stent – ABC CARDIOL

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Editorial

The Choice of Antiplatelet Dual Combination in Coronary Artery Disease: Is this Just a Question of Balance between ischemic Burden and Bleeding Risk?

Maria Cristina Almeida et al. Marildes Luiza de Castro Larissa Neto Espíndola

Acute or chronic coronary syndrome is one of the most important threats to public health. Because of structural and/or functional alterations of the coronary arteries and/or microcirculation, it can culminate in disbalance between myocardial demand and blood supply resulting in ischemia.

Primary prevention of acute coronary ischemic events based on lowering the risk of coronary artery occlusion is a very important measurement. Secondary prevention after myocardial revascularization by percutaneous coronary intervention (PCI) with stent is important to reduce the risk of stent thrombosis, ischemic events and myocardial infarction (MI), particularly early after stenting. Many protocols have been studied, but the dual antiplatelet therapy (DAPT) with aspirin plus a potent P2Y12 inhibitor is the current standard of care after PCI.

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IJCS

Case Report

Acute Coronary Syndrome in a Patient With Single-Vessel Coronary Artery: Case Report

Bruno Dala Vedova Gomes Beato et al. Carolina de Souza Galvão Eduardo Belisário Falchetto Eduardo Kei Marquesini Washizu … Fábio Ávila Tofani Juliano Moreira Reis Filho

Introduction

Anomalies of coronary arteries affect 1-2% of the population.^, They are associated with increased risk of sudden death and coronary artery injury during surgical procedures.^, Among the coronary artery anomalies, the single-vessel coronary artery disease subtype has a low incidence – 0.03-0.04% in patients without other heart diseases and 0.024% in patients with other heart diseases. Concomitant presence of acute coronary syndrome in these patients may have an impact on their prognosis and survival.

Here we report a rare and challenging case of an 81-year-old woman with high-risk unstable angina undergoing emergency catheterization which indicated the presence of single-vessel coronary artery disease with lesions in multiple segments.

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Clinicoradiological Correlation

Case 1/2020 – Very Accentuated Isthmic Coarctation of the Aorta in a Young Individual with Arterial Hypertension Relieved by Interventional Catheterization

Edmar Atik et al. Raul Santiago Arrieta Renata Cassar

Clinical data

Arterial hypertension had been detected 6 months before, after study-related stress in a 16-year-old individual. At the time, diagnostic images (echocardiography and angiotomography) confirmed the presence of accentuated isthmic coarctation of the aorta, with many collaterals that filled the descending aorta. Blood pressure was 170/80 mmHg, which decreased to 130 to 150/80 mmHg with propranolol-80 mg/day. He had been previously submitted to surgery for atrial septal defect closure at 4 years of age. He reported fatigue at exertion since a few months before.

Physical examination: Good overall status, eupneic, acyanotic, wide pulses in the upper limbs and absent in the lower limbs. Weight: 45.5 Kg, Height: 163 cm, right upper limb BP and left upper limb BP = 155/80 mmHg, HR: 55 bpm. Aorta easily palpated at the suprasternal notch.

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IJCS

Case Report

Coronary Artery Disease Associated with Coronary Anomaly and Situs Inversus Totalis in Man Submitted to Angioplasty

Alexandre Fuchs et al. Leandro Bonecker Lora João Renato Cardoso Mourão Fernando César da Costa Duarte … Igor André Telles da Cunha Claudia Regina de Oliveira Cantanheda

Introduction

Dextrocardia associated with situs inversus totalis is a rare condition with an incidence of 1:10,000 in the general population.^, It is characterized by a complete left-to-right reversal of the abdominal organs, including the abnormal position of the heart, resulting from changes in embryological development during the gastrulation stage (third week), characterized by the establishment of the craniocaudal, dorsoventral and right-left axes in the embryo.

This condition is transmitted by autosomal recessive genes, located in the long arm of chromosome 14, which affects the genetic cascade responsible for left-right differentiation. It should be noted that most affected individuals can have normal lives.

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IJCS

Case Report

Coronary Angioplasty with Stent in Woman with Active Vaginal Bleeding

Felipe José de Andrade Falcão et al. Fabiano Lima Cantarelli Aline Hofmann Baião Marco Rivera … Verônica Monteiro Flavio Roberto Azevedo de Oliveira

Abstract

Uterine leiomyoma and coronary artery disease are two common diseases in women. However, the association of uterine bleeding caused by leiomyoma with unstable coronary syndrome is not frequent. Here we describe a case of a patient with active vaginal bleeding and unstable angina who underwent a unique approach by performing percutaneous procedures. The report demonstrates that new interventional options can be used to control active bleeding in patients in need of coronary angioplasty.

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Case Report

Stent Placement in a Neonate with Sano Modification of the Norwood using Semi-Elective Extracorporeal Membrane Oxygenation

Mustafa Gulgun et al. Michael Slack

Abstract

Extracorporeal membrane oxygenation (ECMO) is a well-established tool of cardiopulmonary circulatory support for cardiopulmonary failure in children and adults. It has been used as a supportive strategy during interventional procedures in neonates with congenital heart disease. Herein, we describe a neonate with hypoplastic left heart syndrome who underwent stenting of the Sano shunt and left pulmonary artery after Norwood Sano operation using intra-procedural ECMO support. The use of ECMO as a bridge to recovery might be a feasible and reasonably safe adjunctive approach in the treatment of complications in selective case of neonates having undergone the Norwood Sano procedure.

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Original Article

Percutaneous implantation of endoprostheses in the carotid arteries

José Ribamar Costa Jr. et al. Manuel N. Cano Dinaldo C. Oliveira Antonio M. Kambara … Adriana C. Moreira Rogério Queiroz Silvia Cano Amanda G.M.R. Sousa J. Eduardo M.R. Sousa

OBJECTIVE: To assess the in-hospital evolution of patients undergoing percutaneous stent placement in the carotid arteries. METHODS: From August 1996 to April 2001, we studied 86 patients with carotid arterial obliterative lesions > 70% who were treated with percutaneous stent placement in the carotid arteries. We assessed the rate of success of the implantation and of the procedure, the types of stents used, mortality rate, and neurological complications. RESULTS: Successful implantation was obtained in 98.9% of the cases, and the procedure was successful in 91.8%. The Wallstent was the most frequently used stent (73 patients – 77%). Cerebral strokes occurred as follows: 3 (3.2%) transient ischemic attacks, 1 (1.1%) minor stroke, and 3 (3.1%) major strokes. One (1.1%) patient died during hospitalization. CONCLUSION: The high rate of success of stent implantation (98.9%) in addition to the low rate of cerebral stroke/death (4.2%) showed the efficiency and safety of percutaneous stent placement in carotid arteries.

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Artigo Original

Noninvasive assessment of patients undergoing percutaneous intervention in myocardial infarction

Rica Dodo Delmar Buchler et al. Expedito E. Ribeiro Antonio de Padua Mansur Paola Smanio … Romeu Sergio Meneghelo William Azem Chalela Carlos Alberto Buchpiguel Jorge Roberto Buchler Eric R. Bates Eulogio E. Martinez

BACKGROUND: Restenosis after primary percutaneous coronary intervention (PPCI) remains an important clinical problem, even with stent implantation. The ability of noninvasive testing to diagnose restenosis has had only inconsistent demonstration. OBJECTIVE: Our objective was to evaluate the ability of exercise treadmill testing (ETT) and myocardial perfusion imaging (MPI) to diagnose restenosis in patients treated by PPCI within 12 hours of ST-elevation myocardial infarction (STEMI). METHODS: From August 2003 to January 2006, 64 patients (mean age of 56.2±10.2 years, 53 males) were enrolled after PPCI. Only patients with left ventricular ejection fraction (LVEF) > 40%, as assessed by resting transthoracic echocardiography (TTE), were included. ETT with 12-lead ECG monitoring and right precordial leads, as also MPI were performed at 6 weeks, 6 months, and one year after intervention. Coronary angiography was performed at six months. RESULTS: Single-vessel disease was observed in 46.9% of the patients. The left anterior descending coronary artery was treated in 48.4% of the patients. Angiographic restenosis occurred in 28.8%. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of ETT in detecting restenosis were not significant. Right precordial leads did not add information. MPI sensitivity, specificity, PPV, NPV, and accuracy correlated with restenosis only in the 6-month follow-up, both when considering summed difference score >2 (p=0.006) and >4 (p=0.014). CONCLUSION: ETT did not discriminate restenosis in this population. MPI performed at 6 months correlated with restenosis and proved useful during follow-up.

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Artigo Original

Proximal left anterior descending coronary artery revascularization with drug-eluting stents

Jorge Humberto Guardado et al. Raúl Moreno João Costa Maria J. Perez-Viscayno … Luís Segura Fernando Alfonso Rosana Hernández Javier Escaned Camiño Bañuelos Carlos Macaya

OBJECTIVE: To assess the clinical prognosis of patients with coronary artery diseases undergoing percutaneous revascularization with drug-eluting stent implantation in the proximal left anterior descending coronary artery. METHODS: One hundred and seventy consecutive patients with mean age of 65 years, 49 of them females (29%), undergoing implantation of at least one drug-eluting stent in our medical center. The total number of drug-eluting stents implanted was 189, of which 115 (61%) were sirolimus-eluting (CYPHER TM) and 74 (39%) were paclitaxel-eluting stents (TAXUS TM). In 100 (60%) of the cases, multivessel coronary artery disease was present. In 61 (36%) patients another coronary artery segment was treated in addition to the proximal left anterior descending coronary artery. The mean clinical follow-up period was 11 ± 5 months, and angiographic controls were performed between 6 and 9 months. The final endpoint was a composite of death, acute myocardial infarction and need for reintervention on the anterior descending. The secondary endpoint included the occurrence of restenosis, need for reintervention on the proximal segment of the left anterior descending and stent thrombosis. RESULTS: The procedure achieved immediate angiographic success in all patients. Two deaths, two acute myocardial infarctions, and two percutaneous coronary reinterventions due to stent thrombosis were recorded during in-hospital stay. At the sixth month of follow-up, an additional cardiac death and three myocardial infarctions were observed; three repeat revascularization procedures were required. Up to the end of the follow-up, three additional deaths, three myocardial infarctions and eight revascularization procedures of the anterior descending, two of them surgical, were verified. Survival free from major adverse cardiac events was 91%. Cardiac mortality was 3%. Binary restenosis in the proximal segment of the left anterior descending coronary artery was 4.1%. Target vessel revascularization-free survival was 94%. No cases of late stent thrombosis were observed. CONCLUSION: Percutaneous revascularization of the proximal left anterior descending coronary artery with implantation of drug-eluting stents is a safe and very efficient therapeutic strategy in the short and long terms.

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Artigo Original

Independent predictors of in-hospital outcomes following coronary stent implantation

Antônio José Neri-Souza et al. Bruno Machado Aguiar André Borges Coelho Anderson Jorge Lima Nascimento … Waldemar Souza Oliveira Júnior Antonio Gilson Lapa Godinho Nilson Borges Ramos Álvaro Rabelo Júnior

OBJECTIVE: To identify the clinical and angiographic predictors of early outcome following coronary stent implantation. METHODS: Nine hundred and forty-six patients (pt) [61.04 ± 10.98 years old, range 31 to 91] underwent stent implantation; 580 male (61.3%). Procedural success was defined when a pt had at least one vessel successfully dilated with a residual stenosis < 20%. Clinical success occured when a pt had at least one vessel successfully dilated without a major complication (MC) [death, myocardial infarction (MI), coronary artery bypass graft] during the hospital stay. Clinical and angiographic determinants of outcome were studied. All variables related to early outcome evaluated by univariate analysis were included in a multiple logistic regression analysis (MLR). RESULTS: Procedural success was achieved in 98.9%; clinical success in 95.7%; an unsuccessful uncomplicated outcome in 0.1% and major complications in 4.2%. By MLR, procedural success was related to restenotic lesion, calcification, and irregular contour. Clinical success was related to diabetes mellitus, cardiogenic shock, acute coronary syndromes, age, left ventricular dysfunction, calcification, and total occlusion. Major complications was predicted by diabetes mellitus, cardiogenic shock, acute coronary syndromes, age, multivessel disease, left ventricular dysfunction, calcification, long lesions, and total occlusions. Mortality was predicted by cardiogenic shock, acute coronary syndromes, age, arterial hypertension, and left ventricular dysfunction. CONCLUSION: These results suggest that early outcome was significantly affected by cardiogenic shock, left ventricular dysfunction, age, calcification, and total occlusion.

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Artigo Original

Comparative analysis of intimal hyperplasia after sirolimus-eluting stent and thin-strut bare-metal stent implantation in small coronary arteries

Fernando Stuchi Devito et al. Amanda G. M. R. Sousa Fausto Feres Alexandre Antonio Cunha Abizaid … Rodolfo Staico Luis Alberto Piva Mattos Luis Fernando Leite Tanajura Andréa C. L. S. Abizaid Áurea Jacob Chaves J. Eduardo M. R. Sousa

OBJECTIVE: This study aimed at evaluating reduction in intimal hyperplasia volume following angioplasty using sirolimus-eluting stents (Cypher™) compared with thin-strut bare-metal stents (Pixel™) in patients with small vessels. METHODS: Eighty patients with coronary artery disease were prospectively included in two consecutive series, the first using sirolimus-eluting stents (50) and the second using bare-metal stents (30). RESULTS: The use of sirolimus-eluting stents reduced: in-stent net volume obstruction [5.0% (SE = 0.77) x 39.0% (SE = 4.72), p < 0.001], in-stent late loss [0.25 mm (SE = 0.03) x 1,11 mm (SE = 0.13), p < 0,001], in-segment late loss [0.30 mm (SE = 0.04) x 0.83 mm (SE = 0.11), p < 0.001], in-stent restenosis (0% x 33.3%, p < 0.001) and in-segment restenosis (4% x 36.7%, p < 0.001). The event-free survival rate was 96% in the sirolimus-eluting stent group versus 86.7% in the bare-metal stent group (BMS) (p = 0.190). CONCLUSION: Sirolimus-eluting stents are superior to thin-strut bare-metal stents in reducing intimal hyperplasia (less in-stent obstruction and less late lumen loss) in patients with small vessels. The use of these stents significantly reduced angiographic restenosis at eight months.

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Artigo Original

Comparative assessment of the prognostic value of four biochemical markers of myocardial damage after percutaneous coronary stenting

Marinella Centemero et al. Amanda Sousa Rodolfo Staico Alexandre Abizaid … Fausto Feres Luiz Fernando Tanajura Luiz Alberto Mattos Áurea Chaves Ibraim Pinto Camila Sarteschi Angela Paes J. Eduardo Sousa

OBJECTIVE: To assess the prognostic effect of the changes in the levels of 4 biochemical markers of myocardial damage (CK-MB activity/mass and troponins T and I) after stent implantation in regard to the occurrence of death, infarction, and new myocardial revascularization procedures in a one-year period. The study also aimed at determining the incidence of their elevations and the existence of predictive variables. METHODS: Those 4 markers were measured in 199 patients treated with stent implantation in native arteries in the following 3 periods: before the procedure, 6-8 hours after the procedure, and 14-18 hours after the procedure. Survival curves and Cox logistic regression were used to determine the prognostic impact of the changes on the occurrence of cardiac events in one year. RESULTS: Changes in the levels of the 4 markers after stent implantation are relatively frequent (6.1% to 32.8%), are associated with the degree of complexity of the lesions treated (long lesions and angulations > 45º) and with the development of problems during the procedure (occlusion of the secondary branches, presence of angina, and electrocardiographic changes). The infarction-free survival rate and the need for a new revascularization were significantly lower only in the patients with an elevation in the CK-MB activity after the procedure as compared with those in patients without that alteration (60% x 85.08%; P=0.025). The following variables influenced the event-free survival rate: diabetes mellitus (OR: 2.27; P=0.0256), balloon predilation (OR: 3.16; P=0.0082), and an elevation in the CK-MB activity after the procedure (OR: 3.64; P=0.0162). CONCLUSION: Systematic monitoring of CK-MB activity after coronary stenting is justified due to its clinical and laboratory behavior reported in studies relating its elevation after the procedure to a worse late outcome, and due to its low cost.

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Artigo Original

A comparison of rescue and primary percutaneous coronary interventions for acute myocardial infarction: a multicenter registry report of 9,371 patients

Luiz Alberto Mattos et al. Amanda G.M.R. Sousa Ibraim M.F. Pinto Expedito R. Silva … José Klauber Carneiro J. Eduardo Sousa José Armando Mangione Paulo Caramori Valter Lima Ronaldo L. Bueno

OBJECTIVE: To perform a comparative analysis of in-hospital results obtained from AMI patients who underwent rescue or primary PTCA. METHODS: From the Brazilian Interventional National Registry (CENIC), we selected all consecutive patients who underwent a percutaneous coronary intervention for myocardial infarction (< 24 hours), between 1997 and 2000, analyzing those undergoing a rescue (n=840) or a primary (n=8,531) procedure, and comparing their in-hospital results. RESULTS: Rescue patients were significantly younger males with anterior wall infarctions, associated with left ventricular dysfunction, but had less multivessel disease, compared with those treated with primary intervention. Coronary stents were implanted in at similar rates (56.9% vs. 54.9%; P=0.283). Procedural success were lower for rescue cases (88.1% vs. 91.2%; P<0.001), with higher mortality (7.4% vs. 5.6%; P=0.034), compared with the primary intervention group; target vessel revascularization (< 0.5%), emergency bypass surgery (< 0.3%) and reinfarction (< 2.6%) rates were similar for both strategies. Multivariate analysis identified the rescue procedure as a predictor of in-hospital death [OR(CI=95%) = 1.60 (1.17-2.19); P=0.003]. CONCLUSION: Patients who underwent a rescue coronary intervention had higher in-hospital death rates compared with those who underwent a primary coronary intervention.

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Original Article

Percutaneous Stent Implantation for Treating Multivessel Coronary Disease in Patients with and without Involvement of the Proximal Segment of the Anterior Descending Coronary Artery

Sandro Salgueiro et al. Augusto Daige da Silva Ricardo José Tofano Vinicius Carvalho da Costa … Karina Pizarro Adnan Ali Salman José Armando Mangione

OBJECTIVE: To assess coronary stent placement in patients with multivessel coronary disease and involvement of the proximal portion of the anterior descending coronary artery. METHODS: We retrospectively analyzed the in-hospital and late evolution of 189 patients with multivessel coronary disease, who underwent percutaneous coronary stent placement. These patients were divided into 2 groups as follows: group I (GI) – 59 patients with involvement of the proximal segment of the anterior descending coronary artery; and group II (GII) – 130 patients without involvement of the proximal segment of the anterior descending coronary artery. RESULTS: No significant difference was observed in the success rate of the procedure (91.5% versus 97.6%, p=0.86), nor in the occurrence of major adverse cardiac events (5.1% versus 1.5%, p=0.38), nor in the occurrence of major vascular complications (1.7% versus 0%, p=0.69) in the in-hospital phase. In the late follow-up, the incidence of major adverse cardiac events (15.4% versus 13.7%, p=0.73) and the need for new revascularization (13.5% versus 10.3%, p=0.71) were similar for both groups. CONCLUSION: The in-hospital and late evolution of patients with multivessel coronary disease with and without involvement of the proximal segment of the anterior descending coronary artery treated with coronary stent placement did not differ. This suggests that this revascularization method is an effective procedure and a valuable option for treating these types of patients.

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Original Article

A comparative analysis of primary stenting and optimal balloon coronary angioplasty in acute myocardial infarction. Six month results from the STENT PAMI trial

Luiz Alberto Mattos et al. Cindy L. Grines David Cox J. Eduardo Sousa … Costantino Costantini Gregg Stone Marie C. Morice William O'Neill Eulógio Garcia Judith Boura

OBJECTIVE: To compare the outcome of balloon PTCA with final coronary stenosis diameter (SD) <=30%, with elective coronary stenting. METHODS: We performed a comparative analysis of the 6 month outcomes in patients treated with primary stenting and those who obtained an optimal balloon PTCA result treated during the first 12 hours of AMI onset included in the STENT PAMI randomized trial. RESULTS: The results were analysed into 3 groups: primary stenting (441 patients, SD=22±6%), optimal PTCA (245 patients), and nonoptimal PTCA (182 patients, SD= 37±5%). At the end of the 6 months primary stent group presented with the lowest restenosis(23 vs. 31 vs. 45%, p=0.001, respectively). Ischemia-driven target vessel revascularization rate (TVR) (7 vs. 15.5 vs. 19%, p=0.001, respectively). CONCLUSION: At the 6 month follow-up, primary stenting offered the lowest restenosis and ischemia-driven TVR rates. Compared to optimal balloon PTCA. Nonoptimal primary balloon PTCA pts (SD=31-50%), had the worst late angiographic outcomes and should be treated more actively with coronary stent implantation.

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Artigo Original

Utilization of self-expandable prosthesis (Stent) introduced through the femoral artery for treatment of dissection of the descending aorta

José Honório Palma da Fonseca et al. Enio Buffolo Antonio Carlos Carvalho Nikolaus Geisthovel … Dirceu Rodrigues Almeida José Augusto Marcondes de Souza Ivan Paula Machado Cláudia Maria Rodrigues Alves

PURPOSE: We present four cases of dissection of the thoracic descending aorta that underwent treatment with an auto expandable dácron®-covered stent. METHODS: The stent was deployed through the femoral artery in the hemodinamic laboratory after sedation, local anesthesia in both inguinal areas and systemic heparinization. The catheter with the stent was introduced through a cutdown in the left femoral artery until the area in the thoracic aorta with the previously diagnosed tear. RESULTS: The stent was expanded with immediate occlusion of the false lumen. The whole proccedure took 90 minutes and the patients were discharged without complications. CONCLUSION: Stent utilization is an important step to improve treatment results in type B aortic dissection.

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Original Article

Safety and efficacy of angioplasty with intracoronary stenting in patients with unstable coronary syndromes. Comparison with stable coronary syndromes

Luís C. L. Correia et al. José Carlos Brito Andréa C. Barbosa Antônio M. Azevedo Jr … Mário S. Rocha Heitor G. Carvalho José Péricles Esteves

OBJECTIVE: To assess safety and efficacy of coronary angioplasty with stent implantation in unstable coronary syndromes. METHODS: Retrospective analysis of in-hospital and late evolution of 74 patients with unstable coronary syndromes (unstable angina or infarction without elevation of the ST segment) undergoing coronary angioplasty with stent placement. These 74 patients were compared with 31 patients with stable coronary syndromes (stable angina or stable silent ischemia) undergoing the same procedure. RESULTS: No death and no need for revascularization of the culprit artery occurred in the in-hospital phase. The incidences of acute non-Q-wave myocardial infarction were 1.4% and 3.2% (p=0.6) in the unstable and stable coronary syndrome groups, respectively. In the late follow-up (11.2±7.5 months), the incidences of these events combined were 5.7% in the unstable coronary syndrome group and 6.9% (p=0.8) in the stable coronary syndrome group. In the multivariate analysis, the only variable with a tendency to significance as an event predictor was diabetes mellitus (p=0.07; OR=5.2; 95% CI=0.9-29.9). CONCLUSION: The in-hospital and late evolutions of patients with unstable coronary syndrome undergoing angioplasty with intracoronary stent implantation are similar to those of the stable coronary syndrome group, suggesting that this procedure is safe and efficacious when performed in unstable coronary syndrome patients.

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