Volume 15 - Issue 1 - January, 2004

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...

Sensitivity and Specificity of QCA in Detecting Coronary Arterial Remodeling After Intracoronary Brachytherapy: A Comparison to

Ken Kozuma, MD, PhD, Evelyn Regar, MD, Nico Bruining, PhD, Willem van der Giessen, MD, PhD,
Eric Boersma, PhD, David P. Foley, MD, PhD, Pim J. de Feyter, MD, PhD, *Peter C. Levendag, MD, PhD, Patrick W. Serruys, MD, PhD

For more than a decade, quantitative coronary angiography (QCA) has been the gold standard for the assessment of coronary stenosis because of its accuracy and objectivity as compared to visual and hand-held caliper measurements.1–3 After the introduction of intracoronary brachytherapy, the QCA methodology for the assessment of irradiated coronaries had to be adjusted to this new mode of therapy because of the existence of new regions of interest: the target segment, injured segment, irradiated segment and vessel segment.4 In a recent report, lumen enlargement (negative late loss) was demonst...

Beta Radiation in Lesions > 15 mm: A START Subgroup

1Richard Heuser, MD, 2Warren Laskey, MD, 3Alexandra Lansky, MD, 4Jeffrey Popma, MD, 5Raoul Bonan, MD

While stents have reduced the risk of restenosis,1–3 they induce neointimal hyperplasia,4 and rates of in-stent restenosis following intervention may be as high as 60%,5 particularly in long lesions.6 Studies of gamma-radiation therapy following treatment for in-stent restenosis have demonstrated considerable reduction in the incidence of clinical and angiographic restenosis as compared with placebo.7–11 Late thrombosis has been a problem, and while its origin is poorly understood, it appears to be linked to the short duration of ticlopidine therapy, placement of new stents or the use of m...

Intracoronary Radiation for In-Stent Restenosis in Long Lesions: Too Much, Too Little, Too Late?

Luis Gruberg, MD and Rafael Beyar, MD, DSc

“It’s not enough if I succeed, everyone else should fail.”
- Atila the Hun

Since the introduction of stents almost a decade ago, they have become the mainstream for the treatment of patients with coronary artery disease. Nevertheless, restenosis following stent implantation has been the major limitation of stents. Serial intravascular ultrasound studies have shown that restenosis after conventional balloon angioplasty represents a complex interaction between elastic recoil, smooth muscle proliferation and vascular remodeling, whereas restenosis after stent deployment is d...

Utility of Intracardiac Echocardiography to Facilitate Transvenous Coronary Sinus Lead Placement for Biventricular Cardioverter-

Todd J. Cohen, MD and George Juang, MD

Recently, with the results of the MIRACLE and COMPANION trials, there has been an increase in the demand for implanting cardiac resynchronization devices. One of the initial hurdles that the implanter must overcome is to access the coronary sinus through its ostium. However, in approximately 1–5% of cases, the coronary ostia may be difficult to identify. Muscle bands, bridges, and valves may prevent the operator from entering the coronary sinus and thereby finding an appropriate left ventricular lateral branch. A number of tools have been utilized to facilitate these difficult implants. We d...

In-Hospital Initiation of Cardiovascular Protective Medications for Patients Undergoing Percutaneous Coronary Intervention: Taki

Gregg C. Fonarow, MD

Percutaneous coronary interventional (PCI) procedures have changed the face of cardiovascular care, providing significant improvements in quality of life and survival for patients with debilitating cardiac disease. In 2000, there were over 500,000 patients who underwent PCI procedures in the United States.1 Although these coronary procedures have become routine, they do not modify the underlying disease process of atherosclerosis; they only reduce ischemia by mechanically increasing blood flow. Even when completely revascularized and in the absence of stress-induced ischemia, cardiovascular di...

Multi-Lesion “Culotte” and “Crush” Bifurcation Stenting with Sirolimus-Eluting Stents: Long-Term Angiographic Outcome

Joost Daemen, Pedro A. Lemos, MD, Patrick W. Serruys, MD, PhD

Case Report. A 63-year-old man, an ex-smoker with a history of hypertension and previous myocardial infarction, was admitted with stable angina (Canadian Cardiovascular Society Class 1) for elective percutaneous coronary intervention. Pre-procedure coronary angiogram revealed diffuse disease in the proximal and mid segments of the left circumflex artery (LCx) that was totally occluded in its distal portion (Fig. 1A). The first obtuse marginal branch (OM) presented a severe ostial stenosis (Fig. 1A). Also, the left anterior descending artery (LAD) presented a long stenosis in its mid por...

Anomalous Origin of Left Internal Mammary Artery

Shahid Aziz, MBChB, MRCP, and David R. Ramsdale, MD, FRCP

Origin of the internal mammary artery from sites other than the inferior surface of the first part of the subclavian artery is not uncommon. We describe the case of a left internal mammary artery (LIMA) originating from the third part of the left subclavian artery and its clinical relevance.

Case Report. A 65-year-old man gave a two-week history of unstable angina seven years after successful coronary artery bypass (CABG) surgery. He had required two admissions to the hospital with typical angina at rest associated with ST segment depression in leads V4-V6, I and AVL and raised Tr...

Successful Treatment in a Case of Acute Aortic Dissection Complicated with Acute Myocardial Infarction Due to Occlusion of the L

Yoshikazu Ohara, MD, Yoshikazu Hiasa, MD, Shinobu Hosokawa, MD

Recently, the surgical results of acute aortic dissection (Stanford type A) have improved. However, the treatment of cases complicated with severe organ ischemia, especially myocardial ischemia, is very difficult. When the aortic dissection extends to the coronary artery, catastrophic changes in the hemodynamic state occur; as a result, it is often difficult to save the patient’s life in such cases.1 Most of the cases in which a fatal outcome is avoided are successful emergency operation cases or right coronary myocardial infarction cases.2–6 We reported a case successfully treated by perc...

Considerations on Radiation Source Selection and Utilization in Vascular Brachytherapy

Ian Crocker, MD

The initial evaluation of radiotherapy in animal models of restenosis focused on the used of 192Iridium ribbons, a commercially available source. After initial animal studies revealed that therapy with this isotope reliably inhibited vascular renarrowing following balloon angioplasty, investigation into alternative, more “user-friendly” radiation delivery sources and systems was undertaken. Permanently implanted radioactive stents were very successful in animal models and clinical trials at inhibiting neointimal proliferation within the stent but created problems of narrowing at the ends o...

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