RESUMO
OBJECTIVES: To test the local delivery of sirolimus nanoparticles following percutaneous transluminal coronary angioplasty (PTCA) to treat in-stent restenosis (ISR) in a swine model. BACKGROUND: Coronary bare-metal stent (BMS) implantation reduces major adverse cardiac events when compared with PTCA; however, ISR rates remain high. METHODS: Eighteen swine underwent BMS deployment guided by intravascular ultrasound (IVUS). Of these, 16 developed ISR (1 stent/swine) and underwent angioplasty with a noncompliant balloon (PTCA-NC). The animals were then randomized into four groups for local infusion of sirolimus nanoparticles through a porous balloon catheter, as follows: (1) PTCA-NC alone (control); (2) PTCA-NC + (polylactic acid)-based nanoparticle formulation (anionic 1); (3) PTCA-NC + (polylactic-co-glycolic acid)-based nanoparticle formulation (anionic 2); and (4) PTCA-NC + Eudragit RS nanoparticle formulation (cationic). Coronary angiography and IVUS follow-up were performed 28 days after ISR treatment. RESULTS: There was one episode of acute coronary occlusion with the cationic formulation. Late area loss was similar in all groups at 28 days according to IVUS. However, luminal volume loss (control = 20.7%, anionic 1 = 4.0%, anionic 2 = 6.7%, cationic = 9.6%; P = 0.01) and neointimal volume gain (control = 68.7%, anionic 1 = 17.4%, anionic 2 = 29.5%, cationic = 31.2%; P = 0.019) were significantly reduced in all treatment groups, especially in anionic 1. CONCLUSIONS: PTCA-NC followed by local infusion of sirolimus nanoparticles was safe and efficacious to reduce neointima in this model, and this strategy may be a promising treatment for BMS ISR. Further studies are required to validate this method in humans.
Assuntos
Cateteres Cardíacos , Fármacos Cardiovasculares/administração & dosagem , Reestenose Coronária/terapia , Vasos Coronários/efeitos dos fármacos , Sistemas de Liberação de Medicamentos/instrumentação , Nanopartículas , Intervenção Coronária Percutânea , Sirolimo/administração & dosagem , Resinas Acrílicas/química , Animais , Fármacos Cardiovasculares/química , Química Farmacêutica , Angiografia Coronária , Reestenose Coronária/diagnóstico por imagem , Vasos Coronários/diagnóstico por imagem , Modelos Animais de Doenças , Portadores de Fármacos , Desenho de Equipamento , Infusões Parenterais , Ácido Láctico/química , Neointima , Poliésteres , Ácido Poliglicólico/química , Copolímero de Ácido Poliláctico e Ácido Poliglicólico , Polímeros/química , Porosidade , Sirolimo/química , Suínos , Fatores de Tempo , Ultrassonografia de IntervençãoRESUMO
Introdução: A reestenose coronária é um fenômeno pouco compreendidoe que permanece como um desafio mesmo na era dos stents farmacológicos. Este estudo tem como objetivo identificar genes envolvidos na síntese de proteínas estruturais e funcionais de células musculares lisas com expressão aumentada em placas ateromatosas de humanos associadosa hiperplasia neointimal após o implante de stents não-farmacológicos. Métodos: Placas ateromatosas foram obtidasmediante aterectomia direcionada, previamente ao implante do stent. A análise da expressão dos genes foi realizada utilizando-se o sistema Affymetrix GeneChip. Os pacientes foramsubmetidos a ultrassom intracoronário 6 meses após o procedimento para análise volumétrica intrastent. Foi avaliada a correlação entre a expressão gênica de placas ateromatosas e o porcentual de hiperplasia intimal intrastent. Resultados: A maioria dos pacientes era do sexo masculino (85,7%), com60,2 ± 11,4 anos de idade, 35,7% eram diabéticos e o porcentual de hiperplasia intimal intrastent foi de 29,9 ± 18,7%.Não houve variação do porcentual de hiperplasia intimal intrastent entre os pacientes com ou sem diabetes (29,5% vs. 30,7%; P = 0,89). Não houve correlação entre a extensão do stent e o porcentual de hiperplasia intimal intrastent (r = -0,26; P = 0,26) ou entre o diâmetro do stent e o porcentual dehiperplasia intimal intrastent (r = 0,14; P = 0,56). Oito genes envolvidos na síntese de proteínas estruturais e funcionais de células musculares lisas apresentaram correlação positiva como porcentual de hiperplasia intimal intrastent. Conclusões: As lesões coronárias de novo apresentam expressão aumentada de genes relacionados com a síntese de proteínas estruturais e funcionais de células musculares lisas associados a futurahiperplasia neointimal intrastent significativa, surgindo como novos alvos terapêuticos.
Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Aterectomia Coronária/métodos , Aterectomia Coronária , Expressão Gênica , Reestenose Coronária/complicações , Stents Farmacológicos , Stents , Fatores de RiscoRESUMO
BACKGROUND: Statins have anti-inflammatory and antiproliferative properties irrespective of their cholesterol-lowering effects. The aim of the present study was to evaluate a simvastatin-eluting stent (SimvES) in the treatment of de novo coronary lesions. METHODS AND RESULTS: Forty-two patients with de novo coronary artery lesions were assigned to SimvES, bare-metal stent (BMS) or everolimus-eluting stent (EES) implantation followed by intravascular ultrasound (IVUS) for neointimal quantitative analysis. Six months later, quantitative coronary angiography (QCA) and IVUS were repeated. QCA showed no binary restenosis, a mean in-stent late loss of 1.05 ± 0.25 mm (BMS, 1.12 ± 0.48 mm; EES, 0.20 ± 0.16 mm) and a diameter stenosis of 33.5 ± 7.1% (BMS, 35.5 ± 15.30%; EES, 7.2 ± 3.12%). Control IVUS showed a mean in-stent obstruction of 18.3 ± 9.4% (BMS, 32.8 ± 19.1%; EES, 9.8 ± 2.4%) and a neointimal volume index of 1.58 ± 0.75 mm(3)/mm (BMS, 2.93 ± 1.76 mm(3)/mm; EES, 0.80 ± 0.16 mm(3)/mm). Thrombus, late incomplete apposition and major adverse cardiac events were not observed. CONCLUSIONS: In this sample of patients with de novo coronary lesions, the use of a SimvES was not related to major adverse cardiac events, but it was associated with a higher level of neointimal proliferation than expected.
Assuntos
Anticolesterolemiantes/efeitos adversos , Reestenose Coronária/patologia , Stents Farmacológicos/efeitos adversos , Neointima/patologia , Sinvastatina/efeitos adversos , Idoso , Anticolesterolemiantes/farmacologia , Angiografia Coronária/métodos , Reestenose Coronária/etiologia , Everolimo , Feminino , Humanos , Imunossupressores/efeitos adversos , Imunossupressores/farmacologia , Masculino , Pessoa de Meia-Idade , Neointima/etiologia , Sinvastatina/farmacologia , Sirolimo/efeitos adversos , Sirolimo/análogos & derivados , Sirolimo/farmacologia , Ultrassonografia de Intervenção/métodosRESUMO
Endovascular treatment of ascending aorta pseudoaneurysms with coronary stents implantation at the same procedure was feasible, although longer followup is necessary.
Assuntos
Falso Aneurisma/cirurgia , Angioplastia Coronária com Balão/efeitos adversos , Aneurisma Aórtico/cirurgia , Doença da Artéria Coronariana/terapia , Procedimentos Endovasculares/efeitos adversos , Idoso , Terapia Combinada/efeitos adversos , Feminino , Humanos , Masculino , Mediastinite/etiologia , Mediastinite/cirurgia , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/cirurgia , Reoperação/métodosRESUMO
Introdução: A substituição cirúrgica da valva aórtica é o tratamento de eleição para pacientes com estenose aórtica acentuada. Entretanto, o risco cirúrgico aumenta expressivamente com o avançar da idade e com a associação de comorbidades. Recentemente, iniciou-se a experiência com o implante por cateter de biopróteses aórticas no Brasil. Justifica-se, portanto, a criação de um registro nacional para conhecimento dos resultados desse tipo de procedimento em nosso meio. Descrevemos o racional e o desenho do Registro Brasileiro de Implante de Bioprótese Aórtica por Cateter. Métodos: Trata-se de um registro multicêntrico, prospectivo, que incluirá 200 pacientes portadores de estenose valvar aórtica sintomática de alto risco cirúrgico submetidos a implante por cateter de bioprótese valvular aórtica em centros brasileiros. O desfecho primário do estudo é a mortalidade por qualquer causa aos 30 dias, 12 meses e 24 meses. Os desfechos secundários avaliados incluem, entre outros: 1) sucesso técnico do implante da bioprótese;2) mortalidade cardiovascular aos 30 dias, 12 meses e 24 meses; 3) desfecho combinado de segurança aos 30 dias; e 4) desfecho combinado de eficácia aos 12 meses e 24 meses. Conclusões: A análise dos resultados desse registro nacional permitirá avaliar os defechos do implante percutâneo de biopróteses aórticas em nosso meio.
Background: Surgical replacement of the aortic valve is the therapy of choice for patients with severe aortic stenosis.However, the surgical risk increases dramatically as age advances and with the association of comorbidities. Recently, transcatheter aortic valve implantation has been introduced in Brazil. Therefore, it was important to create a national registry to determine the outcomes of this procedure in our country. The rationale and design of the Brazilian Transcatheter Aortic Valve Implantation Registry is described.Methods: This is a multicenter prospective registry, including 200 patients with symptomatic aortic valve stenosis and high surgical risk submitted to transcatheter aortic valve implantation in Brazilian institutions. The primary endpoint of the study is all cause mortality at 30 days, 12 and 24 months. Secondary endpoints, among others, are: 1) technical success of transcatheter valve implantation; 2)cardiovascular mortality at 30 days, 12 and 24 months; 3) composite safety endpoint at 30 days; and 4) compositeefficacy endpoint at 12 and 24 months. Conclusions: The analysis of the results of this national registry will enable us to evaluate the outcomes of transcatheter aortic valve implantation in our country.
Assuntos
Humanos , Bioprótese , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Implante de Prótese de Valva Cardíaca/mortalidade , Fatores de RiscoRESUMO
INTRODUCTION: The association between erectile dysfunction (ED) and coronary artery disease (CAD) has been described in various settings, but it is unclear if there is an independent interaction with age. AIM: To investigate the interaction of age in the association between ED and CAD. METHODS: This case-control study was conducted among 242 patients referred for elective coronary angiography. One hundred fourteen patients with significant CAD were identified as cases and 128 controls without significant CAD. ED was evaluated by the erectile function domain of the International Index of Erectile Function (IIEF) questionnaire, determined by a score ≤ 25 points. MAIN OUTCOME MEASURES: Significant CAD was based on stenosis of 50% or greater in the diameter in at least one of the major epicardial vessels or their branches. The analysis was conducted in the whole sample and according to the age strata, controlling for the effects of cardiovascular risk factors, testosterone, and C-reactive protein. Results. Patients had on average 58.3 ± 8.9 years. CAD and ED were associated exclusively in patients younger than 60 years (ED in 68.8% of patients with CAD vs. 46.7% of patients without CAD, P = 0.009). The association was independent of cardiovascular risk factors, testosterone and C-reactive protein (risk ratio 2.3, 95% confidence interval from 1.04 to 5.19). Severity of CAD was higher in patients younger than 60 years with ED. CONCLUSIONS: Men with less than 60 years of age who report ED presented a higher risk of having chronic CAD and more severe disease diagnosed by coronary angiography.
Assuntos
Doença da Artéria Coronariana/complicações , Disfunção Erétil/etiologia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Proteína C-Reativa/análise , Estudos de Casos e Controles , Distribuição de Qui-Quadrado , Angiografia Coronária , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Fatores de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Inquéritos e Questionários , Testosterona/sangueRESUMO
Pseudoaneurysm of the ascending aorta is an uncommon pathology and a challenge in high-risk patients who undergo conventional surgery because of high operative morbidity and mortality. Endovascular exclusion of an aortic pseudoaneurysm using an endoprosthesis is a less invasive approach, but few such cases have been reported. Moreover, the use of this approach poses unique therapeutic challenges because there is no specific endoprosthesis for ascending aortic repair, particularly to treat patients with previous coronary artery bypass graft (CABG). We describe the case of a 74-year-old patient who had undergone CABG and later presented with an iatrogenic ascending aortic pseudoaneurysm that occurred during an angiography. This patient was at very high risk for surgical treatment and, therefore, an endovascular approach was adopted: percutaneous coronary intervention for the left main coronary artery, left anterior descending and left circumflex native coronary arteries followed by endovascular endoprosthesis deployment in the ascending aorta to exclude the pseudoaneurysm. Both procedures were successfully performed, and the patient was discharged without complications 4 days later. At 5 months' clinical follow-up, his clinical condition was good and he had no complications.
Assuntos
Falso Aneurisma/cirurgia , Angioplastia Coronária com Balão , Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Cateterismo Cardíaco/efeitos adversos , Ponte de Artéria Coronária , Idoso , Falso Aneurisma/diagnóstico , Falso Aneurisma/etiologia , Aneurisma da Aorta Torácica/diagnóstico , Aneurisma da Aorta Torácica/etiologia , Aortografia/métodos , Humanos , Doença Iatrogênica , Masculino , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
INTRODUÇÃO: Há múltiplos modelos experimentais em animais, entretanto o modelo suíno é o que apresenta características anatômicas e funcionais mais próximas às humanas. Assim sendo, esse trabalho foi realizado com o objetivo de desenvolverr e implementar um protocolo experimental de indução de hiperproliferação neointimal em suínos, visando à criação de técnicasw de lesão vascular simulando a reestenose. Método: De agosto de 2006 a março de 2009, 69 suínos jovens da raça Large White foram submetidos a cinecoronariografia seguida de lesão vascular com implante de 102 stents sobredimensionados, guiados por ultrassom intracoronário. Em 28 dias foi realizado reestudo com nova cinecoronariografia e ultrassom intracoronário. Resultados: O diâmetro luminal mínimo e a área luminal mínima imediatamente após o implante de stent no grupo stent sobredimensionado foram maiores em comparação ao grupo controle...
BACKGROUND: There are several experimental animal models, but, the swine model is the most similar to human anatomic and physiologic characteristics. Therefore, this study was carried out to develop and implement an experimental protocol of vascular neointimal hyperplasia induction in swine, aiming at creating vascular injury techniques simulating restenosis. METHOD: From August 2006 to March 2009, 69 young Large White swine underwent coronary angiography followed by vascular injury and implantation of 102 oversized stents guided by intravascular ultrasound. After 28 days a new coronary angiography and intravascular ultrasound was performed. RESULTS: The minimal luminal diameter and the minimal luminal area immediately after the stent deployment in the group treated with an oversized stent were significantly higher when compared to the control group (3.5 ± 0.3 mm vs. 3 ± 0.2 mm, P < 0.0001 and 40.7 ± 0.3 mm² vs. 30.2 ± 0.2 mm², P < 0.0001). The binary restenosis rate in the group treated with an oversized stent was 92% (69/75 stents), whereas it was 12% (3/25 stents) in the control group, with a statistically significant difference (P < 0.0001). The neointimal hyperplasia volume was significantly higher in the group treated with an oversized stent in comparison to the control group (5.9 ± 0.8 mm³/stent mm vs. 1.8 ± 0.7 mm³/stent mm, P < 0.0001). CONCLUSION: The proposed experimental model of neointimal proliferation induction in swine is effective in inducing instent hyperplasia, and therefore it may be used for the study of the pathophysiologic mechanisms of in-stent restenosis as well as for therapeutic purposes, such as the evaluations of new drugs, new devices and new drug-eluting stents for the prevention and treatment of in-stent restenosis.
Assuntos
Animais , Modelos Animais , Angioplastia Coronária com Balão/métodos , Angioplastia Coronária com Balão , Reestenose Coronária/cirurgia , StentsRESUMO
The aim of this study is to analyze the immediate and late evolution for death and reintervention in a thoracic endovascular aortic repair (TEVAR) group, over a follow-up period of 112 months. Retrospective data of 255 patients, from 1998 to 2007, were obtained. The most prevalent diseases were thoracic aortic aneurysms (89), thoracic and abdominal aneurysms (85) and thoracic aortic dissections (61). The mean age was 63.2 years and 67.1% were male. Three hundred and three endoprostheses were used. Causes of morbidity, in the immediate postoperative period, were hyperthermia (45.9%), endoleaks (9.8% - being 7.1% type I), vascular complications (5.2%), renal insufficiency (3.1%) and neurological complications (3.1%). There were two (0.8%) hospital deaths and 17 (6.7%) late deaths. Time of follow-up was up to 112 months (mean of 60 months). The Kaplan-Meier curve analysis showed an increase of reintervention, compared with death, after a follow-up period of 42 months. Freedom from death at 36, 60 and 112 months was 96%, 89.1%, 85.1% and for reintervention, for the same periods was 93.6%, 82.7%, 57.2%, respectively. This study showed low incidence of prostheses related morbidity and immediate mortality. After a period of 42 months there was an increase on the percentual tax of reintervention.
Assuntos
Aorta Torácica/cirurgia , Doenças da Aorta/cirurgia , Implante de Prótese Vascular , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Dissecção Aórtica/cirurgia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Coartação Aórtica/cirurgia , Doenças da Aorta/mortalidade , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Brasil , Feminino , Mortalidade Hospitalar , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Úlcera/cirurgia , Adulto JovemRESUMO
Horseshoe kidney is a rare congenital anomaly that may cause various technical problems during conventional repairs of abdominal aortic aneurysms. We report the case of a 68-year-old woman with a horseshoe kidney, symptomatic abdominal aortic aneurysm and mild renal failure. The patient underwent endovascular repair using a bifurcated endoprosthesis. The postoperative was uneventful. We describe the diagnosis and the endovascular technique and literature review.