Faculty Bibliography

BACKGROUND: We used intravascular ultrasound (IVUS) to evaluate recurrence after sirolimus-eluting stent (SES) implantation treatment of in-stent restenosis (ISR). METHODS AND RESULTS: Forty-eight ISR lesions (41 patients with objective evidence of ischemia) were treated with SES. Recurrent ISR was identified in 11 lesions (all focal); repeat revascularization was performed in 10. These were compared with 16 patients (19 lesions) without recurrence as documented by angiography. Nine of 11 recurrent lesions had a minimum stent area (MSA) <5.0 mm2 versus 5 of 19 nonrecurrent lesions (P=0.003); 7 of 11 recurrent lesions had an MSA <4.0 mm2 versus 4 of 19 nonrecurrent lesions (P=0.02); and 4 of 11 recurrent lesions had an MSA <3.0 mm2 versus 1 of 19 nonrecurrent lesions (P=0.03). A gap between SESs was identified in 3 of 11 recurrences versus 1 of 19 nonrecurrent lesions. CONCLUSIONS: Stent underexpansion is a significant cause of failure after SES implantation treatment of ISR

The relation between lesion length and effectiveness of gamma radiation treatment (gamma-RT) has not been well described. We evaluated the acute and long-term outcome according to baseline lesion length in 130 patients treated with (192)Ir in the Washington Radiation for In-Stent Restenosis Trial; 44 (35.5%) had baseline short in-stent restenosis (ISR) lesions (length < 15 mm) and 80 (64.5%) long ISR lesions (length > or = 15 mm). At 6-month follow-up after gamma-RT, the short ISR group had larger lumen dimensions and lower late loss than the long ISR group. Restenosis rate was significantly higher in patients with long ISR for both the placebo (74% vs. 39%; P = 0.01) and the gamma-RT arm (31% vs. 5.3%; P = 0.04). gamma-RT significantly improved the angiographic outcome in the short-lesion groups but had the more pronounced effect on the reduction of clinical events after treatment of long ISR group. Lesion length remains a powerful predictor of recurrent ISR and clinical events after treatment of ISR even with gamma-RT

We identified 1,369 consecutive patients who received glycoprotein IIb/IIIa inhibitors during 1,461 stenting procedures (2,382 lesions); of these, 240 (17.5%) were aged > or =75 years (253 procedures, 430 lesions). Very elderly patients (> or =75 years) had similar in-hospital outcomes but a higher hemorrhagic stroke rate than patients aged <75 years

PURPOSE: To determine the impact of symptomatic peripheral arterial disease (PAD) on clinical outcomes in patients treated with percutaneous coronary interventions (PCI). METHODS AND RESULTS: Symptomatic PAD was identified in 1969 (18.9%) of 10440 consecutive patients undergoing PCI. Patients with PAD were older, more frequently female, and had smaller body surface area and more atherosclerotic risk factors, chronic renal insufficiency, and heart failure. Patients with PAD had lower rates of procedural success (94.2% versus 96.2%, p<0.0001) and higher rates of in-hospital complications, including all-cause mortality (2.1% versus 1.1%, p=0.0002), cardiac death (1.5% versus 0.7%, p=0.0009), urgent coronary artery bypass grafting (1.9% versus 1.2%, p=0.01), recurrent ischemia (5.6% versus 2.8%, p<0.0001), re-PCI to the target lesion (2.4% versus 1.1%, p<0.0001), stroke (0.6% versus 0.3%, p=0.0344), transient ischemic attack (0.4% versus 0.1%, p=0.01), femoral hematoma (10.3% versus 8.5%, p=0.01), retroperitoneal hematoma (0.8% versus 0.3%, p=0.009), limb ischemia (3.0% versus 0.7%, p<0.0001), gastrointestinal bleeding (1.9% versus 0.9%, p<0.0001), and blood transfusion (10.1% versus 5.2%, p<0.0001). At 1-year follow-up, patients with PAD had a higher mortality rate (13.6% versus 5.2%, p<0.0001), a higher rate of myocardial infarction (8.3% versus 6.5%, p=0.008), and also more target lesion (21.2% versus 19.8%, p=0.02) or target vessel revascularization (24.6% versus 21.2%, p=0.002). By multivariate analysis, PAD was an independent predictor of 1-year mortality (odds ratio 1.71, 95% confidence interval 1.42 to 2.07, p<0.0001). CONCLUSIONS: Nearly a fifth of patients undergoing PCI have symptomatic PAD. The presence of PAD is associated with lower rates of procedural success, higher rates of in-hospital and 1-year adverse events, and is independently associated with increased 1-year mortality

BACKGROUND: Little is known about causes of intimal hyperplasia (IH) after sirolimus-eluting stent (SES) implantation. METHODS AND RESULTS: Intravascular ultrasound was performed in 24 lesions with intra-SES restenosis and a comparison group of 25 nonrestenotic SESs. To assess stent strut distribution, the maximum interstrut angle was measured with a protractor centered on the stent, and the visible struts were counted and normalized for the number of stent cells. In SES restenosis patients, minimum lumen site was compared with image slices 2.5, 5.0, 7.5, and 10.0 mm proximal and distal to this site. The minimum lumen site had a smaller IVUS lumen area at follow-up (2.7+/-0.9 versus 6.2+/-1.9 mm2; P<0.01), larger maximum interstrut angle (135+/-39 degrees versus 72+/-23 degrees; P<0.01), larger IH area (3.4+/-1.5 versus 0.6+/-1.1 mm2; P<0.01) and thickness (0.7+/-0.3 versus 0.1+/-0.2 mm; P<0.01) at maximum interstrut angle, and fewer stent struts (4.9+/-1.0 versus 6.0+/-0.5; P<0.01) even when normalized for the number of stent cells (0.78+/-0.15 versus 0.97+/-0.07; P<0.01). Compared with nonrestenotic SES, the restenosis lesions also had a smaller minimal lumen area, larger IH area, thicker IH at maximum interstrut angle, fewer stent struts, and larger maximum interstrut angle. Multivariate analysis identified the number of visualized stent struts normalized for the number of stent cells and maximum interstrut angle as the only independent IVUS predictor of IH cross-sectional area (P<0.01 and P<0.01), minimum lumen area (P<0.01 and P<0.01), and IH thickness (P<0.01 and P<0.01). CONCLUSIONS: The number and distribution of stent struts affect the amount of neointima after SES implantation

The purpose of this study was to examine the effect of vascular brachytherapy with gamma-radiation (gamma-RT) in patients with diabetes mellitus (DM) with coronary in-stent restenosis (ISR). In the Washington Radiation for In-Stent Restenosis (WRIST) trial, 130 patients with ISR were treated with (192)Ir or placebo. Of the patients enrolled, 44 (34%) had DM (18 of them treated with gamma-RT and 26 with placebo). Gamma-radiation therapy of ISR in diabetics resulted in similar procedural success and in-hospital outcome compared to nondiabetics. At 6-month follow-up, both DM and non-DM patients treated with gamma-RT had significantly lower target lesion revascularization (TLR), target vessel revascularization, and major adverse cardiac event rates compared to placebo. DM remains a powerful predictor of TLR and major adverse cardiac events even after treatment of ISR with gamma-RT

Arterial closure devices are safe and effective in selected patients, with complication rates similar to or lower than manual compression. The purpose of this study was to compare the safety and efficacy of the first- and new-generation Angio-Seal devices in patients undergoing PCI. This study found that the new Angio-Seal STS Platform device can secure hemostasis after PCI in a safe and effective manner similar to the old device. The new platform is easier for the operator and for the patients

This study shows that cerebrovascular and peripheral arterial diseases frequently co-exist in patients with coronary artery disease who undergo percutaneous coronary interventions. These 2 conditions are associated with adverse in-hospital and 1-year outcomes and independently predict early and 1-year mortality

Coronary remodeling and plaque composition were compared between focal and diffuse coronary lesions. Negative remodeling and fibrous and calcified plaque compositions contribute to stenosis development in diffuse lesions more frequently than in focal lesions

Of 6,929 consecutive patients who were treated with percutaneous coronary intervention, 1,708 (24.6%) had anemia according to criteria of the World Health Organization. Compared with patients who did not have anemia, those who did have anemia were older, more frequently women and African-American, had a smaller body mass index, and higher frequencies of cardiovascular risk factors and co-morbid conditions. Patients who had anemia compared with those who did not have anemia had significantly (p <0.0001) higher mortality rates during hospitalization (1.9% vs 0.4%) and at 1 year (12.8% vs 3.5%). After adjustment for potential confounders, baseline hematocrit remained a significant predictor of a 1-year mortality rate (hazard ratio 0.93 per 1% increase in hematocrit, 95% confidence interval 0.91 to 0.95)