 23 males), we performed PTCA concomitant with the use of cardiac assist devices. The indications for the use of a cardiac assist device were severely impaired LV function (EF 30% ± 8.9%) in combination with significant coronary artery disease (2.7 ± 0.3 vessels) and a significant supply area of the vessel to be dilated. In 6 patients, PCPS was started before coronary angioplasty because of hemodynamic instability. In 21 cases, PCPS was on a standby basis without being connected to the patient's circulation. In 8 patients, a left heart assist device, the 14F-Hemopump, was inserted percutaneously. The patients were analyzed using risk scores of angioplasty and of coronary bypass graft surgery. The calculated risk of hemodynamic compromise during PTCA according to the risk scores was more than 50%. The anticipated risk of a fatal outcome following CABG would have been 19.8%. PTCA was performed on an average of 2.0 coronary arteries per patient and was successful in 85%. We observed a decline in angina pectoris classification (CCS) from 3.5 to 1.6. An average reduction of 1.1 NYHA class was achieved. The in-hospital mortality was 8.6% (3 patients: 1 × sepsis, 1 × early reocclusion, 1 × cerebral embolism). At 24 months follow-up, a re-PTCA was necessary in four cases because of restenosis. In the remainder, NYHA and CCS class were stable during the follow-up period. An additional five patients died during the first year and two patients in the second year. We conclude that PTCA with the use of a cardiac assist device shows favorable short-term results in a subset of patients with extended coronary artery disease and severely impaired LV function who are not suitable for nonsupported PTCA or CABG due to their risk profile. However, the long term results are not satisfying and stress the need for complete revascularisation with CABG once the patient's condition is stabilized by means of supported PTCA.
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