Khung Keong Yeo

Clinical Presentation, Management, and Outcomes of Angiographically Documented Early, Late, and Very Late Stent Thrombosis

OBJECTIVES The aim of this study was to describe differences in treatment and in-hospital mortality of early, late, and very late stent thrombosis (ST). BACKGROUND Early, late, and very late ST may differ in clinical presentation, management, and in-hospital outcomes. METHODS We analyzed definite (angiographically documented) ST cases identified from February 2009 to June 2010 in the CathPCI Registry. We stratified events by timing of presentation: early (≤1 month), late (1 to 12 months), or very late (≥12 months) following stent implantation. Multivariable logistic regression modeling was performed to compare in-hospital mortality for each type of ST after adjusting for baseline comorbidities. RESULTS During the study period, 7,315 ST events were identified in 7,079 of 401,662 patients (1.8%) presenting with acute coronary syndromes. This ST cohort consisted of 1,391 patients with early ST (19.6%), 1,370 with late ST (19.4%), and 4,318 with very late ST (61.0%). Subjects with early ST had a higher prevalence of black race and diabetes, whereas subjects with very late ST had a higher prevalence of white race and a lower prevalence of prior myocardial infarction or diabetes. In-hospital mortality was significantly higher in early ST (7.9%) compared with late (3.8%) and very late ST (3.6%, p<0.001). This lower mortality for late and very late ST persisted after multivariable adjustment (odds ratio: 0.53 [95% confidence interval (CI): 0.36 to 0.79] and 0.58 [95% CI: 0.43 to 0.79], respectively). CONCLUSIONS Significant differences exist in the presentation and outcomes of early, late, and very late ST. Among patients with acute coronary syndromes who are undergoing percutaneous coronary intervention for angiographically documented ST, early ST is associated with the highest in-hospital mortality.

Adherence to Guideline‐Recommended Therapy Is Associated With Decreased Major Adverse Cardiovascular Events and Major Adverse Limb Events Among Patients With Peripheral Arterial Disease

Background Current guidelines recommend that patients with peripheral arterial disease (PAD) cease smoking and be treated with aspirin, statin medications, and angiotensin‐converting enzyme (ACE) inhibitors. The combined effects of multiple guideline‐recommended therapies in patients with symptomatic PAD have not been well characterized. Methods and Results We analyzed a comprehensive database of all patients with claudication or critical limb ischemia (CLI) who underwent diagnostic or interventional lower‐extremity angiography between June 1, 2006 and May 1, 2013 at a multidisciplinary vascular center. Baseline demographics, clinical data, and long‐term outcomes were obtained. Inverse probability of treatment propensity weighting was used to determine the 3‐year risk of major adverse cardiovascular or cerebrovascular events (MACE; myocardial infarction, stroke, or death) and major adverse limb events (MALE; major amputation, thrombolysis, or surgical bypass). Among 739 patients with PAD, 325 (44%) had claudication and 414 (56%) had CLI. Guideline‐recommended therapies at baseline included use of aspirin in 651 (88%), statin medications in 496 (67%), ACE inhibitors in 445 (60%), and smoking abstention in 528 (71%) patients. A total of 237 (32%) patients met all four guideline‐recommended therapies. After adjustment for baseline covariates, patients adhering to all four guideline‐recommended therapies had decreased MACE (hazard ratio [HR], 0.64; 95% CI, 0.45 to 0.89; P=0.009), MALE (HR, 0.55; 95% CI, 0.37 to 0.83; P=0.005), and mortality (HR, 0.56; 95% CI, 0.38 to 0.82; P=0.003), compared to patients receiving less than four of the recommended therapies. Conclusions In patients with claudication or CLI, combination treatment with four guideline‐recommended therapies is associated with significant reductions in MACE, MALE, and mortality.

Operative Mortality in Women and Men Undergoing Coronary Artery Bypass Grafting (from the California Coronary Artery Bypass Grafting Outcomes Reporting Program)

The comparative operative mortality (OM) in women and men undergoing isolated coronary artery bypass graft surgery (CABG) has not been clarified. Therefore, we evaluated factors related to OM in a large cohort of women and men undergoing isolated CABG. Results from 121 hospitals on patients undergoing isolated CABG in 2003 and 2004 were analyzed according to gender, including demographics, clinical characteristics, and surgical outcome. A total of 10,708 women and 29,669 men had isolated CABG in 2003 to 2004. Observed mortality in women was significantly higher than in men (4.60% vs 2.53%, p <0.0001). Although men had a higher prevalence of >3 diseased coronary arteries and left ventricular dysfunction, women were more likely to be older, diabetic, have stage 3 to 5 chronic kidney disease, chronic lung disease, and nonelective CABG. Women were less likely to receive an internal mammary artery graft. Multivariate analysis indicated that women were at higher risk for OM than men (odds ratio 1.61, 95% confidence interval 1.40 to 1.84). In conclusion, data from the large state-mandated CCORP indicate that women are at increased risk of OM after isolated CABG compared to men, despite adjustment for preoperative risk factors.

Excimer laser with adjunctive balloon angioplasty and heparin-coated self-expanding stent grafts for the treatment of femoropopliteal artery in-stent restenosis: twelve-month results from the SALVAGE study.

The aim of the study is to evaluate the safety and effectiveness of treating femoropopliteal in‐stent restenosis (ISR) with debulking with excimer laser followed by implantation of a VIABAHN endoprosthesis.

Angiographic characteristics of femoropopliteal in-stent restenosis: association with long-term outcomes after endovascular intervention.

The purpose of this study was to identify the relationship between angiographic patterns of restenosis and outcomes after endovascular treatment of femoro‐popliteal in‐stent restenosis (FP‐ISR).

Outcomes following treatment of femoropopliteal in-stent restenosis: a single center experience.

Objectives: The aim of this study is to describe a single‐center experience with endovascular treatment of femoropopliteal in‐stent restenosis (ISR). Background: Femoropopliteal artery stenting is associated with a significant risk of ISR. Data are limited on the optimal treatment strategy and associated outcomes. Methods: A single institution retrospective chart review study was performed for patients who underwent endovascular treatment of femoropopliteal ISR from January 2006 to October 2008. Clinical and procedural characteristics, angiographic findings, and 12‐month primary and secondary patency rates were analyzed. Univariate analysis was performed to identify predictors of 12‐month primary patency. Results: Twenty‐two limbs were treated in 20 patients during the study period. Procedural success was achieved in 21 limbs (95.5%). Laser, balloon angioplasty, and excisional atherectomy were the primary therapy in 52.4%, 33.3%, and 14.3% of the cases, respectively. Adjunctive balloon angioplasty was performed after laser and excisional atherectomy in all cases. The mean length of ISR was 13.2 ± 11.3 cm with a significant proportion of cases (40.9%) having Type IV pattern of ISR. At 12 months, primary and combined primary‐assisted and secondary patency rates were 47.6 and 61.9%, respectively. Of the 11 limbs that did not have secondary patency, 6 had mild or no symptoms, and, therefore, repeat intervention was not performed. There was one transmetatarsal amputation during the 12‐month follow‐up period. In this study, there was no significant predictor of 12‐month primary patency. Conclusions: Treatment of ISR remains challenging with significant risk of recurrent restenosis. Further research is required to improve long‐term patency.

Direct flow medical percutaneous aortic valve: proof of concept.

AIMS This paper reports the technical feasibility of using the Direct Flow Medical percutaneous aortic valve (PAV) to treat patients with severe aortic stenosis (AS). METHODS AND RESULTS Eight patients with critical AS underwent temporary implantation of the PAV. Two patients received open surgical implantation of the device while six patients underwent percutaneous implantation. The mean age of these eight patients was 58.1 years, mean pre-procedural aortic valve area was <0.65 cm2 and pre-procedural gradient was 87.6 +/- 12.4 mmHg. Procedural success was achieved in seven out of eight patients, with a mean post-implantation gradient of 17.9 +/- 9.1 mmHg. There was one death related to inferior hypogastric artery dissection. All other patients subsequently received open surgical explantation of the PAV and aortic valve replacement with a mechanical valve. CONCLUSIONS The Direct Flow Medical PAV is technically feasible and safe to deploy in humans with severe AS and results in a significant transaortic gradient reduction.

Nitinol Self-Expanding Stents vs. Balloon Angioplasty for Very Long Femoropopliteal Lesions

Purpose To compare the patency rates and clinical outcomes of balloon angioplasty vs. nitinol stent placement for patients with short (≤150 mm) as compared to long (>150 mm) femoropopliteal (FP) occlusive lesions. Methods Between 2006 and 2011, 254 patients (134 men; mean age 68 years) underwent FP angioplasty. The majority of patients (64%) were treated for critical limb ischemia. One hundred thirty-nine (55%) patients had short FP lesions ≤150 mm, while 115 patients had long FP lesions >150 mm. The mean lesion length was 78±43 mm in the short FP lesion group and 254±58 mm in the long FP lesion group. Duplex ultrasound follow-up with a peak systolic velocity ratio ≥2.0 was used to define restenosis. Results The overall procedure success rate was 98%. One hundred forty-eight (58%) patients underwent stent placement. The mean number of stents deployed for treatment of short FP lesions was 1.0±0.4 vs. 2.0±0.7 for long FP lesions (p<0.001). The primary patency rate of short FP lesions treated with balloon angioplasty vs. stenting was 66% vs. 63% at 1 year (p=0.7). For long FP lesions, the 1-year primary patency rates of balloon angioplasty vs. stenting were 34% vs. 49% (p=0.006). Balloon angioplasty of long FP lesions was also associated with significantly lower assisted primary and secondary patency compared to stenting (p<0.05 for all comparisons). Sustained clinical improvement was >90% at 30 days but declined to 62% to 75% at 1 year. Conclusion Balloon angioplasty and stent placement result in similar patency rates and clinical outcomes for shorter to medium-length FP lesions. In comparison, stent placement in long FP lesions is associated with superior outcomes to balloon angioplasty, even when multiple stents are required. Procedure success and clinical improvement can be achieved in the majority of patients, but rates of restenosis remain high.

Association of dual-antiplatelet therapy with reduced major adverse cardiovascular events in patients with symptomatic peripheral arterial disease

OBJECTIVE This study was conducted to determine whether there is additive benefit of dual-antiplatelet therapy (DAPT) with aspirin (acetylsalicylic acid [ASA]) and clopidogrel compared with ASA monotherapy among patients with symptomatic peripheral arterial disease. METHODS This was an observational cohort analysis that included 629 patients with claudication or critical limb ischemia. The prevalence of patients taking ASA monotherapy vs DAPT was assessed monthly for up to 3 years. A propensity model was constructed to adjust for baseline demographic characteristics and to assess the effect of DAPT on major adverse cardiovascular events (MACEs) and major adverse limb events. RESULTS At baseline, 348 patients were taking DAPT and 281 were taking ASA monotherapy. During 3 years of follow-up, 50 events (20%) occurred in the DAPT group vs 59 (29%) in the ASA monotherapy group. After propensity weighting, DAPT use was associated with a decreased risk of MACEs (adjusted hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.44-0.96) and overall mortality (adjusted HR, 0.55; 95% CI, 0.35-0.89). No association was found between DAPT use and the risk of major amputation (adjusted HR, 0.69; 95% CI, 0.37-1.29). In a subgroup of 94 patients who underwent point-of-care platelet function testing, 21% had decreased response to ASA and 55% had a decreased response to clopidogrel. No association was found between a reduced response to ASA or clopidogrel and adverse events at 1 year. CONCLUSIONS DAPT may be associated with reduced rates of MACEs and death among patients with symptomatic peripheral arterial disease.

Use of stent grafts and coils in vessel rupture and perforation.

Vessel rupture and perforation are important complications of percutaneous treatment of coronary and peripheral arterial disease. These complications can result in abrupt vessel closure, distal organ injury, bleeding into the surrounding tissue, and death. Prompt management of such complications is therefore critically important. This paper reviews the management of vessel rupture and perforation, including the use of different types of covered stents (balloon-expandable and self-expanding), as well as the various types of embolization coils. Particular focus will be placed on percutaneous coronary artery and peripheral arterial interventions.