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Biomedical subjects

G S Roubin

Publications and source records attributed to G S Roubin.

At least 109 records · Page 6Linked to original sources
PubMed1992

Usefulness of serum lipoprotein (a) as a predictor of restenosis after percutaneous transluminal coronary angioplasty.

Serum lipoprotein (a) (Lp[a]) has been associated with coronary artery atherosclerosis. Its association with restenosis after percutaneous transluminal coronary angioplasty (PTCA) has not been previously studied. Serum levels of Lp(a), in addition to other lipoproteins, and their components using standard assays, were determined in subjects undergoing cardiac catheterization within 10 months after PTCA. Clinical (e.g., sex, diabetes, angina class) and angiographic (e.g., PTCA percent diameter reduction) factors were not different between the group without (diameter reduction less than 50%; group A) and the group with (diameter reduction greater than or equal to 50%; Group B) restenosis. Total cholesterol, triglycerides, high- and low-density lipoprotein cholesterol, apolipoprotein A-I, apolipoprotein B and Lp(a) were compared. Univariate predictors of restenosis were serum triglycerides (2.50 +/- 1.07 mmol/liter for group A vs 1.72 +/- 0.79 +/- mmol/litre for group B, p = 0.008), and Lp(a) (median: 7.0 mg/dl [range 0 to 44] for group A vs 19 mg/dl [range 1 to 120] for group B; p = 0.006). Stepwise logistic regression revealed the only significant independent predictor of restenosis to be serum Lp(a) (p = 0.018). Each quintile of Lp(a) was associated with a progressively higher risk of restenosis, with the highest quintile (40 to 120 mg/dl) having an odds ratio of 11 (95% confidence interval 9 to 13) compared with the lowest quintile (0 to 3.9 mg/dl) (p = 0.033). A serum Lp(a) of greater than 19 mg/dl was associated with an odds ratio of 5.9 (95% confidence interval 4.6 to 7.2) (restenosis rates of 58% in the group with 0 to 19 mg/dl and 89% in the group with 19 to 120 mg/dl; p = 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Nonsurgical closure of femoral pseudoaneurysms complicating cardiac catheterization and percutaneous transluminal coronary angioplasty.

OBJECTIVES: This study was performed to describe the initial experience and follow-up of ultrasound-guided compression of pseudoaneurysms in patients receiving systemic anticoagulant or antiplatelet therapy, or both, after recent cardiac catheterization or percutaneous transluminal coronary angioplasty. BACKGROUND: Femoral artery pseudoaneurysm formation after an interventional procedure is becoming more common as larger caliber catheters and prolonged anticoagulant and antiplatelet therapy are being used. Traditional treatment of this complication has been surgical repair. This study describes a new method of closing femoral pseudoaneurysms by using external compression guided by Doppler color flow imaging. METHODS: Fifteen patients, 3 undergoing cardiac catheterization and 12 undergoing coronary angioplasty, developed an expansile groin mass at the vascular access site diagnosed as a femoral artery pseudoaneurysm by Doppler ultrasound. Seven of the patients had undergone coronary stenting and were receiving postprocedural anticoagulant therapy. These patients underwent progressive graded mechanical (C-clamp) external compression guided by ultrasound. The mechanical compression was titrated to obliterate the vascular tracts to these aneurysms and maintain adequate flow in the femoral artery. RESULTS: After an average compression time of 30 min (range 10 to 120), these tracts remained closed. Follow-up ultrasound examination at 24 h or later confirmed continued closure in all. CONCLUSIONS: This study suggests that nonsurgical closure of femoral pseudoaneurysms is feasible. This technique may be valuable in managing vascular access-related complications after diagnostic and interventional procedures, even in patients requiring prolonged anticoagulant therapy.

Adult↗
PubMed1992

Vascular pathology of balloon-expandable flexible coil stents in humans.

The morphologic changes in atherosclerotic coronary arteries and saphenous vein bypass grafts after placement of a balloon-expandable flexible coil stent (Cook) are described. In each case, the vessels were patent despite morphologic evidence of injury and dissection in the vessel wall. The stented region was reendothelialized and the tissue overlying the stent wires consisted primarily of smooth muscle cells. There was minimal inflammatory reaction to the stent wires. These findings suggest that the balloon-expandable flexible coil stent can effectively maintain vessel patency even in the setting of postangioplasty lumen disruption. In addition, the vessels tolerate the metal prosthesis with little evidence of tissue inflammatory reaction.

Aged↗
PubMed1992

Vitamin E supplementation, plasma lipids and incidence of restenosis after percutaneous transluminal coronary angioplasty (PTCA).

To test whether alpha-tocopherol prevents restenosis following percutaneous transluminal coronary angioplasty (PTCA), we enrolled patients in a double-blind, placebo-controlled trial. Patients were randomized after successful PTCA to receive vitamin E in the form of dl-alpha-tocopherol, 1200 IU/day, orally vs an inactive placebo for 4 months. Patients' blood was analyzed at baseline and at 4 months post-PTCA for differences in plasma lipids, lipoproteins, apolipoproteins, alpha-tocopherol, retinol, beta-carotene and lipoperoxide concentrations. One hundred patients completed the protocol. No significant difference was found in any parameter except alpha-tocopherol level between the vitamin E group and the placebo group, verifying compliance. Follow-up cardiac catheterization was obtained in 83% of the patients receiving placebo and in 86% of the patients receiving dl-alpha-tocopherol. Including thallium and exercise stress testing, objective information was obtained for practically all the patients receiving dl-alpha-tocopherol or placebo. Restenosis was defined as the presence of a lesion with greater than or equal to 50% stenosis in a previously dilated artery segment and results were analyzed with respect to pre- and post-PTCA artery diameter, vessel diameter at follow-up, and restenosis rate. Patients receiving dl-alpha-tocopherol had a 35.5% restenosis angiographically documented vs 47.5% restenosis in patients receiving the placebo. The overall incidence of restenosis defined by an abnormal angiogram or thallium test or exercise stress test was 34.6% in patients receiving dl-alpha-tocopherol and 50% in patients receiving the placebo. This difference (p = 0.06) did not reach significance because of an inadequate sample size.

Angioplasty, Balloon, Coronary↗
PubMed1992

Intracoronary stenting for acute and threatened closure complicating percutaneous transluminal coronary angioplasty.

BACKGROUND. Acute closure remains a significant limitation of percutaneous transluminal coronary angioplasty (PTCA) and underlies the majority of ischemic complications. This study details the clinical and angiographic characteristics of a series of patients receiving an intracoronary stent device to manage acute and threatened closure and presents the early clinical results. METHODS AND RESULTS. From October 1989 through June 1991, 115 patients undergoing PTCA received intracoronary stents to treat acute or threatened closure in 119 vessels. Sixty-three percent had multivessel coronary disease, 33 (29%) had undergone prior coronary artery bypass grafting (CABG), and 52 (45%) had had previous PTCA. Using the American College of Cardiology/American Heart Association (ACC/AHA) classification, 15% of lesions were class A, 55% were class B, and 30% were class C. Eight patients were referred with severe coronary dissection and unstable angina after PTCA at other institutions. Acute closure was defined as occlusion of the vessel with TIMI (Thrombolysis in Myocardial Infarction) 0 or 1 flow immediately before stent placement. Threatened closure required two or more of the following criteria: 1) a residual stenosis greater than 50%, 2) TIMI grade 2 flow, 3) angiographic dissection comprising extraluminal dye extravasation and/or a length of greater than 15 mm, 4) evidence of clinical ischemia (either typical angina or ECG changes). Twelve vessels (10%) met the criteria for acute closure, and 87 vessels (73%) satisfied the criteria for threatened closure. Twenty vessels (17%) failed to meet two criteria. Stenting produced optimal angiographic results in 111 vessels (93%), with mean diameter stenosis (+/- 1 SD) reduced from 83 +/- 12% before to 18 +/- 29% after stenting. Overall, in-hospital mortality was 1.7% and CABG was required in 4.2%; Q wave myocardial infarction (MI) occurred in 7% and non-Q wave MI in 9%. Stent thrombosis occurred in nine patients (7.6%). For the 108 patients who presented to the catheterization laboratory without evolving MI, Q wave MI occurred in 4% and non-Q wave MI occurred in 7%. Angiographic follow-up has been performed in 81 eligible patients (76%), and 34 patients (41%) had a lesion of greater than or equal to 50%. CONCLUSIONS. This stent may be a useful adjunct to balloon dilatation in acute or threatened closure. Randomized studies comparing this stent with alternative technologies are required.

Angioplasty, Balloon, Coronary↗
PubMed1991

Causes and correlates of death after unsupported coronary angioplasty: implications for use of angioplasty and advanced support techniques in high-risk settings.

To better understand the factors predisposing a patient to death after elective percutaneous transluminal coronary angioplasty (PTCA) and to gain insight into indications for high-risk PTCA both with and without adjunctive use of support devices, the outcomes of 8,052 consecutive procedures were reviewed. Death occurred after 32 procedures (0.4%) and was directly related to coronary artery closure in 26 (81%) of these cases. Left ventricular failure due to vessel closure at the dilated site, the most common cause of death, was independently correlated with female sex (p less than 0.001), "jeopardy score" (p less than 0.001) and PTCA of a proximal right coronary artery site (p = 0.002), but not with left ventricular ejection fraction or presence of multivessel disease. Right ventricular failure after closure of the proximal right coronary artery, and left main coronary dissection accounted for the majority of the remaining deaths. Systolic blood pressure immediately after coronary artery closure was also closely correlated with jeopardy score, and cardiogenic shock was frequent in women with scores greater than or equal to 3.5 and in men with scores greater than or equal to 5.0. These data highlight the superiority of the jeopardy score versus ejection fraction in the determination of risk, stress the importance of gender in determining outcome and point to the need for better means of right ventricular protection from severe ischemia. Therefore, an initial framework for rational use of PTCA and support devices in the high-risk setting is established.

Aged↗
PubMed1991

Coronary aneurysms after stent placement: a suggestion of altered vessel wall healing in the presence of anti-inflammatory agents.

Coronary aneurysms are rare after conventional angioplasty and have not been reported after coronary stenting. Coronary artery stent sites were examined by follow-up angiography at a median of 4 months in 29 patients who received the Cook stent (Gianturco-Roubin) for acute coronary closure. Nineteen patients were treated with glucocorticoids administered intravenously or orally, or both, with or without colchicine and results were compared with those in 10 patients who were treated with neither agent. Standard therapy for all patients included routine administration of aspirin and heparin before and warfarin sodium (Coumadin) and aspirin after stent placement. Most patients also received dipyridamole and lovastatin during the follow-up period. Compliance with medications was confirmed by telephone conversation with each patient. Six (32%) of the 19 stented arteries showed evidence of coronary artery aneurysm, defined as expansion of the lumen outside the margins of the stent. None of the patients in the control group (who did not receive steroids or colchicine) developed aneurysm. This pattern of altered vascular healing in stented coronary segments appears to be due to the addition of multiple anti-inflammatory drugs rather than to stent presence alone. This observation demonstrates the possibility of medical impairment of normal vascular remodeling after acute injury and stent placement, which may be of benefit in designing future trials on restenosis.

Adult↗
PubMed1991

Effects of nonionic versus ionic contrast media on complications of percutaneous transluminal coronary angioplasty.

To evaluate the effect of contrast agents on percutaneous transluminal coronary angioplasty (PTCA) complications, 913 patients undergoing 1,058 separate PTCA procedures were prospectively randomized to receive either nonionic iopamidol (Isovue-370) [n = 507 PTCA procedures] or ionic contrast media, meglumine sodium diatrizoate (Renografin-76) [n = 551 PTCA procedures]. Angioplasty operators, technicians, nurses and patients were blinded to the agent used. All patients were pretreated with 0.6 mg of atropine sulfate intravenously before any contrast injections. Hypotension (mean arterial pressure less than 65 mm Hg associated with contrast injections) occurred during 8.5% of PTCA procedures in which the patients were receiving iopamidol and during 9.5% of the procedures in which the patients were given diatrizoate (difference not significant). Bradycardia (heart rate of less than 40 beats/min associated with contrast injections) developed during 5.7% of procedures when patients were given iopamidol and during 5.1% of procedures when patients were given diatrizoate (difference not significant). The need for additional atropine or temporary pacing during the procedure was similar for patients given iopamidol and diatrizoate. The overall incidence of ventricular tachycardia or fibrillation, or both, during the procedure occurred less frequently when iopamidol was used compared with diatrizoate (1 vs 2.5%, p = 0.045). These serious ventricular arrhythmias were attributable to contrast injections in 0.6% of the PTCA procedures when iopamidol was given and in 2.0% of the cases in which diatrizoate was the contrast agent (p = 0.09). Only 1 patient had an allergic reaction to the contrast agent, and this was in a patient who received iopamidol.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

Intravascular stenting of the right internal mammary artery.

Despite its tortuous course and small caliber, percutaneous transluminal coronary angioplasty of the internal mammary artery can be performed with a high initial success rate (82-94%). The successful deployment of a balloon expandable coil stent at the mid-right internal mammary artery in a patient with recurrent stenosis of that graft is reported.

Angioplasty, Balloon, Coronary↗
PubMed1991

The coronary artery response to implantation of a balloon-expandable flexible stent in the aspirin- and non-aspirin-treated swine model.

Intracoronary stents may potentially alleviate some of the problems associated with coronary angioplasty. Since the anatomy and physiology of swine coronary arteries closely resemble those of humans, the response to implantation of the Glanturco-Roubin, balloon-expandable, flexible stent was studied in this model. Additionally, the effect of aspirin, 1 mg/kg/day orally, on this response was evaluated. Eighteen Hanford minature swine underwent stenting of the left anterior descending coronary artery. Two died within 24 hours of stent implantation. The 16 survivors were put to death at 4 (n = 4), 11 (n = 4), 28 (n = 4), 56 (n = 3), and 180 (n = 1) days. Angiographically, reduction of stent lumen diameter of 0.1 to 1.3 mm was observed and was maximum at 11 days, with gradual improvement at subsequent time periods. Scanning electron microscopy, transmission electron microscopy, and light microscopy showed early disruption of subjacent endothelium, and adherence of platelets to exposed subendothelium and stent wires. Microthrombi were readily apparent. At 11 days, intimal thickening, made up predominantly of smooth muscle cells with abundant extracellular matrix, was observed and covered the stent wires. At 28 days, regression of intimal thickening was apparent and a confluent endothelium with flow-directed orientation was seen. At 56 and 180 days, the luminal surface was smooth; intimal thickening averaged 525 microns over the stent wires and 55 microns away from the wires. Findings in aspirin-treated animals were similar to results in those that did not receive aspirin. Thus in this swine model, stent implantation results in a time-dependent and self-limited vascular response.

Angioplasty, Balloon, Coronary↗
PubMed1991

Early outcome after placement of a metallic intracoronary stent: initial Mayo Clinic experience.

After percutaneous transluminal coronary angioplasty, 3 to 7% of patients have in-hospital coronary closure, and the risk of subsequent myocardial infarction is high, even with an urgent bypass operation. Disrupted coronary morphologic integrity, particularly with large dissections, may be associated with an increased risk of acute coronary closure. A percutaneously placed coronary vascular stent may rapidly alleviate acute or threatened coronary closure and could reduce morbidity. Between October 1989 and June 1990, placement of a balloon-expandable, flexible metallic coil (Gianturco-Roubin) coronary stent was attempted 16 times in 15 Mayo Clinic patients--for treatment of actual or threatened abrupt coronary closure in 10 patients, for primary treatment of a lesion judged to be at high risk for dissection with conventional balloon angioplasty in 1, and for elective treatment of restenotic lesions in 5. Placement of the stent was successful in 15 attempts (94%). Associated complications, which were uncommon, were similar to those noted after balloon angioplasty. No early deaths occurred, and no patient required coronary artery bypass grafting. Stents were successfully placed in both urgent and elective circumstances in native coronary arteries and saphenous vein grafts, and they were used in primary atheromatous and restenotic lesions. Our initial experience with this metallic coil stent indicates that it is efficacious for vascular disruption that is threatening or causing coronary closure after angioplasty. Furthermore, elective placement of a stent may be safely undertaken in patients with high-risk coronary lesions or recurrent restenotic lesions. The long-term outcome in all groups of patients who receive coronary stents is unknown.

Adult↗
PubMed1990

Predictive value of lipoprotein (a) and other serum lipoproteins in the angiographic diagnosis of coronary artery disease.

To determine the relation among lipids in predicting coronary artery disease (CAD), 213 patients undergoing diagnostic angiography for suspected CAD were prospectively studied. Twenty-one patients had normal coronary arteries and 192 had CAD in 1 to 3 arteries at arteriography with measurements obtained with digital calipers. Lipoproteins were measured and lipoprotein (a) [Lp(a)] was also assayed in a subset of 98 patients with CAD. Statistical analysis was performed using uni- and multivariate techniques to test the association among age, gender, systemic hypertension, diabetes mellitus, cigarette smoking, family history, total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, very low density lipoprotein cholesterol, apolipoproteins (apo) A-I and apo B, ratio of apo A-I to apo B, and ratio of HDL cholesterol to total cholesterol, to Lp(a) and to CAD. All factors except gender, systemic hypertension, diabetes mellitus and cigarette smoking were univariate predictors of CAD. Multivariate predictors were, in decreasing order of significance, family history, age, HDL/total cholesterol ratio and apo B. When Lp(a) was included, multivariate predictors were age, family history, apo B and Lp(a), in that order. Lipid parameters alone showed that the HDL/total cholesterol ratio and that Lp(a) provide the best predictive tests for the detection of CAD in this referral population and may ultimately become important screening tests for CAD.

Coronary Angiography↗
PubMed1990

Effect of pretreatment with aspirin versus aspirin plus dipyridamole on frequency and type of acute complications of percutaneous transluminal coronary angioplasty.

It is unknown whether the addition of dipyridamole to aspirin as pretreatment for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) decreases acute complications. In this study 232 patients were prospectively randomized to receive either aspirin 325 mg orally 3 times daily (group 1, n = 115) or aspirin 325 mg orally 3 times daily plus dipyridamole 75 mg orally 3 times daily (group 2, n = 117) before elective PTCA. All clinical, angiographic and PTCA-related variables were similar between groups. Angiographic success rate was 93% in both groups. Clinical success was achieved in 107 patients (92%) in group 1 and in 101 patients (88%) in group 2 (difference not significant). Q-wave myocardial infarction occurred in 2 patients (1.7%) in group 1 and 5 patients (4.3%) in group 2 (difference not significant). Emergency coronary artery bypass grafting was required in 3 patients (2.6%) in group 1 and 7 patients (6.1%) in group 2 (difference not significant). There was 1 in-hospital death (in group 2). In this study, the addition of dipyridamole to aspirin as pretreatment of patients undergoing PTCA did not significantly reduce acute complications compared to aspirin alone.

Angioplasty, Balloon, Coronary↗
PubMed1990

Usefulness of coronary angioplasty in asymptomatic patients.

Of 6,545 patients who had elective coronary angioplasty procedures performed over a 7.5-year period from June 1980 through December 1987, 114 (1.7%) never had symptoms of myocardial ischemia. Exercise-induced silent myocardial ischemia was documented before angioplasty in 94% of these asymptomatic patients. Angioplasty was successful in 87%, whereas emergency coronary artery bypass grafting was required in 4%, and a further 2% had myocardial infarctions after the procedures. The remaining 7% had unsuccessful angioplasty procedures but experienced no in-hospital cardiac events. The follow-up period after hospital discharge averaged 43 +/- 20 months (range 5 to 93). There were no deaths. In the group of 99 patients with initially successful angioplasty procedures the follow-up interval ranged from 5 to 92 months. During that period, 7 patients underwent coronary bypass surgery, 4 patients had myocardial infarction and 30 patients had repeat angioplasty procedures for restenosis. The cumulative probability of event-free survival over 5 years for the group with successful angioplasty was: 100% freedom from death, 95% freedom from myocardial infarction, 87% freedom from myocardial infarction or coronary bypass surgery and 61% freedom from myocardial infarction, coronary bypass surgery or repeat angioplasty. Thus, coronary angioplasty performed in 114 asymptomatic patients, most with exercise-induced silent myocardial ischemia, achieved very good primary success and was accompanied by low cardiac event rates and no deaths over several years of patient follow-up.

Angioplasty, Balloon, Coronary↗