Per Anton Sirnes

Stenting in chronic coronary occlusion (SICCO): A randomized, controlled trial of adding stent implantation after successful angioplasty

OBJECTIVESnThis study investigated whether stenting improves long-term results after recanalization of chronic coronary occlusions.nnnBACKGROUNDnRestenosis is common after percutaneous transluminal coronary angioplasty (PTCA) of chronic coronary occlusions. Stenting has been suggested as a means of improving results, but its use has not previously been investigated in a randomized trial.nnnMETHODSnWe randomly assigned 119 patients with a satisfactory result after successful recanalization by PTCA of a chronic coronary occlusion to 1) a control (PTCA) group with no other intervention, or 2) a group in which PTCA was followed by implantation of Palmaz-Schatz stents with full anticoagulation. Coronary angiography was performed before randomization, after stenting and at 6-month follow-up.nnnRESULTSnInguinal bleeding was more frequent in the stent group. There were no deaths. One patient with stenting had a myocardial infarction. Subacute occlusion within 2 weeks occurred in four patients in the stent group and in three in the PTCA group. At follow-up, 57% of patients with stenting were free from angina compared with 24% of patients with PTCA only (p < 0.001). Angiographic follow-up data were available in 114 patients. Restenosis (> or = 50% diameter stenosis) developed in 32% of patients with stenting and in 74% of patients with PTCA only (p < 0.001); reocclusion occurred in 12% and 26%, respectively (p = 0.058). Minimal lumen diameter (mean +/- SD) at follow-up was 1.92 +/- 0.95 mm and 1.11 +/- 0.78 mm, respectively (p < 0.001). Target lesion revascularization within 300 days was less frequent in patients with stenting than in patients with PTCA only (22% vs. 42%, p = 0.025).nnnCONCLUSIONSnStent implantation improved long-term angiographic and clinical results after PTCA of chronic coronary occlusions and is thus recommended regardless of the primary PTCA result.

Sustained benefit of Stenting Chronic Coronary occlusion : Long-term clinical follow-up of the Stenting in Chronic Coronary occlusion (SICCO) study

OBJECTIVESnThis study assessed the long-term clinical outcome of stenting chronic occlusions.nnnBACKGROUNDnIn the Stenting in Chronic Coronary Occlusion (SICCO) study, patients were randomized to additional stent implantation (n = 58) or not (n = 59) after successful recanalization and dilation of a chronic coronary occlusion. Palmaz-Schatz stents were used with full anticoagulation. The previously published 6-month angiographic follow-up results showed reduction of the restenosis rate from 74% to 32%.nnnMETHODSnThe primary end point was the occurrence of major adverse cardiac events (cardiac death, lesion-related acute myocardial infarction, repeat lesion-related revascularization or angiographic documentation of reocclusion).nnnRESULTSnLate clinical follow-up was obtained in all patients at 33 +/- 6 months. Major adverse cardiac events occurred in 14 patients (24.1%) in the stent group compared with 35 patients (59.3%) in the percutaneous transluminal coronary angioplasty (PTCA) group (odds ratio 0.22, 95% confidence interval 0.10 to 0.49, p = 0.0002). Target vessel revascularization (including failed PTCA attempts) was performed in 24% of the stent group and in 53% of the PTCA group (p = 0.002). There were no events in the stent group after 8 months, whereas events continued to occur in the PTCA group. By multivariate analysis, allocation to the PTCA group, left anterior descending coronary artery lesion and lesion length were significantly related to the development of major adverse cardiac events.nnnCONCLUSIONSnThese data demonstrate the long-term safety and clinical benefit of stenting recanalized chronic occlusions. There is a continued risk of late clinical events related to nonstented lesions. Implantation of an intracoronary stent should therefore be considered after successful opening of a chronic coronary occlusion.

ESC Core Curriculum for the General Cardiologist (2013)

The previous Core Curriculum for the General Cardiologist defined a model for cardiology training in Europe and it has been adopted as the standard for regulating training, for access to the specialty (certification), and for revalidation in several countries.1nnDuring the last 5 years we have witnessed profound changes in cardiological practice. The work of both hospital and independent cardiologists has been better integrated with that of general practitioners. It has taken into account the requirements of national authorities, re-imbursement organizations, and hospital administrations. Cardiologists face changing patient expectations. General cardiologists, interventional …

Reproducibility of quantitative coronary analysis, Assessment of variability due to frame selection, different observers, and different cinefilmless laboratories.

Because of limited storage capacity for digital images, angiographic laboratories without cinefilm are dependent on locally performed quantitative coronary angiography (QCA) in clinical studies. In the present study the intra-and interobserver variability, as well as variability between different laboratories and variability due to frame selection was analyzed. A total of 20 coronary lesions were studied in two different digital laboratories 12±8 days apart. Images were analyzed on-line and after being transferred to a Cardiac Work Station (CWS). There was no significant difference between the measurement situations. For minimal luminal diameter (MLD) precision (SD of signed errors) ranged from 0.12 mm to 0.20 mm, for reference diameter (RD) from 0.15 mm to 0.28 mm, and for percent diameter stenosis (DS) from 4.2% to 5.8%. Overall relative precision was obtained by normalizing the QCA parameters, and was 11.9% for MLD, 7.0% for RD and 8.5% for DS (p<0.001, RD and DS compared to MLD). The overall variability in the interobserver and in the interlaboratory comparisons was 11.2% and 10.4%, respectively (n.s.) (n.s.). Thus the variability of QCA performed in cinefilmless, digital laboratories is small, and within a range making it an useful tool for clinical practice and group comparisons in clinical studies. However, the error range of QCA measurements must be taken into consideration when judging results from individual patients.

Predictors for restenosis after angioplasty of chronic coronary occlusions

BACKGROUNDnThe Stenting In Chronic Coronary Occlusion (SICCO) study assessed the effects of additional intracoronary stenting (Palmaz-Schatz) after successful percutaneous transluminal coronary angioplasty (PTCA) of chronic coronary occlusions and showed a significant reduction of restenosis in stented patients.nnnMETHODSnUnivariate and logistic regression analyses were used to assess clinical, angiographic and procedure related predictors for restenosis (>50% diameter stenosis at follow-up) and Major Adverse Clinical Events (MACE=cardiac death, lesion-related acute myocardial infarction, repeat lesion-related angioplasty, bypass surgery involving the treated segment or angiographic documentation of reocclusion in non-revascularized patients) in the 114 SICCO patients with an angiographic end-point and 300 days clinical follow-up.nnnRESULTSnBy 6 months the restenosis rate was 53%, and after 300 days MACE had occurred in 39%. Both the rates of restenosis and MACE was significantly reduced by stenting. The restenosis rate was improved by stenting also in patients with a stentlike result after the initial PTCA. In the multivariate model the risk of restenosis was increased by a history of unstable angina, a long lesion and a non-tapering occlusion stump. LAD location was associated with a threefold increased risk of MACE.nnnCONCLUSIONnStent implantation should always be considered in successfully opened chronic occlusions.

The Barath Cutting Balloon versus conventional angioplasty. A randomized study comparing acute success rate and frequency of late restenosis.

In a randomized multicenter study initial success rate and 6 months follow-up were compared between coronary angioplasty performed with the Barath Cutting Balloon (group A, n = 32) and conventional balloons (group B, n = 32) in patients with type A or B lesions in native coronary arteries. The culprit lesion was not reached in one patient in group A. Initial success rates were similar with and without additional stenting (8 in group A and 10 in group B). Angiographic follow-up data (in 95%) revealed a non-significant improvement in minimal lumen diameter, diameter stenosis in group A. Restenosis developed in 16.7% of group A vs 25.8% of group B, (p = 0.57). A separate analysis of stented patients showed no restenosis in group A and restenosis in 4 out of 10 patients in group B (p = 0.10). A possible beneficial effect of the Cutting Balloon with respect to in-stent restenosis requires further studies.

Stenting small coronary arteries using two second-generation slotted tube stents: acute and six-month clinical and angiographic results.

This prospective study assessed the feasibility, safety, as well as clinical and angiographic outcome after 6 months in 96 patients (100 lesions) treated by stent implantation after a suboptimal balloon angioplasty result in coronary arteries < 3 mm and with a lesion length < 25 mm. The lesions were randomized to treatment with BeStent small or NIR‐7. Final quantitative coronary angiography was performed off line. Baseline reference diameter was 2.58 ± 0.22 mm. Complex lesions constituted 52%, and 23% had unstable angina. Angiographic and procedural success was achieved in 98% and 94%, respectively. At follow‐up, 88.5% were free of major adverse cardiac events. The overall restenosis rate was 22.5% (89% angiographic follow‐up). There were no statistically significant differences between the stents regarding predefined endpoints. Thus, provisional stent treatment of small coronary arteries using BeStent small or NIR‐7 is feasible, safe, and has a favorable clinical and angiographic mid‐term outcome. Cathet. Cardiovasc. Intervent. 50:307–313, 2000.