Morphology and Location of Restenosis Following Bare Metal Coronary Stenting
Restenosis following bare metal coronary stenting is common. The location and characteristics of restenotic lesions in patients who have undergone coronary stent implantation is not well described. The purpose of this study was to determine the location, type and temporal distribution of stent-related restenosis. We reviewed the clinical and angiographic characteristics of 203 consecutive patients with stent-related restenosis undergoing a repeat clinically-indicated coronary angiogram, 30 days to 1 year after the index procedure. All lesions within 10 mm of the proximal and distal margins of the stent were included in the analysis. An angiographic classification was developed based on lesion location. Class I lesions were those occurring within the stent, and Class II comprised those lesions occurring within 10 mm of the proximal and distal stent edge. We classified a total of 234 stent-related restenosis lesions. Class I lesions were found in 52% of patients, and Class II in 48%. Three-fifths of the patients who developed new lesions at a stent edge presented 1?3 months following the initial procedure, which was significantly earlier than other lesion types (p < 0.001). A substantial number of patients undergoing repeat angiography after stent placement have lesions proximate, but peripheral, to the stent. This may limit the effectiveness of stent-based efforts to reduce restenosis. The time interval between coronary stenting and symptom recurrence appears to vary according to lesion location.
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Predictors of Recurrent Restenosis After Coronary Stenting: An Analysis of 197 Patients
One of the major limitations in coronary stenting is in-stent restenosis. This study was aimed to identify clinical, angiographic, and procedural factors that may be related to recurrent in-stent restenosis. We analyzed consecutive 197 patients who underwent coronary stenting. Follow-up angiography was available in 170 patients and repeat balloon angioplasty was performed for in-stent restenosis. These patients were subdivided into 3 groups: group A consisted of 100 patients that were never restenosed, group B had 49 patients restenosed once, and in group C were 21 patients restenosed more than twice. Group C was more often female (48%) and included diabetes mellitus patients (52%). Lesion location, reference vessel size and diameter stenosis were similar for all groups. However, the incidence of calcified lesions tended to be higher (50% vs. 29%; p = 0.07), and lesion length was longer in group C than in group A (11.9 ± 5.4 mm vs. 9.0 ± 3.9 mm; p < 0.01). Diameter stenosis after predilation as well as after stenting was significantly higher in group C than in group A (50 ± 10% vs 39 ± 10%; p < 0.01, 32 ± 8% vs. 19 ± 10%; p < 0.01). The incidence of diffuse type of in-stent restenosis was significantly higher in group C than in group B (62% vs. 14%; p < 0.01). Multivariate logistic regression analysis identified diameter stenosis after stenting (p = 0.0022), female (p = 0.0135), and diameter stenosis after predilatation (p = 0.0233) as the significant correlate of recurrent in-stent restenosis. In conclusion, the major recurrent in-stent restenosis predictors identified included female gender, final diameter stenosis, and diameter stenosis after predilatation.
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Intracoronary Brachytherapy for In-Stent Restenosis Using Long Sources Reduces Restenosis
Edge restenosis (?candy wrapper? effect) and late thrombosis remain a problem in various randomized intracoronary brachytherapy (ICBT) trials for the treatment of in-stent restenosis (ISR). Target vessel revascularization (TVR) due to target lesion revascularization (TLR) and edge restenosis can be decreased with the use of longer ICBT sources and debulking devices and has not been systematically studied. We analyzed 226 patients with ISR (240 vessels/264 lesions; average lesion length 17.5 ± 8.9 mm) who had lesion debulking followed by 90 Strontium (Sr) b-irradiation using the Novoste Betacath® system (30 mm source in 144 vessels and 40 mm source in 96 vessels). Dual antiplatelet therapy was recommended for one year. At follow-up of 12 ± 2 months, clinical TVR occurred in 9.7%, with TLR in 7.1% and non-TLR in 2.6% of cases. There was no delayed or late subacute thrombosis. Beta-irradiation using a longer 90Sr source after lesion modification with cutting balloon (CB) and/or rotational atherectomy (RA), along with the use of long-term dual antiplatelet therapy is safe and associated with single-digit clinical restenosis.
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Cutting Balloon Angioplasty
The cutting balloon is a unique angioplasty device used in percutaneous coronary interventions. The advantage of the cutting balloon is its ability to reduce vessel stretch and vessel injury by scoring the vessel longitudinally rather than causing an uncontrolled disruption of the atherosclerotic plaque. The atherotomes deliver a controlled fault line during dilatation to ensure that the crack propagation ensues in an orderly fashion. Lower balloon inflation pressures (4?8 atmospheres) are recommended with the cutting balloon. The cutting balloon also dilates the target vessel with less force to decrease the risk of a neoproliferative response and in-stent restenosis.
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Debulking for In-Stent Restenosis in the Brachytherapy Era: Does it Still Have a Role?
Despite the advent of intracoronary brachytherapy, treatment of in-stent restenosis, particularly diffuse in-stent restenosis, remains problematic. Adjunctive debulking prior to brachytherapy may improve long-term outcomes. We review the literature and report our results of a series of patients treated with excimer laser coronary atherectomy along with balloon angioplasty and brachytherapy for in-stent restenosis. We conclude that adjunctive debulking may improve the long-term clinical outcomes of patients with diffuse in-stent restenosis treated with angioplasty and intracoronary radiation. A randomized controlled trial is warranted.
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Clinical Trials of Intracoronary Gamma Radiation Therapy for In-Stent Restenosis
The only gamma emitter used in clinical trials for in-stent restenosis is 192Iridium (192Ir). The efficacy of intracoronary gamma radiation therapy in reducing clinical and angiographic restenosis in patients with in-stent restenosis has been established. This review is intended to give an overview of the clinical trials utilizing gamma vascular brachytherapy in patients with in-stent restenosis and give insight into the future of intracoronary radiation therapy.
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The Impact of Cutting Balloon Angioplasty for the Treatment of Diffuse In-Stent Restenosis
Objective. To determine the comparable safety and efficacy of cutting balloon angioplasty (CBA) and balloon angioplasty (BA) for diffuse in-stent restenosis (ISR). Background. Previous studies have found that diffuse-type ISR predicts recurrence of ISR. The efficacy of CBA in this clinical setting is incompletely documented. Methods and Results. One hundred and seven consecutive diffuse ISR lesions (length > 10 mm) in 104 patients treated by CBA or BA were retrospectively analyzed. CBA was used in 61 lesions and BA in 46 lesions. Initial success (residual restenosis <= 30% with no major complications) was achieved in 99% of cases in each group. Follow-up angiography was performed in all patients at 131 ± 93 days. Although the percent diameter stenosis after CBA was lower than after BA (19 ± 12% versus 27 ± 12%; p = 0.001), intravascular ultrasound (IVUS) or other QCA data were similar in the 2 groups. In follow-up angiography, recurrent restenosis rate was not statistically different between CBA (34%) and BA (52%); however, recurrent diffuse ISR was lower in the CBA group (20%) than the BA group (48%; p = 0.01). Lesion length at follow-up in the CBA group was smaller compared to the BA group (15.9 ± 7.3 mm versus 24.2 ± 14.4 mm; p < 0.05), while lesion length before procedure was similar. Conclusion. CBA for ISR is safe and effective with favorable long-term outcomes. This effect is mainly due to shortening lesion length.
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A Randomized Trial of the Low-Molecular-Weight Heparin Certoparin to Prevent Restenosis Following Coronary Angioplasty
Objectives. The objectives of this study were to evaluate the effectiveness and safety of the low-molecular-weight heparin (LMWH) certoparin in preventing restenosis following balloon coronary angioplasty. Background. Restenosis following coronary angioplasty continues to limit the long-term efficacy of this procedure. Animal studies have indicated a potential role for LMWH in reducing restenosis by limiting smooth muscle proliferation. Methods. This study tested the effects of certoparin, self-administered for 3 months, in reducing restenosis following balloon coronary angioplasty. One hundred and eighteen patients with 158 lesions treated with angioplasty were enrolled in this randomized, placebo-controlled trial. One hundred and two patients completed the study. The endpoint was relative loss measured with quantitative coronary angiography. Results. The relative loss for placebo was 0.19 ± 0.23 compared to 0.14 ± 0.21 for LMWH (p = NS). The minimum lumen diameter (MLD) was 1.47 ± 0.66 for placebo and 1.40 ± 0.57 for the LMWH (p = NS). There was a reduction (31% for LMWH; 49% for placebo PSDP) in the percent of patients having binary restenosis (MLD < 50% of reference diameter). At the end of the study 77% of the placebo patients and 76% of the LMWH group were asymptomatic (p = NS). There was a low rate of bleeding complications and these were minor. Bone density scans showed that there was no significant occurrence of osteoporosis with 3 months of LMWH. Conclusions. Administration of certoparin for 3 months is safe, but appears ineffective in reducing post-PTCA restenosis.
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Late Stent Thrombosis in Brachytherapy: The Role of Long-term Antiplatelet Therapy
Advances in percutaneous coronary intervention (PCI) have emerged in the past decade. Stenting has improved upon the limitations of angioplasty, acute vessel closure and restenosis by providing mechanical vascular support, resulting in sustained clinical and angiographic benefit. This has led to greater utilization of the technique, although it is associated with a significant incidence of in-stent restenosis. Neointimal hyperplasia is the pathophysiologic process that leads to in-stent restenosis. Brachytherapy can be effective in reducing the occurrence of this process. Unfortunately, brachytherapy trials have identified the phenomenon of late stent thrombosis as a potentially serious complication of this procedure. Late stent thrombosis is thrombosis that occurs > 30 days after PCI. The risk of thrombosis is increased in patients receiving a new stent in addition to brachytherapy. It also appears to be increased when adjunctive antiplatelet therapy with ticlopidine or clopidogrel is discontinued early. Strategies to prevent late stent thrombosis include the prolonged use of combination antiplatelet therapy in addition to limited placement of new stents in patients treated with brachytherapy for in-stent restenosis.
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A Multicenter, Randomized, Dose-Finding Study of Gamma Intracoronary Radiation Therapy to Inhibit Recurrent Restenosis after Stenting
Objectives. The objective of this double-blind, randomized study was to determine the safety and efficacy of intracoronary radiation therapy (ICRT) with a dose of 17 Gray (Gy) compared to the currently recommended dose prescription of 14 Gy for the treatment of in-stent restenosis within bare metal stents. Background. While gamma ICRT for in-stent restenosis has been proven efficacious, the optimal dose is unknown, and radiation failure due to recurrent neointimal hyperplasia remains a significant clinical problem for some patients. A higher radiation dose may improve outcomes, but may potentially increase adverse events. Methods. Following coronary intervention, 336 patients with in-stent restenosis were randomly assigned to receive ICRT with either 14 Gy or 17 Gy at 2 mm from an 192-iridium source. Results. At 8-month follow up, fewer patients in the 17 Gy group underwent target lesion revascularization (TLR = 15.2% versus 27.2%; p = 0.01), target vessel revascularization (21.3% versus 33.1%; p = 0.02), or reached the composite endpoint of death, myocardial infarction, thrombosis, or TLR (17.1% versus 28.4%; p = 0.02). There were no differences in late thrombosis or mortality between treatment groups. There was a strong trend toward reduced in-lesion late loss (0.36 ± 0.63 mm vs. 0.51 ± 0.64 mm; p = 0.09) and a significantly lower rate of binary restenosis (23.9% versus 38.1%; p = 0.031) in the high dose group. Conclusions. Gamma ICRT with 17 Gy is safe and, compared to 14 Gy, reduces recurrent stenosis and clinical events at 8-month follow up. An increase in the currently recommended gamma radiation dose prescription from 14 Gy to 17 Gy should be strongly considered.
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 Electrophysiologic Perspective on the BIPOLAR RF EPICARDIAL ABLATION Procedure for Atrial Fibrillation
Complimentary Accredited Breakfast Symposium
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Location: The St. Regis San Francisco
125 3rd Street
San Francisco, CA 94103
3rd and Mission Streets
Gallery Ballroom, 2nd floor
This activity is supported by an educational grant from AtriCure, Inc.
This program is not part of the Heart Rhythm 2008 Official Scientific Sessions as planned by the Heart Rhythm Society Scientific Sessions Committee. This event is neither sponsored nor endorsed by the Heart Rhythm Society.
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 Newest Perspectives on Drug-Eluting Stents
Complimentary CME Accredited Dinner Meetings Click Here for More Info.
Miami, FL - Date: Friday, April 4, 2008 6:00pm EST -8:00 pm EST
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This activity is supported by an educational grant from Abbott Vascular.
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 CLINICAL EXPERIENCE WITH A NEW HYBRID CORONARY WIRE
On Demand Web Archive
Non-Accredited
This activity is supported by an educational grant from Terumo Medical Corporation.
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 Pharmacoinvasive Management of Acute Coronary Syndrome: Incorporating the 2007 ACC/AHA Guidelines
Complimentary Accredited CME Program
This activity is supported by an educational grant from Sanofi-Aventis.
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 Varicose Veins: Causes, Symptoms, Diagnosis and Treatment of Chronic Venous Insufficiency
A Complimentary Accredited ON-DEMAND Webcast
This activity is supported by an educational grant from Diomed, Inc.
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 Create a Successful Vena Cava Filter Practice
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This activity is supported by an educational grant from Cook Incorporated and has been designed for Interventional Cardiologists, Vascular Surgeons, Fellows and Interventional Cardiovascular Nurses and Technologists.
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Webcast and Web Archives |
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 Achieving Optimal Outcomes in Carotid Stenting: Lessons Learned from Recent Clinical Trials
Complimentary Accredited ON DEMAND Webcast
Topics
1. EVA-3S & Space-Bumps in the road
2. CAPTURE 3500-Lesion morphology & Predictors for Stroke
3. CAPTURE II vs. EXACT 1500-Does open or Closed Cell Stent design really matter?
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Neurologists, Interventional Nurses and Technologists with an interest in the diagnosis and treatment of peripheral artery disease. |
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 Anticoagulation Techniques for Peripheral Vascular Interventions
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This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Podiatric Physicians, Endovascular Allied Professionals, Endocrinologists, Wound Care Specialists, Directors of the Wound Care Clinic, and Primary Care Physicians, Pharmacists, Nurses and Technologists.
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 New Treatment Strategies for the Endovascular Approach to Critical Limb Ischemia: ADVANCEMENTS IN LIMB SALVAGE MEDICINE
Complimentary Accredited ON DEMAND Webcast
This activity has been developed for Interventional Cardiologists, Vascular Surgeons, Interventional Radiologists, Podiatric Physicians, Endovascular Allied Professionals, Endocrinologists, Wound Care Specialists, Directors of the Wound Care Clinic, and Primary Care Physicians, Pharmacists, Nurses and Technologists.
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 Reducing the Incidence of CIN during Cardiac Catheterization and PCI
Complimentary Accredited ON DEMAND
Educational Web Archive
This activity has been developed for nurses and technologists. |
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March 2007 Supplement
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On-Demand Webcast
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Archived Webcast
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Release Date: December 8, 2006