Experimental Stenting?

"The Murdock's" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I am a 48 yo male with 7 angioplasties and 4 stents in the
LAD and 1st diagonal. I have continued with chest pain
during exertion and at rest. My cardiologist after my last
cath said everything looked OK with the exception of some
smaller arteries which were beginning to occlude. He
stated he suspected these were what was causing the pain
but technology wasn't there yet to clear them. Recently
while seeing another Dr for something else I mentioned
this to him during my history. He told me Duke University
was doing some experimental testing with smaller equipment
to access these type arteries and open them. Has anyone
else heard anything on this? (I tried contacting Duke but
so far no response)

"The Murdock's" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I am a 48 yo male with 7 angioplasties and 4 stents in the
LAD and 1st diagonal. I have continued with chest pain
during exertion and at rest. My cardiologist after my last
cath said everything looked OK with the exception of some
smaller arteries which were beginning to occlude. He
stated he suspected these were what was causing the pain
but technology wasn't there yet to clear them. Recently
while seeing another Dr for something else I mentioned
this to him during my history. He told me Duke University
was doing some experimental testing with smaller equipment
to access these type arteries and open them. Has anyone
else heard anything on this? (I tried contacting Duke but
so far no response)

This does not directly address your question. However, the
authors at Duke seem to have a research interest in that
area and that might be a starting point for you.

Also if you post your meds and lipids someone here might
comment on them.

Bill

________________________________________

Commentary Intervening on Small Infarct-Related Arteries:
What Does the Future Hold?

Thaddeus R. Tolleson, MD and Michael H. Sketch, Jr., MD,
Duke University Medical Center, Durham, North Carolina. J
Invasive Cardiol 12(1):20-22, 2000. © 2000 Health Management
Publications, Inc

Introduction The demonstration that thrombolytic therapy
improved mortality in patients with acute myocardial
infarction (MI) ushered in a new era in the treatment of
acute coronary syndromes. Though clearly beneficial, this
therapy is beset with inherent limitations (TIMI 3 flow in
only approximately 55% of patients; rare but devastating
hemorrhagic complications). To overcome these limitations,
mechanical reperfusion by balloon angioplasty without prior
thrombolysis (primary PTCA) has emerged as a promising
alternative to conventional thrombolytic therapy. A number
of prospective, randomized trials comparing primary PTCA and
thrombolytic therapy in over 2,600 patients have now been
performed. A systematic overview of these trials has
recently been published by Weaver et al.[1] demonstrating
that primary PTCA resulted in reduced rates of mortality,
reinfarction, and stroke. Cost-effective analyses by Stone
et al.[2] and de Boer et al.[3] have demonstrated that
primary PTCA, by reducing early and late ischemic events and
facilitating earlier discharge, is as or more cost-effective
than thrombolysis. In this issue of the Journal of Invasive
Cardiology, Brodie et al.[4] report their findings from a
consecutive series of patients treated with primary
angioplasty at a single center. Their study looked
specifically at the influence of vessel size on early and
late outcomes following primary PTCA. This study is of
particular interest to interventional cardiologists for
several reasons. Though there is a growing body of evidence
supporting the benefit of primary angioplasty in the overall
group of patients presenting with acute myocardial
infarction, there is a paucity of literature on the outcome
of those patients with small (generally < 3.0 mm) infarct-
related arteries (IRA). The fact that this was a consecutive
series of patients allowed evaluation of patients with
widely varied risk profiles, including those presenting with
cardiogenic shock, previous coronary artery bypass surgery
(CABG), the elderly (age > 70), and 3-vessel disease.

In their findings, the authors note that both in-hospital
and late outcomes after primary angioplasty for acute MI are
worse in patients with small vessels (< 3.0 mm). Patients
with small vessels have a lower procedural success rate
(91.6 vs. 95.8%; p = 0.002). The authors report a higher
incidence of procedural events, though this was not
statistically significant (p = 0.06). Patients with small
vessels also had a higher incidence of late infarct artery
re-occlusion, worse late left ventricular function, and
higher 30-day and late mortality.[4]

At first glance, these data are very discouraging in terms
of intervening acutely on small vessels; however, several
facts must be considered when evaluating these results.
First, there are differences in baseline variables between
the two groups. The group with vessels less than 3.0 mm had
a significant increase in elderly patients, women,
diabetics, anterior infarcts, cardiogenic shock, congestive
heart failure, and 3 vessel coronary artery disease. Each
of these has been shown to predict worse outcomes in
patients presenting with acute coronary syndromes. After
correcting for these differences in baseline
characteristics, the difference in 30-day mortality between
the two groups was much less pronounced, though still
statistically significant (OR = 1.76, 95% CI = 1.02-3.00).
At a mean follow-up of 4.2 ± 3.6 years, there was no
statistical difference in mortality, late infarction, or
target vessel revascularization (TVR) (p-values 0.13, 0.99,
and 0.93, respectively). Not surprising, the incidence of
restenosis in small vessels was greater (30.2%) than in
larger vessels (25.6%) though this was not statistically
significant (p = 0.08).

Two additional factors to consider when evaluating the data
are the utilization of stents and the use of glycoprotein
IIb/IIIa inhibitors in this patient population. This
consecutive series enrolled patients from 1984 through 1997
with stenting employed in only 181 patients during the last
3 years and abciximab used in only 73 patients in the final
2 years of the study. As the landmark BENESTENT[5] and
STRESS[6] studies revealed, implantation of balloon-
expandable stents can reduce the clinical and angiographic
restenosis rates compared to PTCA in patients undergoing
elective intervention in vessels > 3.0 mm. In a follow-up
analysis, Savage et al.[7] reported the findings of a subset
of 331 patients with vessels < 3.0 mm from STRESS I-II
randomized to stenting versus PTCA. Though overall
restenosis rates in both arms were higher than in larger
vessels, stenting again conferred a significant advantage in
terms of angiographic restenosis (34% vs. 55%; p = <= 0.001)
as well as event-free survival at one year (78% vs. 67%; p
= .019).

More recently, stent implantation in patients presenting
with acute myocardial infarctions has also been evaluated.
Suryanpranata et al.[8] randomized 227 patients presenting
with an acute MI to primary stenting versus balloon
angioplasty. The cardiac event-free survival rate (freedom
from any death, recurrent infarction, or repeat angioplasty
of the infarct-related artery at 6 months) was significantly
higher in the stenting arm versus the balloon angioplasty
arm (95% vs. 80%, p = 0.012). This difference in the
composite primary endpoint was driven by reduced rates of
reinfarction (1% vs. 7%) and TVR (4% vs. 17%) in the stent
cohort, with no difference in mortality. These generalized
results are limited somewhat by the relatively low-risk
population enrolled. Only 50% of the patients with acute MI
undergoing primary PTCA were considered to be clinically and
anatomically eligible for stenting. Randomized patients
compared with excluded patients were younger, more
frequently male, more likely to have single-vessel disease,
and less likely to be hemodynamically unstable. Also, 124
patients (27%) were excluded for small vessel size or
diffuse disease. Despite these limitations, this trial
demonstrated for the first time in a prospective, randomized
manner that primary stenting can be applied safely and
effectively in selected patients with acute MI. To date, 4
additional randomized trials have been completed comparing
primary stenting with primary PTCA: Stent-PAMI,[9]
PASTA,[10] GRAMI,[11] and FRESCO.[12] Overall, a total of
1,517 patients were randomly assigned to either primary
infarct artery stenting or no further intervention after
PTCA. In each study, the incidence of the composite endpoint
of death, nonfatal reinfarction, and repeat TVR was
significantly lower in the stent groups compared with the
PTCA groups. Pooling the data from these 5 studies revealed
a 6-month composite endpoint (death, myocardial infarction,
repeat TVR) of 11.3% in the stent group versus 23.1% in the
PTCA group (p = < .0001).

Unfortunately, a lack of data exist about the efficacy of
stenting in small infarct arteries because 3 of the 5
randomized trials (GRAMI, Zwolle, Stent-PAMI) excluded
patients with a reference vessel diameter < 3.0 mm. In the
two trials that included arteries < 3.0 mm (FRESCO, PASTA),
a separate analysis comparing stenting with PTCA in this
subset of patients has not been published. Thus the benefit
of stenting small vessels in patients presenting with acute
MI remains unresolved, and further studies are needed to
address this issue.

Early randomized trials of stenting were careful to exclude
patients with acute MI and lesions containing thrombus given
the increased subacute stent thrombosis rates associated
with the implantation of a metallic endoprosthesis into a
thrombotic environment.[13] Combined with high-pressure
stent deployment, the improved understanding of the central
role of platelets and subsequent development of effective
antiplatelet regimens have reduced stent thrombosis rates to
between 0 and 3% with contemporary antiplatelet therapy.[14]

The presence of the platelet-rich thrombus in acute MI and
the central role of platelet activation in stent thrombosis
suggest a potentially advantageous role for the new class of
agents that inhibit the platelet surface membrane
glycoprotein (GP) IIb/IIIa receptor. Randomized trials
involving over 15,000 patients have clearly established that
the use of GP IIb/IIIa receptor blockers can reduce the risk
of death, MI, and reintervention in patients at both high
and low risk undergoing PTCA.[15-18] The first prospective,
randomized evaluation of GP IIb/IIIa inhibitors during
primary angioplasty for acute MI was in the ReoPro in Acute
Myocardial Infarction and Primary PTCA Organization and
Randomized Trial (RAPPORT).[19] Administration of abciximab
prior to direct angioplasty resulted in 67% and 48%
reductions in ischemic-driven endpoints (death,
reinfarction, urgent and elective revascularization) at 7
and 30 days, respectively. Although the 6-month composite
endpoint including all target lesion revascularization was
not statistically different, reductions in ischemic-driven
endpoints remained significant (11.6% vs. 17.8%; p =
0.048).[19] The role of abciximab as adjunctive therapy to
primary PTCA and stenting in acute MI will be better defined
by the CADILLAC (Controlled Abciximab and Device
Investigation to Lower Late Complications) trial.[21] In
this trial, 2,000 patients with acute MI are being
randomized in a 2 x 2 factorial design to primary PTCA
alone, PTCA plus abciximab, primary stenting alone, or
stenting plus abciximab. Results of this trial are expected
in early 2000. To date, there are no published reports on
the outcomes of patients with small IRA treated with GP
IIb/IIIa inhibitors.

By virtue of two different mechanisms, the concept of the
combination of stenting with adjunctive IIb/IIIa inhibition
represents an attractive clinical strategy to improve the
outcomes in patients with acute MI. The benefit of this
approach in the subset of patients with small IRAs remains
to be determined in future trials.

References
1.. Weaver WD, Simes RJ, Ellis SG, et al. Comparison of
primary coronary angioplasty and intravenous
thrombolytic therapy for acute myocardial infarction: A
quantitative review. JAMA 1997;278:2093-2098.
2.. Stone GW, Grines CL, Rothbaum D, et al. Analysis of
the relative costs and effectiveness of primary
angioplasty versus tissue-type plasminogen activator:
The Primary Angioplasty in Myocardial Infarction (PAMI)
trial. J Am Coll Cardiol 1997;29:901-907.
3.. De Boer MJ, van Hout VA, Liem AL, et al. A cost-
effective analysis of primary coronary angioplasty
versus thrombolysis for acute myocardial infarction. Am
J Radiol 1995;76:830-833.
4.. Brodie BR, Stuckey TD, Hanson C, et al. Influence of
vessel size on early and late outcomes after primary
angioplasty for acute myocardial infarction. J Invas
Cardiol 2000;12:13-19.
5.. Serruys PW, de Jaegere P, Kiemeneij F, et al. A
comparison of balloon-expandable stent implantation
with balloon angioplasty in patients with coronary
artery disease. N Engl J Med 1994;331:489-495.
6.. Fischman DL, Leon MB, Baim DS, et al. A randomized
comparison of coronary-stent placement and balloon
angioplasty in the treatment of coronary artery
disease. N Engl J Med 1994;331:496-501.
7.. Savage MP, Fischman DL, Rake R, et al. Efficacy of
coronary stenting versus balloon angioplasty in small
coronary arteries. J Am Coll Cardiol 1998;31:307-311.
8.. Suryanpranata H, van't Hof AWJ, Hoorntje JCA, et al.
Randomized comparison of coronary stenting with balloon
angioplasty in selected patients with acute myocardial
infarction. Circulation 1998;97:2502-2505.
9.. Grines DL, Cox DA, Garcia E, et al. Stent PAMI:
Primary endpoint results of a multicenter randomized
trial of heparin coated stenting vs. primary PTCA for
AMI (Abstr). Circulation 1998;98(Suppl I):I-20.
10.. Saito S, Hosakawa G. Primary Palmaz-Schatz stent
implantation for acute myocardial infarction: The final
results of Japanese PASTA (Primary Angioplasty vs.
Stent Implantation in AMI in Japan) trial (Abstr).
Circulation 1997;96(Suppl I):I-595.
11.. Rodriguez A, Bernardi V, Fernandez M, et al. In-
hospital and late results of coronary stents versus
conventional balloon angioplasty in acute
myocardial infarction (GRAMI) trial). Am J Cardiol
1998;81:1286-1291.
12.. Antoniucci D, Santoro GM, Bolognese L, et al. A
clinical trial comparing primary stenting of the infarct-
related artery with optimal primary angioplasty for
acute myocardial infarction: Results from the
Florence Randomized Elective Stenting in Acute
Coronary Occlusions (FRESCO) trial. J Am Coll Cardiol
1998;31:1234-1239.
13.. Fischman DL, Leon MB, Baim DS, et al. A randomized
comparison of coronary stent placement and balloon
angioplasty in the treatment of coronary artery
disease. N Engl J Med 1994;331:496-501.
14.. Colombo A, Hall P, Nakamura S, et al.
Intracoronary stenting without anticoagulation
accomplished with intravascular ultrasound guidance.
Circulation 1995;91:1676-1688.
15.. EPIC Investigators. Use of a monoclonal antibody
directed against the platelet glycoprotein IIb/IIIa
receptor in high-risk coronary angioplasty. N Engl J
Med 1994;330:956-961.
16.. EPILOG Investigators. Platelet glycoprotein IIb/IIIa
receptor blockade and low-dose heparin during
percutaneous coronary revascularization. N Engl J Med
1997;336:1689-1696.
17.. IMPACT-II Investigators. Randomized placebo-
controlled trial of effect of eptifibatide on
complications of percutaneous coronary intervention.
Lancet 1997;349:1422-1428.
18.. RESTORE Investigators. Effects of platelet
glycoprotein IIb/IIIa blockade with tirofiban on
adverse cardiac events in patients with unstable angina
or acute myocardial infarction undergoing coronary
angioplasty. Circulation 1997;96:1445-1453.
19.. RAPPORT Investigators. A randomized placebo-
controlled trial of platelet glycoprotein IIb/IIIa
blockade with primary angioplasty for acute myocardial
infarction. Circulation 1998;98:734-741.
20.. Stone GW. Stenting and IIb/IIIa receptor blockade
in acute myocardial infarction: An introduction to
the CADILLAC trial. J Invas Cardiol 1998;10(Suppl
B):36B-47B.

Reprint Address Address reprint requests to: Michael H.
Sketch, Jr., MD, Duke University, Box 3157, Durham, NC
27710.

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Quoted message said:

Quoted message said:

I am a 48 yo male with 7 angioplasties and 4 stents in
the LAD and 1st diagonal. I have continued with chest
pain during exertion and at rest. My cardiologist after
my last cath said everything looked OK with the
exception of some smaller arteries which were beginning
to occlude. He stated he suspected these were what was
causing the pain but technology wasn't there yet to
clear them.

Technology exists ! he could use a pressure wire to measure
the distal presure and find out what artery or stenosis is
the origin of your pain, and also take a look at the
arteries using ultrasound technology (IVUS) to find out the
real size of the "small" artery. IVUS showed that a lot of
"small" arteries as seen by angiography are actually typical
size arteries but with a lot of disease.

My opinion is that if your Dr doesnot know about this you
should see another one....

Patrick

Thanks for all the info. I agree I need a new cardiologist
as he thinks " I complain too much". IVUS found my first
blockage - a 95% occlusion in the LAD. I was lucky. The only
reason they used IVUS was I agreed to be part of a study
measuring arterial size and disease. The angiogram had only
shown a 70% blockage in the first diagonal but when they
inserted the IVUS into the LAD it completed the blockage and
a heart attack began on the table. When he saw the IVUS
image they removed the probe, started medication and got the
MI stopped. They then took another x-ray with the dye from a
slightly different angle and saw the blockage in the LAD. If
I hadn't agreed to the study I would have left there with a
major blockage and probably dropped dead of an MI within
weeks if not days.

"Patrick B" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Quoted message said:

Quoted message said:

I am a 48 yo male with 7 angioplasties and 4 stents in
the LAD and 1st diagonal. I have continued with chest
pain during exertion and at

rest. My

Quoted message said:

Quoted message said:

Quoted message said:

cardiologist after my last cath said everything looked
OK with the

exception

Quoted message said:

Quoted message said:

Quoted message said:

of some smaller arteries which were beginning to
occlude. He stated

he

Quoted message said:

Quoted message said:

Quoted message said:

suspected these were what was causing the pain but
technology wasn't

there

Quoted message said:

Quoted message said:

Quoted message said:

yet to clear them.

Technology exists ! he could use a pressure wire to
measure the distal presure and find out what artery or
stenosis is the origin of your pain, and also take a look
at the arteries using ultrasound technology (IVUS) to find
out the real size of the "small" artery. IVUS showed that
a lot of "small" arteries as seen by angiography are
actually typical size arteries but with a lot of disease.

My opinion is that if your Dr doesnot know about this you
should see another one....

Patrick

The Murdock's said:

IVUS found my first blockage - a 95% occlusion in the LAD.

So many problems would be identified and cured faster if
only they used more IVUS. I am happy for you and I hope for
all the others that Drs admit that X-ray does not show all
the picture.

Patrick