Richard M. Pomerantz

Angiographic and clinical outcome of intracoronary stenting: Immediate and long-term results from a large single-center experience

OBJECTIVES The purpose of this study was to determine the immediate and long-term angiographic and clinical results of coronary stenting. BACKGROUND Although preliminary trials of endovascular stenting have demonstrated promising results, lack of long-term follow-up has limited the critical evaluation of the role of coronary stenting in the treatment of obstructive coronary artery disease. METHODS A total of 250 procedures using the Palmaz-Schatz stent, performed in 220 patients between June 1988 and July 1991, were examined. Minimal lumen diameter of the treated segments was measured on angiograms obtained before, after and 6 months after intervention. RESULTS Stent placement was successful in 246 (98%) of 250 lesions, reducing diameter stenosis from 77% to -2.5%. There were no deaths or Q wave myocardial infarctions. One patient (0.4%) required emergency bypass surgery and one (0.4%) developed subacute thrombosis. Femoral vascular complications occurred in 36 patients (16%). Six-month angiographic follow-up was obtained in 91% of eligible patients. The overall angiographic restenosis rate (stenosis greater than or equal to 50%) was 25%. By univariable analysis, the rate of restenosis was significantly higher for stents in the left anterior descending versus the right coronary artery (44% vs. 12%; p = 0.002); in diabetic patients (56% vs. 20%; p = 0.006), and in vessels with post-stent lumen diameter less than 3.31 mm (34% vs. 16%; p = 0.05). Stenting of the left anterior descending artery was the strongest predictor (p = 0.01) of restenosis in a multivariable model. Total survival was 97% and event-free survival (freedom from death, myocardial infarction or revascularization) was 70% at 36 months. CONCLUSIONS Palmaz-Schatz stents can be placed successfully with a low incidence of major complications. The angiographic restenosis rate was 25%, and 70% of patients remained free of cardiovascular events at 3 years. Diabetes, small postprocedure lumen diameter and stenting of the left anterior descending artery are associated with higher rates of restenosis.

ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (Writing Committee to Revise the 2007 Clinical Competence Statement on Cardiac Interventional Procedures)

Granting clinical staff privileges to physicians is the primary mechanism institutions use to uphold quality care. The Joint Commission requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians themselves are charged with defining the

Acute and long-term outcome of narrowed saphenous venous grafts treated by endoluminal stenting and directional atherectomy

Angioplasty of the narrowed saphenous vein bypass grafts remains a difficult challenge. Over a 37-month period at this institution, 119 of 176 interventions (68%) on saphenous vein grafts (average age 8.3 years from bypass surgery to graft intervention) were performed using either directional coronary atherectomy (n = 35) or Palmaz-Schatz intracoronary stents (n = 84), representing 37% of all stents and 15% of all atherectomies during the study period, respectively. Of the 57 saphenous vein graft lesions treated with conventional balloon angioplasty during this period, 49 (86%) had 1 or more contraindications to stenting or directional atherectomy (thrombus, total occlusion, reference vessel less than 3 mm in diameter). The acute success rate was 99% for stents (1 failure to dilate) and 94% for directional atherectomy (2 failures to cross the lesion with the atherectomy device). Lumen diameter increased from 0.9 to 3.6 mm (reference vessel 3.6) for stents, and from 0.9 to 3.5 mm (reference 3.8) for atherectomy (for all comparisons, p = not significant), with no major complications (abrupt or subabrupt closure, emergent coronary bypass surgery, death, or Q-wave myocardial infarctions). During the same time period 50 of 57 vein grafts (88%) rejected for stenting or atherectomy were dilated successfully by conventional balloon angioplasty, with 3 patients (5%) requiring emergent coronary bypass surgery. Angiographic follow-up was available for 50 of 64 eligible patients (78%).(ABSTRACT TRUNCATED AT 250 WORDS)

Laser balloon angioplasty: clinical, angiographic and histologic results.

Laser balloon angioplasty combines conventional coronary angioplasty with laser energy to transiently heat vascular tissue. Laser balloon angioplasty, was performed in 21 patients (aged 56 +/- 13 years), including 10 patients treated urgently after acute failure of conventional angioplasty and 11 patients treated with elective laser balloon angioplasty. Immediately after conventional angioplasty, laser doses (1 to 10 doses of 205 to 380 J each) were delivered during inflation of the laser balloon to a pressure of 4 atm. Seven (70%) of 10 patients with acute failure of conventional angioplasty were successfully treated with laser balloon angioplasty, but 3 (30%) were unsuccessfully treated with the laser procedure and required emergency coronary artery bypass surgery. In all three failures, the 3 mm laser balloon angioplasty catheter was not the optimal size for the vessel. In the 11 patients treated with elective laser balloon angioplasty (reference diameter 2.94 +/- 0.22 mm), the minimal luminal diameter increased from 0.45 +/- 0.25 to 1.85 +/- 0.46 mm after conventional angioplasty and to 2.44 +/- 0.29 mm after laser balloon angioplasty (p less than 0.001). This corresponded to a decrease in diameter stenosis from 84 +/- 9% before to 35 +/- 16% after conventional angioplasty and to 15 +/- 10% after laser balloon angioplasty (p less than 0.001). There were no instances of myocardial infarction, emergency coronary artery bypass surgery or death and no acute complications related to delivery of laser energy in this group. Follow-up coronary angiography was performed 5.5 +/- 1.1 months after laser balloon angioplasty in 18 patients discharged from the hospital after a successful procedure. Ten patients (56%) had angiographic restenosis, defined as recurrent diameter stenosis greater than 50%. Six patients were subsequently treated by directional coronary atherectomy, which revealed intimal proliferation indistinguishable from that in patients with restenosis after conventional angioplasty. In conclusion, laser balloon angioplasty may be effective in sealing severe coronary dissections and reversing abrupt closure associated with failed conventional angioplasty. After uncomplicated conventional angioplasty, laser balloon angioplasty improves immediate luminal dimensions, but restenosis appears to be mediated by intimal hyperplasia, similar to that seen after conventional angioplasty.

Frequency and outcome of chest pain after two new coronary interventions (atherectomy and stenting)

Between June 1988 and July 1991, 464 new device interventions (Palmaz-Schatz stent or Simpson directional atherectomy) were performed in 410 patients. Chest pain occurred within 72 hours after the procedure in 94 patients (23%). All patients were evaluated with electrocardiograms and cardiac isoenzymes on the day after the procedure, and urgent repeat coronary angiography was performed in 29 chest pain patients (31%). Whereas all 14 patients with abnormal findings on repeat angiography had electrocardiographic changes, 6 of the 20 restudied patients (30%) with electrocardiographic changes had no angiographic explanation for chest pain. Non-Q-wave myocardial infarction occurred in 22 patients (5%) (10 of 35 [29%] with chest pain and electrocardiographic changes, 3 of 44 [7%] with chest pain and no electrocardiographic change, and 9 of 316 [3%] without chest pain). Factors associated with chest pain after new device intervention included a decreased residual percent stenosis (p = 0.05), incomplete revascularization (p = 0.005) and the presence of multivessel disease (p = 0.001). Vessel dissection after stenting but not atherectomy was associated with postprocedure chest pain. Chest pain is common (23%) after new device intervention. Electrocardiographic changes are a sensitive marker of angiographic abnormality and confer a higher risk of non-Q-wave myocardial infarction, but no increase of in-hospital mortality. Determinants of postprocedure chest pain are lower residual percent stenosis, incomplete revascularization and the presence of multivessel disease. Patients with chest pain but no electrocardiographic changes early after successful stent placement or atherectomy need not routinely undergo urgent recatheterization.

ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures: a Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (Writing Committee to Revise the 2007 Clinical Competence Statement on Cardiac Interventional Procedures).

WRITING COMMITTEE MEMBERS John G. Harold,* MD, MACC, FAHA, Chair, Theodore A. Bass, MD, FACC, FSCAI, Vice Chair, Thomas M. Bashore, MD, FACC, FAHA, FSCAI, Ralph G. Brindiss,* MD, MPH, MACC, FSCAI, John E. Brush JR, MD, FACC, James A. Burke, MD, PhD, FACC, Gregory J. Dehmers, MD, FACC, FAHA, FSCAI, Yuri A. Deychak, MD, FACC, Hani Jneids, MD, FACC, FAHA, FSCAI, James G. Jolliss, MD, FACC, Joel S. Landzberg, MD, FACC, Glenn N. Levine, MD, FACC, FAHA, James B. McClurken, MD, FACC, John C. Messengers,* MD, FACC, FSCAI, Issam D. Moussas, MD, FACC, FAHA, FSCAI, J. Brent Muhlestein, MD, FACC, Richard M. Pomerantz, MD, FACC, FSCAI, Timothy A. Sanborn, MD, FACC, FAHA, Chittur A. Sivaram, MBBS, FACC, Christopher J. Whites, MD, FACC, FAHA, FSCAI, Eric S. Williamss,* MD, FACC,

ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures: A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence

WRITING COMMITTEE MEMBERS John G. Harold,* MD, MACC, FAHA, Chair, Theodore A. Bass, MD, FACC, FSCAI, Vice Chair, Thomas M. Bashore, MD, FACC, FAHA, FSCAI, Ralph G. Brindiss,* MD, MPH, MACC, FSCAI, John E. Brush JR, MD, FACC, James A. Burke, MD, PhD, FACC, Gregory J. Dehmers, MD, FACC, FAHA, FSCAI, Yuri A. Deychak, MD, FACC, Hani Jneids, MD, FACC, FAHA, FSCAI, James G. Jolliss, MD, FACC, Joel S. Landzberg, MD, FACC, Glenn N. Levine, MD, FACC, FAHA, James B. McClurken, MD, FACC, John C. Messengers,* MD, FACC, FSCAI, Issam D. Moussas, MD, FACC, FAHA, FSCAI, J. Brent Muhlestein, MD, FACC, Richard M. Pomerantz, MD, FACC, FSCAI, Timothy A. Sanborn, MD, FACC, FAHA, Chittur A. Sivaram, MBBS, FACC, Christopher J. Whites, MD, FACC, FAHA, FSCAI, Eric S. Williamss,* MD, FACC,