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Volume 2, No 3 - Summer 2001

Volume 2, No 3 - Summer 2001

Table of Contents

In-Stent Restenosis Treatment Update
The decrease in restenosis rates compared with conventional angioplasty, stable angiographic results with a subsequent decreased need for urgent or emergency coronary bypass graft surgery, and reliable treatment of acute or threatened closure resulting from conventional angioplasty have all made stents the treatment of choice for many patients undergoing percutaneous intervention. In-stent restenosis (ISR), however, has become a significant problem. Neointimal hyperplasia with vascular smooth muscle cells is even more exaggerated with stent placement than with conventional angioplasty. In addition, failure to deploy the stent optimally at the time of the initial placement may result in increased restenosis. Symptoms of ISR typically occur within 6 to 9 months following intervention, and range from asymptomatic angiographic narrowing, or even occlusion, to recurrent angina/ischemia or myocardial infarction. Evaluation is by repeat angiography. Treatment with balloon angioplasty is effective for focal in-stent restenotic lesions; for other lesions excimer laser, rotational atherectomy, and directional coronary atherectomy are associated with excellent initial outcome, but long-term outcome of these procedures is unclear. Brachytherapy with both gamma and beta sources has been found to result in improved outcome with less angiographic restenosis and decreased target vessel revascularization. Late thrombosis has been documented in up to 10% of patients treated with vascular gamma brachytherapy, and increased stenosis at the edges of the treated segment is also seen. Prolonged dual antiplatelet therapy and avoidance of a new stent has been shown to reduce late thrombosis in patients treated with vascular brachytherapy. [Rev Cardiovasc Med. 2001;2(3):115–119]
Percutaneous Interventions for Lower-Extremity Peripheral Atherosclerotic Disease Treatment Update
Patients with peripheral arterial disease frequently develop symptoms of claudication that interfere with ambulation and adversely affect quality of life, and some develop critical limb ischemia. Many of these patients have coexisting coronary artery disease, and surgical revascularization poses risks of perioperative myocardial infarction and cardiovascular death. Peripheral catheter-based interventions are a feasible alternative. Percutaneous treatment can preserve the surgical option and is often used as an adjunct to surgery by addressing inflow stenoses and limiting the extent of surgical reconstruction that is necessary. Iliac artery balloon angioplasty has been shown to have a high rate of initial procedural success and long-term patency, and the use of stents is promising, especially in cases complicated by flow-limiting dissection or significant residual stenosis. Percutaneous revascularization of the femoropopliteal arteries has shown high restenosis rates and stents should be confined, at present, to flow-limiting dissections or inadequate results from balloon angioplasty alone. The indication for percutaneous revascularization below the knee is typically limited to those patients with critical limb ischemia who are at high risk for surgical reconstruction; short-term results with modern equipment have been promising and can salvage ischemic limbs. [Rev Cardiovasc Med. 2001;2(3):120–125]
Problems and Pitfalls in Cardiac Drug Therapy Treatment Review
Medical errors in the care of patients may account for 44,000 to 98,000 deaths per year, and 7,000 deaths per year are attributed to medication errors alone. Increasing awareness among health care providers of potential errors is a critical step toward improving the safety of medical care. Because today’s medications are increasingly complex, approved at an accelerated rate, and often have a narrow therapeutic window with only a small margin of safety, patient and provider education is critical in assuring optimal therapeutic outcomes. Providers can use electronic resources such as Web sites to keep informed on drug–drug, drug–food, and drug–nutritional supplements interactions. [Rev Cardiovasc Med. 2001;2(3):126–142]
Acute Coronary Syndrome in a Young Woman
When should an acute coronary event be suspected in a young woman with chest pain? Coronary artery disease is not common in such patients, but the possibility should not be discounted. Correct characterization of the pain, along with presence of known risk factors for CAD, can lead to an accurate diagnosis, even though the presentation may be atypical. [Rev Cardiovasc. 2001;2(3):166–171]