Arvind K. Sharma

Major noncardiac surgery following coronary stenting: when is it safe to operate?

The optimal timing for elective noncardiac surgery (NCS) after coronary stenting is uncertain. We identified 47 patients who underwent elective NCS within 90 days of coronary stent placement between January 1995 and December 2000. Twenty‐seven patients had NCS within 3 weeks of coronary stenting. Six of the seven in whom thienopyridine antiplatelet therapy was discontinued died postoperatively in a manner suggestive of stent thrombosis. In contrast, only 1 of the 20 patients in whom the thienopyridine was continued through the NCS died. The frequency of perioperative hemorrhage was similar whether or not the antiplatelet agent was continued. Only 1 perioperative death occurred in the 20 patients with NCS more than 3 weeks following stenting. Catheter Cardiovasc Interv 2004;63:141–145.

Percutaneous interventions in patients with cocaine-associated myocardial infarction: a case series and review.

Cocaine‐associated myocardial infarction (CAMI) is a well‐reported entity. Most previous reports on CAMI have been limited to conservative care utilizing benzodiazepines, aspirin, nitroglycerin, calcium channel blockers, and thrombolytics. Current guidelines on CAMI advocate immediate use of angiography and angioplasty if available rather than routine administration of thrombolytics. However, based on literature search from 1966 to 2001 (using keywords “cocaine,” “myocardial infarction,” and “angioplasty”), there have been only two case reports of percutaneous coronary intervention (PCI) in patients with cocaine‐associated myocardial infarction. Both were notable for complications either during or immediately after the procedure. We report a series of 10 patients with cocaine‐associated myocardial infarction who were treated with percutaneous interventions, which included angioplasty, stenting, and AngioJet mechanical extraction of thrombus. Despite the different arteriopathic process involved, our findings suggest that PCI can be performed safely and with a high degree of procedural success in patients with CAMI. Cathet Cardiovasc Intervent 2002;56:346–352.

Clinical outcomes following stent implantation in internal mammary artery grafts

We evaluated our experience with percutaneous coronary intervention (PCI) of internal mammary artery (IMA) grafts. From the institutions database we identified 288 patients with 311 IMA lesions. Of these, 82 (26.4%) had stents placed during PCI. Angiographic success was 92%. Mortality at 1 month was 1.7%, myocardial infarction (MI) 15.7%, and target lesion revascularization (TLR) 0.4%. Cumulative 1‐year event rates were mortality 6.4%, MI 20.4%, and TLR 8.0%. TLR rates were significantly higher in the stented lesions than lesions treated with angioplasty alone (19.2% vs. 4.9%; P = 0.004). The higher TLR rate in stented lesions was most apparent at the anastomotic site (25.0% vs. 4.2%; P = 0.006). Percutaneous revascularization of IMA grafts can be performed safely with high procedural success and excellent short‐ and long‐term results. Stenting, particularly at the anastomotic site, was associated with significantly greater rates of TLR than angioplasty alone. Cathet Cardiovasc Intervent 2003;59:436–441.

Percutaneous interventions in radial artery grafts: clinical and angiographic outcomes.

In the modern era, radial artery graft is being used with increasing frequency to replace saphenous vein as a conduit for coronary artery bypass surgery. Several reports have shown encouraging early results of radial grafts compared to saphenous grafts. Despite these advantages, radial artery graft failure requiring revascularization does occur. We report on the clinical, angiographic, and technical characteristics and the follow‐up results of 22 patients who underwent percutaneous intervention of radial grafts. Cathet Cardiovasc Intervent 2003;59:172–175.

Comparison of Intracoronary Gamma Radiation for In-Stent Restenosis in Saphenous Vein Grafts Versus Native Coronary Arteries

Intracoronary gamma radiation is effective in reducing recurrent in-stent restenosis (ISR) involving native coronary arteries. This study compares the effectiveness and safety of intracoronary gamma radiation for the treatment of ISR in saphenous vein grafts (SVGs) versus native coronary arteries. In the Washington Radiation for In-Stent restenosis Trial (WRIST) series of gamma radiation trials, 1,142 patients with ISR (230 in SVG and 912 in native coronary arteries) completed 6-month clinical follow-up. All patients underwent balloon angioplasty, atherectomy, and/or restenting. Different ribbon lengths containing 6 to 23 seeds of iridium-192 were used to cover lesion lengths <80 mm. The prescribed radiation doses were 14 or 15 Gy at 2-mm radial distance from the center of the source. Baseline demographics showed that patients with SVGs were older (65 +/- 13 vs 61 +/- 11 years, p <0.001), more likely male (79% vs 64%, p <0.001), had more multivessel coronary disease (81% vs 50%, p <0.001), and less diffuse lesions (17 +/- 10 vs 24 +/- 12 mm, p <0.001). At 6 months, event-free survival was similar for patients with SVG ISR and native coronary ISR (82% vs 84%, p = 0.35). The SVG ISR population had a low rate of late total occlusion (4.6%) and late thrombosis (3.5%). Thus, treatment of ISR with gamma radiation in SVGs had similar outcome to native coronary arteries. The use of gamma radiation for the treatment of ISR should expand to SVGs.

Usefulness of gamma intracoronary radiation for totally occluded in-stent restenotic coronary narrowing

In this analysis of 669 patients from the WRIST studies, the incidence of totally occluded in-stent restenosis was 12.9%, which was associated with a high rate of successful recanalization using conventional percutaneous techniques. Intracoronary gamma radiation therapy for in-stent restenosis with total occlusion is feasible, safe, and associated with comparable outcomes similar to nonocclusive in-stent restenosis. These high-risk, totally occluded in-stent restenotic lesions should become an important indication for gamma intracoronary radiation.

Acute procedural complications and in-hospital events after percutaneous coronary interventions: eptifibatide versus abciximab.

BACKGROUND Glycoprotein IIb/IIIa antagonists reduce peri-angioplasty ischemic complications and improve in-hospital outcome in patients undergoing percutaneous coronary interventions (PCI). Prior studies have demonstrated favorable results with both eptifibatide and abciximab. The purpose of this study was to assess whether there are any differences in rates of acute procedural complications and in-hospital events with the use of these two agents. METHODS A retrospective review of 359 elective PCIs from June 1998 to August 2000 identified 152 PCIs treated with eptifibatide (bolus 180 microg/kg, infusion 2 microg/kg/min for 12-48 h) and 205 PCIs treated with abciximab (bolus 0.25 mg/kg, infusion 10 microg/min for 12 h). All patients received IIb/IIIa antagonists at the initiation of the intervention. RESULTS The clinical demographics, the angiographic morphology, the indications, and the procedural details were similar in both groups. In the eptifibatide group, the maximum ACT was lower (235+/-45 vs. 253+/-40, P<.0001). The incidence of major procedural and in-hospital events was compared. Eptifibatide and abciximab had similar rates of major complications (death or myocardial infarction) (1.4% vs. 2.9%), repeat PTCA (3.4% vs. 1.9%), and major bleeding (3.3% vs. 4.3%). CONCLUSIONS Eptifibatide is comparable to abciximab in regards to acute procedural complications and in-hospital events after PCI.