Antonio Ramírez

Simple and complex stent strategies for bifurcated coronary arterial stenosis involving the side branch origin

Coronary lesions located in major bifurcations constitute a challenge for the use of stents. Although the occlusion of a side branch covered by a stent is infrequent, the maintenance of a patent, stenosis-free bifurcation may result in a complex procedure. Between September 1994 and April 1998, 70 patients were treated by stent implantation for coronary bifurcation stenosis. The side branch always had a diameter >2 mm. The pairs of treated arteries were: left anterior descending (LAD)/diagonal artery in 32 patients, circumflex/obtuse marginal in 26, right coronary/posterior descending artery in 5, and LAD/circumflex in 7. We applied 2 different techniques of stent implantation: (1) deployment of 1 stent in the parent vessel covering the takeoff of the side branch and subsequent angioplasty of the side branch across the metallic structure (group A, n = 47 patients), and (2) implantation of 1 stent at the ostium of the side branch and complete reconstruction of the entire bifurcation with additional implantation of 1 or 2 stents at the parent vessel (group B, n = 23 patients). There were no significant differences between groups at baseline variables. Procedural success was similar in both groups: 42 (89%) in group A versus 21 (91%) in group B. However, major cardiac events at 18 months follow-up were higher in group B (event-free probability 44% vs 75%, p <0.05). Selected patients with coronary stenosis at major bifurcations can be treated with an acceptable rate of primary and late success. Complex techniques providing radical stent reconstruction of the bifurcation seems to provide no advantages over the simpler stent jail followed by ostial side branch balloon dilation.

A stepwise strategy for the stent treatment of bifurcated coronary lesions.

Several observational studies have shown a better late outcome in patients with coronary bifurcation lesions treated with stents in whom the side branch was not stented. Balloon dilation and provisional stenting for the side branch seem an attractive strategy to manage these challenging types of lesions. This study evaluated the results of a three‐step phase strategy in the stent treatment of bifurcated coronary lesions. We treated 126 patients, 58 ± 11 years old, with major coronary bifurcation stenosis. The therapeutic procedure was undertaken following three phases; progression through each phase was triggered by the failure of one procedure to achieve a <50% residual stenosis at the side branch: in the first step, balloon angioplasty of the side branch followed by stenting of the parent vessel; in the second, balloon redilation of the side‐branch origin across the metallic structure of the stent; in the third, stenting of the side‐branch origin. Immediate success was achieved in 116 patients (92%). Angiographic results in each phase were as follows: in the first step, 35 patients (28%) had procedural success, 3 patients had failure, and 88 crossed to the next step; in the second, 76 patients (86%) had procedural success, 7 patients had failure, and 5 crossed to the next step; in the third, all 5 patients had procedural success. The overall major cardiac event‐free probability at 15 months was 78%. Target vessel revascularization took place in 19 patients (15%) and when stratified by phases were 13% of patients treated in the first step, 16% of patients in the second step, and 20% of patients in the third step. Patients with coronary stenosis at major bifurcations may be treated following an unitary stepwise approach. This attitude may avoid side‐branch stent implantation in most patients, providing good immediate and long‐term results. Cathet Cardiovasc Intervent 2002;55:50–57.

Trombos móviles en cavidades cardíacas derechas en pacientes con tromboembolismo pulmonar grave. Importancia de la ecocardiografía

El tromboembolis mo pulmonar es una enfermedad frecuente, grave y a menudo de dificil diagnostico, en especial en aquellos casos en los que los trombos quedan atrapados en las cavidades derechas cardiacas. Presentamos tres casos de tromboembolismo pulmonar grave en los que mediante ecocardiografia se detecto la presencia de grandes trombos moviles en las cavidades cardiacas derechas, lo que permitio realizar una terapia urgente con buen resultado en todos los casos. Queremos destacar el hecho de que la ecocardiograf ia en estos casos seria la tecnica diagnostica de eleccion evitando la realizacion de una arteriografia pulmonar que podria estar contraindicada por el riesgo de movilizacion del trombo. RIGHT HEART CAVITIES MOBILE THROMBUS IN PATIENTS WITH SEVERE PULMONARY THROMBOEMBOLISM. THE IMPORTANCE OF ECHOCARDIOGRAPHIC STUDY The pulmonary thromboembolism is a frequent and severe disease, usually difficult to recognize, specially in patients with thrombotic material trapped within right heart cavities. We present our experience in three patients with severe pulmonary thromboembolism where echocardiographic study demonstrated the presence of huge mobile thrombus in right heart cavities, which demanded urgent therapy with excellent results. We would like to stress that echocardiographic study in these patients could be elective diagnostic procedure, avoiding the realization of pulmonary arteriography, which could bring risk of posible thrombus mobilization.