Asunto(s)
Humanos , Masculino , Anciano de 80 o más Años , Sirolimus , Tomografía de Coherencia Óptica/métodos , Stents Liberadores de Fármacos , Arterias Mamarias , Enfermedad de la Arteria Coronaria/diagnóstico , Angioplastia Coronaria con Balón/métodos , Resultado del Tratamiento , Reestenosis Coronaria/diagnóstico , Revascularización MiocárdicaAsunto(s)
Síndrome Antifosfolípido , Reestenosis Coronaria , Infarto del Miocardio , Intervención Coronaria Percutánea , Stents , Adulto , Síndrome Antifosfolípido/diagnóstico , Síndrome Antifosfolípido/epidemiología , Síndrome Antifosfolípido/inmunología , Estudios de Casos y Controles , Reestenosis Coronaria/diagnóstico , Reestenosis Coronaria/epidemiología , Reestenosis Coronaria/inmunología , Femenino , Estudios de Seguimiento , Humanos , Masculino , México/epidemiología , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/epidemiología , Infarto del Miocardio/inmunología , Infarto del Miocardio/terapia , Manejo de Atención al Paciente/métodos , Manejo de Atención al Paciente/estadística & datos numéricos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/métodos , Factores de Riesgo , TiempoRESUMEN
In-stent restenosis (ISR) remains a concern even in the drug-eluting stent (DES) era and carries a high risk of recurrence. Brachytherapy is being used as an alternative treatment for resistant ISR, yet the safety and efficacy of this approach has not been well studied. We analyzed the outcomes of 101 patients who underwent coronary brachytherapy for resistant DES ISR. Baseline demographic, clinical, procedural, and outcome data were collected by phone and from electronic records. Comorbidities and overt cardiovascular disease were highly prevalent. Median previous stent layers were 2 with a maximum of 5 layers. Procedural angiographic success rate was 97% and median time to discharge was 1 day after brachytherapy. The primary outcome of target vessel revascularization was 24% at 1 year, 32% at 2 years, and 42% at 3 years. The rate of nonfatal myocardial infarction was 0% at 1 year, 3.5% at 2 years, and 6% at 3 years. The rate of all-cause mortality was 8.5% at 1 year, 12% at 2 years, and 16% at 3 years. We observed only 1 case of late stent thrombosis. After multivariable adjustment, female gender (hazard ratio 2.37, 95% confidence interval 1.02 to 5.52, p = 0.04) and diffuse ISR pattern (hazard ratio 2.95, 95% confidence interval 1.21 to 7.17, p = 0.01) were independently associated with the primary outcome. In conclusion, brachytherapy is feasible for the treatment of resistant DES ISR and is associated with high immediate procedural success and reasonable efficacy in a complex patient population. This approach might be used as an alternative for these patients.
Asunto(s)
Braquiterapia/métodos , Reestenosis Coronaria/radioterapia , Stents Liberadores de Fármacos/efectos adversos , Oclusión de Injerto Vascular/radioterapia , Intervención Coronaria Percutánea/efectos adversos , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/cirugía , Reestenosis Coronaria/diagnóstico , Reestenosis Coronaria/mortalidad , Vasos Coronarios , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/diagnóstico , Oclusión de Injerto Vascular/mortalidad , Humanos , Masculino , Massachusetts/epidemiología , Diseño de Prótesis , Estudios Retrospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de Tiempo , Tomografía de Coherencia Óptica , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
Aproximadamente 30% dos pacientes que se apresentam com quadro de síndrome coronariana aguda têm revascularização prévia do miocárdio. Os eventos coronarianos subsequentes à revascularização do miocárdio podem ocorrer por progressão da doença aterosclerótica no leito coronário nativo, evento relacionado ao stent (reestenose, trombose ou neoaterosclerose) ou evento relacionado à cirurgia de revascularização domiocárdio (degeneração ou oclusão de enxertos cirúrgicos). Esses pacientes que necessitamde um novo procedimento de revascularização têm perfil de alto risco, geralmente associado a doença renal crônica, diabetes mellitus, doença arterial periférica, além deelevada carga aterosclerótica no leito coronariano nativo, degeneração de enxertos de veia safena e reestenose de stents. Este cenário faz com que o segundo procedimento de revascularização tenha maior risco e maior complexidade. Neste artigo discutiremos as características clínicas e as possibilidades terapêuticas de pacientes com SCA e revascularização percutânea ou cirúrgica prévias.
Around 30% of patients who present acute coronary syndrome have undergone previous myocardial revascularization. Coronary events following myocardial revascularization can occur due to progression of atherosclerotic disease in the native coronary bed, an event related to the stent (restenosis, thrombosis or neoatherosclerosis) or to the myocardial revascularization surgery (degeneration or occlusion of surgical grafts). These patients who need a new revascularization procedure have a high-risk profile, generally associated with chronic kidney disease, diabetes mellitus, and peripheral arterial disease, as well as a high atherosclerotic burden in the native coronary bed, degeneration of grafts of the saphenous vein, and restenosis of stents. This scenario confers a higher risk and greater complexity on the second revascularization procedure. In this article, we discuss the clinical characteristics and therapeutic possibilities of patients with ACS and previous percutaneous or surgical revascularization.
Asunto(s)
Humanos , Intervención Coronaria Percutánea/métodos , Reestenosis Coronaria/diagnóstico , Reestenosis Coronaria/terapia , Revascularización Miocárdica/efectos adversos , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/terapia , Angioplastia/métodos , Enfermedad Aguda , Factores de Riesgo , Stents , Trombosis/diagnóstico , Trombosis/terapia , Vasos Coronarios/cirugía , Vena Safena , Ventrículos CardíacosRESUMEN
Desde la llegada de los stents convencionales y farmacoactivos han disminuido considerablemente los eventos de revascularización quirúrgica, sin embargo la trombosis y reestenosis son 2 factores que, aunque han disminuido, permanecen como complicaciones importantes. Existen varios factores que predisponen a la trombosis y a la reestenosis intrastent. La angiografía convencional tiene serias limitaciones para determinar las causas de la falla del stent. La tomografía de coherencia óptica es una técnica sumamente sensible para determinar las causas de trombosis y reestenosis del stent.
Since the advent of bare metal and drug-eluting stents, the surgical revascularization have declined considerably, however the thrombosis and in-stent restenosis are important complications of these devices. There are several factors that predispose to thrombosis and in-stent restenosis. Conventional angiography has serious limitations to determine the causes of stent failure. Optical coherence tomography is a very sensitive technique to determine the cause of thrombosis and in-stent restenosis.
Asunto(s)
Humanos , Masculino , Persona de Mediana Edad , Reestenosis Coronaria/diagnóstico , Reestenosis Coronaria/cirugía , Trombosis Coronaria/diagnóstico , Trombosis Coronaria/cirugía , Stents Liberadores de Fármacos , Falla de Prótesis , Tomografía de Coherencia Óptica , Reestenosis Coronaria/etiología , Trombosis Coronaria/etiología , Cirugía Asistida por ComputadorRESUMEN
Since the advent of bare metal and drug-eluting stents, the surgical revascularization have declined considerably, however the thrombosis and in-stent restenosis are important complications of these devices. There are several factors that predispose to thrombosis and in-stent restenosis. Conventional angiography has serious limitations to determine the causes of stent failure. Optical coherence tomography is a very sensitive technique to determine the cause of thrombosis and in-stent restenosis.
Asunto(s)
Reestenosis Coronaria/diagnóstico , Reestenosis Coronaria/cirugía , Trombosis Coronaria/diagnóstico , Trombosis Coronaria/cirugía , Stents Liberadores de Fármacos , Falla de Prótesis , Tomografía de Coherencia Óptica , Reestenosis Coronaria/etiología , Trombosis Coronaria/etiología , Humanos , Masculino , Persona de Mediana Edad , Cirugía Asistida por ComputadorRESUMEN
First generation drug-eluting stents (DES) are associated with reduced in-stent restenosis but significant increased risk of very late stent thrombosis (VLST). The absence of polymer in DES systems may reduce the occurrence of VLST. Optic coherence tomography (OCT) has been used for stent analysis as a surrogate safety endpoint. This study aimed to assess the long-term follow up of strut apposition and tissue coverage of BioMatrix DES by OCT. 20 patients undergoing BioMatrix DES (n = 15) or S-Stent BMS (n = 5) implantation were followed for at least 5 years and evaluated by quantitative coronary angiography, intravascular ultrasound, and OCT. The difference between the stent types was evaluated by nonparametric Mann-Whitney U test while categorical variables were evaluated by Fisher exact test. Rates of in-stent late loss were similar between groups [0.40 (0.21;0.77) vs. 0.68 (0.66; 0.82) mm, p = 0.205, for BioMatrix and S-Stent, respectively]. The vessel, stent and lumen volumes did not differ between groups. Patients treated with BioMatrix had significantly less stent obstruction [5.6 (4.4;9.7) vs. 28.6 (24.7;29.0) %, p = 0.001]. OCT analysis of 12 stents (Biomatrix = 9 and S-Stent = 3) demonstrated 126 (8.7 %) uncovered struts in the BioMatrix group compared to 23 (4.0 %) in the S-Stent group (p = 0.297), being the majority of them well apposed (117/126 and 21/23, respectively, p = 0.292). Only 9 (0.6 %) struts in the DES and 2 (0.4 %) struts in the BMS groups were simultaneously uncovered and malapposed (p = 0.924). BioMatrix DES was associated with lower rates of in-stent obstruction, and similar percentage of neointimal coverage on struts and of complete strut apposition.
Asunto(s)
Fármacos Cardiovasculares/administración & dosificación , Enfermedad de la Arteria Coronaria/terapia , Reestenosis Coronaria/diagnóstico , Vasos Coronarios/patología , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea/instrumentación , Sirolimus/análogos & derivados , Tomografía de Coherencia Óptica , Anciano , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico , Reestenosis Coronaria/etiología , Reestenosis Coronaria/patología , Vasos Coronarios/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neointima , Intervención Coronaria Percutánea/efectos adversos , Valor Predictivo de las Pruebas , Diseño de Prótesis , Sirolimus/administración & dosificación , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
The present case report refers to the percutaneous treatment of severe left main stem stenosis as a consequence of proliferative in-stent restenosis of left circumflex coronary with retrograde involvement. A reverse mini-crush technique with 2 stents was described.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Angioplastia Coronaria con Balón/métodos , Reestenosis Coronaria/terapia , Estenosis Coronaria/terapia , Stents , Anciano , Angioplastia Coronaria con Balón/efectos adversos , Angiografía Coronaria , Reestenosis Coronaria/diagnóstico , Reestenosis Coronaria/etiología , Estenosis Coronaria/diagnóstico , Femenino , Humanos , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
At present, percutaneous coronary intervention with drug-eluting stent (DES) implantation represents the default strategy to treat coronary artery disease in many institutions around the world. However, concerns regarding long-term safety of first-generation DES have prompted the development of novel DES systems such as the NEVO (Cordis Corporation, Johnson & Johnson, Warren, NJ) sirolimus-eluting stent with biodegradable polymer and reservoir technology. In the current report, we present, for the first time, a complete midterm invasive assessment of a patient treated with this novel device in the Res-Elution I study.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Materiales Biocompatibles , Fármacos Cardiovasculares/administración & dosificación , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Stents Liberadores de Fármacos , Sirolimus/administración & dosificación , Tomografía de Coherencia Óptica , Ultrasonografía Intervencional , Angioplastia Coronaria con Balón/efectos adversos , Enfermedad de la Arteria Coronaria/diagnóstico , Reestenosis Coronaria/diagnóstico , Reestenosis Coronaria/etiología , Reestenosis Coronaria/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Trombosis/diagnóstico , Trombosis/etiología , Trombosis/prevención & control , Factores de Tiempo , Resultado del TratamientoRESUMEN
Despite the expressive reduction in the intimal hyperplasia (IH) formation after DES implantation at the mid-term, late restenosis has been recently noticed. Our objective was to determine, by means of serial angiography (QCA) and intravascular ultrasound (IVUS) at two different time points, whether the occurrence of the "late catch-up" phenomenon occurs after sirolimus-eluting stent (SES) implantation. Thirty-eight non-complex patients treated with a single 18-mm SES who had systematic serial QCA and IVUS analyses at mean 8 and 20 months were enrolled. Primary endpoint is to evaluate the temporal course of IH formation after SES implantation, by comparing QCA in-stent late loss and IVUS percent IH obstruction between the invasive follow-ups. Mean cohort age was 59.3 years and 31.6% were diabetics. Baseline reference vessel diameter was 2.8 ± 0.4 mm and lesion length was 11.5 ± 3.5 mm. Left anterior descending artery was the most frequent target vessel (55.3%). Between 8 and 20 months, a non-significant increase in in-stent late loss from 0.10 ± 0.18 to 0.15 ± 0.30 mm (P = 0.38) was observed. By IVUS, a slight increase in the percent IH obstruction (1.03 ± 2.13 to 1.76 ± 1.87%, P = 0.12) was detected between the two evaluations. Interestingly, all the neoformed tissue accrued from 8 to 20 months accumulated in the distal portion of the stent. In the non-complex scenario, SES implantation was associated with a minimal, non-significant increase in the IH volume between 8 and 20 months.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Fármacos Cardiovasculares/administración & dosificación , Angiografía Coronaria/métodos , Enfermedad de la Arteria Coronaria/terapia , Reestenosis Coronaria/diagnóstico , Stents Liberadores de Fármacos , Sirolimus/administración & dosificación , Tomografía Computarizada por Rayos X , Ultrasonografía Intervencional , Anciano , Análisis de Varianza , Angioplastia Coronaria con Balón/efectos adversos , Brasil , Distribución de Chi-Cuadrado , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Reestenosis Coronaria/diagnóstico por imagen , Reestenosis Coronaria/etiología , Femenino , Humanos , Hiperplasia , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Diseño de Prótesis , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
INTRODUÇÃO: A reestenose clínica após o implante de stent coronário costuma ser tratada com revascularização da lesão-alvo (RLA). Nosso objetivo foi relatar o perfil clínico e os desfechos de pacientes com reestenose intrastent (RIS) sintomática que não foram submetidos a nova RLA. Métodos: Identificamos pacientes que presentaram reestenose clínica após colocação de stent coronário entre janeiro de 1997 e dezembro de 2001. As características clínicas e angiográficas e os desfechos clínicos dos pacientes que não passaram por nova revascularização (grupo sem RLA) foram comparados aos de pacientes revasclarizados (grupo com RLA). Todos os pacientes tiveram acompanhamento de pelo menos dois anos após implante do stent para ocorrência de eventos cardíacos adversos maiores (ECAM). Resultados:No período do estudo, 1.221 stents foram implantados em 1.149 pacientes. Observou-se RIS em 135 pacientes (12 por cento) dos quais 104 tiveram acompanhamento clínico e angiográfico completo, 23 no grupo sem RLA e 81 no grupo vom RLA. O período médio de acompanhamento após a colocação de stent coronário foi de 30,8 +- 7,5 meses. Pacientes do grupo sem RLA tiveram porcentual significativamente mais alto de doença...
BACKGROUND: Clinical restenosis after coronary stenting is generally treated by target vessel revascularization (TVR). This study was aimed at reporting the clinical profile and outcomes of patients with symptomatic in-stent restenosis (ISR) who were not submitted to a TVR. METHOD: Patients who presented clinical restenosis after coronary stenting between January 1997 and December 2001 were identified. Clinical and angiographic characteristics and clinical outcomes of patients who did not undergo a new revascularization (no-TVR group) were compared with revascularized patients (TVR group). All of the patients had at least 2 years of follow-up for the occurrence of major adverse cardiac events (MACE) after stent implantation. RESULTS: In the study period, 1,221 stents were implanted in 1,149 patients. ISR was observed in 135 patients (12%), of which 104 had complete clinical and angiographic follow-up, 23 in the no-TVR group and 81 in the TVR group. The mean follow-up period after coronary stenting was 30.8 ± 7.5 months. Patients in the no-TVR group had a significantly higher percent of one vessel disease (82% vs. 47%; P < 0.01). Patients in the no-TVR group had a long-term MACE rate of 21.7% (5 patients: 2 deaths, 3 myocardial infarctions), whereas those submitted to a new revascularization showed a subsequent MACE rate of 9.8% (8 patients: 1 death, 4 myocardial infarctions, 3 coronary artery bypass graft surgery; P = 0.11). CONCLUSION: Patients with clinical ISR not treated with a TVR more frequently presented one-vessel disease and a trend towards higher incidence of MACE when compared to those treated with a new TVR.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Angioplastia/métodos , Angioplastia , Reestenosis Coronaria/complicaciones , Reestenosis Coronaria/diagnóstico , StentsRESUMEN
Introdução: Neste estudo, buscamos avaliar os resultados clínicos de pacientes com lesões coronarias em vasos de fino calibre, numa coorte de pacientes do mundo real submetidos a intervenção coronária percutânea (ICP) com stents farmacológicos. Método: Entre maio de 2002 e dezembro de 2009, 1.380 pacientes consecutivos do Registro DESIRE (Drug Eluting Stents in the Real World), com 1.683 lesões em vasos de fino calibre (< ou igual 2,5 mm de diâmetro), foram submetidos a ICP, eletiva ou de urgência, com implante de 1.818 stents farmacológicos (Cypher(tm), 89 por cento; Taxus(tm), 7,5 por cento; Xience V(tm)/Promus(tm), 3 por cento; Endeavor(tm), 0,33 por cento; Biomatrix(tm), 0,2 por cento) e incluídos neste estudo. O seguimento clínico de até 7 anos (mediana 2,8 anos) foi completo em 98 por cento, sendo obtido com 1, 6 e 12 meses e, então, anualmente. Tivemos como objetivo determinar as taxas de eventos cardíacos adversos maiores (ECAM) ao longo do período do acompanhamento clínico. Resultados: A média de idade foi de 64,5 + ou - 11,7 anos, com predomínio de pacientes do sexo masculino (76,7 por cento). Diabetes melito foi encontrado em 31,6 por cento dos casos e 9,8 por cento eram portadores de insuficiência renal crônica. A artéria descendente anterior foi o vaso mais frequentemente tratado (43,4 por cento) e dois terço das lesões eram de alta complexidade (B2/C). Sucesso angiográfico do procedimento foi obtido em 98,8 por cento dos casos. A taxa de ECAM foi de 12,8 por cento durante o seguimento,...
BACKGROUND: In this study, we sought to evaluate the clinical outcomes of patients with coronary lesions in small vessels in a cohort of real world patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). METHODS: Between May 2002 and December 2009, 1,380 consecutive patients from the DESIRE Registry (Drug Eluting Stents In The Real World), with 1,683 lesions in small vessels (< 2.5 mm in diameter) were consecutively submitted to elective or emergency PCI, with 1,818 DES (CypherTM, 89%; TaxusTM, 7.5%; Xience V TM/PromusTM, 3%; Endeavor, 0.33%; BiomatrixTM, 0.2%) and included in this study. The clinical follow-up of up to 7 years (median, 2.8 years) was completed for 98%, and was obtained at 1, 6, 12 months and then annually. Our objective was to determine the rates of major cardiac events (MACE) during clinical follow-up. RESULTS: Mean age was 64.5 ± 11.7 years, with a prevalence of male patients (76.7%). Diabetes mellitus was observed in 31.6% of the cases and 9.8% had chronic renal failure. Left anterior descending artery was the most frequent vessel treated (43.4%) and two-thirds of the lesions were complex lesions (B2/C). Angiographic success was obtained in 98.8% of the cases. The rate of MACE was 12.8% during follow-up with 4.5% of cardiac death, 4.2% of acute myocardial infarction, 4.5% of repeat target lesion revascularization and 1.5% of stent thrombosis. CONCLUSIONS: In the DESIRE Registry, the use of DES to treat small vessels in non-selected patients was associated with excellent early and late outcomes and low thrombosis rates.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Angioplastia Coronaria con Balón/métodos , Angioplastia Coronaria con Balón , Reestenosis Coronaria/complicaciones , Reestenosis Coronaria/diagnóstico , Stents Liberadores de FármacosRESUMEN
Desde a introdução da intervenção coronária percutânea como alternativa menos invasiva de revascularização em pacientes com doença arterial coronária, a reestenose tem sido o principal fator limitante para sua mais ampla utilização, podendo ocorrer em até 30 por cento dos casos, a depender da complexidade clínica e angiográfica. Em 1999 iniciou-se uma nova era na cardiologia intervencionista, com a introdução dos chamados stents farmacológicos, tecnologia que combina uma plataforma metálica convencional com um polímero carreador de fármaco antiproliferativo. Nestes últimos dez anos centenas de estudos randomizados e registros de mundo real demonstraram a superioridade dessa nova tecnologia em relação aos stents não-farmacológicos, o que resultou na ampliação das indicações da interveção coronária percutânea para territórios antes restritos à cirurgia de revascularização miocárdica. Nesta revisão são abordados os mais relevantes ensaios clínicos que culminam com a aprovação dos principais stents farmacológicos hoje disponíveis comercialmente.
Asunto(s)
Humanos , Angioplastia Coronaria con Balón/métodos , Angioplastia Coronaria con Balón , Reestenosis Coronaria/cirugía , Reestenosis Coronaria/diagnóstico , Stents Liberadores de FármacosRESUMEN
AIMS: The aim of this study was to investigate the angiographic and intravascular ultrasound (IVUS) findings of the Endeavor zotarolimus-eluting stent (ZES) in patients from a "real-world" clinical practice. METHODS AND RESULTS: From January to March 2006, 100 patients undergoing routine or emergency percutaneous intervention were prospectively enrolled at one institution. Overall, 39% of the patients were diabetics and 80.8% of lesions were type B2/C. A total of 140 lesions were successfully treated with 174 ZES, and procedural success was 98%. Mean vessel diameter was 2.69 mm and mean lesion length was 16.0 mm; at 6-month angiographic follow-up (completed in 96%), in-stent late lumen loss was 0.66 mm, and in-segment restenosis was 8.2%. Angiographic restenosis was increased among diabetics (15.5 vs. 2.6%, p=0.009), and diabetes was the only significant predictor of angiographic restenosis (OR=15.27 [95%CI 2.45-95.04], p=0.003). By IVUS (performed in 88% at 6-month), % volume obstruction was 14.4+/-13.4%, and there was no late acquired incomplete stent apposition (ISA). At 1-year, overall MACE rate was 6%, including 5 TLRs (4% of patients), with no occurrence of stent thrombosis. CONCLUSIONS: In this prospective "real-world" experience, the ZES demonstrated favourable angiographic and IVUS results in complex patients, with overall in-stent late lumen loss of 0.66 mm, and absence of late acquired ISA. At 1-year, there were no safety concerns including absence of death and stent thrombosis.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Fármacos Cardiovasculares/administración & dosificación , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Reestenosis Coronaria/diagnóstico , Stents Liberadores de Fármacos , Sirolimus/análogos & derivados , Ultrasonografía Intervencional , Anciano , Angioplastia Coronaria con Balón/efectos adversos , Angioplastia Coronaria con Balón/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico , Enfermedad de la Arteria Coronaria/mortalidad , Reestenosis Coronaria/etiología , Reestenosis Coronaria/mortalidad , Reestenosis Coronaria/prevención & control , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Diseño de Prótesis , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Sirolimus/administración & dosificación , Trombosis/etiología , Trombosis/prevención & control , Factores de Tiempo , Resultado del TratamientoRESUMEN
Introdução: Pacientes submetidos a intervenção percutânea em hospitais públicos brasileiros não têm acesso aos stents farmacológicos. No início de 2006, participamos de um registro multicêntrico internacional que disponibilizava o uso rotineiro dessas próteses, no cenário do mundo real. Neste artigo, procuramos identificar os perfis clínico, angiográfico e do procedimento de pacientes consecutivamente tratados em períodos subseqüentes de dois meses, de acordo com a disponibilidade desses modelos, visando à identificação de eventuais alterações nesses perfis. Método: Estudo observacional de uma série de 471 pacientes, divididos em dois grupos: A, 229 casos dilatados na vigência da disponibilidade de stents farmacológicos; e B, 242 pacientes subseqüentes tratados da forma usual. Não houve critérios de inclusão/exclusão. Resultados: Stents farmacológicos foram mais implantados no grupo A (44% vs. 2%; p < 0,0001). No que se refere às características de base, observou-se predomínio significante de diabéticos dependentes de insulina em A (8% vs. 3%; p = 0,02), o mesmo ocorrendo com lesões-alvo tipos B2 ou C (73% vs. 57%; p < 0,0001), lesões situadas em bifurcações (15% vs. 9%; p = 0,02) e intervenções multiarteriais (15% vs. 6%; p = 0,003). A angiografia quantitativa identificou os casos de A como portadores de estenoses situadas em vasos de menor calibre (2,4 mm vs. 2,6 mm; p = 0,0004), também exibindo lesões mais longas (14,9 mm vs. 12,7 mm; p = 0,0008). Conclusões: A disponibilidade dos stents farmacológicos gerou alterações no perfil dos casos tratados, que passou a abordar situações mais predispostas à reestenose, como os diabéticos dependentes de insulina, os multiarteriais com lesões de alta complexidade e os portadores de lesões mais longas em vasos de fino calibre.
Introduction: Patients submitted to percutaneous intervention in public hospitals in Brazil have no access to DES. At the beginning of 2006, we participated in an international multicenter registry which made available the routine use of these prosthesis, in a "real world" scenario. In this article, we intend to identify the clinical, angiographical and procedural profiles of the patients, consecutively treated in twomonth subsequent periods, according to the availability of these models, with the aim of identifying eventual changes in their profiles. Method: Observational series of 471 patients, divided into two groups: A) 229 cases, treated during a period of availability of DES for routine use; and B) 242 patients subsequently treated as usual (no routine avalilability of DES). There were no inclusion/exclusion criteria. Results: More DES were implanted in group A (44% vs. 2%; p<0.0001). Regarding baseline clinical and angiographic characteristics, a significant predominance of insulin-dependent diabetics was observed in group A (8% vs. 3%; p=0.02), as well as B2 or C lesions (73% vs. 57%; p<0.0001); lesions in bifurcations (15% vs. 9%; p=0.02), and multiarterial interventions (15% vs. 6%; p=0.003). Quantitative angiography identified the A group cases as bearers of stenosis placed in smaller vessels (2.4 mm vs. 2.6 mm; p=0.0004), also exhibiting longer lesions (14.9 mm vs. 12.7 mm; p=0.0008). Conclusions: The availability of DES changed the profile of the patients treated, being more likely situations prone to restenosis, such as insulin dependent diabetics, multiarterial disease, patients presenting complex lesions, longer lesions and smaller target vessels.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Stents , Angioplastia Coronaria con Balón/métodos , Angioplastia Coronaria con Balón , Reestenosis Coronaria/complicaciones , Reestenosis Coronaria/diagnósticoRESUMEN
Os stents coronários são usados em mais de 90 por cento das intervenções coronárias percutâneas. Emtretanto, sua eficácia está limitada pela ocorrência de reestenose, variando de 15 por cento a 50 por cento dos casos, dependendo da morfologia da lesão e da presença de co-morbidade (como, por exemplo, diabetes melito e insuficiência renal). Nos últimos anos os stents farmacológicos provaram ser eficazes em suprimir a hiperplasia neo-intimal, reduzindo a taxa de reestenose para um dígito. Neste artigo, os autores descrevem um caso de reestenose em stent com eluição de sirolimus relacionada à fratura de stent.
The latest great revolution in the management of restenosis has been the introduction of the drug-eluting-stents (DES). They have been proven very effective in suppressing neointimal proliferation and reduces restenosis rates to single digit numbers. A case of DES strut fracture-induced restenosis is described.
Asunto(s)
Humanos , Masculino , Persona de Mediana Edad , Stents , Reestenosis Coronaria/complicaciones , Reestenosis Coronaria/diagnóstico , SirolimusRESUMEN
Introdução: O estudo STEALTH I demonstrou a eficácia e segurança dos stents eluidores de Biolimus A (BA9) em reduzir a perda-tardia angiográfica e apresentar uma baixa incidência de eventos cardíacos maiores, entretanto os achados de ultra-som intracoronário (USIC) ainda não foram descritos. O objetivo deste estudo é descrever os achados de análise volumétrica por USIC nos pacientes recrutados em nossa instituição. Métodos e Resultados: Quarenta e cinco pacientes apresentando lesão coronária de novo, única, foram randomizados 2:1 para receber stents eluidores de BA9 (n igual 30) ou stents controle (n igual 15). A média de idade foi de 58 anos, com 16 por cento diabéticos e 62 por cento do sexo masculino. As características clínicas e angiográficas foram similares entre os grupos. Aos 6 meses de seguimento não houve diferença significativa entre os grupos quanto a desfechos clínicos. O índice de hiperplasia intimal intra-stent foi inferior no grupo dos stents eluidores de BA9 em comparação ao grupo controle 0,19 mais/menos 0,08 vs. 2.71 mais/menos 0.50, ) menor 0.0001), assim como o percentual de obstrução...
Background: Biolimus A9 (BA9) is a novel sirolimus analog with similar antiproliferative properties. BA9-eluting stents reduce angiographic late-loss compared to bare metal stents (BMS), with a low incidence of major adverse cardiac events (MACE), as reported in the randomized, controlled STEALTH I trial. We describe the intravascular ultrasound (IVUS) volumetric findings of patients enrolled at our institution. Methods and Results: Forty-five patients presenting a single, de novo coronary lesion (2.5-4.0 mm vessels; lesion length <24 mm) were randomly assigned in a 2:1 basis to receive either BA9-eluting (n=30) or bare metal stents (n=15). Mean age was 58 years, with 16% diabetics and 62% men. Baseline clinical and angiographic characteristics were similar between groups. At 6 month follow-up, there was no statistical difference in clinical outcomes between groups. In-stent intimal hyperplasia index measured by IVUS was 0.19+/-0.08 mm3/ mm3 for the BA9 group vs. 2.71+/-0.50 mm3/mm3 for BMS controls. The percentage of stent obstruction was also significantly lower for the BA9 group when compared to BMS (2.2+/-0.80% vs. 19.9+/-4.67%, P<0.0001). No stent thrombosis, aneurysm formation or incomplete stent apposition was observed in any group. Conclusions: Using IVUS volumetric analysis, we showed that BA9-eluting stents have a potent inhibitory effect on neointimal proliferation when compared to BMS at 6-month follow-up.
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Stents , Reestenosis Coronaria/complicaciones , Reestenosis Coronaria/diagnóstico , Sirolimus/análogos & derivados , Materiales Biocompatibles Revestidos/efectos adversosRESUMEN
Introdução: No tratamento de obstruções coronárias longas e complexas recomenda-se cobertura total da lesão. Quando mais de um stent é implantado, torna-se mandatário um "overlapping" ou sobreposição dos stents para evitar espaços não cobertos entre eles. Há pouca evidência na literatura sobre a eficácia e segurança de se realizar sobreposição de stents liberadores de sirolimus (Cypher, SES) e paclitaxel (Taxus, SEP). Objetivo: Avaliar, por meio de estudo seriado com ultra-sonografia intravascular (USIC), a eficácia na redução da proliferação neointimal e as mudanças na parede vascular no segmento com sobreposição de stents farmacológicos SES e SEP. Método: Um total de 52 pacientes (72 lesões) foram prospectivamente incluídos nesta análise e randomizados para tratamento percutâneo com implante de SES ou SEP. Cartoze pacientes do grupo SES e 12 do grupo SEP apresentaram segmentos de sobreposição. Angiografia Coronária quantitativa e USIC foram realizados imediatamente após o implante dos stents e repetidos após oito meses. Resultados: Ambos os grupos apresentavam características clínicas e angiográficas basais...
Introduction: To treat long complex coronary obstructions, total lesion coverage is recommended. When more than one stent is deployed an overlap segment is mandatory to avoid uncovered gaps between stents. There is no data comparing Sirolimus- (SES) versus Paclitaxel-eluting stents (PES) at overlapping segments in regards to neointimal inhibition or toxic effects on the vessel wall. Objective: To evaluate, by means of serial intravascular ultrasound (IVUS), the efficacy in reducing neointimal proliferation and the vessel changes in the overlapping segment comparing these two drug-eluting stents. Method: Fifty-two patients with 72 de novo coronary lesions were randomized for SES or PES. Fourteen patients in the SES Group and twelve in the PES Group had overlapping segments. Quantitative coronary angiography and IVUS were performed at the time of the procedure and at 8 months follow-up. Results: No significant baseline differences were identified between the 2 groups. The mean stent/lesion ratios were similar (1.74 ± 0.89 for SES vs. 2.01 ± 0.92 for PES; p= 0.47). SES and PES were comparable in reducing neointima hyperplasia in the overlapping zone (neointima volume 2.24 ± 0.9 mm3 after SES vs. 2.53 ± 1.5 mm3 after PES; p=0.1 and % neointima obstruction of 18.15 ± 8.5% after SES vs. 26.7 ± 16.8% after PES; p=0.1). There was no positive remodeling in the overlapping segment for both groups (expansion ratio 0.74 ± 0.18 vs. 0.76 ± 0.14, respectively; p=0.74). Other IVUS volumetric measurements were also equivalent between the two cohorts. Conclusion: In our preliminary experience, overlapping of DESs proved...