Background-Recently, thoracic aortic stent grafting has emerged as an alternative therapeutic modality for patients with thoracic aortic aneurysms and aortic dissections. However, its application has been limited to descending thoracic aortic aneurysms distal to the aortic arch. We report our initial clinical experience of endovascular branched stent graft repair for aortic arch aneurysms. Methods and Results-Endovascular grafting with Inoue branched stent grafts was attempted for 15 patients with thoracic aortic aneurysms and aortic dissections under local anesthesia (nϭ14) or general anesthesia (nϭ1). Single-branched stent grafts were used in 14 patients, and a triple-branched stent graft in one. The branched stent grafts were delivered through a 22F or a 24F sheath under fluoroscopic guidance and implanted across the aneurysmal aortic arch. In 2 patients, the single-branched stent graft did not pass through the 22F sheath used. Complete thrombosis of the aneurysm was ultimately achieved in 11 patients (73%). Of 4 persistent leaks, 1 minor leak spontaneously thrombosed and 1 major leak was successfully treated by additional straight stent graft placement. In 1 patient, the right external iliac artery ruptured during the withdrawal of the sheath and was successfully repaired by the implantation of a straight stent graft.One patient with severe stenosis of the aortic graft section was successfully managed by additional stent deployment. Peripheral microembolization to a toe occurred in 1 patient, and cerebral infarction occurred in 1 other patient. Two patients who had failed to receive endovascular stent grafts died during an average follow-up of 12.6 months, 1 of pneumonia and the other of rupture of a concomitant abdominal aortic aneurysm. Key Words: aneurysm Ⅲ vessels Ⅲ aorta Ⅲ stents Ⅲ grafting T he leading cause of death for patients with surgically untreated thoracic aortic aneurysms is ruptured aneurysm. [1][2][3] Currently, the standard treatment of thoracic aortic aneurysms is surgery with artificial graft replacement, for which perioperative mortality rates of 5% to 35% have been documented in multicenter reports. 4 -10 The surgical treatment has achieved remarkable advancement due to the introduction of deep hypothermic circulatory arrest and myocardial protection with cardioplegic solution. Despite recent progress of thoracic aortic surgery, complications are still prevalent in repair of aortic arch aneurysms, especially in patients with advanced age and coexisting morbid conditions. 4,11,12 Recently, catheter-based strategy for the treatment of coronary heart disease and valvular heart disease has progressed dramatically. 13 Therefore, the development of new, minimally invasive treatment for aortic aneurysms is desired. Conclusions-ThisTransluminal endovascular stent graft placement has recently been introduced as a promising alternative to surgical treatment of aortic aneurysms. For thoracic aortic aneurysms, Dake and colleagues first reported the clinical feasibility of endovascular repair with ...

Background-The process of progression in coronary artery disease is unknown. Methods and Results-The subjects were 36 patients with 36 objective vessels with clinically significant progression of coronary artery disease (Ն15% per year) in whom 4 serial coronary arteriograms (CAGs) were performed at intervals of Ϸ4 months in a 1-year period. The degree of progression of percent stenosis between each of 2 serial CAGs was classified as marked (M: Ն15%), slight (S: 5% to 14%), and no progression (N: Ͻ5%). From the pattern of progression, the 36 vessels were classified as 14 type 1 vessels with marked progression (N3 N3 M in 13 vessels and S3 S3 M in 1 vessel) and 22 type 2 vessels without marked progression (S3 S3 S in 18 vessels, N3 S3 S in 4). Percent stenosis at the first, second, third, and final CAGs was 44Ϯ14%, 46Ϯ13%, 46Ϯ13%, and 88Ϯ10% (PϽ0.05 versus first CAG) in type 1 vessels and 44Ϯ11%, 50Ϯ9%, 59Ϯ9%, and 67Ϯ9% in type 2 vessels (PϽ0.05 for second, third, and final CAGs versus first CAG). Type 1 vessels featured the sudden appearance of severe stenosis due to marked progression, angina pectoris, or myocardial infarction (71%) and Ambrose type II eccentric lesions indicating plaque rupture or thrombi (57%). Type 2 vessels featured continuous slight progression of stenosis with smooth vessel walls; angina pectoris (14%) occurred when the percent stenosis reached a severe level. An increase in serum C-reactive protein was observed only in the type 2 vessel group, which suggests a relation between continuous slight progression and inflammatory change. Conclusions-Two types of stenosis progression provide a new insight into the mechanism of coronary artery disease.(Circulation. 1999;100:903-909.)

hile coronary perforation is an uncommon complication following percutaneous coronary intervention (PCI), [1][2][3][4][5][6][7][8] it is one that may lead to cardiac tamponade, 6-9 emergency coronary artery bypass surgery (CABG), or pseudoaneurysm formation, 10 with the potential for late coronary rupture. New coronary devices that resect (eg, directional or transluminal extraction atherectomy), ablate (eg, rotational atherectomy or excimer laser angioplasty), or score (eg, the cutting balloon) atherosclerotic plaque may increase the risk of coronary perforation, and a number of angiographic risk factors for its occurrence have been described previously. [11][12][13][14] The use of newer higher-weight and hydrophilic coronary guidewires may also increase the risk of coronary perforation, particularly during the treatment of chronic coronary occlusions. Clinical algorithms for the treatment of coronary perforation based on angiographic and clinical criteria have been Circulation Journal Vol.66, April 2002 less well studied. Moreover, descriptions of the long-term sequelae after coronary perforation, and delineation of the potential risk for late pseudoaneurysm formation and coronary rupture, have been lacking.The present study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat the perforation, and describes the long-term prognosis in patients who have developed coronary perforation during PCI. To address these issues, we reviewed our experience with coronary perforation in a consecutive series of 7,443 patients undergoing PCI at a single, highvolume clinical center. Methods Patient PopulationBetween January 1992 and December 1996, 7,443 coronary interventional procedures were performed in the Cardiac Catheterization Laboratory at National Toyohashi Higashi Hospital. These procedures included conventional balloon angioplasty (n=4,895; 65.8%), cutting balloon angioplasty (n=1,274; 17.1%), coronary artery stenting (n=810; 10.9%), directional coronary atherectomy (DCA) (n=440; 5.9%), and transluminal extraction catheter atherectomy (n=24, 0.32%). Coronary perforation is a rare but serious complication that occurs during percutaneous coronary intervention (PCI). This study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat perforations, and describes the long-term prognosis of patients who have developed coronary perforation during PCI. Coronary perforations were found in 69 (0.93%) of 7,443 consecutive PCI procedures, occurring more often after use of a new device (0.86%) than after use of balloon angioplasty (0.41%) (p<0.05).Coronary perforation was attributable solely to the coronary guidewire in 27 (0.36%) cases. Coronary perforations were divided into 2 types: (1) Those with epicardial staining without a jet of contrast extravasation (type I, n=51), and (2) those with a jet of contrast extravasation (type II, n=18). Patients with type I and type II perforations were managed by observation only (3...

In patients with acute anterior MI, analysis of postsystolic shortening in the infarct region predicts the recovery of systolic LV function after reperfusion. Postsystolic shortening represents active contraction and indicates viable myocardium.