Volume 15 - Issue 1 - January, 2004

Use of Lepirudin During Percutaneous Vascular Interventions in Patients with Heparin-Induced Thrombocytopenia

Kevin Cochran, MD, Tony J. DeMartini, MD, Bruce E. Lewis, MD, James O’Brien, RN, Lowell H. Steen, MD, Eric D. Grassman, MD, PhD, Ferdinand Leya, MD

Percutaneous coronary intervention is a common procedure, with over 750,000 interventions performed in the United States per year. Balloon inflation and stent deployment cause endothelial injury and plaque disruption, leading to platelet activation, thrombin generation and an inflammatory response. Aspirin, clopidogrel, platelet glycoprotein (GP) IIb/IIIa receptor inhibitors and unfractionated or low-molecular weight heparin are routinely used to counteract the effects of thrombin and the stimulated platelet population. The GP IIb/IIIa inhibitors block the final common pathway of platelet acti...

Thrombolytic Therapy for Right Atrial and Pulmonary Embolus

David G. Rizik, MD, Bernard J. Villegas, MD, Andre P. Bouhasin, MD, Richard Levinson, MD

A 68-year-old male with a history of hypertension presented to the emergency department with acute onset pain and severe swelling of the left lower extremity. Pleuritic chest discomfort was also noted. He had been traveling by automobile from Canada to the Desert Southwest for 3 days and admitted to very little activity during this period. Physical exam was notable for a swollen, painful left calf with an easily reproducible Homan’s sign. He was noted to have a murmur of tricuspid regurgitation. Shortly after initial evaluation, he became visibly dyspneic with oxygen saturations of 89–90% ...

PCI Options in Heparin-Induced Thrombocytopenia

George Dangas, MD, PhD, and Eugenia Nikolsky, MD, PhD

Heparin-induced thrombocytopenia (HIT) is a rather rare complication of heparin therapy, but may occasionally lead to devastating or even life-threatening complications. HIT is more frequent after therapy with unfractionated than low molecular weight heparin. The inherent problem of prothrombosis in HIT can be a major obstacle in patients who need therapy with percutaneous coronary interventions (PCI), especially with stent implantation. This is due to the iatrogenic plaque disruption and promotion of an endovascular thrombosis process during PCI, and the added risk of stent thrombosis. Theref...

Treatment of In-Stent Restenosis in a Gastroepiploic Artery Coronary Bypass Graft with Brachytherapy

William B. Hillegass, MD, MPH, Gilbert J. Zoghbi, MD, Anand Pandey, MD, Vijay K. Misra, MD, Gregory D. Chapman, MD, Brigitta C. Brott, MD

Since it was first used in 1984 and reported in 1987,1,2 the right gastroepiploic artery (RGEA) has emerged as an effective third or isolated arterial conduit for complete arterial bypass grafting or for use in cases of limited graft numbers or poor quality vein for grafts.3–5 The RGEA can be used as a pedicled or free graft with or without cardiopulmonary bypass.6 The RGEA grafts are superior to vein grafts, with > 95% short-term patency rates and actuarial 5-year patency rates of 80–85%,7–9 with a 5-year survival rate > 92%.5,9 Ischemic events related to pedicled RGEA grafts result fro...

Benefits of Cutting Balloon Before Stenting

1David G. Rizik, MD, 2Jeffrey P. Popma, MD, 3Martin B. Leon, MD, 4Gary S. Mintz, MD, 5Bonnie Weiner, MD, 6Eric Cohen, MD, 4Alexandra J. Lansky, MD, 7Antoine M. Adem, MD, Andre P. Bouhasin, MD, 7Carol Wojciechowski, RN, 8Neil J. Weissman, MD

Cutting balloon (CB) technology combines the features of microsurgical incision with balloon dilation to treat atherosclerotic lesions. The CB has a non-compliant dilation balloon with microsurgical blades (atherotomes) attached to the outer surface. The cutting blades serve to radially incise the atherosclerotic lesion prior to balloon expansion. Linear incisions made by the blades facilitate expansion of the atherosclerotic lesion at lower inflation pressures, resulting in less barotrauma-related injury to the vessel wall.1 In addition, the symmetric and orderly disruption of the plaque lesi...

Percutaneous Coronary Artery Stenting of an Anomalous Right Coronary Artery with High Anterior Takeoff Using Standard Size 7

*†Benjamin I. Lee, MD, ‡Herman C. Gist Jr., MD, †Edward I. Morris, MD

The anomalous right coronary artery (RCA) with high anterior takeoff is an uncommon, yet technically difficult vessel to cannulate, moreover to intervene upon. The high anterior location of the anomalous ostium is often difficult to reach with standard catheters and because of the immediate posterior direction of the vessel, percutaneous intervention requires more secure guiding catheter support compared to the normally located RCA. Several published case studies have described the technical difficulties associated with balloon angioplasty and stenting of anomalous RCAs and successful outcomes...

Influence of Frequency of Stenting on Acute and One-Year Follow-up Results

Haresh Mehta, MD, Renate Hotz, MD, Stephan Windecker, MD, Franz R. Eberli, MD, Bernhard Meier, MD

Stents were introduced as a bail-out therapy for threatened abrupt closure1–5 following plain balloon coronary angioplasty. They were subsequently demonstrated to lower the restenosis rates in selected patient populations.6–8 The smooth appearance of the vessel after stenting has seduced the interventionist. The stenting rates are reported to be approximately 70%9 and move toward 100%. Stenting, albeit an essential and effective tool, has downsides such as stent thrombosis (still a concern in spite of newer antiplatelet drugs) and intricate in-stent restenosis. The long and diffuse variety...

Editor's Message - November 2003

Richard E. Shaw, PhD, FACC

This issue of the Journal of Invasive Cardiology coincides with the Annual Scientific Sessions of the American Heart Association and includes original research articles, case reports, a special review, two CME offerings and articles from the journal special sections “the Electrophysiology Corner,” “Clinical Decision Making” and “Clinical Images.”

The first research article, submitted by Dr. Kenneth Mahaffey from the Duke Clinical Research Institute on behalf of the ATBAT investigators, is a report of a multicenter trial examining the role of bivalirudin as adjunct therapy for ...

Benefits of Cutting Balloon Before Stenting “Cut and Stent”

*Raoul Bonan, MD and †David Meerkin, MBBS

Neointimal hyperplasic response following angioplasty (PTCA), and especially stent implantation, is linked to overstretch injury, causing modulation of the vascular cytoskeleton and subsequent production of mediators.1 These result in smooth muscle cell migration and replication, and production of extra cellular matrix.2–7 These processes associated with vascular remodeling or lack of adequate vascular compliance result in restenosis. Stents have been demonstrated to affect a larger post-angioplasty lumen.8,9 This results in reduced restenosis, in spite of an increased neointimal response wh...

Provisional Stenting Versus Routine Stenting: Is it Worth the Price?

Manesh R. Patel, MD and Eric D. Peterson, MD, MPH

On September 16th, 1977, Andreas Gruentzig performed the first coronary angioplasty on a 38-year-old man with a discrete proximal left anterior descending artery lesion. The procedure was a success, and the field of interventional cardiology was born.1,2 Percutaneous coronary intervention (PCI) grew over the next 25 years to become the dominant mode of coronary revascularization with over 1 million annual procedures performed in the United States alone. Even with its success, PCI remains in a constant state of technological evolution. The challenge for the interventionalist is to decide when i...

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