Primary percutaneous treatment of AMI related to acute vein graft occlusion is still an uncommon practice. Primary stenting improved luminal diameter and offered higher rates of success; however, this strategy did not reduce the in-hospital reinfarction and death rate, compared with that occurring with PTCA treatment.
Evaluation of the Diagnostic Accuracy of Coronary Computed Tomographic Angiography Introduction: Coronary computed tomographic angiography (CCTA) has been widely accepted as a non-invasive diagnostic tool for coronary artery disease (CAD). The objective of this study was to evaluate the diagnostic performance of CCTA and its influence on modification of percutaneous revascularization strategies. Method: The study included two groups of patients: a main group (MG), including 100 patients screened with a suspect of severe CAD by CCTA and indication for coronary cineangiography (CINE), and a control group (CG) for comparison, including 100 patients selected during the same period, with indication for CINE according to clinical criteria or by positive functional tests. We evaluated the performance of CCTA for the diagnosis of lesions > 50% in coronary segments, arteries and patients and the revascularization strategies adopted. Results: The sensitivity, specificity and positive and negative predictive values of CCTA were 86%, 95%, 71% and 100% for the coronary segments, 91%, 92%, 80% and 100% for the coronary arteries and 100%, 90%, 100% and 100% for patients, respectively. In the MG, percutaneous coronary intervention (PCI) was performed in 90% of the patients, whereas in the CG, percutaneous coronary intervention was performed in 43% of the patients (P = 0.01). Conclusion: CCTA had a high diagnostic performance in detecting CAD and allowed ad hoc PCI to be performed in 90% of the patients. This strategy, however, must await randomized studies to confirm these results.
RESUMOIntrodução: Os idosos representam significativa parcela da população em nosso País e a população com idade > 90 anos triplicou nas últimas três décadas. Este estudo retrospectivo teve como objetivo analisar os resultados da intervenção percutânea em pacientes nonagenários. Método: No total, foram avaliados, retrospectivamente, 31 pacientes nonagenários (G1), submetidos a tratamento coronário percutâneo, tratados entre janeiro de 1995 e janeiro de 2009. Esses pacientes foram comparados a outros 6.222 pacientes com idade < 80 anos (G2), tratados nesse mesmo período. Foram avaliadas as características clínicas, angiográficas e do procedimento, assim como os eventos cardíacos adversos maiores (ECAM) iniciais e tardios (óbito, acidente vascular cerebral, infarto do miocárdio, isquemia recorrente). Resultados: Os pacientes nonagenários apresentaram maior prevalência de diabetes, angina instável, comorbidades crônicas, doença coronária triarterial e fração de ejeção do ventrículo esquerdo < 50%. O sucesso do procedimento diferiu entre os dois grupos (87% vs. 95,1%; P = 0,049), assim como a incidência hospitalar de óbito (6,4% vs. 0,3%; P = 0,022) e de infarto agudo do miocárdio (6,4% vs. 3,6%; P = 0,035). Na evolução tardia, ocorreram diferenças significativas na sobrevivência livre de ECAM (68% vs. 91%; P < 0,001). Fração de ejeção do ventrículo esquerdo < 50% (RR 1,08, IC 0,39-2,99; P = 0,022), mais de dois vasos coroná-rios com lesão > 50% (RR 1,82, IC 1,04-3,19; P = 0,011), lesão do tronco de coronária esquerda (RR 2,98, IC 0,97-9,17; P = 0,001), presença de angina instável (RR 2,48, IC 0,97-9,17; P = 0,0013) e presença de diabetes (RR 2,35, IC 1,21-4,55; P = 0,0015) foram as variáveis preditoras de ECAM. Conclusão: Os pacientes nonagenários demonstraram maior incidência de eventos cardiovasculares comparativamente aos pacientes mais jovens. No entanto, quando a técnica é factível e o paciente se encontra em condições ABSTRACT Percutaneous Coronary Intervention in Ninety-Year-Old PatientsBackground: Elderly people represent a significant part of the Brazilian population and the population > 90 years has tripled in the past three decades. This retrospective study was aimed at analyzing the results of percutaneous coronary intervention in ninety-year-old patients. Method: Overall, 31 ninety-year-old patients (G1) undergoing percutaneous coronary treatment from January 1995 to January 2009 were retrospectively evaluated. These patients were compared to 6,222 patients < 80 years of age (G2), treated within the same period. Clinical, angiographic and procedure characteristics were assessed as well as early and late major adverse cardiovascular events (MACE) (death, stroke, myocardial infarction, recurrent ischemia). Results: Ninety-yearold patients had a greater prevalence of diabetes, unstable angina, chronic comorbidities, three vessel coronary disease and left ventricular ejection fraction < 50%. Procedure success was different between both groups (87% vs. 95.1%; P = 0.049), as well as the incidence of in-hospi...
Objective: To evaluate the clinical efficacy of percutaneous renal revascularization with stenting to control hypertension and preserve/restore renal function in patients with atherosclerotic renovascular disease. Methods:From May/1999 to October/2003, 46 patients with atherosclerotic renal artery stenosis (ARAS) underwent revascularization with stenting. The indication for the procedure was hypertension control and/or renal function preservation/ restoration. Clinical characteristics: age range: 33-84 years (median = 58.5 ±10.7), males: 26 (56.5%), 4 (10%) patients with dia betes mellitus, 21 (46%) patients with coronary artery disease, creatinine <2.0mg/dl: 39 (64%), 6 patients (14%) with congestive heart failure, 20 (43%) patients with ostial stenosis and 15 (33%) patients with bilateral stenosis. Hypertension control was evaluated by the number of drugs used before the procedure and at follow-up (FU) and by blood pressure (BP) measurement. Results:The minimum follow-up was 7 months (range of 7-52, median: 23, mean: 24.2 ± 15.2). There were no major complications. No patient experience any cardiovascular event. There was only one non-cadiac death (2%) and one technical failure in the treatment(2%). There was no serious complication in the procedure. None of the patients presented cardiovascular events. The renal function improved or stabilized in 32 patients (82%) and worsened in 4 (10%). The BP control improved in 19/44 (43,8%) patients and worsened / stabilized in 6 patients (14%). Conclusion:Angioplasty with renal artery stenting for ARAS showed to be an effective treatment strategy to restore and preserve renal function and to control blood pressure. Atherosclerotic renal artery stenosis (ARAS) is one of the causes of systemic hypertension (SH) and renal failure 1-3 . Its real prevalence is unknown, but it is estimated that up to 5% of hypertensive patients have ARAS as the etiology of SH. The clinical relevance of ARAS has increased due to global longer life expectancy and higher prevalence of SH and diabetes mellitus 4,5 . In this group of patients, the simultaneous occurrence of atherosclerosis in different sites is very common 6 . A study carried out by Baboolal, in 1998, described the mortality, the rate of renal function decrease and the incidence of end-stage renal disease in 51 patients with bilateral ARAS, who were followed up during a mean of 52 months 7 . Such patients did not undergo percutaneous or surgical intervention. The evaluation of renal function showed impairment at the time of angiography and a variable, non-uniform decline during the observation period. After 5 years, there was a progressive increase in the incidence of end-stage renal disease (ESRD). Six out of 51 patients who were evaluated with angiography presented ESRD. The therapeutic resources for ARAS are the control of SH and other risk factors for cardiovascular events and renal revascularization, which can be achieved by surgery or angioplasty (with or without stent placement).Percutaneous revascularization techniques are...
Introdução: A avaliação da isquemia e viabilidade miocárdicas é recomendável antes da intervenção coronária percutânea (ICP) em oclusões crônicas. Avaliamos os eventos cardiovasculares adversos tardios de pacientes com ICP da oclusão crônica no segmento proximal da artéria descendente anterior, comparando pacientes de acordo com a presença ou não de isquemia ou viabilidade miocárdicas. Métodos: Os pacientes foram alocados nos grupos com isquemia/viabilidade miocárdicas (G1, n = 91) e sem isquemia/viabilidade miocárdicas (G2, n = 65) e avaliados os eventos clínicos combinados tardios (óbito, infarto do miocárdio, revascularização do vaso-alvo e insuficiência cardíaca congestiva). Resultados: A maioria dos pacientes era do sexo masculino (68,1% vs. 69,2%; P = 0,56), com média de idade de 65,4 ± 10,4 anos vs. 63,5 ± 8,7 anos (P = 0,61), e quase um terço era de diabéticos (33% vs. 29,2%; P = 0,76). Os grupos não mostraram diferenças em relação ao perfil clínico-angiográfico, com exceção da fração de ejeção do ventrículo esquerdo (48,6 ± 13,7% vs. 39,5 ± 11,8%; P = 0,04) e do grau de circulação colateral para a artéria descendente anterior, mais evidente no G1 (P = 0,03). A incidência de eventos clínicos combinados em um período de três anos foi menor nos pacientes com isquemia/viabilidade miocárdicas ABSTRACT Background: Evaluation of myocardial ischemia and viability is recommended prior to percutaneous coronary intervention (PCI) for chronic total occlusions. We evaluated late adverse cardiovascular events of patients with PCI for proximal left anterior descending artery occlusions, comparing patients with or without myocardial ischemia or viability. Methods: Patients were allocated to groups with myocardial ischemia/ viability (G1, n = 91) and without myocardial ischemia/ viability (G2, n = 65) and adverse cardiovascular events (death, myocardial infarction, target-vessel revascularization and congestive heart failure) were compared. Results: Most patients were male (68.1% vs 69.2%; P = 0.56), with a mean age of 65.4 ± 10 years vs 63.5 ± 8.7 years (P = 0.61) and almost one third were diabetics (33% vs 29.2%; P = 0.76). No differences regarding the clinical and angiographic profile were observed, except for the left ventricular ejection fraction (48.6 ± 13.7% vs 39.5 ± 11.8%; P = 0.04) and the degree of angiographic collateral flow grade to the left anterior descending artery, which was more evident in G1 (P = 0.03). The 3-year follow-up incidence of composite adverse cardiovascular events was lower in patients with myocardial ischemia/viability (12.5% vs 31.1%; P < 0.01). The factors that contributed the most for this difference were the incidence of congestive heart failure (3.3% vs 15.3%; P = 0.02) and death (2.2% vs 7.7%; P = 0.13). Conclusions: Treatment of proximal left anterior descending artery chronic total occlusions in patients with evidence of
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