Carlo Cernetti

Intracoronary thrombectomy improves myocardial reperfusion in patients undergoing direct angioplasty for acute myocardial infarction

OBJECTIVES We sought to evaluate the effects of mechanical thrombectomy on myocardial reperfusion during direct angioplasty for acute myocardial infarction (AMI). BACKGROUND Embolization of thrombus and plaque debris may occur during direct angioplasty for AMI. This may lead to distal vessel or side branch occlusion and to obstructions in the microvascular system, resulting in impaired myocardial reperfusion. Mechanical thrombectomy is used to reduce distal embolization. METHODS Ninety-two patients with AMI and angiographic evidence of intraluminal thrombus were randomized to either intracoronary thrombectomy followed by stenting or to a conventional strategy of stenting. Thrombectomy was performed using the X-Sizer catheter (EndiCOR Inc., San Clemente, California). Myocardial reperfusion was assessed by myocardial blush and ST resolution. RESULTS Postprocedure Thrombolysis in Myocardial Infarction-3 flow was not different between groups (93.5% vs. 95.7%, p = 0.39). Myocardial blush-3 was observed in 71.7% of patients undergoing thrombectomy and in 36.9% of patients undergoing conventional strategy (p = 0.006). ST-segment resolution >or=50% occurred more often in patients undergoing thrombectomy (82.6% vs. 52.2%, p = 0.001). By multivariate analysis, adjunctive thrombectomy was an independent predictor of blush-3 (odds ratio, 3.27; 95% confidence interval, 1.06 to 10.05; p = 0.039). CONCLUSIONS Intracoronary thrombectomy as adjunct to stenting during direct angioplasty for AMI improves myocardial reperfusion as assessed by myocardial blush and ST resolution.

Intimal medial thickening of common carotid artery as indicator of coronary artery disease

The authors investigated the relation between coronary atherosclerosis, angiographically detected, and intimal-medial (I-M) thickening of the common carotid artery (CCA), as measured by high-resolution B-mode ultrasound system. They studied 31 patients with coronary artery disease (CAD) and 23 healthy control subjects. I-M thickening of CCAs and atheromatous plaques at the carotid bifurcation were evaluated. A score system was defined (range 0-20) based on the absence or presence of atherosclerotic lesions at common and internal carotid arteries. A coronary angiography score was defined based on the presence of atherosclerotic lesions at nine coronary arterial segments (range 0-36) . The thickness of CCAs (M ±SD) in CAD patients was significantly higher (1.45 ±0.95 mm) than in controls (0.87 ±0.10 mm, P < 0.005), and an I-M thickening of 1.1 mm or more was specific and positively predictive of CAD. A significant positive correlation between coronary and carotid score was observed (P < 0.028, r=0.373). The study suggests that I-M thickening could be helpful for the identification of patients at risk for CAD.

Endovascular treatment of in-stent restenosis after carotid artery stenting: immediate and midterm results.

Purpose: To evaluate the immediate and midterm outcome and analyze the debris captured after repeat endovascular intervention for the treatment of in-stent restenosis after carotid artery stenting (CAS). Methods: Thirty-one consecutive patients (27 men; mean age 63.7±13.0 years, range 53–81) underwent repeat endovascular intervention (balloon angioplasty and provisional stenting) for the treatment of 32 in-stent restenoses following CAS. Results: Procedural success was achieved in all patients. An additional stent was implanted in 10 (31%) cases. No procedural complication was observed. Filter analysis was performed in 17 (53%) procedures; on 12 (71%), macroscopically visible material was captured. The histomorphometric analysis performed on 6 (19%) filters showed fibrin nets entrapping erythrocytes, leucocytes, platelets, and in 2 cases, fibrous hypercellular tissue fragments. At 30 days and during follow-up (mean 17±5 months), no deaths, transient ischemic attacks, or strokes were observed. In 1 (3.1%) patient, asymptomatic recurrence of ISR was found on Doppler ultrasonography and successfully treated with balloon angioplasty. Conclusion: Repeat endovascular intervention using balloon angioplasty with provisional stenting and routine cerebral protection appears to be a feasible, safe, and clinically effective strategy for the treatment of in-stent restenosis after CAS.

Impact of Diabetes, Patient Age, and Gender on the 30-Day Incidence of Stroke and Death in Patients Undergoing Carotid Artery Stenting with Embolus Protection: A Post-Hoc Subanalysis of a Prospective Multicenter Registry

Purpose: To assess the impact of diabetes, patient age, and gender on major periprocedural (30-day) complications (major and minor strokes, all-cause deaths) following carotid artery stenting (CAS). Methods: An exploratory analysis was performed of 695 patients (516 men; mean age 69.9±8.4 years) enrolled consecutively between September 1999 and September 2002 in a multicenter Italian/German registry of routine CAS using cerebral protection devices. There were 535 nondiabetic patients and 160 diabetic patients in the analysis. Results: Logistic regression analysis revealed that diabetes and age, but not gender, impacted the cumulative 30-day incidence of any stroke and death (OR 2.1, 95% CI 1.0 to 4.8, p=0.068 and OR 1.06, 95% CI 1.01 to 1.12, p=0.031, respectively), as well as the 30-day incidence of major strokes and deaths (OR 5.9, 95% CI 1.6 to 21.8, p=0.007 and OR 1.13, 95% CI 1.02 to 1.25, p=0.018, respectively). According to receiver-operating characteristic analysis, age had no discriminatory power to predict complications in nondiabetic patients, but an age of 75 years was identified as the optimal cut point to predict complications in diabetic patients. Compared with nondiabetic patients, diabetics ≥75 years had a 4.3 greater risk of experiencing any stroke or death (95% CI 1.3 to 12.3, p=0.016) and a 12.0 greater risk of a major stroke or death (95% CI 2.1 to 66.5, p=0.005). Diabetics < 75 years had no increase in risk over that of nondiabetic patients. Conclusion: Diabetic patients ≤75 years carry a significantly increased risk for strokes or death after protected CAS. The findings should be taken into consideration when treating elderly diabetic patients.

Deferred Urgency Carotid Artery Stenting in Symptomatic Patients: Clinical Lessons and Biomarker Patterns from a Prospective Registry

INTRODUCTION The aim of this prospective observational registry was to study the outcome of symptomatic patients presenting with recent TIA or minor stroke and severe carotid stenosis, submitted to early percutaneous treatment by stenting. A secondary aim was to evaluate the biological activity of the symptomatic carotid plaques by serial serum and urinary markers (PAPP-A, hs-CRP, MMP-2/MMP-9, IL-6/IL-8, TNF alpha, CD40L) measured by enzyme-linked immunosorbent assay before and after treatment. METHODS From May 2005 to June 2006, 57 patients were enrolled in this prospective registry. All patients underwent carotid stenting using a concentric filter for cerebral protection. The procedure was performed within 24-48hrs of the last attack in patients with TIA (n=24, 42%) and between 14 and 30 days in patients with stroke (n=33, 58%). RESULTS Successful stent implantation was achieved in all cases (100%). Adverse events at 1 month were 1 death (1.7%) and 2 TIAs (3.5%). Some of the vulnerability markers, in particular those reflecting an active systemic inflammatory process of the plaque (PAPP-A, hs-CR, and IL-6), were significantly elevated at the time of enrolment, increased after stenting and decreased after 30 days. CONCLUSION Deferred CAS is feasible and safe in selected patients with symptomatic carotid stenosis. This preliminary study in a limited series of patients with unstable carotid plaques revealed that endovascular treatment has a satisfactory outcome considering the very high risk profile of the patient population. The evaluation of some biomarkers suggested an inflammatory role in the process of an unstable carotid plaque generating an acute cerebral event.

Percutaneous interventions in patients with acute ischemic stroke related to obstructive atherosclerotic disease or dissection of the extracranial carotid artery.

Purpose: To determine the safety, feasibility, and efficacy of carotid artery stenting (CAS) in patients with acute stroke who underwent angioplasty of the extracranial internal carotid artery (ICA). Methods: Patients were eligible for CAS if they presented within 6 hours of symptom onset and had a National Institutes of Health Stroke Scale (NIHSS) score >4. The records of all 18 acute stroke patients (11 men; mean age 68.3±14.3 years) who underwent endovascular intervention in the stroke-related extracranial ICA between May 2003 and February 2006 were reviewed. Fourteen (77.8%) had atheromatous obstructions and 4 (22.2%) had dissection of the extracranial ICA. Major adverse cerebral and cardiac events (MACCEs) and neurological status, including NIHSS and the modified Rankin Scale (mRS) scores, were recorded for all patients. Results: Successful revascularization was achieved in 83.3% (15/18) of the patients. Cerebral protection devices were applied successfully in 13 (72.2%). At discharge, a neurological improvement (NIHSS reduction ≥4) was observed in 77.8% (14/18) of patients. The clinical success rate was 72.2% (13/18). The median NIHSS was 8.5 on admission versus 4.5 at discharge (p<0.01). The 30-day death and stroke rate was 11.1%. During the 14.6±9.3-month followup, the MACCE and the death/stroke rates were 33.3% and 27.8%, respectively. The median mRS scores at 30 days and at midterm followup were 1 and 2.5, respectively (p=NS). Conclusion: Endovascular revascularization of the extracranial ICA in patients with acute ischemic stroke is associated with high procedural success rates and favorable midterm outcome.

Clinical outcome of patients with de novo coronary bifurcation lesions treated with the Tryton Side Branch Stent. The SAFE-TRY prospective multicenter single arm study.

BACKGROUND Coronary bifurcation lesions represent a difficult problem regularly confronting interventional cardiologist, in part due to the lack of dedicated device. OBJECTIVE To investigate the feasibility, safety and effectiveness of the Tryton Side Branch Stent (Tryton Medical, Durham, NC, USA), a dedicated bare metal stent deployed in conjunction with a standard drug-eluting stent to treat bifurcation lesions. METHODS The SAFE-TRY is a prospective single arm multicenter registry including patients with de novo bifurcation lesions in native coronary arteries and syntax score <32. The primary endpoint was target vessel failure (TVF) at 30 days that comprised cardiac death, target vessel myocardial infarction and clinically driven target vessel revascularization. Secondary endpoints included device, angiographic and procedural success, 9-month major adverse cardiac and cerebrovascular event (MACCE), and stent thrombosis (ST) rates (ClinicalTrials.gov identifier: NCT01174433). RESULTS Among 252 enrolled patients, 24% had diabetes and 35.3% unstable angina. True bifurcation lesions involving both branches occurred in 96.8% of cases with Medina classification 1.1.1 in 62%. The left anterior descending artery and the left main were treated in 70% and 8.3% of the patients, respectively. A 6 Fr guide catheter was used in 61% of the cases. Device, angiographic and procedural success rates were 99.6%, 99.6% and 97.2% respectively. The 30-day TVF was 2.8%; the 9-month MACCE rate was 13.7%, with target lesion revascularization being 4.4%. No definite ST occurred. CONCLUSIONS This prospective, multicenter study confirmed the feasibility, safety and effectiveness of the Tryton Side Branch Stent to treat patients with de novo complex bifurcation lesions.

Coronary artery aneurysms

Coronary artery aneurysms are defined as coronary dilations as greater than 1.5 times the largest diameter of the adjacent coronary segment. They are a relatively rare finding on coronary angiography, with prevalence ranging from 0.3% to 5% depending on case series. The identification of a coronary artery aneurysm is often a dilemma for both the clinician and the interventionist in terms of diagnosis, treatment and follow-up. This review summarizes the etiologic, pathogenetic, clinical and therapeutic aspects of coronary artery aneurysms in the light of the latest research on this topic.

Pratica clinica attuale e trend di variazione in cardiologia interventistica strutturale. Risultati di una survey multicentrica SICI-GISE in sei Regioni italiane: Toscana, Lombardia, Veneto, Emilia-Romagna, Campania e Puglia

BACKGROUND: Significant developments have occurred in the field of percutaneous interventions for structural heart disease over the last decade. The introduction of several innovations has expanded significantly the spectrum of therapeutic applications of structural interventional cardiology. However, the translation of the most recent scientific evidence into clinical practice and the adoption of new technologies may be susceptible to large variability, even within the same geographic area. This study aimed at describing current status and changing trends of structural heart interventions within 6 Regions in Italy. METHODS: Between July 2015 and October 2015, 6 regional delegations of the Italian Society of Interventional Cardiology (SICI-GISE) promoted a web-based multicenter survey concerning structural heart interventions. An ad hoc questionnaire was administered to head physicians of the cath-labs of 4 Regions of Northern Italy (Tuscany, Lombardy, Veneto and Emilia-Romagna) and 2 Regions of Southern Italy (Puglia and Campania). Also, in this study we considered previous data from a similar survey that involved Tuscany, Lombardy, Veneto and Emilia-Romagna between April 2014 and May 2014. Data from the two surveys were compared, observing the changing trends between 2014 and 2015. RESULTS: The 2015 survey was completed in more than two thirds (68%) of the 145 eligible cath-labs. According to the survey, the application of percutaneous structural heart interventions and the availability of devices were wide and homogeneous within the 6 Regions involved. The main factors perceived as limiting the execution of structural heart interventions resulted economic (e.g. cost of procedures and devices) or organizational (e.g. limited diffusion of hybrid operating rooms). CONCLUSIONS: In this study, which was based on the results of a recent survey conducted in 6 Italian Regions, structural heart interventions resulted widely growing throughout the investigated area. The indications for treatment and the availability of devices were relatively homogeneous between the regions involved, as well as the limiting factors, which appear to be mainly economic-organizational.

Superselective embolization of renal hemorrhage occurring after percutaneous coronary intervention.

A 69-year-old female was hospitalized for acute coronary syndrome and received full antiplatelet and anticoagulant therapy. The patient underwent angioplasty and stent implantation on right coronary and left circumflex arteries with good angiographic result. After the procedure, the patient developed hemorrhagic shock due to massive left renal hemorrhage. An emergent digital subtraction angiography showed bleeding from a left segmental renal artery. The hemorrhage was successfully managed with transcatheter superselective embolization. The patient was discharged after 22 days in good general condition with normal renal function. One-year follow-up was uneventful.