Chronic occlusions in patients with coronary heart disease: results of recanalization

The paper analyzes the results of endovascular treatment in 298 patients with chronic occlusions or subtotal stenoses of coronary arteries. The authors show that balloon coronary angioplasty for chronic coronary occlusions is an effective and relatively safe techniques of myocardial revascularization. Successful endovascularization has been achieved in 68.1% of patients with chronic coronary occlusions and in 97.5% of those with subtotal coronary stenoses. The results show a high incidence of restenosis and asymptomatic reocclusion.     

Variations with age in the topographic distribution of coronary atherosclerotic lesions as assessed by image analysis

The localization of macroscopic coronary atherosclerotic lesions was investigated for 184 cases by image analysis. Atherosclerotic lesions were classified into 2 types: fatty streaks and raised lesions. The overall distribution of fatty streaks in arteries involved only by fatty streaks and the distribution of raised lesions in those arteries having raised lesions were demonstrated at similar sites in 3 coronary vessels. If the localization of lesions was examined within age groups, those sites involved with fatty streaks in one age group were replaced with raised lesions in the next older age group; fatty streaks in this older group were located distally to the raised lesions. Subsequently the areas occupied with fatty streaks were replaced with raised lesions in the next older age group. Furthermore, raised lesions seldom appeared at the site where fatty streaks had not existed in the preceding age group. Similar changes in topographic distribution were present if such changes were analyzed according to extent of atherosclerosis. Data from cases with myocardial bridges show that both fatty streaks and raised lesions are seldom observed in the region distal to myocardial bridge. We conclude, thus, that fatty streaks are the precursors of raised lesions in the coronary artery.     

Immediate and long-term outcomes of the use of a Crossflex wire coronary stent in the treatment of patients with different forms of ischemic heart disease

Immediate and medium-term prognoses were studied in patients with coronary heart disease in whom a Crossflex wire coronary stent (Cordis, Johnson & Johnson, USA) had been inserted into the coronary arteries. The study indicated that it could be effectively used in patients with both chronic coronary heart disease and its exacerbation (acute myocardial infarction). It was found that in the vast majority of patients anginal attacks ceased and the clinical course ran smoothly in both immediate and medium-term postoperative periods. In the immediate period, various complications were observed only in 6.7% of cases. In the late period, the incidence of restenosis was 24%. If restenosis occurred, repeated balloon dilatation was successfully made in the great majority of cases by resulting in recovery of the vascular lumen.     

Femoral Artery Complications after Diagnostic Procedures

Of 36 cases of arterial complications after femoral artery puncture 11 were excessive haemorrhage and 25 femoral artery occlusions. Soft arteries are more likely to tear than atheromatous ones, and this had occurred in 9 of the 11 patients. A high puncture, soft arteries, and a low cardiac output are important factors predisposing to thrombosis.An aggressive policy is recommended for treatment of both conditions.     

腹型肥胖对急性冠脉综合征患者冠状动脉病变严重程度的影响

目的:研究腹型肥胖对急性冠脉综合征(ACS)患者冠状动脉病变严重程度的影响。方法:选择2012年4月至2013年4月在我院接受治疗的ACS患者120例,根据腰围身高比(RWH)将患者分为无腹型肥胖者60例(对照组,RWH0.5)及腹型肥胖者60例(观察组,RWH0.5)。测量所有患者的基本参数,计算RWH,利用冠脉造影判断冠脉病变的支数和程度,根据Gensini评分法对冠脉造影结果进行评价,分析冠脉病变范围、Gensini积分和RWH的相关性。结果:观察组的收缩压(SBP)、空腹血糖(FPG)、总胆固醇(TC)、甘油三酯(TG)、低密度脂蛋白(LDL-C)及Gensini积分水平均显著高于对照组,差异均有统计学意义(均P0.05)。观察组的高密度脂蛋白(HDL-C)水平显著低于对照组,差异有统计学意义(P0.05)。双支病变的RWH及Gensini积分水平显著高于单支病变,三支病变的RWH及Gensini积分水平显著高于单支病变及双支病变,差异均有统计学意义(均P0.05)。根据Spearman法分析相关性可知,冠脉病变范围、Gensini积分和RWH均呈正相关(r=0.635,0.739;P=0.000,0.000)。结论:ACS患者RWH水平增高与冠脉病变的严重程度关系密切,有效控制腹型肥胖对于降低心血管类疾病发病率以及降低冠脉病变的程度具有重要意义。     

Argyrophilic nucleolar organizer region (AgNOR) technique: a helpful tool for differential diagnosis in urinary cytology

The aim of this study was to investigate whether the AgNOR technique could be helpful for the cytologic diagnosis of neoplastic and non-neoplastic urinary tract lesions. We analysed the AgNOR pattern in urinary cytology in samples from 70 patients. In every case the average number of silver precipitations per nucleus was counted and the range between the minimum and maximum AgNOR value calculated. Furthermore we noted whether the AgNOR precipitations had a homogeneous or heterogeneous distribution. The diseases were classified in three groups: non-neoplastic lesions, low grade and high grade carcinoma. Linear discriminant analysis (with jack-knife procedure) was performed with the AgNOR parameters as independent variables. The final diagnosis of each patient had been established by histological analysis of bladder biopsies. We obtained a correct classification in 84.3% of the cases. All patients with normal or reactive lesions were correctly classified and only two cases of low grade malignancy were erroneously diagnosed as non-malignant. Five high grade neoplasms had been classified as low grade and four low grade carcinomas had been over-diagnosed as high grade neoplasms. We conclude that a combined qualitative and quantitative AgNOR analysis can be useful in the differential diagnosis of urinary cytology.     

Chronic Total Occlusions in Sweden – A Report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR)

Introduction

Evidence for the current guidelines for the treatment of patients with chronic total occlusions (CTO) in coronary arteries is limited. In this study we identified all CTO patients registered in the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and studied the prevalence, patient characteristics and treatment decisions for CTO in Sweden.

Methods and Results

Between January 2005 and January 2012, 276,931 procedures (coronary angiography or percutaneous coronary intervention) were performed in 215,836 patients registered in SCAAR. We identified all patients who had 100% luminal diameter stenosis known or assumed to be ≥3 months old. After exclusion of patients with previous coronary artery bypass graft (CABG) surgery or coronary occlusions due to acute coronary syndrome, we identified 16,818 CTO patients. A CTO was present in 10.9% of all coronary angiographies and in 16.0% of patients with coronary artery disease. The majority of CTO patients were treated conservatively and PCI of CTO accounted for only 5.8% of all PCI procedures. CTO patients with diabetes and multivessel disease were more likely to be referred to CABG.

Conclusion

CTO is a common finding in Swedish patients undergoing coronary angiography but the number of CTO procedures in Sweden is low. Patients with CTO are a high-risk subgroup of patients with coronary artery disease. SCAAR has the largest register of CTO patients and therefore may be valuable for studies of clinical importance of CTO and optimal treatment for CTO patients.     

Long-term results of chronic occlusion recanalization in patients with coronary heart disease

The study was undertaken to assess the long-term results of recanalization of chronically occluded coronary arteries, by applying drug-eluting stents to patients with coronary heart disease. The study enrolled 585 patients with one-vessel occlusive lesion of one of three great coronary arteries (TIMI 0; occlusion duration, > or = 3 months): 321 patients who underwent successful recanalization of chronic occlusion and further implantation of drug-eluting stents and 264 patients who received drug therapy (a control group). The short- and long-term results of recanalization were investigated. The follow-up averaged 1095 +/- 36 days; reexaminations were made after 1, 2, and 3 years. The direct success rate of recanalization of chronically occluded coronary arteries was 84.9% (321/378). The results of a 3-year follow-up showed the efficiency and expediency of endovascular recanalization of chronic occlusions: the invasively treated patients had the symptoms of angina pectoris and heart failure significantly less frequently, showed higher exercise tolerance and a less need for antianginal therapy, and had a better long-term prognosis.     

A single center experience with the newly designed R Stent in small coronary vessels

BACKGROUND: Over the past 10 years stents have been used more frequently for the treatment of de novo coronary artery stenosis. Initally these devices were used primarily in coronary arteries with diameters ranging from 3.0 to 4.0 mm. Traditionally, coronary arteries less than 3.0 mm in diameter were treated with only balloon angioplasty, due to the unavailablity of flexible, low profile, small diameter stents. In the past three years, many stents have been designed to be implanted in small coronary arteries. OBJECTIVE: The objective of this study was to evaluate the safety and feasiblity of the R Stent in patients with coronary lesions located in coronary arteries with a reference diameter 2.5-3.0 mm. METHODS AND RESULTS: Between November 1998 and September 1999, 32 patients with stable (37%) and unstable (63%) angina treated with the R Stent were included in this study. The treated lesions were in the right coronary artery (RCA) (n = 13), left cirumflex coronary artery (LCX) (n = 10), and left anterior descending coronary artery (LAD) (n = 9). Of these lesions thirteen were anatomically complex. Stent deployment was successful in 97% with one crossing failure in a patient with a vessel tortuosity of greater than 75 degrees of the circumflex artery. No post-procedual major adverse cardiac and cerebrovascular event (MACCE) occurred within 30 days of stent implantation. After the procedure, patients were scheduled for a two-week telephone follow-up and a one-month clinical evaluation. At 30 days, only one patient (3%) experienced the recurrence of angina Canadian cardiovascular society classification ((CCS) Class 2). All other patients were event and angina free. CONCLUSION: This first clinical experience in patients with small vessel disease shows that the use of the R stent is safe and feasible with low rates of acute stent thrombosis.     

Diagnostic possibilities of contrast magnetic resonance tomography

The practice of examinations of more than 400 patients in the diagnostic center of CRIRR showed a high diagnostic efficiency of contrast MRA, especially in stenoses, occlusions, pathologic bends of the brachiocephalic vessels; aneurysms and stenoses of the abdominal and thoracic aorta, stenoses and occlusions of visceral branches of the abdominal aorta, iliac arteries including condition of vessels after surgical correction. Valuable facts have been obtained in vasorenal hypertension caused by stenoses, occlusions, extravasal compressions, additional arteries, and in the portal system (thrombosis of the main trunk and branches of the portal vein, signs of portal hypertension).     

冠心病合并代谢综合征患者的冠状动脉病变特点及与 代谢综合征组分的相关性研究

目的:探讨冠心病合并代谢综合征(metabolic syndrome,MS)患者的冠脉病变特点及冠心病与MS各组分的相关性。方法:选取540例冠心病患者为研究对象,其中合并MS患者164例,非合并MS患者376例,并将所有患者根据MS的组分个数进行分组,比较冠心病合并MS的病变特点、MS组分个数对冠状动脉病变程度的影响及冠状动脉病变程度与代谢综合症各组分的相关性;结果:①冠心病合并MS组BMI、FBG、TG、LDL-C、TC、UA、FIB、高血压分级等指标较非MS组高,差异有统计学意义(P<0.01),HDL-C、LVEF较非MS组低,差异有显著性(P<0.01);②MS组冠脉Gensini积分较高,三支病变、主干病变发生率高,差异有显著性(P<0.01);③随着合并MS组分个数的增加,冠脉Gensini积分也逐渐增加,各组间比较有显著性差异(P<0.01);④冠脉Gensini积分与MS组分BMI、高血压分级、TG、TC、LDL-C、UA等指标存在正相关(P<0.05),与性别、HDL-C存在负相关(p<0.01);调整传统危险因素后,Gensini积分与MS的组分数显著相关(r=0.739、P<0.01)。结论:冠心病患者有较高的MS患病率,冠心病合并MS患者冠脉病变程度更重,且以多支病变、主干病变为主;随着合并MS组分个数的增加,冠脉病变程度也呈加重趋势;MS的各个组分均与冠状动脉病变程度显著相关,可以作为冠心病严重程度的预测指标。     

Diagnostic usefulness of endometrial aspiration cytology for endometrial cancer cases with normal curettage findings

OBJECTIVE: To determine whether endometrial aspiration cytology is useful for endometrial cancer cases with normal endometrial curettage findings. STUDY DESIGN: Eleven cases in which endometrial cancer could be detected by endometrial aspiration cytology but not endometrial curettage were classified into 2 groups by cancer locus, on the endometrial surface (A) or in the myometrium (B). A clinicopathologic and cytologic analysis was performed to compare the 2 groups. RESULTS: Five cases had cancer lesions localized at the fundus and one at the isthmus (group A). The other 5 had lesions localized in the myometrium (group B). The myometrium invasion was beyond half the myometrium in group B and within half in group A. It required > 2 cytologic examinations for a definitive diagnosis in 33.3% of group A and 80.0% of group B. The endometrial cytology differed clearly between the groups: large clusters of malignant cells with a dirty background (group A) vs. small clusters with a clean background (group B). The log-rank test revealed that group B had significantly poorer prognoses than did group A despite nearly the same rate of stage I/II cases in the 2 groups (p = 0.004). CONCLUSION: Endometrial aspiration cytology was useful for endometrial cancer cases with normal curettage findings as part of early detection. However, the cytologic diagnosis did not indicate good prognoses in the cases of cancer localized in the myometrium.     

Changes in the phospholipid composition of the arterial cell can result in severe atherosclerotic lesions

The oxysterol concentration in the plasma and the phospholipid composition of vascular tissue obtained by coronary artery bypass grafting (CABG) were compared with plasma and vascular tissue from age and sex matched controls. The plasma from CABG patients had a higher concentration of oxysterols than was present in the controls. Human endothelial cells were cultured for 72 hours in a medium containing plasma obtained from CABG patients, from controls or from the same controls to which 5 oxysterols were added to make the total oxysterol level equivalent to that in the CABG plasma and then pulsed with calcium (45Ca(2+)) for one hr. A significantly higher influx of 45Ca(2+) was noted in the endothelial cells cultured in the plasma obtained from CABG patients and from the controls with 5 added oxysterols, but not in those cultured without added oxysterols indicating that oxysterols increased calcium influx into endothelial cells. A phospholipid analysis indicated that the arterial tissue from CABG patients had 48.2% sphingomyelin in its phospholipid fraction compared to 10% in arterial tissue from umbilical cords. The saphenous vein obtained during CABG surgery from the same patient had only 24% sphingomyelin in its phospholipid fraction and unlike the coronary arteries had no atherosclerotic lesions. The higher level of oxysterol in the plasma of patients suffering from severe atherosclerosis could increase the concentration of sphingomyelin in the arterial cell membrane and thereby increase calcium influx required for producing the calcific type VII lesions in the coronary arteries.     

Soluble glycoprotein 130 is inversely related to severity of coronary atherosclerosis

Purpose: Recent studies indicate that the effects of interleukin 6 (IL-6) realized via soluble IL-6 receptor (sIL-6R) facilitate the development of various pathological processes. Soluble gp130 (sgp130) is a naturally occurring inhibitor of signal transduction via this pathway. In this study, we assessed the relationship between circulating levels of IL-6, sIL-6R and sgp130 and severity of coronary atherosclerosis in patients with stable coronary artery disease (CAD).

Methods: Plasma levels of IL-6, sIL-6R and sgp130 were measured in patients with atherosclerotic coronary lesions (n?=?128, group 1) and with intact coronary arteries (n?=?48, group 2). The severity of coronary atherosclerosis was evaluated by the number of affected arteries and by Gensini Score index.

Results: Circulating IL-6 levels in group 1 were significantly higher than those in group 2. The levels of sIL-6R did not differ considerably in both the groups. The levels of sgp130 in group 1 were significantly lower than in group 2. A negative correlation has been revealed between sgp130 levels and the number of affected coronary arteries and Gensini Score index.

Conclusions: Serum concentration of sgp130 in patients with stable CAD is inversely related to severity of coronary damage. Low sgp130 level may serve as an additional indicator of coronary atherosclerosis severity.     

Prevalence of asymptomatic myocardial ischaemia in diabetic subjects.

OBJECTIVE--To compare the prevalence of silent myocardial ischaemia associated with coronary artery disease in diabetic subjects with that in controls of similar age and sex. DESIGN--A controlled study in which subjects with positive findings on exercise electrocardiography, 24 hour electrocardiographic recording, or dynamic thallium scintigraphy (diabetics only) underwent coronary angiography. SETTING--Academic medical centre; referral based cardiology clinic. SUBJECTS--136 Diabetic subjects, of whom 72 (33 women, 39 men (mean age 46.0] were insulin dependent and 64 (19 women, 45 men (mean age 49.3] non-insulin dependent. 80 Controls matched for age and sex; all were clients of the Occupational Health Service of Oulu University Central Hospital or the State Occupational Health Service Station in Oulu in whom diabetes had been excluded by a glucose tolerance test. INTERVENTIONS--Any subject showing signs of myocardial ischaemia was referred for cardiac catheterization. MAIN OUTCOME MEASURES--Exercise electrocardiography and 24 hour electrocardiographic recording were regarded as positive if there were ST depressions of greater than or equal to 1 mm that were planar or downsloping and persisted for 0.08 seconds after the J point. Thallium tomographic imaging. With cardiac catheterisation, coronary artery lesions were classified as significant in half or more of the vessel lumen was narrowed, or insignificant if such narrowing was less than half. RESULTS--40 (29%) diabetes and four (5%) controls had positive results in one or more of the non-invasive tests. Coronary angiography was performed on 34 of the diabetics (six refused); 12 had significant coronary artery narrowing; seven had unimportant atherosclerosis; 15 had patent coronary arteries. Among the controls only one had unimportant atherosclerosis; the other three had patent arteries. CONCLUSIONS--These results confirm the high prevalence of asymptomatic myocardial ischaemia in diabetics. Non-invasive screening of diabetic subjects, however, does not seem justified because of the low preset probability of the presence of the disease and the inaccuracy of the available test methods.     

Numbers of cells and cell proliferation in intima of different human arteries

Increased cell proliferation in early atherosclerotic lesions is recognized as an essential event of atherogenesis but the levels of cell proliferation in different stages of atherosclerotic plague formation in different types of human large arteries are still insufficiently studied. In the present work, we studied intima thickness and proliferation of newly "infiltrates" hematogenous and resident cells in atherosclerotic lesions of the carotid and coronary arteries and compared these parameters with those in the aorta, reported by us in earlier publication. Analysis of intima thickness and proliferation in grossly unaffected intima and in different types pf atherosclerotic lesions (initial lesions, fatty streaks, lipofibrous, plaques, and fibrous plaque) revealed that although there were similar tendencies in the change of the infiltration levels of hematogenous cells and proliferation in different types of arteries, there were significant quantitative differences between different types of arteries. Hematogenous cells in lipofibrous plaques of the coronary and carotid arteries were found to account for a third and almost for a half of the total cell population, respectively, while atherosclerotic lesions in the aorta, as it has been shown by us earlier, to contain no more than 15% ofhematogenous cells. This suggests that the contribution of hematogenous cells to the development of atherosclerosis in the carotid and the coronary artery appears to be more significant than that in the aorta. Despite the differences in numbers of accumulating hematogenous cells in the intima, a similar "bell-shaped" dependence of cell numbers on the lesion type, involved in the following sequence: unaffected intima-initial lesions-fatty streaks-lipofibrous plaques-fibrous plaques, was detected in the coronary and carotid arteries. The visualization of proliferating cells (PCNA-positive) in atherosclerotic and unaffected zones of the coronary and carotid arteries revealed similar patterns. The maximum numbers of PCNA-positive resident cells were identified in lipofibrous plaques. The changes in the total cell numbers were accompanied by the changes in the numbers of both proliferating resident cells and proliferating hematogenous cells.     

血肌酐与非ST段抬高急性冠脉综合征冠脉病变程度及其预后

目的:研究血清肌酐(serum creatinine,SCr)与非ST段抬高急性冠脉综合征(non-ST-elevation acute coronary syndrome,NSTE-ACS)患者冠脉病变程度及其预后的关系。方法:对293例患者进行回顾性分析,依据冠脉造影结果分为NSTE-ACS组和非冠心病组。根据Gensini积分系统,评价NSTE-ACS患者冠脉病变程度,并将患者分为轻度病变组、中度病变组和重度病变组。检测患者SCr水平,应用SPSS16.0分析SCr与NSTE-ACS患者冠脉病变程度及其预后关系。结果:(1)与非冠心病组相比,NSTE-ACS患者SCr较高(P0.05);其中,重度冠脉病变NSTE-ACS患者SCr水平尤高(P0.001)。(2)SCr是NSTE-ACS冠脉病变的危险因子;SCr与NSTE-ACS冠脉病变程度呈正相关(r=0.263,P0.000);SCr与NSTE-ACS主要心血管不良事件(Major Adverse Cardiovascular Events,MACE)呈正相关(r=0.183,P0.01)。结论:SCr是NSTE-ACS患者冠脉病变的独立危险因子,且与NSTE-ACS患者预后相关。SCr对于NSTE-ACS的诊疗有潜在临床价值。     

Recanalization of chronic total coronary occlusions: the impact of a new specific guidewire on primary success rate

BACKGROUND: Although chronic total occlusions are encountered frequently in patients with coronary artery disease, an effective strategy to deal with them has yet to be devised. Various new guidewires have been designed in an attempt to negotiate chronic occlusions successfully. The authors have analysed the impact of the Athlete guidewire on procedural success in this lesion subset. METHODS: Sixty-two consecutive patients undergoing percutaneous intervention for chronic total occlusions over a two-year period were retrospectively studied. For the initial attempt, conventional guidewires were used. In case of failure, further attempts were made using the Athlete guidewire. Procedural success rates with the use of conventional and Athlete guidewires were assessed. RESULTS: Failure of the first attempt with the conventional guidewire occurred in 32 (51.6%) patients and success was achieved in 30 (48.4%) patients. In the former patients, a second attempt was made using the Athlete guidewire to cross the occlusion. The second attempt was successful in 20 patients (60%) in whom the first attempt was unsuccessful, while in the remaining 12 (40%) patients the occlusion could not be crossed even during the second attempt and the procedure was then terminated. Following the use of the Athlete guidewire, the success rate increased to 62% (p < 0.001). No complication occurred during the first attempt, while one patient had a coronary perforation using the Athlete guidewire, which was managed successfully without the need for bypass surgery. CONCLUSION: The use of the Athlete guidewire is feasible and safe, and enhances the chances of successfully treating chronic total occlusions during percutaneous coronary revascularization procedures.     

Pseudo-aortic dissection after primary PCI

A 49-year-old female was admitted to our hospital because of an acute anteroseptal wall myocardial infarction. The patient had no previous coronary artery or heart disease. Chest pain with radiation to the left shoulder associated with severe transpiration and nausea had been present since one hour before presentation. After transportation to the catheterisation laboratory she underwent a primary percutaneous coronary intervention (PCI) procedure of the left anterior descending coronary artery which was occluded after the first septal branch. A bare metal stent (Vision, Guidant) was implanted. The other coronary arteries showed no significant lesions.     

Recanalisation of coronary chronic total occlusions with new techniques including the retrograde approach via collaterals

Objective

Percutaneous treatment of coronary chronic total occlusions (CTO) remains one of the major challenges in interventional cardiology. The strategies of recanalisation in CTO have changed drastically due the development of new techniques such as the retrograde approach via collaterals. In this single-centre experience we sought to analyse the success rates with the use of different CTO techniques, the complication rates, and we evaluated predictors of failed CTO recanalisation attempts.

Methods and Results

In this single-centre observational study we analysed the prospectively entered data of 331 consecutive patients, undergoing percutaneous coronary intervention (PCI) for CTO in 338 lesions at the Heart Center Wuppertal between June 2007 and July 2010. Nineteen lesions were attempted twice and one lesion three times (=358 procedures). The lesion-related success rates were 81.1%. Single-wire usage was the predominant strategy used in 198 antegrade cases (65.6%) followed by parallel wire technique and see-saw technique in 94 cases (31.1%). In the retrograde procedures, the reverse CART technique was predominantly used (35.7%), followed by retrograde wire passage (17.9%), marker wire (17.9%) and CART (14.3%). The in-hospital complications were low and comparable with conventional PCI data. The presence of blunt stump, severe calcification, severe tortuosity and occlusion length >30 mm were independent predictors of procedural failure.

Conclusions

A high degree of success with low in-hospital complications comparable with conventional PCI data can be expected in the hands of experienced CTO operators. A second try with a retrograde approach after antegrade failure should be considered.