Milton Macedo Soares Neto

Eficácia clínica da revascularização renal percutânea com implante de stent em pacientes com doença renovascular aterosclerótica

OBJECTIVE To evaluate the clinical efficacy of percutaneous renal revascularization with stenting to control hypertension and preserve/restore renal function in patients with atherosclerotic renovascular disease. METHODS From May/1999 to October/2003, 46 patients with atherosclerotic renal artery stenosis (ARAS) underwent revascularization with stenting. The indication for the procedure was hypertension control and/or renal function preservation/restoration. Clinical characteristics: age range: 33-84 years (median = 58.5 +/-10.7), males: 26 (56.5%), 4 (10%) patients with diabetes mellitus, 21 (46%) patients with coronary artery disease, creatinine <2.0mg/dl: 39 (64%), 6 patients (14%) with congestive heart failure, 20 (43%) patients with ostial stenosis and 15 (33%) patients with bilateral stenosis. Hypertension control was evaluated by the number of drugs used before the procedure and at follow-up (FU) and by blood pressure (BP) measurement. RESULTS The minimum follow-up was 7 months (range of 7-52, median: 23, mean: 24.2 +/- 15.2). There were no major complications. No patient experience any cardiovascular event. There was only one non-cadiac death (2%) and one technical failure in the treatment(2%). There was no serious complication in the procedure. None of the patients presented cardiovascular events. The renal function improved or stabilized in 32 patients (82%) and worsened in 4 (10%). The BP control improved in 19/44 (43,8%) patients and worsened / stabilized in 6 patients (14%). CONCLUSION Angioplasty with renal artery stenting for ARAS showed to be an effective treatment strategy to restore and preserve renal function and to control blood pressure.

Orally administered rapamycin does not modify rat aortic vascular tone.

Rapamycin (RP; rapamune, sirolimus) is a potent inhibitor of vascular smooth muscle cell proliferation and migration. RP was demonstrated to reduce vascular neointimal formation in different animal models of vascular smooth muscle cell proliferation, and clinical use of RP-eluting stents promotes significant reductions in in-stent restenosis rates. However, high costs still preclude the widespread use of these devices. Oral administration of RP associated to bare metal stent delivery has been advocated as an effective and considerably less expensive alternative for restenosis prevention. It is noteworthy that the presence of RP-eluting stents has been associated with reduced endothelial-dependent vasodilation and coronary spasm. In addition, RP has been demonstrated to prevent vasculogenesis. This study evaluated the effects of RP on endothelium-dependent vascular tone and demonstrated that in vitro incubation with high concentrations of RP did not modify either contraction or relaxation of aortic rings. Similar results were obtained after in vivo administration of the drug. These findings suggest that function of adult, non-proliferative rat endothelial cells involved in vascular tone control is not affected by orally administered RP.

Avaliação da acurácia diagnóstica da angiotomografia coronária de múltiplos detectores

INTRODUCTION: Coronary computed tomographic angiography (CCTA) has been widely accepted as a non-invasive diagnostic tool for coronary artery disease (CAD). The objective of this study was to evaluate the diagnostic performance of CCTA and its influence on modification of percutaneous revascularization strategies. METHOD: The study included two groups of patients: a main group (MG), including 100 patients screened with a suspect of severe CAD by CCTA and indication for coronary cineangiography (CINE), and a control group (CG) for comparison, including 100 patients selected during the same period, with indication for CINE according to clinical criteria or by positive functional tests. We evaluated the performance of CCTA for the diagnosis of lesions > 50% in coronary segments, arteries and patients and the revascularization strategies adopted. RESULTS: The sensitivity, specificity and positive and negative predictive values of CCTA were 86%, 95%, 71% and 100% for the coronary segments, 91%, 92%, 80% and 100% for the coronary arteries and 100%, 90%, 100% and 100% for patients, respectively. In the MG, percutaneous coronary intervention (PCI) was performed in 90% of the patients, whereas in the CG, percutaneous coronary intervention was performed in 43% of the patients (P = 0.01). CONCLUSION: CCTA had a high diagnostic performance in detecting CAD and allowed ad hoc PCI to be performed in 90% of the patients. This strategy, however, must await randomized studies to confirm these results.

Intervenção coronária percutânea em pacientes nonagenários

BACKGROUND: Elderly people represent a significant part of the Brazilian population and the population > 90 years has tripled in the past three decades. This retrospective study was aimed at analyzing the results of percutaneous coronary intervention in ninety-year-old patients. METHOD: Overall, 31 ninety-year-old patients (G1) undergoing percutaneous coronary treatment from January 1995 to January 2009 were retrospectively evaluated. These patients were compared to 6,222 patients 2 vessel disease (RR 1.82, IC 1.04-3.19; P = 0.011), left main coronary artery lesion (RR 2.98, IC 0.97-9.17; P = 0.001), presence of unstable angina (RR 2.48, IC 0.97-9.17; P = 0.0013) and diabetes (RR 2.35, IC 1.21-4.55; P = 0.0015) were MACE predicting variables. CONCLUSION: Ninety-year-old patients had a higher incidence of cardiovascular events than younger patients. However, when the technique is feasible and patients have good clinical condition, percutaneous coronary intervention may be effectively used with an acceptable safety margin.

Desempenho do stent farmacológico firebird em diabéticos portadores de doença coronária multiarterial

BACKGROUND: Preliminary data have shown the Firebird™ and the Cypher® stents have similar safety and efficacy profiles. However, to date, no study has evaluated the percutaneous coronary intervention (PCI) with the Firebird™ stent in diabetic patients. METHODS: The performance of the Firebird™ stent in diabetic patients with multivessel coronary artery disease (CAD) (n = 100) was compared to that of the Cypher® stent, using historical data from the ARTS-II study (n = 159). We compared the major adverse cardiovascular events (MACE) at one year. RESULTS: Most of the patients in the Firebird™ group were male (65%), with mean age of 63.3 ± 10.4 years and 5% were receiving insulin. Stable coronary syndromes were prevalent (60%), 45% had three-vessel CAD and ventricular function was preserved (56.6 ± 13.7%). In patients with three-vessel CAD, 135 lesions were treated with > 3 stents in 78% of the cases and 2 stents in the remaining ones. In patients with two-vessel CAD, 110 lesions were treated with > 2 stents in 80% of the cases and 1 stent in the remaining ones. The incidence of MACE at one year of the Firebird™ stent was 21%, death was observed in 3% of the patients, myocardial infarction in 2% and a new revascularization procedure in 18%, predominantly at the expense of a new PCI in 14% of the cases. Comparison with the Cypher® group did not show differences for any of the evaluated endpoints. CONCLUSIONS: In our study, the use of the Firebird™ stent showed similar results to those of patients in the ARTS-II study, which makes it attractive for use in the complex scenario of diabetic patients with multivessel CAD.

The use of primary stenting or balloon percutaneous transluminal coronary angioplasty for the treatment of acutely occluded saphenous vein grafts. Results from the Brazilian National Registry - CENIC

OBJECTIVE We conducted a comparative analysis of the in-hospital outcomes of patients who underwent primary percutaneous transluminal angioplasty (PTCA) or stent implantation because of an acute myocardial infarction (AMI) related to an acute vein graft occlusion. METHODS Since 1991 the Brazilian Society of Hemodynamic and Interventional Cardiology has maintained a large database (CENIC). From these, we selected all consecutive patients, who underwent primary PTCA or stenting in the first 24 hours of AMI, with the target vessel being an occluded vein graft. Immediate results and major coronary events occurring up until hospital discharge were analyzed. RESULTS During this period, 5,932 patients underwent primary PTCA or stenting; 158 (3%) of the procedures were performed because of an acute vein graft occlusion. Stenting was performed in 74 (47%) patients. Patients treated with stents had a higher success rate and lower mean residual stenosis compared with those who underwent primary balloon PTCA. The incidence of reinfarction and death were similar for stenting and balloon PTCA. CONCLUSION Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.

Impacto clínico da isquemia e viabilidade miocárdicas após tratamento de oclusão coronária crônica no segmento proximal da artéria descendente anterior

BACKGROUND: Evaluation of myocardial ischemia and viability is recommended prior to percutaneous coronary intervention (PCI) for chronic total occlusions. We evaluated late adverse cardiovascular events of patients with PCI for proximal left anterior descending artery occlusions, comparing patients with or without myocardial ischemia or viability. METHODS: Patients were allocated to groups with myocardial ischemia/viability (G1, n = 91) and without myocardial ischemia/viability (G2, n = 65) and adverse cardiovascular events (death, myocardial infarction, target-vessel revascularization and congestive heart failure) were compared. RESULTS: Most patients were male (68.1% vs 69.2%; P = 0.56), with a mean age of 65.4 ± 10 years vs 63.5 ± 8.7 years (P = 0.61) and almost one third were diabetics (33% vs 29.2%; P = 0.76). No differences regarding the clinical and angiographic profile were observed, except for the left ventricular ejection fraction (48.6 ± 13.7% vs 39.5 ± 11.8%; P = 0.04) and the degree of angiographic collateral flow grade to the left anterior descending artery, which was more evident in G1 (P = 0.03). The 3-year follow-up incidence of composite adverse cardiovascular events was lower in patients with myocardial ischemia/viability (12.5% vs 31.1%; P < 0.01). The factors that contributed the most for this difference were the incidence of congestive heart failure (3.3% vs 15.3%; P = 0.02) and death (2.2% vs 7.7%; P = 0.13). CONCLUSIONS: Treatment of proximal left anterior descending artery chronic total occlusions in patients with evidence of myocardial ischemia or viability reduces the incidence of adverse cardiovascular events in the long term.

Performance of the Firebird™ Drug-eluting Stent in Diabetic Patients with Multivessel Coronary Artery Disease

Background: Preliminary data have shown that the Firebird TM and the Cypher® stents have similar safety and efficacy profiles. However, to date, no study has evaluated percutaneous coronary intervention (PCI) with the Firebird TM stent in diabetic patients. Methods: The performance of the FirebirdTM stent in diabetic patients with multivessel coronary artery disease (CAD) (n = 100) was compared with that of the Cypher® stent using historical data from the ARTS-II study (n = 159). One-year major adverse cardiovascular events (MACE) were compared. Results: Most of the patients in the FirebirdTM group were male (65%), with a mean age of 63.3 ± 10.4 years, and 5% were on insulin. Stable coronary syndrome was prevalent (60%), and 45% of patients had three-vessel CAD with preserved ventricular function (56.6 ± 13.7%). In patients with three-vessel CAD, 135 lesions were treated with three or more stents in 78% of cases and with two stents in the remainder. In patients with two-vessel CAD, 110 lesions were treated with two or more stents in 80% of the cases and with one stent in the remainder. The one-year incidence of MACE with the FirebirdTM stent was 21%. Mortality occurred in 3% of the patients, myocardial infarction in 2%, and a new revascularisation procedure in 18%, predominantly a new PCI (14% of cases). Comparison with the Cypher® group did not show differences for any of the evaluated endpoints. Conclusions: In the present study, the use of the FirebirdTM stent showed similar results to those of the patients in the ARTS-II study, demonstrating its suitability for use in the complex scenario of diabetic patients with multivessel CAD. DESCRIPTORS: Coronary disease. Angioplasty. Drug-eluting stents. Diabetes mellitus.

Estado da arte do procedimento percutâneo: paciente octogenário submetido com sucesso, em apenas uma sessão, a valvotomia pulmonar, implante de stent coronário e implante de marcapasso definitivo

This report describes a case involving an 82 year old patient with mild renal insufficiency, severe pulmonary valve stenosis (PVS), severe anterior descending artery stenosis and complete atrioventricular block, who successfully underwent, in a single session, coronary angioplasty and a stent implant, pulmonary valvotomy and a permanent pacemaker implant.