Percutaneous endoluminal treatment of aorto-abdominal occlusive diseases

JACC Febnlary Igq8 4.~3A The Impact of Time to Thrombolytlc Therapy on Outcome In Patients With Acute Myocardial Infarction ( A M i ) P, Chareonthaitnwee, RJ, Gibbons, RS, Roberts, TrF Chnstian, R. Bums, S Yusut For the CORE Investigators; Ma]K~Clinic, Rochester, Minnesota, USA; McMaMer Unit~erMy, Hami#on, O~tari~ Canada Pno~ ~ t ~ m haNe suggested that the greatest t ~ f i t s of e<lfly thrombolysis may t~ o~zerv~ if administered within ~ holm of ~ y ~ t o m onset+ The Ipu~<~ of ~ s i ~ t i o n wi~ to exan~ne the impact of ~ m to ~rom. bofy~ ~ on ~ AM! outcome velnaPles in CORE, ~n interr~ltional, ~ e g tn~! of pofoxamer 188, Mortal~ (M) 4nd remf4rctmn fate (RR) were meaI~red in 2,954 r ~ patients with AMI (.< 12 hogm' d~r~tmn) recewed ~ ther4~. S ~ m ~ c l ~ umng T ~ e m ~ t a m , t . lanai ~ (IS) and reldion~,mhde~ electron ~ (EF) measured by ~mn~'al ~ a t o n e s mvOIved I,C~5 and 1,075 patmms, mspact~W, who amalyzable ~ . ~ time to thrombalyttc therapy was ~gmfcantiy asso~ated ~ IS, EF, M. ned RR: Tume !o Theomtmlys+s IS |%LV) EFt%) 3 5 ~ M 1%) E ~ t ~ t t M |%) 35-(t=-y RR t%l 19S t~ I~ 051=.012 55 69 62 2"25:20 04S ¢ 0 1 4 70 S,2 32 2 4 1 1 19 048:013 77 10 1 4I 2~S ~ 2~ 048¢015 t2a 155 09 0.014 0008 00001 <00001 0 0(~11 Coe~t~s~ns: 1} There are c~emonstrabM benefits el eadre~ relped~smn therapy Onm~a~ m..-e,election fradmn, and ~ t t y . 2) +~baug~ rite effect of tin.re to ff~ron~d~'sis On in~,~'t stze and eiection fracton ~spnmanly restricted to therapy ~ w~thm 2 hours e! sym~om onseL me effect of time on mo~alily is evident over all tm~e m~enrats. 3) Re~arctmn rate as htgl~r m patients Ireated ~ earker t h ~ t~erapy. Stenting: Carotid, Peripheral, Renal (11), a n d R e s t e n o s i s Diabetes II W e d n e s d a y , April 1, 1 9 9 8 , N o o n - 2 : 0 0 p.m. Georgia World Congress Center, West Exhibit Hall Level P r e s e n t a t i o n Hour:. N o o n - - 1 : 0 0 p.m. ~ -~--~ inRial With the Corvita E n d o l u m i n a l Graft in Peripheral Arteries M Hemy, M Amo~. I. Henry. K. Tzvetanov. O. Tncodm. U CC.L. Potyctz.,~/ue. Essay-tee-Nancy. France Puq3Ose: To evaluate a self--expanding er~olummal vascular prostttes=s, the Con.ta Endoluminal Graft (CEG). allewm~ percutaneous bypass gm~ng m peni~erel artenes. Method and Matenats: The CEG census of 2 ~ n ~ : a ~t-expandab~ cyfindncal wire ~ , a h~ghly porous, elast¢ coating on ,nner surface of structure, m wh~-'h b~ood can coagulate, seahng the CEG to form a new blood tight vessel wall. This flexible CEG can be compressed atria 8.-10F introducer sheat'-s a,qo~ng porcutaneeus entry, ts produced an vanous I~gths (3-30 cm). diameters (4 to 44 ram). cut to length by user, released from t n ~ r sheath at intended site by coa.=al ~ of a "tlof~ng" catheter/slew pull back of the introducer sheath ResuffS: 58 pts (M: 46, F: 12. mean age: 644 ± 9.7 ym [39-86]) with occti.stve lesions (47)(sten.: 28, oocl.: 19), aneurysms (11), in lliac (35). temo~opop. (23) arteries treated with CEG. Mean lesion length: iliac~ 58.3 ± 24.3 mm (40-100), lemoropop.: 105.8 ± 7 ram. Mean % steno~s; 79 ± 6.2. 65 stents easily placed percutaneously (10 pts had contralateral approach). 6 lesions >12 cm treated ~ t h 2 overlapped slants. Immediate technical success: 100%. Complications: 7 thromboses titian: 2, femoropoD: 5), 4 les~ons > 15 cm, requinng bypass (3), Fogarty (1). new angioptasty with success (3). At 6 months, 3 reslenoses appeared outside the ~iu.; trebled by now angioplast~,. Primary I~tency at 1 year: lliac: 95%, fern.pop.: 60% (p < 0.00t). Secondary patency respectively: 100, 75% (p < 0.001). Conclusion: The CEG seems an alternative to surgery to treat occlusive lesions and aneurysms, allowing true internal bypass by percutaneous approach. Yet, treatment of long lesions leads to higher thrombosis rate. ~ Renal Arterial Stenting. A 7 Year Single C e n t e r E x p e r i e n c e With a Serles of 206 Stented A r t e d e s M Henry, M Amor, I. Henry, K. Tzvetanov, I. Masson, B. Mentre. Polyclinique, Essey-les-Nanc~. France Pu;pose: To evaluate the role of percutaneous stenting in the treatment of renal 9ffenal lestons 9fter failure of previous 10alloonangtoplasty. tv~thoclan<1M~tenats. 224 balloon e~panda¢~ steP~ (Palmaz: 164, AVE 60) placed in 206 renal aNanea of 181 patHmt~ tectal ~ : 140, non. oatiol: 66) suffenng from HTN remtant to therapy (181), reflal dy~gnct~n (41) with 9theromatou~ (197), tibremu~ut4r (7), "rakay4shu (2) ¢J~ses. 25 pts had t~laleral lesions, 3 a solitary kidney, Ind~-.atmns'. uf~a~factory balloon a n g ~ p ~ resuits (173), mete.am (26), ~ s s e ~ n (7), Mean les~e length; 11,9 .+- 4.3 rnm (5-.30), M ~ n 4tlmo~e %: 6 2 3 ± 6.4 (70-100) 14 very cal01i~ o ~ ! lemoni treate~ by Rofal01ator, ~uIP~." gmmed~el~ leche~l success;205/?06,3 major ¢omplc~t~s (15%): 1 acu~_ m m m ~ i s cure¢l by fit~noly~, 1 aelanst perfom~on, 1 artenal rapture ( ¢ ~ t h after surgery), 6 montt~ el~poo~~ foaow.up m el~ pts (175); rosteno~t# in I:~ pts (6.9%), Im~led by el new angmplaety. C!,~cal results: systolic blood pmssm drop from (mmH0) 1"/8 ± 9 to 141 ± 12 (p ~ 0,001) pant.slant, ~ ~ preuum (.wVHg) mop from 106 ± 6 to B2 ± 10 (p .~ 0,01), ¢maumn (n~l) did nol ct~ange, n u n ~ of dmg~patmnt; baseline*. 2,6, pos1-~mt; 1,;2(p < O,02-J,HTN; cured: 32/161 ( ~ ) , iml~'Oved: 98/161 (61%), o~llanged: 30/161 (19%). Henal o~/sh~,~ tmn: Improved: 12/41 (30%), u~llanged; 27141 (1~%), ~ ; ~41 (4%), At ? years, at! lesions: i~imary pstency: 76%, aecondary: ~ % , non osl~t les~nS respectively 78, 100%, Ostlst leS~nS: BO elnd 93% (p:n.s.). C o n c l ~ : Renal aflery stsnting is sale, effe¢tNe, may be an alternative to Surgery. partlcutarty in o~tJal lesK~ng. Our expenen~e shows md~ction m restenomS rote, compared to conventional angmptasty. All ostlal ~l~ouldbe slanted. ~ P e f ~ u t a n e o u s E n d o l u m l n a l Treatment o f m l A n o u l ~ / i m L A S i n g l e Centl~ F ~ With e ~ k ~ o s o f 3S A n o u w s m s M. Henry, M. Arose, I. Henry, K. Tzvetanov, P. Khofer. Po/yc//mque, ~Na.c~, France Purpose: To evalume fea~l~lfly, efficacy at percutaneoustreatment of penpheralaneuq/smst0,~thcoveredstentsm most of the cases, CraggEndopm System 1 (CES) and Corvita Endolummal Graft (CEG). Meft/o~ and Ma~J/a/s: 33 pts (M: 28, F: 5, mean age: 65.4 ± 9.6 yrs H7-83]) ~ l h 35 aneurysms treated w~h covered stems (CES: 10, CEG: 13, non @ov~red stertts: 2, =i=~i graft: 1). ~ loCatlon: lenlorel ~'~. 12. poplrteal: 8, d~c:15. Mean leslon length.61.1 m m ± 21.3. Percutaneous approach used m all cases, femoral antegracle (n = 19), lemofal retrograde (n = 14), fern_ coqntralateral (n = 1). poptrteal (n = 1). Sten~ are ~tre~uced tt~ougll 7-10F st~eattts. Multiple slenl~ used to cov~r all les~ns in 8 cases Slants: from 6 to 12 mm in diameter, frem 30 to 120 mm in length. Re~.d~: Sten~ ~ implanled in 34 cases, no leakage. In 1 long, very tot'gJot~ femoropopliteal aneurysm, m ' q 3 o ~ e to cover rts low pint. the dewce (CES) being too ng~d.No complicationobserved dunng the procedure. 3 of5 0 e v e k ~ non-+nfecllo~s fever/local pain with CES. 5 mremboses: 3 in a palm,teal a n e ~ t in a femoral aneu~s,m treated by bypass, 1 In an thac aneu~am treated by Fogady techn=que. All othe~ slenis remaonpatent, the aneuWSm completely exclucled o~er a mean follow-up of 13.3 ~ 10.4 and a max. folfow.-upof 46 rrm:~m. Primary palency at 42 months: all Insane: T~=, ili~c ~teurysms: 100%, femoral aneurySm: 91%, poplttoat: 34%. Secondary patertcy: all lemons: 85%, iliac aneurysms: 100%, femoral: 91%. po~liteal- 56%. Cor~usnon: Percutaneous endelummal treatment of p e n ~ r a l aneurysms seems safe. effect~e, effanng t~gh technical success with good told+term results, except tot poptPeal lecalization. Long term result~ need to ba analyzed. Thts method could be an altematwe to surgical bypass and may be the first treatment to propose for this kind 01 disease. ~ P e r c u t a n e o u s Endoluminal Treatment of A o r t a - A b d o m i n a l O c c l u s i v e Diseases M. Henry, M. Amor. I. Henry, K. Tzvetanov, B. Mentre, D. Weill. UCCI.. Pofycl/nKTue, Essey4es.Nancg France PurpOse:To evaluate the feasibility and efficacy of percutaneous endoluminal treatment of aorta-abdominal occlusive diseases. Methc~ and Materfafs: 28 pts (M: 25, P 3, mean age: 52.5 ± 113 ym) were treated by Percutaneous Transluminal Angtoplasty' (PTA) tar aortaabdominal occluswe diseases. Lesions were located in the infremnal aorta alone (stenoses: 12). or extended 1o lilac artenes (stanoses: 12, occlusions: 4). Mean % stenosiS: 80.4 ~_ 11.7. Mean lesion length: 33.5 ± 7.2 ram. 7 lesions were calcified, 9 ulcerated. 16 excentrated. Owing to Fontatrm's clasmtication, 26 ~ were in stage It severe, 2 in stage III. Resu/ts: Technical success in al: cases (100%). The 4 oo:lusions were initially treated with tibnnolysis (3) or ultrasound mechanical thrombectomy device (1). Stentts were implanted in 23 pts (Palmaz in 18 pts, Wallstent in 2 and Optimecl in 3). A.B.I. increased from 0.63 :~ 0.15 to 0.97 ± 0.05. No immediate complication. Max. follow-up: 9 years, mean follow-up: 26.4 E D N E :,~, S O A y P 0 S E R 454A JACC months, At 3 yrs, we report 2 rostonosos, 1 treated by PTA alone, 1 by PTA and stent. All arteries remained patent, Conclusion: PTA el infrarenat aorta. ,)cctt.lSlVOdlse~, ;os is sate and cOcolive Slant placement are necessary In most el the cases, Leng term results ar~t o~collent This technique is an alternative to surgery "o"' So.ported C..o,,d Ang,op,.,y (..CA) In . . . . . . . . . . . . . . Patients With Symptomatic Coronary Artery Disease: Acute and Long Term Results F/A, Shawl, A, Efstrotieu, F, Lapetlna, A, Dukevoic, T, Shahab, 8,B, Heft, K,G, DO~lghnrty, Wa,~hingtorlAdventist H&~piIal. dikes# Prqrk. MD. USA C~rolid endarteroctomy (CE) in tl~fl pro~onco el r~ymptomatte coronary artery disease (SCAD) has boon associated with high molbidily and mortality Of 06 pie with SCAD who undnrwenl SSCA, 77 were conaiderod poor CE candidates (g had scent MI, 27 had 8ovate LV dy~lunclien with Class III or IV nngina pre~ent in 50), Twenty leHt wore ,g0 years, 0 l~nd eontralatorol carotid o~oluslen, 20 had bilateral atano~is. 70%, 52 presented with TIA's or eVA, 5 scent h~miplegla, and evolving stroke was prose~t In t, ~ C A was undaftakon in g0 internal and 7 common carotid artenea with implanlatlca el 14t Palma~, stent~ with everlappieg sleet in 33% to Incroaae radial stronglh. Pmeed~lr~l succo,~ we~ff100% (tl~(:;l~ldlnt155w!th combiner4 or at~god PTCA) rodllclng the carotid Me.healSfrom 86 t 7% to 5 ~ 2% There were no deaths, MI or meier strokes, hut, 3 pts l~r~dminer neurolofllc deficit which resolved in 7 day& Moat (75%1 were discharged within 24 hetlrs, On fellow.up (g t 5 months), 6 p16 died teen combrava~c~dl~r) and 2 with known LV tl~mmbus so(feed minor ~trekn In 71 p(s eligible for 6 monll~ anglograplric (4~ pts) of uttr~se~,md (Tt pts) follow.up ~eveidcd, t asymptomatic ioslenotHs, wl~lch wa~ ro.diltUed Conchrsien: SSCA is associated with n high success tats, low recurrence rat~ and infrequent complications, L~8:~ - Is Combined Parcutaneous Carotid Artery Slanting and Coronary or Extra-Coronary Artery Angloplasty a Safe Procedure? JC. Laborde, J, Faiadet, B Cassagnoau, C Jordan, R Calms, T Joseph, J P Laumnt, J Memo Unitd de Cmdlotoqie Infen.ent~onnelle, Chn~que P&~ltr, TouletL~o, F~anct~ Background: To evaluate the risks and bnnohts el carotid orient stontmg m comhtnation with coroner's, or oxtra-c"~renary angioplasty dunng the same setting in patients at risk for ondartorectomy. Mefhc~d.~ From 4/15/96 to 7,'20197, we pertormod combmed procedures tn 22 pahonts ( t 8 males, mona ago 71 2 t 4 ? years, range: 62-78), considered at nsk fo~ su~tcal ondarlorectomy Assoclahon of caretid stontmg and coronary ang~oplasty (balloon +stont: 5 pts, balloon angloplasty atone: 4 pls, 3therectomy + balloon 2mq~oplasty 1 pt) was performed in 10 pts, bilateral camt~d stontmg ,~ 9 pts; carehd slenlmg ar(d ponphoral angloplasty (renal stentmg: 1 pt; ihae stenhng: 1 pt; femoral angloplasty: 1 Dr) in 3 pie. Twelve pts (55%'t had neurologlc symptoms incladtng transient ischomic attacks (8 pts) and recent stroke (4 pts). The remaining pts wore asymptomatic. Twenty pts (91%4 had severe coronary associatod orion,/lesions. Moan diameter stonosls of the carehd Ios~ons was ?9"0 frange: 65-95%). All pabonts wore treated without downtlow carotid protection. Results: Procedural success was achieved ~n 21/22 Dis (955%) Immediate comphcahons conmsfed ot 1 rumor stroke (45%,) At 30 days follow-up, we obsewod one death t4,5",,) duo to cardiac arrest, non fatal cardiac events m 2 pts (1 heart lailure, 1 ventncular tachycardia), 1 abdominal haemorrago, no MI, no stroke. At follow-up, mean 5,7 t 4.1 months, we observed { 2 cardiac deaths, 2 PTCA for restonoms, no MI, no stroke Conclusfons: Combination of carotid artery stentlng with controlatoral carotid stoat implantahon or w~th coronary and extra-coronary angtoplasty dunng the same setting appeared not to mcrease significantly the ask el carotid stenting in high-risk pts lor surgery, ~ L a c k of Benefit of Stentlng Compared to B a l l o o n Angloplasty for Native Coronary Stenoses in Diabetics M.H. Ghatoun, GC. Timmls. T, Catlin, D, Aliabadi. R+D. Safian, J.A. Goldstem, W.W O'Neill Wdliam Beaumont Hospital. Royal Oak, Mich.gan. UqA As suggested m recent teals of balloon angioplasty vs bypass surgew, diabetic patients may tare less well with angioplasty, Intracorenary stenting reduces restenosis rates in pts undergoing elective angioplasty of native coronary stenoses. However, whether stenting conlers such benefits in diabetics has not been established. Therefore, we retrospectively analyzed the outcome over 9 months in diabetic patients undergoing balloon angioplasty Fehnlary I ~81,I alone (N = 154) or elective stonting (N ~ 87) of native coronary lesions, Endpoints el the study included target vessel rovascularizatlon (TVR) and major clinical outcomes (MI, stroke and death), No differences w e e found between groups with aspect to ago or gender. Acute success rotes between balloon nnd stont groups were similar. Over 9 months, them w e e no ai~niflennt difference between angioplasty end stent groups with regard to TVR roto~ (24% vs 28"/0, P = NS), MI (4,3% vs 3,8% P ~ NS), stake (P,~, vs 9.6%, P ==NS) or death (? R"/,,v~ .q,2%, P = NS), These data suggest that oomparod with balloon nngioplaaty, elective intmooronaly stenting dens not provide additional benefit in diabolic pts undergoing percutanoega rovascgl~nZ~tlon el nntive ceronnry lesions, The moat elteCtlVe revaact!!rletolion strategy for tl~nso pts has not boon dotetmmed ' ==== (111]I]~B4 ~---'j The Effect of Dlel~tee and Revas©u!er!zetlon + - - ~ Technique on Eerly Outcomes G C Timmia, R T Collie, L Tomaka, W.W, O'Ned! WtlhamB~+umont Hospffal, Revel/Oak, MI, US.4 Beeal.lse el the interaction at diabetes (DM) and mvasculalizattee technique on eulcomea we interrogated our !nt~n/onhenal Outcomes Regtst~ Database tel the following In,hospital events: death, IofalClion (b(3lh qMI and nqMl) SllOkO, lllgellt 6lllglca! levascu!arl~aften, ca~iel~nl~ shock~ and reoo~Iuslon a~ inlhteeced by DM status (beth type I and II) m~d by procedure (PTCA vs sleet) There were 17',00g patients (pts) having procedures tree t,1,94 Ihreugh 3,31-97, 4,056 (29%) were diabetic (type Iaad It) but stmdar m a g e gender and disease seventy There wore 62 and 104 doatbs m the OM v,s non.DM pls (1 25%, vS 0.86%; p = 0.01 cJ). This was duo to an eKcess mo~akty m PTCA pts with DM (1,22% vs 0.83% non, DM PTCA pts; p = 002.5) There was no slgndleant mortalLty dlllemn¢o in sleeted DM vs non-DM pts tt 48% vs 1 05%; p =, 0.3g) Roocclusions wore mere likely to complicate PTCA regardless el the presence o! DM (1.68%, vs 0.49% with stoats; p = 0032) of Its ab~enc~ (t 7~i% vs O~75% wtth stoats; p = O.OOt/ ConverserK MIs ¢~'re more lreqnont with stents (2.33% vs 1.29%; p = 0.000) but wore equally dlstnbuled beh~oon DM and non-DM pts regardless el procedure ~,~reover, combining ~lt endpomts there was no stgmllcant difference per d~abot~cstatus (p = 0.38) regaElloss ot procedure (stool: p = 027; PTCA: p = 0.48). No other ondpetnt wos intktonced by DM status Iocludmg acute or delayed reoccluston Conclusion: Hospital mortality is higher in OM pts alter PTCA but not alter stealing. However, the combined endpoint was not influenced by diabetic status bul rather by procedure mcluding polar differences in reoo=lusmn and MI, These early outcemes unno~score the importance el adiunchve therapy ~1_8-8~ -- Predictors of Target Lesion Revascularization in Diabetic Patients Treated With Palmaz-Schatz Stents A AbzzaLd, G.S Mmtz, B Otlaca. K M Kent, L F Sailer. A O Plchard. H Wu, R Mehran, T Bucher, J J Popes, M B Leon Washmgton Hospital Center, Washmgton, DC USA To ovahtate the predicterS el target leslol~ ~eva~culartzatlon (TLR) m diabetics treated w~th Palma=-Schatz stoats, t 51 native vessel lesions m 130 consecutwe pts were analysed using (lt pre and post-intervention mtravascular ultrasound (IVUS: reterence and lesion ar(eeal, lumen, and plaque areas and plaque burden (plaque/adenal area)} and t2) quanhtative angtography {QCA: relorence diameter, mmimum htmen diameter (MLD), and diameter stonosis (%DS)}. All pts were followed for at least 1 yr. Univanate predictors included N h,:,oh~'lIher3py QCA R~lelelIce Pest MLDt%) IVUS Rt!tetel~t~ lumer~areatan12) Referenceplaquebulden Postleslon lumenareatam ?) Post MLD (am) TLR 39 61 ~o no TLR 112 44% O001 2 95 t 0 F,8 268 '~ 049 3 10 t 0 66 294 : 066 e 05 003 7 50 52 6 70 2.55 9 57 t 47 : 7 53 t 2 76 t 000t 0066 0 02 0 002 .* 179 t 12 .* 174 t O28 3 48 12 2 57 0 52 p Insulin-treated diabet,cs had a TLR rate of 3t°o (vs 19% for non-insulin diabetics). Using multivariate logistic regression analysis, the mdependent predictors of TLR were insulin therapy (Odds ratio = 0167. p = 0.048) and IVUS final lumen area (Odds ratio = 0.034. p = 0.011). We Conclude: Diabetic pts, especially those treated with insulin, have a high rate of TLR 1 yr after stent placement (25% overall, 31% for insulintreated diabetics). However. even in these pts the IVUS final lumen CSA is an important predictor of late events.