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Notes: Background: Embolic protection during SVG interventions using distal balloon occlusion and aspiration has shown to reduce periprocedural complications compared to unprotected SVG interventions. A similar effect is expected from filter wires. Patients and Methods: A total of 174 SVG interventions carried out with (group A; n = 87) or without distal filter wire protection (group B; n = 87) were retrospectively matched for the location of distal graft anastomosis and analyzed for baseline and procedural characteristics, for TIMI flow grade before and after PCI, for the postprocedural CK elevation, and for major adverse cardiac events at 30 days and 6 months (primary end point). Location of distal graft anastomosis was the left anterior descending artery in 19.6%, the left diagonal branch in 6.9%, the left marginal branch in 17.2%, the left posterolateral branch in 24.2%, the mid-segment of the right coronary artery in 28.7%, and the posterior descending artery in 3.4%. Results: Baseline clinical demographics showed no relevant differences between both the groups. Mean age of vein grafts was 11.7 ± 4.3 years in group A versus 10.6 ± 4.9 years in group B (P = 0.15). The number of stents per lesion was 1.4 ± 0.8 in group A versus 1.0 ± 0.8 in group B (P 〈 0.01). The total length of stents was 32.2 ± 16.2 mm in group A versus 20.9 ± 12.1 mm in group B (P 〈 0.01). TIMI flow grade pre was 2.5 ± 0.8 in group A versus 2.7 ± 0.6 in group B (P 〈 0.05). TIMI flow grade post was 2.9 ± 0.3 versus 2.9 ± 0.2. Improvement of TIMI flow grade after SVG intervention was 0.4 ± 0.7 in group A versus 0.2 ± 0.6 in group B (P 〈 0.05). Postprocedural CK-MB elevations were observed in 17 patients of group A versus 14 patients of group B (P = 0.18). At 30 days, there were no myocardial infarctions (MIs) and no deaths in either group. One patient of group A had to be reoperated and four patients of group A underwent repeat PCI (4.6%) versus one patient of group B (1.2%). At 6 months, there were again no MIs and no deaths in either group. Target lesion revascularization rate was 17.3% in group A versus 11.5% in group B (P 〈0.02). Conclusion: When distal filter wire protection is used in high risk SVG lesions, the clinical outcome of percutaneous interventions may be equal to low risk SVG lesions without filter wire protection.

Notes: Background: The widespread use of drug-eluting stents in patients with coronary artery disease (CAD) is hampered by unequal regulations for reimbursement. Identification of patients with maximal benefit from this technology may be achieved by assessing long-term clinical outcome after implantation of uncoated bare metal stents. Patients and Methods: A consecutive series of 1,000 patients with CAD treated with bare metal coronary stents of various designs from January 1995 to December 1995 was retrospectively followed over 4 years. The primary end points of the study were major adverse cardiac events. Results: The mean age of patients was 62 ± 10.3 years, 77.5% were male, and 18% were diabetic. Clinical follow-up was obtained in 821 patients (82.1%) after 4.6 ± 1.1 years. During this period of time, 31.8% were admitted for repeat PCI, 15.1% underwent CABG operation, 3.5% had myocardial infarctions, and 3.7% died. At 4 years, 46.3% of diabetic patients survived without event versus 57.6% of nondiabetic patients (P 〈 0.05). Patients with CAD I survived without event in 65.3% versus 54.0% of patients with CAD II and 48.5% of patients with CAD III (P 〈 0.02). Conclusion: Implantation of uncoated stents provides the worst long-term clinical outcome in patients with diabetes and those with multivessel CAD. Both groups of patients appear to be primary candidates for the use of drug-eluting stents. (J Interven Cardiol 2003;16:469–473)

Notes: Despite the growing use of drug-eluting stents, restenosis remains to occur especially in high risk subgroups like patients with diffuse in-stent restenosis. This observation is supporting the search for new and potentially even more effective drug eluting stent systems. Everolimus has been used in conjuction with a new bioabsorbable polymer and gave promising results in initial clinical studies. In FUTURE I, a single-center, single-blinded randomized safety and feasibility study enrolling 15 patients with bare metal stents and 27 patients with everolimus-coated stents, 30-day MACE rate was 0% in both groups. In-stent late loss at six months was 0.83 mm in the controll group and 0.10 mm in the everolimus group (p 〈 0.0001). In FUTURE II, a randomized multi-center study, a total of 64 patients were enrolled confirming safety and feasibility. After 6 months late loss was 0.85 mm in the control group and 0.12 mm in the everolimus group (p 〈 0.001).

Notes: Background The quantitative assessment of myocardial infarctions using delayed contrast-enhanced magnetic resonance imaging (MRI) has recently been validated using postmortem histopathological animal studies. In a prospective study, we investigated the correlation between infarct size as assessed by delayed contrast-enhanced MRI, elevation of creatine kinase (CK), and c-reactive protein (CRP) as well as the time from onset of symptoms to intervention. Methods Four to 10 days after immediate PCI in 45 acute ST-segment elevation myocardial infarction (STEMI) patients (〈24 hour) with stenting of the infarct-related artery and treatment with abciximab, we performed gadolinium contrast-enhanced three-dimensional inversion recovery gradient-echo MR sequences with complete coverage of the LV-myocardium in short-axis slices. The mass of infarcted tissue based on the volume of hyperenhanced myocardium was calculated and linear regression analysis was performed to assess the correlation between absolute size of infarctions (g) as well as relative size (LV%) with peak values of CK, CRP, and the time to PCI. Results There was a significant correlation between absolute size of infarctions (g) and peak CK values (r = 0.72; P 〈 0.001) as well as the relative size (LV%) and peak CK (r = 0.77; P 〈 0.001). No correlations were found between absolute size (r = 0.33) as well as relative size (r = 0.27) of infarctions and peak CRP. There was also no correlation between absolute (r = 0.29) as well as relative size of infarctions (r = 0.27) and the time from onset of symptoms to PCI. Conclusions In patients with acute STEMI (〈24 hour) undergoing immediate PCI with stenting and treatment with abciximab, peak CK values correlated well with infarct size as assessed by delayed contrast-enhanced MRI. There were no correlations between infarct size and peak CRP as well as the time to intervention.

Notes: Percutaneous endovascular procedures are increasingly applied to treat symptomatic peripheral occlusive artery disease. While the primary technical success and recanalization rates in iliac and infrainguinal interventions are high, differences in the long-term patency rates exist with respect to the anatomic localization, separating the iliac, femoropopliteal, and infrapopliteal arterial regions. In iliac arteries, even complex lesions can be recanalized with good long-term patency rates, especially when using self-expanding nitinol stents. In the infrainguinal arteries the method of choice is still under debate (e.g., balloon angioplasty vs stent implantation). A high restenosis rate represents one of the major limitations in femoropopliteal and infrapopliteal interventions. Therefore, additional methods and treatment strategies for peripheral interventions with the potential for future applications are under investigation and will be discussed such as drug-eluting stents, brachytherapy, subintimal angioplasty, laser angioplasty, atherectomy/thrombectomy, cutting balloon, polytetrafluoroethylene (PTFE)-covered stent grafts, biodegradable stents, and cryoplasty. The increasing amount of data on successful peripheral interventions supports the necessity to adapt and reevaluate the current consensus guidelines that were put together in 2000.

Notes: Electron beam computed tomography (EBCT) and magnetic resonance imaging (MRI) represent modern noninvasive imaging technologies. MRI in particular has improved diagnosis of many extracardiac diseases. It is claimed that these technologies are superior to the established technique of coronary angiography (CA) for diagnosis of coronary artery disease (CAD) because they are easily repeatable, eliminating the risk of an invasive procedure, and potentially cost saving. Both EBCT and MRI have produced excellent images of proximal coronary arteries. However, their imaging precision is far from that of CA, especially for distal artery segments and the left circumflex and right coronary arteries. An improved image quality probably will be achieved in the future. However, for the next several years CA is essential for diagnosis of CAD and planning of therapy. In selected patients, MRI will provide additional information to angiographic and echocardiographic data (e.g., for assessment of coronary flow, myocardial viability, and morphology of extracardiac vessels). For reasons of cost containment, in many patients with CAD the simultaneous procedure of diagnostic CA and therapeutic angioplasty seems more reasonable than the additional expensive performance of EBCT and MRI.

Notes: Background: Laser ablation of neointimal tissue prior to balloon dilatation has been shown to be a potential treatment modality for restenosis within previously implanted stents. It remains controversial whether this treatment provides superior acute and long-term results compared to conventional balloon dilatation. Methods and Results: Between November 1995 and November 1996, 96 patients with significant (≥ 50%) in-stent restenosis were randomized to receive excimer laser angioplasty with adjunctive balloon dilatation (ELCA + PTC A, n = 47) or PTCA alone (n = 49). Both groups did not differ with regard to gender, clinical history, location of the lesion, reference diameter, or lesion length. Angiographic success was achieved in 46 patients with ELCA + PTCA (98%) and in 48 patients with PTCA alone (98%). In-hospital complications included acute closure in one patient of each group, one CABG, one repeat PTCA, and one non-Q wave MI with ELCA + PTCA, versus two bleeding and one death with PTCA. Clinical follow-up was obtained in all patients, while angiographic follow-up was available in 35 of 47 (ELCA+PTCA) versus 35 of 49 (PTCA) patients with a mean follow-up time of 163 ± 81 days. With ELCA+PTCA, MLD increased from 0.82 ± 0.38 to 1.99 ± 0.33 mm versus 0.81 ± 0.39 mm to 2.07 ± 0.60 mm with PTCA (P = NS). At follow-up, MLD was 1.32 ± 0.60 mm with ELCA + PTCA versus 1.45 ± 0.75 mm with PTCA (P = NS). Late adverse events included nine repeat PTCA with ELCA +PTCA (19%) versus 12 with PTCA (24%), three CABG with ELCA +PTCA (6%) versus two with PTCA (4%), and one death (2%) with PTCA (P = NS). Angiographic restenosis rate was 52% with ELCA + PTCA versus 47% with PTCA alone (P = NS). Conclusion: Our data suggest that excimer laser angioplasty with adjunctive balloon dilatation for the treatment of in-stent restenosis provides similar acute results as plain balloon dilatation and may offer no advantage over PTCA alone with regard to intermediate-term outcomes.

Notes: Background: Conventional coronary bypass surgery applies single internal mammary arteries and saphenous vein graft conduits for revascularization of occluded coronary arteries. While the use of saphenous vein grafts is limited by early graft occlusion, little data exist on clinical experiences with complete arterial revascularization. Patients and Method: From January 2003 to July 2004, 390 patients were transferred from Red Cross Hospital Cardiology Center to the Rotenburg Cardiovascular Center for coronary bypass operation. From these patients, 200 were selected for complete arterial revascularization. Mean age of the patients was 66.7 ± 8.0 years; 80.5% were male; 68.5% had triple-vessel disease, 31% had two-vessel disease, and 0.5% had single-vessel disease; 32% were diabetic; and 6.5% had a previous bypass operation. Left ventricular ejection fraction was 〉50% in 85.5% and 30–50% in 14.5%. Double internal mammary artery grafts were used in 98% and single internal mammary artery grafts in 2%. In 51%, the right internal mammary artery was connected with the left internal mammary artery as a T-graft and in 17%, it was used as a free aortocoronary graft. Radial artery grafts were used in 4%. The average number of anastomoses per patient was 3.4. Results: During the primary in-hospital stay, 1.5% of the patients had to undergo reoperation, 3.5% had myocardial infarctions, 3.5% had wound healing complications, 1.0% experienced an ischemic stroke, and 1 patient died following an acute myocardial infarction. At 12 months, 1.0% underwent percutaneous reinterventions, 0.5% had to be reoperated, 0.5% had a myocardial infarction, and 1.0% died. The actuarial survival rate at 12 months was 99%. Conclusion: When both the internal mammary arteries are used as the preferred surgical strategy, complete arterial revascularization can be performed with excellent clinical results over 12 months.

Notes: The safety, simplicity, and low complication rate of diagnostic and therapeutic coronary interventions depend on the coronary anatomy, the vascular access site, and the route to the heart. Therefore, the femoral approach competes with the brachial and, recently, with radial access to the arterial vasculature. There are some niche conditions where only one of the methods is possible (e.g., complete arterial occlusion). Usually, both routes are available for the majority of patients. We recommend the femoral approach as the standard because of its ease of use, minimal x-ray exposure, and low consumption of contrast medium. Repetitive punctures and access to all branching arteries of the aortic arch are possible. Closure devices reduce the in-hospital stay compared with the brachial or radial approach. Furthermore, in our experience, it is possible and less expensive to perform the majority of diagnostic procedures with 4Fr catheters and therapeutic interventions, including stent implantations with 5Fr guiding devices leading to a short in-hospital stay.

Notes: Preventing interventional PTCA complications starts with a precisely planned procedure that takes into consideration the possible pitfalls for each case, choice of materials, including alternatives for guiding catheters, wires, balloons, stents, and the possibility of emergency surgery. Beginners should have enough experience with diagnostic procedures and should start with type A lesions. The overall low rate of severe complications, despite the greater number of complex lesions, is based on the increasing worldwide individual and institutional PTCA experience. Therefore, even high risk PTCA procedures can be carried out with acceptable good results, but should be performed by the most experienced colleague available. This is the best prerequisite for the management of complications.