Images in cardiology. Unusual case of coronary-subclavian steal syndrome.
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Coronary Angiography↗
Biomedical subjects
J Reimers
Publications and source records attributed to J Reimers.
[Percutaneous revascularization of multivessel coronary disease using stents - a multicenter, prospective study].
BACKGROUND AND OBJECTIVE: Symptomatic patients with multivessel coronary disease (MVD) benefit from both coronary artery bypass grafting (CABG) and percutaneous coronary angioplasty (PTCA). The >>German Angioplasty Bypass Investigation<< (GABI-I) trial randomized patients to one of these treatment strategies between 1986 and 1991. In order to evaluate the impact of current technology, in particular coronary stents, the GABI-II trial was initiated, which in 1996 and 1997 prospectively enrolled patients according to the initial GABI-I criteria. PATIENTS AND METHODS: Into the study 136 consecutive patients (108 men, 28 women; 63 +/- 12 years) were included. Patients from GABI-I served as controls. RESULTS: A mean of 2.1 +/- 0.5 vessels were treated per patient (vs. 1.9 +/- 0.5 vessels in the PTCA arm of GABI-I) and 63 % of the lesions were covered with stents. With respect to the primary endpoint less patients remained with a CCS class III or IV in GABI-II after 12 months (1,5 % vs. 8 % in the PTCA arm of GABI-I, p<0,01). No patient required emergency or urgent bypass operation in GABI-II (vs. 9 % in GABI-I, p < 0.01). After 12 months, 8 % of the patients were sent for bypass surgery (CABG) vs. 21 % in GABI-I (p < 0.001), and 20 % (vs. 23 % in GABI-I) of the patients underwent Re-PTCA. The percentage of patients without reinterventions was 72 % vs. 56 % in GABI-I (p < 0.01), but remained lower compared to patients randomized to CABG in GABI-I (94 %, p < 0.001). CONCLUSION: PTCA in patients with MVD is still associated with a higher reintervention rate as compared with CABG. However, in contrast to angioplasty a decade ago, PTCA in conjunction with stents significantly lowered the need for subsequent revascularization, which was mainly driven by the reduced necessity for bypass surgery.
Aged↗
Membrane-covered stents: a new treatment strategy for saphenous vein graft lesions.
The restenosis rate after stenting of lesions in aortocoronary venous bypass grafts still has to be considered unsatisfactorily high. We investigated a new stent design characterized by an expandable polytetrafluorethylene (PTFE) membrane in between two layers of struts. Five consecutive male patients (age 70 +/- 6 years) were followed prospectively who presented with at least two de novo lesions in different grafts 13 +/- 3 years after bypass surgery. A total of 11 lesions were treated located in grafts anastomosed to the circumflex (n = 3), to the LAD (n = 7), and to the right coronary artery (n = 1). Within the same procedure, every patient received membrane-covered stents (n = 6) and conventional stents (n = 5) in either of their lesions. All patients underwent successful interventions. The minimal luminal diameter increased from 1.0 +/- 0.5 to 2.9 +/- 0.6 mm in lesions treated by the membrane-covered stents and from 0.8 +/- 0.4 to 2.4 +/- 0.7 mm in the lesions treated by conventional stents. During follow-up, four out of five patients required angioplasty for in-stent restenosis of lesions covered by a conventional stent, whereas no patient underwent revascularization for a lesion treated by a membrane-covered device. The mean minimal luminal diameter of lesions covered by a conventional stent decreased by 42% to 1.4 +/- 0.6 mm; the mean minimal luminal diameter of the lesions treated by a stent graft declined by 9% to 2.8 +/- 0.6 mm (P < 0.05). This series of intraindividual comparisons suggests that membrane-covered stents may have the power to reduce in-stent restenosis in obstructed aortocoronary venous bypass grafts.
Aged↗
Initial experience with a hydrophilic-coated guidewire for recanalization of chronic coronary occlusions.
Chronic coronary occlusions are still a therapeutic challenge to the interventional cardiologist. New techniques such as laser wire have improved recanalization rates, but outcomes are still far from satisfactory. We report the results of a nonrandomized single-center investigation using a hydrophilic-coated guidewire (Terumo Crosswire). Between September 1996 and September 1998, 107 chronic occlusions in 106 patients were approached when previous attempts with conventional guidewires failed. Median occlusion duration in these cases was 4 months (range, 0.5-122); mean occlusion length was 19 +/- 11 mm (range, 5-60). Forty-five (42%) of these attempts were successful. Attempts were successful in 42% in the left anterior descending artery, in 30% in the left circumflex artery, in 48% in the right coronary artery, and in 43% in coronary artery bypass grafts. Success rates ranged from 56% for occlusions of less than 4-month duration to 18% for occlusions of more than 36-month duration. The success rate in TIMI 1-flow lesions was significantly higher than in TIMI 0 flow lesions, 85% vs. 36%. In a multivariate regression analysis, TIMI flow grade and occlusion age were independent predictors of success. There were no deaths or Q-wave myocardial infarctions; two cases of hemopericardium were treated successfully. In five cases, pericardial contrast staining due to vessel perforation occurred. Our results indicate that the Crosswire is an effective tool in the treatment of chronic coronary occlusions, even when recanalization attempts with conventional guidewires fail. Cathet. Cardiovasc. Intervent. 49:45-50, 2000.
Adult↗
Membrane-covered stents for the treatment of aortocoronary vein graft disease.
We report of a 78-year-old patient who underwent angioplasty for two de novo lesions in different aortocoronary venous bypass grafts. Whereas one lesion was treated by conventional stents, two adjacent lesions in a second bypass graft were covered by two newly designed stents with a polytetrafluorethylene (PTFE) membrane in between two layers of struts. The patient was first readmitted at month 5 with recurrent angina pectoris. High-grade in-stent restenosis of the lesion covered by the conventional stent was diagnosed, whereas the lesions treated by the membrane-covered stent revealed no restenosis. The patient underwent subsequent balloon angioplasty and was readmitted with unstable angina 8 months after the initial procedure. The angiogram revealed subtotal occlusion of the vein graft due to diffuse in-stent restenosis within the conventional stent. Undergoing re-PTCA, the patient received an additional membrane-covered stent placed over the proximal device. For the following 7 months, the patient stayed asymptomatic and underwent elective reangiography, which revealed a satisfying long-term result with no relevant luminal loss at the target site. This intraindividual comparison of stents in aortocoronary vein grafts suggests that PTFE membrane-covered stents might reduce restenosis as compared to conventional stents in venous bypass grafts. Furthermore, these stents potentially represent a new treatment strategy to fight in-stent restenosis in selected lesions.
Aged↗
Six-month clinical and angiographic outcome after successful excimer laser angioplasty for in-stent restenosis.
OBJECTIVES: This study evaluated the clinical and angiographic six-month follow-up after excimer laser coronary angioplasty (ELCA) for restenosed coronary stents. BACKGROUND: Excimer laser coronary angioplasty has recently been shown to be safe and efficient for the treatment of in-stent restenosis. METHODS: Ninety-six consecutive patients successfully treated with ELCA within 141 stents were included in a six-month clinical and angiographic follow-up. RESULTS: During follow-up there was one sudden death and one patient with documented myocardial infarction. Angina pectoris classified as > or = Canadian Cardiovascular Society II reoccurred in 49 patients. Follow-up angiography was obtained in 89 patients (93%) with 133 stents. Quantitative coronary angiography revealed a mean diameter stenosis of 77 +/- 10% before intervention, 41 +/- 12% after laser treatment and 11% +/- 12% after adjunctive percutaneous transluminal coronary angioplasty (p < 0.001). Six months after ELCA the mean diameter stenosis had increased to 60 +/- 26% (p < 0.001). A > or =50% diameter stenosis was present in 48 patients (54%); in 24 of these patients diameter stenosis was > or =70%. Total occlusions occurred in an additional 10 patients (11%). There was a trend toward an increased recurrent restenosis rate in patients with diabetes mellitus and long lesions or total occlusions (p = 0.059). Forty-eight patients (50%) received medical treatment after six months. Reinterventions were necessary in 30 patients (31%), and coronary artery bypass surgery was performed in 17 patients (18%). Event-free survival was 50%. CONCLUSIONS: Excimer laser angioplasty for in-stent restenosis was associated with a high incidence of recurrent restenosis in this group of patients, suggesting that this technique is unlikely to reduce recurrent in-stent restenosis and that other approaches are necessary.
Adult↗
Protection of side-branches in coronary lesions with a new stent design.
Side-branches often complicate stenting of coronary lesions. We investigated a new stent, characterized by four wider cells in its center, which can be expanded up to 3.5 mm and which are meant to be placed over the ostium of a major side-branch. Forty-seven consecutive patients with lesions involving 48 side-branches received one side-branch stent each. Stent deployment was successful in all patients. Twenty-five side-branches needed additional treatment. Nineteen side-branches received a PTCA, and 6 additional side-branches were stented. Postinterventional CK-(creatine kinase) elevation was observed in 3 patients (6%). One additional patient was sent for CABG on the day of the procedure due to loss of a stent intended to be placed into the side-branch. The investigated stent proved to be a safe and effective tool to treat this complex subgroup of stenoses in the presence of favorably preserved flow in the side-branches, with a low incidence of periprocedural complications.
Angioplasty, Balloon, Coronary↗
[Acute results of ablation of coronary in-stent restenoses with eccentric excimer laser catheters].
UNLABELLED: Laser catheters which run eccentrically on a guide wire were developed for maximization of luminal gain by excimer laser angioplasty (ELCA). We investigated the safety and efficacy of ELCA with these new catheters plus PTCA in patients with restenoses or occlusions in coronary stents. ELCA was performed in 57 patients (60 +/- 9 years) with stenoses in 75 stents (35 AVE Micro stents, 26 Palmaz-Schatz stents, 7 NIR stents, 7 other stents). In 44 patients eccentric 1.7 mm catheters and in 13 patients 2.0 mm catheters were used. The success of the intervention was analyzed by intravascular ultrasound (IVUS) in a subgroup of 7 patients treated with five 1.7 mm and two 2.0 mm catheters. The laser catheters could be advanced through the in-stent restenoses in 56 patients. A passage inhibition occurred in one patient with an inadequately expanded stent < 2.0 mm in diameter. ELCA reduced the diameter stenoses from 77 +/- 10% before intervention to 44 +/- 8% after treatment with the 1.7 mm catheter (n = 43) or to 34 +/- 9% after passages with the 2.0 mm catheter (P < 0.001). PTCA further reduced the diameter stenosis to 11 +/- 12% (P < 0.001). The IVUS analysis revealed a smooth ablation profile in all patients. In 4 patients creatine kinase elevations > or = 2 times normal value occurred. There was no evidence of a Q-wave infarction. No dissections were observed within the stents. Outside of the stents there were dissections in 5 vessels, which required the implantation of additional stents. CONCLUSIONS: ELCA with eccentric laser catheters for treatment of in-stent restenosis is safe and effective. The incidence of complications is acceptable.
Adult↗
Treatment of in-stent coronary restenosis by excimer laser angioplasty.
We evaluated the efficacy and safety of excimer laser angioplasty (ELCA) with adjunctive balloon angioplasty in patients with restenotic or occluded coronary stents. ELCA was performed in 70 patients (60 +/- 9 years), who had previously been treated with Micro Stents (n = 65), Palmaz-Schatz (n = 38), Wiktor, NIR, Freedom, and Multi-Link stents (n = 1 each). Restenosis (> or =50% diameter stenosis) was documented in 90 stents, another 17 stents were occluded. Laser energy was delivered to the lesions with catheters 1.4, 1.7 (eccentric), and 2.0 mm in diameter. Procedural success was controlled by intravascular ultrasound in a subgroup. Laser catheters crossed all restenotic or occluded stents and decreased diameter stenosis from 80 +/- 13% to 44 +/- 11% (p <0.001). Adjunctive balloon angioplasty further reduced diameter stenosis to 13 +/- 13% (p <0.001). In 13 patients with 21 stents, serial intravascular ultrasound imaging revealed a reduction of plaque area within the stent by 34 +/- 22% (from 4.2 +/- 1.8 mm2 to 2.7 +/- 1.1 mm2) after ELCA and a reduction by 65 +/- 16% (to 1.5 +/- 0.7 mm2) after balloon angioplasty (p <0.01). There were 4 patients with an increase of creatine kinase levels, 8 patients with major dissections (in 7 patients they were related to adjunctive balloon angioplasty), 1 patient with distal embolization, 2 with minor perforations, and 1 patient with stent dislocation. Reintervention during hospitalization was necessary in 3 patients. ELCA is an efficient and safe technique to debulk tissue in restenotic lesions and total occlusions within stents. The incidence of procedure related complications was low.
Adult↗
Intravascular therapeutic ultrasound thrombolysis in acute myocardial infarctions.
Catheter-delivered, therapeutic ultrasound was shown to effectively dissolve thrombus in vitro and in vivo. This first study in 14 patients with acute myocardial infarctions demonstrates that it is a safe and effective treatment alternative that deserves further clinical evaluation.
Adult↗
Models of metabolism in Rhizopus oryzae.
A flux analysis of glucose metabolism in Rhizopus oryzae was achieved using [14C]-labeled glucose and acetate. The rates of glucose utilization and end product production were estimated, and metabolite pool sizes and specific radioactivities were determined. These data were analysed using a specific radioactivity curve-matching program called TFLUX. The analysis is consistent with the existence of separate mitochondrial and cytosolic pools of pyruvate, malate and fumarate.
Acetates↗
Angiographic follow-up results of a randomized study on angioplasty versus bypass surgery (GABI trial). GABI Study Group.
Although several randomized trials have been performed to compare the outcomes of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass surgery (CABG) in patients with multivessel disease, there is little data available on angiographic follow-up results. The present substudy of the German angioplasty versus bypass surgery investigation (GABI Trial) compares the angiographic revascularization status in these two cases 6 months after treatment. Follow-up angiograms were available in 102 CABG patients and 117 PTCA patients. Although the protocol excluded patients with total occlusion, on follow-up 6 months after treatment we found total occlusion of 94 native arteries (36.9%) in the CABG group and of six arteries (2.5%) in the PTCA group (P < 0.001). The rate of occluded native vessels did not correlate significantly with the severity of the lesion before bypass surgery. In the CABG group 31 bypass grafts (12.2%) were found to be occluded at the 6 month follow-up examination (29/225 vein grafts [12.9%]; 2/30 mammary artery grafts [6.7%]). The main pathway, defined as the nutrient vessel (native vessel or bypass graft) providing the least resistance to blood flow, was narrowed by a lesion with a diameter stenosis of 70-100% for 36 target lesions (14.1%) in the CABG group and 39 target lesions (16.2%) in the PTCA group (P, ns). However, the prevalence of moderately severe lesions with a 50-69% diameter reduction of the main pathway was significantly greater in the PTCA group (44 lesions, 18.3%) than in the CABG group (19 lesions, 7.5%, P < 0.01). Thus, 6 months after randomized allocation to PTCA or CABG, we found comparable rates of high-grade lesions in the main pathways of both treatment groups. Whereas moderately severe lesions of the main pathway were predominantly seen in the PTCA group, there was marked disease progression to total occlusion in the native circulation after bypass grafting.
Aged↗
[Preliminary clinical results with intracoronary ultrasound angioplasty].
UNLABELLED: BASIS AND AIM OF STUDY: Low-frequency, high-intensity ultrasound has been shown, both in vivo and in vitro, selectively to remove arteriosclerotic plaques and thrombi. This study was undertaken to investigate the safety and effectiveness of intracoronary ultrasound angioplasty. PATIENTS AND METHODS: Ultrasound coronary angioplasty (UCA) with highly flexible ultrasound catheters (1.2 mm or 1.7 mm probe tip) was performed in 50 patients (36 men, 14 women; mean age 64.7 [33-79] years) with coronary heart disease involving one (n = 26 or several (n = 24) vessels. Indications for treatment were exercise-induced (n = 35) or unstable (n = 14) angina or acute myocardial infarction (n = 11). Treated lesions were in the anterior interventricular branch (n = 25), circumflex branch of the left coronary artery (n = 3) and right coronary artery (n = 22). 19 vessels were occluded, 24 lesions were partially thrombosed, 19 were calcified. 22 stenoses were longer than 20 mm. According to AHA/ACC criteria, 10 type A, 17 type B1, 6 type B2 and 17 type C lesions were treated. RESULTS: Total ultrasound time was 336 +/- 308 s; mean passing time through the stenosis was 233 +/- 289 (10-556) s. 17 of 19 occlusions were recanalised after 285 +/- 224 s. Percutaneous transluminal angioplasty (PTCA) was subsequently performed in 49 patients. The mean stenosis grade was reduced by UCA from initially 82 +/- 3 to 64 +/- 2% and by subsequent PTCA to 38 +/- 1%. Average flow grade rose from 1.5 to 1.9 after UCA and to 2.8 after PTCA. No vasospasm, atrioventricular block or perforation was caused by UCA. Angiography demonstrated dissection after PTCA in seven patients, treated in two with a stent. Both UCA and PTCA failed to achieve recanalization in one patient with a thrombotic occluded coronary artery after acute myocardial infarction. In all other patients there were no complications. CONCLUSION: The results show UCA to be a safe method for removing high-degree coronary artery stenosis or recanalize thrombotic occlusions.
Adult↗
Foot deformity and the length of the triceps surae in Danish children between 3 and 17 years old.
We report the results of examination in 1991 of 759 children and adolescents between 3 and 17 years old, comprising 98% of pupils in different age groups from seven schools and ten kindergartens in Funen (Denmark). The triceps surae was considered to be short if the foot held with the talus in neutral position relative to the calcaneus could only be dorsiflexed to a right angle. The proportion of children with shortening of one or both triceps surae rose from 24% to 62% between the ages of 3 and 17 years with no difference between the sexes. In 13% of adolescents, one or both feet failed to reach a right angle by > or = 5 degrees. Footprints made in 1,520 feet showed that the proportion of feet with a high arch increased from 2% to 7%; there was a smaller number of such feet with a short triceps surae than in feet with a normal arch. The proportion of feet with a flat arch declined from 42% to 6% in spite of a strong relationship with a short triceps surae. In the oldest age group, all the flat feet had a short triceps surae, which is probably one of the reasons for the persistence of the deformity.
Adolescent↗
A randomized study of coronary angioplasty compared with bypass surgery in patients with symptomatic multivessel coronary disease. German Angioplasty Bypass Surgery Investigation (GABI)
BACKGROUND: The standard treatment for patients with symptomatic multivessel coronary artery disease is coronary-artery bypass grafting (CABG). Percutaneous transluminal coronary angioplasty (PTCA) is widely used as an alternative approach to revascularization, but a systematic comparison of the two procedures is needed. We compared the outcomes in patients one year after complete revascularization with CABG or PTCA. METHODS: A total of 8981 patients with multivessel coronary disease were screened at eight clinical sites, and 359 patients were randomly assigned to undergo CABG (177 patients) or PTCA (182 patients). Enrollment required that complete revascularization of at least two major vessels supplying different myocardial regions be deemed clinically necessary and technically feasible. RESULTS: Among the patients in the CABG group, an average of 2.2 +/- 0.6 vessels were grafted, and among those in the PTCA group, 1.9 +/- 0.5 vessels were dilated. After CABG, hospitalization was longer (median, 19, as compared with 5 days for PTCA), and Q-wave myocardial infarction in relation to the procedure was more frequent (8.1 percent, as compared with 2.3 percent after PTCA; P = 0.022), whereas in-hospital mortality did not differ significantly between the two groups (2.5 percent in the CABG group and 1.1 percent in the PTCA group). At discharge 93 percent of the patients in the CABG group were free of angina, as compared with 82 percent of those in the PTCA group (P = 0.005). During the first year of follow-up, further interventions were necessary in 44 percent of the patients in the PTCA group (repeated PTCA in 23 percent, CABG in 18 percent, and both in 3 percent) but in only 6 percent of the patients in the CABG group (repeated CABG in 1 percent and PTCA in 5 percent; P < 0.001). Seventy-four percent of the patients in the CABG group and 71 percent of those in the PTCA group were free of angina one year after treatment. Exercise capacity improved similarly in both groups. However, 22 percent of the CABG group, as compared with only 12 percent of the PTCA group, did not require antianginal medication (P = 0.041). CONCLUSIONS: In selected patients with multivessel coronary disease, PTCA and CABG as initial treatments resulted in equivalent improvement in angina after one year. However, in order to achieve similar clinical outcomes, the patients treated with PTCA were more likely to require further interventions and antianginal drugs, whereas the patients treated with CABG were more likely to sustain an acute myocardial infarction at the time of the procedure.
Aged↗
[Incidence of complaints about heel-, knee- and back-related discomfort among Danish children, possible relation to short muscles].
Four hundred and fifty-nine children and adolescents from third, sixth and ninth classes in seven schools on Funen were questioned in 1991. Seven percent had complaints from back and knee, and 3% from the heel. When the hamstrings were so short that one knee had an extension deficit gently measured to more than 40 degrees, when the hip was flexed 90 degrees, the incidence of back pain rose significantly to 15%. Furthermore 18% had complaints from the knee and 35% from the heel when the passive range of motion of the foot was less than 0 degrees of dorsiflexion measured with the knee extended. As 75% of the boys and 35% of the girls over age ten have short hamstrings and 13% of both sexes have short Achilles tendons, it is recommended that school children be involved in a daily stretching programme in order to diminish the complaints from the extremities often seen in this group.
Adolescent↗
Coronary ultrasound thrombolysis in a patient with acute myocardial infarction.
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Catheterization↗
[Foot deformities and relation to the length of leg muscles in Danish children aged 3-17 years].
Seven hundred and sixty-nine children and adolescents from three to seventeen years of age, being 98% of the pupils in different classes in seven schools and ten kindergartens on Funen, Denmark, were examined in 1991. The Triceps Surae muscle was found to be too short, if the corrected foot can only be pressed slowly to the right angle. The 1520 footprints showed an increase in the number of highly-arched feet through the age groups from 2.3% to 7.3% and a decrease in flat-footedness from 41.8% to 5.7%. In the two oldest age groups, 39% of those with a high arch, 56% of those with a normal arch and 77% of those with flat feet had short calf muscles. We therefore conclude, that it is necessary that a few minutes be spent daily in Danish kindergartens and schools on stretching the triceps surae.
Adolescent↗