Original article Herz 2014 DOI 10.1007/s00059-014-4184-0 Received: 8 September 2014 Revised: 27 October 2014 Accepted: 2 November 2014 © Urban & Vogel 2014
M. Karakyriou1 · S. Hadjimiltiades1 · S. Meditskou2 · E. Nenopoulou3 · G. Efthimiadis1 · P. Vogazianos4 · C. Karvounis1 · I. Styliadis1 1 Department of Cardiology, AHEPA Hospital, Aristotle University, Thessaloniki 2 Laboratory of Histology and Embryology, Aristotle University, Thessaloniki 3 Department of Pathology, Aristotle University, Thessaloniki 4 Department of Computer Science, University of Cyprus, Nicosia
Embolization after percutaneous coronary intervention in acute coronary syndrome Saphenous vein grafts versus native coronary arteries
Advanced percutaneous revascularization techniques have been used successfully in the treatment of ischemic coronary artery disease with a remarkable increase in the safety of the procedure; however, percutaneous coronary interventions (PCI) cause mechanical injury and fragmentation of the atherosclerotic plaque, which may lead to distal embolization. Several studies suggested that distal embolization during PCI may lead to periprocedural myonecrosis in otherwise successful procedures or may be associated with the noreflow phenomenon [1, 2, 3, 4, 5]. Clinical, biochemical, and histological evidence indicates that macro- or microembolization occurs not only in saphenous vein grafts (SVG) but also in native coronary arteries [4, 6, 7]. The impact of this embolization may be disproportionate to the extent of the anatomic obstruction, due to the local release of inflammatory factors, and underlies a more extensive left ventricular dysfunction than expected from perfusion imaging studies [3, 8]. Emboli protection devices have been proven to reduce periprocedural myocardial injury in saphenous vein grafts interventions [9, 10, 11]. A few studies have shown that the use of a distal vascular protection device in native artery interventions has the potential to reduce periprocedural myocardial injury [12, 13]; however, randomized trials on primary PCI
in ST-elevation myocardial infarction (STEMI) patients have repeatedly shown no benefit of protection devices [14] and there are scarce data in patients with unstable or stable angina based on randomized studies performed in the time frame of the first 48 h [15, 16]. The aim of this study was to assess the occurrence of distal embolization and to quantify the amount of embolic material captured by the protection devices during stent implantation, in native coronary arteries as compared with SVG, and define subgroups of patients with the highest embolic load.
Patients and methods Study population and procedure The study population consisted of patients with acute coronary syndromes or patients with a definable period of instability followed by medical stabilization undergoing native coronary or SVG PCI up to a period of 6 months. Patients with STEMI within 48 h of presentation were not included. The study was approved by the Ethics Committee of our institution and written informed consent was obtained from all the enrolled patients. All patients were on aspirin and clopidogrel before the procedure and unfractionated heparin was administered to
maintain an activated clotting time (ACT) of between 250 and 300 s. The use of glycoprotein IIb/IIIa inhibitors before or during PCI was at the operator’s discretion. The embolic protection devices that were used were the PercuSurge Guardwire (Medronic Vascular, Santa Rosa, Calif.), the Angioguard filter wire (Cordis Inc.), the FilterWire (Boston Scientific, Natwick, Mass.), and the SpiderFX Embolic Protection Device (Covidien). The procedure was performed via the femoral approach using 6F or 7F guiding catheters. A complete hematologic and biochemical profile was obtained before the procedure including creatine kinase (CK) plus the MB fraction (CK-MB), which was also assessed 18–24 h after the procedure. The CPK-MB elevation was considered positive with a value above the upper limit of the reference value. Angiographic parameters of the treated vessel were evaluated before the procedure. The operator involved in the study was encouraged to use a protection device, irrespective of any impression of a low probability of embolization. The PCI was performed in a standard way with the filter deployed before any intervention, whenever that was feasible.
Herz 2014
| 1
Original article
Pathological, clinical, and angiographic characteristics
Tab. 1 Baseline patient characteristics
N=104 Native coronary arteries (n=52) Age (years) 54.87±11.44 Men 50 (96) Hypertension 24 (50) Diabetes 8 (16) Hyperlipidemia 40 (82) Current smoking 21 (45) Family history of CAD 11 (23) Previous MI (>6 months) 20 (40) Peripheral vascular disease 2 (4) Previous PCI 10 (20) Number of diseased vessels (>50% stenosis) p2 weeks 29 (56) >1 month 7 (13)
SVG (n=52)
p
66.92±9.42 51 (98) 36 (70) 7 (14) 46 (84) 9 (19) 10 (20) 29 (58) 7 (14) 16 (32)
20 mm Length ≤20 mm Eccentricity Irregular borders Thrombus Gp IIb/IIIa AHA/ACC Type A Type B Type C
RCA n=30 19 (63) 11 (37) 21 (75) 14 (50) 1 (3) 2 (6) 1 10 19 (63)
LAD and LCX n=23 10 (43) 16 (70) 18 (78) 9 (39) 1 (4) 3 (13) 1 11 10 (45)
SVG n=59 36 (64) 20 (36) 45 (85) 36 (64) 2 (3) 4 (7) 1 8 49 (84)
Total n=112 65 (60) 44 (40) 84 (81) 59 (56) 4 (4) 9 (8) 3 29 78 (71)
Numbers in parentheses = % of total lesions treated AHA/ACC American Heart Association/American College of Cardiology, LAD left anterior descending, LCX left circumflex, RCA right coronary artery, SVG saphenous vein graft
Tab. 3 Procedural characteristics by type of vessel Parameter Maximum stent diameter (mm) Total stent length (mm) Number of stents Maximum pressure (atm) Number dilatations Postdilation balloon minus stent diameter (mm)
RCA n=30 Mean±SE 3.75±0.04 27.62±1.95 1.20±0.08 18.10±0.51 5.10±0.63 0.01±0.05
LAD and LCX n=20
SVG n=56
3.65±0.05 23.40±2.44 1.23±0.09 17.15±0.73 3.95±0.54 0.12±0.07
3.93±0.09 33.75±3.56 1.36±0.06 18.07±0.45 3.92±0.43 0.07±0.04
p 0.073 0.132 0.494 0.508 0.239 0.396
RCA right coronary artery, LAD left anterior descending, LCX left circumflex, SVG saphenous vein graft
2 |
Herz 2014
The distal end of the filter on a wire protection device was cut and transported upright in 15-ml conical tubes containing 10 ml of 10% neutral-buffered formalin. The filters were opened on the long axis and the debris was gently removed and flushed from the filter and processed for histological evaluation. Paraffin-embedded sections, 7 μm thick, were stained with hematoxylin and eosin and processed for morphometric analysis with a microscope incorporated with a Nikon DS-Fi1-L2 digital camera with an internal morphometric measurements system. One representative section was analyzed and the following quantitative parameters were assessed: (1) the longest diameter of each particle (particle size); (2) the total cross-sectional area of each particle; and (3) the sum of the cross-sectional area of all the particles for each patient. These parameters represented quantitative indices of the embolic burden. The clinical and angiographic variables per type of vessel are presented in . Tab. 1 and . Tab. 2. Complex lesions were defined according to the ACC/ AHA classification and the lesion length (grouped as 220 mg/dl or treatment with lipid-lowering medications), current smoking (defined as smoking for the last month prior to the index event), family history of coronary artery disease, previous myocardial infarction, peripheral vascular disease, and previous revascularization.
Herz 2014 · [jvn]:[afp]–[alp] DOI 10.1007/s00059-014-4184-0 © Urban & Vogel 2014
Statistical analysis
Zusammenfassung Ziel. Ziel der Arbeit war es, bei Patienten zu verschiedenen Zeiten nach einem akuten Koronarsyndrom das Auftreten einer distalen Embolusbildung zu bestimmen und die Menge an embolischem Material zu quantifizieren, die sich bei der Stentimplantation in den patienteneigenen Koronararterien im Vergleich zu einem V.-saphena-Transplantat ansammelt. Methoden. Bei 104 Patienten, die sich mit einer instabilen oder stabilen Angina vorstellten, erfolgte an 107 Gefäßen eine perkutane Koronarintervention (PCI) und bei 112 Läsionen eine Stentimplantation, 53% davon in einem V.-saphena-Transplantat. Ergebnisse. Das Einsetzen und Wiederauffinden der Implantate war bei 111 Läsionen erfolgreich. In 74% der Schutzfilter wurde embolisches Material entdeckt. Eine früh erfolgende PCI innerhalb von 2 Wochen nach der letzten ischämischen Episode ging mit einer größeren embolischen Last einher, insbesondere in der rechten Koronararterie. Die Länge der Läsion war die einzige präprozedurale unabhängige Variable, die sich als signifikanter Prädiktor des Vorliegens von Emboli herausstellte (p=0,002). Der
Results are reported as numbers (%) or mean ±SD. Differences in proportion and categorical variables were compared using the chi-square statistic and Fisher’s exact test. One-way ANOVA and post hoc analysis (Scheffe) were used to compare continuous variables in multiple groups. Logistic regression analysis was used to investigate the predictive value of baseline clinical, angiographic, and procedural variables for the presence of embolic material. Linear regression analysis was used to evaluate the relation between angiographic and procedural variables to the morphometric measurements of embolic material. Statistical analyses were performed using the SPSSn17 statistical software (Chicago, Ill.) and the Statistica software (StaSoft, Tulsa, Okla.). A p value less than 0.05 was considered statistically significant.
M. Karakyriou · S. Hadjimiltiades · S. Meditskou · E. Nenopoulou · G. Efthimiadis · P. Vogazianos · C. Karvounis · I. Styliadis
Embolization after percutaneous coronary intervention in acute coronary syndrome. Saphenous vein grafts versus native coronary arteries Abstract Aims. The aim of this study was to assess the occurrence of distal embolization and to quantify the amount of embolic material captured during stent implantation in native coronary arteries, as compared with saphenous vein grafts (SVG) in patients at different time periods after an acute coronary syndrome. Patients and methods. In all, 104 patients presenting with unstable or stable angina underwent percutaneous coronary intervention (PCI) in 107 vessels and stent implantation in 112 lesions, 53% of which were in SVG. Results. Device deployment and retrieval was successful in 111 lesions. Embolic material was detected in 74% of the protection devices. Early PCI, during a 2-week period after the last ischemic episode, was associated with larger embolic load, especially in the right coronary artery. The length of the lesion was the only preprocedural independent variable that was found to be a significant predictor for the presence of embo-
li (p=0.002). The stent diameter and the maximum dilatation pressure were the two procedural variables found to be significant predictors for the presence of emboli (p=0.025 and p=0.008, respectively). The irregularity of the lesion and the number of stents deployed were found to have a predictive correlation to the total area of the embolic particles (p=0.04 and p=0.005, respectively). Conclusion. Distal embolization of atherosclerotic debris is a frequent phenomenon after PCI not only in SVG but also in native vessels. The amount of embolic material seems to be related to the atherosclerotic burden of the vessel and to the early timing of the procedure as related to acute coronary syndrome. Keywords Acute coronary syndrome · Embolization · Stent implantation · Saphenous vein grafts · Native coronary artery
Embolusbildung nach perkutaner koronarer Intervention bei akutem Koronarsyndrom. V.-saphenaTransplante vs. natürliche Koronararterien Stentdurchmesser und der maximale Dilatationsdruck waren die beiden prozeduralen Variablen, die sich als signifikante Prädiktoren für das Vorliegen von Emboli herausstellten (p=0,025 und p=0,008). Für die Unregelmäßigkeit der Läsion und die Anzahl der verwendeten Stents wurde eine prädiktive Korrelation mit der Gesamtfläche embolischer Partikel festgestellt (p=0,04 bzw. p=0,005). Schlussfolgerung. Eine distale Embolusbildung durch atherosklerotische Ablagerungen ist nicht nur in V.-saphena-Transplantaten, sondern auch in den natürlichen Gefäßen ein häufiges Phänomen nach PCI. Die Menge embolischen Materials scheint mit der atherosklerotischen Last des Gefäßes und einem frühen Zeitpunkt der Maßnahme in Hinblick auf das akute Koronarsyndrom in Zusammenhang zu stehen. Schlüsselwörter Akutes Koronarsyndrom · Embolusbildung · Stentimplantation · V.-saphenaTransplantate · Natürliche Koronararterie
Herz 2014
| 3
Original article
Results
12,000 Mean Mean±SE Mean±SD Outliers Extremes
Longest diameter of the largest particle (µm)
10,000
F(2,78) = 2.1453; p = 0.1239
8,000
6,000
4,000
2,000
1,209
1,645 579
0
-2,000 SVBG
RCA
LEFT
type of vessel
Fig. 1 8 Longest diameter of the largest particle in native vessels and vein grafts. LEFT left coronary artery, RCA right coronary artery, SVBG saphenous vein graft 6 SVBG 5
RCA
Mean total area of particles per lesion (mm2)
LEFT F(2,73) = 3.6790, p = .03004
4 3.23
3 2
1.89 1.04
1 0.42 0
0.93 0.29
-1 -2 -3
2 wks Time to PCI (weeks)
Fig. 2 8 Mean total particle area per lesion in native vessels and vein grafts as related to the time of percutaneous coronary intervention (PCI) after the index event (vertical bars denote 0.95 confidence intervals). LEFT left coronary artery, RCA right coronary artery, SVBG saphenous vein graft
4 |
Herz 2014
In total, 104 consecutive patients underwent PCI in 107 vessels and stent implantation in 112 lesions, 53% of which were in SVG. Device deployment and retrieval was successful in 111 lesions. The type of embolic protection device, in order of frequency used, was the Filterwire (64%), the Angioguard (22%), the SpiderFX (11%), and the PercuSurge (3%). The Angioguard device was used more frequently in SVG and the PercuSurge device exclusively in SVG. Baseline patient clinical and angiographic characteristics are shown in . Tab. 1 and . Tab. 2 and procedural characteristics in . Tab. 3. Most of the lesions were complex, 70% of them were type C (AHA/ACC), and type C were significantly more in SVG (χ2 =12,972, p=0.011). The procedures were equally distributed to the two time periods of >2 weeks or ≤2 weeks after the last episode of rest angina; however, in native-vessel PCI 44% of the cases were postmyocardial infarction as compared with 9% in veingraft PCI cases. Postprocedural CPK-MB values were elevated in eight of 46 patients (17.4%) after PCI in native vessels and in two of 42 patients (4.8%) after PCI in SVG lesions. The strategy of low-pressure deployment of the stent and then filter deployment and dilatation of the stent at high pressures, required in our cases for technical reasons, was associated with higher postprocedural CPK-MB levels compared with patients who had the device placed at the beginning of the procedure or after small balloon predilatation [ANOVA F(2, 83), p
M. Karakyriou1 · S. Hadjimiltiades1 · S. Meditskou2 · E. Nenopoulou3 · G. Efthimiadis1 · P. Vogazianos4 · C. Karvounis1 · I. Styliadis1 1 Department of Cardiology, AHEPA Hospital, Aristotle University, Thessaloniki 2 Laboratory of Histology and Embryology, Aristotle University, Thessaloniki 3 Department of Pathology, Aristotle University, Thessaloniki 4 Department of Computer Science, University of Cyprus, Nicosia
Embolization after percutaneous coronary intervention in acute coronary syndrome Saphenous vein grafts versus native coronary arteries
Advanced percutaneous revascularization techniques have been used successfully in the treatment of ischemic coronary artery disease with a remarkable increase in the safety of the procedure; however, percutaneous coronary interventions (PCI) cause mechanical injury and fragmentation of the atherosclerotic plaque, which may lead to distal embolization. Several studies suggested that distal embolization during PCI may lead to periprocedural myonecrosis in otherwise successful procedures or may be associated with the noreflow phenomenon [1, 2, 3, 4, 5]. Clinical, biochemical, and histological evidence indicates that macro- or microembolization occurs not only in saphenous vein grafts (SVG) but also in native coronary arteries [4, 6, 7]. The impact of this embolization may be disproportionate to the extent of the anatomic obstruction, due to the local release of inflammatory factors, and underlies a more extensive left ventricular dysfunction than expected from perfusion imaging studies [3, 8]. Emboli protection devices have been proven to reduce periprocedural myocardial injury in saphenous vein grafts interventions [9, 10, 11]. A few studies have shown that the use of a distal vascular protection device in native artery interventions has the potential to reduce periprocedural myocardial injury [12, 13]; however, randomized trials on primary PCI
in ST-elevation myocardial infarction (STEMI) patients have repeatedly shown no benefit of protection devices [14] and there are scarce data in patients with unstable or stable angina based on randomized studies performed in the time frame of the first 48 h [15, 16]. The aim of this study was to assess the occurrence of distal embolization and to quantify the amount of embolic material captured by the protection devices during stent implantation, in native coronary arteries as compared with SVG, and define subgroups of patients with the highest embolic load.
Patients and methods Study population and procedure The study population consisted of patients with acute coronary syndromes or patients with a definable period of instability followed by medical stabilization undergoing native coronary or SVG PCI up to a period of 6 months. Patients with STEMI within 48 h of presentation were not included. The study was approved by the Ethics Committee of our institution and written informed consent was obtained from all the enrolled patients. All patients were on aspirin and clopidogrel before the procedure and unfractionated heparin was administered to
maintain an activated clotting time (ACT) of between 250 and 300 s. The use of glycoprotein IIb/IIIa inhibitors before or during PCI was at the operator’s discretion. The embolic protection devices that were used were the PercuSurge Guardwire (Medronic Vascular, Santa Rosa, Calif.), the Angioguard filter wire (Cordis Inc.), the FilterWire (Boston Scientific, Natwick, Mass.), and the SpiderFX Embolic Protection Device (Covidien). The procedure was performed via the femoral approach using 6F or 7F guiding catheters. A complete hematologic and biochemical profile was obtained before the procedure including creatine kinase (CK) plus the MB fraction (CK-MB), which was also assessed 18–24 h after the procedure. The CPK-MB elevation was considered positive with a value above the upper limit of the reference value. Angiographic parameters of the treated vessel were evaluated before the procedure. The operator involved in the study was encouraged to use a protection device, irrespective of any impression of a low probability of embolization. The PCI was performed in a standard way with the filter deployed before any intervention, whenever that was feasible.
Herz 2014
| 1
Original article
Pathological, clinical, and angiographic characteristics
Tab. 1 Baseline patient characteristics
N=104 Native coronary arteries (n=52) Age (years) 54.87±11.44 Men 50 (96) Hypertension 24 (50) Diabetes 8 (16) Hyperlipidemia 40 (82) Current smoking 21 (45) Family history of CAD 11 (23) Previous MI (>6 months) 20 (40) Peripheral vascular disease 2 (4) Previous PCI 10 (20) Number of diseased vessels (>50% stenosis) p2 weeks 29 (56) >1 month 7 (13)
SVG (n=52)
p
66.92±9.42 51 (98) 36 (70) 7 (14) 46 (84) 9 (19) 10 (20) 29 (58) 7 (14) 16 (32)
20 mm Length ≤20 mm Eccentricity Irregular borders Thrombus Gp IIb/IIIa AHA/ACC Type A Type B Type C
RCA n=30 19 (63) 11 (37) 21 (75) 14 (50) 1 (3) 2 (6) 1 10 19 (63)
LAD and LCX n=23 10 (43) 16 (70) 18 (78) 9 (39) 1 (4) 3 (13) 1 11 10 (45)
SVG n=59 36 (64) 20 (36) 45 (85) 36 (64) 2 (3) 4 (7) 1 8 49 (84)
Total n=112 65 (60) 44 (40) 84 (81) 59 (56) 4 (4) 9 (8) 3 29 78 (71)
Numbers in parentheses = % of total lesions treated AHA/ACC American Heart Association/American College of Cardiology, LAD left anterior descending, LCX left circumflex, RCA right coronary artery, SVG saphenous vein graft
Tab. 3 Procedural characteristics by type of vessel Parameter Maximum stent diameter (mm) Total stent length (mm) Number of stents Maximum pressure (atm) Number dilatations Postdilation balloon minus stent diameter (mm)
RCA n=30 Mean±SE 3.75±0.04 27.62±1.95 1.20±0.08 18.10±0.51 5.10±0.63 0.01±0.05
LAD and LCX n=20
SVG n=56
3.65±0.05 23.40±2.44 1.23±0.09 17.15±0.73 3.95±0.54 0.12±0.07
3.93±0.09 33.75±3.56 1.36±0.06 18.07±0.45 3.92±0.43 0.07±0.04
p 0.073 0.132 0.494 0.508 0.239 0.396
RCA right coronary artery, LAD left anterior descending, LCX left circumflex, SVG saphenous vein graft
2 |
Herz 2014
The distal end of the filter on a wire protection device was cut and transported upright in 15-ml conical tubes containing 10 ml of 10% neutral-buffered formalin. The filters were opened on the long axis and the debris was gently removed and flushed from the filter and processed for histological evaluation. Paraffin-embedded sections, 7 μm thick, were stained with hematoxylin and eosin and processed for morphometric analysis with a microscope incorporated with a Nikon DS-Fi1-L2 digital camera with an internal morphometric measurements system. One representative section was analyzed and the following quantitative parameters were assessed: (1) the longest diameter of each particle (particle size); (2) the total cross-sectional area of each particle; and (3) the sum of the cross-sectional area of all the particles for each patient. These parameters represented quantitative indices of the embolic burden. The clinical and angiographic variables per type of vessel are presented in . Tab. 1 and . Tab. 2. Complex lesions were defined according to the ACC/ AHA classification and the lesion length (grouped as 220 mg/dl or treatment with lipid-lowering medications), current smoking (defined as smoking for the last month prior to the index event), family history of coronary artery disease, previous myocardial infarction, peripheral vascular disease, and previous revascularization.
Herz 2014 · [jvn]:[afp]–[alp] DOI 10.1007/s00059-014-4184-0 © Urban & Vogel 2014
Statistical analysis
Zusammenfassung Ziel. Ziel der Arbeit war es, bei Patienten zu verschiedenen Zeiten nach einem akuten Koronarsyndrom das Auftreten einer distalen Embolusbildung zu bestimmen und die Menge an embolischem Material zu quantifizieren, die sich bei der Stentimplantation in den patienteneigenen Koronararterien im Vergleich zu einem V.-saphena-Transplantat ansammelt. Methoden. Bei 104 Patienten, die sich mit einer instabilen oder stabilen Angina vorstellten, erfolgte an 107 Gefäßen eine perkutane Koronarintervention (PCI) und bei 112 Läsionen eine Stentimplantation, 53% davon in einem V.-saphena-Transplantat. Ergebnisse. Das Einsetzen und Wiederauffinden der Implantate war bei 111 Läsionen erfolgreich. In 74% der Schutzfilter wurde embolisches Material entdeckt. Eine früh erfolgende PCI innerhalb von 2 Wochen nach der letzten ischämischen Episode ging mit einer größeren embolischen Last einher, insbesondere in der rechten Koronararterie. Die Länge der Läsion war die einzige präprozedurale unabhängige Variable, die sich als signifikanter Prädiktor des Vorliegens von Emboli herausstellte (p=0,002). Der
Results are reported as numbers (%) or mean ±SD. Differences in proportion and categorical variables were compared using the chi-square statistic and Fisher’s exact test. One-way ANOVA and post hoc analysis (Scheffe) were used to compare continuous variables in multiple groups. Logistic regression analysis was used to investigate the predictive value of baseline clinical, angiographic, and procedural variables for the presence of embolic material. Linear regression analysis was used to evaluate the relation between angiographic and procedural variables to the morphometric measurements of embolic material. Statistical analyses were performed using the SPSSn17 statistical software (Chicago, Ill.) and the Statistica software (StaSoft, Tulsa, Okla.). A p value less than 0.05 was considered statistically significant.
M. Karakyriou · S. Hadjimiltiades · S. Meditskou · E. Nenopoulou · G. Efthimiadis · P. Vogazianos · C. Karvounis · I. Styliadis
Embolization after percutaneous coronary intervention in acute coronary syndrome. Saphenous vein grafts versus native coronary arteries Abstract Aims. The aim of this study was to assess the occurrence of distal embolization and to quantify the amount of embolic material captured during stent implantation in native coronary arteries, as compared with saphenous vein grafts (SVG) in patients at different time periods after an acute coronary syndrome. Patients and methods. In all, 104 patients presenting with unstable or stable angina underwent percutaneous coronary intervention (PCI) in 107 vessels and stent implantation in 112 lesions, 53% of which were in SVG. Results. Device deployment and retrieval was successful in 111 lesions. Embolic material was detected in 74% of the protection devices. Early PCI, during a 2-week period after the last ischemic episode, was associated with larger embolic load, especially in the right coronary artery. The length of the lesion was the only preprocedural independent variable that was found to be a significant predictor for the presence of embo-
li (p=0.002). The stent diameter and the maximum dilatation pressure were the two procedural variables found to be significant predictors for the presence of emboli (p=0.025 and p=0.008, respectively). The irregularity of the lesion and the number of stents deployed were found to have a predictive correlation to the total area of the embolic particles (p=0.04 and p=0.005, respectively). Conclusion. Distal embolization of atherosclerotic debris is a frequent phenomenon after PCI not only in SVG but also in native vessels. The amount of embolic material seems to be related to the atherosclerotic burden of the vessel and to the early timing of the procedure as related to acute coronary syndrome. Keywords Acute coronary syndrome · Embolization · Stent implantation · Saphenous vein grafts · Native coronary artery
Embolusbildung nach perkutaner koronarer Intervention bei akutem Koronarsyndrom. V.-saphenaTransplante vs. natürliche Koronararterien Stentdurchmesser und der maximale Dilatationsdruck waren die beiden prozeduralen Variablen, die sich als signifikante Prädiktoren für das Vorliegen von Emboli herausstellten (p=0,025 und p=0,008). Für die Unregelmäßigkeit der Läsion und die Anzahl der verwendeten Stents wurde eine prädiktive Korrelation mit der Gesamtfläche embolischer Partikel festgestellt (p=0,04 bzw. p=0,005). Schlussfolgerung. Eine distale Embolusbildung durch atherosklerotische Ablagerungen ist nicht nur in V.-saphena-Transplantaten, sondern auch in den natürlichen Gefäßen ein häufiges Phänomen nach PCI. Die Menge embolischen Materials scheint mit der atherosklerotischen Last des Gefäßes und einem frühen Zeitpunkt der Maßnahme in Hinblick auf das akute Koronarsyndrom in Zusammenhang zu stehen. Schlüsselwörter Akutes Koronarsyndrom · Embolusbildung · Stentimplantation · V.-saphenaTransplantate · Natürliche Koronararterie
Herz 2014
| 3
Original article
Results
12,000 Mean Mean±SE Mean±SD Outliers Extremes
Longest diameter of the largest particle (µm)
10,000
F(2,78) = 2.1453; p = 0.1239
8,000
6,000
4,000
2,000
1,209
1,645 579
0
-2,000 SVBG
RCA
LEFT
type of vessel
Fig. 1 8 Longest diameter of the largest particle in native vessels and vein grafts. LEFT left coronary artery, RCA right coronary artery, SVBG saphenous vein graft 6 SVBG 5
RCA
Mean total area of particles per lesion (mm2)
LEFT F(2,73) = 3.6790, p = .03004
4 3.23
3 2
1.89 1.04
1 0.42 0
0.93 0.29
-1 -2 -3
2 wks Time to PCI (weeks)
Fig. 2 8 Mean total particle area per lesion in native vessels and vein grafts as related to the time of percutaneous coronary intervention (PCI) after the index event (vertical bars denote 0.95 confidence intervals). LEFT left coronary artery, RCA right coronary artery, SVBG saphenous vein graft
4 |
Herz 2014
In total, 104 consecutive patients underwent PCI in 107 vessels and stent implantation in 112 lesions, 53% of which were in SVG. Device deployment and retrieval was successful in 111 lesions. The type of embolic protection device, in order of frequency used, was the Filterwire (64%), the Angioguard (22%), the SpiderFX (11%), and the PercuSurge (3%). The Angioguard device was used more frequently in SVG and the PercuSurge device exclusively in SVG. Baseline patient clinical and angiographic characteristics are shown in . Tab. 1 and . Tab. 2 and procedural characteristics in . Tab. 3. Most of the lesions were complex, 70% of them were type C (AHA/ACC), and type C were significantly more in SVG (χ2 =12,972, p=0.011). The procedures were equally distributed to the two time periods of >2 weeks or ≤2 weeks after the last episode of rest angina; however, in native-vessel PCI 44% of the cases were postmyocardial infarction as compared with 9% in veingraft PCI cases. Postprocedural CPK-MB values were elevated in eight of 46 patients (17.4%) after PCI in native vessels and in two of 42 patients (4.8%) after PCI in SVG lesions. The strategy of low-pressure deployment of the stent and then filter deployment and dilatation of the stent at high pressures, required in our cases for technical reasons, was associated with higher postprocedural CPK-MB levels compared with patients who had the device placed at the beginning of the procedure or after small balloon predilatation [ANOVA F(2, 83), p
