Heart & Vascular Center of Arizona Launches New Web Site

The Heart & Vascular Center of Arizona launched a new patient web site to better service patients.  The new site has a new look and will be the link to a new patient portal that will be launched in the next month.   The new patient portal will make it easier for patients to access key information on their overall health.  Watch the site for new information on when the patient portal will be accessible.

For more information contact the Heart & Vascular Center of Arizona at (602) 307-0070.

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Launch of New Patient Portal Coming Soon

In the next month, the Heart & Vascular Center of Arizona will be launching a new patient portal which will be accessible from their new web site.  Patients will click on the "Patient Portal" button on the right hand side of their screen to login to the portal.  A user name and password will be used to access their own patient information, get forms, schedule appointments and many other items to make it more convenient for patients to get information at any time of day.

New patients will be able to register ahead of their new appointment time, filling out all of the necessary paperwork normally handled in the office. 

For more information, contact the Heart & Vascular Center of Arizona at (602) 307-0070.

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Local Cardiologist Lauds FDA Approved Procedure

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Dr. Nathan Laufer, Dr. Ashish Pershad and Dr. Ashish Sadhu were listed on this year's Top Docs Phoenix List.  Look for them in the April 2010 Phoenix Magazine!  Dr. Laufer, Medical Director of Heart & Vascular Center of Arizona, is a nine year Top Docs Award Winner for Cardiology.  

Dr. Pershad is featured this year in Phoenix Magazine's "Fantastic Five."  The article features five of the Valley's most innovative physicians.  An HVCA Interventional Cardiologist, Ashish Pershad, MD is one of a dozen doctors in the country performing the retrograde approach to coronary recanilization. 

Dr. Ashish Sadhu, an Electrophysiologist at HVCA,  was recognized this year for the first time.  Electrophysiologists are cardiologists who have additional education and training in the diagnosis and treatment of abnormal heart rhythms. 

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Join Heart & Vascular Center of Arizona's physicians and staff at the 2010 Phoenix "Start!" Heart Walk.  Opening Ceremonies begins at 8:30am on Saturday, February 27th, Tempe Town Lake.

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Heart & Vascular Center Physicians Embrace E-Prescribing

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Percutaneous Endovascular Abdominal Aneurysm Repair  
Course Director: Ashish Pershad, MD
October 22-23, 2009

 

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Abiomed will be honoring a site within the PROTECT II Clinical Trial community each month that has displayed outstanding excellence and enthusiasm. This month we would like to highlight Banner Good Sam in Phoenix, Arizona. They were late to enter the trial but they successfully recruited six patients within five months of their activation date. They have displayed great enthusiasm in helping PROTECT II become a successful trial. “I think the Impella device is a true game changer in the field of interventional cardiology. The ease of use is truly a huge advantage for these high risk PCI procedures. I am anxiously awaiting the completion of PROTECT 2 so that we can identify “the patient” who would benefit most from this device and confirm our proof of concept about superiority over the balloon pump,” said Dr. Ashish Pershad, PI at Banner Good Sam. 

For such a successful trial, Gabriella Diaz, RN recommends, “Collaborative education is one of the largest assets for success in not just enrolling subjects in the study, also obtaining the large data set required. The cooperation of multiple specialties to include, Cardiac Catheterization Lab, Pre-Op, holding area and bedside staff has been the key to achieving research goals. We are not islands unto ourselves. Respecting all the professionals involved through education and cooperation is a catalyst to obtaining clean, quality data that will support subject safety and industry quality.” 

Thank you Banner Good Sam!

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Congress is closer than ever to passing a health system reform bill, and we can't lose this opportunity for real health reform. However, members of the AMA's Patients' Action Network and doctors from around the country--in states like Florida, Nebraska, Colorado, Texas and Missouri--are all concerned about how this legislation will affect your access to your doctor.

In the U.S. Senate, the health reform bill that's been proposed would use Medicare as a foundation--and that foundation is crumbling because of an archaic payment system already in place. This system is scheduled to cut Medicare physician payments by more than 20 percent Jan. 1, 2010, with repeated annual cuts coming after that.

These annual cuts are a huge problem for patients--and for many families--because they will prevent doctors from taking on new Medicare patients, discourage many from investing in new health technology and make some think about closing their medical practices altogether.

Right now, the Senate is promoting another one-year Band-Aid for this problem, which means that we’ll be dealing with an even bigger problem next year.

Watch doctors from around the country discuss the reality of what this means for you and your family, then call Sen. John McCain (R) and Sen. Jon Kyl (R) at (888) 434-6200 or e-mail them here.

Please don't put this off. Your senators need to hear from you now, to protect your family's access to health care today and in the future. Tell your senators that the short-term, Band-Aid approaches used in the past will no longer do. Real health system reform must include Medicare reform.

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CPR Class for Kids

 American Heart Association, Arizona Cardinals Preparatory  Academy, and Phoenix Fire Team Up to Share the Gift of CPR with Students!

First-of-its-kind program for Maricopa County students to kickoff on September 22, 2009

Phoenix, AZ--- The American Heart Association has teamed up with  Cardinals Charities, the Arizona Cardinals Preparatory Academy and the City of Phoenix Fire Department, to kickoff a special CPR instructional program for 7th and 8th grade students.  Through the use of the CPR Anytime kit, students will each be given their own mini blow-up mannequin and instructional DVD and workbook.  Phoenix Fire personnel will facilitate the training.

The program, called Heartbeat of Arizona, will teach students across Maricopa County the skills needed to perform cardiopulmonary resuscitation in only 22 minutes.  

On Tuesday, September 22, 2009 from 1 p.m. – 2p.m., students at the Arizona Cardinals Preparatory Academy will be the first in Maricopa County to be trained with the CPR Anytime program.  The campus is located at the Royal Palms Middle School on the corner of Butler Ave. and 19th Ave. in the Washington Elementary School District. The training will take place at the campus Community Center.  Cardinals Quarterback Kurt Warner, along with his wife Brenda, and other Arizona Cardinals players will be on hand to help train the students.

“Teaching the lifesaving skill of CPR reinforces the mission of the academy and the school district and that is to cultivate student achievement, prepare all students to become responsible and successful contributors to our diverse society.  We’re honored that Cardinals Charities and the American Heart Association chose our academy to kickoff this great educational opportunity," says Principal Jackie Jackson, Ed D.

"The Phoenix Fire Department is excited about partnering with the American Heart Association and the Arizona Cardinals Preparatory Academy to bring CPR knowledge to Maricopa County students," said Chief Bob Khan.  "Not only are we empowering children in the fight against sudden cardiac arrest, we are bringing that knowledge into the home, where the majority of these kinds of emergencies occur."

“The American Heart Association has found that only 6.4% of sudden cardiac arrest victims survive because the vast majority of those witnessing the incident are people who do not know how to perform CPR,” says Suzanne Sorof, MD, and board president of the Phoenix American Heart Association.  Cities such as Seattle that have implemented heart safe programs boast survival rates around 40 percent, according to the American Heart Association.  When sudden cardiac arrest occurs, the victim collapses, becomes unresponsive to gentle shaking, stops normal breathing and after two rescue breaths, still isn't breathing normally, coughing or moving. CPR helps maintain vital blood flow to the heart and brain and increases the amount of time that an electric shock from a defibrillator can be effective, according to the American Heart Association.

Recent studies have shown that students as young as 9 years are able to successfully and effectively learn basic life support skills including AED [automated external defibrillator] deployment, correct recovery position and emergency calling.  A critical component of the program is that after kids learn CPR in the classroom, they then take the CPR Anytime kit home to share it with family and friends.

Heartbeat of Arizona is made possible by generous funding from Phoenix area businesses including the Cardinals Charities, Blue Cross Blue Shield of Arizona and Aetna.  More than $1 million dollars is needed to sustain the program over the next three years.

About The Cardinals Academy:

The Cardinals Academy offers accelerated instruction to help students focus on their education and service learning to help students achieve success. The academy promotes a small school environment of not more than 120 students, quality teachers, and community resources delivered in an accessible way to reduce or eliminate nonscholastic barriers to staying in school.

About the American Heart Association:

Founded in 1924, the American Heart Association today is the nation’s oldest and largest voluntary health organization dedicated to reducing disability and death from diseases of the heart and stroke. These diseases, America’s No. 1 and No. 3 killers, and all other cardiovascular diseases claim over 870,000 lives a year. In fiscal year 2005–06 the association invested over $543 million in research, professional and public education, advocacy and community service programs to help all Americans live longer, healthier lives. To learn more, call 1-800-AHA-USA1 or visit americanheart.org.

Additional Facts on Sudden Cardiac Arrest and CPR:

- About 80 percent of all out-of-hospital cardiac arrests occur in private residential settings, so being trained to perform cardiopulmonary resuscitation (CPR) can mean the difference between life and death for a loved one.

- Effective bystander CPR, provided immediately after cardiac arrest, can double a victim’s chance of survival.

- CPR helps maintain vital blood flow to the heart and brain and increases the amount of time that an electric shock from a defibrillator can be effective.

- Approximately 93 percent of sudden cardiac arrest victims die before reaching the hospital.

- Death from sudden cardiac arrest is not inevitable. If more people knew CPR, more lives could be saved.

- Brain death starts to occur four to six minutes after someone experiences cardiac arrest if no CPR and defibrillation occurs during that time.

- If bystander CPR is not provided, a sudden cardiac arrest victim’s chances of survival fall 7 percent to 10 percent for every minute of delay until defibrillation. Few attempts at resuscitation are successful if CPR and defibrillation are not provided within minutes of collapse.

- Coronary heart disease accounts for about 446,000 of the over 864,000 adults who die each year as a result of cardiovascular disease.

- There are 294,851 emergency medical services-treated out-of-hospital cardiac arrests annually in the United States.

- There are about 138,000 coronary heart disease deaths within one hour of symptom onset each year in the United States. 

- Sudden cardiac arrest is most often caused by an abnormal heart rhythm called ventricular fibrillation (VF). Cardiac arrest can also occur after the onset of a heart attack or as a result of electrocution or near-drowning.

- When sudden cardiac arrest occurs, the victim collapses, becomes unresponsive to gentle shaking, stops normal breathing and after two rescue breaths, still isn’t breathing normally, coughing or moving. 

Date and Time: Tuesday, September 22, 2009 from 1 p.m. – 2p.m

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One-Year Outcomes for Recanalization of Long Superficial Femoral Artery Chronic Total Occlusions with the Viabahn Stent Graft

VOLUME: 21 PUBLICATION DATE: Jun 01 2009

Sidebars_in_article: 

 

 

Issue Number: 

6 (June 2009)

Start Page: 

278

End Page: 

281

author(s): 

*Nahel Farraj, DO, §A. Srivastava, MD, *,§,£Ashish Pershad, MD

ABSTRACT: Objective. The treatment of long superficial femoral artery (SFA) chronic total occlusions (CTOs) remains controversial. There are several percutaneous treatment options available for the recanalization of these lesions. Percutaneous transluminal angioplasty (PTA) alone, nitinol stents, and expanded PTFE-lined nitinol stents are all viable treatment alternatives to femoral-popliteal bypass surgery. There are, however, limited data on outcomes of patients with SFA CTOs undergoing endovascular treatment. This study was performed to evaluate the safety, efficacy and 1-year patency rates of the Viabahn (WL Gore and Associates, Flagstaff, Arizona) e-polytetrafluoroethylene (e-PTFE) stent grafts at a major medical center in Phoenix, Arizona. Methods. Thirty patients (32 limbs) were prospectively treated for activity-limiting claudication after failing medical therapy. These patients received traditional angioplasty and stenting techniques using the Viabahn e-PTFE stent graft. Follow-up ankle-brachial index (ABI) examinations and duplex surveillance were completed at 6 and 12 months in all patients. Results. The mean age of the patients was 58.4 years. There were 12 women (40%) and 18 men (60%). Five of the patients (16.67%) were diabetics. The procedural success rate was 100%, with no in-hospital morbidity or mortality. The mean preprocedural ABI was 0.54 and the mean SFA occlusion length was 15.4 cm. The mean stented length was 24.6 cm. The median stent diameter was 6 mm. One patient (3.3%) did have subacute stent thrombosis at 4 months. On follow-up testing, the mean post-procedure ABI at 1 year was 0.76 with a primary patency rate of 80% and a primary assisted patency rate of 86%. Silent asymptomatic occlusions were noted in 10% (3/30) of the patients. Restenosis was a prespecified endpoint and was defined as being significant if the proximal peak velocity ratio (PVR) exceeded 2.4 on duplex interrogation. This endpoint was detected in 6.6% of the patient population (2/30) (proximal peak velocity ratio is the ratio of the maximum intrastenotic PSV and the maximum prestenotic PSV). Conclusions. Percutaneous e-PTFE stent-grafting with the Viabahn stent graft is a viable treatment option for TASC D occlusions in the SFA in claudicants and patients with critical limb ischemia. Primary and primary assisted patency rates at 1 year are comparable to historical surgical outcomes using PTFE grafts as bypass conduits. Long-term data (> 5 years) in a larger patient cohort are necessary before definite conclusions can be drawn.

J INVASIVE CARDIOL 2009;21:278–281

Key words: Peripheral vascular disease; endovascular; intervention;
expanded polytetrafluoroethylene (e-PTFE); ankle brachial index (ABI)

Atherosclerotic peripheral vascular disease (PVD) is often an underdiagnosed, undertreated and debilitating disease.1 The 2007 Trans-Atlantic Inter-Society Consensus (TASC) for the Management of Peripheral Arterial Disease document estimates that there are currently 27 million people in Europe and North America who are afflicted with this disease. There are also an estimated 413,000 hospital discharges per year due to chronic PVD.2 The prevalence of PVD increases progressively with age, beginning after the age of 40, a relationship demonstrated by the National Health and Nutrition Examination Survey. The authors found that PVD was present in 0.9% of those between the ages of 40–49 years, 2.5% of those 50–59 years old, 4.7% in the 60–69 year-old group and 14.5% in those ≥ 70 years.3 PVD will thus continue to grow in clinical significance as the world’s population ages.

The use of percutaneous transluminal angioplasty (PTA) to revascularize the superficial femoral artery (SFA) can result in initial technical success rates > 95%, with a low risk of complications.4 However, late clinical failure remains an important concern. Restenosis occurs in 40–60% of treated segments after 1 year. The use of angioplasty to treat extensive disease of the SFA has particularly poor results: at 1 year, the rates of restenosis exceed 70% for lesions longer than 10 cm.5

Stents avoid the problems of early recoil and flow-limiting dissection after balloon angioplasty and can thus be used for the treatment of long and complex lesions. Initial studies of stenting of the SFA reported promising results, with patency rates > 85% at 18 months.6 However, subsequent studies found that exaggerated neointimal hyperplasia frequently leads to in-stent restenosis, and randomized, controlled trials failed to demonstrate any benefit of a stainless-steel stent over angioplasty alone.7

Investigation into evaluating efficacy of percutaneous stenting versus angioplasty alone has yielded conflicting results. The VIENNA trial demonstrated a 37% restenosis rate at 12 months in those with SFA stenting versus a 64% restenosis rate for those with angioplasty alone.8 This was further supported by the RESILIENT trial, which demonstrated superiority with target vessel revascularization (TVR) at 12 months in those with SFA stenting over angioplasty alone.9 It is important to note that the RESILIENT results were primarily from TASC A and B lesions, with significantly higher crossover than previous studies. In contrast, the FAST trial demonstrated no difference in binary restenosis at 12 months between PTA and stenting compared to PTA alone.10 This finding was confirmed by a recent meta-analysis, which concluded that while initial procedural success is higher with routine stenting, there was no detectable difference in restenosis or TVR in long-term follow up.11 Stenting of the SFA for TASC A and B lesions is currently recommended only as a bailout procedure after technical failure of angioplasty.12

The last decade has ushered in many new endovascular treatment modalities for PVD including endovascular cryoplasty, cutting-balloon angioplasty, subintimal angioplasty, excisional atherectomy, excimer laser-assisted angioplasty, drug-eluting stents, biodegradable stents and e-PTFE covered self-expanding stents.13,14 The TASC II guidelines recommend endovascular treatment for TASC A and B lesions. Surgical revascularization has been the recommendation for TASC D lesions (lesion classifications are provided in Table 1). The guidelines are ambiguous as to how TASC C lesions are approached. There remains equipoise, with some recommending a trial of endovascular therapy first, while others suggest open surgical techniques as the frontline therapy. Though the guidelines recommend open surgery for the more severe cases (TASC C and D), many of these patients may benefit from less invasive endovascular treatments because they are not candidates for surgery due to a prohibitively high perioperative cardiovascular risk or other medical comorbidities. Many of these patients are denied any treatment, and thus frequently end up with the catastrophic consequence of limb loss.

Chronic total occlusions (CTOs) of the SFA are a particularly challenging lesion subset. Recanalization rates in CTOs are reported as > 85%. Pooled results also show 1- and 3-year patency rates for CTOs of 65% and 48% for PTA alone, and 73% and 64% for PTA/stent.15 There are no long-term data for PTA/stent, but the 5-year patency rates of PTA alone for stenosis and occlusion are 55% and 42%, respectively. Because of these success rates, many feel that patients with more extensive disease should be considered for percutaneous treatment and then referred for surgery if this approach fails. Bypass surgery with venous grafts must still be considered the most durable and extensively studied revascularization technique for patients with chronic limb ischemia and extensive disease of the SFA. The Bypass Surgery versus Angioplasty in Severe Ischemia of the Leg trial found that the rates of amputation-free survival after surgery and balloon angioplasty were similar for at least the first 2 years.18

Nitinol stents may be an effective alternative to surgical revascularization for longer lesions in patients who are poor candidates for surgery, such as those with severe coexisting cardiovascular conditions. Furthermore, stenting may be an option for patients without available saphenous vein grafts, since the 12-month patency data for stents are similar to those for prosthetic bypass grafts, and stenting has a considerably lower rate of complications. However, the endovascular approach seems justified as long as the rates of complications are low and the surgical target zone for the distal anastomosis of a potential secondary bypass operation remains unaffected by the interventional procedure.

This study, conducted at a major teaching hospital, evaluated the safety, efficacy and 1-year patency rates of the Viabahn expanded-PTFE (e-PTFE) stent grafts (WL Gore and Associates, Flagstaff, Arizona) in patients with SFA disease and Functional Class II and III claudication.

Methods

Thirty patients (32 limbs) were prospectively treated for activity and lifestyle-limiting claudication. All patients included in this study were symptomatic and refractory to maximal outpatient medical management including smoking cessation, use of cilostazol and exercise therapy. Asymptomatic patients, despite known severe SFA stenoses or occlusions, were not included in this investigation. Twenty-eight patients (93.33%) were Functional Class III–IV claudicants, while 2 patients (6.67%) presented with critical limb ischemia. None of the patients had tissue loss.

Traditional angioplasty and stenting techniques were employed in all patients. During the procedure, these patients received the Viabahn e-PTFE stent graft. Access for the intervention was obtained from the contralateral route in 22 patients (73.3%), via the antegrade ipsilateral route in 4 patients (13.3%), and via the ipsilateral popliteal approach in 6 patients (20%). No stent grafts < 5 mm in diameter were implanted, as these have known higher graft occlusion and lower graft patency rates. Stent grafts were not implanted in heavily calcified arteries that were resistant to balloon angioplasty due to known lower graft patency rates in this population. All patients were subsequently discharged on lifelong aspirin and clopidogrel. Follow-up clinical visits with ABI examinations and duplex surveillance were completed at 6 and 12 months for all patients.

Results

The mean age of the patients was 58.4 years. In all, there were 12 women (40%) and 18 men (60%). Five of the patients (16.67%) were diabetic. The technical success rate was 100%, with no in-hospital morbidity or mortality. There were no incidents of myocardial infarction, pseudoaneurysm, groin infection or death. One patient (3.3%) did have stent thrombosis at 4 months. The patient presented with acute limb ischemia and was treated with an open surgical approach using an autologous vein for a femoral-popliteal bypass procedure. The angiogram was consistent with a thrombotic occlusion of the stent graft, and no attempt was made to perform thrombectomy as an alternative treatment strategy. The mean preprocedure ABI was 0.54, and the mean SFA length of occlusion was 15.4 cm. The mean stented length was 24.6 cm. The median stent diameter was 6 mm. On follow-up testing, the mean post-procedure ABI at 1 year was 0.76 (Figure 1), with a primary patency rate of 80% at 1 year. Silent asymptomatic occlusions were noted in 10% (3/30) of the patients. Restenosis was detected on duplex surveillance in 6.6% (2/30) of the patients, with subsequent TVR via PTA. The 1-year primary assisted patency rate was 86%.

Discussion

The advent of endovascular treatment modalities has heralded a new era in caring for those with PVD. However, early adoption was limited to those with milder forms of disease (short focal stenosis or occlusions). In addition, the poor results seen in the early days of PTA/stenting had resulted in less acceptance of this strategy as a primary form of treatment for the more severe cases. As stents were initially used provisionally for unfavorable PTA results, earlier studies may have had a bias against stenting.17 However, with the advancement in technology and the introduction of nitinol stents, as well as e-PTFE-lined stents, PTA/stenting can finally be applied as a primary treatment in a large number of patients.

Data have been scarce from randomized clinical trials comparing surgical bypass with percutaneous intervention. This can be attributed to the fact that the two procedures have been historically reserved for different patient subsets. In 2005, Adam et al published a randomized study of 452 patients evaluating the efficacy of angioplasty and surgery in patients with severe lower-extremity ischemia. In this study, the authors found no difference in amputation-free survival at 1 year.18 In contrast to this, Wolf et al conducted a multicenter, prospective randomized trial comparing PTA to bypass surgery in 263 male patients with iliac, femoral or popliteal obstruction. However, in the 56 patients with long SFA stenoses, the 1-year primary patency rates after PTA and surgery were 43% and 82%, respectively.19 The results of this study, however, suggest otherwise, even in the toughest subset of patients, and are more in line with results obtained by Shaikh et al.20 The primary and primary-assisted patency rates obtained at 1 year, 80% and 86%, respectively, are encouraging and comparable to autologous vein bypass surgery.

Long-term patency, however, continues to be an issue of concern with endovascular treatment in the SFA. Coverage of side branches that supply collaterals has also been suggested as a potential problem in using stent grafts in the SFA. In this small study, neither of these issues seemed to be a significant problem. Dual antiplatelet therapy was rigorously enforced and may have had a favorable impact on the low incidence of stent thrombosis (1/30 patients: 3.3%) in this study. The current generation of heparin-coated Viabahn stent grafts were not used in this study. The potential for further reducing thrombotic risk with heparin coating appears promising.

The anatomy of the SFA plays a major role in long-term success, or lack thereof, using endovascular intervention. The SFA is subject to extrinsic dynamic forces (compression, torsion, elongation) that predispose stents to restenosis and fracture.21–23 The Viabahn stent graft consists of an e-PTFE liner attached to an external nitinol stent structure with significant flexibility, which enables it to be more easily placed across tortuous segments of the SFA and conform more closely to the anatomy of the artery. The procedural success rate and 1-year primary and primary assisted patency rates seen in this study indicate that percutaneous e-PTFE stent grafting with the Viabahn stent graft is a viable treatment option for TASC D occlusions in the SFA in claudicants and the occasional patient with critical limb ischemia. Long-term data (> 5 years) in a larger patient cohort are necessary before definite conclusions can be drawn.

Study limitations. This is not a randomized study comparing stents with surgery. The number of patients enrolled in this single-center registry was small, and follow up, though 100%, was reported only for 1 year. In spite of these limitations, this study is thought-provoking and adds to the body of evidence that endovascular treatment for TASC D SFA lesions may not be farfetched, and a randomized, controlled trial comparing surgery and stenting for TASC C and D lesions is warranted to better define the preferred treatment approach for this difficult lesion subset.

_________________________

From the *Cardiology Fellowship, §Interventional Cardiology Fellowship, Banner Good Samaritan Medical Center and £Heart and Vascular Center of Arizona, Phoenix, Arizona.

The authors report no conflicts of interest regarding the content herein.

Manuscript submitted December 30, 2008, provisional acceptance given February 5, 2009, final version accepted February 16, 2009.

Address for correspondence: Nahel Farraj, DO, 7004 West Keim Dr., Glendale, AZ 85303. E-mail: nahelfarraj@yahoo.com

References: 

1. Dippel E, Shammas N, Takes V, et al. Twelve-month results of percutaneous endovascular reconstruction for chronically occluded superficial femoral arteries: A quality-of-life assessment. J Invasive Cardiol 2006;18:316–321.

2. Galaria I, Surowiec S, Rhodes J, et al. Implications of early failure of superficial femoral artery endoluminal interventions. Ann Vasc Surg 2005;19:787–792.

3. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: Results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation 2004;110:738.

4. Dormandy JA, Rutherford B. Management of peripheral arterial disease. J Vasc Surg 2000;31:251–296.

5. Capek P, McLean GK, Berkowitz HD. Femoro-popliteal angioplasty: Factors influencing long term success. Circulation 1991;83:(Suppl 2):170–180.

6. Henry M, Amor M, Beyar I, et al. Clinical experience with a new mitinol self expanding stent in peripheral arterial disease. J Endovasc Surg 1996;3:369–379.

7. Becquemin JP, Favre JP, Marzella J, et al. Systematic versus selective stent placement after superficial femoral artery balloon angioplasty: A multicenter prospective randomized study. J Vasc Surg 2003;37:487–494.

8. Schillinger M, Sabeti S, Loewe C, et al. Balloon Angioplasty versus implantation of nitinol stents in the superficial femoral artery. N Engl J Med 2006;354:1879–1888.

9. Katzen BT, Laird J; RESILIENT investigators. The RESILIENT trial. 12-Month analysis. TCT 2007 (Transcatheter Cardiovascular Therapeutics). Washington, D.C., 20–25 October 2007. http://www.cardiosource.com/clinicaltrials/trial.asp?trialID51615 (5 November 2008).

10. Krankenberg H, Schlüter M, Steinkamp HJ, et al. Nitinol stent implantation versus percutaneous transluminal angioplasty in superficial femoral artery lesions up to 10 cm in length: The Femoral Artery Stenting Trial (FAST). Circulation 2007;116:285–292.

11. Kasapis C, Henke PK, Chetcuti SJ, et al. Routine stent implantation vs. percutaneous transluminal angioplasty in femoropopliteal artery disease: A meta-analysis of randomized controlled trials. Eur Heart J2009;30:44–55.

12. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine and Biology, and the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). American College of Cardiology Web Site. Available at: http://www.acc.org/clinical/guidelines/pad/ index.pdf.

13. Lyden S, Shimshak T. Contemporary endovascular treatment for disease of the superficial femoral and popliteal arteries: An integrated device-based strategy. J Endovasc Ther 2006;13(Suppl II):II41–II51.

14. Tepe G, Schmehl J, Heller S, et al. Superficial femoral artery: Current treatment options. Eur Radiol 2006;16:316–1322.

15. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg 2007;33:S1–S70.

16. Duda SH, Pusich B, Richter G, et al. Sirolimus eluting stents for the treatment of obstructive superficial femoral artery disease: 6-Month results. Circulation 2002;106:1505–1509.

17. Gordon I, Conroy R, Arefi M, et al. Three-year outcome of endovascular treatment of superficial femoral artery occlusion. Arch Surg 2001;136:221–228.

18. Adam DJ, Beard JD, Cleveland, T, et al. Bypass versus angioplasty in severe ischemia of the leg (BASIL): Multicenter randomized controlled trial. Lancet 2005;366:1925–1934.

19. Wolf G, Wilson S, Cross A, et al. Surgery or balloon angioplasty for peripheral vascular disease: A randomized clinical trial. Principal Investigators and their Associates of Veterans Administration Cooperative Study Number 199. J Vasc Interv Radiol 1993;4:639–648.

20. Shaikh F, Djelmami-Hani M, Solis J, et al. Percutaneous endovascular treatment of SFA disease using the Gore Viabahn® endoprosthesis. Do the procedural success and 1-year follow-up data make this the treatment of choice? Endovasc Today 2007(Suppl).

21. Laird J. Limitations of percutaneous transluminal angioplasty and stenting for the treatment of disease of the superficial femoral and popliteal arteries. J Endovasc Ther 2006;13(Supp II):II30–II40

22. Ferreira M, Lanziotti L, Monteiro M, et al. Superficial femoral artery recanalization with self-expanding nitinol stents: Long-term follow-up results. Eur J Vasc Endovasc Surg 2007;34:702–708.

23. Kessel D, Wijesinghe L, Robertson I, et al. Endovascular stent-grafts for superficial femoral artery disease: Results of 1-year follow-up. J Vasc Interv Radiol 1999;10:289–296.

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American Heart Association's - Go Red For Women Luncheon

More than 600 women from across the Valley took part in the Go Red For Women Luncheon on Friday, May 1 at 11:45 a.m. The 5th annual luncheon, was held at the Sheraton Phoenix Downtown Hotel, will raise awareness around heart disease, the No.1 killer of women. The American Heart Associations Go Red For Women campaign encourages women to take charge of their heart health and make it a top priority to live a stronger and healthier life.

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Dr. Suzanne Sorof answers reader's question regarding Diabetes and Heart Disease in the azcentral. com Southwest Valley Column.

Southwest Valley

Diabetes increases woman's heart-attack risk

Jan. 30, 2009 02:44 PM
Special for The Republic

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Author: Adam Klawonn
Issue: April, 2008, Page 201

Photo by Brandon Sullivan
 
Specialty: Cardiology
Medical School: McGill University, Montreal, Canada
Years Practicing: 24
Hometown: Montreal, Canada

What brought you to Phoenix?
“I recognized an opportunity, and I liked to teach and do research, and I didn’t want to have to worry about tenure and the university politics. I came here and was able to do everything in the realm of private practice. I was the coronary care unit director at Good Sam from 1986 until 1991. Now I am the director of Banner Health’s interventional cardiology fellowship program, which teaches young doctors how to do angioplasty and stints.”

Are people here healthier than in other places you’ve worked, such as Michigan?
“I don’t think people are healthier necessarily. I think younger people are healthier, but we have a lot of people that move here from elsewhere who have cardiac problems. The chance of having a heart attack today is going down across the country because patients in general are taking better care of themselves. But there is certainly plenty of coronary disease to keep us busy.”

Why do you think coronary disease is still so prevalent?
“I think a lot of the public is looking for a quick fix – a magic pill – and do not want to do the things that are necessary, such as diet and exercise. The public wants instant gratification. They want laser [treatment] for their carotid arteries rather than preventing these things to begin with. They view medicine as a pit stop in the race of life, whereas a little preventive maintenance goes a lot further.”

We live in a caffeinated society. How does that affect our tickers?
Too much of anything is never good. Everything in moderation should be the motto. One to two cups of coffee a day are best, no more. Caffeine is also a mild diuretic. People think that because there is water in coffee, it hydrates you. But actually, it’s just the opposite.

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Reprinted from The Arizona Republic

Quality of life is issue, local expert says

Improving one's diet and exercise vs. having a stent implanted may be equal in terms of preventing a heart attack, but the two appraches may vary greatly in their effects on your quality of life, according to a Valley cardiology expert.

"You have to ask, why are we doing these procedures?" asked Dr. Nathan Laufer, director of interventional cardiology at Banner Good Samaritan Medical Center, where about 3,500 stent interventions are performed every year.

The number of angioplasties performed in Arizona has risen over the past several years.  In 2000, there were 11,854 of the procedures; in 2005, there were 17,039.

Having a stent implanted is "not necessarily to make the patient live longer, but to help them live better."

In Canada, where angioplasties are not as common as in the United States, many patients improve their diet and exercise but are still medically disabled. 

Although exercise can relive pain and tightness, it doesn't mean ite will go away.  An angiioplasty can improve those chances, said Laufer, who also is medical director of the Heart & Vascular Center of Arizona.

-- Connie Cone Sexton and Michael Clancy

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Intermediate Term (2 YEAR) Outcomes Following Unprotected Left Main Trunk Percutaneous Intervention With Drug Eluting Stents.

Type: Poster
Starts On: TBD
Presenter/Author:
Ashish Pershad, MD, Rajendran Sabapathy, MD, Adam Brodsky, Renee Espinosa, MD, Nathan Laufer, MD, Heart and Vascular Center of AZ, Phoenix, AZ
Abstract Number: 366

Background: Bypass surgery remains the revascularization strategy of choice for left main trunk coronary artery disease in an unselected group of patients. Drug eluting stents have been proposed as a viable alternative to bypass surgery for left main trunk lesions but their intermediate and long term outcomes are still under scrutiny.

Methods: A series of 50 patients with significant unprotected left main trunk stenosis (>50%) underwent revascularization with drug eluting stents (sirolimus and paclitaxel stents ) and were enrolled in a registry. Follow up angiography was clinically driven for recurrent chest pain and ischemia on MPI. Prespecified primary endpoints of this registry were major adverse cardiac event at 2 year follow up. Major adverse cardiac events were defined as death; ST elevation MI; Need for urgent CABG; Non Q MI defined as CPK -MB measurements at 3 times the upper limit of normal; persistent ischemia by nuclear imaging and target lesion revascularization. Target lesion revascularization was defined as intervention within the left main trunk or within 10mm distal to the branch vessel ostia.

Results: The mean age of patients was 68 years. 40% of the subjects were female. 32.5% of patients were diabetic and the mean EF was 45%.
Clinical follow up at 2 years was complete in all 50 patients (100%). Angiographic follow up was necessary in 20 patients (40%). The lesion treated was in the distal LMT in 24/50 (49 %) patients. Heavy fluoroscopic calcification was noted in 10/50 (20%) patients. The RCA was occluded in 3/50 (6%) patients. Peri-procedural IABP was used in 10/50 (20%) patients. Elective or bailout IIb IIIa use was in 13/50 (25%) patients. Two stents were used in 23/50 (46%) patients. Bifurcation technique used was V/T stent approach in 22/23 (95% ) and crush tehnique in 1/23 (04%) patients.

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INDUSTRY WRAPUPS - From the October 1, 2004 print edition of Health

Heart center gets FDA nod for stroke prevention

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Local doctor investigates drug-coated coronary stent
 

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Heart device getting good local reviews
 

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