Gishel New

Immediate and Late Clinical Outcomes of Carotid Artery Stenting in Patients With Symptomatic and Asymptomatic Carotid Artery Stenosis

Background—Carotid stenting is a less invasive percutaneous procedure than carotid endarterectomy for the treatment of carotid stenosis. Reports suggest that it can be performed with periprocedural complication rates similar to those of carotid endarterectomy. The purpose of this study was to determine short- and long-term outcomes in the largest prospective cohort of carotid stenting patients. Methods and Results—This study followed 528 consecutive patients (604 hemispheres/arteries) undergoing carotid stenting. There was a 0.6% (n=3) fatal stroke rate and 1% (n=5) nonstroke death rate at 30 days. The major stroke rate was 1% (n=6), and the minor stroke rate was 4.8% (n=29). The overall 30-day stroke and death rate was 7.4% (n=43). Over the 5-year study period, the 30-day minor stroke rate improved from 7.1% (n=7) for the first year to 3.1% (n=5) for the fifth year (P<0.05 for trend). The best predictor of 30-day stroke and death was age ≥80 years. After the 30-day period, the incidence of fatal and nonf...

Percutaneous Coronary Intervention and Adjunctive Pharmacotherapy in Women A Statement for Healthcare Professionals From the American Heart Association

More than 1.2 million percutaneous coronary interventions are performed annually in the United States, with only an estimated 33% performed in women, despite the established benefits of percutaneous coronary intervention and adjunctive pharmacotherapy in reducing fatal and nonfatal ischemic complications in acute myocardial infarction and high-risk acute coronary syndromes. This statement reviews sex-specific data on the safety and efficacy of contemporary interventional therapies in women.

Safety, efficacy, and durability of carotid artery stenting for restenosis following carotid endarterectomy: a multicenter study.

Purpose: To present the results of a multicenter registry established to collect data on carotid stent procedures in patients with restenosis following carotid endarterectomy. Methods: The procedural details, outcomes, and late follow-up results were collected from 14 centers in the United States. Thirty-day and late stroke and death rates were analyzed. Results: Three hundred and thirty-eight patients (201 men; 71 ± 8 years) underwent carotid stenting in 358 arteries. The average duration from carotid endarterectomy was 5.5 ± 7.3 years. Sixty-one percent of the patients were asymptomatic. The overall 30-day stroke and death rate was 3.7%. The minor stroke rate was 1.7% (6/358), and the major nonfatal stroke rate was 0.8% (3/358). The fatal stroke rate was 0.3% (1/358), and the nonstroke-related death rate was 0.9% (3/338). There was 1 (0.3%) fatal and 1 (0.3%) nonfatal stroke during the follow-up period. The overall 3-year rate of freedom from all fatal and nonfatal strokes was 96% ± 1% (±SE). Conclusions: Carotid artery stenting can be performed in patients with restenosis following carotid endarterectomy with 30-day complication rates comparable to those of most published studies on repeat carotid endarterectomy. Results of late follow-up suggest that this technique is durable and efficacious.

Intramural coronary delivery of advanced antisense oligonucleotides reduces neointimal formation in the porcine stent restenosis model

OBJECTIVESnWe evaluated the long-term influence of intramural delivery of advanced c-myc neutrally charged antisense oligonucleotides (Resten-NG) on neointimal hyperplasia after stenting in a pig model.nnnBACKGROUNDnNeointimal hyperplasia after percutaneous coronary interventions is one of the key components of the restenotic process. The c-myc is a critical cell division cycle protein involved in the formation of neointima.nnnMETHODSnIn short-term experiments, different doses (from 500 microg to 5 mg) of Resten-NG or saline were delivered to the stent implantation site with an infiltrator delivery system (Interventional Technologies, San Diego, California). Animals were euthanized at 2, 6 and 18 h after interventions, and excised vessels were analyzed for c-myc expression by Western blot. In long-term experiments, either saline or a dose of 1, 5 or 10 mg of Resten-NG was delivered in the same fashion, and animals were euthanized at 28 days after the intervention.nnnRESULTSnWestern blot analysis demonstrated inhibition of c-myc expression and was dose dependent. Morphometry showed that the intimal area was 3.88 +/- 1.04 mm(2) in the control. There was statistically significant reduction of intimal areas in the 5 and 10 mg groups (2.01 +/- 0.66 and 1.95 +/- 0.91, respectively, p < 0.001) but no significant reduction in the 1 mg group (2.81 +/- 0.56, p > 0.5) in comparison with control.nnnCONCLUSIONSnThis study demonstrated that intramural delivery of advanced c-myc neutrally charged antisense morpholino compound completely inhibits c-myc expression and dramatically reduces neointimal formation in a dose dependent fashion in a porcine coronary stent restenosis model, while allowing for complete vascular healing.

Estrogen-eluting, phosphorylcholine-coated stent implantation is associated with reduced neointimal formation but no delay in vascular repair in a porcine coronary model

Estrogen can inhibit intimal proliferation and accelerate endothelial regeneration after angioplasty. This suggests that estrogen may prevent in‐stent restenosis. Unlike other therapies to prevent restenosis, estrogen may also not delay endothelial regrowth, thereby avoiding the risk of late stent thrombosis. The purpose of this work was to determine the effect of a 17β‐estradiol–eluting stent on neointimal formation in a porcine model. Each artery of six pigs was randomized to either a control, low‐dose, or high‐dose 17β‐estradiol–eluting stent. All animals were sacrificed at 30 days for histopathological analysis. There was a 40% reduction in intimal area in the high‐dose stents compared with control stents (2.54 ± 1.0 vs. 4.13 ± 1.1 mm2, for high dose vs. control, respectively; P < 0.05). There was complete endothelial regeneration at 30 days and similar inflammatory response to stenting on histopathology in all the stent groups. This is the first study to show that 17β‐estradiol–eluting stents are associated with reduced neointimal formation without affecting endothelial regeneration in the pig model of in‐stent restenosis. Estrogen‐coated stents may have a potential benefit in the prevention and treatment of in‐stent restenosis. Cathet Cardiovasc Intervent 2002;57:266–271.

Advanced c-myc antisense (AVI-4126)-eluting phosphorylcholine-coated stent implantation is associated with complete vascular healing and reduced neointimal formation in the porcine coronary restenosis model

An advanced six‐ring morpholino backbone c‐myc antisense (AVI‐4126) was shown to inhibit c‐myc expression and intimal hyperplasia after local catheter delivery in a porcine balloon injury model. The purpose of this study was to investigate the effects of an AVI‐4126‐eluting phosphorylcholine‐coated (PC) stent on c‐myc expression restenosis and vascular healing after stent implantation in porcine coronary arteries. PC stents were loaded with AVI‐4126 using soak trap. Nine pigs underwent AVI‐4126 PC coronary stent implantation (two stents/animal). Two to six hours postprocedure, three pigs were sacrificed and stented segments were analyzed by Western blot for c‐myc expression. In chronic experiments, six pigs (12 stent sites) were sacrificed at 28 days following intervention and vessels were perfusion‐fixed. High‐performance liquid chromatography analysis of plasma samples showed minimal presence of the antisense. Western blot analysis of the stented vessels demonstrated inhibition of c‐myc expression at 2 and 6 hr after procedure. Quantitative histologic morphometry showed that the neointimal area was significantly reduced (by 40%) in the antisense‐coated group compared with control (2.3 ± 0.7 vs. 3.9 ± 0.8 mm2, respectively; P = 0.0077). Immunostaining and electron microscopy demonstrated complete endothelialization, without fibrin deposition, thrombosis, or necrosis in all implanted stents. In the porcine coronary model, an advanced c‐myc‐eluting PC stent blocked c‐myc expression and significantly inhibited myointimal hyperplasia and allowed complete reendothelialization and healing response. Catheter Cardiovasc Interv 2004;61:518–527.

Carotid Stenting with Distal-Balloon Protection via the Transbrachial Approach:

Purpose: To document the feasibility of brachial artery access for carotid stenting with distal-balloon protection of the internal carotid artery (ICA). Technique: Via percutaneous access to the brachial artery, a large double-curve catheter is advanced into the aortic arch over a hydrophilic guidewire to cannulate the left common carotid artery. Following sheath exchange, a GuardWire distal-protection balloon is positioned within the left ICA distal to the stenosis. The lesion is dilated, followed by deployment and dilation of a self-expanding stent. Transcranial Doppler monitoring shows only scarce microembolic signals during the procedure. Conclusions: Carotid stenting with distal balloon protection via the brachial artery appears feasible as an alternative to standard femoral access.

Embolization via collateral circulation during carotid stenting with the distal balloon protection system.

Purpose: To describe a potential route for embolization to the middle cerebral artery (MCA) during carotid stenting with the distal balloon protection system. Case Report: An 82-year-old man with symptomatic severe carotid artery stenosis underwent elective carotid stenting with distal-balloon protection. Despite complete occlusion of the distal internal carotid artery, frequent emboli were detected in the ipsilateral MCA by transcranial Doppler (TCD) during the procedure. Intracranial angiography, performed during the distal-balloon protection, revealed filling of the MCA through collaterals from the ipsilateral external carotid artery. The procedure was successfully completed without complications. The patient remains asymptomatic at 6 months. Conclusions: During carotid stenting with distal-balloon protection, asymptomatic embolization into the ipsilateral MCA may occur through collateral circulation. The clinical significance of these emboli is uncertain.

Carotid artery stenting: Rationale, indications, and results

Carotid stenting is a percutaneous, minimally invasive treatment for carotid stenosis. It does not carry the surgical risks of carotid endarterectomy and therefore can be applied to the elderly and to patients with comorbidities. Complications and late events appear low.

Comparison of Outcomes in Men Versus Women Having Percutaneous Coronary Interventions in Small Coronary Arteries

Previous studies investigating the effect of gender on outcomes after percutaneous coronary intervention (PCI) have reported that women have higher in-hospital adverse event rates and a higher mortality rate than men. 1,2 This has been attributed to both the smaller size of women 3,4 and to the older age of women at the time of PCI. Older populations who undergo PCI are associated with increased rates of comorbid disease and an increased cardiac risk factor profi le. 5 Because women tend to have smaller coronary arteries than men, we hypothesized that the adverse outcomes may be partly due to the smaller coronary artery diameters. To test this hypothesis we compared men and women with small coronary arteries to evaluate whether gender remained a determinant