Patch angioplasty versus primary closure for carotid endarterectomy
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Occlusion or severe stenosis, with a reduction in the diameter of more than 70% of the extracranial arteries may lead to hpoperfusion of the brain with an increased risk of cerebral infarction. The aim of this study was to investigate whether endarterectomy of stenosed internal carotid arteries leads to alternations in cerebral metabolism in regions in which no infarcts were visible with magnetic resonance imaging (MRI). We studied 10 healthy control subjects and 20 patients with transient or nondisabling cerebral ischemia with MRI and 1H magnetic resonance spectroscopic imaging. All patients underwent carotid endarterectomy. Patients were examined 1 week before and 3-6 months after carotid endarterectomy. The N-acetyl aspartate (NAA)/choline ratio in the symptomatic hemisphere before endarterectomy (2.29 +/- 0.42) was significantly (p < 0.001) lower than for control subjects (3.18 +/- 0.32). In five of the patients lactate was detected preoperatively in regions that were not infarcted. The NAA/choline ratio in the symptomatic hemisphere of these five patients did not increase significantly after endarterectomy (1.99 +/- 0.22 vs. 2.23 +/- 0.48). The NAA/choline ratio in patients without lactate preoperatively increased significantly (p < 0.01) after endarterectomy to a normal level (from 2.39 +/- 0.42 to 2.92 +/- 0.52). These results indicate that the presence of cerebral lactate may predict whether the NAA/choline ratio increases after carotid endarterectomy.
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Intracoronary artery radiation can significantly reduce restenosis rates after angioplasty, according to a new report (Circulation 2000;101:350-1,360-5).
Angioplasty is often complicated by restenosis, or coronary artery renarrowing. An estimated 30-50% of vessels dilated by angioplasty develop restenosis, a process that seriously limits the efficacy of the procedure. Restenosis can occur early or late after angioplasty and is heralded by symptoms of recurrent angina or even by myocardial infarct.
Restenosis is a consequence of the blood vessel wall responding to the “injury” of angioplasty and can thus be …
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The records of 1162 consecutive patients undergoing their first percutaneous transluminal coronary angioplasty at a centre between March 1980 and June 1987 were reviewed. Initial angioplasty was successful in 1011 patients (87%). In 202 (20%) symptomatic restenosis developed. Of these, 196 were treated with redilatation; this was successful in 181 (92%). After a second dilatation, restenosis developed in 47 patients (26%). Of these, 41 (87%) were treated with a third angioplasty, with primary success in 38 (93%). A further restenosis developed in 13 of these 38 patients (34%). Eight patients were treated with a fourth angioplasty with restenosis in four (50%). Two of these four patients underwent a fifth angioplasty (with continuing success at long term follow up in both). Overall, 14 of the 47 (30%) patients who developed restenosis twice were eventually treated with coronary bypass surgery. Most patients (33), however, were treated only with repeated angioplasties. Of these 33 patients, 27 were treated with a third angioplasty, four with a fourth procedure, and two with a fifth. Twenty-nine (88%) were symptom free at a mean follow up of 28 (range 8 to 86) months. The combined success rate for a third, fourth, and fifth angioplasty was 94%. These data suggest that most patients with recurrent restenosis after angioplasty may be managed successfully and safely with repeated redilatations.
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Despite widespread use of coronary balloon angioplasty, advances in angioplasty technology, and improvements in operator technique, restenosis at the angioplasty site is the major problem limiting the long-term efficacy of this procedure. The article reviews morphologic-histologic observations at angioplasty restenosis sites, speculates about the connection between the acute injury patterns of balloon angioplasty and the development of restenosis, and briefly reviews the currently understood pathways to restenosis and possible approaches to its reduction or elimination.
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Abstract In order to compare the processes of restenosis after balloon angioplasty as compared to that after directional coronary atherectomy, we performed qualitative and quantitative analysis of 72 lesions in 68 patients with recurrent ischemia following a successful initial procedure. For each lesion, we reviewed the pre‐intervention, immediate post‐intervention, and restenosis angiograms. The morphology of the restenotic lesions could not be predicted from pre‐ or post‐intervention angiograms. The restenotic lesions after directional atherectomy, as compared to balloon angioplasty, did not show a statistically significant difference, although there was a trend to more eccentric narrowing. © 1995 Wiley‐Liss, Inc.
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